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  • 1.
    Baroudi, Mazen
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Petersen, Solveig
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Namatovu, Fredinah
    Umeå University, Faculty of Arts, Department of historical, philosophical and religious studies.
    Annelie, Carlsson
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Preteen children’s health related quality of life in Sweden: changes over time and disparities between different sociodemographic groups2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 139Article in journal (Refereed)
    Abstract [en]

    Background: Assessing disparities in health-related quality of Life (HRQoL) is important as a part of health-related disparities in the society. The aim of this study was to explore HRQoL among 12-year-olds in Sweden in terms of differences between years 2005 and 2009 and disparities related to sociodemographic background.

    Methods: During the school years 2005 and 2009, a total of 18,325 sixth grade students in Sweden were invited to a celiac disease screening study; 13,279 agreed to participate. Jointly with the celiac screening, the children answered a questionnaire that included EuroQol 5 Dimensions-youth (EQ-5D-Y) and their parents responded to separate questionnaires about their own and their child’s country of birth, family structure, their employment status, occupation, and education. In total 11,009 child-parent questionnaires were collected. Logistic regression was used to study differences in HRQoL between 2005 and 2009, and between various sociodemographic subgroups.

    Results: Compared with 2005, children in 2009 reported more pain (OR: 1.20, 95% CI: 1.1–1.3) and more mood problems (OR: 1.35, 95% CI: 1.2–1.5). In general, girls reported more pain and mood problems and had more disparities than boys. There were no significant differences based on parents’ occupation, however, children of parents with low or medium education levels reported less “mood problems” than those of parents with high education levels (OR: 0.65, 95% CI: 0.46–0.92) and (OR: 0.84, 95% CI: 0.73–0.96), respectively. A slight variation was seen in HRQoL between children with different migration background. Girls living in small municipalities reported more pain (OR: 1.51, 95% CI: 1.14–2.01), and problems performing usual activities (OR: 3.77, 95% CI: 2.08–6.84), compared to girls living in large municipalities. In addition, children living with two parents had less mood problems than children living in other family constellations.

    Conclusion: More children reported pain and mood problems in 2009 compared with 2005. To study future trends, health outcomes among children in Sweden should continue to be reported periodically. More efforts should be invested to increase the awareness of health-related disparities as highlighted in this study especially for girls living in small municipalities and children of parents with high education level.

  • 2.
    Cameron, David
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ubels, Jasper
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review2018In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 11, no 1, article id 1447828Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: The amount a government should be willing to invest in adopting new medical treatments has long been under debate. With many countries using formal cost-effectiveness (C/E) thresholds when examining potential new treatments and ever-growing medical costs, accurately setting the level of a C/E threshold can be essential for an efficient healthcare system.

    OBJECTIVES: The aim of this systematic review is to describe the prominent approaches to setting a C/E threshold, compile available national-level C/E threshold data and willingness-to-pay (WTP) data, and to discern whether associations exist between these values, gross domestic product (GDP) and health-adjusted life expectancy (HALE). This review further examines current obstacles faced with the presently available data.

    METHODS: A systematic review was performed to collect articles which have studied national C/E thresholds and willingness-to-pay (WTP) per quality-adjusted life year (QALY) in the general population. Associations between GDP, HALE, WTP, and C/E thresholds were analyzed with correlations.

    RESULTS: Seventeen countries were identified from nine unique sources to have formal C/E thresholds within our inclusion criteria. Thirteen countries from nine sources were identified to have WTP per QALY data within our inclusion criteria. Two possible associations were identified: C/E thresholds with HALE (quadratic correlation of 0.63), and C/E thresholds with GDP per capita (polynomial correlation of 0.84). However, these results are based on few observations and therefore firm conclusions cannot be made.

    CONCLUSIONS: Most national C/E thresholds identified in our review fall within the WHO's recommended range of one-to-three times GDP per capita. However, the quality and quantity of data available regarding national average WTP per QALY, opportunity costs, and C/E thresholds is poor in comparison to the importance of adequate investment in healthcare. There exists an obvious risk that countries might either over- or underinvest in healthcare if they base their decision-making process on erroneous presumptions or non-evidence-based methodologies. The commonly referred to value of 100,000$ USD per QALY may potentially have some basis.

  • 3.
    Forsner, Maria
    et al.
    Umeå University, Faculty of Medicine, Department of Nursing. Högskolan Dalarna.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nordyke, Katrina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindh, Viveca
    Umeå University, Faculty of Medicine, Department of Nursing.
    Relaxation and guided imagery used with 12-year-olds during venipuncture in a school-based screening study2014In: Journal of Child Health Care, ISSN 1367-4935, E-ISSN 1741-2889, Vol. 18, no 3, p. 241-252Article in journal (Refereed)
    Abstract [en]

    Needle-related procedures are reported to be problematic for children. In a school-based celiac disease screening, 12-year-olds' experiences with relaxation and guided imagery (R-GI) during venipuncture were investigated. One group tried nurse-led R-GI (n = 60) and another group received standard care (SC; n = 49). A mixed method design was applied using short written narratives, facial affective scale (FAS), and visual analog scale (VAS) for pain intensity. Qualitative content analysis highlighted that diversity and contradictions when facing blood tests. FAS scores were significantly lower in the SC group before (p = 0.01), during (p = 0.01), and after (p = 0.01) venipuncture. VAS scores did not differ between the groups. The blood test was mostly experienced as unproblematic, and GI during venipuncture did not decrease pain or affect. However, the fact that a number of children scored high FAS indicates a need for effective methods to help children cope with needle-related school-based procedures.

  • 4.
    Ivarsson, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Kinsman, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Johansson, Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Mohamud, Khalif Bile
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Freij, Lennart
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dalmar, Abdirisak Ahmed
    Ibrahim, Abdirashid Omer
    Hagi, Abdisamad Abikar
    Abdi, Abshir Ali
    Hussein, Abdullahi Sheik
    Shirwa, Abdulkadir Mohamed
    Warsame, Amina
    Ereg, Derie Ismail
    Aden, Mohamed Hussain
    Qasim, Maryan
    Ali, Mohamed Khalid
    Elmi, Abdullahi
    Afrah, Abdullahi Warsame
    Sabtiye, Faduma Omar
    Guled, Fatuma Ege
    Ahmed, Hinda Jama
    Mohamed, Halima
    Tinay, Halima Ali
    Mohamud, Kadigia Ali
    Yusuf, Mariam Warsame
    Omar, Mayeh
    Abdi, Yakoub Aden
    Abdulkadir, Yusuf
    Johansson, Annika
    Kulane, Asli Ali
    Schumann, Barbara
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Essen, Birgitta
    Kalengayi, Faustine Nkulu
    Elgh, Fredrik
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Virology.
    Norström, Fredrik
    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.
    Norder, Helene
    Schröders, Julia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Erlandsson, Kerstin
    Edin, Kerstin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sahlen, Klas-Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Gustafsson, Lars L.
    Persson, Lars-Ake
    Eriksson, Malin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Emmelin, Maria
    Hasselberg, Marie
    Klingberg, Marie
    Preet, Raman
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hogberg, Ulf
    Sjostrom, Urban
    Omar, Saif
    Healing the health system after civil unrest2015In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 8, p. 1-4Article in journal (Other academic)
  • 5.
    Ivarsson, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    van der Pals, Maria
    Department of Pediatrics, Clinical Sciences, Skånes University Hospital, Lund University, Lund, Sweden.
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Högberg, Lotta
    Pediatric Clinic, Norrköping Hospital, Norrköping, Sweden, and Department of Clinical and Experimental Medicine, Division of Pediatrics, Linköping University, Linköping, Sweden .
    Danielsson, Lars
    Pediatric Clinic, Norrtälje Hospital, Norrtälje, Sweden.
    Halvarsson, Britta
    Pathology and Cytology, Aleris Medilab, Täby, Sweden.
    Hammarroth, Solveig
    Pediatric Clinic, Norrtälje Hospital, Norrtälje, Sweden.
    Hernell, Olle
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Karlsson, Eva
    Pediatric Clinic, Växjö Hospital, Växjö, Sweden..
    Stenhammar, Lars
    Pediatric Clinic, Norrköping Hospital, Norrköping, Sweden, and Department of Clinical and Experimental Medicine, Division of Pediatrics, Linköping University, Linköping, Sweden .
    Charlotta, Webb
    Department of Pediatrics, Clinical Sciences, Skånes University Hospital, Lund University, Lund, Sweden.
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Carlsson, Annelie
    Department of Pediatrics, Clinical Sciences, Skånes University Hospital, Lund University, Lund, Sweden.
    Reduced prevalence of childhood celiac disease: an effect of changes in infant feeding?Manuscript (preprint) (Other academic)
  • 6.
    Ivarsson, Anneli
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    van der Pals, Maria
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Medical Biosciences, Medical and Clinical Genetics.
    Högberg, Lotta
    Danielsson, Lars
    Halvarsson, Britta
    Hammarroth, Solveig
    Hernell, Olle
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Karlsson, Eva
    Stenhammar, Lars
    Webb, Charlotta
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Carlsson, Annelie
    Prevalence of childhood celiac disease and changes in infant feeding2013In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 131, no 3, p. e687-e694Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Between 1984 and 1996, Sweden experienced an "epidemic" of clinical celiac disease in children <2 years of age, attributed partly to changes in infant feeding. Whether infant feeding affects disease occurrence and/or the clinical presentation remains unknown. We investigated and compared the total prevalence of celiac disease in 2 birth cohorts of 12-year-olds and related the findings to each cohort's ascertained infant feeding.

    METHODS: A 2-phase cross-sectional screening study was performed in which 13 279 children from 2 birth cohorts participated: children born during the epidemic (1993) and children born after the epidemic (1997). Previously diagnosed cases were reported and confirmed. Blood samples were analyzed for serological markers and children with positive values were referred for small intestinal biopsy. Infant feeding practices in the cohorts were ascertained via questionnaires. Prevalence comparisons were expressed as prevalence ratios.

    RESULTS: The total prevalence of celiac disease was 29 in 1000 and 22 in 1000 for the 1993 and 1997 cohorts, respectively. Children born in 1997 had a significantly lower risk of having celiac disease compared with those born in 1993 (prevalence ratio: 0.75; 95% confidence interval: 0.60-0.93; P = .01). The cohorts differed in infant feeding (specifically, in the proportion of infants introduced to dietary gluten in small amounts during ongoing breastfeeding).

    CONCLUSIONS: A significantly reduced prevalence of celiac disease in 12-year-olds indicates an option for disease prevention. Our findings suggest that the present infant feeding recommendation to gradually introduce gluten-containing foods from 4 months of age, preferably during ongoing breastfeeding, is favorable.

  • 7.
    Johansson, Katarina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nordyke, Katrina
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Celiac Dietary Adherence Test simplifies Determining Adherence to a Gluten-Free Diet in Swedish Adolescents2019In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801Article in journal (Refereed)
    Abstract [en]

    Objectives: The aims of the study were to ascertain whether the Celiac Dietary Adherence Test (CDAT) could contribute in determining adherence to a gluten-free diet in celiac disease patients and to evaluate the diet adherence and well-being of a study population five years after a celiac disease screening known as “Exploring the Iceberg of Celiacs in Sweden”.

    Methods: Through the screening, 90 adolescents (born 1997) were diagnosed with biopsy-proven celiac disease at twelve-years of age. Of them, 70 (78%) came to a five-year follow-up where anti–tissue transglutaminase antibodies 2 (TG2-IgA) was tested and a questionnaire was filled in, including CDAT, which consists of seven questions related to adherence. Non-parametrical tests were utilized to determine associations between adherence measures.

    Results: Among the adolescents, 86% were adherent to a gluten-free diet five years after screening, 38% reported their general well-being as excellent, 50% very well, and 12% well. Statistically significant associations were seen between TG2-IgA and the CDAT score (p=0.033), and the self-reported adherence question and the CDAT score (p < 0.001).

    Conclusions: The screening-detected adolescents reported a high level of well-being and adherence to a gluten-free diet five years after screening. We conclude that the CDAT can be used in clinical practice as an estimation of adherence to a gluten-free diet. It would be most suitable to use in conjunction with currently used adherence measures, but can also be used as a stand-alone method when others are not accessible.

  • 8.
    Kautto, Ethel
    et al.
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Högberg, L
    Division of Pediatrics, Department of Clinical and Experimental Medicine, Faculty of Health Science, Linköping University, Linköping, Sweden and Department of Pediatrics in Norrköping, County Council of Östergötland, Norrköping, Sweden.
    Carlsson, A
    Department of Pediatrics, SUS University Hospital, Lund University, Lund, Sweden.
    Hörnell, Agneta
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Nutrient intake in adolescent girls and boys diagnosed with coeliac disease at an early age is mostly comparable to their non-coeliac contemporaries2014In: Journal of human nutrition and dietetics (Print), ISSN 0952-3871, E-ISSN 1365-277X, Vol. 27, no 1, p. 41-53Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Food habits, nutrient needs and intakes differ between males and females, although few nutritional studies on patients with coeliac disease (CD) have reported results stratified by gender.

    OBJECTIVES: To compare energy and nutrient intakes among 13-year olds diagnosed with CD in early childhood with those of a non-coeliac (NC) age- and gender-matched control group, and also with estimated average requirements (EAR).

    METHODS: A case-control study was conducted in Sweden 2006-2007 within the coeliac screening study ETICS (Exploring The Iceberg of Coeliacs in Sweden). Dietary intake was assessed among 37 adolescents (23 girls) diagnosed with CD at median age 1.7 years (CD group) and 805 (430 girls) NC controls (NC group) using a food-frequency questionnaire covering 4 weeks. Reported energy intake was validated by comparison with the calculated physical activity level (PAL).

    RESULTS: Regardless of CD status, most adolescents reported an intake above EAR for most nutrients. However, both groups had a low intake of vitamin C, with 13% in the CD-group and 25% in the NC-group below EAR, and 21% of boys in the CD-group below EAR for thiamine. The intake of fatty acids was unbalanced, with a high intake of saturated and a low intake of unsaturated fats. Girls and boys in the CD-group had an overall lower nutrient density in reported food intake compared to girls and boys in the NC-group.

    CONCLUSIONS: Nutrient intake of adolescent girls and boys with CD was mostly comparable to intakes of NC controls. Dietitians should take the opportunity to reinforce a generally healthy diet when providing information about the gluten-free diet.

  • 9.
    Kautto, Ethel
    et al.
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition. Umeå University, Faculty of Social Sciences, Umeå Centre for Gender Studies (UCGS).
    Rydén, Petra
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Olsson, Cecilia
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Högberg, Lotta
    Carlsson, Annelie
    Hagfors, Linda
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Hörnell, Agneta
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    What happens to food choices when a gluten-free diet is required?: A prospective longitudinal population-based study among Swedish adolescent with coeliac disease and their peers2014In: Journal of Nutritional Science, ISSN 2048-6790, E-ISSN 2048-6790, Vol. 3, no e2Article in journal (Refereed)
    Abstract [en]

    A dietary survey was performed during a large screening study in Sweden among 13-year-old adolescents. The aim was to study how the intake of food groups was affected by a screening-detected diagnosis of celiac disease (CD) and its gluten-free (GF) treatment. Food intake, was reported using a food frequency questionnaires (FFQ) and intake reported by the adolescents who was screened to CD was compared with the intake of two same-aged referent groups: i) adolescents diagnosed to CD prior screening and ii) adolescents without CD.. The food intake groups were measured at baseline before the screening-detected cases were aware of their CD, and 12-18 months later.

    The result showed that the food intakes are affected by a screen detected CD and its dietary treatment. Many flour-based foods were reduced such as pizza, fish fingers, and pastries. The result also indicated that the bread intake was lower before the screened diagnosis compared to the other studied groups, but increased afterwards. Specially manufactured GF-products (e.g. pasta and bread) were frequently used in the screened CDgroup after changing to a GF-diet. Our results suggest that changing to a GF-diet reduces the intake of some popular foods, and the ingredients on the plate are altered, but this do not necessarily include a change of food groups. The availability of manufactured GF-replacement products makes it possible for adolescents to keep many of their old food habits when diagnosed with CD in Sweden.

  • 10.
    Myléus, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Webb, Charlotta
    Danielsson, Lars
    Hernell, Olle
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Högberg, Lotta
    Karlsson, Eva
    Lagerqvist, Carina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stenhammar, Lars
    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.
    Carlsson, Annelie
    Celiac disease revealed in 3% of Swedish 12-year-olds born during an epidemic2009In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 49, no 2, p. 170-176Article in journal (Refereed)
    Abstract [en]

    Objetive: Sweden experienced a marked epidemic of celiac disease between 1984 and 1996 in children younger than 2 years of age, partly explained by changes in infant feeding. The objective of this study was to determine the prevalence of celiac disease in 12-year-olds born during the epidemic (1993), including both symptomatic and screening detected cases.

    Patients and methods: All sixth-grade children in participating schools were invited (n = 10,041). Symptomatic and, therefore, previously diagnosed celiac disease cases were ascertained through the National Swedish Childhood Celiac Disease Register and/or medical records. All serum samples were analyzed for antihuman tissue transglutaminase (tTG)-IgA (Celikey), and serum-IgA, and some for tTG-IgG and endomysial antibodies. A small intestinal biopsy was recommended for all children with suspected undiagnosed celiac disease.

    Results: Participation was accepted by 7567 families (75%). Previously diagnosed celiac disease was found in 67 children; 8.9/1000 (95% confidence interval [CI] 6.7-11). In another 192 children, a small intestinal biopsy was recommended and was performed in 180. Celiac disease was verified in 145 children, 20/1000 (95% CI 17-23). The total prevalence was 29/1000 (95% CI 25-33).

    Conclusions: The celiac disease prevalence of 29/1000 (3%)-with two thirds of cases undiagnosed before screening-is 3-fold higher than the usually suggested prevalence of 1%. When these 12-year-olds were infants, the prevailing feeding practice was to introduce gluten abruptly, often without ongoing breast-feeding, which might have contributed to this unexpectedly high prevalence.

  • 11.
    Neumann, Anne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Center of Evidence-Based Healthcare, University Hospital, Technische Universität Dresden, Germany.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Schoffer, Olaf
    Klug, Stefanie J.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The cost-effectiveness of interventions targeting lifestyle change for the prevention of diabetes in a Swedish primary care and community based prevention program2017In: European Journal of Health Economics, ISSN 1618-7598, E-ISSN 1618-7601, Vol. 18, no 7, p. 905-919Article in journal (Refereed)
    Abstract [en]

    Background: Policymakers need to know the cost-effec-tiveness of interventions to prevent type 2 diabetes (T2D). The objective of this study was to estimate the cost-effectiveness of a T2D prevention initiative targeting weight reduction, increased physical activity and healthier diet in persons in pre-diabetic states by comparing a hypothetical intervention versus no intervention in a Swedish setting. Methods: A Markov model was used to study the cost-effectiveness of a T2D prevention program based on lifestyle change versus a control group where no prevention was applied. Analyses were done deterministically and probabilistically based on Monte Carlo simulation for six different scenarios defined by sex and age groups (30, 50, 70 years). Cost and quality adjusted life year (QALY) differences between no intervention and intervention and incremental cost-effectiveness ratios (ICERs) were estimated and visualized in cost-effectiveness planes (CE planes) and cost-effectiveness acceptability curves (CEA curves). Results: All ICERs were cost-effective and ranged from 3833 € /QALY gained (women, 30 years) to 9215 € /QALY gained (men, 70 years). The CEA curves showed that the probability of the intervention being cost-effective at the threshold value of 50,000 € per QALY gained was very high for all scenarios ranging from 85.0 to 91.1%. Discussion/conclusion: The prevention or the delay of the onset of T2D is feasible and cost-effective. A small investment in healthy lifestyle with change in physical activity and diet together with weight loss are very likely to be cost-effective.

  • 12.
    Neumann, Anne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Schoffer, Olaf
    Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
    Norström, Fredrik
    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.
    Klug, Stefanie J.
    Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Risk equations for the development of worsened glucose status and type 2 diabetes mellitus in a Swedish intervention program2013In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, article id 1014Article in journal (Refereed)
    Abstract [en]

    Background: Several studies investigated transitions and risk factors from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2D). However, there is a lack of information on the probabilities to transit from normal glucose tolerance (NGT) to different pre-diabetic states and from these states to T2D. The objective of our study is to estimate these risk equations and to quantify the influence of single or combined risk factors on these transition probabilities. Methods: Individuals who participated in the VIP program twice, having the first examination at ages 30, 40 or 50 years of age between 1990 and 1999 and the second examination 10 years later were included in the analysis. Participants were grouped into five groups: NGT, impaired fasting glucose (IFG), IGT, IFG&IGT or T2D. Fourteen potential risk factors for the development of a worse glucose state (pre-diabetes or T2D) were investigated: sex, age, education, perceived health, triglyceride, blood pressure, BMI, smoking, physical activity, snus, alcohol, nutrition and family history. Analysis was conducted in two steps. Firstly, factor analysis was used to find candidate variables; and secondly, logistic regression was employed to quantify the influence of the candidate variables. Bootstrap estimations validated the models. Results: In total, 29 937 individuals were included in the analysis. Alcohol and perceived health were excluded due to the results of the factor analysis and the logistic regression respectively. Six risk equations indicating different impacts of different risk factors on the transition to a worse glucose state were estimated and validated. The impact of each risk factor depended on the starting or ending pre-diabetes state. High levels of triglyceride, hypertension and high BMI were the strongest risk factors to transit to a worsened glucose state. Conclusions: The equations could be used to identify individuals with increased risk to develop any of the three pre-diabetic states or T2D and to adapt prevention strategies.

  • 13.
    Neumann, Anne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Cancer Epidemiology, University Cancer Center, University Hospital.
    Schoffer, Olaf
    Cancer Epidemiology, University Cancer Center, University Hospital.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Klug, Stefanie J
    Cancer Epidemiology, University Cancer Center, University Hospital.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health-related quality of life for pre-diabetic states and type 2 diabetes mellitus: a cross-sectional study in Västerbotten Sweden2014In: Health and Quality of Life Outcomes, ISSN 1477-7525, E-ISSN 1477-7525, Vol. 12, no 1, article id 150Article in journal (Refereed)
    Abstract [en]

    Background: Type 2 diabetes (T2D) decreases health-related quality of life, but there is a lack of information about the health status of people in pre-diabetic states. However, information on health utility weights (HUWs) for pre-diabetic states and T2D are essential to estimate the effect of prevention initiatives. We estimated and compared HUWs for healthy individuals, those with pre-diabetes and those with T2D in a Swedish population and evaluated the influence of age, sex, education and body mass index on HUWs.

    Methods: Participants of the Västerbotten Intervention Program, Sweden, between 2002 and 2012, who underwent an oral glucose tolerance test or indicated they had T2D and who filled in the Short Form-36 questionnaire (SF-36) were included. Individuals were categorized as healthy, being in any of three different pre-diabetic states, or as T2D. The pre-diabetic states are impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or a combination of both (IFG&IGT). The SF-6D index was used to convert SF-36 responses to HUWs. HUWswere stratified by age, sex, education and body mass index. Beta regression analyses were conducted to estimate the effect of multiple risk factors on the HUWs.

    Results: In total, 55 882 individuals were included in the analysis. The overall mean HUW was 0.764. The mean HUW of healthy individuals was 0.768, 0.759 for those with IFG, 0.746 for those with IGT, 0.745 for those with IFG&IGT, and 0.738 for those with T2D. In the overall model, all variables except underweight vs. normal weight were significantly associated with HUW. Younger age, male sex, and higher education were associated with increased HUW. Normal weight, or being overweight was associated with elevated HUW, while obesity was associated with lower HUW.

    Conclusions: Healthy individuals had higher HUWs than participants with T2D, while individuals with IFG, IGT or IFG&IGT had HUWs that ranged between those for NGT and T2D. Therefore, preventing the development of pre-diabetic states would improve health-related quality of life in addition to lowering the risk of developing T2D.

  • 14.
    Nordyke, Katrina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    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 Global Health.
    Carlsson, Annelie
    Danielsson, Lars
    Emmelin, Maria
    Department of Clinical Sciences, Lund University, Lund, Sweden .
    Högberg, Lotta
    Karlsson, Eva
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health-related quality-of-life in children with coeliac disease, measured prior to receiving their diagnosis through screening2011In: Journal of Medical Screening, ISSN 0969-1413, E-ISSN 1475-5793, Vol. 18, no 4, p. 187-192Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To compare the health-related quality-of-life (HRQoL) of children with screening-detected coeliac disease (CD), before they learned of their diagnosis, with that of children without CD and in those previously diagnosed with CD.

    METHODS: In a cross-sectional CD screening study ('ETICS': Exploring the Iceberg of Coeliacs in Sweden), of 10,041 Swedish 12-year-olds invited, 7567 (75%) consented to participate, and 7208 (72%) children without previously diagnosed CD had serological markers analysed. Before the screening results were known, 7218 children (72%) and 6524 of their parents (65%) answered questionnaires. Questionnaires included the Swedish child-friendly pilot version of the EQ-5D instrument and proxy version of the EQ-5D instrument, which are generic tools used to describe HRQoL.

    RESULTS: We found no significant difference in HRQoL between the groups of children with screening-detected CD, without CD, and those previously diagnosed with CD.

    CONCLUSION: The HRQoL reported by 12-year-olds with screening-detected CD, before they learned of their diagnosis, was not worse than that of the children without CD or those previously diagnosed with CD. Thus, mass screening for CD should not be justified on the basis that children with unrecognized CD have a poor HRQoL. However, because these children rated their HRQoL before diagnosis and treatment, they may not have recognized or perceived symptoms as severe enough to seek medical attention which demonstrates how difficult clinical/active case finding can be. Mass screening may still, therefore, be considered if the aim is early detection and prevention of future complications.

  • 15.
    Nordyke, Katrina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    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 Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health-related quality of life in adolescents with screening-detected celiac disease, before and one year after diagnosis and initiation of gluten-free diet, a prospective nested case-referent study2013In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, article id 142Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Celiac disease (CD) is a chronic disorder in genetically predisposed individuals in which a small intestinal immune-mediated enteropathy is precipitated by dietary gluten. It can be difficult to diagnose because signs and symptoms may be absent, subtle, or not recognized as CD related and therefore not prompt testing within routine clinical practice. Thus, most people with CD are undiagnosed and a public health intervention, which involves screening the general population, is an option to find those with unrecognized CD. However, how these screening-detected individuals experience the diagnosis and treatment (gluten-free diet) is not fully understood. The aim of this study is to investigate the health-related quality of life (HRQoL) of adolescents with screening-detected CD before and one year after diagnosis and treatment.

    METHODS: A prospective nested case-referent study was done involving Swedish adolescents who had participated in a CD screening study when they were in the sixth grade and about 12 years old. Screening-detected adolescents (n = 103) and referents without CD who participated in the same screening (n = 483) answered questionnaires at the time of the screening and approximately one year after the screening-detected adolescents had received their diagnosis that included the EQ-5D instrument used to measure health status and report HRQoL.

    RESULTS: The HRQoL for the adolescents with screening-detected CD is similar to the referents, both before and one year after diagnosis and initiation of the gluten-free diet, except in the dimension of pain at follow-up. In the pain dimension at follow-up, fewer cases reported problems than referents (12.6% and 21.9% respectively, Adjusted OR 0.50, 95% CI 0.27-0.94). However, a sex stratified analysis revealed that the significant difference was for boys at follow-up, where fewer screening-detected boys reported problems (4.3%) compared to referent boys (18.8%) (Adjusted OR 0.17, 95% CI 0.04-0.73).

    CONCLUSIONS: The findings of this study suggest that adolescents with unrecognized CD experience similar HRQoL as their peers without CD, both before and one year after diagnosis and initiation of gluten-free diet, except for boys in the dimension of pain at follow-up.

  • 16. Norström, Fredrik
    A comparison of methods for classification in remote sensing using simulated data sets with imperfectionsManuscript (preprint) (Other academic)
  • 17.
    Norström, Fredrik
    Centre of Biostochastics, Swedish Univ. of Agricultural Sciences.
    Comparative performance of classification and stratification methods in remote sensing and forest applications: Simulation studies2003Licentiate thesis, comprehensive summary (Other academic)
  • 18. Norström, Fredrik
    Forest inventory estimation using remotely sensed data as a stratification tool - a simulation studyManuscript (preprint) (Other academic)
  • 19.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    How is Health Affected by Unemployment?: A Review of Methodological Shortcomings2015In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 44, p. 278-278Article in journal (Other academic)
  • 20.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Poor quality in the reporting and use of statistical methods in public health: the case of unemployment and health2015In: Archives of Public Health, ISSN 0778-7367, E-ISSN 2049-3258, Vol. 73, article id 56Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: It has previously been reported that many research articles fail to fulfill important criteria for statistical analyses, but, to date, these reports have not focused on public health problems. The aim of this study was to investigate the quality of reporting and use of statistical methods in articles analyzing the effect of unemployment on health.

    METHODS: Forty-one articles were identified and evaluated in terms of how they addressed 12 specified criteria.

    RESULTS: For most of these criteria, the majority of articles were inadequate. These criteria were conformity with a linear gradient (100 % of the articles), validation of the statistical model (100 %), collinearity of independent variables (97 %), fitting procedure (93 %), goodness of fit test (78 %), selection of variables (68 % for the candidate model; 88 % for the final model), and interactions between independent variables (66 %). Fewer, but still alarmingly many articles, failed to fulfill the criteria coefficients presented in statistical models (48 %), coding of variables (34 %) and discussion of methodological concerns (24 %). There was a lack of explicit reporting of statistical significance/confidence intervals; 34 % of the articles only presented p-values as being above or below the significance level, and 42 % did not present confidence intervals. Events per variable was the only criterion met at an undoubtedly acceptable level (2.5 %).

    CONCLUSIONS: There were critical methodological shortcomings in the reviewed studies. It is difficult to obtain unbiased estimates, but there clearly needs to be some improvement in the quality of documentation on the use and performance of statistical methods. A suggestion here is that journals not only demand that articles fulfill the criteria within the STROBE statement, but that they include additional criteria to decrease the risk of incorrect conclusions being drawn.

  • 21.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The burden of celiac disease and the value of having it diagnosed2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Celiac disease is a chronic disease characterized by intolerance to gluten. It is considered a public health problem affecting about 1% of Western populations, but, with most cases still undiagnosed. A glutenfree diet is the only effective treatment for the disease.

    Objectives: To investigate the burden of celiac disease and the value of having it diagnosed. Additionally, the implications for a potential future celiac disease mass screening are discussed.

    Methods: A questionnaire was sent during 2009 to 1,560 randomly selected adult members of the Swedish Society for Coeliacs, in equal-sized age- and sex strata, and 1,031 (66%) responded. Members were asked about symptoms, health-related quality of life as measured by EQ-5D, and health care consumption during the year prior to diagnosis and during the past year. They were also asked about the delay in having their celiac disease diagnosed and the appearance of other immune-mediated diseases. A school-based celiac disease screening of 12-year-olds was performed during 2005-2006. After blood sampling the 7,567 participating children and their parents received a questionnaire including the EQ-5D instrument in order to measure the child’s health-related quality of life. Comparisons were made between children with screening-detected celiac disease, those with previously diagnosed disease and those without the disease. Parents were asked about their willingness to pay for a celiac disease screening of their child, which was compared with the actual cost of a screening.

    Results: Adult celiac disease patients had a poorer health-related quality of life than the general population, and a high prevalence of symptoms before celiac disease diagnosis. The mean delay from symptoms to diagnosis was 9.7 years. After initiated treatment with a gluten-free diet, health-related quality of life was improved to the level of the general population, and symptom relief and reduction in health care consumption were also reported. For children, health-related quality of life was similar across groups. The average cost per child for a screening was 47 EUR. Parents’ mean willingness to pay for a screening was 79 EUR, median 10 EUR.

    Conclusion: The delay in celiac disease diagnosis is long, and treatment with a gluten-free diet substantially improved health for clinically detected cases. For screening-detected celiac disease the health benefits are still uncertain. A mass screening might nevertheless be justified to avoid the burden of living with undiagnosed disease, and parents’ willingness to pay indicates that performing it in childhood might be economically motivated. However, as both the cost-effectiveness of a screening and the short- and long term health benefits for screening-detected cases have not yet been sufficiently investigated, it is too early to make a recommendation for a celiac disease mass screening.

  • 22.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    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 Global Health.
    Carlsson, Annelie
    Danielsson, Lars
    Högberg, Lotta
    Karlsson, Eva
    Löfgren, Curt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Parents' willingness to pay for coeliac disease screening of their child2011In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 52, no 4, p. 452-459Article in journal (Refereed)
    Abstract [en]

    Swedish parents' WTP for school-based CD screening of their child was higher than the average cost per child; however, only a minority of the parents were willing to pay that amount.

  • 23.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nordyke, Katrina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences.
    Carlsson, A.
    Hammarroth, S.
    Högberg, L.
    Stenhammar, L.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The Cost-Effectiveness of a Screening for Celiac Disease2015In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 44, p. 250-250Article in journal (Other academic)
  • 24.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Is unemployment in young adulthood related to self-rated health later in life?: Results from the Northern Swedish cohort2017In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 17, article id 529Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Many studies have reported that unemployment has a negative effect on health. However, little is known about the long-term effect for those who become unemployed when they are young adults. Our aim was to examine how unemployment is related to long-term self-rated health among 30 year olds, with an emphasis on how health differs in relation to education level, marital status, previous health, occupation, and gender.

    METHODS: In the Northern Swedish Cohort, 1083 teenagers (~16 years old) were originally invited in 1981. Of these, 1001 participated in the follow-up surveys in 1995 and 2007. In our study, we included participants with either self-reported unemployment or activity in the labor force during the previous three years in the 1995 follow-up so long as they had no self-reported unemployment between the follow-up surveys. Labor market status was studied in relation to self-reported health in the 2007 follow-up. Information from the 1995 follow-up for education level, marital status, self-reported health, and occupation were part of the statistical analyses. Analyses were stratified for these variables and for gender. Analyses were performed with logistic regression, G-computation, and a method based on propensity scores.

    RESULTS: Poor self-rated health in 2007 was reported among 43 of the 98 (44%) unemployed and 159 (30%) of the 522 employed subjects. Unemployment had a long-term negative effect on health (odds ratio with logistic regression 1.74 and absolute difference estimates of 0.11 (G-computation) and 0.10 (propensity score method)). At the group level, the most pronounced effects on health were seen in those with upper secondary school as their highest education level, those who were single, low-level white-collar workers, and women.

    CONCLUSIONS: Even among those becoming unemployed during young adulthood, unemployment is related to a negative long-term health effect. However, the effect varies among different groups of individuals. Increased emphasis on understanding the groups for whom unemployment is most strongly related to ill health is important for future research so that efforts can be put towards those with the biggest need. Still, our results can be used as the basis for deciding which groups should be prioritized for labor-market interventions.

  • 25.
    Norström, Fredrik
    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 Global Health.
    Sandstrom, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nordyke, Katrina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Delay to celiac disease diagnosis and its implications for health-related quality of life2011In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 11, no 1, p. 118-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To determine how the delay in diagnosing celiac disease (CD) has developed during recent decades and how this affects the burden of disease in terms of health-related quality of life (HRQoL), and also to consider differences with respect to sex and age.

    METHODS: In collaboration with the Swedish Society for Coeliacs, a questionnaire was sent to 1,560 randomly selected members, divided in equal-sized age- and sex strata, and 1,031 (66%) responded. HRQoL was measured with the EQ-5D descriptive system and was then translated to quality-adjusted life year (QALY) scores. A general population survey was used as comparison.

    RESULTS: The mean delay to diagnosis from the first symptoms was 9.7 years, and from the first doctor visit it was 5.8 years. The delay has been reduced over time for some age groups, but is still quite long. The mean QALY score during the year prior to initiated treatment was 0.66; it improved after diagnosis and treatment to 0.86, and was then better than that of a general population (0.79).

    CONCLUSIONS: The delay from first symptoms to CD diagnosis is unacceptably long for many persons. Untreated CD results in poor HRQoL, which improves to the level of the general population if diagnosed and treated. By shortening the diagnostic delay it is possible to reduce this unnecessary burden of disease. Increased awareness of CD as a common health problem is needed, and active case finding should be intensified. Mass screening for CD might be an option in the future.

  • 26.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandström, Olof
    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.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A gluten-free diet effectively reduces symptoms and health care consumption in a Swedish celiac disease population2012In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 12, no 1, p. 125-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A gluten-free diet is the only available treatment for celiac disease. Our aim was to investigate the effect of a gluten-free diet on celiac disease related symptoms, health care consumption, and the risk of developing associated immune-mediated diseases.

    METHODS: A questionnaire was sent to 1,560 randomly selected members of the Swedish Society for Coeliacs, divided into equal-sized age- and sex strata; 1,031 (66%) responded. Self-reported symptoms, health care consumption (measured by health care visits and hospitalization days), and missed working days were reported both for the year prior to diagnosis (normal diet) and the year prior to receiving the questionnaire while undergoing treatment with a gluten-free diet. Associated immune-mediated diseases (diabetes mellitus type 1, rheumatic disease, thyroid disease, vitiligo, alopecia areata and inflammatory bowel disease) were self-reported including the year of diagnosis.

    RESULTS: All investigated symptoms except joint pain improved after diagnosis and initiated gluten-free diet. Both health care consumption and missed working days decreased. Associated immune-mediated diseases were diagnosed equally often before and after celiac disease diagnosis.

    CONCLUSIONS: Initiated treatment with a gluten-free diet improves the situation for celiac disease patients in terms of reduced symptoms and health care consumption. An earlier celiac disease diagnosis is therefore of great importance.

  • 27.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A gluten-free diet effectively reduces symptoms and health care consumption in a Swedish celiac disease populationManuscript (preprint) (Other academic)
  • 28.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    van der Pals, Maria
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Hammarroth, Solveig
    Högberg, Lotta
    Isaksson, Anders
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Carlsson, Annelie
    Impact of Thyroid Autoimmunity on Thyroid Function in 12-year-old Children With Celiac Disease2018In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 67, no 1, p. 64-68Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Celiac disease (CD) is associated with thyroid autoimmunity and other autoimmune diseases. However, data are lacking regarding the relationship between thyroid autoimmunity and thyroid function, especially in regard to CD. Our aim was to investigate the impact of thyroid autoimmunity on thyroid function in 12-year-old children with CD compared to their healthy peers.

    METHODS: A case-referent study was conducted as part of a CD screening of 12-year-olds. Our study included 335 children with CD and 1,695 randomly selected referents. Thyroid autoimmunity was assessed with antibodies against thyroid peroxidase (TPOAb). Thyroid function was assessed with thyroid stimulating hormone and free thyroxine.

    RESULTS: TPOAb positivity significantly increased the risk of developing hypothyroidism in all children. The odds ratios (with 95% confidence intervals) were: 5.3 (2.7-11) in healthy 12-year-olds, 10 (3.2-32) in screening-detected CD cases, 19 (2.6-135) in previously diagnosed CD cases, and 12 (4.4-32) in all CD cases together. Among children with TPOAb positivity, hypothyroidism was significantly more common (odds ratio 3.1; 95% CI 1.03-9.6) in children with CD (10/19) than in children without CD (12/46).

    CONCLUSIONS: The risk of thyroid dysfunction due to thyroid autoimmunity is larger for those with CD than their healthy peers. Our study indicate that a gluten-free diet does not reduce the risk of thyroid dysfunction. Further studies are required for improved understanding of the role of the gluten-free diet for the risk of autoimmune diseases in children with CD.

  • 29.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Virtanen, Pekka
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarström, Anne
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Gustafsson, Per E.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Social medicine.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    How does unemployment affect self-assessed health?: A systematic review focusing on subgroup effects2014In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, no 1, article id 1310Article, review/survey (Refereed)
    Abstract [en]

    BACKGROUND: Almost all studies on the effect on health from unemployment have concluded that unemployment is bad for your health. However, only a few review articles have dealt with this relation in recent years, and none of them have focused on the analysis of subgroups such as age, gender, and marital status. The objective of our article is to review how unemployment relates to self-assessed health with a focus on its effect on subgroups.

    METHODS: A search was performed in Web of Science to find articles that measured the effect on health from unemployment. The selection of articles was limited to those written in English, consisting of original data, and published in 2003 or later. Our definition of health was restricted to self-assessed health. Mortality- and morbidity-related measurements were therefore not included in our analysis. For the 41 articles included, information about health measurements, employment status definitions, other factors included in the statistical analysis, study design (including study population), and statistical method were collected with the aim of analysing the results on both the population and factor level.

    RESULTS: Most of the studies in our review showed a negative effect on health from unemployment on a population basis. Results at the factor levels were most common for gender (25 articles), age (11 articles), geographic location (8 articles), and education level (5 articles). The analysis showed that there was a health effect for gender, age, education level, household income, and geographic location. However, this effect differed between studies and no clear pattern on who benefits or suffers more among these groups could be determined. The result instead seemed to depend on the study context. The only clear patterns of association found were for socioeconomic status (manual workers suffer more), reason for unemployment (being unemployed due to health reasons is worse), and social network (a strong network is beneficial).

    CONCLUSIONS: Unemployment affects groups of individuals differently. We believe that a greater effort should be spent on specific groups of individuals, such as men or women, instead of the population as a whole when analysing the effect of unemployment on health.

  • 30.
    Norström, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Waenerlund, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nygren, Rebecka
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Sahlén, Klas-Göran
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Brydsten, Anna
    Stockholms universitet.
    Does unemployment contribute to poorer health-related quality of life among Swedish adults?2019In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 19, article id 457Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies have shown that unemployment has negative impacts on various aspects of health. However, little is known about the effect of unemployment on health-related quality of life. Our aim was to examine how unemployment impacts upon health-related quality of life among Swedish adults, and to investigate these effects on population subgroups defined by education level, marital status, previous health, and gender.

    METHODS: As part of a cross-sectional study, a questionnaire was sent to 2500 randomly selected individuals aged 20 to 64 years living in Sweden in 2016. The questionnaire included the EuroQol 5 dimensions (EQ-5D) instrument and was answered by 967 individuals (39%). Quality-adjusted life year (QALY) scores were derived from the EQ-5D responses. Of the respondents, 113 were unemployed and 724 were employed. We used inverse probability-weighted propensity scores in our analyses to estimate a risk difference. Gender, age, education level, marital status, and previous health were used as covariates in our analyses.

    RESULTS: There was a statistically significant lower QALY score by 0.096 points for the unemployed compared to the employed. There were also statistically significant more problems due to unemployment for usual activities (6.6% more), anxiety/depression (23.6% more), and EQ-5D's Visual Analogue Scale (7.5 point lower score). Grouped analyses indicated a larger negative health effect from becoming unemployed for men, those who are married, and young individuals.

    CONCLUSIONS: In our study, we show that the health deterioration from unemployment is likely to be large, as our estimated effect implies an almost 10% worse health (in absolute terms) from being unemployed compared to being employed. This further highlights that unemployment is a public health problem that needs more focus. Our study also raises further demands for determining for whom unemployment has the most negative effects and thus suggesting groups of individuals who are in greatest need for labor market measures.

  • 31. Ramji, Rathi
    et al.
    Arnetz, Judy
    Nilsson, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jamil, Hikmet
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Maziak, Wasim
    Wiklund, Ywonne
    Arnetz, Bengt
    Determinants of waterpipe use amongst adolescents in Northern Sweden: a survey of use pattern, risk perception, and environmental factors2015In: BMC Research Notes, ISSN 1756-0500, E-ISSN 1756-0500, Vol. 8, article id 441Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Determinants of waterpipe use in adolescents are believed to differ from those for other tobacco products, but there is a lack of studies of possible social, cultural, or psychological aspects of waterpipe use in this population. This study applied a socioecological model to explore waterpipe use, and its relationship to other tobacco use in Swedish adolescents.

    METHODS: A total of 106 adolescents who attended an urban high-school in northern Sweden responded to an anonymous questionnaire. Prevalence rates for waterpipe use were examined in relation to socio-demographics, peer pressure, sensation seeking behavior, harm perception, environmental factors, and depression.

    RESULTS: Thirty-three percent reported ever having smoked waterpipe (ever use), with 30 % having done so during the last 30 days (current use). Among waterpipe ever users, 60 % had ever smoked cigarettes in comparison to 32 % of non-waterpipe smokers (95 % confidence interval 1.4-7.9). The odds of having ever smoked waterpipe were three times higher among male high school seniors as well as students with lower grades. Waterpipe ever users had three times higher odds of having higher levels of sensation-seeking (95 % confidence interval 1.2-9.5) and scored high on the depression scales (95 % confidence interval 1.6-6.8) than non-users. The odds of waterpipe ever use were four times higher for those who perceived waterpipe products to have pleasant smell compared to cigarettes (95 % confidence interval 1.7-9.8). Waterpipe ever users were twice as likely to have seen waterpipe use on television compared to non-users (95 % confidence interval 1.1-5.7). The odds of having friends who smoked regularly was eight times higher for waterpipe ever users than non-users (95 % confidence interval 2.1-31.2).

    CONCLUSION: The current study reports a high use of waterpipe in a select group of students in northern Sweden. The study adds the importance of looking at socioecological determinants of use, including peer pressure and exposure to media marketing, as well as mental health among users.

  • 32. Ranneby, Bo
    et al.
    Norström, Fredrik
    A probabilistic classifier of remotely sensed data - a simulation studyManuscript (preprint) (Other academic)
  • 33.
    Rydén, Petra
    et al.
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Kautto, Ethel
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Olsson, Cecilia
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Högberg, L
    Department of Clinical and Molecular Medicine, Linköping University.
    Carlsson, A
    Department of Pediatrics, Lund University.
    Hagfors, Linda
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Hörnell, Agneta
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    What happens with the healthiness of the diet among Swedish adolescent  boys and girls when a gluten-free diet is required?Manuscript (preprint) (Other academic)
    Abstract [en]

    Objectives To explore how diagnosis of celiac disease (CD) in early adolescence affects overall food intake and healthiness of the diet in comparison with age- and sex matched controls and children with CD diagnosed in early childhood.

    Methods This is a longitudinal dietary sub-study of a school-based CD-screening of 12-year-olds (ETICS - Exploring the Iceberg of Coeliacs in Sweden), a part of the PreventCD project. The dietary study was conducted in 2005-2008 and included the following groups resulting from the screening: I) screening-detected CD cases (n=80), II) previously diagnosed CD cases (n=28), and III) two samples of age- and sex matched non-CD children (admission, n=619; follow-up, n=447). All CD cases completed two food-frequency-and-amount-questionnaires (FFQ), covering the previous four weeks; one at admission and one at a follow-up 18-24 months later. The screening-detected CD cases completed the first FFQ before a gluten free diet was initiated. The non-CD children consisted of a cross-sectional sample at each time point, and thus only completed one FFQ each (i.e. either at admission or follow-up). The Goldberg cut-off method was used to validate reported energy intake. The food choices at admission and follow-up were compared among the three groups, and the healthiness of the diet evaluated using two Swedish dietary indexes.

    Results and Conclusion Intakes of most food groups were similar at baseline. The adolescents diagnosed with CD did only minor changes in their overall food choices. Visible changes were reductions within food groups where gluten-free alternatives are not readily available, such as pastries and pizza. In contrast, total intake of bread and pasta did not change. All three groups scored fairly low on the dietary indexes at both time points, and there is an obvious need to improve the healthiness of the adolescent diet, whether CD is present or not.

  • 34.
    Stewart Williams, Jennifer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    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. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Disability and ageing in China and India – decomposing the effects of gender and residence: Results from the WHO study on global ageing and adult health (SAGE)2017In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 17, article id 197Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: China and India are the world's two most populous countries. Although their populations are growing in number and life expectancies are extending they have different trajectories of economic growth, epidemiological transition and social change. Cross-country comparisons can allow national and global insights and provide evidence for policy and decision-making. The aim of this study is to measure and compare disability in men and women, and in urban and rural dwellers in China and India, and assess the extent to which social and other factors contribute to the inequalities.

    METHODS: National samples of adults aged 50 to 79 years in China (n = 11,694) and India (n = 6187) from the World Health Organization (WHO) longitudinal Study on global AGEing and adult health (SAGE) Wave 1 were analysed. Stratified multiple linear regressions were undertaken to assess disability differences by sex and residence, controlling for other biological and socioeconomic determinants of disability. Oaxaca-Blinder decomposition partitioned the two-group inequalities into explained and unexplained components.

    RESULTS: In both countries women and rural residents reported more disability. In India, the gender inequality is attributed to the distribution of the determinants (employment, education and chronic conditions) but in China about half the inequality is attributed to the same. In India, more than half of the urban rural inequality is attributed to the distribution of the determinants (education, household wealth) compared with under 20% in China.

    CONCLUSIONS: Education and employment were important drivers of these measured inequalities. Overall inequalities in disability among older adults in China and India were shaped by gender and residence, suggesting the need for policies that target women and rural residents. There is a need for further research, using both qualitative and quantitative methods, to question and challenge entrenched practices and institutions and grasp the implications of global economic and social changes that are impacting on population health and ageing in China and India.

  • 35. van der Pals, Maria
    et al.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Högberg, Lotta
    Svensson, Johan
    Carlsson, Annelie
    Prevalence of thyroid autoimmunity in children with celiac disease compared to healthy 12-year olds.2014In: Autoimmune Diseases, ISSN 2090-0422, E-ISSN 2090-0430, Vol. 2014, p. 417356-Article in journal (Refereed)
    Abstract [en]

    Objectives. Studies have suggested a correlation between untreated celiac disease and risk for other autoimmune diseases. We investigated the prevalence of thyroid autoimmunity in 12-year-old children (i) with symptomatic celiac disease diagnosed and treated with a gluten-free diet, (ii) with screening-detected untreated celiac disease, and (iii) without celiac disease. Methods. Blood samples from 12632 children were collected. All celiac disease cases, previously diagnosed and newly screening-detected, were identified. Per case, 4 referents were matched. Blood samples were analyzed for autoantibodies against thyroid peroxidase (TPOAb). The cut-off value for TPO positivity was set to 100 U/mL. Results. Altogether, 335 celiac disease cases were found. In the entire celiac disease group, 7.2% (24/335) had elevated titers of TPOAb compared to 2.8% (48/1695) of the referents. Among the previously diagnosed celiac disease cases, 7.5% (7/93, OR 2.8, 95% CI 1.2-6.4) was TPOAb positive and among screening-detected cases, 7.0% (17/242, OR 2.6, 95% CI 1.5-4.6) was TPOAb positive. Conclusion. Children with celiac disease showed a higher prevalence of thyroid autoimmunity. We could not confirm the hypothesis that untreated celiac disease is associated with increased risk of developing thyroid autoimmunity. Early initiation of celiac disease treatment might not lower the risk for other autoimmune diseases.

  • 36. van der Pals, Maria
    et al.
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarroth, Solveig
    Högberg, Lotta
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Carlsson, Annelie
    Body mass index is not a reliable tool in predicting celiac disease in children2014In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 14, p. 165-Article in journal (Refereed)
    Abstract [en]

    Background: Untreated celiac disease is traditionally believed to be associated with malabsorption and underweight. However, studies describing body mass index (BMI) in individuals at the time of diagnosis have shown contradictory results. We investigated the differences in weight, height, and BMI in 12- year-old children with screening-detected celiac disease compared to their healthy peers.

    Methods: In a population-based screening study of 12,632 12-year-old children, blood samples were analyzed for markers of celiac disease. Children with elevated markers were referred for a small bowel biopsy. Weight and height were measured in 239 out of 242 children with screening-detected celiac disease (57.3% girls) and in 12,227 children without celiac disease (48.5% girls). BMI was categorized according to the International Obesity Task Force. Age- and sex-specific cut-off points for underweight, normal weight, and overweight were used.

    Results: Children with celiac disease weighed less and were shorter than their peers (median weight 45.2 kg, interquartile range (IQR) 40.2-52.2 kg vs. 47.0 kg, IQR 41.1-54.4 kg, respectively, p = 0.01; median height 156.5 cm, IQR 151.0-162.0 cm vs. 157.5 cm, IQR 152.0-163.0 cm, respectively, p = 0.04). In comparing those with celiac disease to their healthy peers, 4.2% vs. 5.2% were underweight, 82.0% vs. 72.8% were normal weight, and 13.8% vs. 21.9% were overweight, respectively. There was no association between being underweight and the risk of having undiagnosed celiac disease (Odds ratio (OR) 1.3, 95% CI 0.7-2.4), but the risk was significantly lower among overweight children (OR 0.56, 95% CI 0.4-0.8). Median BMI was slightly lower among the children with screening-detected celiac disease compared to their healthy peers (18.6 kg/m(2), IQR 17.1-19.8 kg/m(2) vs. 18.8 kg/m(2), IQR 17.2-21.1 kg/m(2), respectively, p = 0.05), but most of the celiac disease cases had a normal BMI.

    Conclusions: At a population level, children with celiac disease weigh less, are shorter, and have a lower BMI compared to their peers without celiac disease, and this emphasizes the importance of early recognition and treatment of the condition. However, at an individual level, growth parameters are not reliable in establishing the diagnosis.

  • 37.
    Wagner, Ryan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bertram, MY
    Tollman, Stephen
    Forsgren, Lars
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Hofman, Karen
    Newton, CR
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A community health workers to improve adherence to anti-epileptic drugs in rural sub-Saharan Africa: Is it cost-effective?Article in journal (Refereed)
  • 38. Webb, Charlotta
    et al.
    Halvarsson, Britta
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Carlsson, Annelie
    Danielsson, Lars
    Högberg, Lotta
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Karlsson, Eva
    Stenhammar, Lars
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Accuracy in Celiac Disease Diagnostics by Controlling the Small-bowel Biopsy Process.2011In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 52, no 5, p. 549-553Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES:: In a Swedish celiac disease screening study (Exploring the Iceberg of Celiacs in Sweden), we systematically reviewed the clinical diagnostic procedures with the aim to evaluate the diagnostic accuracy and to take advantage of lessons learned for improving diagnostic routines. MATERIALS AND METHODS:: A school-based celiac disease screening study involving 5 Swedish centers, with 10,041 invited 12-year-olds with 7567 consenting participation. All 192 children with elevated serological markers were recommended to undergo small-bowel biopsy, performed and evaluated according to local clinical routines. All of the mucosal specimens were reevaluated by 1 and, when needed, 2 expert pathologists to reach diagnostic consensus. RESULTS:: Small-bowel biopsies were performed in 184 children: 130 by endoscopy and 54 by suction capsule. Endoscopic biopsies were inconclusive in 0.6%, compared with 7.4% of biopsies by suction capsule. A patchy enteropathy was found in 9.1%. Reevaluation by the expert pathologist resulted in 6 additional cases with celiac disease and 1 cleared. Sixteen children with normal or inconclusive biopsies, 4 after endoscopy, and 12 after suction capsule were endoscopically rebiopsied, resulting in another 8 cases. The celiac disease prevalence of 30 of 1000 (95% confidence interval 26-34) was not statistically different from that previously reported. CONCLUSIONS:: The present review revealed the importance of controlling each step of the diagnostic procedure. Several cases would have been missed by relying only on local routines. To improve the quality of childhood celiac disease diagnostics, we recommend multiple endoscopic biopsies from both proximal and distal duodenum and standardized evaluation by a pathologist with good knowledge of celiac disease.

  • 39. Webb, Charlotta
    et al.
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hammarroth, Solveig
    Högberg, Lotta
    Lagerqvist, Carina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Stenhammar, Lars
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Carlsson, Annelie
    High adherence to a gluten-free diet in adolescents with screening-detected celiac disease2015In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 60, no 1, p. 54-59Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To evaluate the gluten-free diet (GFD) adherenceafter one year of follow-up in children with screening-detected celiac disease (CD) in a general population. METHODS: A total of 18,325 12 year olds were invited to participate in apopulation-based CD screening (ETICS- Exploring the Iceberg of Celiacs in Sweden), of whom 13,279 participated. In 240 children, CD was detected through elevated anti-tissue transglutaminase antibodies 2 (TG2-IgA) and verified by a small-intestinal biopsy. This sub-study included the 210 children with TG2-IgAevaluated both at the initialbiopsy occasion and at the one-year follow-up. GFD adherence was evaluated by a combination of TG2-IgA measurements and self-reported adherence (n = 193). RESULTS: After one year, 83% (179/210) had normalizedTG2-IgA levels (<5U/mL). Among those who had >50 U/mL at diagnosis,25% (16/63) still had elevated TG2-IgA but for the majority their initial values were more than halved. Most reported a high level ofGFD adherence ('always' 75%(158/193) and 'often' 14%(30/193)), and 75% (145/193) reported always adhereingcombined with normalized TG2-IgA. Although reporting that they were always adherent, 13 (6.7%) had not yet normalized their TG2-IgA levels completely, however, a majority of these initially had the highestTG2-IgA levels. CONCLUSIONS: GFD adherence is high in adolescents with CD detected by screening of the general population of Swedish 12yearolds. Almost all had normalized serology and reported GFD adherenceat the one-year follow-up. However, a few adolescents whoreported GFD adherence still had elevated TG2-IgA levelssuggesting more severe disease and/or non-adherence.

  • 40. Webb, Charlotta
    et al.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Myléus, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ivarsson, Anneli
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Halvarsson, Britta
    Högberg, Lotta
    Lagerqvist, Carina
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Rosén, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sandström, Olof
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenhammar, Lars
    Carlsson, Annelie
    Celiac disease can be predicted by high levels of anti-tissue transglutaminase antibodies in population-based screening2015In: Journal of Pediatric Gastroenterology and Nutrition - JPGN, ISSN 0277-2116, E-ISSN 1536-4801, Vol. 60, no 6, p. 787-791Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To evaluate any potential correlation between anti-tissue transglutaminase antibodies of type immunoglobulin A (tTG-IgA) and the degree of gluten induced enteropathy in children participating in a screening study for celiac disease (CD) and to assess to what extent the revised ESPGHAN (European Society for Paediatric Gastroenterology, Hepatology and Nutrition) guidelines cover this group of patients.

    METHODS: This is a sub-study of a cross-sectional CD screening study, ETICS (Exploring the Iceberg of Celiacs in Sweden), a two-phased study performed during 2005-2006 and 2009-2010. The 13,279 participating children had a blood test obtained and those with positive tTG-IgA were recommended a small intestinal biopsy. The tTG-IgA levels at the time of biopsy were compared with the assessment of the biopsy.

    RESULTS: There were 267 children included, of whom 230 were diagnosed with CD. Out of all children, 67 children had low tTG-IgA levels (<5 U/mL), whereof 55% had Marsh 3 lesions. All children with tTG-IgA levels exceeding 10 times the upper limit of normal values of 5 U/mL, i.e. 50 U/mL, were diagnosed with CD. Lowering the cut-off to 3 U/mL, all but one child with 30 U/mL got CD diagnosis.

    CONCLUSION: By adapting the revised ESPGHAN criteria, biopsies could have been omitted in a fourth of all cases. Our results indicate, that the criteria might be useful even on screened children. Further studies are needed to confirm whether the 2012 ESPGHAN guidelines should be revised to also apply to the populations being screened.

  • 41.
    Zingmark, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR). Community Care Administration, Municipality of Östersund, 83182 Östersund, Sweden.
    Nilsson, Ingeborg
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy. Umeå University, Faculty of Social Sciences, Centre for Demographic and Ageing Research (CEDAR).
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sahlén, Klas-Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Nursing.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cost effectiveness of an intervention focused on reducing bathing disability2017In: European Journal of Ageing, ISSN 1613-9372, E-ISSN 1613-9380, Vol. 14, no 3, p. 233-241Article in journal (Refereed)
    Abstract [en]

    The onset of bathing disability among older people is critical for a decline in functioning and has implications for both the individuals’ quality of life and societal costs. The aim of this study was to evaluate longterm cost effectiveness of an intervention targeting bathing disability among older people. For hypothetical cohorts of community-dwelling older people with bathing disability, transitions between states of dependency and death were modelled over 8 years including societal costs. A five-state Markov model based on states of dependency was used to evaluate Quality-adjusted life years (QALYs) and costs from a societal perspective. An intervention group was compared with a no intervention control group. The intervention focused on promoting safe and independent performance of bathing-related tasks. The intervention effect, based on previously published trials, was applied in the model as a 1.4 increased probability of recovery during the first year. Over the full follow-up period, the intervention resulted in QALY gains and reduced societal cost. After 8 years, the intervention resulted in 0.052 QALYs gained and reduced societal costs by €2410 per person. In comparison to the intervention cost, the intervention effect was a more important factor for the magnitude of QALY gains and long-term societal costs. The intervention cost had only minor impact on societal costs. The conclusion was that an intervention targeting bathing disability among older people presents a cost-effective use of resources and leads to both QALY gains and reduced societal costs over 8 years.

  • 42.
    Zingmark, Magnus
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Health and Social Care Administration, Municipality of Östersund, 83182 Östersund, Sweden.
    Norström, Fredrik
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Dahlin-Ivanoff, Synneve
    Göteborgs universitet.
    Gustafsson, Susanne
    Göteborgs universitet.
    Modelling long-term cost-effectiveness of health promotion for community-dwelling older people2019In: European Journal of Ageing, ISSN 1613-9372, E-ISSN 1613-9380Article in journal (Refereed)
    Abstract [en]

    The effectiveness of health promotion for community-dwelling older people is well documented; however, there is a general lack of health economic evaluations. The aim of the present study was to evaluate long-term cost-effectiveness over 4 years of two health promoting interventions: senior meetings and a preventive home visit, for community-dwelling older people in relation to no intervention. We applied a Markov model including five states defined in relation to level of dependency of home help and place of residency. The model included transitions between dependency states, scores for quality of life and societal costs for each state, intervention costs and intervention effects for two formats of health promoting interventions. For each intervention and a no-intervention control group, we calculated the accumulated quality-adjusted life years (QALYs) and societal costs over 4 years. Sensitivity analyses included higher intervention costs, lower intervention effects and additional intervention costs and effects related to booster sessions. The results of all analyses indicated that health promotion implemented for community-dwelling older people in the format of senior meetings or a preventive home visit was cost-effective. Both interventions lead to QALY gains and reduce societal costs at any follow-up over 4 years, and thus, resources can be used to implement other interventions. The most important factor for the magnitude of QALY gains and cost savings was the intervention effect. Yearly booster sessions implemented for those persons who maintained their level of functioning extended the intervention effects adding additional QALYs and further reducing societal costs.

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