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  • 1.
    Al-Alawi, Kamila
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Department of Training and Studies, Royal Hospital, Ministry of Health, Muscat, Oman.
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Al Mandhari, Ahmed
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Are the resources adoptive for conducting team-based diabetes management clinics?: An explorative study at primary health care centers in Muscat, Oman2018In: Primary Health Care Research and Development, ISSN 1463-4236, E-ISSN 1477-1128, Vol. 20, p. 1-28, article id E3Article in journal (Refereed)
    Abstract [en]

    AIM: The aim of this study is to explore the perceptions among primary health center staff concerning competencies, values, skills and resources related to team-based diabetes management and to describe the availability of needed resources for team-based approaches.

    BACKGROUND: The diabetes epidemic challenges services available at primary health care centers in the Middle East. Therefore, there is a demand for evaluation of the available resources and team-based diabetes management in relation to the National Diabetes Management Guidelines.

    METHOD: A cross-sectional study was conducted with 26 public primary health care centers in Muscat, the capital of Oman. Data were collected from manual and electronic resources as well as a questionnaire that was distributed to the physician-in-charge and diabetes management team members.

    FINDINGS: The study revealed significant differences between professional groups regarding how they perceived their own competencies, values and skills as well as available resources related to team-based diabetes management. The perceived competencies were high among all professions. The perceived team-related values and skills were also generally high but with overall lower recordings among the nurses. This pattern, along with the fact that very few nurses have specialized qualifications, is a barrier to providing team-based diabetes management. Participants indicated that there were sufficient laboratory resources; however, reported that pharmacological, technical and human resources were lacking. Further work should be done at public primary diabetes management clinics in order to fully implement team-based diabetes management.

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  • 2.
    Andersson, Elin M
    et al.
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Reactions for actions? Trust in protective behaviors and safeguarding measures in the early phase of the Covid-19 pandemic in Sweden2023In: Preventive Medicine Reports, E-ISSN 2211-3355, Vol. 32, article id 102133Article in journal (Refereed)
    Abstract [en]

    To minimize the spread of Covid-19, changing every-day behavior has been key. Trust in the effectiveness of individual protective measures (response efficacy) and confidence in collective safeguarding measures (strategy efficacy), offers an incitement for acting adequately. Efficacy beliefs of protective measures might be especially relevant to study in the Swedish context, since Sweden, in contrast to countries facing hard lock-downs, launched safeguarding measures based on individual responsibility and voluntary actions. We aimed to assess associations between on the one hand, response efficacy and strategy efficacy, and on the other hand, propensity for behavior change and support of protective measures. Furthermore, to assess associations between the efficacy beliefs and comprehension of and confidence in information about the virus, prosocial beliefs and worry of Covid-19. Reactions were assessed in a Swedish sample close in time to experiences via the SEMA3 app from March 25th to May 17th 2020. Study participants had replied to questions on strategy efficacy (n = 175) or response efficacy (n = 157) and 146 participants had replied to both. High response efficacy was associated with propensity for behavior change, support of protective measures and confidence in Covid-19 information. Low strategy efficacy was associated with lower comprehension of and confidence in information about Covid-19. The results suggest that strengthening efficacy beliefs can be a way to promote protective behaviors. Furthermore, the result underscores the importance of information being easy to understand and trustworthy. Finding ways to increase public understanding of the effectiveness of protective measures, including vaccination, seems crucial in pandemic times.

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  • 3. Araghi, Marzieh
    et al.
    Galanti, Maria Rosaria
    Lundberg, Michael
    Lager, Anton
    Engström, Gunnar
    Alfredsson, Lars
    Knutsson, Anders
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sund, Malin
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Trolle Lagerros, Ylva
    Bellocco, Rino
    Pedersen, Nancy L.
    Östergren, Per-Olof
    Magnusson, Cecilia
    Use of moist oral snuff (snus) and pancreatic cancer: pooled analysis of nine prospective observational studies2017In: International Journal of Cancer, ISSN 0020-7136, E-ISSN 1097-0215, Vol. 141, no 4, p. 687-693Article in journal (Refereed)
    Abstract [en]

    While smoking is a well-established risk factor for pancreatic cancer, the effect of smokeless tobacco is less well understood. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between Swedish snus use and the risk of pancreatic cancer. A total of 424,152 male participants from nine cohort studies were followed up for risk of pancreatic cancer through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors. During 9,276,054 person-years of observation, 1,447 men developed pancreatic cancer. Compared to never-snus use, current snus use was not associated with risk of pancreatic cancer (HR 0.96, 95% CI 0.83–1.11) after adjustment for smoking. Swedish snus use does not appear to be implicated in the development of pancreatic cancer in men. Tobacco smoke constituents other than nicotine or its metabolites may account for the relationship between smoking and pancreatic cancer.

  • 4. Araghi, Marzieh
    et al.
    Galanti, Maria Rosaria
    Lundberg, Michael
    Liu, Zhiwei
    Ye, Weimin
    Lager, Anton
    Engström, Gunnar
    Alfredsson, Lars
    Knutsson, Anders
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lagerros, Ylva Trolle
    Bellocco, Rino
    Pedersen, Nancy L.
    Östergren, Per-Olof
    Magnusson, Cecilia
    No association between moist oral snuff (snus) use and oral cancer: pooled analysis of nine prospective observational studies2021In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 49, no 8, p. 833-840Article in journal (Refereed)
    Abstract [en]

    Aims: Worldwide, smokeless-tobacco use is a major risk factor for oral cancer. Evidence regarding the particular association between Swedish snus use and oral cancer is, however, less clear. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between snus use and oral cancer.

    Methods: A total of 418,369 male participants from nine cohort studies were followed up for oral cancer incidence through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors.

    Results: During 9,201,647 person-years of observation, 628 men developed oral cancer. Compared to never-snus use, ever-snus use was not associated with oral cancer (adjusted HR 0.90, 95% CI: 0.74, 1.09). There were no clear trends in risk with duration or intensity of snus use, although lower intensity use (<= 4 cans/week) was associated with a reduced risk (HR 0.65, 95% CI: 0.45, 0.94). Snus use was not associated with oral cancer among never smokers (HR 0.87, 95% CI: 0.57, 1.32).

    Conclusions: Swedish snus use does not appear to be implicated in the development of oral cancer in men.

  • 5. Araghi, Marzieh
    et al.
    Galanti, Maria Rosaria
    Lundberg, Michael
    Liu, Zhiwei
    Ye, Weimin
    Lager, Anton
    Engström, Gunnar
    Manjer, Jonas
    Alfredsson, Lars
    Knutsson, Anders
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Palmqvist, Richard
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Gylling, Björn
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Pathology.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lagerros, Ylva Trolle
    Bellocco, Rino
    Pedersen, Nancy L
    Östergren, Per-Olof
    Magnusson, Cecilia
    Smokeless tobacco (snus) use and colorectal cancer incidence and survival: Results from nine pooled cohorts2017In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 45, no 8, p. 741-748Article in journal (Refereed)
    Abstract [en]

    AIMS: Although smoking is considered to be an established risk factor for colorectal cancer, the current evidence on the association between smokeless tobacco and colorectal cancer is scant and inconclusive. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess this association.

    METHODS: A total of 417,872 male participants from nine cohort studies across Sweden were followed up for incidence of colorectal cancer and death. Outcomes were ascertained through linkage to health registers. We used shared frailty models with random effects at the study level to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

    RESULTS: During 7,135,504 person-years of observation, 4170 men developed colorectal cancer. There was no clear association between snus use and colorectal cancer overall. Exclusive current snus users, however, had an increased risk of rectal cancer (HR 1.40: 95% CI 1.09, 1.79). There were no statistically significant associations between snus use and either all-cause or colorectal cancer-specific mortality after colorectal cancer diagnosis.

    CONCLUSIONS: Our findings, from a large sample, do not support any strong relationships between snus use and colorectal cancer risk and survival among men. However, the observed increased risk of rectal cancer is noteworthy, and in merit of further attention.

  • 6. Axelsen, Mette
    et al.
    Danielsson, Maria
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Sjöberg, Agneta
    Eating habits and physical activity: Health in Sweden: The National Public Health Report 2012. Chapter 82012In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 40, no 9 Suppl, p. 164-175Article in journal (Refereed)
    Abstract [en]

    Although eating habits in Sweden have largely deteriorated since 1980, some improvements have been observed in the most recent years. Between 1980 and 2010, the consumption of sweets rose from 10 to 15 kilos per person per year, while consumption of soft drinks increased from 30 to 90 litres. The average amount of energy consumed rose by 11 per cent, probably contributing to an increase in the number of overweight people.

    Moreover, our energy intake is almost 10 per cent higher compared to 1980. Protein intake has shown a particularly stable rise. Swedes continue to eat too little fruit, vegetables and fish, according to the Swedish National Food Agency’s dietary recommendations. Fewer than one person in ten eats fruit and vegetables five times a day. Women have better eating habits than men, well-educated people have better eating habits than the less well-educated, and male workers on low incomes eat the least amount of fruit and vegetables.

    The eating habits of children have improved in recent years. More children eat fruit and vegetables, and the consumption of soft drinks and sweets declined markedly between 2001 and 2005. However, children continue to consume excessive amounts of sweets, soft drinks, ice cream, snacks and pastry. On average, children drank 2 decilitres of soft/fruit drinks a day and ate 1.5 hectograms of sweets a week in 2003. Children who regularly eat breakfast often have better eating habits than other young people.

    The desire to lose weight is fairly prevalent. Just over half the adult population have tried to lose weight or plan to do so. Nowadays, there are a number of methods for losing weight, and the debate between those who are for or against fat in the diet has become polarised. Most of these methods, however, involve increasing one’s consumption of vegetables, fruit and pulses and lowering one’s consumption of chocolate, sweets, soft drinks and snacks.

    Physical activity has many positive effects on health and helps prevent the most common diseases. People who are least fit have the most to gain in terms of improved health by increasing their physical activity.

    Physical inactivity during leisure time is more widespread among men than women. It is three times more common among women and men born outside Europe than among native-born Swedes. Physical inactivity has become less common among women in all socioeconomic groups according to the Survey of Living Conditions. In the case of men physical inactivity has only decreased among upper-level white-collar employees. Several other studies show no appreciable improvement, inactivity during leisure time is just as common today as it was 20 years ago.

    Approximately two-thirds of adults are physically active for at least half an hour every day. The level of activity may be described as at least moderate, thus fulfilling the minimum recommended physical activity requirement. According to the Västerbotten Health Studies, the proportion of the population who are moderately active has declined in recent years. On the other hand, the amount of intense physical activity has risen, particularly among women. A higher level of physical activity is recommended for children and young people. However, this recommendation is only met by 10–20 per cent of children in Sweden, a lower figure than in most other European countries.

  • 7.
    Bengtsson, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lindvall, Kristina
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Increased knowledge makes a difference!–general practitioners’ experiences of pictorial information about subclinical atherosclerosis for primary prevention: an interview study from the VIPVIZA trial2021In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 39, no 1, p. 77-84Article in journal (Refereed)
    Abstract [en]

    Objectives: To explore how pictorial information on subclinical atherosclerosis affects GPs’ perception of patient cardiovascular disease (CVD) risk, their communication with patients, and GPs’ attitude to the treatment of CVD risk factors.

    Design, setting and subjects: Fifteen individual interviews were conducted between March 2014 and December 2016, with GPs who had received pictorial information regarding their patients’ subclinical atherosclerosis. The pictorial information was also received by the patients together with written information regarding atherosclerosis and CVD risk prior to the appointment with their GP. The interviews were recorded, transcribed and analyzed using qualitative content analysis.

    Results: Three categories were identified in the analysis. Increased knowledge makes a difference: When patients had more in-depth knowledge regarding atherosclerosis, the consultation became more patient-centered and moved towards shared decision making. This is real, not just a number: GPs described their risk assessment and the patient’s risk perception as more accurate with pictorial information about subclinical atherosclerosis. How to deal with the result–A passive to active approach: Some GPs acted promptly on the pictorial information while others took no action.

    Conclusion and implications: Pictorial information regarding patients’ subclinical atherosclerosis affected GPs’ assessment of CVD risk. The communication shifted towards shared decision-making although the GPs’ attitude to the result and treatment of CVD risk factors varied. Informing patients about examination results, both in writing and pictures, prior to a consultation can facilitate shared decision making and enhance preventive measures.

    Trial registration: https://clinicaltrials.gov/ct2/show/NCT01849575.

    KEY POINTS: Providing pictorial information about carotid ultrasound results and information regarding atherosclerosis to GPs and patients affects primary prevention:

    • Informing patients about examination results prior to a consultation can be useful in clinical practice to enhance preventive measures
    • GPs experienced that increased patient knowledge resulted in a more patient-centered consultation and improved shared decision-making
    • GPs described their risk assessment and patients’ risk perception as more accurate with pictorial information about subclinical atherosclerosis.
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  • 8.
    Bengtsson, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Grönlund, Christer
    Umeå University, Faculty of Medicine, Department of Radiation Sciences, Radiation Physics.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Lindahl, Bernt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Lindahl, Bertil
    Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
    Nordin, Steven
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Nyman, Emma
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    The beneficial effect over 3 years by pictorial information to patients and their physician about subclinical atherosclerosis and cardiovascular risk: results from the VIPVIZA randomized clinical trial2021In: American Journal of Preventive Cardiology, ISSN 2666-6677, Vol. 7, article id 100199Article in journal (Refereed)
    Abstract [en]

    Objective: Non-adherence to guidelines and preventive measures is a major challenge, particularly so to ob- tain long-term adherence to lifestyle changes and recommended medication. The objective was to investigate if pictorial information regarding subclinical carotid atherosclerosis provided to individuals and physicians gave sustained effects on cardiovascular risk beyond the previously reported effect after 1 year and up to 3 years. 

    Methods: A Prospective Randomized Open Blinded End-point (PROBE) trial. Within a CVD prevention program in Västerbotten County, Sweden, 3532 healthy individuals aged 40, 50 or 60 years were enrolled and 1:1 ran- domized to intervention ( n = 1749; pictorial information with additional prevention materials to participants and physicians) or control group ( n = 1783; no pictorial information to participants and physicians). Preventive measures were managed within primary care. Participants were investigated at baseline during 2013–2016 and at follow-up after 1 and 3 years. 

    Results: A beneficial effect on cardiovascular risk was observed at 3-year follow-up; Framingham Risk Score (FRS) was 13.38 for the intervention group and 14.08 for the control group ( p = 0.047) and SCORE was 1.69 vs. 1.82 ( p = 0.022). The effect observed at 1-year was sustained over 3 years after adjustment for sex and education and more pronounced among participants with a severe atherosclerotic picture at baseline.

    Conclusions: This study provides evidence of sustained beneficial effects on the adherence to prevention guidelines over 3 years of pictorial information about subclinical carotid atherosclerosis, resulting in lower cardiovascular risk regardless of sex and educational level. Direct visualization of the underlying still subclinical atherosclerotic disease, rather than just indirect information about risk factors and statistical risk of future myocardial infarction, stroke and death, is one way to tackle the problem of non-adherence to prevention of cardiovascular diseases.

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  • 9.
    Bengtsson, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nyman, Emma
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Grönlund, Christer
    Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Association of cardiovascular disease risk factors with combined carotid ultrasound measurements in subclinical atherosclerosisManuscript (preprint) (Other academic)
  • 10.
    Bengtsson, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Nyman, Emma
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Grönlund, Christer
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Multi-view carotid ultrasound is stronger associated with cardiovascular risk factors than presence of plaque or single carotid intima media thickness measurements in subclinical atherosclerosis2023In: The International Journal of Cardiovascular Imaging, ISSN 1569-5794, E-ISSN 1875-8312, Vol. 39, no 8, p. 1461-1471Article in journal (Refereed)
    Abstract [en]

    We aimed to explore the prevalence of atherosclerosis by using multi-view ultrasound examination of the carotid arteries and its association with clinical risk factors in a middle-aged population at low to intermediate risk of cardiovascular disease (CVD). Carotid vascular ultrasound was performed in 3532 participants in the VIPVIZA trial. Mean and maximal carotid intima media thickness (cIMT) at prespecified angles and plaque presence were examined on the left and right side. Associations between CVD risk factors and ultrasound variables were quantified by partial least squares (PLS) regression. A combined ultrasound variable was computed using weights of the first PLS component. Associations between CVD risk factors and the combined multi-view ultrasound variable, single cIMT and plaque measurements, respectively, were determined using linear regression modelling. The participants’ mean age was 55.7 years and 52.9% were women. Plaque prevalence was 51.1% in men and 39.0% in women. cIMT was higher in men than in women and in the left compared with the right carotid artery. The strongest association of CVD risk factors was observed with the combined multi-view ultrasound variable (R2 = 24%), compared with single cIMT variables (R2 = 14–18%) and plaque presence (R2 = 15%). The pattern was similar in both sexes. The association with CVD risk factors and the combined ultrasound variable was stronger in 40-year olds (R2 = 22%) compared with 50- or 60-year olds (R = 12%). CVD risk factors are stronger associated with a combined ultrasound variable than plaque presence or single cIMT measures suggesting that carotid multi-view ultrasonography better captures the focality of early atherosclerosis. Clinical Trial Registration: ClinicalTrials.gov, number NCT01849575. May 8, 2013.

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  • 11.
    Blomstedt, Yulia
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Boman, Kurt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine. Research Unit Medicine-Geriatric Clinic, Skellefteå County Hospital, SE-931 86 Skellefteå, Sweden..
    Lönnberg, Göran
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Flawed conclusions on the Vasterbotten Intervention Program by San Sebastian et .al2019In: BMC Public Health, E-ISSN 1471-2458, Vol. 19, no 1, article id 1095Article in journal (Refereed)
    Abstract [en]

    An evaluation of Vasterbotten Intervention Programme (VIP) was recently conducted by San Sebastian et al. (BMC Public Health 19:202, 2019). Evaluation of health care interventions of this kind require 1) an understanding of both the design and the nature of the intervention, 2) correct definition of the target population, and 3) careful choice of the appropriate evaluation method. In this correspondence, we review the approach used by San Sebastian et al. as relates to these three criteria. Within this framework, we suggest important explanations for why the conclusions drawn by these authors contradict a large body of research on the effectiveness of the VIP.

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

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

    DESIGN: Dynamic cohort study.

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

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

    PRIMARY OUTCOMES: All-cause and CVD mortality.

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

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

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  • 13.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Dahlström, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindholm, Lars Hjalmar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lönnberg, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hallström, Sara
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Persson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    From efficacy in trials to effectiveness in clinical practice: The Swedish Stroke Prevention Study2016In: Blood Pressure, ISSN 0803-7051, E-ISSN 1651-1999, Vol. 25, no 4, p. 206-211Article in journal (Refereed)
    Abstract [en]

    Blood pressure treatment has shown great efficacy in reducing cardiovascular events in randomized controlled trials. If this is effective in reducing cardiovascular disease in the general population, is less studied. Between 2001 and 2009 we performed an intervention to improve blood pressure control in the county of Vasterbotten, using Sodermanland County as a control. The intervention was directed towards primary care physicians and included lectures on blood pressure treatment, a computerized decision support system with treatment recommendations, and yearly feed back on hypertension control. Each county had approximately 255000 inhabitants. Differences in age and incidence of cardiovascular disease were small. During follow-up, more than 400000 patients had their blood pressure recorded. The mean number of measurements was eight per patient, yielding a total of 3.4 million blood pressure recordings. The effect of the intervention will be estimated combining the blood pressure data collected from the electronic medical records, with data on stroke, myocardial infarction and mortality from Swedish health registers. Additional variables, from health registers and Statistics Sweden, will be collected to address for confounders. The blood pressure data collected within this study will be an important asset for future epidemiological studies within the field of hypertension.

  • 14.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden.
    Dahlström, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Lindholm, Lars H.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lönnberg, Göran
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Association of Physician Education and Feedback on Hypertension Management With Patient Blood Pressure and Hypertension Control2020In: JAMA Network Open, E-ISSN 2574-3805, Vol. 3, no 1, article id e1918625Article in journal (Refereed)
    Abstract [en]

    Importance: Elevated systolic blood pressure (SBP) is the most important risk factor for premature death worldwide. However, hypertension detection and control rates continue to be suboptimal.

    Objective: To assess the association of education and feedback to primary care physicians with population-level SBP and hypertension control rates.

    Design, Setting, and Participants: This pooled series of 108 population-based cohort studies involving 283 079 patients used data from primary care centers in 2 counties (Västerbotten and Södermanland) in Sweden from 2001 to 2009. Participants were individuals aged 18 years or older who had their blood pressure (BP) measured and recorded in either county during the intervention period. All analyses were performed in February 2019.

    Exposures: An intervention comprising education and feedback for primary care physicians in Västerbotten County (intervention group) compared with usual care in Södermanland County (control group).

    Main Outcomes and Measures: Difference in mean SBP levels between counties and likelihood of hypertension control in the intervention county compared with the control county during 24 months of follow-up.

    Results: A total of 136 541 unique individuals (mean [SD] age at inclusion, 64.6 [16.1] years; 57.0% female; mean inclusion BP, 142/82 mm Hg) in the intervention county were compared with 146 538 individuals (mean [SD] age at inclusion, 65.7 [15.9] years; 58.3% female; mean inclusion BP, 144/80 mm Hg) in the control county. Mean SBP difference between counties during follow-up, adjusted for inclusion BP and other covariates, was 1.1 mm Hg (95% CI, 1.0-1.1 mm Hg). Hypertension control improved by 8.4 percentage points, and control was achieved in 37.8% of participants in the intervention county compared with 29.4% in the control county (adjusted odds ratio, 1.30; 95% CI, 1.29-1.31). Differences between counties increased during the intervention period and were more pronounced in participants with higher SBP at inclusion. Results were consistent across all subgroups.

    Conclusions and Relevance: This study suggests that SBP levels and hypertension control rates in a county population may be improved by educational approaches directed at physicians and other health care workers. Similar strategies may be adopted to reinforce the implementation of clinical practice guidelines for hypertension management.

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  • 15.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. School of Public Health and Community Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Dahlström, John
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Lindholm, Lars H.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Nyström, Lennarth
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Association of education and feedback on hypertension management with risk for stroke and cardiovascular disease2022In: Blood Pressure, ISSN 0803-7051, E-ISSN 1651-1999, Vol. 31, no 1, p. 31-39Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Education and feedback on hypertension management has been associated with improved hypertension control. This study aimed to assess the effectiveness of such interventions to reduce the risk of stroke and cardiovascular events. MATERIALS AND METHODS: Individuals ≥18 years with a blood pressure (BP) recording in Västerbotten or Södermanland County during the study period 2001 to 2009 were included in 108 serial cohort studies, each with 24 months follow-up. The primary outcome was risk of first-ever stroke in Västerbotten County (intervention) compared with Södermanland County (control). Secondary outcomes were first-ever major adverse cardiovascular event (MACE), myocardial infarction, and heart failure, as well as all-cause and cardiovascular mortality. All outcomes were analysed using time-to-event data included in a Cox proportional hazards model adjusted for age, sex, hypertension, diabetes, coronary artery disease, atrial fibrillation, systolic BP at inclusion, marital status, and disposable income. RESULTS: A total of 121 365 individuals (mean [SD] age at inclusion 61.7 [16.3] years; 59.9% female; mean inclusion BP 142.3/82.6 mmHg) in the intervention county were compared to 131 924 individuals (63.6 [16.2] years; 61.2% female; 144.1/81.1 mmHg) in the control county. A first-ever stroke occurred in 2 823 (2.3%) individuals in the intervention county, and 3 584 (2.7%) individuals in the control county (adjusted hazard ratio 0.96, 95% CI 0.90 to 1.03). No differences were observed for MACE, myocardial infarction or heart failure, whereas all-cause mortality (HR 0.91, 95% CI 0.87 to 0.95) and cardiovascular mortality (HR 0.91, 95% CI 0.85 to 0.98) were lower in the intervention county. CONCLUSIONS: This study does not support an association between education and feedback on hypertension management to primary care physicians and the risk for stroke or cardiovascular outcomes. The observed differences for mortality outcomes should be interpreted with caution.

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  • 16. Byhamre, Marja Lisa
    et al.
    Norberg, Margareta
    Näslund, Ulf
    Wennberg, Patrik
    Snus use, mortality, and socioeconomic factorsManuscript (preprint) (Other academic)
  • 17. Carlsson, S
    et al.
    Andersson, T
    Araghi, M
    Galanti, R
    Lager, A
    Lundberg, M
    Nilsson, P
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Pedersen, N L
    Trolle-Lagerros, Y
    Magnusson, C
    Smokeless tobacco (snus) is associated with an increased risk of type 2 diabetes: results from five pooled cohorts2017In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 281, no 4, p. 398-406Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Smoking and nicotine exposure increase insulin resistance and the risk of type 2 diabetes. Swedish smokeless tobacco (snus) is high in nicotine, and its use is prevalent in Scandinavian countries, but few studies have investigated snus use in relation to diabetes risk.

    OBJECTIVE: To explore the association between snus use and risk of type 2 diabetes using pooled data from five cohorts.

    METHODS: Analyses were based on prospective studies conducted between 1990 and 2013 including 54 531 never-smoking men and 2441 incident cases of type 2 diabetes identified through screening, self-reporting and hospital and prescription registries. Hazard ratios (HRs) and 95% confidence intervals (CIs) were assessed and adjusted for age, body mass index, educational level, alcohol consumption and physical activity.

    RESULTS: Compared to never users, the HR of type 2 diabetes was 1.15 (95% CI: 1.00-1.32) in current users of snus. In individuals consuming 5-6 boxes per week, the HR was 1.42 (95% CI: 1.07-1.87); in those consuming ≥7 boxes per week, the HR was 1.68 (95% CI: 1.17-2.41). Each additional box of snus consumed per week yielded an HR of 1.08 (95% CI: 1.01-1.16).

    CONCLUSION: Our findings indicate that high consumption of snus is a risk factor for type 2 diabetes. The risk was similar to that in smokers, implying that smokers will not reduce their risk of type 2 diabetes by changing to snus use. The results also support the notion that nicotine increases the risk of type 2 diabetes.

  • 18. Engström, Karin S
    et al.
    Wennberg, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Department of Medicine, Skellefteå Hospital, Skellefteå, Sweden.
    Strömberg, Ulf
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lundh, Thomas
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Rentschler, Gerda
    Vessby, Bengt
    Skerfving, Staffan
    Broberg, Karin
    Evaluation of the impact of genetic polymorphisms in glutathione-related genes on the association between methylmercury or n-3 polyunsaturated long chain fatty acids and risk of myocardial infarction: a case-control study2011In: Environmental Health, E-ISSN 1476-069X, Vol. 10, p. Article nr 33-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The n-3 polyunsaturated fatty acids eicosapentaenoic acid and docosahexaenoic acid, which are present in fish, are protective against myocardial infarction. However, fish also contains methylmercury, which influences the risk of myocardial infarction, possibly by generating oxidative stress. Methylmercury is metabolized by conjugation to glutathione, which facilitates elimination. Glutathione is also an antioxidant. Individuals with certain polymorphisms in glutathione-related genes may tolerate higher exposures to methylmercury, due to faster metabolism and elimination and/or better glutathione-associated antioxidative capacity. They would thus benefit more from the protective agents in fish, such as eicosapentaenoic+docosahexaenoic acid and selenium. The objective for this study was to elucidate whether genetic polymorphisms in glutathione-related genes modify the association between eicosapentaenoic+docosahexaenoic acid or methylmercury and risk of first ever myocardial infarction.

    METHODS: Polymorphisms in glutathione-synthesizing (glutamyl-cysteine ligase catalytic subunit, GCLC and glutamyl-cysteine ligase modifier subunit, GCLM) or glutathione-conjugating (glutathione S-transferase P, GSTP1) genes were genotyped in 1027 individuals from northern Sweden (458 cases of first-ever myocardial infarction and 569 matched controls). The impact of these polymorphisms on the association between erythrocyte-mercury (proxy for methylmercury) and risk of myocardial infarction, as well as between plasma eicosapentaenoic+docosahexaenoic acid and risk of myocardial infarction, was evaluated by conditional logistic regression. The effect of erythrocyte-selenium on risk of myocardial infarction was also taken into consideration.

    RESULTS: There were no strong genetic modifying effects on the association between plasma eicosapentaenoic+docosahexaenoic acid or erythrocyte-mercury and risk of myocardial infarction risk. When eicosapentaenoic+docosahexaenoic acid or erythrocyte-mercury were divided into tertiles, individuals with GCLM-588 TT genotype displayed a lower risk relative to the CC genotype in all but one tertile; in most tertiles the odds ratio was around 0.5 for TT. However, there were few TT carriers and the results were not statistically significant. The results were similar when taking plasma eicosapentaenoic+docosahexaenoic acid, erythrocyte-selenium and erythrocyte-mercury into account simultaneously.

    CONCLUSIONS: No statistically significant genetic modifying effects were seen for the association between plasma eicosapentaenoic+docosahexaenoic acid or erythrocyte-mercury and risk of myocardial infarction. Still, our results indicate that the relatively rare GCLM-588 TT genotype may have an impact, but a larger study is necessary for confirmation.

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    Evaluation of the impact of genetic polymorphisms in glutathione-related genes on the association between methylmercury or n-3 polyunsaturated long chain fatty acids and risk of myocardial infarction: a case-control study
  • 19. Feldman, Adina L
    et al.
    Griffin, Simon J
    Ahern, Amy L
    Long, Grainne H
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Impact of weight maintenance and loss on diabetes risk and burden: a population-based study in 33,184 participants2017In: BMC Public Health, E-ISSN 1471-2458, Vol. 17, article id 170Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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

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

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

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

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

  • 21.
    Feldman, Adina L
    et al.
    MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge.
    Long, Gráinne H
    MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Griffin, Simon J
    MRC Epidemiology Unit, Institute of Metabolic Science, University of Cambridge.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Change in lifestyle behaviors and diabetes risk: evidence from a population-based cohort study with 10 year follow-up2017In: International Journal of Behavioral Nutrition and Physical Activity, E-ISSN 1479-5868, Vol. 14, article id 39Article in journal (Refereed)
    Abstract [en]

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

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

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

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

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  • 22.
    Fortuin-de Smidt, Melony
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Bergman, Frida
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Grönlund, Christer
    Umeå University, Faculty of Medicine, Department of Radiation Sciences.
    Hult, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wennberg, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Early adulthood exercise capacity, but not muscle strength, associates with subclinical atherosclerosis 40 years later in Swedish men2023In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 30, no 5, p. 407-415Article in journal (Refereed)
    Abstract [en]

    AIMS: Poor exercise capacity and muscle strength in early adulthood are risk factors for cardiovascular disease (CVD). However, it is unclear how these factors relate to subclinical atherosclerosis due to a lack of longitudinal studies. This study investigated whether early adulthood exercise capacity and muscle strength associated with later adulthood subclinical atherosclerosis.

    METHODS AND RESULTS: This study included Swedish men (n = 797) who were eligible for military conscription (at ∼18-years of age) and who participated in the baseline assessment of the visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention trial between 2013 and 2016 (at 60 years of age). At conscription, isometric muscle strength (dynamometer) and maximum exercise capacity (maximal load cycle ergometer test) were measured. During later adulthood (at 60 years old), the presence of carotid plaques and intima media thickness were measured by using high-resolution ultrasound. At follow-up, plaques were present in 62% (n = 493) of men. Exercise capacity in early adulthood associated with 19% lower odds of plaques [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.68-0.96], independent of muscle strength. This association was not mediated by any single CVD risk factor. However, the total indirect effect of later, but not early, adulthood CVD risk factors was significant, while the direct effect was non-significant (OR 0.85, 95% CI 0.71-1.02). Associations between muscle strength and subclinical atherosclerosis were non-significant.

    CONCLUSION: Higher exercise capacity during early adulthood, but not muscle strength, may protect against carotid plaque development during adulthood mediated by the combination rather than a single later adulthood CVD risk factors.

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  • 23. Ghandour, Rula
    et al.
    Mikki, Nahed
    Abu Rmeileh, Niveen M. E.
    Jerdén, Lars
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eriksson, Jan W.
    Husseini, Abdullatif
    Complications of type 2 diabetes mellitus in Ramallah and al-Bireh: The Palestinian Diabetes Complications and Control Study (PDCCS)2018In: Primary Care Diabetes, ISSN 1751-9918, E-ISSN 1878-0210, Vol. 12, no 6, p. 547-557Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Type 2 diabetes mellitus (T2DM) is a growing pandemic that will lead, if not managed and controlled, to frequent complications, poor quality of life, and high rates of disability and death. Little is known about T2DM complications in Palestine. The aim of this study is to estimate the prevalence of T2DM complications in Ramallah and al-Bireh governorate of Palestine.

    METHODS: The study was conducted in eleven primary healthcare clinics offering services for persons with T2DM. Macrovascular complications were assessed using the Diabetes complication index. Microvascular complications were measured by physical examinations and laboratory tests. Questionnaires, laboratory tests, and physical examinations were used to assess socio-demographic characteristics, co-morbidities and other risk factors.

    RESULTS: 517 adult men and nonpregnant women participated in the study (166 men, 351 women). The response rate was 84%. Mean age and mean duration of diabetes were 58.1 and 9.4 years respectively. Prevalence of diagnosed microvascular and macrovascular complications was 67.2% and 28.6% respectively. 78.2% of the participants had poor glycemic control (HbA1c≥7.0%).

    CONCLUSION: Significant proportions of persons with T2DM had macro- and microvascular complications and poor metabolic control. These findings are important for policy development and the planning of health services.

  • 24.
    Granlund, Lena E.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Ramnemark, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Andersson, Christer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lindkvist, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics. Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Vitamin D status was not associated with anxiety, depression, or health-related quality of life in Middle Eastern and African-born immigrants in Sweden2020In: Nutrition Research, ISSN 0271-5317, E-ISSN 1879-0739, Vol. 75, p. 109-118Article in journal (Refereed)
    Abstract [en]

    Active vitamin D is a neurosteroid that may modulate brain function. Associations between vitamin D deficiency and depression and anxiety have been demonstrated. We hypothesized that there was an association between anxiety, depression, and health-related quality of life (HRQOL) and vitamin D status. To test this hypothesis, we examined the association between anxiety, depression, and HRQOL and 25-hydroxyvitamin D (25[OH]D) concentrations in the Middle Eastern and African-born immigrant population. All immigrants aged 25-65 years, born in 9 African or Middle Eastern countries, and living in 3 districts in Umea (n = 1306) were invited, with 195 English- or Swedish-speaking immigrants (104 men and 91 women) participated. Anxiety and depression were measured using the Hospital Anxiety and Depression scale. HRQOL was measured using EuroQoL-5 Dimension 3 Level Questionnaire and EuroQoL Visual Analogue Scale. Serum 25(OH)D was measured using liquid chromatography-tandem mass spectrometry. Associations were determined using logistic and linear regression. Analyses were adjusted for sex, age, origin, socioeconomic factors, lifestyle, chronic diseases, and obesity. In total, 71% had 25(OH)D less than 50 nmol/ L and 11% had 25(OH)D less than 25 nmol/L. Anxiety, depression, and HRQOL were not associated with 25(OH)D in the immigrant population. Anxiety was common in female immigrants from the Middle East (32.7%); and after adjustment, lower 25(OH)D concentrations were associated with higher risk of anxiety (25[OH]D <= 49 nmol/L vs 25[OH] D >= 50 nmol/L: odds ratio 23.2 [95% confidence interval 1.97 - 271.9] P = .012) in this subgroup only; however, reverse causality could not be excluded. In conclusion, the study showed no association between depression, anxiety, or HRQOL and vitamin D status in the immigrant population.

  • 25.
    Granlund, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Ramnemark, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Andersson, Christer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Vitamin D is associated with lower limb muscle strength and grip strength in Middle Eastern- and African-born immigrants in Sweden2018In: Nutrition Research, ISSN 0271-5317, E-ISSN 1879-0739, Vol. 59, p. 29-35Article in journal (Refereed)
    Abstract [en]

    There is increasing evidence that vitamin D status is associated with muscle function. Vitamin D deficiency is common in immigrants. We hypothesized that there was a positive association between vitamin D status and muscle strength in immigrants. The aim of this study was to examine associations between vitamin D status and muscle strength in an immigrant population in Sweden. All immigrants aged 25-65 years, born in 9 African or Middle East countries, and living in a district in Umeå (n = 1306) were invited. A total of 111 men and 105 women (16.5%) completed the study. Lower limb muscle strength was examined using a standardized muscle function indices of muscle strength. Grip strength was examined using a JAMAR hand dynamometer. Serum 25-hydroxyvitamin D [25(OH)D] was measured using liquid chromatography–tandem mass spectrometry. The analyses were adjusted for sex, age, height, body mass index, years since immigration, 25(OH)D, vitamin D deficiency, physical activity, and medical and socioeconomic factors. Twelve percent of the immigrants had vitamin D deficiency [25(OH)D levels <25 nmol/L]. In multivariable analyses, reduced lower limb muscle strength remained linearly associated with lower 25(OH)D concentrations (P = .008) and weaker grip strength remained associated with vitamin D deficiency (P = .022) after adjustments. The association between vitamin D deficiency and reduced lower limb muscle strength did not reach statistical significance (P = .052). The results demonstrate that vitamin D deficiency and low 25(OH)D concentrations were associated with muscle weakness in immigrants.

  • 26.
    Granlund, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Ramnemark, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Andersson, Christer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lindkvist, Marie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Prevalence of vitamin D deficiency and its association with nutrition, travelling and clothing habits in an immigrant population in Northern Sweden2016In: European Journal of Clinical Nutrition, ISSN 0954-3007, E-ISSN 1476-5640, Vol. 70, no 3, p. 373-379Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To study prevalence and determinants of vitamin D deficiency in immigrants from Africa and the Middle East living in Umeå, Sweden.

    DESIGN: Cross-sectional population based.

    SETTING: Umeå, Sweden (63° N).

    SUBJECTS/METHODS: Immigrants aged 25-65 years from nine countries in Africa or the Middle East (n=1306) were invited. A total of 111 men and 106 women (16.5%) completed the study. S-25-hydroxyvitamin D3 was measured with HPLC. Anthropometry, medical, socioeconomic and lifestyle data were registered.

    RESULTS: Vitamin D status was insufficient or deficient in 73% of the participants. Specifically, 12% had vitamin D deficiency (25(OH)D3<25 nmol/l), and only 3.7% had optimal vitamin D status (25(OH)D3 75-125 nmol/l). Mean 25(OH)D3 level was 41.0 nmol/l (±16.6) with no difference between sexes. Levels of 25(OH)D3 were lower (P=0.030) and vitamin D deficiency was twice as common in immigrants from Africa compared with those from the Middle East. In the multiple regression analysis, vitamin D deficiency was significantly associated with low fatty fish intake (OR 4.31, 95% CI 1.61-11.55), not travelling abroad (OR 3.76, 95% CI 1.18-11.96) and wearing long-sleeved clothes in summer (OR 3.15, 95% CI 1.09-9.12).

    CONCLUSIONS: The majority of immigrants from Africa and the Middle East who live in northern Sweden have vitamin D deficiency or insufficiency. Our results are consistent with sun exposure and a diet with high intake of fatty fish being most important in avoiding vitamin D deficiency.

  • 27.
    Granlund, Lena
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Ramnemark, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
    Andersson, Christer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Lindkvist, Marie
    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.
    Fhärm, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Associations between vitamin D status and anxiety, depression and health related quality of life in an immigrant population. A cross-sectional study from SwedenManuscript (preprint) (Other academic)
  • 28. Handberg, A
    et al.
    Norberg, Margareta
    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.
    Hallmans, G
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Attermann, J
    Eriksson, J W
    Soluble CD36 (sCD36) Clusters with Markers of Insulin Resistance, and High sCD36 Is Associated with Increased Type 2 Diabetes Risk.2010In: The Journal of clinical endocrinology and metabolism, ISSN 1945-7197Article in journal (Refereed)
    Abstract [en]

    Context and Objective: Soluble CD36 (sCD36) may be an early marker of insulin resistance and atherosclerosis. The objective of this prospective study was to evaluate sCD36 as a predictor of type 2 diabetes and to study its relationship with components of the metabolic syndrome (MetSy). Design, Setting, Participants, and Outcome Measures: We conducted a case-referent study nested within a population-based health survey. Baseline variables included sCD36, body mass index, blood pressure, blood lipids, adipokines, inflammatory markers, and beta-cell function. A total of 173 initially nondiabetic cohort members who developed type 2 diabetes during 10 yr of follow-up were matched (1:2) with referents. Exploratory factor analysis was applied to hypothesize affiliation of sCD36 to the MetSy components. Results: Doubling of baseline sCD36 increases the odds ratio for diabetes development by 1.24 in the general study population and by 1.45 in the female population (P < 0.025). Comparing upper sCD36 quartiles with lower, odds ratio for diabetes was 4.6 in women (P = 0.001), 3.15 in men (P = 0.011), and 2.6 in obese individuals (P < 0.025). Multivariate analysis shows that sCD36 does not predict diabetes independent of fasting plasma glucose and insulin. Factor analysis of 15 variables generates a six-factor model explaining 66-69% of total variance, where sCD36, body mass index, insulin, proinsulin, and leptin were assigned to the obesity/insulin resistance cluster. Conclusions: Upper quartile sCD36 is associated with elevated diabetes risk independent of age, gender, and obesity. Baseline sCD36 does not, however, predict diabetes independent of fasting glucose and insulin. sCD36 clusters with important markers of insulin resistance and MetSy that are key predictors of type 2 diabetes.

  • 29.
    Hemberg, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Holmberg, H.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Tobacco use is not associated with groin hernia repair, a population-based study2017In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 21, no 4, p. 517-523Article in journal (Refereed)
    Abstract [en]

    Purpose The pathogenesis of groin hernia is not fully understood and some suggested risk factors are debatable. This population-based study evaluates the association between groin hernia repair and tobacco use. Method An observational study based on register linkage between the Swedish Hernia Register and the Vasterbotten Intervention Program (VIP). All primary groin hernia repairs performed from 2001 to 2013 in the county of Vasterbotten, Sweden, were included. Results VIP provided data on the use of tobacco in 102,857 individuals. Neither smoking nor the use of snus, increased the risk for requiring a groin hernia repair. On the contrary, heavy smoking decreased the risk for men, HR 0.75 (95% CI 0.58-0.96), as did having a BMI over 30 kg/m 2 HR (men) 0.33 (95% CI 0.27-0.40). Conclusion Tobacco use is not a risk factor for requiring a groin hernia repair, whereas having a low BMI significantly increases the risk.

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  • 30.
    Hernestål-Boman, Jenny
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jansson, Jan-Håkan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eliasson, Mats
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Medicine, Sunderby Hospital, Luleå, Sweden.
    Eriksson, Jan W
    Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Gothenburg and AstraZeneca R&D, Mölndal, Sweden.
    Lindahl, Bernt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Johansson, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Signs of dysregulated fibrinolysis precede the development of type 2 diabetes mellitus in a population-based study2012In: Cardiovascular Diabetology, ISSN 1475-2840, E-ISSN 1475-2840, Vol. 11, p. 152-Article in journal (Refereed)
    Abstract [en]

    Background: Diabetic patients experience stimulated coagulation and dysfibrinolysis, which is associated with an increased risk of cardiovascular events. This imbalance may precede the manifest diagnosis. We investigated whether elevated antigen levels of tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), the tPA/PAI-1 complex, or von Willebrand Factor (VWF) precede type 2 diabetes mellitus (T2DM) diagnosis, and whether this elevation occurs before increased fasting plasma glucose (FPG) or 2-hour plasma glucose (2hPG) in individuals who later develop T2DM.

    Methods: We conducted a prospective incident case-referent study within the Vasterbotten Intervention Programme. Cardiovascular risk factor data as well as FPG and 2hPG and blood samples for future research were collected at a baseline health examination between 1989 and 2000, (n= 28 736). During follow-up in January 2001, 157 cases had developed T2DM. Referents without T2DM were matched for sex, age, and year of participation (n=277). Subgroup analysis was performed for cases with normal baseline glucose levels (FPG <6.1 mmol/L and 2hPG < 8.9 mmol/L) and cases with elevated levels (FPG 6.1-6.9 mmol/L and/or 2hPG 8.9-12.1 mmol/L).

    Results: After adjusting for BMI, family history of diabetes, physical activity, smoking, systolic blood pressure and levels of C-reactive protein and triglycerides, independent associations were found between incident T2DM and elevated levels of tPA (OR=1.54, 95% CI 1.06-2.23), PAI-1 (OR=1.61, 95% CI 1.14-2.28), and tPA/PAI-1 complex (OR=2.45, 95% CI 1.56-3.84). In participants with normal glucose levels, PAI-1 (OR=2.06, 95% CI 1.10 - 3.86) exhibited an independent relationship with incident T2DM after the adjustments.

    Conclusions: Elevated levels of fibrinolytic variables precede the manifestation of T2DM after adjusting for metabolic and cardiovascular risk factors and can be detected several years before changes in glucose tolerance.

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    Signs of dysregulated fibrinolysis precede the development of type 2 diabetes mellitus in a population-based study
  • 31.
    Holmberg, Henrik
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sönnerstam, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Själander, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Improved adherence to statin treatment and differences in results between men and women after pictorial risk communication: a sub-study of the VIPVIZA RCT2024In: European Journal of Clinical Pharmacology, ISSN 0031-6970, E-ISSN 1432-1041Article in journal (Refereed)
    Abstract [en]

    Background: People with intermediate CVD risk constitute most of the population. Within this group, the proportion of events is lower compared to the high-risk group, but they contribute with the largest absolute number of events. Atherosclerosis is a dynamic process and progression can be slowed or even reversed with medication and lifestyle changes, but adherence to prescribed treatment is crucial.

    Aim: To investigate the long-term effects of interventions with pictorial risk communication of cardiovascular (CVD) risk on average adherence in a group of statin users. Compare response in adherence over time between men and women after intervention.

    Methods: Participants on active statin treatment were followed up to 5 years after being randomly assigned to an intervention program aimed at raising CVD risk awareness among participants and their physicians. Merging prescribed medication databases with VIPVIZA study to study adherence over time. A moving average adherence was used to compare groups.

    Results: Generally, the average adherence to statins among the 512 participants was high. Men had a higher average adherence over time, while women had a sharper increase in adherence in conjuncture with the intervention program.

    Conclusions: Both men and women were receptive to pictorial information regarding CVD risk, but the intervention effect was more pronounced in women. Sex differences are important when considering risk communication strategies. Periodically repeating the intervention was beneficial for maintaining the intervention effect over time.

    Trial registration: The VIPVIZA study is registered with ClinicalTrials.gov, May 8, 2013, number NCT01849575.

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  • 32.
    Holmberg, Henrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Sjölander, Maria
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB).
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Själander, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Time to initiation of lipid-lowering drugs for subclinical atherosclerosis: sub-study of VIPVIZA randomized controlled trial, with single-arm cross-over2022In: European Heart Journal Open, E-ISSN 2752-4191, Vol. 2, no 1, article id oeac003Article in journal (Refereed)
    Abstract [en]

    AIMS: Visual information about subclinical atherosclerosis was provided to physicians and participants in the VIPVIZA trial, inclusion 2013-16 in northern Sweden, aiming to improve adherence to cardiovascular disease (CVD) prevention guidelines. Pictorial risk information may be more actionable. The aim of this study was to investigate the effect of intervention with pictorial risk information on time to first dispensing of statins.

    METHODS AND RESULTS: Asymptomatic atherosclerotic disease was screened for by carotid ultrasound examination in 3532 participants enrolled in VIPVIZA, of those 3000 met the criteria for this study. Participants were randomly assigned to receive pictorial risk information consisting of graphical representation of atherosclerosis as compared to a control group without intervention. Time to initiation of statins was assessed during 5 years of follow-up through the National prescribed drug register. After 3 years, both groups were re-examined and received the intervention information. In the intervention group, initiation of statins increased considerably for the first 3 years and a smaller increase was also seen after re-intervention. After the cross-over, the control group showed a sharp increase in initiation of statins, almost reaching the same proportion treated at 5 years. The propensity to initiate statin treatment increased over the study period and there was no difference between men and women.

    CONCLUSIONS: The pictorial information had an effect on time to initiation of statins, both as original and repeated intervention and also in the control group after single-arm cross-over. The current study supports pictorial information as a tool to shorten time to initiation of statins for CVD prevention.

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  • 33.
    Häggström, Jenny
    et al.
    Umeå University, Faculty of Social Sciences, Department of Statistics.
    Westerlund, Olle
    Umeå University, Faculty of Social Sciences, Department of Economics.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    de Luna, Xavier
    Umeå University, Faculty of Social Sciences, Department of Statistics.
    Divorcing in middle age and its effects on BMIManuscript (preprint) (Other academic)
  • 34. Imseeh, Sawsan
    et al.
    Mikki, Nahed
    Ghandour, Rula
    Giacaman, Rita
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jerden, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Husseini, Abdullatif
    Self-care and glycaemic control: a cross-sectional study2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 382, p. 19-19Article in journal (Other academic)
  • 35.
    Jacobson, Sofie
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Larsson, Peter
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Idrottsmedicin.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wadell, Göran
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research. Umeå University, Faculty of Medicine, Department of Biobank Research.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Leptin independently predicts development of future sepsis and determines survival in the acute phaseManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To determine if levels of the adipocyte-derived hormones leptin and adiponectin (adipokines) predict sepsis development and if intra-individual changes in circulating levels from baseline to the acute phase affect outcome.

    Method: A nested case-referent study within the framework of the Northern Sweden Health and Disease Study (NSHDS) and the Northern Sweden Maternity Cohort (NSMC). Patients aged 18 years or more with documented sepsis within 24 hours after admission to the intensive care unit (ICU) were included if they had participated in a health survey and donated blood samples prior to the sepsis event, and if possible also had stored plasma from the acute phase. Two matched referents free of known sepsis were selected for each case. Baseline and acute phase plasma leptin and adiponectin levels were determined. The associations between adipokines and sepsis and its severity and outcome were determined.

    Results: We identified 57 men and 97 women with a first-time sepsis event 6.5 years (median with IQR 7.7) after participation in the health survey, and 83% of them had also samples from the acute septic phase. Hyperleptinemia associated with a future sepsis event (OR 1.77, 95% CI 1.04-3.00, P=0.03), with stronger associations with severe sepsis and septic shock than with sepsis. High leptin levels were also associated with hospital death in the fully adjusted model. Leptin remained associated with sepsis in men (P=0.02), but not in women (P=0.36), after stratification and adjustment for BMI. In the acute phase, leptin increased more in men than in women (P=0.001), and high leptin levels were associated with increased risk for in-hospital death in women (OR 4.18, 95%CI 1.17-15.00, P=0.03), while being protective in men (OR 0.05, 95% CI 0.01-0.48, P=0.01). Adiponectin did not associate with sepsis or outcome.

    Conclusions: Hyperleptinemia independently predicted the development of sepsis, and an unfavourable outcome in men. Adiponectin was not associated with sepsis development.

  • 36.
    Jacobson, Sofie
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Åberg, Anna-Maja
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wadell, Göran
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research. Umeå University, Faculty of Medicine, Department of Biobank Research.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Levels of mannose-binding lectin (MBL) predicts sepsis and associates with sepsis-related in-hospital mortality differentially in men and womenManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: To determine if levels of mannose-binding lectin (MBL) predict sepsis development and if intra-individual changes in circulating levels from baseline to the acute septic phase associate with in-hospital mortality.

    Method: A nested case-referent study within the framework of the Northern Sweden Health and Disease Study (NSHDS) and the Northern Sweden Maternity Cohort (NSMC). Patients aged 18 years or more with documented sepsis within 24 hours after admission to the intensive care unit were included if they had participated in a health survey and donated blood samples prior to the sepsis event. A subset of these patients had stored plasma also from the acute phase. Two matched referents free of known sepsis were selected for each case. Baseline and acute phase plasma MBL levels were determined. The association between MBL and sepsis, sepsis severity and in-hospital mortality were determined.

    Results: We identified 57 men and 95 women with a first-time sepsis event 6.5 years (median with IQR 7.7) after participation in a health survey, of which 127 also had samples from the acute septic phase. High baseline levels predicted future sepsis (OR 1.81, 95% CI 1.01-3.26), but were not associated with severity of sepsis or in-hospital fatality. Both high MBL levels in the acute phase (OR 4.94, 95% CI 1.44-16.89), and an increase from base line to the acute phase (OR 3.67, 95% CI 1.19-11.28) were associated with increased risk for in-hospital death in women, but not in men (OR 0.71, 95% CI 0.18-2.88). Low levels at baseline were not associated with future sepsis. Neither low levels at baseline, nor in the acute phase were associated with sepsis severity or in-hospital mortality.

    Conclusions: High pre-sepsis levels predicted a future sepsis event, and an increase from baseline to the acute phase as well as high levels in the acute phase associated with an unfavourable outcome in women.

  • 37.
    Jacobsson, Sofie
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Larsson, Peter
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Johansson, Göran
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Wadell, Göran
    Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Winsö, Ola
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Leptin independently predicts development of sepsis and its outcome2017In: Journal of Inflammation, E-ISSN 1476-9255, Vol. 14, article id 19Article in journal (Refereed)
    Abstract [en]

    Background: Sepsis is a life-threatening condition and obesity is related to the clinical outcome. The underlying reasons are incompletely understood, but the adipocyte derived hormones leptin and adiponectin may be involved.

    Methods: Patients aged 18 years or more with documented first time sepsis events were included in a nested case-referent study if they had participated in previous health surveys. Two matched referents free of known sepsis were identified. Circulating levels of leptin and adiponectin were determined in stored plasma, and their impact on a future sepsis event and its outcome was evaluated.

    Results: We identified 152 patients (62% women) with a sepsis event and a previous participation in a health survey. Eighty-three % had also blood samples from the acute event. Hyperleptinemia at health survey associated with a future sepsis event (OR 1.77, 95% CI 1.04-3.00) and with hospital death. After adjustment for BMI leptin remained associated with sepsis in men, but not in women. High levels in the acute phase associated with increased risk for in hospital death in women (OR 4.18, 95% CI 1.17-15.00), while being protective in men (OR 0.05, 95% CI 0.01-0.48). Furthermore, leptin increased more from baseline to the acute phase in men than in women. Adiponectin did not predict sepsis and did not relate to outcome.

    Conclusions: Hyperleptinemia independently predicted the development of sepsis and an unfavourable outcome in men, and inertia in the acute response related to worse outcome.

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  • 38.
    Krachler, Benno
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Eriksson, Jan W
    Hallmans, Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Nutritional Research.
    Johansson, Ingegerd
    Umeå University, Faculty of Medicine, Department of Odontology.
    Vessby, Bengt
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Lindahl, Bernt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Fatty acid profile of the erythrocyte membrane preceding development of Type 2 diabetes mellitus.2008In: Nutrition, metabolism, and cardiovascular diseases : NMCD, ISSN 1590-3729, Vol. 18, no 7, p. 503-510Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND AIMS: The respective roles of dietary fatty acids in the pathogenesis of diabetes are as yet unclear. Erythrocyte membrane fatty acid (EMFA) composition may provide an estimate of dietary fatty acid intake. This study investigates the relation between EMFA composition and development of Type 2 diabetes mellitus. METHODS AND RESULTS: In a nested case-referent design we studied 159 individuals tested as non-diabetic at baseline who after a mean observation time of 5.4+/-2.6years were diagnosed with Type 2 diabetes mellitus and 291 sex- and age-matched referents. Higher proportions of pentadecanoic acid (15:0) and heptadecanoic acid (17:0) were associated with a lower risk of diabetes. In accordance with earlier findings, higher proportions of palmitoleic (16:1 n-7), dihomo-gamma-linolenic (20:3 n-6) and adrenic (22:4 n-6) acids were associated with increased risk, whereas linoleic (18:2 n-6) and clupanodonic (22:5 n-3) acids were inversely associated with diabetes. After adjustment for BMI, HbA1c, alcohol intake, smoking and physical activity the only significant predictors were 15:0 and 17:0 as protective factors and 22:4 n6 as risk factor. CONCLUSION: In accordance with previous studies, our results indicate that EMFA-patterns predict development of Type 2 diabetes mellitus. The inverse association with two saturated fatty acids, previously shown to reflect consumption of dairy products, is a new finding.

  • 39. Lassale, Camille
    et al.
    Tzoulaki, Ioanna
    Moons, Karel G. M.
    Sweeting, Michael
    Boer, Jolanda
    Johnson, Laura
    Huerta, José María
    Agnoli, Claudia
    Freisling, Heinz
    Weiderpass, Elisabete
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    van der A, Daphne L.
    Arriola, Larraitz
    Benetou, Vassiliki
    Boeing, Heiner
    Bonnet, Fabrice
    Colorado-Yohar, Sandra M.
    Engström, Gunnar
    Eriksen, Anne K.
    Ferrari, Pietro
    Grioni, Sara
    Johansson, Matthias
    Kaaks, Rudolf
    Katsoulis, Michail
    Katzke, Verena
    Key, Timothy J.
    Matullo, Giuseppe
    Melander, Olle
    Molina-Portillo, Elena
    Moreno-Iribas, Concepción
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Overvad, Kim
    Panico, Salvatore
    Quirós, J. Ramón
    Saieva, Calogero
    Skeie, Guri
    Steffen, Annika
    Stepien, Magdalena
    Tjønneland, Anne
    Trichopoulou, Antonia
    Tumino, Rosario
    van der Schouw, Yvonne T.
    Verschuren, W. M. Monique
    Langenberg, Claudia
    Di Angelantonio, Emanuele
    Riboli, Elio
    Wareham, Nicholas J.
    Danesh, John
    Butterworth, Adam S.
    Separate and combined associations of obesity and metabolic health with coronary heart disease: a pan-European case-cohort analysis2018In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 39, no 5, p. 397-406Article in journal (Refereed)
    Abstract [en]

    Aims: The hypothesis of 'metabolically healthy obesity' implies that, in the absence of metabolic dysfunction, individuals with excess adiposity are not at greater cardiovascular risk. We tested this hypothesis in a large pan-European prospective study.

    Methods and results: We conducted a case-cohort analysis in the 520 000-person European Prospective Investigation into Cancer and Nutrition study ('EPIC-CVD'). During a median follow-up of 12.2 years, we recorded 7637 incident coronary heart disease (CHD) cases. Using cut-offs recommended by guidelines, we defined obesity and overweight using body mass index (BMI), and metabolic dysfunction ('unhealthy') as ≥ 3 of elevated blood pressure, hypertriglyceridaemia, low HDL-cholesterol, hyperglycaemia, and elevated waist circumference. We calculated hazard ratios (HRs) and 95% confidence intervals (95% CI) within each country using Prentice-weighted Cox proportional hazard regressions, accounting for age, sex, centre, education, smoking, diet, and physical activity. Compared with metabolically healthy normal weight people (reference), HRs were 2.15 (95% CI: 1.79; 2.57) for unhealthy normal weight, 2.33 (1.97; 2.76) for unhealthy overweight, and 2.54 (2.21; 2.92) for unhealthy obese people. Compared with the reference group, HRs were 1.26 (1.14; 1.40) and 1.28 (1.03; 1.58) for metabolically healthy overweight and obese people, respectively. These results were robust to various sensitivity analyses.

    Conclusion: Irrespective of BMI, metabolically unhealthy individuals had higher CHD risk than their healthy counterparts. Conversely, irrespective of metabolic health, overweight and obese people had higher CHD risk than lean people. These findings challenge the concept of 'metabolically healthy obesity', encouraging population-wide strategies to tackle obesity.

  • 40.
    Lilja, Mikael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    The iImpact of Leptin and Adiponectin on incident type 2 Diabetes is modified by sex and insulin resistance2012In: Metabolic Syndrome and Related Disorders, ISSN 1540-4196, E-ISSN 1557-8518, Vol. 10, no 2, p. 143-151Article in journal (Refereed)
    Abstract [en]

    Background: Adiponectin and leptin and their ratio have been associated with incident type 2 diabetes (T2DM), although the data presented are conflicting and the populations studied have been small. In this large, prospective, nested, case referent study, we hypothesized that these associations are sex specific and may be modified by insulin resistance. Methods: Men and women aged 30-60 years with incident T2DM (n = 640) and a prior health survey within the Vasterbotten Intervention Programme (VIP) and matched referents (n = 1564) were identified. Using conditional logistic regression analyses, we tested whether baseline plasma adiponectin and leptin levels and their ratio independently predicted incident T2DM, stratified for gender and insulin resistance. Results: Adjusted for traditional risk factors, fourth-quartile levels of adiponectin were associated with a reduced risk of T2DM in men [odds ratio (OR) 0.55 (0.36-0.86)] and women [OR 0.47 (0.27-0.83)]. Quartile four of the leptin/adiponectin ratio predicted T2DM in both men [OR 3.08 (1.68-5.67)] and women [OR 3.31 (1.56-7.03)], whereas quartile-four levels of leptin predicted T2DM only in men [OR 2.30 (1.32-4.02)]. When stratified for insulin sensitivity and adjusted for body mass index (BMI), loge-transformed leptin predicted T2DM in insulin-sensitive men [OR 1.56 (1.13-2.17)] but not in insulin-resistant men [OR 1.03 (0.76-1.39)]. The effect of adiponectin and the leptin/adiponectin ratio was not influenced by the insulin sensitivity status. Conclusions: Leptin in men and adiponectin in both sexes were independent predictors of T2DM. The association was modified by the degree of insulin sensitivity. The leptin/adiponectin ratio may add predictive information beyond the separate hormones.

  • 41.
    Lilja, Mikael
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Rolandsson, Olov
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The impact of leptin and adiponectin on incident type 2 diabetes is modified by sex and insulin resistanceManuscript (preprint) (Other academic)
    Abstract [en]

    Background Adiponectin and leptin and their ratio have been associated with incident type 2 diabetes (T2DM), although presented data are conflicting and populations studied have been small. In this large prospective nested case referent study, we hypothesised that these associations are sex-specific and may be modified by insulin resistance.

    Methods Men and women aged 30–60 years with incident T2DM (n=640) and a prior health survey within the Västerbotten Intervention Programme (VIP), and matched referents (n=1564) were identified. Using conditional logistic regression analyses, we tested whether baseline plasma adiponectin and leptin levels and their ratio independently predicted incident T2DM, stratified for gender and insulin resistance.

    Results Adjusted for traditional risk factors, fourth-quartile levels of adiponectin were associated with a reduced risk of T2DM in men (OR 0.55 [0.36–0.86]) and women (OR 0.47 [0.27–0.83]). Quartile four of the leptin/adiponectin ratio predicted T2DM in both men (OR 3.08 [1.68–5.67]) and women (OR 3.31 [1.56–7.03]), while quartile-four levels of leptin predicted T2DM only in men (OR 2.30 [1.32–4.02]). When stratified for insulin sensitivity and adjusted for BMI, loge-transformed leptin predicted T2DM in insulin-sensitive men (OR 1.56 [1.13–2.17]) but not in insulin-resistant men (OR 1.03 [0.76–1.39]). The effect of adiponectin and the leptin/adiponectin ratio was not influenced by the insulin sensitivity status.

    Conclusions Leptin in men and adiponectin in both sexes were independent predictors of T2DM. The association was modified by the degree of insulin sensitivity. The leptin/adiponectin ratio may add predictive information beyond the separate hormones

  • 42.
    Lindahl, Bernt
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Johansson, Helene
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lindvall, Kristina
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Nordin, Maria
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Nordin, Steven
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Persson, Amanda
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Vanoli, Davide
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Schulz, Peter J.
    Institute of Communication and Health, University of Lugano, Switzerland.
    Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk2020In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 27, no 2, p. 209-215Article in journal (Refereed)
    Abstract [en]

    Aims: Health literacy, the degree to which individuals understand and act upon health information, may have a pivotal role in the prevention of cardiovascular disease (CVD), with low health literacy potentially explaining poorer adherence to prevention guidelines. We investigated the associations between health literacy, ultrasound-detected carotid atherosclerosis and cardiovascular risk factors.

    Methods: Baseline data (cross-sectional analysis) from a randomized controlled trial, integrated within the Västerbotten Intervention Program, Northern Sweden, was used. We included 3459 individuals, aged 40 or 50 years with ≥1 conventional risk factor or aged 60 years old. The participants underwent clinical examination, blood sampling, carotid ultrasound assessment of intima-media wall thickness (CIMT) and plaque formation, and answered a questionnaire on health literacy – the Brief Health Literacy Screen. The European Systematic Coronary Risk Evaluation and Framingham Risk Score were calculated.

    Results: About 20% of the participants had low health literacy. Low health literacy was independently associated with the presence of ultrasound-detected carotid artery plaques after adjustment for age and education, odds ratio (95% confidence interval) 1.54 (1.28–1.85), demonstrating a similar level of risk as for smoking. Health literacy was associated with CIMT in men. Low health literacy was associated with higher CVD risk scores. Sensitivity analyses with low health literacy set to 9% or 30% of the study sample, respectively, yielded essentially the same results.

    Conclusions: Low health literacy was independently associated with carotid artery plaques and a high level of CVD risk scores. Presenting health information in a fashion that is understood by all patients may improve preventive efforts.

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  • 43.
    Lindahl, Bernt
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Stenlund, Hans
    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.
    Increasing glucose concentrations and prevalence of diabetes mellitus in northern Sweden, 1990-20072010In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 3, p. Article nr 5222-Article in journal (Refereed)
    Abstract [en]

    Background: The prevalence of diabetes in the world is projected to rise from 2.8% in the year 2000 to 4.4% in 2030, an increase suggesting an ongoing global epidemic of diabetes.

    Objective: To examine time trends in fasting and 2-h glucose concentrations, prevalence and 10-year cumulative incidence of diabetes, and the role of education in these trends. Design: Each year the Vasterbotten Intervention Programme invites all 40, 50, and 60-year-old individuals to a health survey, which includes a cardiovascular risk factor screening and oral glucose tolerance test. The cross-sectional part of the study is based on health examinations conducted between 1990 and 2007 (n = 102,822). The prospective subset (panel dataset) of the study is based on individuals who have had two health examinations 10 years apart and were not defined as having diabetes at their first health examination (n = 23,546).

    Results: Between 1990 and 2007, the mean population fasting glucose concentration increased 0.5 mmol/L. Comparing the prevalence in 1990-1995 with 2002-2007 demonstrated a significant 44% increase in men (p < 0.001) and a significant 17% increase in women (p < 0.001). Socioeconomic status, here represented by education, clearly influenced both prevalence and incidence of diabetes and glucose concentration. In all time periods and in all age groups, individuals with low education were more likely to have or get diabetes. The 10-year risk of developing diabetes was four to five times higher in the oldest age group (50-60 years) compared with the youngest (30-40 years). A 30% reduction in the 10-year risk of developing diabetes was found in women (p < 0.001) between 2000-2003 and 2004-2007.

    Conclusions: Despite a clear increase in glucose concentrations and diabetes prevalence between 1990 and 2007, especially in men, there was a decline in the 10-year risk of developing diabetes in women between 2000-2003 and 2004-2007.

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    Increasing glucose concentrations and prevalence of diabetes mellitus in northern Sweden, 1990-2007
  • 44.
    Lindholm, Lars
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenling, Anna
    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.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A cost-effectiveness analysis of a community based CVD program in Sweden based on a retrospective register cohort2018In: BMC Public Health, E-ISSN 1471-2458, Vol. 18, article id 452Article in journal (Refereed)
    Abstract [en]

    Background: Several large scale community-based cardiovascular disease prevention programs were initiated in the 80s, and one was the Västerbotten Intervention Programme, Sweden. As an initial step in 1985, a pilot study was introduced in the Norsjö municipality that combined individual disease prevention efforts among the middle-aged population with community-oriented health promotion activities. All citizens at 30, 40, 50, and 60 years of age were invited to a physical examination combined with a healthy dialogue at the local primary health care centre. Västerbotten Intervention Program is still running following the same lines and is now a part of the ordinary public health in the county. The purpose of this study is to estimate the costs of running Västerbotten Intervention Programme from 1990 to 2006, versus the health gains and savings reasonably attributable to the program during the same time period. Methods: A previous study estimated the number of prevented deaths during the period 1990-2006 which can be attributed to the programme. We used this estimate and calculated the number of QALYs gained, as well as savings in resources due to prevented non-fatal cases during the time period 1990 to 2006. Costs for the programmes were based on previously published scientific articles as well as current cost data from the county council, who is responsible for the programme. Result: The cost per QALY gained from a societal perspective is SEK 650 (Euro 68). From a health care sector perspective, the savings attributable to the VIP exceeded its costs. Conclusion: Our analysis shows that Västerbotten Intervention Programme is extremely cost-effective in relation to the Swedish threshold value (SEK 500000 per QALY gained or Euro 53,000 per QALY gained). Other research has also shown a favorable effect of Västerbotten Intervention Programme on population health and the health gap. We therefore argue that all health care organizations, acting in settings reasonably similar to Sweden, have good incentive to implement programs like Västerbotten Intervention Programme.

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  • 45.
    Lindvall, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jenkins, Paul
    Emmelin, Maria
    Lund Univ, Dept Clin Sci Social Med & Global Hlth.
    Scribani, Melissa
    Bassett Healthcare Network Res Inst.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Larsson, Christel
    Umeå University, Faculty of Social Sciences, Department of Food and Nutrition.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS).
    Primary weight maintenance: an observational study exploring candidate variables for intervention2013In: Nutrition Journal, ISSN 1475-2891, E-ISSN 1475-2891, Vol. 12, p. 97-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Previous studies have focused on weight maintenance following weight loss, i.e. secondary weight maintenance (SWM). The long-term results of SWM have been rather modest and it has been suggested that preventing initial weight gain, i.e. primary weight maintenance (PWM), may be more successful. Therefore, developing a prevention strategy focused on PWM, enabling normal weight or overweight individuals to maintain their weight, would be of great interest. The aim of this study was to identify attitudes, strategies, and behaviors that are predictive of PWM in different age, sex and BMI groups in Northern Sweden. METHODS: A questionnaire was mailed to 3497 individuals in a Swedish population that had two measured weights taken ten years apart, as participants in the Västerbotten Intervention Programme. Subjects were between 41-63 years of age at the time of the survey, had a baseline BMI of 20-30, and a ten year percent change in BMI greater than -3%. The respondents were divided into twelve subgroups based on baseline age (30, 40 and 50), sex and BMI (normal weight and overweight). Analysis of variance (ANOVA), correlation, and linear regression were performed to identify independent predictors of PWM. RESULTS: Of the 166 predictors tested, 152 (91.6%) were predictive of PWM in at least one subgroup. However, only 7 of these 152 variables (4.6%) were significant in 6 subgroups or more. The number of significant predictors of PWM was higher for male (35.8) than female (27.5) subgroups (p=0.044). There was a tendency (non significant) for normal weight subgroups to have a higher number of predictors (35.3) than overweight subgroups (28.0). Adjusted R-squared values ranged from 0.1 to 0.420. CONCLUSIONS: The large number of PWM predictors identified, and accompanying high R-squared values, provide a promising first step towards the development of PWM interventions. The large disparity in the pattern of significant variables between subgroups suggests that these interventions should be tailored to the person's demographic (age, sex and BMI). The next steps should be directed towards evaluation of these predictors for causal potential.

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  • 46.
    Lindvall, Kristina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jenkins, Paul
    Scribani, Melissa
    Emmelin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Larsson, Christel
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Weinehall, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Comparisons of weight change, eating habits and physical activity between women in Northern Sweden and Rural New York State-results from a longitudinal study2015In: Nutrition Journal, ISSN 1475-2891, E-ISSN 1475-2891, Vol. 14, article id 88Article in journal (Refereed)
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  • 47.
    Ljungberg, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Holmgren, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Biobank Research.
    Hultdin, Johan
    Umeå University, Faculty of Medicine, Department of Medical Biosciences, Clinical chemistry.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Näslund, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Lipoprotein(a) and the Apolipoprotein B/A1 Ratio Independently Associate With Surgery for Aortic Stenosis Only in Patients With Concomitant Coronary Artery Disease2017In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 6, no 12, article id e007160Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Aortic stenosis (AS) has different clinical phenotypes, including AS with or without concomitant coronary artery disease (CAD). It is unknown whether these phenotypes share the same risk factors. In particular, lipoprotein(a) [Lp(a)] and apolipoproteins (Apo) are associated with AS, but it is unknown whether these associations differ among phenotypes. In this prospective analysis we examined the impact of Lp(a) and Apo in subgroups of patients with AS.

    METHODS AND RESULTS: We identified 336 patients (mean age at survey 56.7 years, 48% female) who underwent surgery for AS after a median 10.9 years (interquartile range 9.3 years), participants in 1 of 3 large population surveys. For each patient, 2 matched referents were allocated. Lp(a) and Apo were analyzed in the baseline samples. Uni- and multivariable logistic regression analyses were used to estimate risks related to a 1 (ln) standard deviation increase in Lp(a) and the ratio of Apo B to Apo A1 (Apo B/A1 ratio). High levels of Lp(a) predicted surgery for AS in 203 patients with concomitant CAD (odds ratio [95% confidence intervals]) (1.29 [1.07-1.55]), but not in 132 patients without CAD (1.04 [0.83-1.29]) in the fully adjusted model. Similarly, a high Apo B/A1 ratio predicted surgery in patients with concomitant CAD (1.43 [1.16-1.76]) but not in those without CAD (0.87 [0.69-1.10]).

    CONCLUSIONS: High levels of Lp(a) and a high Apo B/A1 ratio were associated with surgery for AS in patients with concomitant CAD but not in those with isolated AS. This finding may lead to a new avenue of research for targeted risk factor interventions in this population.

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  • 48.
    Ljungberg, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Albertsson, Elin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Holmer, Paul
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Biobank Research.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Traditional Cardiovascular Risk Factors and Their Relation to Future Surgery for Valvular Heart Disease or Ascending Aortic Disease: A Case-Referent Study2017In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 6, no 5, article id e005133Article in journal (Refereed)
    Abstract [en]

    Background: Risk factors for developing heart valve and ascending aortic disease are based mainly on retrospective data. To elucidate these factors in a prospective manner, we have performed a nested case-referent study using data from large, population-based surveys. Methods and Results: A total of 777 patients operated for heart valve disease or disease of the ascending aorta had previously participated in population-based health surveys in Northern Sweden. Median time (interquartile range) from survey to surgery was 10.5 (9.0) years. Primary indications for surgery were aortic stenosis (41%), aortic regurgitation (12%), mitral regurgitation (23%), and dilatation/dissection of the ascending aorta (17%). For each case, referents were allocated, matched for age, sex, and geographical area. In multivariable models, surgery for aortic stenosis was predicted by hypertension, high cholesterol levels, diabetes mellitus, and active smoking. Surgery for aortic regurgitation was associated with a low cholesterol level, whereas a high cholesterol level predicted surgery for mitral regurgitation. Hypertension, blood pressure, and previous smoking predicted surgery for disease of the ascending aorta whereas diabetes mellitus was associated with reduced risk. After exclusion of cases with coronary atherosclerosis, only the inverse associations between cholesterol and aortic regurgitation and between diabetes mellitus and disease of the ascending aorta remained. Conclusions: This is the first truly prospective study of traditional cardiovascular risk factors and their association with valvular heart disease and disease of the ascending aorta. We confirm the strong association between traditional risk factors and aortic stenosis, but only in patients with concomitant coronary artery disease. In isolated valvular heart disease, the impact of traditional risk factors is varying.

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  • 49.
    Ljungberg, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Bergdahl, Ingvar A
    Umeå University, Faculty of Medicine, Department of Biobank Research.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology.
    Arterial hypertension and diastolic blood pressure associate with aortic stenosis2019In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 53, no 2, p. 91-97Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Due to age-related differences in aortic valve structure, it is likely that the pathophysiology of aortic stenosis (AS) and associated risk factors differ between age groups. Here we prospectively studied the influence of traditional cardiovascular risk factors on AS development requiring surgery among patients without concomitant coronary artery disease (CAD) and stratified for age.

    DESIGN: This study included 322 patients, who had prior to surgery for AS participated in population-based surveys, and 131 of them had no visible CAD upon preoperative coronary angiogram. For each case, we selected four referents matched for age, gender, and geographic area. To identify predictors for surgery, we used multivariable conditional logistic regression with a model including arterial hypertension (or measured blood pressure and antihypertensive medication), cholesterol levels, diabetes, body mass index (BMI), and smoking.

    RESULTS: In patients without CAD, future surgery for AS was associated with arterial hypertension and elevated levels of diastolic blood pressure in patients younger than 60 years at surgery (odds ratio [95% confidence interval]), (3.40 [1.45-7.93] and 1.60 [1.09-2.37], respectively), and with only impaired fasting glucose tolerance in patients 60 years or older at surgery (3.22 [1.19-8.76]).

    CONCLUSION: Arterial hypertension and elevated diastolic blood pressure are associated with a risk for AS requiring surgery in subjects below 60 years of age. Strict blood pressure control in this group is strongly advocated to avoid other cardiovascular diseases correlated to hypertension. If hypertension and elevated diastolic blood pressure are risk factors for developing AS requiring surgery need further investigations. Notably, elevated fasting glucose levels were related to AS requiring surgery in older adults without concomitant CAD.

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  • 50.
    Ljungberg, Johan
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Johansson, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Bergdahl, Ingvar A.
    Umeå University, Faculty of Medicine, Department of Biobank Research.
    Söderberg, Stefan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Arterial hypertension and elevated diastolic blood pressure is associated with developing aortic stenosis requiring surgery in persons less than 60 years of ageManuscript (preprint) (Other academic)
    Abstract [en]

    Background:  Due to age-related differences in aortic valve structure, it is likely that the pathophysiology of aortic stenosis and associated risk factors differ between age groups. Here we prospectively studied the influence of traditional cardiovascular risk factors on aortic stenosis development among patients without concomitant coronary artery disease, and stratified for age. 

    Methods: This study included 131 patients from previous population-based surveys, who underwent surgery for aortic stenosis and had no visible coronary arteriosclerosis upon preoperative coronary angiogram. The younger group included 49 patients of <60 years old at surgery: median age, 54.4 years; median follow-up, 8.7 years. The older group included 82 patients of ≥60 years old at surgery: median age, 71.3 years; median follow-up, 11.0 years. For each case, we selected four referents matched for age, gender, and geographic area. To identify predictors for surgery, we used multivariable conditional logistic regression with a model including arterial hypertension, cholesterol levels, diabetes, BMI, and smoking. 

    Results:  Future surgery for aortic stenosis was associated with arterial hypertension and elevated levels of diastolic blood pressure in the younger group (odds ratio, 3.40; 95% confidence interval, 1.45–7.93, and odds ratio 1,60; 95% confidence interval, 1.09–2.37, respectively), and with only impaired fasting glucose tolerance in the older group (odds ratio, 3.22; 95% confidence interval, 1.19–8.76). 

    Conclusion: Arterial hypertension and elevated diastolic blood pressure are associated with a risk for aortic stenosis development in subjects below 60 years of age. Strict blood pressure control in this group are strongly advocated to avoid other cardiovascular diseases correlated to hypertension. If hypertension and elevated diastolic blood pressure are risk for developing aortic stenosis need further investigations. Notably, elevated fasting glucose levels were related to aortic stenosis in older adults without concomitant coronary artery disease. 

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