Scandinavian Journal of Public Health

Aims: To explore the effects of body fat percentage (BF%) on incidence of and mortality from cardiovascular disease (CVD) and to study the cardio-protective effect of physical activity in relation to BF%. Methods: A total of 26,942 men and women, aged 45—73 years, without history of CVD were followed up for incidence of coronary events (CE), ischaemic stroke, and CVD mortality over seven years in relation to sex-specific quartiles (Q1—Q4) of BF%. The cardio-protective effect of leisure-time physical activity was studied in relation to BF%. Results: In men, the relative risk (RR) for CE and CVD mortality increased progressively with BF%. RR for CE in Q4 was 1.37 (95% confidence interval: 1.07—1.74), adjusted for age, height, smoking, high alcohol intake, and physical activity, compared with Q1. In women, BF% was significantly associated with incidence of CE and stroke. BF% was more strongly correlated to body mass index (BMI) (r=0.83) and waist circumference (r=0.76) in women than in men (r=0.59 and r=0.66, respectively). BF% was a stronger risk factor than BMI in women, and equally strong as waist circumference. A significant interaction (p=0.013 for incidence of CE, p=0.026 for ischaemic stroke) was found between BF% and sex. The raised cardiovascular risk was reduced by physical activity in subjects with high BF%. Conclusions: BF% is a risk factor for CE, ischaemic stroke, and CVD mortality. An interaction between BF% and sex suggests that BF% is a stronger CVD risk factor in women. The raised cardiovascular risk associated with high BF% is reduced by physical activity.

Aim: Combined effects of genetic and environmental factors underlie the clustering of cardiovascular risk factors in the metabolic syndrome (MetSy). The aim was to investigate associations between several lifestyle factors and MetSy, with a focus on the possible role of smokeless tobacco in the form of Swedish moist snuff (snus). Methods: A population-based longitudinal cohort study within the Västerbotten Intervention Programme in Northern Sweden. All inhabitants at the ages of 30, 40, 50, and 60 are invited to participate in a health survey that includes a questionnaire on psychosocial conditions and lifestyle and measurement of biological variables. Individuals examined in 1990—94 (n=24,230) and who also returned for follow-up after 10 years were included (total of 16,492 individuals: 46.6% men and 53.4% women). Regression analyses were performed. MetSy was the outcome and analyses were adjusted for age, sex, alcohol abuse, and family history of CVD and diabetes. Results: Ten-year development of MetSy was associated with high-dose consumption of snus at baseline (OR 1.6 [95% CI 1.26—2.15]), low education (2.2 [1.92—2.63]), physical inactivity (1.5 [1.22—1.73]) and former smoking (1.2 [1.06—1.38]). Snus was associated with separate components of MetSy, including triglycerides (1.6, 1.30—1.95), obesity (1.7 [1.36—2.18]) but not hypertension, dysglycemia and low HDL cholesterol. Conclusions: MetSy is independently associated with high consumption of snus, even when controlling for smoking status. The finding is of public health interest in societies with widespread use of snus. More research is needed to better understand the mechanisms underlying this effect.

Background: The implication of medication is that a drug is given against an illness. Over the last few decades an expanding number of drugs have appeared that focus on reducing risk factors and lifestyle conditions. Aims: To investigate the apprehension in respect of chronic disease among the working population in a Swedish community in 2000 compared with 1980. Methods: In 1980 and 2000 an analogous questionnaire assessing chronic diseases and medication was mailed to 250 randomly selected persons from a local population between 25 and 70 years of age. Results: Some 80% of the persons (n=201) replied in 1980 and 78% (n=195) in 2000. Individuals declaring a chronic disease increased from 23% (46/201) in 1980 to 39.5% in 2000 (p=0.0005). Corresponding figures for men were 20.6% (20/97) in 1980 and 40.8% (40/98) in 2000 (p=0,004) and for women 25.0% (26/104) in 1980 and 38.1% (37/97) in 2000 (p=0.064). Persons who regularly see a doctor increased from 13% to 26% (p=0.002) and the use of drugs for chronic diseases increased from 19% to 33% (p=0.002). In 2000 an average of 2.3 drugs per person were used among those with a chronic disease, an increase of 53% since 1980. Conclusion: Stated chronic diseases and use of drugs for such diseases increased greatly between1980 and 2000. Prescribing drugs for a ``risk'' with no apparent illness may be confused with the remedy for an illness.

Aims: To study the risk-factor profile for the incidence of non-fatal and fatal stroke among middle-aged men according to the stroke subtypes subarachnoid or intracerebral haemorrhage, cerebral infarction, and unspecified stroke. Methods: The study design is a prospective cohort study. A total of 16,209 men aged 40—49 years resident in Oslo were screened for cardiovascular disease risk factors in 1972—73. Of these, 14,403 men had no cardiovascular symptoms or diseases or diabetes. The incidence of stroke after 21 years of follow-up of all men was extracted from hospital records and linkage to Statistics Norway. Results: A total of 429 non-fatal and 107 fatal stroke events were registered. Case fatality within 28 days (number and percentage of cases) was 51% (41, 7.7%) for subarachnoid haemorrhage, 39% (67, 12.6%) for cerebral haemorrhage, 10% (246, 46.3%) for cerebral infarct, and 19% (177, 33.4%) for unspecified stroke. Risk of stroke (not subarachnoid haemorrhage) increased with the presence of symptoms or a history of cardiovascular disease or diabetes. In multivariate analysis of men without CVD or diabetes, high blood pressure was a risk factor for all subtypes of stroke; furthermore, daily smoking was a risk factor for all subtypes except subarachnoid haemorrhage. Serum cholesterol and glucose concentrations and height (inverse association) were independently associated with cerebral infarction. Smoking was a significantly stronger predictor of fatal than non-fatal events. Conclusions: The risk-factor profile differed according to the underlying subtype of stroke. Cerebral infarction clearly shared with myocardial infarction the classical risk factors, including non-fasting glucose concentration.

Aims: To compare primary healthcare (PHC) provided by an independent not-for-profit organization (INPO) with that provided by two public municipal organizations (MO1 and MO2), in terms of clients' perceptions of performance, acceptance, and trust. Methods: A survey using a pre-tested questionnaire to all clients visiting a health centre (HC) doctor or nurse during one week in 2000 (n=511, 51% response rate) and 2002 (n=275, 47%). The data were analysed by descriptive statistics and cumulative logistic regression analysis. Results: The INPO differed from both publicly provided services in accessibility, consistency of service, and outcomes. Clients reported lower trust in HC provided by public organizations compared with the INPO. Trust was higher if clients also reported experiencing ``very good'' or ``moderate'' organizational access — or if general satisfaction was ``very high'' or ``moderate'' or if they experienced outcomes as ``very good'' or ``moderate'' compared with the ``very poor or low'' situation. Women reported lower trust in HC than men. When the family doctor was included in the same logistic regression model with the service provider, only the family doctor was a significant explanatory variable. Reported acceptance of private alternative service providers among clients was similar between the study organizations. Conclusions: Clients of the INPO generally rated the service more positively than clients of publicly provided services. The results indicate that trust in HC depends more on a family doctor system than a service provider.

Aim: Carbon monoxide (CO) in blood as assessed by the COHb% is a marker of the cardiovascular (CV) risk in smokers. Non-smokers exposed to tobacco smoke similarly inhale and absorb CO. The objective in this population-based cohort study has been to describe inter-individual differences in COHb% in never smokers and to estimate the associated cardiovascular risk. Methods: Of the 8,333 men, aged 34—49 years, from the city of Malmö, Sweden, 4,111 were smokers, 1,229 ex-smokers, and 2,893 were never smokers. Incidence of CV disease was monitored over 19 years of follow up. Results: COHb% in never smokers ranged from 0.13% to 5.47%. Never smokers with COHb% in the top quartile (above 0.67%) had a significantly higher incidence of cardiac events and deaths; relative risk 3.7 (95% CI 2.0—7.0) and 2.2 (1.4—3.5), respectively, compared with those with COHb% in the lowest quartile (below 0.50%). This risk remained after adjustment for confounding factors. Conclusion: COHb% varied widely between never-smoking men in this urban population. Incidence of CV disease and death in non-smokers was related to COHb%. It is suggested that measurement of COHb% could be part of the risk assessment in non-smoking patients considered at risk of cardiac disease. In random samples from the general population COHb% could be used to assess the size of the population exposed to second-hand smoke.

Objective: To examine whether fruit and vegetable consumption in pregnancy is associated with birth weight in a Western population. Design: Prospective cohort study based on telephone interviews, a food frequency questionnaire (FFQ), and extractions of birth characteristics from national health registries. Subjects and setting: The 43,585 Danish women from the Danish National Birth Cohort who had completed the FFQ in mid-pregnancy and on whom information about birth outcome was available. The exposures were frequency of green leafy vegetable (GLV) intake and quantified intake of fruit, fruit and vegetables, and fruit and vegetables and juice. The outcomes were birth weight and z-score for expected birth weight adjusted for sex and gestation week. Information on maternal height, weight, smoking, and other potential confounders was obtained through telephone interviews. Results: Significant associations were found for all exposures to fruit and vegetable intake with birth weight and most with z-score. The strongest association was found for fruit intake in which case birth weight increased by 10.7 g (95% CI 7.3—14.2) per quintile. All associations were stronger among lean women (BMI<20, n=7,169), whose children's birth weight increased by 14.6 g (95% CI 6.4—22.9) per quintile increase in fruit intake. For GLV the results were more inconclusive. When adjusted for confounders, but not for energy, the association between GLV and birth weight was significant, but the same was not the case for z-score. Conclusion: Fruit and vegetable consumption in pregnancy is positively associated with birth weight in well-nourished Danish women, especially among lean women.

Background: Decreasing rates of participation in population-based studies increasingly challenge the interpretation of study results, in both analytic and descriptive epidemiology. Consequently, estimates of possible differences between participants and non-participants are increasingly important for the interpretation of study results and generalization to the background population. Methods: An age-specific, population-based cohort of 1,198 individuals was examined at age 40, 45, 51, and 60. Participants were compared with non-participants and when possible also with the background population using a wide range of detailed information on somatic and mental health collected at each examination, including data from a clinical examination, biochemical measurements, questionnaires, interviews, and public registers. Results: Participation rates were higher than 80% at examinations at age 40, 45, and 51, but decreased to 65% at age 60. At the baseline investigation at age 40, analyses indicated that participants were representative of the cohort as well as the background population. However, the mortality rate was higher among non-participants in the succeeding 20 years. Among living cohort members at the 60-year examination, non-participants had lower socioeconomic status, higher hospitalization rate, and a worse overall health profile than participants. Conclusions: The detailed data presented reinforce the contention that the health profile of non-participants is typically worse than that of participants. The results also indicate that while data from public registers give easily accessible information about non-participants, these crude proxy measures of health may not be enough to document representativeness.

Study objective: To (1) describe the setting and design of the Good Ageing in Lahti Region (GOAL) programme; (2) by using the baseline results of the GOAL cohort study, to examine whether living in urban, semi-urban, or rural communities is related to risk factors for chronic diseases and functional disability in ageing individuals. Design: The baseline data of a cohort study of ageing individuals living in three community types (urban, semi-urban, rural). Data were collected by two questionnaires and laboratory assessments. Setting: Fourteen municipalities in the Lahti region (Päijät-Häme County) in Finland. Participants: A regionally and locally stratified random sample of men and women born in 1946—50, 1936—40, and 1926—30. A total of 4,272 were invited and 2,815 (66%) participated. Main results: Elevated serum cholesterol, obesity, disability, sedentary lifestyle (<2 times/week walking), and high fat intake were more prevalent in rural vs. urban and semi-urban communities. After adjustment for sex, age, education, obesity, diet, physical activity, smoking, and alcohol use, rural communities remained the only community type with increased (p<0.05) probability for high BMI (OR 1.33) and high waist circumference (OR 1.43). Conclusions: The unfavourable health and lifestyle profile, together with an old population, makes health promotion for elderly citizens a special challenge for rural communities such as those in Päijät-Häme County, Finland. Most, if not all, of the differences in health between the three community types were explained by educational background, physical activity, and smoking.

Aim: This article aims to review current knowledge concerning the cost-effectiveness of healthcare-based interventions aimed at improving physical activity. Method: A search was performed for economic evaluations containing the terms ``physical activity'', ``exercise'', or ``fitness''. Cost-effectiveness for the articles found was described based on a model for evaluating interventions intended to promote physical activity. Results: A total of 26 articles were found in the search. Nine of them concern a general population, 7 evaluated older people, and 10 studied disease-specific populations. A preventive perspective is most common, but some have a treatment perspective. Around 20 of the interventions studied were cost-effective according to their authors, but all analyses had some shortcomings in their evaluation methods. Conclusion: This review found many examples of cost-effective interventions. There is a lack of evidence for the cost-effectiveness of interventions aimed at those whose only risk factor for illness is a sedentary lifestyle. There is more evidence, although it is limited, for the cost-effectiveness of interventions aimed at high-risk groups or those who manifest poor health related to physical inactivity. Most of the evidence for cost-effectiveness is for older people and those with heart failure. Promotion of physical activity can be cost-effective with different methods and in different settings, but there remains a lack of evidence for specific methods in specific populations.

Aim: To investigate opinions on and experiences of the new Pharmaceutical Benefits Reform (PBR) among physicians working in the Swedish county council of Region Västra Götaland. Methods: Questionnaires were sent to all private practitioners who had contracts with the county council of Region Västra Götaland (n=320) and a random sample of 25% of the doctors employed by the same county council (n=1,068). The questionnaire comprised questions on how the physicians had received information on the PBR and sought opinions on the introduction of generic substitution in pharmacies, workplace codes, individual prescriber codes, and the Pharmaceutical Benefits Board. Analyses were performed with logistic regression. Results: The response rate was 65%. The majority of doctors had received sufficient information about the reform, most often from their employer, followed by the Drug and Therapeutics Committees. More than half of the respondents were positive about the introduction of generic substitution, which was associated with the respondent's age, experiences, and employer. Most of the doctors thought that generic substitution could reduce the health system's pharmaceutical expenditure, which was associated with the employer. One-third reported that generic substitution had caused problems for their patients in the past month. The probability of being mainly positive towards the newly created Pharmaceutical Benefits Board, which decides on reimbursement, increased with increasing age. Conclusions: Most participating doctors had received sufficient information about the reform and thought that generic substitution could save money for society. Age, employer, and experiences appeared to influence opinions on several issues.

Background: Smoking in pregnancy is a well-documented risk factor for fetal growth impairment and poor perinatal outcomes. Less is known about the long-term effects of maternal smoking on offspring mortality. Methods: A follow-up study in national registers on total mortality and cancer based on a birth cohort from Helsingborg, Sweden, including data on 2,010 sons and 1,982 daughters born to mothers for whom the smoking habits during pregnancy (50% smokers) have been recorded. Results: A total of 92 offspring deaths were recorded (54 men, 38 women) during follow-up. Of these deaths, 43 deaths were related to trauma, 6 to circulatory disease, and 2 to endocrine disorders. In men, an elevated mortality risk was associated with increasing maternal smoking habits (p for trend 0.011), but in women with low birth weight (p for trend 0.006). A total of 47 incident offspring cancers were registered (18 in men and 29 in women). No significant relation was noted for maternal smoking habits and cancer in the offspring. Conclusions: Maternal smoking during pregnancy is associated with an increased mortality risk in early adult life for male offspring but not for female offspring. This could represent the possible consequence of an increased susceptibility in male fetuses.

Aim: In cross-sectional studies it may be difficult to ascertain the temporal order of exposure and disease, which may have consequences for causal inference. The authors aimed to illustrate the possible magnitude of this potential bias using data from a cross-sectional study on coffee consumption and work stress in relation to type 2 diabetes. Methods: By a series of computer simulations the authors examined to what extent the observed negative association between type 2 diabetes and high coffee consumption and positive association between type 2 diabetes and high work stress could be due to reverse causality, by assuming that cases changed their exposures in response to development of the disease. Results: If the negative association between coffee and type 2 diabetes was a consequence of reversed causality, 30—40% of the cases would have to decrease their coffee consumption from≥5 cups of coffee per day to 3—4 cups per day and from 3—4 cups per day to≤2 cups of coffee per day. Moreover, approximately 60% of the cases would have to increase their work stress from low to medium work stress and from medium to high work stress, in order to produce the positive association with diabetes that was observed. Conclusion: Even if the type 2 diabetic patients to some extent may have changed their exposure in response to disease development, it seems unlikely that the associations observed between type 2 diabetes, coffee consumption, and work stress are due to this bias.