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- Norberg, Margareta, 1951-
(författare)
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Identifying risk of type 2 diabetes : epidemiologic perspectives from biomarkers to lifestyle
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Type 2 diabetes is a significant health problem because of its high prevalence and strong association with cardiovascular morbidity and mortality. An increase of type 2 diabetes is predicted due to increasing obesity and sedentary lifestyle habits. The development from latent to diagnostic disease spans many years and during this time it is possible to prevent or postpone type 2 diabetes using lifestyle and pharmacological interventions. The objective of this thesis is to investigate and describe early patterns and risk indicators of type 2 diabetes. The focus is on type 2 diabetes as one component in metabolic syndrome, i.e. the clustering of several cardiovascular risk markers. Two studies based on the Västerbotten Intervention Programme (VIP) provided the data; one case-referent study nested within VIP which includes 237 diabetes cases that were clinically diagnosed 5.4 years after the health survey, each with two referents; and one panel study with 5 consecutive annual cohorts including subjects that participated in VIP between1990 and 1994 and returned to a follow-up after 10 years, a total of 16 492 individuals. Associations between risk markers and type 2 diabetes or metabolic syndrome are evaluated by several statistical techniques. A model of metabolic syndrome is hypothesized. A prediction model for developing type 2 diabetes among middle-aged individuals is proposed, where high risk is defined as having at least two out of three risk criteria (fasting plasma glucose ≥6.1 mmol/L, HbA1c ≥4.7% (Swedish Mono-S standard) and BMI ≥27 in men and BMI ≥30 in women). With positive predictive values of 32% in men and 46% in women, this model performs at least as well as other published prediction models. Information on family history of diabetes does not improve the result and the cumbersome oral glucose tolerance test is not needed. Therefore this model should be feasible for use in routine care. A model of metabolic syndrome with five composite factors, based on 14 variables including markers produced by adipose tissue and b-cells, suggest that obesity with insulin resistance and b-cell decompensation are the core perturbations in the early stages of type 2 diabetes, while inflammation and dyslipidemia could not be shown to be independent early risk indicators. The composite factors do not improve the prediction as compared to the single markers of fasting glucose, BMI and proinsulin and, possibly blood pressure values. Stress (measured as passive or tense working conditions) and weak social support (measured as emotional support), are suggested to be strong risk indicators along with high BMI for type 2 diabetes in women. In men BMI is predictive, but the stress variables are not shown to be associated with future type 2 diabetes. A social gap is indicated by double risk of metabolic syndrome among subjects with low (≤ 9 years at school) compared to high education (≥ 13 years). High consumption of Swedish smokeless tobacco, snuff (>4 cans/week), is independently associated with metabolic syndrome, obesity and hypertriglyceridemia, but not with dysregulation of glucose. To conclude, single markers, that are commonly used in daily practice, are useful and sufficient for identification of subjects that are in the early stages of type 2 diabetes. Obesity with insulin resistance and b-cell decompensation are the core perturbations in early development to T2DM. Lifestyle, socioeconomic and psychosocial markers, in addition to biomarkers, are important determinants of future type 2 diabetes and metabolic syndrome, albeit not similarly among men and women.
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| 2. |
- Pujilestari, Cahya Utamie, 1982-
(författare)
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Abdominal obesity among older population in Indonesia : socioeconomic and gender inequality, pattern and impacts on disability and death
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Population ageing has contributed to the rise of chronic non-communicable diseases (NCDs). Concurrently, obesity prevalence is increasing in all age groups and has become a serious public health problem. Obesity is the main risk factors of the major chronic NCDs such as type 2 diabetes and has been linked to disability and mortality. Studies of socioeconomic inequalities in obesity among older people in Indonesia are scarce. Understanding socioeconomic inequalities are essential to develop appropriate health programme to improve the population health. This thesis describes the pattern of socioeconomic and gender inequality in abdominal obesity and analyses its impact on disability and all-cause mortality among older people in Indonesia.Methods: This thesis is based on four studies conducted in Purworejo Health and Demographic Surveillance System (HDSS) site in Purworejo district, Central Java, Indonesia. This thesis uses both quantitative and qualitative methods. The qualitative study (sub-study 1) was based on 12 Focus Group Discussions (FGDs) with 68 participants from different age groups, sex, and living area. Content analysis was used to describe the community perceptions on diabetes and its risk factors. The quantitative studies (sub-study 2 to 4) utilized longitudinal panel data from the 1st (n = 11,753 individuals) and 2nd wave (n = 14,235 individuals) of the WHO-INDEPTH Study on global AGEing and adult health (SAGE) conducted among all individuals aged 50 years and older in 2007 and 2010. Sub-study 2 used concentration index and decomposition analysis to analyse the pattern of socioeconomic and gender inequality in abdominal obesity. Sub-study 3 used linear regression to examine the association between abdominal obesity and disability. Sub-study 4 used Cox regression analysis with restricted cubic splines to examine the impact of abdominal obesity on all-cause mortality.Results: The FGDs reveals that the community holds unrealistic optimism in perceiving diabetes its risk factors. The community stated that chronic NCD such as diabetes is caused by modern lifestyles and mostly attacks those who are considered as the wealthy (sub-study 1). Socioeconomic inequality in abdominal obesity exists in Purworejo HDSS. Abdominal obesity was more prevalent among the affluent men and women, with a lesser inequality gaps between rich and poor among women. The main contributing factors to inequalities in abdominal obesity were occupation, wealth index, and education (sub-study 2). In three-year period, the mean waist circumference decreased significantly among the poor. An increase in waist circumference was significantly associated with disability, and the poor people were more disabled compared to the rich (sub-study 3). A U-shaped association was observed between waist circumference and all-cause mortality, particularly among women. This indicated an increased risk of mortality in the lower and upper end of the waist circumference distribution. The poor with low waist circumference had a higher risk of mortality than the rich (sub-study 4).Conclusion: Abdominal obesity was disproportionately more prevalent among older Indonesian women. Though the wealthy people have higher burden of abdominal obesity, the poor people experiences more disability and higher risk of death. Misperception on chronic NCDs and its risk factors exist among the Indonesian population. Abdominal obesity prevention strategies are needed to prevent chronic NCDs, disabilities, and mortality among Indonesian older population. The prevention strategies should be culturally sensitive and address all socioeconomic levels. Special attention should be given to disadvantaged women as the most vulnerable group.
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| 3. |
- Bengtsson, Anna, 1973-
(författare)
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Pictorial presentation of subclinical atherosclerosis : a measure to reduce the risk for cardiovascular disease
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim was improved cardiovascular disease (CVD) prevention through the VIPVIZA intervention. This includes the provision of pictorial information of subclinical atherosclerosis to participants and their general practitioners (GPs), follow-up phone call, and written information to the participant. VIPVIZA is a Prospective Randomized Open Blinded End-point (PROBE) trial nested within VIP, a CVD prevention program in primary health care in Västerbotten county, Sweden. Middle-aged individuals at low/intermediate CVD risk were enrolled to VIPVIZA and randomized 1:1 to an intervention (n=1749) or control group (n=1783 who received no pictorial or other information). Preventive measures were managed within primary health care.At baseline, clinical risk factors were measured and carotid ultrasound examination was performed. The prevalence of subclinical atherosclerotic disease was assessed as intima media thickness and presence of plaque. The association between clinical risk factors and measures of subclinical atherosclerosis was investigated. In addition to conventional risk factor-based risk evaluation, the impact of the VIPVIZA intervention on CVD risk, traditional risk factors and pharmacological treatment was evaluated after 1 and 3 years. Individual interviews were conducted with 15 GPs to explore how a pictorial representation of subclinical atherosclerosis affects physicians in their perception and communication of CVD risk. The interviews were analyzed by qualitative content analysis.The plaque prevalence was 44.7% in this population. Clinical risk factors explained more of the variation in a combined ultrasound measurement than single measurements. The results up to three years showed a VIPVIZA intervention effect, with lower and sustained CVD risk in the intervention as compared to the control group. The effect was partly mediated by differences in intake of lipid-lowering medication and partly by lifestyle behaviour. The GPs described their risk assessment and patients’ risk perception as more accurate with the VIPVIZA intervention. Informing patients about examination results prior to a consultation can facilitate shared decision-making and enhance adherence to preventive measures.The results show that the VIPVIZA intervention reduces CVD risk over three years. In the long run this has the potential to reduce the incidence of CVD events.
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| 4. |
- Brower Scribani, Melissa, 1979-
(författare)
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Insights on weight maintenance and impacts of obesity for two rural populations in the United States and Sweden
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Obesity is a serious public health concern worldwide, and nearly 40% of all adults in the United States and 21% in Sweden are now living with obesity. Efforts focusing mainly on weight loss have fallen short in reducing obesity prevalence. There is a great need for improved insight into what factors may promote a healthy weight, thereby avoiding the adverse health outcomes linked to obesity. Primary weight maintenance is a prevention strategy that emphasizes keeping a long-term stable weight in the non-obese range.Aim: The overall aims of this thesis were to improve understanding of the patterns of obesity and obesity-related mortality among rural adults in Central New York State (U.S.) and Västerbotten County (Sweden), and to explore factors that are related to primary weight maintenance.Material and methods: Data from U.S. health surveys and health examinations in Sweden were used to compare twenty-year (1989-2009) trends in body mass index (BMI) and obesity using multi-factor analysis of variance. The association between obesity and risk of 1) premature all-cause death, and 2) premature circulatory death, was compared between the U.S. and Sweden using proportional hazards regression. In 2009, a longitudinal questionnaire of attitudes, behaviors and perceptions regarding weight maintenance was administered to U.S. subjects. Associations between ten-year weight change and survey variables were tested using multiple linear regression, separately for sex and age strata. To gain a deeper understanding of influences, facilitators and barriers to healthy eating and physical activity, a qualitative interview study was conducted with U.S. women aged 26-35, with data analyzed by qualitative content analysis.Results: Over twenty years, BMI increased for both men and women in all age strata in both countries, and those with no university education consistently had higher BMI than their university-educated counterparts. BMI increased more for younger groups (ages 36-45) compared to those aged 46-55 and 56-62. U.S. females aged 36-45 showed the greatest increases in average BMI, particularly when comparing 1999 to 2009. Increases in the prevalence of obesity (BMI≥30) in Sweden were more modest than in the U.S. Severe obesity (BMI≥35) was associated with significantly increased risk of premature death from all causes and from circulatory causes for all subjects. Severe obesity was less common in Sweden (2% of men, 3% of women) than in the U.S. (8% of men, 9% of women). Nonetheless, severely obese Swedish men had 2.9 times the risk of premature death from all causes compared to those of normal weight, and 4.9 times the risk for circulatory causes. The gradient of risk among U.S. men was significantly lower than in Sweden; those with severe obesity had a 1.6 times increased risk for all-cause premature death and 3.2 times increased risk for premature circulatory death. The pattern of risk among women did not differ between countries. Longitudinal analysis of U.S. health survey participants showed that women aged 26-35 gained the most weight of any group (mean=10.3kg gained over ten years). The variables found to be associated with ten-year weight change were different across sex and age groups. Among women, all variables associated with weight change were exercise-related. Among men, three of the four predictors were focused on eating habits. Interviews with women aged 26-35 revealed the challenges of healthy eating and engaging in physical activity. Women often identified as caregivers for others, and those with more social support, who were financially stable and showed self-efficacy around healthy choices were able to more consistently engage in healthy habits.Conclusions: Obesity is an increasing problem for the rural adult population in both the U.S. and Sweden. When primary weight maintenance strategies are designed to support individuals towards healthy eating and increased physical activity, the complexity of the living environment must be considered. Individual conditions and personal relationships as well as the physical environment, home environment and work environment must be included in the assessment. Development of targeted programs for primary weight maintenance should be a focus of public health work for adults in rural areas in both Sweden and the U.S.
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