Involving supermarkets in health promotion interventions in the Danish Project SoL. A practice-oriented qualitative study on the engagement of supermarket staff and managers

BACKGROUND

Supermarkets have been suggested as relevant settings for environmental and educational initiatives encouraging healthier shopping and eating decisions, but in the literature, limited attention has been paid to the context, perspectives, and everyday practices of supermarket staff. The aim of this study was to examine the engagement of supermarket staff in a health promotion project from a practice-oriented perspective.

METHODS

The study was based on qualitative data collected in the supermarket setting of Project SoL; a community-based health promotion project in Denmark. We conducted 26 in-depth interviews with store managers and other key staff members in seven participating supermarkets. In addition, we collected data on planning, implementation, and perceptions of supermarket staff of in-store interventions and other project-related activities. These field data included short telephone interviews, observational notes, photos, and audiotapes of meetings. Data were analysed from the perspective of practice theory.

RESULTS

Although supermarket staff found community-based health promotion meaningful to engage in, the study observed that their engagement was challenged by a business mindset, practical routines and structural requirements favouring sales promotion over health promotion. Nevertheless, there were also examples of how health promotion activities and ways of thinking were successfully incorporated in everyday staff practices during and after Project SoL.

CONCLUSIONS

Our findings point to both potentials and challenges for using supermarkets as settings for health promotion. The voluntary engagement of supermarket staff in community-based health projects cannot stand alone but should be supplemented by more long-lasting strategies and policies regulating this and other food environments. Context-sensitive and practice-oriented analyses in local food environments could inform such strategies and policies to make sure they target unwanted elements and practices and not just individual behavior.

A Community-Based, Participatory, Multi-Component Intervention Increased Sales of Healthy Foods in Local Supermarkets-The Health and Local Community Project (SoL)

Project SoL was a 19-month (September 2012 to April 2014) community-based multi-component intervention based on the supersetting approach that was designed to promote healthier eating and physical activity among children and their families. The aim of this study was to examine the effects of a multi-component intervention (level 1) and a mass media intervention alone (level 2) compared to a control area (level 3) on food sales. The design was quasi-experimental. Weekly sales data for all Coop supermarkets in the intervention and control areas were analysed via longitudinal linear mixed-effects analyses. Significant increases in the sales of fish (total) (29%; p = 0.003), canned fish (31%; p = 0.025) and oatmeal (31%; p = 0.003) were found for the level 1 intervention area compared to the control area. In the level 2 intervention area, significant increases in the sales of vegetables (total) (17%; p = 0.038), fresh vegetables (20%; p = 0.01), dried fruit (51%; p = 0.022), oatmeal (19%; p = 0.008) and wholegrain pasta (58%; p = 0.0007) were found compared to the control area. The sales of canned fish increased by 30% in the level 1 area compared to the level 2 area (p = 0.025). This study demonstrated significant increases in the sales of healthy foods, both in the areas with multi-component and mass media interventions alone compared to the control area.

Cardiac rehabilitation for patients with heart failure: association with readmission and mortality risk

AIMS

To examine the temporal trends and factors associated with national cardiac rehabilitation (CR) referral and compare the risk of hospital readmission and mortality in those referred for CR versus no referral.

METHODS AND RESULTS

This cohort study includes all adult patients alive 120 days from incident heart failure (HF) identified by the Danish Heart Failure Registry (n = 33 257) between 2010 and 2018. Multivariable logistic regression models were used to assess the association between CR referral and patient factors and acute all-cause hospital readmission and mortality at 1 year following HF admission. Overall, 46.7% of HF patients were referred to CR, increasing from 31.7% in 2010 to 52.2% in 2018. Several factors were associated with lower odds of CR referral: male sex [odds ratio (OR): 0.85; 95% confidence interval: 0.80-0.89], older age, unemployment, retirement, living alone, non-Danish ethnic origin, low educational level, New York Heart Association (NYHA) class IV vs. I (OR: 0.75; 0.60-0.95), left ventricular ejection fraction >40%, and comorbidity (stroke, chronic kidney disease, atrial fibrillation/flutter, and diabetes). Myocardial infarction, arthritis, coronary artery bypass grafting, percutaneous coronary intervention, valvular surgery, NYHA class II, and use of angiotensin-converting enzyme inhibitors were associated with higher odds of CR referral. CR referral was associated with lower risk of acute all-cause readmission (OR: 0.92; 0.87-0.97) and all-cause mortality (OR: 0.65; 0.58-0.72).

CONCLUSION

Although increased over time, only one in two HF patients in Denmark were referred to CR in 2018. Strategies are needed to reduce referral disparities, focusing on subgroups of patients at highest risk of non-referral.

The Effects of a Lifestyle Intervention Supported by the InterWalk Smartphone App on Increasing Physical Activity Among Persons With Type 2 Diabetes: Parallel-Group, Randomized Trial

Background

Effective and sustainable implementation of physical activity (PA) in type 2 diabetes (T2D) health care has in general not been successful. Efficacious and contemporary approaches to support PA adherence and adoption are required.

Objective

The primary objective of this study was to investigate the effectiveness of including an app-based (InterWalk) approach in municipality-based rehabilitation to increase moderate-and-vigorous PA (MVPA) across 52 weeks compared with standard care among individuals with T2D.

Methods

The study was designed as a parallel-group, randomized trial with 52 weeks’ intervention and subsequent follow-up for effectiveness (52 weeks from baseline). Participants were recruited between January 2015 and December 2016 and randomly allocated (2:1) into 12 weeks of (1) standard care + InterWalk app–based interval walking training (IWT; IWT group; n=140), or (2) standard care + the standard exercise program (StC group; n=74). Following 12 weeks, the IWT group was encouraged to maintain InterWalk app–based IWT (3 times per week for 30-60 minutes) and the StC group was encouraged to maintain exercise without structured support. Moreover, half of the IWT group (IWTsupport group, n=54) received additional motivational support following the 12-week program until 52-week follow-up. The primary outcome was change in objectively measured MVPA time (minutes/day) from baseline to 52-week follow-up. Key secondary outcomes included changes in self-rated physical and mental health–related quality of life (HRQoL), physical fitness, weight, and waist circumference.

Results

Participants had a mean age of 59.6 (SD 10.6) years and 128/214 (59.8%) were men. No changes in MVPA time were observed from baseline to 52-week follow-up in the StC and IWT groups (least squares means [95% CI] 0.6 [–4.6 to 5.8] and –0.2 [–3.8 to 3.3], respectively) and no differences were observed between the groups (mean difference [95% CI] –0.8 [–8.1 to 6.4] minutes/day; P=.82). Physical HRQoL increased by a mean of 4.3 (95% CI 1.8 to 6.9) 12-item Short-Form Health Survey (SF-12) points more in the IWT group compared with the StC group (Benjamini-Hochberg adjusted P=.007) and waist circumference apparently decreased a mean of –2.3 (95% CI –4.1 to –0.4) cm more in the IWT group compared with the StC group but with a Benjamini-Hochberg adjusted P=.06. No between-group differences were observed among the remaining key secondary outcomes.

Conclusions

Among individuals with T2D referred to municipality-based lifestyle programs, randomization to InterWalk app–based IWT did not increase objectively measured MVPA time over 52 weeks compared with standard health care, although apparent benefits were observed for physical HRQoL.

Trial Registration

ClinicalTrials.gov NCT02341690; https://clinicaltrials.gov/ct2/show/NCT02341690

Patients' assessment of care for type 2 diabetes: Results of the Patient Assessment of Chronic Illness Care scale in a Danish population

Background

The Patient Assessment of Chronic Illness Care (PACIC) scale is the most appropriate for assessing self-reported experience in chronic care. We aimed to validate the PACIC questionnaire by (1) assess patients’ perception of the quality of care for Danish patients with type 2 diabetes, (2) identify which factors are most important to the quality of care designated by the five subscales in PACIC, and (3) the validity of the questionnaire.

Methods

A survey of 7,745 individuals randomly selected from the National Diabetes Registry. Descriptive statistics inter-item and item-rest correlations and factor analysis assessed the PACIC properties. Quality of care was analysed with descriptive statistics; linear and multiple regression assessed the effect of forty-nine covariates on total and subscale scores.

Results

In total, 2,696 individuals with type 2 diabetes completed ≥ 50 % of items. The floor effect for individual items was 8.5–74.5 %; the ceiling effect was 4.1–47.8 %. Cronbach’s alpha was 0.73–0.86 for the five subscales. The comparative fit index (CFI) and the Tucker–Lewis index (TLI) were 0,87, and 0,84, respectively. Mean PACIC score was 2.44 (± 0.04). Respondents, who receive diabetes care primarily at general practice and outpatient clinics had higher scores compared to those receiving care at a private specialist. Receiving rehabilitation was followed by higher scores in all subscales. Those 70 years or older had lower mean total and subscale scores compared to younger patient groups.

A higher number of diabetes visits were associated with higher total scores; a higher number of emergency department visits were associated with lower total scores. The effects of healthcare utilisation on subscale scores varied.

Conclusions

These results provide insight into variations in the quality of provided care and can be used for targeting initiatives towards improving diabetes care. Factors important to the quality of perceived care are having a GP or hospital outpatient clinic as the primary organization. Also having a higher number of visits to the two organizations are perceived as higher quality of care as well as participating in a rehabilitation program. Floor and ceiling effects were comparable to an evaluation of the PACIC questionnaire in a Danish population. Yet, floor effects suggest a need for further evaluation and possible improvement of the PACIC questionnaire in a Danish setting. Total PACIC scores were lower than in other healthcare systems, possible being a result of different contexts and cultures, and of a need for improving diabetes care in Denmark.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07051-6.

Understanding the mechanisms generating outcomes in a Danish peer support intervention for socially vulnerable people with type 2-diabetes: a realist evaluation

BACKGROUND

Despite an increasing use and positive effects of peer support interventions, little is known about how the outcomes are produced. Thus, it is essential not only to measure outcomes, but also to identify the mechanisms by which they are generated. Using a realist evaluation approach, we aimed to identify the mechanisms generating outcomes in a Danish peer support intervention for socially vulnerable people with type 2-diabetes (peers). By investigating the participating peers' interactions, we furthermore examined how their individual contextual factors either facilitated or hindered the mechanisms in operation.

METHODS

We used a multi-method case-study design (n = 9). Data included semi-structured interviews with four key groups of informants (peer, peer supporter, project manager, and a diabetes nurse) for each case (n = 25). Furthermore, we collected survey data from peers both before and after participation (n = 9). The interview data were analysed using a systematic text condensation, and the Intervention-context-actor-mechanism-outcome framework was used to structure the analysis.

RESULTS

We identified 2 groups of mechanisms that improved diabetes self-management and the use of healthcare services (outcomes): 'perceived needs and readiness' and 'encouragement and energy'. However, the mechanisms only generated the intended outcomes among peers with a stable occupation and financial situation, a relatively good health condition, and sufficient energy (all defined as contextual factors). Independent of these contextual factors, 'experience of social and emotional support' was identified as a mechanism within all peers that increased self-care awareness (defined as output). Dependent on whether the contextual factors facilitated or hindered the mechanisms to generate outcomes, we categorised the peers into those who achieved outcomes and those who did not.

CONCLUSIONS

We identified two groups of mechanisms that improved the peers' diabetes self-management and use of healthcare services. The mechanisms only generated the intended outcomes if peers' individual contextual factors facilitated an active interaction with the elements of the intervention. However, independent of these contextual factors, a third group of mechanisms increased self-care awareness among all peers. We highlight the importance of contextual awareness of the target groups in the design and evaluation of peer support interventions for socially vulnerable people with type 2-diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov, Retrospective Registration (20 Jan 2021), registration number NCT04722289 .

Perceived Benefits, Barriers, and Facilitators of a Digital Patient-Reported Outcomes Tool for Routine Diabetes Care: Protocol for a National, Multicenter, Mixed Methods Implementation Study

BACKGROUND

There is growing evidence that digital patient-reported outcome (PRO) questionnaires and PRO-based decision support tools may help improve the active engagement of people with diabetes in self-care, thereby improving the quality of care. However, many barriers still exist for the real-world effectiveness and implementation of such PRO tools in routine care. Furthermore, limited research has evaluated the acceptability, feasibility, and benefits of such tools across different health care settings.

OBJECTIVE

This study aims to evaluate the acceptability, feasibility, and perceived benefits of the Danish digital PRO diabetes tool in different health care settings in Denmark and to determine the factors affecting its implementation. Furthermore, the study evaluates the psychometric characteristics of the Danish PRO Diabetes Questionnaire and the validity of the scoring algorithms for dialogue support. The objective of this study is to guide the ongoing optimization of the PRO diabetes tool, its implementation, and the design of future randomized controlled effectiveness studies.

METHODS

We designed a multicenter, mixed methods, single-arm acceptability-feasibility implementation study protocol to contribute to the real-world pilot test of a new digital PRO diabetes tool in routine diabetes care. The use of the tool involves two main steps. First, the people with diabetes will complete a digital PRO Diabetes Questionnaire in the days before a routine diabetes visit. Second, the health care professional (HCP) will use a digital PRO tool to review the PRO results together with the people with diabetes during the visit. The PRO diabetes tool is designed to encourage and support people to take an active role for the people with diabetes in their own care and to expedite the delivery of person-centered, collaborative, and coordinated care.

RESULTS

A multicenter pilot study protocol and psychometrically designed digital data collection tools for evaluation were developed and deployed as part of a national evaluation of a new digital PRO diabetes intervention. A total of 598 people with diabetes and 34 HCPs completed the study protocol by April 1, 2021.

CONCLUSIONS

A large-scale, mixed methods, multicenter study for evaluating the use of the nationally developed PRO Diabetes Questionnaire in routine care across all health care sectors in Denmark by using the RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) model as a framework has been designed and is ongoing. This study is expected to provide new important and detailed information about the real-world acceptability, perceived relevance, and benefits of the PRO diabetes tool among a large heterogeneous population of people with diabetes in Denmark and HCPs in different care settings. The results will be used to further improve the PRO tool, design implementation facilitation support strategies, and design future controlled effectiveness studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28391.

The Danish SoL Project: Effects of a Multi-Component Community-Based Health Promotion Intervention on Prevention of Overweight among 3-8-Year-Old Children

The aim of the study was to determine the effects of a multi-component community-based health promotion intervention on body mass index (BMI) z-scores and waist circumference (WC) in three- to eight-year-old children. A quasi-experimental design was adopted to evaluate the effects of the SoL intervention involving three intervention and three control communities. The 19-month intervention was based on the supersetting approach and was designed to promote healthier eating and physical activity among children and their families. BMI z-scores and WC were measured at baseline and follow-up. At baseline, 238 (54%) and 214 (51%) of all eligible children were measured from intervention and control, respectively. The change over time in the BMI z-scores of children from the intervention group was significantly different from that of the control group (p = 0.001). BMI z-scores increased over time in the intervention group in contrast to the control group, whose BMI z-scores decreased (difference in change between groups 0.19 z-scores 95% CI 0.08, 0.30). No significant differences were observed for WC. The results showed no favourable effects of the intervention of Project SoL on BMI z-scores and WC in children. Further studies based on a larger sample size and a longer intervention duration are needed.

Integrated personalized diabetes management goes Europe: A multi-disciplinary approach to innovating type 2 diabetes care in Europe

Type 2 diabetes mellitus represents a multi-dimensional challenge for European and global societies alike. Building on an iterative six-step disease management process that leverages feedback loops and utilizes commodity digital tools, the PDM-ProValue study program demonstrated that integrated personalized diabetes management, or iPDM, can improve the standard of care for persons living with diabetes in a sustainable way. The novel "iPDM Goes Europe" consortium strives to advance iPDM adoption by (1) implementing the concept in a value-based healthcare setting for the treatment of persons living with type 2 diabetes, (2) providing tools to assess the patient's physical and mental health status, and (3) exploring new avenues to take advantage of emerging big data resources.

Health Technology Readiness Profiles Among Danish Individuals With Type 2 Diabetes: Cross-Sectional Study

Background

Information technologies (IT) are increasingly implemented in type 2 diabetes (T2D) treatment as a resource for remotely supported health care. However, possible pitfalls of introducing IT in health care are generally overlooked. Specifically, the effectiveness of IT to improve health care may depend on the user’s readiness for health technology.

Objective

We aim to investigate readiness for health technology in relation to mental well-being, sociodemographic, and disease-related characteristics among individuals with T2D.

Methods

Individuals with T2D (aged ≥18 years) who had been referred to self-management education, exercise, diet counseling, smoking cessation, or alcohol counseling completed a questionnaire survey covering (1) background information, (2) the 5-item World Health Organization Well-Being Index (WHO-5), (3) receptiveness to IT use in physical activity, and (4) the Readiness and Enablement Index for Health Technology (READHY), constituted by dimensions related to self-management, social support, and eHealth literacy. Individuals were divided into profiles using cluster analysis based on their READHY scores. Outcomes included differences across profiles in mental well-being, sociodemographic, and disease-related characteristics.

Results

Participants in the study were 155 individuals with T2D with a mean age of 60.2 (SD 10.7) years, 55.5% (86/155) of which were men and 44.5% (69/155) of which were women. Participants were stratified into 5 health technology readiness profiles based on the cluster analysis: Profile 1, high health technology readiness; Profile 2, medium health technology readiness; Profile 3, medium health technology readiness and high level of emotional distress; Profile 4, medium health technology readiness and low-to-medium eHealth literacy; Profile 5, low health technology readiness. No differences in sociodemographic and disease-related characteristics were observed across profiles; however, we identified 3 vulnerable subgroups of individuals: Profile 3 (21/155, 13.5%), younger individuals (mean age of 53.4 years, SD 8.9 years) with low mental well-being (mean 42.7, SD 14.7) and emotional distress (mean 1.69, SD 0.38); Profile 4 (20/155, 12.9%), older individuals (mean age 66.3 years, SD 9.0 years) with less IT use (50.0% used IT for communication) and low-to-medium eHealth literacy; and Profile 5 (36/155, 23.2%) with low mental well-being (mean 43.4, SD 20.1) and low readiness for health technology.

Conclusions

Implementation of IT in health care of individuals with T2D should be based on comprehensive consideration of mental well-being, emotional distress, and readiness for health technology rather than sociodemographic and disease-related characteristics to identify the individuals in need of social support, self-management education, and extensive IT support. A one-size-fits-all approach to IT implementation in health care will potentially increase the risk of treatment failure among the most vulnerable individuals.

Ethnic differences in participation in diabetes education programmes

Background

Immigrants from non-Western countries have a higher prevalence of type 2 diabetes. In addition, immigrants have an increased risk of developing diabetes complications, compared with the general population. Diabetes education programmes facilitate essential knowledge and skills that enable people to manage their condition in daily life. However, fewer immigrants attend and complete diabetes education compared with the general population. The aim of this study is to explore what characterises those who decline and accept participation in diabetes education in relation to ethnicity, household composition and diabetes burden in the family.

Methods

The study population consisted of adults with type 2 diabetes referred to a municipal diabetes centre (n = 1819). Individual medical record data was linked to national registry data. Descriptive statistics and logistic regression models were applied.

Results

Preliminary results showed that 23% of individuals from the study population participated in diabetes education. We found no overall differences in participation rates between the general population and non-Western immigrants (24% vs. 18%, P = 0.12). However, when examining the immigrant groups by language (Arabic, Urdu and Turkish), the results indicated a non-significant tendency: Urdu speaking groups’ participation was similar to the general population (24%), whereas Arabic and Turkish speaking groups had lower participation rates (17% and 11%, P = 0.25/0.40).

Conclusions

The results suggest that there are differences in participation between some immigrant groups and the general population. Increased knowledge about which mechanisms affecting participation in diabetes education programme is required to ensure equal access. Further studies and analyses will explore how immigrants’ social relations enable and/or hamper participation in diabetes education and investigate which factors can be changed to improve participation rates.

Key messages

There are differences in participation in diabetes education programmes across different ethnic groups, which suggests a need for in-depth analysis into which mechanisms that affect participation. The results will be used to give input for future practices that can increase immigrant’s participation and retention in diabetes education programmes.

Culturally sensitive diabetes education supporting ethnic minorities with type 2 diabetes

Background

Ethnic minorities of non-Western origin are at higher risk of type 2 diabetes and diabetes complications, compared to the general population. Diabetes education programmes are essential to support people with diabetes to initiate and sustain behaviours needed to manage their condition throughout their lives. However, shaping diabetes education that provide culturally sensitive education that is acceptable to and supports diabetes self-management among members of ethnic minorities is needed.

Objectives

In this study, we develop and evaluate a culturally sensitive diabetes education programme in a community health setting, focusing on Arabic, Urdu or Turkish languages (n = 100). The programme aims to support ethnic minorities with type 2 diabetes in making health-promoting decisions about their care. Also, it will produce knowledge about methods and tools to improve content and format, and about the skills of those delivering the education. Using design-based research, the development comprised three phases: needs assessment, co-creation and testing. The target groups were actively involved in all phases.

Results

The needs assessment was based on fieldwork, workshops and interviews with the target groups and educators. Data showed that self-blame and learned helplessness undermined health-promoting decisions in the target groups. Also, a lack of clear roles between educators and peer educators, and a limited focus on goal setting in the educational setting was observed. The needs assessment informed the development of a 6 week group-based programme, supported by 11 dialogue tools. Preliminary findings show a high level of programme acceptability and participation as well as engagement in diabetes and care in the target groups.

Conclusions

By actively involving the target groups, health care professionals and as well as health services directly engaged with the target group, the outcomes of the programme are likely to be relevant to individuals and institutions.

Key messages

This study gives voice to ethnic minorities with type 2 diabetes through the co-creation of a diabetes education programme aiming to support health-promoting decisions. Innovative and involving methods are highly relevant to develop acceptable and effective diabetes education programmes targeting ethnic minority groups.

Project SoL-A Community-Based, Multi-Component Health Promotion Intervention to Improve Healthy Eating and Physical Activity Practices among Danish Families with Young Children Part 2: Evaluation

Project SoL is implemented over a period of four years with the aim to promote healthy eating and physical activity among children aged 3⁻8 years by targeting the families in a Danish municipality based on the multi-component, supersetting strategy. Interventions are implemented in childcare centres, schools and supermarkets in three local communities as well as in local mass media and social media during a 19 months period in the Municipality of Bornholm. The matching Municipality of Odsherred serves as a control site based on its similarity to Bornholm regarding several socio-demographic and health indicators. The present paper gives an account of the design used for the summative and formative evaluation based on a realistic evaluation and a mixed methods approach combining qualitative and quantitative methods. Summative studies are conducted on changes of health behaviours among the involved families and within the municipalities in general, changes in community awareness of the project, changes in purchase patterns, changes in overweight and obesity among the targeted children and changes in knowledge and preferences among children due to sensory education workshops. The formative research comprises studies on children's perceptions of health, perceptions of staff at supermarkets and media professionals on their roles in supporting the health promotion agenda, and motivations and barriers of community stakeholders to engage in health promotion at community level. The paper discusses operational issues and lessons learnt related to studying complex community interventions, cross-disciplinarily, interfaces between practice and research and research capacity strengthening; and suggests areas for future research. The development and implementation of the intervention and its theoretical foundation is described in a separate paper.

Ups and downs of a peer-based smoking cessation intervention help tailored to hospital-employees with low socioeconomic status: The RESPEKT Study

INTRODUCTION

Smoking is one of the most important determinants of socioeconomic inequality in mortality. Few studies have tested which interventions are effective in smokers with low socioeconomic status (SES).

METHODS

All hospitals in the Capital Region of Denmark were included and randomized to intervention or control groups. The target-group was smokers with low SES. Intervention hospitals: smokers in the target-group assisted researchers to tailor a group-based smoking cessation intervention. Further they helped recruiting smoking colleagues and motivating them to stay abstinent. Control hospitals: ‘as usual’. Unforeseen organizational challenges led to a change of study design; the hospital-level assessment was reduced to two cross-sectional surveys.

RESULTS

Response rates in hospitals’ smoking status survey were very low. Smoking status was reported by 1876 out of 7003 employees at baseline and 2280 out of 7496 employees at 1-year follow-up. Two cross-sectional surveys showed no significant difference in self-reported smoking at 1-year follow-up between intervention and control hospitals (p=0.262). We recruited 100 smokers in the group-based smoking cessation intervention tailored to smokers with low SES (corresponding to approx. 10% of smokers in target-group); 32.4% of these were validated as continuously abstinent at 6 months follow-up.

CONCLUSIONS

Involving smokers with low SES as partners at an early stage of study design facilitated both recruitment and development of the intervention. Despite high validated long-term abstinence rates in smoking cessation groups in the intervention hospitals we found no apparent effect of the intervention at hospital-level after one year. However, larger involvement of the target-group seems feasible and is recommended.

Glucose patterns during an oral glucose tolerance test and associations with future diabetes, cardiovascular disease and all-cause mortality rate

AIMS/HYPOTHESIS

In addition to blood glucose concentrations measured in the fasting state and 2 h after an OGTT, intermediate measures during an OGTT may provide additional information regarding a person's risk of future diabetes and cardiovascular disease (CVD). First, we aimed to characterise heterogeneity of glycaemic patterns based on three time points during an OGTT. Second, we compared the incidences of diabetes and CVD and all-cause mortality rates among those with different patterns.

METHODS

Our cohort study included 5861 participants without diabetes at baseline from the Danish Inter99 study. At baseline, all participants underwent an OGTT with measurements of plasma glucose levels at 0, 30 and 120 min. Latent class mixed-effects models were fitted to identify distinct patterns of glycaemic response during the OGTT. Information regarding incident diabetes, CVD and all-cause mortality rates during a median follow-up time of 11, 12 and 13 years, respectively, was extracted from national registers. Cox proportional hazard models with adjustment for several cardiometabolic risk factors were used to compare the risk of diabetes, CVD and all-cause mortality among individuals in the different latent classes.

RESULTS

Four distinct glucose patterns during the OGTT were identified. One pattern was characterised by high 30 min but low 2 h glucose values. Participants with this pattern had an increased risk of developing diabetes compared with participants with lower 30 min and 2 h glucose levels (HR 4.1 [95% CI 2.2, 7.6]) and participants with higher 2 h but lower 30 min glucose levels (HR 1.5 [95% CI 1.0, 2.2]). Furthermore, the all-cause mortality rate differed between the groups with significantly higher rates in the two groups with elevated 30 min glucose. Only small non-significant differences in risk of future CVD were observed across latent classes after confounder adjustment.

CONCLUSIONS/INTERPRETATION

Elevated 30 min glucose is associated with increased risk of diabetes and all-cause mortality rate independent of fasting and 2 h glucose levels. Therefore, subgroups at high risk may not be revealed when considering only fasting and 2 h glucose levels during an OGTT.

Accessibility of fast food outlets is associated with fast food intake. A study in the Capital Region of Denmark

Literature suggests that people living in areas with a wealth of unhealthy fast food options may show higher levels of fast food intake. Multilevel logistic regression analyses were applied to examine the association between GIS-located fast food outlets (FFOs) and self-reported fast food intake among adults (+ 16 years) in the Capital Region of Denmark (N = 48,305). Accessibility of FFOs was measured both as proximity (distance to nearest FFO) and density (number of FFOs within a 1km network buffer around home). Odds of fast food intake ≥ 1/week increased significantly with increasing FFO density and decreased significantly with increasing distance to the nearest FFO for distances ≤ 4km. For long distances (>4km), odds increased with increasing distance, although this applied only for car owners. Results suggest that Danish health promotion strategies need to consider the contribution of the built environment to unhealthy eating.

The impact of socioeconomic status and multimorbidity on mortality: a population-based cohort study

OBJECTIVE

Multimorbidity (MM) is more prevalent among people of lower socioeconomic status (SES), and both MM and SES are associated with higher mortality rates. However, little is known about the relationship between SES, MM, and mortality. This study investigates the association between educational level and mortality, and to what extent MM modifies this association.

METHODS

We followed 239,547 individuals invited to participate in the Danish National Health Survey 2010 (mean follow-up time: 3.8 years). MM was assessed by using information on drug prescriptions and diagnoses for 39 long-term conditions. Data on educational level were provided by Statistics Denmark. Date of death was obtained from the Civil Registration System. Information on lifestyle factors and quality of life was collected from the survey. The main outcomes were overall and premature mortality (death before the age of 75).

RESULTS

Of a total of 12,480 deaths, 6,607 (9.5%) were of people with low educational level (LEL) and 1,272 (2.3%) were of people with high educational level (HEL). The mortality rate was higher among people with LEL compared with HEL in groups of people with 0-1 disease (hazard ratio: 2.26, 95% confidence interval: 2.00-2.55) and ≥4 diseases (hazard ratio: 1.14, 95% confidence interval: 1.04-1.24), respectively (adjusted model). The absolute number of deaths was six times higher among people with LEL than those with HEL in those with ≥4 diseases. The 1-year cumulative mortality proportions for overall death in those with ≥4 diseases was 5.59% for people with HEL versus 7.27% for people with LEL, and 1-year cumulative mortality proportions for premature death was 2.93% for people with HEL versus 4.04% for people with LEL. Adjusting for potential mediating factors such as lifestyle and quality of life eliminated the statistical association between educational level and mortality in people with MM.

CONCLUSION

Our study suggests that LEL is associated with higher overall and premature mortality and that the association is affected by MM, lifestyle factors, and quality of life.

Social disparities in the prevalence of multimorbidity - A register-based population study

BACKGROUND

Prevalences of multimorbidity vary between European studies and several methods and definitions are used. In this study we examine the prevalence of multimorbidity in relation to age, gender and educational attainment and the association between physical and mental health conditions and educational attainment in a Danish population.

METHODS

A cross-sectional design was used to study the prevalence of multimorbidity, defined as two or more chronic conditions, and of comorbid physical and mental health conditions across age groups and educational attainment levels among 1,397,173 individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. After calculating prevalence, odds ratios for multimorbidity and mental health conditions were derived from logistic regression on gender, age, age squared, education and number of physical conditions (only for odds ratios for mental health conditions). Odds ratios for having multimorbidity and mental health conditions for each variable were adjusted for all other variables.

RESULTS

Multimorbidity prevalence was 21.6%. Half of the population aged 65 and above had multimorbidity, and prevalence was inversely related to educational attainment: 26.9% (95% CI, 26.8-26.9) among those with lower secondary education versus 13.5% (95% CI, 13.5-13.6) among people with postgraduate education. Adjusted odds ratios for multimorbidity were 0.50 (95% CI, 0.49-0.51) for people with postgraduate education, compared to people with lower secondary education. Among all population members, 4.9% (95% CI, 4.9-4.9) had both a physical and a mental health condition, a proportion that increased to 22.6% of people with multimorbidity. Physical and mental health comorbidity was more prevalent in women (6.33%; 95% CI, 6.3-6.4) than men (3.34%; 95% CI, 3.3-3.4) and approximately 50 times more prevalent among older persons than younger ones. Physical and mental health comorbidity was also twice as prevalent among people with lower secondary education than among those with postgraduate education. The presence of a mental health condition was strongly associated with the number of physical conditions; those with five or more physical conditions had an adjusted odds ratio for a mental health condition of 3.93 (95% CI, 3.8-4.1), compared to those with no physical conditions.

CONCLUSION

Multimorbidity prevalence and patterns in the Danish population are comparable to those of other European populations. The high prevalence of mental and physical health conditions highlights the need to ensure that healthcare systems deliver care that takes physical and mental comorbidity into account. Further, the higher prevalence of multimorbidity among persons with low educational attainment emphasizes the importance of having a health care system providing care that is beneficial to all regardless of socioeconomic status.

Relationship between retinal vessel diameters and retinopathy in the Inter99 Eye Study

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Non-invasive imaging of the eye can throw light on systemic disease processes.

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Retinopathy and cardiovascular disease share many associated risk factors.

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Wider retinal vessel diameters are associated with retinopathy.

Purpose

To examine the association between retinal vessel diameters and retinopathy in participants with and without type 2 diabetes in a Danish population-based cohort.

Methods

The study included 878 persons aged 30 to 60 years from the Inter99 Eye Study. Retinopathy was defined as a presence of one or more retinal hemorrhages or one or more microaneurysms. Vessel diameters were expressed as central retinal artery equivalent diameter (CRAE) and central retinal vein equivalent diameter (CRVE). Multiple linear regression analyses were performed.

Results

Among participants with diabetes, CRAE was 6.3 µm (CI 95%: 1.0 to 11.6, p = 0.020) wider and CRVE was 7.9 µm (CI 95%: 0.7 to 15.2, p = 0.030) wider in those with retinopathy compared to those without retinopathy, after adjusting for age, gender, HbA1c, blood pressure, smoking, serum total and HDL cholesterol. In all participants, CRAE increased with presence of retinopathy (p = 0.005) and with smoking (p = 0.001), and CRAE decreased with hypertension (p < 0.001), high HDL cholesterol (p = 0.016) and age (p < 0.001). Central retinal vein equivalent diameter increased with presence of retinopathy (p = 0.022) and with smoking (p < 0.001), and decreased with higher HDL cholesterol (p < 0.001) and age (p = 0.015). Female gender was associated with wider CRVE (p = 0.029).

Conclusions

Wider retinal vessel diameters were associated with the presence of retinopathy in participants with diabetes, but not in participants without diabetes. The associations between retinal vessel diameters and known retinopathy risk factors were confirmed. These results suggest that information obtained by non-invasive imaging of the interior of the eye can contribute to a better understanding of systemic disease processes.

Predicting glycated hemoglobin levels in the non-diabetic general population: Development and validation of the DIRECT-DETECT prediction model - a DIRECT study

Aims/hypothesis

To develop a prediction model that can predict HbA1c levels after six years in the non-diabetic general population, including previously used readily available predictors.

Methods

Data from 5,762 initially non-diabetic subjects from three population-based cohorts (Hoorn Study, Inter99, KORA S4/F4) were combined to predict HbA1c levels at six year follow-up. Using backward selection, age, BMI, waist circumference, use of anti-hypertensive medication, current smoking and parental history of diabetes remained in sex-specific linear regression models. To minimize overfitting of coefficients, we performed internal validation using bootstrapping techniques. Explained variance, discrimination and calibration were assessed using R², classification tables (comparing highest/lowest 50% HbA1c levels) and calibration graphs. The model was externally validated in 2,765 non-diabetic subjects of the population-based cohort METSIM.

Results

At baseline, mean HbA1c level was 5.6% (38 mmol/mol). After a mean follow-up of six years, mean HbA1c level was 5.7% (39 mmol/mol). Calibration graphs showed that predicted HbA1c levels were somewhat underestimated in the Inter99 cohort and overestimated in the Hoorn and KORA cohorts, indicating that the model’s intercept should be adjusted for each cohort to improve predictions. Sensitivity and specificity (95% CI) were 55.7% (53.9, 57.5) and 56.9% (55.1, 58.7) respectively, for women, and 54.6% (52.7, 56.5) and 54.3% (52.4, 56.2) for men. External validation showed similar performance in the METSIM cohort.

Conclusions/interpretation

In the non-diabetic population, our DIRECT-DETECT prediction model, including readily available predictors, has a relatively low explained variance and moderate discriminative performance, but can help to distinguish between future highest and lowest HbA1c levels. Absolute HbA1c values are cohort-dependent.