Low-dose metoprolol CR/XL and fluvastatin slow progression of carotid intima-media thickness: Main results from the Beta-Blocker Cholesterol-Lowering Asymptomatic Plaque Study (BCAPS)

BACKGROUND

Statins reduce cardiovascular events and progression of carotid intima-media thickness (IMT). beta-Blockers are also known to reduce cardiovascular events, but less is known about their effects on carotid IMT.

METHODS AND RESULTS

We conducted a randomized, double-blind, placebo-controlled, single-center trial to compare the effects of low-dose metoprolol CR/XL (25 mg once daily) and fluvastatin (40 mg once daily) on the progression of carotid IMT during 36 months of treatment in 793 subjects who had carotid plaque but no symptoms of carotid artery disease. Changes in mean IMT in the common carotid artery and maximal IMT in the bulb were the main outcome variables. Death and cardiovascular events were monitored. Progression of IMT(max) in the carotid bulb at both 18 and 36 months was reduced by metoprolol CR/XL (-0.058 mm/y; 95% CI, -0.094 to -0.023; P=0.004; and -0.023 mm/y; 95% CI, -0.044 to -0.003; P=0.014, respectively). Incidence of cardiovascular events tended to be lower in metoprolol CR/XL-treated patients (5 versus 13 patients, P=0.055). Rate of IMT(mean) progression in the common carotid at 36 months was reduced by fluvastatin (-0.009 mm/y; 95% CI, -0.015 to -0.003; P=0.002). Women in the fluvastatin group had increased frequency of transiently high liver enzymes.

CONCLUSIONS

This is the first randomized trial to show that a beta-blocker can reduce the rate of progression of carotid IMT in clinically healthy, symptom-free subjects with carotid plaque. This suggests that beta-blockers may have a favorable effect on atherosclerosis development.

Multiple risk intervention trial in high risk hypertensive men: comparison of ultrasound intima-media thickness and clinical outcome during 6 years of follow-up

OBJECTIVES

The objective was to analyse whether a favourable change in risk factors, caused by a comprehensive risk factor modification programme, affected intima-media thickness (IMT) in the common carotid artery, and whether any such change was associated with a change in cardiovascular events during a 6-year follow-up.

DESIGN

Patients were randomized 1 : 1 to special intervention or usual care.

SETTING

Hypertension Unit at university hospital.

SUBJECTS

A total of 164 patients were randomized. Inclusion criteria were male, aged 50-72 years (at randomization) and one or more of the following: Serum cholesterol level > 6.5 mmol L(-1), smoking or diabetes mellitus. All patients were prescribed antihypertensive treatment since many years. In 142 men good quality ultrasound recording of the common carotid IMT were achieved at baseline, 119 were re-examined after 3.3 years, and 97 patients were available for examination after mean follow-up time of 6.2 years. Cardiovascular events were available for all randomized patients.

INTERVENTIONS

The nonpharmacological special intervention programme was based on one information meeting followed by five weekly 2-h sessions with participation of patients and spouses. The diet recommendations were similar to established guidelines. Overweight patients were instructed to lose weight, and diabetic patients were systematically taught self-monitoring of blood glucose. Smokers were invited to a smoking cessation programme with five weekly meetings. Follow-up visits were thereafter scheduled every 6 months. Lipid lowering drugs were recommended in the intervention group if the treatment goals using nonpharmacological measures were not achieved. Patients in the usual care group were told to quit smoking and to lower their consumption of fat and glucose. Antihypertensive treatment (i.e., selection of drugs) was on purpose kept similar in the two groups.

MAIN OUTCOME MEASURES

The IMT of the common carotid artery as measured by ultrasound. Cardiovascular events during follow-up.

RESULTS

Significant net reductions were seen for serum cholesterol, triglycerides, fasting glucose and smoking. No difference in change in IMT was observed during follow-up between the two randomization groups. The explanation was that patients with positive plaque status at baseline had a much larger increase in IMT over time than patients with negative plaque status, and that patients with positive plaque status more often survived and were available for re-examination after 6 years in the intervention group than in the usual care group. Total mortality was lower in the intervention group, compared with the usual care group, 13 and 29%, respectively (P=0.028).

CONCLUSIONS

In high risk populations, long-term studies with surrogate endpoints may be misleading because of missing data in patients where a large increase in IMT would have been observed, had they been re-examined. Another important conclusion from our study was that the gloomy prognosis for this patient category may be improved by a dedicated risk factor intervention programme. The improved prognosis was observed mainly in those patients at highest risk judged from history of cardiovascular disease or positive ultrasound plaque status at baseline.

Serum concentrations of beta-carotene and alpha-tocopherol are associated with diet, smoking, and general and central adiposity

BACKGROUND

Previous studies of associations between diet, obesity, and blood concentrations of alpha-tocopherol and beta-carotene have been equivocal. Furthermore, most studies used only body mass index (BMI) as an obesity measure.

OBJECTIVES

Our objectives were to examine the associations between energy and nutrient intakes, alcohol consumption, tobacco use, and serum cholesterol and serum concentrations of alpha-tocopherol and beta-carotene, and to examine the associations between different measures of general and central adiposity and serum concentrations of alpha-tocopherol and beta-carotene.

DESIGN

This was a cross-sectional, population-based study of 253 men and 276 women aged 46-67 y. Nutrient data were collected by a modified diet history method. Measures of obesity included BMI, percentage of body fat (impedance analysis), waist-to-hip ratio, and waist circumference. The associations between serum nutrient concentrations and the other factors were examined by multiple linear regression.

RESULTS

Twenty-one percent of men and 34% of women used antioxidant supplements. The mean BMI was 26.1 in men and 25.4 in women. Serum beta-carotene concentration was positively associated with serum cholesterol concentration, fiber intake, and beta-carotene intake, and negatively associated with smoking and all measures of obesity. In men, serum beta-carotene concentration was not significantly associated with central adiposity after adjustment for body fat. Serum alpha-tocopherol concentration was positively correlated with serum cholesterol, obesity, and vitamin E intake. In women, serum alpha-tocopherol concentration was also positively associated with intakes of ascorbic acid and selenium. Serum alpha-tocopherol concentration was associated with central adiposity after adjustment for body fat.

CONCLUSION

Serum beta-carotene and alpha-tocopherol concentrations have different associations with diet, smoking, general adiposity, and central adiposity.

Randomized trial of adjuvant tamoxifen and/or goserelin in premenopausal breast cancer--self-rated physiological effects and symptoms

After primary surgery, 149 premenopausal breast cancer patients, with node-negative disease, were randomized to one of four treatment groups: goserelin, tamoxifen, goserelin plus tamoxifen or to a systematically untreated control group. The aim was to assess the effects of adjuvant endocrine therapy in terms of physical symptoms and perception of anxiety and depressive symptoms. Assessments were made before randomization, at 3-4 months and at 12 months. Treatment with goserelin resulted in early and more intense menopausal symptoms, while the effects of tamoxifen were slower and milder. The side effects with goserelin appeared to be alleviated by concurrent tamoxifen except for vasomotor symptoms (hot flashes, sweating, feeling warm). No significant group differences were found for anxiety and depressive symptoms. In conclusion, chemical castration with goserelin was associated with the highest level of physical symptoms. The group treated with tamoxifen alone showed the lowest levels of symptoms among the treatment groups, except for vaginal discharge and irregular bleedings.

Smoking associated with hormone receptor negative breast cancer

Women who smoke have less favourable prognosis following breast-cancer diagnosis. Some studies suggest that this is due to a more advanced stage at diagnosis, on average. Our present aim was to assess whether smoking is associated with other prognostic markers as well, e.g., hormone receptor status, histopathology and tumour differentiation. The evaluation was based on 268 incident cases in a cohort of 10,902 women (35% smokers) followed for an average of 12.4 years. An immunohistochemical method on recuts of tumour tissue was used to assess hormone receptor status. One pathologist classified all tumours according to the WHO system, Nottingham grade and Nottingham Prognostic Index. The relative risk (RR) of oestrogen receptor-negative tumours was, for current smokers, 2.21 [95% confidence interval (CI) 1.23-3.96] and, for ex-smokers, 2.67 (95% CI 1.41-5.06) compared to never-smokers. Ex-smokers had an increased risk of progesterone receptor-negative tumours (RR = 1.61, 95% CI 1.07-2.41), but there were no other significant associations between smoking habits and oestrogen receptor-positive or progesterone receptor-positive or -negative tumours. The incidence of Nottingham grade III tumours was higher in ex-smokers than in never-smokers (RR = 2.03, 95% CI 1.17-3.54). In terms of histopathological type or Nottingham Prognostic Index, there were no significant differences between smoking groups. We conclude that smoking is associated with an increased occurrence of hormone receptor-negative tumours.

Tobacco smoking increases the risk for gastric adenocarcinoma among Helicobacter pylori-infected individuals

BACKGROUND

The importance of tobacco smoking and Helicobacter pylori infection as risk factors in the development of gastric carcinoma was investigated through multivariate conditional logistic regression analysis in a nested case-control study.

METHODS

Blood samples and a questionnaire on smoking habits were collected from a cohort of 32,906 city residents during a health screening programme from 1974 to 1992. Fifty-six cases of gastric cancer and 224 matched controls were selected. The mean interval between screening and cancer diagnosis was 5.7 years. H. pylori infection was determined by IgG-serology. Occupation categorized into blue-collar workers, white-collar workers, self-employed and unknown occupation was included in the statistical analysis as an indicator of socio-economic status.

RESULTS

The proportion of current smokers was 61% among gastric cancer cases, versus 41% among controls. H. pylori seropositivity was present in 82% of the cases and 49% of the controls. In a multivariate model current smokers had an odds ratio (OR) of 2.2 (95% confidence interval (CI): 1.2-4.2). With different levels of tobacco consumption, smoking less than 20 g tobacco each day gave the OR of 2.1 (95% CI: 0.98-4.4), and the OR when smoking more than 20 g tobacco per day was 2.5 (95% CI: 1.1-5.6). The OR of H. pylori infection was 5.0 (95% CI: 2.2-11.2). Among H. pylori-seropositive citizens, current smoking was associated with an increased risk of 2.3 (95% CI: 1.1-4.7) compared with non-smoking H. pylori-positive persons.

CONCLUSIONS

Tobacco smoking and H. pylori are both risk factors in the development of gastric cancer, and tobacco smoking is still a risk factor among H. pylori-infected individuals. The risk of gastric cancer among H. pylori-infected current smokers is 11 times that of non-infected individuals not currently smoking.

Risk of breast cancer in relation to anthropometry, blood pressure, blood lipids and glucose metabolism: a prospective study within the Malmö Preventive Project

Insulin resistance may be a risk factor for breast cancer, possibly through increased levels of oestrogens or insulin-like growth factor I. Insulin resistance has been associated with obesity, hypertension, dyslipidaemia and impaired glucose tolerance. We studied the relation of these factors to breast cancer risk in a prospective cohort study of 9738 women. Menopausal status was defined a priori, and 112 cases of invasive breast carcinoma occurred in women who were premenopausal at baseline and 157 cases in subjects who were peri/postmenopausal. Relative risks (RR) for breast cancer were calculated by Cox's proportional hazards analysis for different quartiles of height, weight, body mass index, blood pressure, pulse rate and serum levels of total cholesterol, triglycerides, fasting blood glucose and glucose at 120 min after an oral dose of glucose. Peri/postmenopausal women had a significantly increased age-adjusted relative risk of breast cancer associated with height (RR = 1.78 for the highest versus lowest quartile), and the RR was increased over quartiles of cholesterol levels (P-value for trend: 0.05). No other significant associations were found. Adjustments for potential confounding factors or restriction of the analysis to cases and person-years before 55 years of age (premenopausal women), or after 55 years (peri/postmenopausal women), did not change

Predicting anxiety and depression among cancer patients: a clinical model

The aim of this study was to investigate the possibility of predicting anxiety and depression 6 months after the cancer diagnosis on the basis of measures of anxiety, depression (Hospital Anxiety and Depression, HAD scale), subjective distress (Impact of Event, IES scale) and some aspects of social support in connection with the diagnosis. A further purpose was to attempt identification of individual patients at risk of prolonged psychological distress, and to develop an easily applicable clinical tool for such detection. A consecutive population-based series of 522 newly diagnosed patients with breast, colorectal, gastric and prostate cancer were interviewed in connection with the diagnosis and 6 months later. Anxiety and depression close to the diagnosis explained 39% of the variance in anxiety and depression 6 months later. Patients scoring as doubtful cases/cases for HAD anxiety and/or depression were more than 11 times more likely than non-cases to score as doubtful cases/cases at 6 months. Additional risk factors were having an advanced disease and nobody in addition to the family to rely on in case of difficulties. Levels of anxiety and depression at diagnosis predict a similar status 6 months later. The results also indicate that the HAD scale in combination with a single question about social support may be a suitable screening tool for clinical use.

Prevention of cardiovascular disease and diabetes: lessons from the Malmö Preventive Project

Major public health problems such as cardiovascular disease and type 2 diabetes pose a challenge to both the medical profession and the health care system of most Western countries. In spite of widespread knowledge about risk factors and pathophysiological processes, it has been difficult to find effective preventive mass strategies based on evidence from controlled clinical trials. In the Malmö Preventive Project, Sweden, 33 346 subjects were screened for risk factors between 1974 and 1992, and a quarter of them were offered preventive help for cardiovascular disease risk or alcohol abuse. The overall finding of the project was that benefits of screening and prevention on mortality risk could only be shown in certain subgroups of younger men and women, not in the total screened cohort, as compared with a nonscreened reference population. These findings therefore question the effectiveness of preventive methods and drugs used during previous decades. New preventive methods are therefore needed and should be properly evaluated to form a basis for evidence-based prevention (EBP) in cardiovascular medicine.

Differences in body fat and central adiposity between Swedes and European immigrants: the Malmö Diet and Cancer Study

OBJECTIVE

Comparative data on ecological differences in body fatness and fat distribution within Europe are sparse. Migration studies may provide information on the impact of environmental factors on body size in different populations. The objective was to investigate differences in adiposity between European immigrants and native Swedes, specifically to examine gender differences and the effect of time since immigration, and to compare two selected immigrant groups with their native countrymen.

RESEARCH METHODS AND PROCEDURES

A cross-sectional analysis of 27,808 adults aged 45 to 73 years participating in the Malmö Diet and Cancer prospective cohort study in Sweden was performed. Percentage body fat (impedance analysis) and waist-hip ratio (WHR) were compared between Swedish-born and foreign-born participants.

RESULTS

Obesity was 40% more prevalent in non-Swedish Europeans compared with Swedes. Controlling for age, height, smoking, physical activity, and occupation, it was found that women born in the former Yugoslavia, southern Europe, Hungary, and Finland had a significantly higher percentage of body fat, and those from Hungary, Poland, and Germany had more centralized adiposity compared with Swedish women. Men born in the former Yugoslavia, Hungary, and Denmark had a significantly higher mean percentage of body fat compared with Swedish-born men, whereas Yugoslavian, Finnish, and German men differed significantly in mean WHR. Length of residence in Sweden was inversely associated with central adiposity in immigrants. A comparison between German and Danish immigrants, their respective native populations, and Swedes indicated an intermediate positioning of German immigrants with regard to body mass index and WHR.

DISCUSSION

Differences in general and central adiposity by country of origin appear to remain after migration. Central adiposity seems to be more influenced than fatness per se by time of residency in Sweden.

Survival of women with breast cancer in relation to smoking

OBJECTIVE

To compare survival of patients with breast cancer who had never smoked, were smokers, and who were ex-smokers.

DESIGN

Observational study.

SETTING

City of Malmö, Sweden.

PATIENTS

792 patients with breast cancer diagnosed between 1977-1986 in the Malmö mammographic screening trial.

INTERVENTIONS

Follow-up of breast cancer cases through record-linkage with the Swedish Cause of Death Registry.

MAIN OUTCOME MEASURES

Death from breast cancer. Relative risk (RR) with 95% confidence interval (CI) of death from breast cancer was calculated for different smoking groups using Cox's proportional hazards analysis.

RESULTS

During a mean follow-up of 12.1 years, 145 patients died of breast cancer. Breast cancer mortality was 1347/10(5) person-years in those who had never smoked, 1941/10(5) in smokers, and 1493/10(5) in ex-smokers. The crude RR for smokers and ex-smokers, compared with those who had never smoked were 1.44 (1.01 to 2.06) and 1.13 (0.66 to 1.94), respectively. The RR associated with smoking remained significant after adjustment for age and stage at diagnosis, 2.14 (1.47 to 3.10), and other potential confounders.

CONCLUSIONS

Survival after breast cancer was, as expected, strongly related to stage at diagnosis. However, stage by stage there was considerable variation between individual patients. We conclude that differences with regard to exposure to smoking contribute to this heterogeneity.

Self-administered questionnaire compared with a personal diary for assessment of current use of hormone therapy: an analysis of 16,060 women

A personal diary may be more appropriate than a questionnaire for assessing self-reported current use of hormone therapy (estrogens, progestagens, or their combination); however, use of a questionnaire is more feasible and less expensive. The authors compared both methods for 16,060 Swedish women aged 45-73 years from the Malmo Diet and Cancer Study (baseline, 1991-1996). In a reliability analysis, the authors investigated the agreement (kappa value) between the questionnaire and the diary regarding current hormone therapy use (yes vs. no), studying the ability to replicate results whether or not they were correct. They also explored associations between discrepancy and individual characteristics. A validity analysis was conducted to determine whether use of the questionnaire achieved an outcome without systematic error (i.e., high specificity and sensitivity); the personal diary was considered the "gold standard." Agreement between both methods was high: 95.5% (kappa = 0.840). The sensitivity was 84.9% and the specificity 97.7%. Higher body mass index and being a widow were associated with agreement, whereas age (50-59 years), use of anxiolytics/hypnotics or opiates, high alcohol consumption, past smoking, and higher educational level were associated with discrepancy. Compared with a personal diary, a simple self-administered questionnaire is a valid method for assessing current use of hormone therapy.

Prediction of diabetes using ADA or WHO criteria in post-menopausal women: a 10-year follow-up study

AIMS/HYPOTHESIS

To study the risk of women with impaired fasting glucose (IFG) as against impaired glucose tolerance (IGT) developing diabetes.

METHODS

Oral glucose tolerance tests (75 g) were done in 265 women selected at random at baseline (age 55-57 years) and at a 10-year follow-up. Of the women 42 had IFG/NGT (fasting glucose 6.1-6.9 mmol/l, 2-h glucose < 7.8 mmol/l), 66 IGT/ NFG (2-h glucose 7.8-11.0 mmol/l, fasting glucose < 6.1 mmol/1), 30 IGT/IFG and 127 NFG/NGT.

RESULTS

The 10-year progression to diabetes was similar in IGT/NFG (12.1%) and IFG/NGT groups (11.9%, p = 0.97). In IGT/IFG, 20.0% had developed diabetes, which was not significantly higher than in IFG/NGT and IGT/NFG (p = 0.53). In NFG/ NGT at baseline, only 3.9 % had developed diabetes, which was lower than in the other groups (p = 0.023).

CONCLUSION/INTERPRETATION

Fasting and 2-h glucose concentrations are equally good in predicting diabetes development over a 10-year period in Caucasian postmenopausal women. Because IGT is more common than IFG, measuring only fasting glucose concentrations would, however, result in missing a prediabetic stage in a large group of people at risk for diabetes and cardiovascular diseases.

Socioeconomic differences in smoking cessation: the role of social participation

OBJECTIVES

The aim of this study was to investigate whether psychosocial resources explain socioeconomic differences in smoking cessation and its maintenance.

METHODS

A subpopulation of 11,837 individuals from the Malmö Diet and Cancer Study interviewed in 1992-94, age range 45-64 years, was investigated in this cross-sectional study. A multivariate logistic regression model was used to assess relative risks of having stopped smoking, adjusting for age, country of origin, previous/current diseases, and marital status.

RESULTS

An odds ratio of 1.9 (1.4-2.5; 95% CI) for men and 2.0 (1.4-2.7; 95% CI) for women of having stopped smoking was found for higher non-manual employees when compared with unskilled manual workers. A decrease in these odds ratios was found when social participation was introduced into the model. The other three social network and social support variables were non-significant.

CONCLUSION

High social participation is a predictor of maintenance of smoking cessation. It seems possible to interpret parts of the socioeconomic differences in smoking cessation and its maintenance as a consequence of differing social network resources and social capital between socioeconomic groups.

Fruit and vegetable consumption in relation to risk factors for cancer: a report from the Malmö Diet and Cancer Study

OBJECTIVE

To examine the associations between the consumption of fruit and vegetables and other markers of cancer risk.

DESIGN

A cross-sectional survey within the population-based prospective Malmö Diet and Cancer (MDC) Study. Information on food habits was collected through the modified diet history method designed and validated for the MDC Study. Data on smoking and alcohol habits, leisure time physical activity, birth country, education, socioeconomic status and cohabitation status were collected through a questionnaire.

SETTING

Malmö, the third largest city in Sweden.

SUBJECTS

All subjects who entered the MDC Study during winter 1991 to summer 1994 (men and women living in Malmö, aged between 46 and 68 years), with a total of 15 173.

RESULTS

Women consumed more fruit and vegetables than men. Low consumption of both fruits and vegetables was associated with unfavourable nutrient profiles: higher percentage of energy from fat and lower intakes of antioxidant nutrients and dietary fibre. Low consumption was also associated with smoking, low leisure time physical activity, low education and being born in Sweden. High age was associated with low vegetable consumption in both genders.

CONCLUSION

This study indicates that several established risk markers and risk factors of cancer may be independently associated with low fruit and vegetable consumption. The findings suggest that the adverse effects of factors such as smoking, low physical activity and a high-fat diet could partly be explained by low consumption of fruit or vegetables. The implied health benefits of a low or moderate alcohol consumption may be similarly confounded by high consumption of fruit or vegetables.

The role of the general practitioner in cancer care and the effect of an extended information routine

OBJECTIVE

To describe the role of the General Practitioner (GP) in the care of one specified cancer patient per GP, and to explore the GP's knowledge about that patient's disease and treatments, and what information she/he wanted versus received from the specialist clinic. A further aim was to evaluate the effects of an Extended Information Routine (EIR), including increased information from the specialist clinic to the GP.

DESIGN

Semi-structured interviews with GPs about a patient randomised between an extended information routine and standard information from the specialist clinics.

SETTINGS

Primary Health Care.

SUBJECTS

20 GPs, 10 who received extended information about the specified patient and 10 who did not.

MAIN OUTCOME MEASURES

The extent of GPs' contact with the patient, GPs' potential or actual possibilities to support the patient, desired and received information from the specialist clinic.

RESULTS AND CONCLUSIONS

GPs are commonly involved in the care of cancer patients, particularly in the diagnostics of the disease but also during the periods of treatment and follow-up. The information from the specialist clinic to the GP is insufficient in standard care. The extended information routine increased the GPs' knowledge of the disease and treatments, and facilitated their possibilities to determine patients' need for support.

Occupational status, educational level, and the prevalence of carotid atherosclerosis in a general population sample of middle-aged Swedish men and women: results from the Malmö Diet and Cancer Study

The associations among educational level, occupational status, and atherosclerosis were investigated during 1992-1994 in a general population sample of 4,176 Swedish men and women. Carotid artery intima-media thickness (IMT) and carotid stenosis were determined by B-mode ultrasound. Socioeconomic differences in mean carotid IMT and odds ratios for carotid stenosis prevalence were estimated. In women, the associations among educational level, occupational status, and IMT were weak. In men, there was no association between education and IMT, while low occupational status was associated with a thicker IMT. Women with low education had an increased odds of carotid stenosis compared with women with high education (odds ratio (OR) = 2.04, 95% confidence interval (CI): 1.53, 2.73), while this pattern was weaker among men. Women in manual occupations had an increased odds of carotid stenosis compared with women in high- or medium-level nonmanual occupations (OR = 1.75, 95% CI: 1.29, 2.36), which could not be seen among men. After adjustment for risk factors, the association between IMT and occupational status in men disappeared, while the associations among educational level, occupational status, and carotid stenosis in women persisted. The results imply that the atherosclerotic process is associated with socioeconomic status in both sexes, and they also indicate the possibility of sex differences in the mechanisms connecting socioeconomic status to atherosclerosis.

Prevalence and clinical spectrum of chronic viral hepatitis in a middle-aged Swedish general urban population

BACKGROUND

Although abundant data are available regarding the prevalence of chronic hepatitis B or C virus (HBV, HCV) among both blood donors and patients with liver diseases, corresponding data for the general population are scarce. Accordingly, this study was designed to investigate the prevalence and clinical spectrum of HBV and HCV in a general Swedish middle-aged urban population.

METHODS

Demographic data and blood samples were collected from subjects enrolled in a prospective study of cancer development in the city of Malmö (population 250,000). The participation rate in the preliminary examination was 46.2%. From 12,445 individuals born between 1926 and 1945 and included in the study, a statistically representative subsample of 6103 persons was selected. Blood samples were available from 5533 of these. The mean age of the subjects in the series was 58.5 +/- 5.9 years, and 59% were women. The HBV markers used were anti-HBc and HBsAg. HCV antibodies were detected with a third generation anti-HCV ELISA, followed by immunoblotting (RIBA 3) if the test was positive. Immunoblot-reactive samples were analysed for HCV-RNA by polymerase chain reaction and genotyped. In all patients with signs of chronic HBV or HCV, epidemiological data were evaluated and liver biopsies obtained.

RESULTS

Of the series as a whole (n = 5533), 4.2% (n = 211) tested positive for anti-HBc and 0.2% (n = 10) for HBsAg. RIBA 3 analysis showed 0.37% (18/5533) to be anti-HCV-positive, of whom 83% (15/18) were HCV-RNA-positive. Apart from two (both from HBsAg carriers) with normal histology, all liver biopsies manifested various degrees of inflammation and fibrosis. Among anti-HCV-positives, median grade was 6 and median stage 1 (Knodell score).

CONCLUSION

The prevalence of both chronic HBV and HCV is low in the Swedish general urban middle-aged population. Nonetheless, the long-term effects on the population and the health care system may be significant.

Sociodemographic factors associated with long-term weight gain, current body fatness and central adiposity in Swedish women

OBJECTIVES

To examine sociodemographic factors associated with long-term adult weight gain and current general and central adiposity in women.

DESIGN

Cross-sectional analysis based on data from the Malmö Diet and Cancer prospective cohort Study (MDCS), Sweden.

SUBJECTS

5464 women aged 45-73 y, who participated in the MDCS between 1994 and 1996.

MEASUREMENTS

Weight change was defined as the difference between measured weight and recalled weight at age 20. Body composition was estimated from bioelectrical impedance analysis. Waist circumference and waist-hip ratio (WHR) were indicators of central obesity. Sociodemographic factors studied included reproductive, lifestyle and socioeconomic characteristics obtained from a questionnaire.

RESULTS

At current age 13% of all women were obese (BMI>/=30), and nearly one-third had a body fat content of >33%. Since age 20, the majority of women (77%) had gained more than 10% of their initial weight. On average, the mean weight change was 12.6+/-10.0 kg during adult life. Age-adjusted group mean comparisons identified a number of significant sociodemographic variables predicting past weight gain and current obesity. In multivariate analysis, significant independent correlates of weight gain were: age, initial small body size, high parity, early menarche, non-use of hormone therapy, low self-rated health, non-smoking, no consumption of alcohol, sedentary leisure activity, past change in diet, retirement, low education, low socioeconomic status, and low socioeconomic status of origin. Many of the same variables were independently associated with current waist circumference, WHR, and percentage body fat.

CONCLUSIONS

Large weight gain during adult life and a high rate of overweight were observed in this group of Swedish women. Many sociodemographic characteristics were associated with long-term weight gain and recent obesity indices. Initial BMI, smoking, age, physical activity and early socioeconomic status accounted for most of the explained variance in weight change. The findings indicate the importance of identifying environmental determinants of both weight gain and attained fatness, as well as fat distribution.

Food patterns defined by cluster analysis and their utility as dietary exposure variables: a report from the Malmö Diet and Cancer Study

OBJECTIVE

To explore the utility of cluster analysis in defining complex dietary exposures, separately with two types of variables.

DESIGN

: A modified diet history method, combining a 7-day menu book and a 168-item questionnaire, assessed dietary habits. A standardized questionnaire collected information on sociodemographics, lifestyle and health history. Anthropometric information was obtained through direct measurements. The dietary information was collapsed into 43 generic food groups, and converted into variables indicating the per cent contribution of specific food groups to total energy intake. Food patterns were identified by the QUICK CLUSTER procedure in SPSS, in two separate analytical steps using unstandardized and standardized (Z-scores) clustering variables.

SETTING

: The Malmö Diet and Cancer (MDC) Study, a prospective study in the third largest city of Sweden, with baseline examinations from March 1991 to October 1996.

SUBJECTS

A random sample of 2206 men and 3151 women from the MDC cohort (n = 28 098).

RESULTS

Both variable types produced conceptually well separated clusters, confirmed with discriminant analysis. 'Healthy' and 'less healthy' food patterns were also identified with both types of variables. However, nutrient intake differences across clusters were greater, and the distribution of the number of individuals more even, with the unstandardized variables. Logistic regression indicated higher risks of past food habit change, underreporting of energy and higher body mass index (BMI) for individuals falling into 'healthy' food pattern clusters.

CONCLUSIONS

The utility in discriminating dietary exposures appears greater for unstandardized food group variables. Future studies on diet and cancer need to recognize the confounding factors associated with 'healthy' food patterns.

Group rehabilitation for cancer patients: satisfaction and perceived benefits

Satisfaction with a group rehabilitation programme (GR) was evaluated in a heterogeneous group of cancer patients. Of the patients that were invited, 67% (N = 132) participated in the GR. The GR included eight sessions plus one booster-session, each including information and/or cognitive-behavioural techniques combined with physical training and relaxation and started approximately 4 months after diagnosis. Men and women participated to the same extent. A mailed questionnaire was used to assess patients' satisfaction, perceived benefits and level of difficulty of the GR components. The majority of patients stated that the number of sessions and timing of the GR was adequate. The usefulness of the GR components were rated in the following descending order: relaxation, physical training, encountering others in the same situation, breathing exercises, information and cognitive-behavioural skills. Patients were more satisfied with diagnosis-specific group meetings than with those including several diagnoses. Assessment of patient satisfaction seems appropriate to elucidate patient priorities.

Distribution and determinants of ischaemic heart disease in an urban population. A study from the myocardial infarction register in Malmö, Sweden

OBJECTIVE

Age adjusted incidence of myocardial infarction has been found to vary substantially between the residential areas of the city of Malmö. The objective of this study was to assess the extent to which major biological risk factors and socio-economic circumstances account for the differences in incidence of and mortality from myocardial infarction.

DESIGN

Ecological study of risk factor prevalence and incidence and mortality from myocardial infarction.

SETTING

Seventeen administrative areas in Malmö, Sweden.

SUBJECTS

Assessment of risk factor prevalence was based on 28 466 men and women, ranging from 45 to 73 years old, who were recruited as participants in the Malmö Diet and Cancer study. Information on serum lipids was available in a random subsample of 5362 subjects. Information about socio-economic level of the residential area was based on statistics from the Malmö City Council and Statistics Sweden.

MAIN OUTCOME MEASURES

Weighted least square regressions between prevalence of risk factors (i.e. smoking, hypertension, obesity, diabetes, hypercholesterolemia and hypertriglyceridemia), a myocardial infarction risk score, a socio-economic score and incidence and mortality from myocardial infarction.

RESULTS

The risk factor prevalence and myocardial infarction incidence was highest in areas with low socio-economic level. Prevalence of smoking, obesity and hypertension was significantly associated with myocardial infarction incidence and mortality rates amongst men (all r > 0.60). Prevalence of smoking was significantly associated with incidence and mortality from myocardial infarction amongst women (r = 0.66 and r = 0.61, respectively). A myocardial infarction risk score based on four biological risk factors explained 40-60% of the intra-urban geographical variation in myocardial infarction incidence and mortality. The socio-economic score added a further 2-16% to the explained variance.

CONCLUSION

In an urban population with similar access to medical care, well-known biological cardiovascular risk factors account for a substantial proportion of the intra-urban geographical variation of incidence of and mortality from myocardial infarction. The socio-economic circumstances further contribute to the intra-urban variation in disease.

Breast cancer incidence in relation to smoking cessation

High plasma levels of oestrogens are associated with increased breast cancer risk. If smoking, as has been suggested, have both a tumour initiating mutagenic effect and a protective anti-oestrogenic effect, one would assume that smokers who give up smoking have the highest incidence of breast cancer. This was evaluated in the follow-up of a cohort of 10,902 women of whom 4,359 were premenopausal. Record-linkage with official cancer registries yielded 416 incident cases during an average follow-up of 13.6 years. The adjusted relative risk in all ex-smokers was 1.31 (1.02-1.69), as compared to never smokers, and in premenopausal ex-smokers it was 1.57 (1.07-2.30). Breast cancer incidence in premenopausal ex-smokers was inversely related to time since cessation, (p for trend = 0.01), and was highest among the women who had given-up smoking less than 12 months before screening: 2.76 (1.55-4.91). There was no significant association between current smoking and breast cancer risk. We conclude that incidence of breast cancer in premenopausal women who have given up smoking is higher than it is in smokers and never smokers. To what extent this may be related to endocrine effects associated with smoking cessation remains to be evaluated.

Intra-urban differences in breast cancer mortality: a study from the city of Malmö in Sweden

STUDY OBJECTIVE

To assess whether in an urban population stage at breast cancer diagnosis is related to area of living and to what extent intra-urban differences in breast cancer mortality are related to incidence respectively stage at diagnosis.

DESIGN

National registries were used to identify cases. Mortality in 17 residential areas was studied in relation to incidence and stage distribution using linear regression analysis. Areas with high and low breast cancer mortality, incidence and proportion of stage II+ tumours at diagnosis were also compared in terms of their sociodemographic profile.

SETTING

City of Malmö in southern Sweden.

PATIENTS

The 1675 incident breast cancer cases and 448 deaths that occurred in women above 45 years of age in Malmö 1986-96.

MAIN RESULTS

Average annual age standardised breast cancer mortality ranged between residential areas, from 35/10(5) to 107/10(5), p = 0.04. Mortality of breast cancer was not correlated to incidence, r = 0.22, p = 0.39. The ratio of stage II+/0-I cancer incidence varied between areas from 0.45 to 1.99 and was significantly correlated to breast cancer mortality, r = 0.53, p = 0.03. Areas with high proportion of stage II+ cancers and high mortality/incidence ratio were characterised by a high proportion of residentials receiving income support, being foreigners and current smokers.

CONCLUSIONS

Within this urban population there were marked differences in breast cancer mortality between residential areas. Stage at diagnosis, but not incidence, contributed to the pattern of mortality. Areas with high proportion of stage II+ tumours differed unfavourably in several sociodemographic aspects from the city average.

Relation between insulin resistance and carotid intima-media thickness and stenosis in non-diabetic subjects. Results from a cross-sectional study in Malmö, Sweden

AIMS

To assess whether there is an association between insulin resistance and carotid intima-media thickness and stenosis in non-diabetic subjects free from symptomatic cardiovascular disease.

METHODS

A cross-sectional population-based study in Malmö, Sweden, of 4,816 (40% men) subjects, born 1926-1945. The prevalence of insulin resistance was established by the homeostasis model assessment (HOMA) and defined as values above the 75th percentile. Criteria issued by the European Group for the Study of Insulin Resistance (EGIR) were used for the definition of the insulin resistance syndrome. Common carotid artery intima-media thickness (IMT) and carotid stenosis (> 15%) were measured by B-mode ultrasonography.

RESULTS

Age and sex-adjusted common carotid IMT among subjects with the insulin resistance syndrome (12.7%) and controls was 0.812 mm, respectively, 0.778 mm (P < 0.001). The prevalence of stenosis in the two groups was 22.9 and 19.2% (P = 0.040). Insulin resistance per se was after adjustment for age and sex associated with increased IMT (0.780 mm vs. 0.754 mm, P < 0.001). This association disappeared, however, when other factors included in the insulin resistance syndrome were taken into account.

CONCLUSIONS

Fasting serum insulin covaries with a number of factors and conditions known to influence the development of atherosclerosis. It is concluded that the association between insulin resistance, as assessed by the HOMA method in non-diabetic subjects, and atherosclerosis is explained by its covariance with established risk factors for cardiovascular disease of which hypertension seems to be the most significant.