Diversity of dietary patterns observed in the European Prospective Investigation into Cancer and Nutrition (EPIC) project

OBJECTIVE

To describe the diversity in dietary patterns existing across centres/regions participating in the European Prospective Investigation into Cancer and Nutrition (EPIC).

DESIGN AND SETTING

Single 24-hour dietary recall measurements were obtained by means of standardised face-to-face interviews using the EPIC-SOFT software. These have been used to present a graphic multi-dimensional comparison of the adjusted mean consumption of 22 food groups.

SUBJECTS

In total, 35 955 men and women, aged 35-74 years, participating in the EPIC nested calibration study.

RESULTS

Although wide differences were observed across centres, the countries participating in EPIC are characterised by specific dietary patterns. Overall, Italy and Greece have a dietary pattern characterised by plant foods (except potatoes) and a lower consumption of animal and processed foods, compared with the other EPIC countries. France and particularly Spain have more heterogeneous dietary patterns, with a relatively high consumption of both plant foods and animal products. Apart from characteristics specific to vegetarian groups, the UK 'health-conscious' group shares with the UK general population a relatively high consumption of tea, sauces, cakes, soft drinks (women), margarine and butter. In contrast, the diet in the Nordic countries, The Netherlands, Germany and the UK general population is relatively high in potatoes and animal, processed and sweetened/refined foods, with proportions varying across countries/centres. In these countries, consumption of vegetables and fruit is similar to, or below, the overall EPIC means, and is low for legumes and vegetable oils. Overall, dietary patterns were similar for men and women, although there were large gender differences for certain food groups.

CONCLUSIONS

There are considerable differences in food group consumption and dietary patterns among the EPIC study populations. This large heterogeneity should be an advantage when investigating the relationship between diet and cancer and formulating new aetiological hypotheses related to dietary patterns and disease.

Underreporting of energy intake is less common among pregnant women in Indonesia

OBJECTIVES

To evaluate the ratio of reported energy intake to basal metabolic rate (EI/BMR) among pregnant Indonesian women, as well as identifying risk factors for being an underreporter.

DESIGN

Longitudinal study of dietary intake, using six repeated 24-hour diet recalls each trimester. Basal metabolic rate was estimated from body weight and physical activity from occupation. The lower 95% confidence interval for plausible EI/BMR was calculated and the proportion of underreporters estimated. Risk factors for being an underreporter were assessed in multivariate logistic regression analyses.

SETTING

Purworejo District, central Java, Indonesia.

SUBJECTS

Pregnant women

RESULTS

For the three trimesters, EI/BMR ratio was and (mean+/-standard deviation), respectively. The proportion of underreporters was 29.7%, 16.2% and 17.6%. Characteristics significantly associated with underreporting in at least one trimester included high body mass index and low education.

CONCLUSIONS

Levels of underreporting were low among the pregnant Indonesian women during the second and third trimesters. The low EI/BMR ratio during the first trimester likely reflects a true low intake due to nausea, rather than underreporting. Risk factors for being an underreporter included those known from developed countries, i.e. obesity and low education.

Energy intake during economic crisis depends on initial wealth and access to rice fields: the case of pregnant Indonesian women

Starting in August 1997, Indonesia experienced a radical and rapid deterioration in its economy. Between 1996 and 1998, dietary intake during the second trimester was measured in 450 pregnant women in Purworejo, Central Java, Indonesia. Using six 24 h recalls we describe the consequences of the economic crisis on the energy intake of pregnant Indonesian women. Depending on the date of data collection, women were grouped into 'before crisis', 'transition' and 'during crisis'. Mean energy intake among groups was compared using ANOVA and Student's t-test. All groups of pregnant women already had a mean energy intake before the emerging crisis that was lower than the Indonesian recommended dietary allowances (RDA). Nevertheless, energy intake differed significantly among women with different education levels (P = 0.00) and from different socio-economic groups (P = 0.00). 'During transition', a significant decrease in energy intake was experienced by urban poor women (P = 0.01). Poor women with access to rice fields had a higher rice consumption than other groups throughout the period. Our results most likely reflect the effect of higher rice price on income and welfare. 'During crisis', energy intake improved among vulnerable groups, perhaps reflecting government intervention.

Weight-gain patterns from prepregnancy until delivery among women in Central Java, Indonesia

BACKGROUND

Representative data on pregnancy weight-gain patterns from developing countries are scarce. The reasons include difficulties in obtaining population-based samples and in collecting data before and throughout pregnancy.

OBJECTIVE

The objective was to measure weight-gain patterns from prepregnancy until after delivery in a population-based sample of rural Indonesian women.

DESIGN

Two cross-sectional surveys of nutritional status among nonpregnant women of reproductive age were carried out through a surveillance system in Purworejo District, Central Java, Indonesia, in 1996 and 1997. Between 1996 and 1998, 846 newly pregnant women were enrolled in a cohort study in which weight was monitored monthly throughout pregnancy. Prepregnancy weights and other anthropometric measures were available for 251 of the women who had live births.

RESULTS

Before pregnancy, 16.7% of the women had chronic energy deficiency and 10.0% were obese. The mean total pregnancy weight gain for all the women was 8.3 +/- 3.6 kg, and 79% did not meet the international recommendation regarding weight gain for their prepregnant body mass index. The rate of weight gain was highest during the second trimester (0.34 kg/wk). In the first and third trimesters, it was 0.08 and 0.26 kg/wk, respectively. Total weight gain was associated with prepregnant body mass index, education, and socioeconomic status.

CONCLUSIONS

Many women in rural Central Java, Indonesia, enter pregnancy with suboptimal nutritional status. For most of these women, total weight gain during pregnancy is insufficient. It is likely that this contributes to adverse health outcomes for both the mothers and their newborns.

Vitamin A intake is low among pregnant women in central Java, Indonesia

From 1996-1998, a longitudinal study on nutritional status during pregnancy was carried out in Purworejo District, Central Java, Indonesia. Dietary intake was assessed in each trimester using six 24-hour recalls, and analyzed cross-sectionally among 493 women. The proportion of women below the Indonesian RDI for vitamin A (700 RE) ranged from 83% in the first trimester to 76% in the third. Regardless of total vitamin A intake, plant sources contributed 64-79% in all three trimesters. The contribution from animal and fortified sources was generally lower throughout pregnancy for those with low education compared to those with high education. Significant risk factors for having a low vitamin A intake (< FAO/WHO basal RDI, 370 RE) in the second and third trimesters were fewer than six years of education, low socio-economic status, a low energy intake, and a low vitamin A intake in the previous trimester. Home gardening and chicken-raising were not positively associated with vitamin A intakes. Given the large percentage of women with inadequate vitamin A intakes, further strategies are needed to increase the vitamin A intake of all pregnant women in this area.

Trust and transparency in human encounters in tuberculosis control: lessons learned from Vietnam

The purpose of this study was to elucidate understanding of mechanisms of the tuberculosis sickness trajectory in Vietnam. In-depth interviews with 24 TB patients and 16 health care providers involved in TB care were concurrently conducted, coded, and analyzed according to the grounded theory method. A need for quality interaction based on transparency and trust among patient, family, society, and provider was observed. Providers lacked an awareness of differences between male and female patients with regard to social situation and support. In particular, female patients needed social support, as they received less support from their families than men did. A need for active intervention to decrease social isolation and increase social support was more pronounced in families with a female TB patient.

Difference in symptoms suggesting pulmonary tuberculosis among men and women

Longer delays in diagnosis and lower case-detection of tuberculosis (TB) among women remain a problem in many countries. This study describes reported symptoms of new smear-positive pulmonary TB among men and women, and their association with TB diagnostic delays. All 1,027 new smear-positive pulmonary TB cases aged 15 years or over (757 men and 270 women) diagnosed by 23 district TB units of four provinces in Vietnam during 1996 were interviewed at the time of diagnosis. Among these, 540 patients diagnosed during January-June 1996 were followed up during treatment course. Pattern of symptoms was similar between the sexes. However, symptoms of cough (90.7% women, 94.7% men, P = .021), sputum expectoration (83.6% women, 89.9% men, P = .006), and hemoptysis (27.8% women, 34.9% men, P = .033) were less common among women than among men. Absence of cough and sputum expectoration was significantly associated with increased doctor's delays. Two months after treatment, cough and sputum expectoration recovered significantly more quickly among women compared to men.

Health seeking behaviour and diagnosis for pulmonary tuberculosis in an HIV-epidemic mountainous area of Thailand

SETTING

Chiang Rai Hospital, Chiang Rai Province, the epicentre of the human immunodeficiency virus (HIV) in Thailand.

OBJECTIVE

To describe the health seeking behaviour among tuberculosis (TB) patients, to measure patient and provider delays and to analyse factors determining these delays.

DESIGN

All patients aged over 15 years with new smear-positive pulmonary TB detected in Chiang Rai Hospital (n = 557) were interviewed using a structured questionnaire.

RESULTS

The median patient delays for HlV-positive and HIV-negative patients and those whose HIV status was unknown were 10, 15 and 15 days respectively, while provider delays were respectively 7, 7.5 and 10 days. HIV-positive patients suffered more symptoms and had a shorter patient's delay. Risk factors of long patient delay (>21 days) included being HIV-negative, having no health insurance, hill tribe ethnicity, no previous visits to the hospital, and borrowing money for hospital visits. Multivariate logistic analysis suggested that being married or widowed and being HIV-positive led to the shortest patient delay. Provider delay was significantly longer in female patients than male patients.

CONCLUSION

Although patient and provider delays were favourably short, certain specific groups require further attention. Hill tribe people should be targeted to improve accessibility to TB treatment. Active case-finding services for people known to be HIV-positive should be encouraged. The reasons for the longer provider delay in female patients require further investigation.

Fear and social isolation as consequences of tuberculosis in VietNam: a gender analysis

SETTING

The study was conducted in four districts in different regions of Vietnam.

OBJECTIVE

To describe the socio-economic consequences of tuberculosis (TB) in Vietnam with special reference to gender differentials concerning social stigma and isolation.

DESIGN

Sixteen focus group discussions were carried out with men and women, TB patients and non-TB participants. Data was analysed using modified grounded theory technique.

RESULTS

Generally, the participants had good knowledge about TB. However, knowledge and practice were not closely related in the sense that most non-TB participants perceived that TB can be successfully cured, while patients were seriously shocked when they were told that they had TB. Male patients often worried about economic-related problems, while female patients worried about social consequences of the disease. Both in the family and the community, isolation could be subtle, but it could also be obvious and had a tendency to continue much longer than medically justified.

CONCLUSION

Information on stigma and isolation due to TB and gender differences is important for understanding patient dynamics and its effects on the disease. Tuberculosis control programmes need better understanding of the gender differences in attitudes and beliefs to improve case-detection and treatment outcome.

Feasibility of home-based and health centre-based DOT: perspectives of TB care providers and clients in an HIV-endemic area of Thailand

Focus groups were conducted in a high human immunodeficiency virus (HIV) prevalence area of Thailand to elicit perspectives of health staff and clients regarding the feasibility of directly observed therapy (DOT) for tuberculosis. Most participants perceived health centre-based DOT to be impractical for clients due to severe illness, travel inconvenience, and interference with employment. Most providers perceived home-based DOT to be difficult because of the inconvenience of travel, staff shortages and the high tuberculosis caseload. Most clients except HIV-negative tuberculous females considered home visits to be undesirable due to stigma. The preparedness of providers for home-based DOT might be improved through awareness building among staff about multidrug-resistant tuberculosis.

Carotenoids, alpha-tocopherols, and retinol in plasma and breast cancer risk in northern Sweden

OBJECTIVE

Using a nested case-referent design we evaluated the relationship between plasma levels of six carotenoids, alpha-tocopherol, and retinol, sampled before diagnosis, and later breast cancer risk.

METHODS

In total, 201 cases and 290 referents were selected from three population-based cohorts in northern Sweden, where all subjects donated blood samples at enrolment. All blood samples were stored at -80 degrees C. Cases and referents were matched for age, age of blood sample, and sampling centre. Breast cancer cases were identified through the regional and national cancer registries.

RESULTS

Plasma concentrations of carotenoids were positively intercorrelated. In analysis of three cohorts as a group none of the carotenoids was found to be significantly related to the risk of developing breast cancer. Similarly, no significant associations between breast cancer risk and plasma levels of alpha-tocopherol or retinol were found. However, in postmenopausal women from a mammography cohort with a high number of prevalent cases, lycopene was significantly associated with a decreased risk of breast cancer. A significant trend of an inverse association between lutein and breast cancer risk was seen in premenopausal women from two combined population-based cohorts with only incident cases. A non-significant reduced risk with higher plasma alpha-carotene was apparent throughout all the sub-analyses.

CONCLUSION

In conclusion, no significant associations were found between plasma levels of carotenoids, alpha-tocopherol or retinol and breast cancer risk in analysis of three combined cohorts. However, results from stratified analysis by cohort membership and menopausal status suggest that lycopene and other plasma-carotenoids may reduce the risk of developing breast cancer and that menopausal status has an impact on the mechanisms involved.

Women's strategic responses to violence in Nicaragua

STUDY OBJECTIVE

To describe the responses of women in León, Nicaragua to partner abuse and identify contextual factors associated with the use of certain coping mechanisms and the likelihood of permanent separation.

DESIGN

Cross sectional population-based survey.

SETTING

León, Nicaragua.

PARTICIPANTS

188 women 15-49 years of age who had experienced physical partner abuse, out of 488 women interviewed.

MAIN RESULTS

66% of women defended themselves effectively from abuse either physically or verbally. Forty one per cent of women had left home temporarily because of violence and 20% had sought help outside the home. Women experiencing severe abuse were more likely to leave or seek help, whereas women with less severe abuse were more able to defend themselves effectively. Seventy per cent of women eventually left abusive relationships. Help seeking and temporary separations increased the likelihood of a permanent separation, whereas women who defended themselves and were able to stop the violence, at least temporarily, were more likely to remain in abusive relationships.

CONCLUSIONS

Women in Nicaragua use a variety of methods in order to overcome physical partner abuse. Temporary leaving and help seeking are critical steps in the process of leaving a violent relationship. However, many women indicated that they did not receive support for their situation. More interventions are needed to help women recognise and deal with violence, as well as strengthening the community support networks available to abused women.

Researching domestic violence against women: methodological and ethical considerations

The results of three population-based studies on violence against women in Nicaragua are compared in this article. Two of the studies were regional in scope (León and Managua) and focused specifically on women's experiences of violence, whereas the third study was a Demographic and Health Survey (DHS) conducted with a nationally representative sample of women. The lifetime prevalence estimates for women's undergoing physical violence from a partner were significantly higher in the León study (52 percent) and Managua study (69 percent), compared with that given in the DHS (28 percent). Possible explanations for the differences are examined through pooled multivariate logistic regression analysis, as well as analysis of six focus-group discussions carried out with field-workers and staff from the three studies. The most important differences that were found concerned ethical and safety procedures and the interview setting. The results indicate that prevalence estimates for violence are highly sensitive to methodological factors, and that underreporting is a significant threat to validity.

Infant mortality among Indonesian boys and girls: effect of sibling status

The effect of gender and sibling status on the infant mortality rate (IMR) in Purworejo District, Central Java, Indonesia was investigated using direct estimation of IMR. A cohort of 1,948 infants born between 1 January 1995 and 31 December 1996 was followed for 1 year within a surveillance system. IMR was higher (not significantly) in male infants, and males (but not females) had a higher mortality rate if born after more than two siblings. This was significant in the Highland area only. Mothers' education and quality of drinking water had no modifying effect in either sex on the association between IMR and sibling status. Thus, in contrast with studies from South Asia, there are no indications of preferential treatment of infant boys compared with infant girls in Central Java.

Impact of intestinal helminth infection on anemia and iron status during pregnancy: a community based study in Indonesia

A cohort study was carried out in Purworejo District, Central Java, Indonesia to investigate prevalence of anemia and low iron stores during pregnancy in relation to intestinal helminth infection. 442 pregnant women were followed until 5-10 weeks postpartum, during the period of April 1996 - August 1998. Information on intestinal helminths, hemoglobin and serum ferritin was collected each trimester. Highest prevalence of anemia in pregnancy (37.1%) was found in the second trimester, while the highest prevalence of low iron stores (49.5%) was found in the third trimester. Most pregnant women (69.7%) were infected with at least one species of pathogenic intestinal helminths. The most common helminth detected was Trichuris trichiura followed by Necator americanus (hookworm) and Ascaris lumbricoides. A significant negative association was found between hookworm infection and serum ferritin at the first trimester (p = 0.010). It is concluded that hookworm infection can interfere iron stores. Other causes of anemia among pregnant women should be considered. Anthelminthic therapy could be given to infected women before conception as public health strategy to improve iron status.

Variability in nutrient intakes among pregnant women in Indonesia: implications for the design of epidemiological studies using the 24-h recall method

Few studies have assessed the reliability of dietary intake methods during pregnancy. Between 1996 and 1998, a longitudinal study of dietary intake during pregnancy was carried out among 451 women in Central Java, Indonesia. Six 24-h recalls were performed each trimester. We report here on intraindividual and interindividual variability in energy and nutrient intakes, as well as the reliability of the 24-h diet recall method. Implications of the use of different numbers of replicate days for estimating dietary intake and the relationships between dietary intake and health outcomes are also discussed. Intravariance-to-intervariance ratios were <1 for energy and carbohydrates and >1 for all other nutrients throughout pregnancy. Reliability analyses found good agreement (reliability coefficient >0.7) with three replicates for the macronutrients, but at least six replicates were needed for an agreement of > or =0.6 for the micronutrients. To estimate true individual average intake with a precision of +/-20%, six replicate recalls were sufficient for energy, carbohydrates, vitamin A, iron and vitamin C. In conclusion, mean intake of several nutrients can be reliably measured with the 24-h recall method, using a limited number of days. The nutrient of interest, the primary objectives and method of analyses should all be taken into account when planning sample size and number of replicates.

Candies in hell: women's experiences of violence in Nicaragua

The aim of this study was to describe the characteristics of domestic violence against women in León, Nicaragua. A survey was carried out among a representative sample of 488 women between the ages of 15-49. The physical aggression sub-scale of the Conflict Tactics Scale was used to identify women suffering abuse. In-depth interviews with formerly battered women were performed and narratives from these interviews were analysed and compared with the survey data. Among ever-married women 52% reported having experienced physical partner abuse at some point in their lives. Median duration of abuse was 5 years. A considerable overlap was found between physical, emotional and sexual violence, with 21% of ever-married women reporting all three kinds of abuse. Thirty-one percent of abused women suffered physical violence during pregnancy. The latency period between the initiation of marriage or cohabitation and violence was short, with over 50% of the battered women reporting that the first act of violence act took place within the first 2 years of marriage. Significant, positive associations were found between partner abuse and problems among children, including physical abuse. Both the survey data and the narrative analysis pointed to extreme jealousy and control as constant features of the abusive relationship. Further, the data indicate that battered women frequently experience feelings of shame, isolation and entrapment which, together with a lack of family and community support, often contribute to women's difficulty in recognizing and disengaging from a violent relationship. These findings are consistent with theoretical conceptualisations of domestic violence developed in other countries, suggesting that, to a large degree, women's experiences of violence transcend specific cultural contexts.

High AIDS awareness may cause tuberculosis patient delay: results from an HIV epidemic area, Thailand

OBJECTIVE

To elicit community perceptions about tuberculosis (TB) and the behaviour of TB patients in an area where significant public health attention has been focused on AIDS.

SETTING

Chiang Rai, Thailand, the epicentre of HIV/AIDS in this country.

DESIGN

Eleven focus group sessions with a cross-section of the population.

PARTICIPANTS

Health centre staff, community members, persons having HIV, TB patients (with and without HIV infection), and male injecting drug users; five female groups and six male groups.

RESULT

People had good knowledge of AIDS but they knew little about TB. Only a few female patients, whose husbands had died of TB and AIDS, recognized their symptoms as TB and immediately sought care. People defined persons losing weight, having fever and cough as AIDS rather than TB. This resulted in delay in seeking care and non-adherence to TB treatment in some patients who suspected they had AIDS, and feared AIDS detection. Most HIV-negative TB patients were also suspected by their relatives and neighbours of having AIDS. Most participants, except HIV-positive females, believed TB to be curable. Although less than AIDS, the community stigmatized TB patients because of it being contagious and easily transmitted through exhalations, foods and drinks and closeness to TB patients.

CONCLUSION

In HIV/AIDS high endemic situation, increased awareness and stigmatization of AIDS and inadequate knowledge of TB can result in delay in seeking TB care and in treatment non-adherence.

God should give daughters to rich families only: attitudes towards childbearing among low-income women in Punjab, Pakistan

We evaluated perceptions and experiences of bearing sons and daughters among 42 women in Punjab, Pakistan, with special emphasis on son preference, changes in women's status within the marital family and resulting health effects. Data were collected through repeated, in-depth interviews in Urdu or Punjabi in an urban area in Lahore and a village 40 km. outside of Lahore. For triangulation purposes, four focus group discussions were performed with additional women, as well as in-depth interviews with eight mothers-in-law, three traditional practitioners and three medical practitioners. In general, these women felt that they had limited control over their lives, and this was exemplified by early marriages, high expectations on newly wed women to conceive and poor access to contraceptives. Women frequently expressed a strong preference for sons, mostly for economic reasons, reflecting women's subordinate position in society and the low economic value placed on women's work. Mothers of sons mainly discussed health problems during pregnancy and health effects of repeated childbearing. Mothers of daughters and women without children spoke of harassment in the family as well as in society. The results should be of importance in the public health planning in Pakistan as well as for those engaged in women's health issues internationally.

Predicting under- and overnutrition among women of reproductive age: a population-based study in central Java, Indonesia

OBJECTIVES

To evaluate changes over 1 year in weight and body mass index (BMI) among a population-based sample of non-pregnant women in Indonesia and to identify risk factors for developing under- and overnutrition.

DESIGN

Cross-sectional studies in 1996 and 1997 in the same population.

SETTING

Purworejo District, central Java, Indonesia.

SUBJECTS

Non-pregnant women (n = 4132) aged 15-49 years of age who participated in both 1996 and 1997. Based on BMI, women were classified as having chronic energy deficiency (CED), and as being either of normal weight or obese.

RESULTS

The mean height of the women was below the fifth percentile of international standards. In 1996, 16.2% had CED, 72.2% were normal and 11.6% were obese. In 1997, the corresponding figures were 14.4%, 71.2% and 14.3%, respectively, revealing a significant mean increase in weight and BMI. Among women classified as normal in 1996, 3.0% developed CED in 1997. Significant risk factors for developing CED were experiences of child deaths and non-use of contraceptives. Among women classified as normal in 1996, 5.3% developed obesity in 1997. Here, significant risk factors included most indicators of wealth as well as occupation.

CONCLUSIONS

The results should be important for future efforts to prevent CED and obesity in the general population; conditions which are both associated with health risks.

Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam

This study explores the perspectives of tuberculosis patients on which factors influenced their health seeking behaviour, with special reference to gender differentials in terms of delays in health seeking. In 1996, a multi-disciplinary research team carried out 16 focus group discussions. The study was done in four districts in Vietnam, both in the south and north of the country and in urban and rural areas. Qualitative analysis of data was performed following general principles of modified grounded theory technique. Participants in the focus groups described three main factors as contributing to delay in health seeking. These were fear of social isolation, economic constraints and inadequate staff attitudes and poor quality of health services. A model illustrating different factors influencing health seeking was elaborated and served as a basis for discussion of the findings. The main factor contributing to delay among women was described as fear of social isolation from the family or the community. Stigma was described as closely related to contextual factors such as gender-roles, socio-economic status and level of education and seemed to be mediated via denial and concealment of tuberculosis diagnosis and disease, thus causing delay. The main factor contributing to delay among men was described as fear of individual costs of diagnosis and treatment. Staff attitudes and quality of health service facilities were described as not always corresponding to people's expectations of appropriate health services. Women saw themselves and were seen by others as being more sensitive than men to poor service conditions and staff attitudes. A typical feature of the described health seeking behaviour of men was that they neglected symptoms until the disease reached a serious stage, by which time they tended to go directly to public health services without first visiting private health practitioners. Women, on the other hand, were described as having a tendency to seek out private services and practice self-medication before seeking care at public services. In conclusion, there is a need for better understanding of behavioural factors and for developing strategies, that take these into account. Health workers need to better understand gender and social aspects of tuberculosis control, particularly aspects that influence the likelihood for achieving equity in diagnosis and cure.

Stress from working conditions among home care personnel with musculoskeletal symptoms

A large proportion of the working population experiences musculoskeletal symptoms, which affect the individual's quality of life. Neck/shoulder and/or low back complaints are common among home care personnel. This occupational sector is characterized by high physical and psychosocial demands and the staff is typically female. The aim of this qualitative study was to gain a deeper understanding of those factors in the work environment of home care personnel that the individuals perceive as demanding and problematic. Eight employees in the home care service were interviewed in depth. Each interview was transcribed and Grounded Theory was applied. Stress, related to demanding physical and psychosocial working conditions, emerged as the core variable that probably contributed to the development and maintenance of musculoskeletal symptoms. Financial cut-backs at the municipality was seen as a cause of the demanding working conditions. In future studies it is important to evaluate prevention programmes focused upon coping strategies against stress.

Fatty-acid composition in serum phospholipids and risk of breast cancer: an incident case-control study in Sweden

The study of the relationship between dietary intake of fatty acids and the risk of breast cancer has not yielded definite conclusions with respect to causality, possibly because of methodological issues inherent to nutritional epidemiology. To evaluate the hypothesis of possible protection of n-3 polyunsaturated fatty acids (PUFA) against breast cancer in women, we examined the fatty-acid composition of phospholipids in pre-diagnostic sera of 196 women who developed breast cancer, and of 388 controls matched for age at recruitment and duration of follow-up, in a prospective cohort study in Umeâ, northern Sweden. Individual fatty acids were measured as a percentage of total fatty acids, using capillary gas chromatography. Conditional logistic-regression models showed no significant association between n-3 PUFA and breast-cancer risk. In contrast, women in the highest quartile of stearic acid had a relative risk of 0.49 (95% confidence interval, 0.22-1.08) compared with women in the lowest quartile (trend p = 0.047), suggesting a protective role of stearic acid in breast-cancer risk. Besides stearic acid, women in the highest quartile of the 18:0/18:1 n-9c ratio had a relative risk of 0.50 (95% confidence interval, 0.23-1.10) compared with women in the lowest quartile (trend p = 0.064), suggesting a decrease in breast-cancer risk in women with low activity of the enzyme delta 9-desaturase (stearoyl CoA desaturase), which may reflect an underlying metabolic profile characterized by insulin resistance and chronic hyper-insulinemia.