Chapter 5.3: Major public health problems — overweight and obesity

Cardiovascular risk factors differ between rural and urban Sweden: the 2009 Northern Sweden MONICA cohort

BACKGROUND

Rural communities have a higher burden of cardiovascular risk factors than urban communities. In Sweden, socioeconomic transition and urbanization have led to decreased populations in rural areas and changing characteristics of the remaining inhabitants. We investigated the risk factors in urban and rural populations in Northern Sweden.

METHODS

The 2009 Northern Sweden MONICA Study invited a random sample of 2,500 people, 25 to 74 years and 69.2% participated. Community size was classified as rural = <1,000 inhabitants, town = 1,000-15,000, or urban/city = >15,000. We adjusted our analysis for age, gender and education.

RESULTS

The rural population was older and the proportion of men was higher than in the urban areas. Having only primary education was more common in rural areas than in urban areas (26.2% vs. 12.3%). Waist and hip circumference, body mass index (BMI), and total cholesterol levels were higher in rural areas than in urban areas, even after adjusting for differences in age and gender. The largest differences between rural and urban dwellers were seen in waist circumference of women (4.8 cm), BMI of women (1.8 units) and cholesterol of men (0.37 mmol/l). Blood pressure was higher in rural areas, but not after adjusting for age and gender.Participants in rural areas were more often treated for hypertension and hyperlipidaemia, hospitalized for myocardial infarction and diagnosed with diabetes. However, after adjusting for age and gender, there were no differences. The odds ratio for being physically active comparing rural areas to urban areas was 0.73 (95% CI 0.53; 1.01). Smoking, snuff use and the prevalence of pathological glucose tolerance did not differ between community sizes. Middle-sized communities often had values in between those found in rural and urban communities, but overall they were more similar to the rural population. Further adjustment for education did not change the results for any variable.

CONCLUSIONS

In 2009 the rural population in northern Sweden was older, with less education, higher BMI, more sedentary lifestyle, and had higher cholesterol levels than the urban population. The rural population should be considered targets for focused preventive interventions, but with due consideration of the socioeconomic and cultural context.

The changing faces of diabetes, hypertension and arthritis in a Caribbean population

BACKGROUND

Globally, chronic illnesses are the leading cause of mortality, and this is no different in developing countries, particularly in the Caribbean. Little information emerged in the literature on the changing faces of particular self-reported chronic diseases.

AIMS

This study examines the transitions in the demographic characteristics of those with diabetes, hypertension and arthritis, as we hypothesized that there are changing faces of those with these illnesses.

MATERIALS AND METHODS

A sample of 592 respondents from the 2002 and 2007 Jamaica Survey of Living Conditions. Only respondents who indicated that they were diagnosed with these particular chronic conditions were used for the analysis.

RESULTS

The prevalence of particular chronic diseases increased from 8 per 1,000 in 2002 to 56 per 1,000 in 2007. The average annual increase in particular chronic diseases was 17.2%. Diabetes mellitus showed an exponential average annual increase of 185% compared to hypertension (+ 12.7%) and arthritis (- 3.8%). Almost 5 percent of diabetics were less than 30 years of age (2.4% less than 15 years), and 41% less than 59 years. Three percent of hypertensive respondents were 30 years and under as well as 2% of arthritics.

CONCLUSION

The demographic transition in particular chronic conditions now demands that data collection on those illnesses be lowered to < 15 years. This research highlights the urgent need for a diabetes campaign that extends beyond parents to include vendors, confectionary manufacturers and government, in order to address the tsunami of chronic diseases facing the nation.

Preventing obesity: challenges and pitfalls for health promotion

OBJECTIVE

To explore challenges to health promotion strategies against obesity, with special attention to the Scandinavian context.

METHODS

Analytic induction, a procedure for verifying theories and propositions, based on purposefully selected literature references, with subsequent critical reflection.

RESULTS

Health promotion efforts against obesity face challenges related to the unequal distribution of vulnerability to weight gain within the population, and to the complex neuroregulatory determinants that explain why obesity is not just a simple matter of lifestyle. Cultural understandings of identity and morality may create victim blaming and disempowerment, thus obstructing clinical health promotion strategies for weight control. Finally, the conceptual validity of obesity measurements and their predictive power deserves attention.

CONCLUSION

Preventing obesity is difficult. Awareness of individual vulnerability and neurobiological mechanisms that lead to weight gain must be taken into account when strategies for health promotion are developed. These strategies must transcend a simplistic energy balance view.

PRACTICE IMPLICATIONS

Clinical health promotion needs to be highly individualized and tailored. Preventing weight gain requires attention to the person's sociodemographic, cultural and genetic characteristics. Cultural trends such as sedentary lifestyles and the nutrition transition should be counteracted without turning body weight control into a question of morality and inferior identity.

Gender differences in trends of acute myocardial infarction events: the Northern Sweden MONICA study 1985 - 2004

Background

The registration of non-fatal and fatal MI events initiated 1985 in the WHO MONICA project has been ongoing in northern Sweden since the end of the WHO project in 1995. The purpose of the present study was to analyze gender differences in first and recurrent events, case fatality and mortality in myocardial infarction (MI) in Northern Sweden during the 20-year period 1985 – 2004.

Methods

Diagnosed MI events in subjects aged 25–64 years in the Counties of Norrbotten and Västerbotten were validated according to the MONICA protocol. The total number of events registered up to January 1, 2005 was 11,763: 9,387 in men and 2,376 in women.

Results

The proportion of male/female events has decreased from 5.5:1 to 3:1. For males the reductions were 30% and 70% for first and recurrent MI, respectively, and for women 0% and 40% in the 55–64 year group. For both sexes a 50% reduction in 28-day case fatality was seen in the 25–64 year-group. Mortality was reduced by 69% and 45% in men and women, respectively.

Conclusion

First and recurrent events of myocardial infarction was markedly reduced in men over the 20-year observation period, but for women the reduction was seen only for recurrent infarctions. Case fatality, on the other hand, was markedly reduced for both sexes. As a result of the positive effects on incidence and case fatality a substantial reduction was seen in total mortality, most pronounced for men.

Psychological distress and risk of pre-diabetes and Type 2 diabetes in a prospective study of Swedish middle-aged men and women

AIMS

To determine the role of psychological distress as a predictor of pre-diabetes and Type 2 diabetes.

METHODS

This cohort study comprised 2127 Swedish middle-aged men and 3100 women with baseline normal glucose tolerance measured by oral glucose tolerance test. At follow-up 8-10 years later, 245 men and 177 women had pre-diabetes [impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and IFG + IGT] and Type 2 diabetes was detected in 103 men and 57 women. Baseline psychological distress was measured by an index of five questions concerning anxiety, apathy, depression, fatigue and insomnia. Odds ratios (ORs) were estimated for pre-diabetes and Type 2 diabetes in association with total psychological distress. In addition, ORs of the single-item questions were calculated.

RESULTS

In men, adjusted ORs (95% confidence interval) in the highest index group of psychological distress compared with the lowest group were 1.9 (1.2-2.8) and 2.2 (1.2-4.1) for pre-diabetes and Type 2 diabetes, respectively. Corresponding estimates in women were 1.2 (0.7-2.1) and 0.5 (0.2-1.2). In the middle symptoms groups, adjusted ORs in men were 1.1 (0.8-1.4) for pre-diabetes and 1.2 (0.7-2.0) for Type 2 diabetes and in women 1.8 (1.1-3.0) and 0.7 (0.3-1.4). When analysed separately, the associations with each of the five single factors were similar.

CONCLUSIONS

The results indicate that psychological distress, including symptoms of anxiety, apathy, depression, fatigue and insomnia, increases the risk of pre-diabetes and Type 2 diabetes in Swedish middle-aged men. Increased risks were not present in women, except for pre-diabetes in the middle index group.

Place of residence and obesity in 1,578,694 young Swedish men between 1969 and 2005

OBJECTIVE

To compare prevalence of overweight and obesity in young adult men from rural areas with those from urban areas of Sweden over three decades.

METHODS AND PROCEDURES

Eighty-two percent of the Swedish male population at military conscription age between 1969 and 2005 (n = 1,578,694; 18.3 +/- 0.4 years) was grouped by urban, semiurban, and rural place of residence. BMI was calculated from measured height and weight. Comparisons were made with and without adjustments for parental education, socioeconomic position (SEP), and intelligence quotient (IQ).

RESULTS

During the study period, the prevalence of obesity more than quintupled from 0.9-5.1%, while overweight tripled from 7.1-20.5% (P < 0.0001). An urban-rural gradient was observed within all socioeconomic and education strata. After adjustment for SEP, IQ, parental education level, and testing year, the odds ratios (ORs) were 1.28 (1.23-1.34) and 1.20 (1.18-1.22) for obesity and overweight, respectively, in a rural compared to an urban area. The corresponding ORs for semiurban place of residence were 1.16 (1.13-1.19) and 1.11 (1.10-1.12), respectively. Significant effect modification by time was seen, with evidence of an increasing gradient until the early 1990s (P < 0.001).

DISCUSSION

A strong and persisting gradient of increasing overweight and obesity from urban to rural areas was observed that could not be explained by individual or family-related factors such as IQ, parental education level, or SEP. These results indicate the presence of strong environmental or contextual obesogenic factors affecting the energy balance of people in rural areas more negatively than those in urban communities.

Crisis and chaos in behavioral nutrition and physical activity

Resnicow & Vaughn challenged the field of behavioral nutrition and physical activity to conduct research in new ways. They challenged the predictiveness of our models, sensitivity to initial conditions, factors predisposing to change and measurement procedures. While the predictiveness of our models will reflect the sophistication of our thinking and research, and the sensitivity to initial conditions is subsumed under the sophistication of our models, research on conditions predisposing to change (e.g. epiphanies), more longitudinal designs, refined measurement procedures and testing of critical issues can only enhance the quality of our research. Improved research quality should lead to enhanced efficacy and effectiveness of our interventions, and thereby our making meaningful contributions to mitigating the chaos in our field and the crisis from the rising epidemic of obesity.