Health effects of reduced occupational sedentary behaviour in type 2 diabetes using a mobile health intervention: a study protocol for a 12-month randomized controlled trial-the ROSEBUD study

BACKGROUND

Short-term trials conducted in adults with type 2 diabetes mellitus (T2DM) showed that reducing sedentary behaviour by performing regular short bouts of light-intensity physical activity enhances health. Moreover, support for reducing sedentary behaviour may be provided at a low cost via mobile health technology (mHealth). There are a wide range of mHealth solutions available including SMS text message reminders and activity trackers that monitor the physical activity level and notify the user of prolonged sitting periods. The aim of this study is to evaluate the effects of a mHealth intervention on sedentary behaviour and physical activity and the associated changes in health in adults with T2DM.

METHODS

A dual-arm, 12-month, randomized controlled trial (RCT) will be conducted within a nationwide Swedish collaboration for diabetes research in primary health care. Individuals with T2DM (n = 142) and mainly sedentary work will be recruited across primary health care centres in five regions in Sweden. Participants will be randomized (1:1) into two groups. A mHealth intervention group who will receive an activity tracker wristband (Garmin Vivofit4), regular SMS text message reminders, and counselling with a diabetes specialist nurse, or a comparator group who will receive counselling with a diabetes specialist nurse only. The primary outcomes are device-measured total sitting time and total number of steps (activPAL3). The secondary outcomes are fatigue, health-related quality of life and musculoskeletal problems (self-reported questionnaires), number of sick leave days (diaries), diabetes medications (clinical record review) and cardiometabolic biomarkers including waist circumference, mean blood pressure, HbA1c, HDL-cholesterol and triglycerides.

DISCUSSION

Successful interventions to increase physical activity among those with T2DM have been costly and long-term effectiveness remains uncertain. The use of mHealth technologies such as activity trackers and SMS text reminders may increase awareness of prolonged sedentary behaviour and encourage increase in regular physical activity. mHealth may, therefore, provide a valuable and novel tool to improve health outcomes and clinical management in those with T2DM. This 12-month RCT will evaluate longer-term effects of a mHealth intervention suitable for real-world primary health care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04219800 . Registered on 7 January 2020.

Osteoporotic fractures in second-generation immigrants and Swedish natives

In this national study of osteoporotic fractures in second-generation immigrants in Sweden, we found a similar risk of osteoporotic fractures in general compared to Swedish natives, which suggests that environmental factors are important for the high risk of osteoporotic fractures in Nordic countries.

INTRODUCTION

Second generation immigrants may have a similar environment as individuals with two native-born parents. These individuals may be of interest to study concerning whether environmental or hereditary factors could be mostly associated to the risk of osteoporotic fractures. The aim of this study was to analyse the risk of osteoporotic fractures in second-generation immigrants compared to Swedish natives.

METHODS

This was a nationwide study of individuals aged 50 years of age and older (N = 1,377,035; 691,750 men and 685,285 women). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident osteoporotic fractures in second generation immigrants compared to Swedish natives. The Cox regression models were adjusted for age, comorbidities and for sociodemographic status.

RESULTS

A total of 114,505 osteoporotic fractures were registered, 109,622 (8.4%) were among individuals with Swedish-born parents and 4883 (7.5%) among those with foreign-born parents, with distal forearm fractures dominating in general (44.9%). Fully adjusted HRs (95% CI) were for all immigrants 0.95 (95% CI, 0.91-0.99), for men 0.96 (95% CI, 0.89-1.04) and for women 0.95 (95% CI, 0.90-1.00).

CONCLUSIONS

We observed a similar risk of osteoporotic fractures among second-generation immigrants as in Swedish natives, which suggests that environmental factors are important for osteoporotic fractures.

Osteoporotic fractures among foreign-born individuals: a national Swedish study

In this national study of osteoporotic fractures in foreign-born individuals, we found a lower risk of osteoporotic fractures in general among foreign-born individuals compared with Swedish-born, especially in immigrants from southern Europe. A higher risk was found among some groups, i.e. men and women from Bosnia and Iraq and men from Lebanon.

INTRODUCTION

The aim of this study was to analyse risk of osteoporotic fractures in foreign-born individuals compared with Swedish-born individuals.

METHODS

This was a nationwide study of individuals 50 years of age and older (N = 2,775,736). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 99% confidence intervals (CI)) of incident osteoporotic fractures in foreign-born compared with Swedish-born individuals. The Cox regression models were stratified by sex and adjusted for age, comorbidities and sociodemographic status.

RESULTS

A total of 362,899 osteoporotic fractures were registered (96,847 among men and 266,052 among women), with hip fractures dominating (54.0% among men, 42.6% among women). Fully adjusted HRs (99% CI) were for all immigrant men 0.75 (99% CI, 0.73-0.78) and women 0.83 (99% CI, 0.81-0.84), with significantly lower HRs among most groups but with higher HRs in certain countries. For the specific fractures, higher HRs were found for lower forearm fractures for men from Asia and for vertebral fractures among women from Asia.

CONCLUSIONS

We observed a generally lower risk of osteoporotic fractures among first-generation immigrants, with few exceptions.

TNFR1 is associated with short-term mortality in patients with diabetes and acute dyspnea seeking care at the emergency department

BACKGROUND

Circulating levels of TNF alpha receptor 1 (TNFR1) and 2 (TNFR2) are associated with increased long-term mortality and impaired kidney function.

AIM

To study association between circulating levels of TNFR1 and TNFR2 and short-term mortality in patients with diabetes and dyspnea.

POPULATION AND METHODS

Patients aged ≥ 18 years seeking at emergency department (ED) during daytime on weekdays between December 2013 and July 2018, with diabetes and acute dyspnea, identified at the triage process, were included. Participants (n = 291) were triaged according to Medical Emergency Triage and Treatment System-Adult score, and blood samples were collected. Association between TNFR1 and TNFR2, respectively, and 90-day mortality were estimated by Cox regression models adjusted for age, sex, BMI, creatinine and CRP.

RESULTS

Univariate models showed significant associations between TNFR1 and TNFR2, respectively, and CRP, age and creatinine. TNFR1 and TNFR2 tended to be elevated in patients with the highest triage level, compared to patients with lower triage levels (ns). In longitudinal analyses, TNFR1 but not TNFR2 was associated with increased short-term mortality, HR adjusted for age, BMI and creatinine 1.43 (95% CI 1.07-1.91), but not in the model also adjusted for CRP, HR 1.29 (95% CI 0.94-1.77). In secondary analysis for quartile 4 versus quartiles 1-3 of TNFR1, corresponding HRs were 2.46 (95% CI 1.27-5.15) and 2.21 (95% CI 1.07-2.56).

CONCLUSIONS

We found a trend for the association between circulating TNFR1 levels and short-term mortality in patients with diabetes and acute dyspnea at the ED, possibly suggesting an inflammatory pathway for the association.

Epilepsy in second-generation immigrants: a cohort study of all children up to 18 years of age in Sweden

BACKGROUND AND PURPOSE

Our purpose was to study the association between country of birth and incident epilepsy in second-generation immigrants in Sweden.

METHODS

The study population included all children (n = 4 023 149) aged up to 18 years in Sweden. Epilepsy was defined as at least one registered diagnosis of epilepsy in the National Patient Register. The incidence of epilepsy, using individuals with Swedish-born parents as referents, was assessed by Cox regression, expressed in hazard ratios (HRs) and 95% confidence interval (95% CI). All models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and comorbid conditions, also using data from the Total Population Register.

RESULTS

A total of 26 310 individuals had a registered epilepsy event, i.e. 6.5/1000 (6.6/1000 amongst boys and 6.3/1000 amongst girls). After adjustment, the risk of epilepsy was lower than in children of Swedish-born parents. Amongst girls the significant HR was 0.85 (95% CI 0.81-0.88), but in boys only when adjusting also for comorbidity (HR 0.96, 95% CI 0.92-0.99). Amongst specific immigrant groups, a higher incidence of epilepsy was observed amongst boys with parents from Turkey and Africa, but not when adjusting for comorbidity, and a lower risk was observed in many other groups (boys with parents from Latvia, girls with parents from Finland, Iceland, Southern Europe, countries from the former Yugoslavia, and Asia).

CONCLUSION

The risk of epilepsy was lower in second-generation immigrant children compared to children with Swedish-born parents, but with substantial differences between different immigrant groups.

Comorbidities, risk factors and outcomes in patients with heart failure and an ejection fraction of more than or equal to 40% in primary care- and hospital care-based outpatient clinics

OBJECTIVE

The aim of this study is to describe patients with heart failure and an ejection fraction (EF) of more than or equal to 40%, managed in both Primary- and Hospital based outpatient clinics separately with their prognosis, comorbidities and risk factors. Further to compare the heart failure medication in the two groups.

DESIGN

We used the prospective Swedish Heart Failure Registry to include 9654 out-patients who had HF and EF ≥40%, 1802 patients were registered in primary care and 7852 in hospital care. Descriptive statistical tests were used to analyze base line characteristics in the two groups and multivariate logistic regression analysis to assess mortality rate in the groups separately.

SETTING

The prospective Swedish Heart Failure Registry.

SUBJECTS

Patients with heart failure and an ejection fraction (EF) of more than or equal to 40%.

MAIN OUTCOME MEASURES

Comorbidities, risk factors and mortality.

RESULTS

Mean-age was 77.5 (primary care) and 70.3 years (hospital care) p < 0.0001, 46.7 vs. 36.3% women respectively (p < 0.0001) and EF ≥50% 26.1 vs. 13.4% (p < 0.0001). Co-morbidities were common in both groups (97.2% vs. 92.3%), the primary care group having more atrial fibrillation, hypertension, ischemic heart disease and COPD. According to the multivariate logistic regression analysis smoking, COPD and diabetes were the most important independent risk factors in the primary care group and valvular disease in the hospital care group. All-cause mortality during mean follow-up of almost 4 years was 31.5% in primary care and 27.8% in hospital care. One year-mortality rates were 7.8%, and 7.0% respectively.

CONCLUSION

Any co-morbidity was noted in 97% of the HF-patients with an EF of more than or equal to 40% managed at primary care based out-patient clinics and these patients had partly other independent risk factors than those patients managed in hospital care based outpatients clinics. Our results indicate that more attention should be payed to manage COPD in the primary care group. KEY POINTS 97% of heart failure patients with an ejection fraction of more than or equal to 40% managed at primary care based out-patient clinics had any comorbidity. Patients in primary care had partly other independent risk factors than those in hospital care. All-cause mortality during mean follow-up of almost 4 years was higher in primary care compared to hospital care. In matched HF-patients RAS-antagonists, beta-blockers as well as the combination of the two drugs were more seldom prescribed when managed in primary care compared with hospital care.

High prevalence of diabetes mellitus, hypertension and obesity among persons with a recorded diagnosis of intellectual disability or autism spectrum disorder

BACKGROUND

Obesity and lack of physical activity are frequently reported in persons with intellectual disability (ID) or autism spectrum disorder (ASD). We hypothesised a higher prevalence of diabetes and hypertension in this population.

METHOD

We used administrative data for all primary and specialist outpatient and inpatient healthcare consultations for people with at least one recorded diagnosis of diabetes mellitus, hypertension or obesity from 1998 to 2015. Data were drawn from the central administrative database for Stockholm County, Sweden. It was not possible to separate data for type 1 and type 2 diabetes. We stratified 26 988 individuals with IDs or ASD into three groups, with Down syndrome treated separately, and compared these groups with 1 996 140 people from the general population.

RESULTS

Compared with the general population, men and women with ID/ASD had 1.6-3.4-fold higher age-adjusted odds of having a registered diagnosis of obesity or diabetes mellitus, with the exception of diabetes among men with Down syndrome. A registered diagnosis of hypertension was only more common among men with ID/ASD than in the general population.

CONCLUSIONS

Diabetes and blood pressure health screening, along with efforts to prevent development of obesity already in childhood, are necessary for individuals with IDs and ASD. We believe that there is a need for adapted community-based health promotion programmes to ensure more equitable health for these populations.

The use of a Swedish telephone medical advice service by the elderly - a population-based study

OBJECTIVE

The present study aimed to describe contact made by the elderly to Sweden's nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres.

DESIGN

De-identified data from recorded calls to HGP was extracted for analysis (n = 7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system.

SETTING

Västerbotten County, Sweden.

SUBJECTS

Patients over 80 years.

MAIN OUTCOME MEASURES

Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations.

RESULTS

The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r = 0.30, p < 0.05) and calls that were given advice correlated with acute primary healthcare visits (r = 0.38, p = 0.005).

CONCLUSION

The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service's present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly's medication regimens. Key points Patients over 80 years of age had a high utilisation of the telephone medical advice service compared with other age groups. Drug-related questions were the most common reason for contact. A significant proportion of all calls made resulted in further heatlhcare contacts.

Psychometric Testing of an Instrument About Intimate Partner Violence

This study used step-by-step exploratory factor analysis in the framework of confirmatory factor analysis (EFA/CFA) to evaluate the psychometric properties of the translated and culturally adapted Swedish version of "The Violence Against Women Health Care Provider Survey." The Swedish version of the instrument was needed to measure district nurses' preparedness to encounter women exposed to intimate partner violence. In the first step of EFA/CFA, the eight-factor model was confirmed. The item-total correlations ranged from .22 to 1.01, and Cronbach's alphas from .68 to .71. After removing four items, the corrected item-total correlations ranged from .40 to .97. On the basis of the analysis, we concluded that the Swedish version of the instrument is valid and reliable for evaluating the preparedness of district nurses in Sweden to encounter women exposed to intimate partner violence.

Prevalence and incidence of diabetes mellitus: a nationwide population-based pharmaco-epidemiological study in Sweden

AIM

To investigate the changes in prevalence and incidence of pharmacologically and non-pharmacologically treated diabetes in Sweden during 2005 to 2013.

METHODS

We obtained data on gender, date of birth and pharmacologically and non-pharmacologically treated diabetes from national registers for all Swedish residents.

RESULTS

During the study period a total of 240 871 new cases of pharmacologically treated diabetes was found. The age-standardized incidence during the follow-up was 4.34 and 3.16 per 1000 individuals in men and women, respectively. A decreasing time trend in incidence for men of 0.6% per year (0.994, 95% CI 0.989-0.999) and for women of 0.7% per year (0.993, 95% CI 0.986-0.999) was observed. The age-standardized prevalence increased from 41.9 and 29.9 per 1000 in 2005/2006 to 50.8 and 34.6 in 2012/2013 in men and women, respectively. This corresponds to an annually increasing time trend for both men (1.024, 95% CI 1.022-1.027) and women (1.019, 95% CI 1.016-1.021). The total age-standardized prevalence of pharmacologically and non-pharmacologically treated diabetes (2012) was 46.9 per 1000 (55.6 for men and 38.8 for women). This corresponds to an annually increasing time trend (2010-2012) for both men (1.017, 95% CI 1.013-1.021) and women (1.012, 95% CI 1.008-1.016).

CONCLUSIONS

The prevalence of pharmacologically treated diabetes increased moderately during 8 years of follow-up, while the incidence decreased modestly. This is in contrast to the results reported by most other studies. The total prevalence of diabetes (both pharmacologically and non-pharmacologically treated) in Sweden is relatively low, from a global viewpoint.

Effects of Nordic walking on cardiovascular risk factors in overweight individuals with type 2 diabetes, impaired or normal glucose tolerance

BACKGROUND

Physical activity remains a valuable prevention for metabolic disease. The effects of Nordic walking on cardiovascular risk factors were determined in overweight individuals with normal or disturbed glucose regulation.

METHODS

We included 213 individuals, aged 60 ± 5.3 years and with body mass index (BMI) of 30.2 ± 3.8 kg/m(2); of these, 128 had normal glucose tolerance (NGT), 35 had impaired glucose tolerance (IGT) and 50 had type 2 diabetes mellitus (T2DM). Participants were randomized to unaltered physical activity or to 5 h per week of Nordic walking with poles, for a 4-month period. Dietary habits were unaltered. BMI, waist circumference, blood pressure, glucose tolerance, clinical chemistry, maximal oxygen uptake (peak VO(2)) and self-reported physical activity (questionnaire) were assessed at the time of inclusion and after 4 months. The participants in the exercise-intervention group kept a walking diary.

RESULTS

In the NGT exercise group, self-reported physical activity increased markedly, and body weight (-2.0 ± 3.8 kg), BMI (-0.8 ± 1.4 kg/m(2)) and waist circumference (-4.9 ± 4.4 cm) (mean ± SD) decreased. Exercise power output (12.9 ± 9.9 W) and peak VO(2) (2.7 ± 2.8 mL/kg/min) increased in the IGT exercise group. More cardiovascular risk factors were improved after exercise intervention in people with NGT compared with those with IGT or T2DM. Exercise capacity improved significantly in all three groups of participants who reported at least 80% compliance with the scheduled exercise.

CONCLUSIONS

Nordic walking improved anthropometric measurements and exercise capacity. However, unsupervised Nordic walking may not provide a sufficient increase in exercise intensity to achieve ultimate health-promoting benefits on the cardiovascular parameters assessed in this study, particularly for those with disturbed glucose regulation.

Effects of Nordic walking on health-related quality of life in overweight individuals with type 2 diabetes mellitus, impaired or normal glucose tolerance

AIMS

To assess the effects of 4 months of increased physical activity on health-related quality of life in overweight individuals with Type 2 diabetes mellitus, normal or impaired glucose tolerance.

METHODS

We included 212 individuals without severe physical or cardiovascular impairments aged 61 (57-64) years, with BMI of 29 (27.5-32) kg/m². Numbers are median (25th-75th percentile). Subjects were stratified based on normal glucose tolerance (n = 128), impaired glucose tolerance (n = 34) or Type 2 diabetes mellitus (n = 50). They were randomized into either a control group (n= 125), who maintained unaltered habitual lifestyle, or an exercise intervention group (n = 87), who were directed to engage in Nordic walking with walking poles, 5 h per week over 4 months. Self-reported physical activity and health-related quality of life was assessed at the time of inclusion and after 4 months.

RESULTS

Baseline health-related quality of life of this study cohort was similar to, or better than, an age- and sex-matched Swedish population sample, for 12 of 13 scales. Quality of sleep and BMI were improved for participants with normal glucose tolerance after 4 months of Nordic walking, with little or no musculoskeletal pain as compared with control subjects. No correlation was evident between improved quality of sleep and improved BMI.

CONCLUSIONS

Quality of sleep improved in the group with normal glucose tolerance following 4 months of Nordic walking. BMI reduction did not account for this improvement. Nordic walking can be introduced in a primary health care setting as a low-cost mode of exercise that promotes weight loss and improved health satisfaction.

Diabetes and impaired glucose tolerance among Turkish immigrants in Sweden

AIM

To investigate whether the prevalence of diabetes and impaired glucose tolerance (IGT) was higher among Turkish immigrants in Sweden, than in their area of origin in Turkey.

METHODS

238 Turkish immigrants aged 20 years and older living in Flemingsberg, Sweden, were compared with 1549 participants of the same age living in the Konya area of Turkey. Data collection included anthropometric measurements, blood pressure (BP) measurements, and an oral glucose tolerance test (OGTT).

RESULTS

Prevalence of laboratory-verified diabetes was 11.8% among participants in Sweden compared to 7.1% among participants in Turkey (p 0.018). Turkish women in Sweden had a higher prevalence of diabetes than Turkish women in Turkey, 12.8% vs. 7.6% (p=0.037). Similarly, IGT was 17.8% among Turkish men in Sweden compared to 4.9% among men in Turkey (p<0.001) and 2-h blood glucose was higher among the immigrants (p<0.001). Systolic BP was also higher among the immigrants, especially in men (p<0.001) who also had a higher BMI (p=0.003).

CONCLUSIONS

The higher prevalence of diabetes and IGT among Turkish immigrants in Flemingsberg, Sweden, suggests that migration is associated with diabetes and that there are important implications for public health in Sweden.

Daily energy expenditure and cardiovascular risk in Masai, rural and urban Bantu Tanzanians

BACKGROUND

Several studies have revealed that the Masai, pastoralists in Tanzania, have low rates of coronary heart disease despite a diet high in saturated fat. It has also been suggested that they may be genetically protected. Recent studies detailing other potential protective factors, however, are lacking.

METHODS

A cross-sectional investigation of 985 Tanzanian men and women (130 Masai, 371 rural Bantu and 484 urban Bantu) with mean age of 46 (9.3) years. Anthropometric measures, blood pressure, serum lipids, and the reported dietary pattern and physical activity level were assessed.

RESULTS

82% of Masai subjects reported a high fat/low carbohydrate intake, whereas 77% of the rural Bantu subjects reported a low fat/high carbohydrate intake, while a high fat/high carbohydrate intake was the main dietary pattern of the urban Bantu group as, reported by 55%. The most conspicuous finding for the Masai was the extremely high energy expenditure, corresponding to 2565 kcal/day over basal requirements, compared with 1500 kcal/day in the rural and 891 kcal/day for the urban Bantu. Mean body mass index among the Masai was lower than the rural and urban Bantu. Mean systolic blood pressure of the Masai was also lower compared with their rural and urban Bantu counterparts. The Masai revealed a favourable lipid profile.

CONCLUSION

The potentially atherogenic diet among the Masai was not reflected in serum lipids and was offset probably by very high energy expenditure levels and low body weight.

The trend of cardiovascular disease in immigrants in Sweden

Little is known as to whether the declining trend in cardiovascular disease (CVD) and coronary heart disease (CHD) in the Western countries has reached the immigrant populations. Incidence rates of CVD and CHD between 1991-1993 and 1997-1999 were compared by analysing the relative risk (RR) using the Poisson regression model and the data from 1991-1993 within each group as a reference. The whole Swedish population aged 35-74 years was included and we focused on 12 different immigrant groups. The morbidity from CHD in men from Sweden, Finland and countries in the OECD decreased slightly in an age-adjusted model (RR: 0.91, 0.93, and 0.88, respectively) during the 1990s. The opposite results were observed in women from Southern Europe, Turkey and Iran, in whom CHD morbidity increased (RR: 1.35, 1.54 and 1.40, respectively). The declining trend in CVD and CHD is continuing among men from Sweden, Finland and the OECD countries, but it is unchanged for women from these countries and all other groups studied, and even with increases in some female groups. This might be a sign of a breaking trend in these diseases.

Morbidity in cardiovascular diseases in immigrants in Sweden

INTRODUCTION

Although immigration to Sweden has increased in the last few decades, the incidence rates of cardiovascular disease and coronary heart disease in immigrants are unknown. The aim of the present study is to estimate whether place of birth affects the incidence rates of cardiovascular disease and coronary heart disease.

MATERIAL AND METHODS

The study was designed as a follow-up study on morbidity in cardiovascular disease and coronary heart disease between 1 January 1997 and 31 December 1998, including three and a half million persons with age range 35-64 years, of whom 550 000 were born abroad, from the database MigMed consisting of the whole Swedish population. Incidence rates and relative risks were estimated by indirect standardization and a proportional hazard model.

RESULTS

The age-adjusted risk of coronary heart disease was higher in most foreign-born groups than in Swedes. For example, in nine of 12 male groups, the relative risks varied between 1.1 and 2.2, and in seven of 12 female groups, the relative risks varied between 1.4 and 2.5. When also adjusting for level of education and employment status, the risks were still high, but on a lower level.

CONCLUSIONS

Foreign-born people possess an over-risk of cardiovascular or coronary heart disease(CVD/CHD) compared with Swedish-born persons, also when level of education and employment status are taken into account.

Risk factors in established coronary heart disease: evaluation of a secondary prevention programme

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death in the developed world. We studied compliance to a secondary prevention programme for CHD patients and possible gender differences.

DESIGN AND METHODS

Cross-sectional survey of CHD patients aged up to 75 years attending a hospital cardiology outpatient clinic (n = 441; 16 cardiologists) and 12 primary care centres (n = 319; 28 primary care physicians), by means of a questionnaire.

RESULTS

Therapeutic goals in hospital care and in primary care were reached by 36% and 29% (P < 0.05) for cholesterol, 42% and 50% (P < 0.01) for triglycerides, 66% and 72% for blood glucose, 84% and 86% for blood pressure, and 16% and 20% for smoking, respectively. Echocardiography was more frequent in hospital care patients (odds ratio 2.69, P < 0.001). ACE-inhibitors, beta-blockers, antiplatelet and anticoagulant therapy were prescribed similarly in both groups, antidiabetics were less common in hospital care (odds ratio 0.53, P < 0.05). Men were more often subject to echocardiography (odds ratio 2.59, P < 0.001). ACE-inhibitors (odds ratio 2.04, P < 0.01), beta-blockers (odds ratio 1.82, P < 0.001) and antiplatelet or anticoagulant drugs (odds ratio 1.82, P < 0.01) were more common in men; diuretics (odds ratio 0.49, P < 0.01) were more common in women.

CONCLUSIONS

CHD patients have a high prevalence of modifiable risk factors. Few reach therapeutic goals for lipid levels, whereas other risk factors are better controlled. A secondary prevention programme is an important aid in preventing CHD but must be followed by further educational efforts in order to be more effective.

Functioning and well-being of patients with type 2 diabetes or angina pectoris, compared with the general population

This study compares the health-related quality of life (HRQOL) of patients with type 2 diabetes mellitus or angina pectoris with that of a standard population sample (SPS). The HRQOL was assessed by the Swedish Health-Related Quality of Life Survey (SWED-QUAL), a generic HRQOL questionnaire adapted from the Medical Outcomes Study (MOS), with twelve scales tapping aspects of physical, mental, social and general health. Subjects between 45 and 84 years of age who answered the questionnaire were included, i.e. 266 patients with type 2 diabetes, 758 patients with mild angina pectoris (Canadian Classes I and II) and 908 with severe angina (Canadian Classes III and IV). As controls, we used 1126 subjects from the SPS. Patients with type 2 diabetes, mild angina and severe angina showed an increasing degree of health disturbance, compared with the SPS. Diabetic patients with no heart disease showed only a minor impact on the HRQOL, while the presence of a heart disease showed a considerable impact. In angina patients, the presence of diabetes also to some extent added to the decrease in HRQOL. On comparing the impact of the heart disease and diabetes on the HRQOL, the heart disease showed a stronger effect on most aspects of the HRQOL than diabetes. It is concluded that coronary heart disease is an important predictor of the impact on the HRQOL of type 2 diabetes patients.

Diagnostic tests, treatment and follow-up in heart failure patients--is there a gender bias in the coherence to guidelines?

AIMS

To relate clinical data in a consecutive cohort of patients admitted with heart failure in Sweden to demographic data and the use of diagnostic tests, medical treatment, care process and mortality.

METHODS AND RESULTS

Retrospective investigation of all charts concerning patients discharged with primary diagnosis of heart failure in two Swedish hospitals during the second half of 1995 was undertaken. Records from 187 men and 192 women were analyzed, median age was 78 years. During hospital stay 75% of the patients, regardless of gender, were examined with chest radiography. Echocardiography was performed in 59% of all patients, more often in men than in women (68% vs. 55%, P<0.011). The proportion of patients receiving ACE-inhibitors was higher if echocardiography had been performed, in both men (38% vs. 72%, P<0.001) and women (38% vs. 55%, P<0.033). Mean hospital stay was 6.4 days. After discharge 57% of the patients were referred to the general practitioners (GP), 21% to the hospital outpatient clinic. Young age (P<0.001), male gender (P<0.01) and treatment with beta-blocking agents (P<0.035) were independently related to referral to hospital outpatient clinic. Within the group referred to the GPs, 62% of the patients had a follow-up visit within 3 months after discharge while 49% had visited the hospital outpatient clinic. The 1-year mortality rate was high, 30%.

CONCLUSION

Patients admitted with heart failure in Sweden are old and carry a poor prognosis. In spite of the poor prognosis, only approximately half of the patients are followed-up within 3 months after discharge. There is, in contrast to practice guidelines, an underuse of diagnostic tests of left ventricular function and medical treatment is often suboptimal. These unsatisfactory findings were more pronounced in women.

[A five-year follow-up of 115 patients treated with anticoagulants. Bleeding complications may be underestimated]

The prevalence of anticoagulant treatment in Sweden has increased in recent years. However, such treatment may be associated with a risk of serious complications. At 5-year follow-up of 115 primary care patients treated with anticoagulants in 1992, 39 were found to have died, eight of anticoagulant-induced bleeding complications (six of intracranial haemorrhages, and two after profuse gastro-intestinal haemorrhages). In only two of these cases, had an adverse reaction been diagnosed. The fatal complication rate was estimated to be 2.1 per cent per treatment year. There were 17 major complications requiring hospitalisation, the estimated rate being 4.4 per cent per treatment year. Three patients died of thromboembolic episodes during anticoagulant treatment, and a further three after completed treatment.