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Background Alcohol consumption contributes to many negative health consequences and is a risk factor for death. Some previous studies however suggest a J-shaped relationship between the level of alcohol consumption and all-cause mortality. These findings have in part been suggested to be due to confounders. The aim of our study was to analyze the relationship between self-reported alcohol intake and all-cause mortality in women, adjusted for sociodemographic, lifestyle factors and diseases such as diabetes and previous ischemic heart disease. Methods All women aged 50–59 years (born between 1935 and 1945) that lived in any of the five municipalities in southern Sweden were invited to participate in a health survey. From December 1995 to February 2000 a total of 6916 women (out of 10,766, the total population of women in 1995) underwent a physical examination and answered a questionnaire. We followed the women from the day of screening until death, or if no event occurred until May 31st 2015. Mortality was ascertained through the national cause-of-death register. Results In this study a total of 6353 women were included. Alcohol consumption showed a J-formed relationship with mortality, when adjusted for education, marital status, smoking, BMI, physical fitness, diabetes and ischemic heart disease before screening. Non consumption of alcohol was associated with increased mortality as well as higher levels of consumption, from 12 grams per day and upwards. Conclusions There was a clear J-shaped relation between the amount of alcohol consumption and all-cause mortality even after controlling for sociodemography, lifestyle factors and diseases such as diabetes and previous ischemic heart disease. The observed protective effect of light drinking (1–12 grams/day) could thus not be attributed to any of these known confounders.

Background The aim of this longitudinal study was to analyze whether mean Body Mass Index (BMI), assessed at four occasions, changed within different age groups and birth cohorts over time, i.e., between 1980/81 and 2004/05, after adjustment for possible confounders. Methods A sample of 2728 men and 2770 women aged 16–71 years at study start were randomly drawn from the Swedish Total Population Register and followed from 1980/81 to 2004/05. The same sample was assessed on four occasions during the 24-year study period (i.e., every eighth year). The outcome variable, BMI, was based on self-reported height and weight. A mixed model, with random intercept and random slope, was used to estimate annual changes in BMI within the different age groups and birth cohorts. Results Mean BMI increased from 24.1 to 25.5 for men and from 23.1 to 24.3 for women during the 24-year study period. The annual change by age group was highest in the ages of 32–39, 40–47 and 48–55 years among men, and in the ages of 24–31, 32–39, and 40–47 years among women. The highest annual changes were found in the youngest birth cohorts for both men and women, i.e., those born 1958–65, 1966–73, and 1974–81. For each birth cohort, the annual change in BMI increased compared to the previous, i.e., older, birth cohort. In addition, age-by-cohort interaction tests revealed that the increase in BMI by increasing age was higher in the younger birth cohorts (1966–1989) than in the older ones. Conclusions Public health policies should target those age groups and birth cohorts with the highest increases in BMI. For example, younger birth cohorts had higher annual increases in BMI than older birth cohorts, which means that younger cohorts increased their BMI more than older ones during the study period.

Background During the last decades, global migration has increased and many immigrant groups have a higher prevalence than the native born population of several cardiovascular disease risk factors, including poor dietary habits. However, it is uncertain if dietary habits in immigrant populations reflect dietary habits in their country of origin or if the current diet is a consequence of the migration and possible change of dietary habits. The aim of this study was to examine possible dietary differences between elderly Iranians living in Stockholm, Sweden with elderly Iranians living in Tehran, Iran, taking into account sex, age, marital status, and education. Methods Dietary intakes were assessed by semi - quantitative food frequency questionnaire in a cross-sectional study of 121 Iranians living in Stockholm and 52 Iranians living in Tehran, aged 60-80. Differences in dietary habits between the two groups was analysed by bootstrapped regression analyses with 1000 replications. Results Iranians living in Sweden had significantly higher intake of protein, total fat, fiber than Iranians living in Iran, but lower consumption of carbohydrates. The observed differences in intake of macronutrients were reflected in consumed amount of all food items, which were higher among Iranians living in Iran with the exception of bread and grain consumption which was lower. Conclusions There are general differences in dietary habits between Iranians living in Iran and Iranians living in Sweden. Parts of observed differences in dietary habits may reflect a favourable adoption process to the Swedish dietary habits after migration. Meanwhile other differences are point of concern in light of the high prevalence of overweight, among Iranians living in Sweden and can have unfavourable impact in particular in the context of cardiovascular health.

Background Despite a strong social gradient in the prevalence of obesity, there is little scientific understanding of obesity in people settled in deprived neighbourhoods. Few studies are actually based on objectively measured data using random sampling of residents in deprived neighbourhoods. In addition, most studies use a crude measure, the body mass index, to estimate obesity. This is of concern because it may cause inaccurate estimations of the true prevalence and give the wrong picture of the factors associated with obesity. The aim of this study was to estimate the prevalence of, and analyse the sociodemographic factors associated with, three indices of obesity in different ethnic groups settled in two deprived neighbourhoods in Sweden. Methods Height and weight, waist circumference and body fat percentage were objectively measured in a random sample (n = 289). Sociodemographic data were obtained through a survey. Established cut-offs were used to determine obesity. Country of birth was categorized as Swedish, Other European, and Middle Eastern. Odds ratios were estimated by unconditional logistic regression. Results One third of the sample was classified as obese overall, with 39.0% of women being abdominally obese. After adjusting for age, we found higher odds of obesity in Middle Eastern women than in Swedish women regardless of outcome with odds ratios ranging between 2.74 and 5.53. Men of other European origin had higher odds of BMI obesity than Swedish men. Most associations between country of birth and obesity remained in the full model. Conclusion This study demonstrates the magnitude of the obesity problem and the need for prevention programmes targeting native and immigrant adults in deprived neighbourhoods in Sweden. The initiatives should also focus on particular groups, e.g. immigrant women and those experiencing economic difficulties. Further studies are needed on behavioural and environmental factors influencing the risk of obesity in residents settled in deprived neighbourhoods.

Background Previous studies have reported discrepancies in cause-specific mortality among groups of individuals with different socio-economic status. However, most of the studies were limited by the specificity of the investigated populations and the broad definitions of the causes of death. The aim of the present population-based study was to explore the dependence of disease specific mortalities on the socio-economic status in Sweden, a country with universal health care. Another aim was to investigate possible gender differences. Methods Using the 2006 update of the Swedish Family-Cancer Database, we identified over 2 million individuals with socio-economic data recorded in the 1960 national census. The association between mortality and socio-economic status was investigated by Cox's proportional hazards models taking into account the age, time period and residential area in both men and women, and additionally parity and age at first birth in women. Results We observed significant associations between socio-economic status and mortality due to cardiovascular diseases, respiratory diseases, to cancer and to endocrine, nutritional and metabolic diseases. The influence of socio-economic status on female breast cancer was markedly specific: women with a higher socio-economic status showed increased mortality due to breast cancer. Conclusion Even in Sweden, a country where health care is universally provided, higher socio-economic status is associated with decreased overall and cause-specific mortalities. Comparison of mortality among female and male socio-economic groups may provide valuable insights into the underlying causes of socio-economic inequalities in length of life.

Background The increasing cost of public social sickness insurance poses a serious economic threat to the Swedish welfare state. In recent years, expenditures for social insurance in general, as well as social sickness insurance in particular, have risen steeply in Sweden. This cross-sectional study analyzed the association between sickness absence (SA) and self-reported reduced working capacity due to a longstanding illness (>3 months), as well between SA and a number of other health problems. Methods Self-reported data on longstanding illness and resultant reduced working capacity, socioeconomic factors, working environment, psychosomatic complaints, anxiety, and general health were obtained for 22,281 employed (paid) persons aged 25 to 64 years. These data were retrieved from the Swedish Living Conditions Survey for 1995 to 2002. National civic registration numbers, replaced with serial numbers to ensure anonymity, were used to link these data to individual-level SA records from the National Social Insurance Board. A logistic regression model was used to estimate the odds ratio of the main outcome variable for the three levels of the SA variable (0–28, 29–90, >90 days/year). Results There was an obvious increasing gradient in length of SA and increasing odds of reporting reduced working capacity. Odds ratios ranged from 3.5 to 19.0; i.e., those with more than ninety days of SA had 19.0 times higher odds of reporting reduced working capacity than those with 0–28 days of SA a year. This very strong association changed less than 10% after adjusting for demographic, socioeconomic, and working environment characteristics. A total of 48.7% of persons on sick leave ≥ 29 days reported no longstanding illness and reduced working capacity. Of these persons, about 43% reported one or more other health problem. Conclusion We confirmed that longstanding illness that results in self-reported reduced working capacity is an important variable related to length of SA, even after taking important confounders into consideration. We found a little less than half of those on sick leave reported no reduced working capacity due to longstanding illness, and some of these reported no other health problems. However, it is possible that some respondents had health problems not captured in the survey.

Background Enlargement of the European Union has caused worries about the possibility of increased migration from its new members, the former Soviet countries, and consequently increased demands on the health care systems of the host countries. This study investigated whether or not earlier immigrants from the former Soviet Bloc have poorer self-reported mental health, measured as self-reported psychiatric illness and psychosomatic complaints, than the host population in Sweden. It also examined the particular factors which might determine the self-reported mental health of these immigrants. Methods The cross-sectional national sample included 25–84-year-old Swedish-born persons (n = 35,459) and immigrants from Poland (n = 161), other East European countries (n = 164), and the former Soviet Union (n = 60) who arrived in Sweden after 1944 and were interviewed during 1994–2001. Unconditional multivariate logistic regression was used in the analyses. Results The findings indicated that the country of birth had a profound influence on self-reported mental health. Polish and other East European immigrants in general had a twofold higher odds ratio of reporting psychiatric illness and psychosomatic complaints, which fact could not be explained by adjustments for the demographic and socioeconomic variables. However, immigrants from the former Soviet Union had odds similar to those of the Swedish-born reference group. Adjustments for migration-related variables (language spoken at home and years in Sweden) changed the association between the country of birth and the outcomes only to a limited extent. Conclusion Since poor mental health may hinder acculturation, the mental health of immigrants from Poland and other East European countries should be acknowledged, particularly with the expansion of the European Union and inclusion of nine former Soviet Bloc countries by 2007.

Background Non-concordance with medication remains a major public health problem that imposes a considerable financial burden on the health care system, and there is still a need for studies on correlates of non-concordance. Our first aim is to analyse whether any of the individual characteristics age, educational level, financial strain, self-rated health, social participation, and trust in the health care system are associated with primary non-concordance with medication. Our second aim is to investigate whether people living in the same area have similar probability of primary non-concordance with medication, that relates to area social participation. Methods We analysed cross sectional data from 9 070 women and 6 795 men aged 18 to 79 years, living in 78 areas in central Sweden, who participated in the Life & Health year 2000 survey, with multilevel logistic regression (individuals at the first level and areas at the second level). Results Younger age, financial strain, low self-rated health, and low trust in the health care system were associated with primary non-concordance with medication. However, area social participation was not related to primary non-concordance, and the variation in primary non-concordance between the areas was small. Conclusion Our results indicate that people in central Sweden with younger age, financial difficulties, low self-rated health, and low trust in the health care system may have a higher probability of primary non-concordance with medication. However, the area of residence – as defined by administrative boundaries – seems to play a minor role for primary non-concordance.

Background Mortality from cardiovascular diseases is higher among immigrants than native Swedes. It is not clear whether the high mortality persists from the country of birth or is a result of migration. The purpose of the present study was to analyse whether all-cause and coronary heart disease mortality differ between immigrants in Sweden and in the country of birth. Methods Two cohorts including the total population from Swedish national registers and WHO were defined. All-cause and CHD mortality are presented as age-adjusted incidence rates and incidence density ratios (IDR) in eight immigrant groups in Sweden and in their country of birth. The data were analysed using Poisson regression. Results The all-cause mortality risk was lower among seven of eight male immigrant groups (IDR 0.39–0.97) and among six of eight female immigrant groups (IDR 0.42–0.81) than in their country of birth. The CHD mortality risk was significantly lower in male immigrants from Norway (IDR = 0.84), Finland (IDR = 0.91), Germany (IDR = 0.84) and Hungary (IDR = 0.59) and among female immigrants from Germany (IDR = 0.66) and Hungary (IDR = 0.54) than in their country of birth. In contrast, there was a significantly higher CHD mortality risk in male immigrants from Southern Europe (IDR = 1.23) than in their country of birth. Conclusion The all-cause mortality risk was lower in the majority of immigrant groups in Sweden than in their country of birth. The differences in CHD mortality risks were more complex. For countries with high CHD mortality, such as Finland and Hungary, the risk was lower among immigrants in Sweden than in their country of birth. For low-risk countries in South Europe, the risk was higher in immigrants in Sweden than in South Europe.

Background: It has been reported that there is a difference in drug prescription between males and females. Even after adjustment for multi-morbidity, females tend to use more prescription drugs compared to males. In this study, we wanted to analyse whether the gender difference in drug treatment could be explained by gender-related morbidity. Methods. Data was collected on all individuals 20 years and older in the county of Östergötland in Sweden. The Johns Hopkins ACG Case-Mix System was used to calculate individual level of multi-morbidity. A report from the Swedish National Institute of Public Health using the WHO term DALY was the basis for gender-related morbidity. Prescription drugs used to treat diseases that mainly affect females were excluded from the analyses. Results: The odds of having prescription drugs for males, compared to females, increased from 0.45 (95% confidence interval (CI) 0.44-0.46) to 0.82 (95% CI 0.81-0.83) after exclusion of prescription drugs that are used to treat diseases that mainly affect females. Conclusion: Gender-related morbidity and the use of anti-conception drugs may explain a large part of the difference in prescription drug use between males and females but still there remains a difference between the genders at 18%. This implicates that it is of importance to take the gender-related morbidity into consideration, and to exclude anti-conception drugs, when performing studies regarding difference in drug use between the genders.

Background In order to screen for the most inactive individuals in the population and target health-related interventions where they are most needed it is important to assess different forms of physical activity in population-based studies. The aims were (1) to identify the most inactive individuals in the population by assessing two dimensions of physical activity, (2) to investigate the correlation between exercise and total physical activity and (3) to investigate the association between exercise, total physical activity and good self-rated health. Methods A simple random sample of the Swedish population aged 25–64 years were interviewed about their living conditions, health and lifestyle in a survey performed by Statitics Sweden. In total 1876 women and 1880 men completed the survey during 1999 (response rate 76.6%) when two different questions about physical activity assessed exercise and total physical activity in all domains (e.g. transportation, exercise, and at work). Logistic regression models were used to estimate odds ratios. Results The most inactive individuals (no exercise and total physical activity ≤ 2 hours per week) constituted 4.3% of the sample. The correlation between exercise and total physical activity was low (gamma = 0.4, p = 0.02). There were significant associations between higher levels of exercise, total physical activity and good self-rated health after adjustment for age, gender, country of birth, education, employment, marital status, housing tenure, smoking and BMI. Conclusion Both exercise and total physical activity were independently associated with good self-rated health. It seems to be advantageous to use more than one question in population based surveys in order to evaluate several dimensions of physical activity and identify the most inactive individuals.

Background Immigrants from the Middle-East are at high risk of developing type 2 diabetes (T2D). The aim of the present survey was to measure, in a single deprived neighbourhood, the prevalence rates of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and T2D in residents originating from Iraq and to compare them to those in residents born in Sweden. An additional aim was to identify metabolic, lifestyle and socioeconomic risk factors associated with IFG/IGT and T2D in these residents. Methods The study was conducted February 1'st to March 31'st 2010. Men and women aged 45 to 65 years of Swedish or Iraqi origin, living in the neighbourhood of Rosengård, Malmö, Sweden, were randomly selected from the census register. Each participant signed a written informed consent form, underwent a physical examination and an oral glucose tolerance test (OGTT), provided blood samples and filled in a questionnaire. A total of 175 subjects participated (Swedish origin n = 79, Iraqi origin n = 96), reflecting an overall response rate of almost 60%. Results In total, 21.9% and 19.0% of the Iraqi and Swedish participants, respectively, suffered from T2D, while 24.0% of the Iraqi participants and 25.3% of the Swedish participants had IFG/IGT. There were no significant differences in prevalence rates relating to country of origin. Obesity (BMI ≥30 kg/m2) and sedentary leisure time physical activity were highly prevalent in both groups, while a family history of diabetes was more prevalent in participants from Iraq (49.2%) than in those from Sweden (22.8%) (p = 0.001). Being obese or having a sedentary leisure time were, independently associated with T2D (OR 5.43 (95% CI 2.10-14.02) and 2.89 (95% CI 1.03-8.10) respectively), while economic difficulties were independently associated with IFG/IGT (OR 2.55 (95% CI 1.06-6.15)) after adjustment for the confounding effects of other common risk factors for T2D. Conclusions This study reveals a high prevalence of T2D, independently of country of origin (Iraq or Sweden), in a socially vulnerable area and additionally presents a risk factor profile that is markedly different from that of Sweden in general.

Background Low adherence is a key factor in explaining impaired effectiveness and efficiency in the pharmacological treatment of hypertension. However, little is known about which factors determine low adherence in actual practice. The purpose of this study is to examine whether low social participation is associated with low adherence with antihypertensive medication, and if this association is modified by the municipality of residence. Methods 1288 users of antihypertensive medication were identified from The Health Survey in Scania 2000, Sweden. The outcome was low adherence with antihypertensives during the last two weeks. Multilevel logistic regression with participants at the first level and municipalities at the second level was used for analyses of the data. Results Low social participation was associated with low adherence with antihypertensives during the last two weeks (OR = 2.05, 95% CI: 1.05–3.99), independently of low educational level. However, after additional adjustment for poor self-rated health and poor psychological health, the association between low social participation and low adherence with antihypertensives during the last two weeks remained but was not conclusive (OR = 1.80, 95% CI: 0.90–3.61). Furthermore, the association between low social participation and low adherence with antihypertensives during the last two weeks varied among municipalities in Scania (i.e., cross-level interaction). Conclusion Low social participation seems to be associated with low adherence with antihypertensives during the last two weeks, and this association may be modified by the municipality of residence. Future studies aimed at investigating health-related behaviours in general and low adherence with medication in particular might benefit if they consider area of residence.

Background Amyloidosis is a heterogeneous disease caused by deposition of amyloid fibrils in organs and thereby interfering with physiological functions. Hardly any incidence data are available and most survival data are limited to specialist clinics. Methods Amyloidosis patients were identified from the Swedish Hospital Discharge and Outpatients Registers from years 2001 through 2008. Results The incidence of non-hereditary amyloidosis in 949 patients was 8.29 per million person-years and the diagnostic age with the highest incidence was over 65 years. Secondary systemic amyloidosis showed an incidence of 1 per million and a female excess and the largest number of subsequent rheumatoid arthritis deaths; the median survival was 4 years. However, as rheumatoid arthritis deaths also occurred in other diagnostic subtypes, the incidence of secondary systemic amyloidosis was likely to be about 2.0 per million. The median survival of patients with organ-limited amyloidosis was 6 years. Most myeloma deaths occurred in patients diagnosed with unspecified or ‘other’ amyloidosis. These subtypes probably accounted for most of immunoglobulin light chain (AL) amyloidosis cases; the median survival time was 3 years. Conclusions The present diagnostic categorization cannot single out AL amyloidosis in the Swedish discharge data but, by extrapolation from myeloma cases, an incidence of 3.2 per million could be ascribed to AL amyloidosis. Similarly, based on rheumatoid arthritis death rates, an incidence of 2.0 could be ascribed to secondary systemic amyloidosis.

Background: The diversity of the Swedish population has increased substantially over the past three decades. The aim of this study was to assess whether living in an ethnic enclave is associated with risk of diabetes mellitus (DM) among first and second-generation immigrants and native Swedes. Methods: Cumulative incidence of DM in three urban municipalities was assessed from 2006-2010 by linking records from the national census, multi-generational family register, and prescription drug register. Immigrant enclaves were identified using Moran's Index. Multi-level logistic regression was used to assess the relationship between enclave residence and risk of DM for three groups: Iraqi immigrants, non-Iraqi immigrants, and native Swedes (N=887,603). Results: The cumulative incidence of DM was greater in Iraqi enclaves compared to other neighborhoods (4.7% vs. 2.3%). Among Iraqi immigrants, enclave residence was not associated with odds of DM (Odds ratio (OR): 1.03, 95% Confidence Interval (CI): 0.86-1.24). Among other immigrants, enclave residence was not associated with DM after accounting for neighborhood deprivation. Among native Swedes, enclave residence was associated with elevated risk of DM even after accounting for neighborhood deprivation and individual-level characteristics (OR: 1.23, 95% CI: 1.11-1.36). Conclusions: Residential ethnic composition is associated with DM but this relationship differs across ethnic group. Enclave residence is not associated with increased odds of DM for immigrants, regardless of their nation of origin, but it is associated with increased likelihood of DM for native Swedes.