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AIM: Understanding barriers and facilitators for limiting occupational sitting and what impact it has on health on those with type 2 diabetes is essential for future trials and intervention development in primary healthcare settings. This study aimed to explore the feasibility and acceptability of an intervention using mobile health (mHealth) technology, together with counselling by a diabetes specialist nurse, to reduce occupational sitting in adults with type 2 diabetes. METHODS: Individual semi-structured interviews were conducted in 15 participants with type 2 diabetes who completed a 3-month intervention including mHealth; activity tracker (Garmin Vivofit3) and SMS reminders, one initial face-to-face patient-centred counselling session and three telephone follow-up calls by a diabetes specialist nurse within the primary healthcare system in Sweden. The interviews were recorded, transcribed verbatim and analysed using qualitative content analysis. RESULTS: Two themes were identified: (1) 'From baby steps to milestones' reflecting three categories; 'Small changes make it easier to reduce sitting', 'Encouraged by trustworthy coaching', 'Physical and mental rewards matter' and (2) 'Tailoring strategies that fit me and my workplace' reflecting four categories; 'It's up to me', 'Taking advantage of the support', 'Using creativity to find practical solutions for interrupting sitting' and 'Living up to expectations'. CONCLUSION: The intervention was perceived as feasible and acceptable in different office workplaces, and led to increased awareness of sedentary behaviour in adults with type 2 diabetes. Stepwise goal setting together with personalization of the mHealth intervention should be emphasized in individual type 2 diabetes programmes aiming to reduce workplace sitting.

Objectives To explore how pictorial information on subclinical atherosclerosis affects GPs’ perception of patient cardiovascular disease (CVD) risk, their communication with patients, and GPs’ attitude to the treatment of CVD risk factors. Design, setting and subjects Fifteen individual interviews were conducted between March 2014 and December 2016, with GPs who had received pictorial information regarding their patients’ subclinical atherosclerosis. The pictorial information was also received by the patients together with written information regarding atherosclerosis and CVD risk prior to the appointment with their GP. The interviews were recorded, transcribed and analyzed using qualitative content analysis. Results Three categories were identified in the analysis. Increased knowledge makes a difference: When patients had more in-depth knowledge regarding atherosclerosis, the consultation became more patient-centered and moved towards shared decision making. This is real, not just a number: GPs described their risk assessment and the patient’s risk perception as more accurate with pictorial information about subclinical atherosclerosis. How to deal with the result – A passive to active approach: Some GPs acted promptly on the pictorial information while others took no action. Conclusion and implications Pictorial information regarding patients’ subclinical atherosclerosis affected GPs’ assessment of CVD risk. The communication shifted towards shared decision-making although the GPs’ attitude to the result and treatment of CVD risk factors varied. Informing patients about examination results, both in writing and pictures, prior to a consultation can facilitate shared decision making and enhance preventive measures. Trial registration https://clinicaltrials.gov/ct2/show/NCT01849575.KEY POINTSProviding pictorial information about carotid ultrasound results and information regarding atherosclerosis to GPs and patients affects primary prevention:•Informing patients about examination results prior to a consultation can be useful in clinical practice to enhance preventive measures•GPs experienced that increased patient knowledge resulted in a more patient-centered consultation and improved shared decision-making•GPs described their risk assessment and patients’ risk perception as more accurate with pictorial information about subclinical atherosclerosis

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasou ...

It remains unclear whether high plasma glucose levels are associated with venous thromboembolism (VTE). This study investigated the association between fasting plasma glucose (FPG), oral glucose tolerance test (two-hour post-load plasma glucose (2HPG)), diabetes, and VTE.The population-based, prospective Venous thromboEmbolism In Northern Sweden (VEINS) cohort study included 108,025 residents of Västerbotten County in northern Sweden. The participants were aged 30 to 60 years and had no previous VTE events. They were included from 1985 onwards and were followed until a VTE event, death, emigration, or the study end on September 5, 2014. All underwent a health examination that measured weight, height, FPG, and 2HPG and included a questionnaire regarding smoking, education level, and history of diabetes. Potential VTE events were identified by an extensive diagnosis registry search and were validated by reviewing medical records and radiology reports.An objectively verified first-time VTE event was experienced by 2054 participants during 1,496,669 person-years of follow-up. In univariable analysis, there were associations between FPG, 2HPG, diabetes, and the risk of VTE. These associations disappeared after adjustment for potential confounders (age, sex, body mass index, cancer at inclusion, education level, smoking, and hypertension). The adjusted hazard ratios were 1.01 (95% confidence interval 0.83-1.23) for diabetes, 1.01 for each standard deviation of FPG (95% confidence interval 0.97-1.05), and 0.96 for each standard deviation of 2HPG (95% confidence interval 0.91-1.00).There were no independent associations between FPG, 2HPG, diabetes, and future risk of VTE.

Background Clinical risk factors of cardiovascular diseases (CVD) are related to atherosclerosis and cIMT and plaque are signs of early atherosclerosis. However, associations between risk factors and ultrasound variables are not fully established and comparison between studies is hampered by different imaging protocols. There is limited data regarding study population characteristics and ultrasound measurements differ regarding arterial bed, projections, and plaque definitions and inclusion Purpose 1/ To describe the distribution of asymptomatic atherosclerosis as assessed by carotid ultrasound in a middle-aged population at low/intermediate risk of CVD. 2/ To investigate the associations between clinical risk factors and a set of ultrasound variables Method Bilateral carotid ultrasound examinations were performed according to a standardized protocol in 3532 healthy VIPVIZA-participants with at least one conventional CVD risk factor. CIMT was measured in the distal far wall of CCA, 240o and 210o left and 150o and 120o right side, based on Meijer arch. For each angle, mean and max IMT was measured in a 10 mm segment. Plaques were identified according to the Mannheim consensus. Socio-economic data was also recorded. Associations between the risk factors and the set of ultrasound variables were quantified by a partial least squares (PLS) regression. A new compound ultrasound variable was computed, PLS UL, bya combining all IMT variables and plaque using the weights of the first PLS component. In a second step, to estimate how much risk factors explained the variability of the ultrasound results, associations between risk factors and both PLS UL and single cIMT variables and plaque were determined using step-wise linear regression modelling Results Mean age was 55.6 and 55.8 years among men and women (52.7% women), 13% were smokers in both sexes, and 50.8% and 39.3%, respectively, had carotid plaque. Mean of mean cIMT was 0.68 mm vs 0.64 mm (p All ultrasound variables had similar univariate associations with clinical risk factors, positive associations for all risk factors except physical activity, fruit and vegetable consumption, education and HDL-cholesterol. The strongest association between risk factors and ultrasound variables was found with PLS UL (R2=23%), compared to single cIMT variables (R2=14–18%) and plaque (R2=15%). The pattern was similar in both sexes with most risk factors shared between the sexes. The association with factors and PLS UL was stronger among 40-year olds (R2=22%) than among 50- and 60-year olds (R=12%) Conclusion A combination of ultrasound variables are stronger associated to CVD risk factors than plaque or a single CIMT measurement. The pattern is similar in men and women. These findings are relevant for development of a consensus for cIMT measurements Acknowledgement/Funding Västerbotten County Council, the Swedish Research Council, the Heart and Lung Foundation, the Swedish Society of Medicin, Carl Bennet Ltd, Sweden

Active vitamin D is a neurosteroid that may modulate brain function. Associations between vitamin D deficiency and depression and anxiety have been demonstrated. We hypothesized that there was an association between anxiety, depression, and health-related quality of life (HRQOL) and vitamin D status. To test this hypothesis, we examined the association between anxiety, depression, and HRQOL and 25-hydroxyvitamin D (25[OH]D) concentrations in the Middle Eastern and African-born immigrant population. All immigrants aged 25-65 years, born in 9 African or Middle Eastern countries, and living in 3 districts in Umeå (n = 1306) were invited, with 195 English- or Swedish-speaking immigrants (104 men and 91 women) participated. Anxiety and depression were measured using the Hospital Anxiety and Depression scale. HRQOL was measured using EuroQoL-5 Dimension 3 Level Questionnaire and EuroQoL Visual Analogue Scale. Serum 25(OH)D was measured using liquid chromatography-tandem mass spectrometry. Associations were determined using logistic and linear regression. Analyses were adjusted for sex, age, origin, socioeconomic factors, lifestyle, chronic diseases, and obesity. In total, 71% had 25(OH)D less than 50 nmol/L and 11% had 25(OH)D less than 25 nmol/L. Anxiety, depression, and HRQOL were not associated with 25(OH)D in the immigrant population. Anxiety was common in female immigrants from the Middle East (32.7%); and after adjustment, lower 25(OH)D concentrations were associated with higher risk of anxiety (25[OH]D ≤ 49 nmol/L vs 25[OH]D ≥ 50 nmol/L: odds ratio 23.2 [95% confidence interval 1.97 - 271.9] P = .012) in this subgroup only; however, reverse causality could not be excluded. In conclusion, the study showed no association between depression, anxiety, or HRQOL and vitamin D status in the immigrant population.

There is increasing evidence that vitamin D status is associated with muscle function. Vitamin D deficiency is common in immigrants. We hypothesized that there was a positive association between vitamin D status and muscle strength in immigrants. The aim of this study was to examine associations between vitamin D status and muscle strength in an immigrant population in Sweden. All immigrants aged 25-65 years, born in 9 African or Middle East countries, and living in a district in Umea (n = 1306) were invited. A total of 111 men and 105 women (16.5%) completed the study. Lower limb muscle strength was examined using a standardized muscle function indices of muscle strength. Grip strength was examined using a JAMAR hand dynamometer. Serum 25-hydroxyvitamin D [25(OH)D] was measured using liquid chromatography-tandem mass spectrometry. The analyses were adjusted for sex, age, height, body mass index, years since immigration, 25(OH)D, vitamin D deficiency, physical activity, and medical and socioeconomic factors. Twelve percent of the immigrants had vitamin D deficiency [25(OH)D levels

Aims/hypothesis We aimed to investigate whether diabetes cases detected through screening have better health outcomes than clinically detected cases in a population-based cohort of adults who were eligible to be screened for diabetes at 10 year intervals. Methods The Västerbotten Intervention Programme is a community- and individual-based public health programme in Västerbotten County, Sweden. Residents are invited to clinical examinations that include screening for diabetes by OGTTs at age 30, 40, 50 and 60 years (individuals eligible for screening, n = 142,037). Between 1992 and 2013, we identified 1024 screen-detected cases and 8642 clinically detected cases of diabetes using registry data. Clinically detected individuals were either prior screening participants (n = 4506) or people who did not participate in screening (non-participants, n = 4136). Study individuals with diabetes were followed from date of detection until end of follow-up, emigration, death or incident cardiovascular disease (CVD), renal disease or retinopathy event, and compared using Cox proportional hazard regression adjusted for calendar time, age at detection, year of detection, sex and socioeconomic status. Results The average age at diabetes diagnosis was 4.6 years lower for screen-detected individuals compared with clinically detected individuals. Overall, those who were clinically detected had worse health outcomes than those who were screen-detected (HR for all-cause mortality 2.07 [95% CI 1.63, 2.62]). Compared with screen-detected study individuals, all-cause mortality was higher for clinically detected individuals who were screening non-participants (HR 2.31 [95% CI 1.82, 2.94]) than for those clinically detected who were prior screening participants (HR 1.70 [95% CI 1.32, 2.18]). Estimates followed a similar pattern for CVD, renal disease and retinopathy. Conclusions/interpretation Individuals with screen-detected diabetes were diagnosed earlier and appeared to fare better than those who were clinically detected with regard to all-cause mortality, CVD, renal disease and retinopathy. How much of these associations can be explained by earlier treatment because of screening rather than healthy user bias, lead time bias and length time bias warrants further investigation.

Aims: The aim was to evaluate treatment goal achievements early in the course of Type 2 diabetes, and their effect on 10-year risk of coronary heart disease in patients receiving usual care. Method ...

Studies have revealed low adherence to guidelines for treatment of diabetes and cardiovascular risk factors.To explore GPs' experiences regarding treatment practice in type 2 diabetes with specific focus on the prevention of cardiovascular disease.Fourteen experienced GPs from nine health care centres with group practices were interviewed in focus groups. The interviews were digitally recorded, transcribed verbatim and analysed by qualitative content analysis.The overall theme was 'dilemmas' in GPs' treatment practice for type 2 diabetes patients. Five main dilemma categories were identified. First, the GPs were hesitant about labelling someone who feels healthy as ill. Second, regarding communicating a diabetes diagnosis and its consequences; should the patient be frightened or comforted? Third, the GPs experienced uncertainty in their role; were they to take responsibility for the care or not? Fourth, the GPs expressed a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties in integrating science into reality.The five dilemmas in the GPs' approach to diabetes patients and the treatment of their cardiovascular risk were related to the GPs' professional role and communication with the patient. To consider these dilemmas in educational efforts is probably essential to achieve improved diabetes care and guideline adherence.

Background: New guidelines were introduced in Sweden in 1999 to reduce the risk of cardiovascular disease among diabetes patients. The impact of the new guidelines on lipid levels in a diabetes patient population has not been extensively studied. Our aim was to study whether the introduction of treatment goals for dyslipidaemia was reflected in lower cholesterol levels in patients with diabetes in a general population. Methods: In a population of 59,338 individuals, 971 (1.6%) had diabetes. All subjects were 40, 50 or 60 years of age and participated in the Vasterbotten Intervention Programme in 1995-2004. Cholesterol levels and use of lipid-lowering drugs were measured, and trends in cholesterol levels were analysed before and after the guidelines were introduced in 1999. Results: In this effectiveness study, there was a marked decrease in mean plasma total cholesterol levels among patients with diabetes (5.79 (± 1.21) mmol/1 in 1995-1999 and 5.07 (± 1.00) mmol/1 in 2000-2004 (p

To study prevalence and determinants of vitamin D deficiency in immigrants from Africa and the Middle East living in Umeå, Sweden.Cross-sectional population based.Umeå, Sweden (63° N).Immigrants aged 25-65 years from nine countries in Africa or the Middle East (n=1306) were invited. A total of 111 men and 106 women (16.5%) completed the study. S-25-hydroxyvitamin D3 was measured with HPLC. Anthropometry, medical, socioeconomic and lifestyle data were registered.Vitamin D status was insufficient or deficient in 73% of the participants. Specifically, 12% had vitamin D deficiency (25(OH)D325 nmol/l), and only 3.7% had optimal vitamin D status (25(OH)D3 75-125 nmol/l). Mean 25(OH)D3 level was 41.0 nmol/l (± 16.6) with no difference between sexes. Levels of 25(OH)D3 were lower (P=0.030) and vitamin D deficiency was twice as common in immigrants from Africa compared with those from the Middle East. In the multiple regression analysis, vitamin D deficiency was significantly associated with low fatty fish intake (OR 4.31, 95% CI 1.61-11.55), not travelling abroad (OR 3.76, 95% CI 1.18-11.96) and wearing long-sleeved clothes in summer (OR 3.15, 95% CI 1.09-9.12).The majority of immigrants from Africa and the Middle East who live in northern Sweden have vitamin D deficiency or insufficiency. Our results are consistent with sun exposure and a diet with high intake of fatty fish being most important in avoiding vitamin D deficiency.

BACKGROUND: Abdominal complaints are common reasons for contacting primary care physicians, and it can be challenging for general practitioners (GPs) to identify patients with suspected colorectal cancer (CRC) for referral to secondary care. The immunochemical faecal occult blood test (iFOBT) is used as a diagnostic aid in primary care, but it is unclear how test results are interpreted. Studies show that negative tests are associated with a risk of delayed diagnosis of CRC and that some patients with positive tests are not investigated further. The aim of this study was to explore what makes GPs suspect CRC and to investigate their practices regarding investigation and referral, with special attention on the use of iFOBTs. METHOD: Semi-structured individual interviews were conducted with eleven purposely selected GPs and registrars in Region Jämtland Härjedalen, Sweden, and subjected to qualitative content analysis. RESULTS: In the analysis of the interviews four categories were identified that described what made the physicians suspect CRC and their practices. Careful listening-with awareness of the pitfalls: Attentive listening was described as essential, but there was a risk of being misled by, for example, the patient's own explanations. Tests can help-the iFOBT can also complicate the diagnosis: All physicians used iFOBTs to various extents. In the absence of guidelines, all found their own ways to interpret and act on the test results. To refer or not to refer-safety margins are necessary: Uncertainty was described as a part of everyday work and was handled in different ways. Common vague symptoms could be CRC and thus justified referral with safety margins. Growing more confident-but also more humble: With increasing experience, the GPs described becoming more confident in their decisions but they were also more cautious. CONCLUSIONS: Listening carefully to the patient's history was essential. The iFOBT was frequently used as support, but there were considerable variations in the interpretation and handling of the results. The diagnostic process can be described as navigating uncertain waters with safety margins, while striving to keep the patient's best interests in mind. The iFOBT may be useful as a diagnostic aid in primary care, but more research and evidence-based guidelines are needed. This study was made possible by unrestricted grants from the Region Jämtland Härjedalen, the Regional Cancer Centre North, the Northern County Councils (Visare Norr), the Swedish Society of Medicine, the Cancer Research Foundation in Northern Sweden, and the Jämtland County Cancer and Nursing Fund.

OBJECTIVE: To examine the association between meeting behavioural goals and diabetes incidence over 10years in a large, representative Swedish population. METHODS: Population-based prospective cohort study of 32,120 individuals aged 35 to 55years participating in a health promotion intervention in Västerbotten County, Sweden (1990 to 2013). Participants underwent an oral glucose tolerance test, clinical measures, and completed diet and activity questionnaires. Poisson regression quantified the association between achieving six behavioural goals at baseline - body mass index (BMI)

AIMS/HYPOTHESIS: Thus far, it is unclear whether lifestyle recommendations for people with diabetes should be different from those for the general public. We investigated whether the associations between lifestyle factors and mortality risk differ between individuals with and without diabetes.METHODS: Within the European Prospective Investigation into Cancer and Nutrition (EPIC), a cohort was formed of 6,384 persons with diabetes and 258,911 EPIC participants without known diabetes. Joint Cox proportional hazard regression models of people with and without diabetes were built for the following lifestyle factors in relation to overall mortality risk: BMI, waist/height ratio, 26 food groups, alcohol consumption, leisure-time physical activity, smoking. Likelihood ratio tests for heterogeneity assessed statistical differences in regression coefficients.RESULTS: Multivariable adjusted mortality risk among individuals with diabetes compared with those without was increased, with an HR of 1.62 (95% CI 1.51, 1.75). Intake of fruit, legumes, nuts, seeds, pasta, poultry and vegetable oil was related to a lower mortality risk, and intake of butter and margarine was related to an increased mortality risk. These associations were significantly different in magnitude from those in diabetes-free individuals, but directions were similar. No differences between people with and without diabetes were detected for the other lifestyle factors.CONCLUSIONS/INTERPRETATION: Diabetes status did not substantially influence the associations between lifestyle and mortality risk. People with diabetes may benefit more from a healthy diet, but the directions of association were similar. Thus, our study suggests that lifestyle advice with respect to mortality for patients with diabetes should not differ from recommendations for the general population.

Objectives To investigate the benefits and risks associated with aspirin treatment in patients with type 2 diabetes and no previous cardiovascular disease (CVD) in clinical practice. Design Population-based cohort study between 2005 and 2009, mean follow-up 3.9 years. Setting Hospital outpatient clinics and primary care in Sweden. Participants Men and women with type 2 diabetes, free from CVD, including atrial fibrillation and congestive heart failure, at baseline, registered in the Swedish National Diabetes Register, with continuous low-dose aspirin treatment (n=4608) or no aspirin treatment (n=14 038). Main outcome measures Risks of CVD, coronary heart disease (CHD), stroke, mortality and bleedings, associated with aspirin compared with no aspirin, were analysed in all patients and in subgroups by gender and estimated cardiovascular risk. Propensity scores were used to adjust for several baseline risk factors and characteristics at Cox regression, and the effect of unknown covariates was evaluated in a sensitivity analysis. Results There was no association between aspirin use and beneficial effects on risks of CVD or death. Rather, there was an increased risk of non-fatal/fatal CHD associated with aspirin; HR 1.19 (95% CI 1.01 to 1.41), p=0.04. The increased risk of cardiovascular outcomes associated with aspirin was seen when analysing women separately; HR 1.41 (95% CI 1.07 to 1.87), p=0.02, and HR 1.28 (95% CI 1.01 to 1.61), p=0.04, for CHD and CVD, respectively, but not for men separately. There was a trend towards increased risk of a composite of bleedings associated with aspirin, n=157; HR 1.41 (95% CI 0.99 to 1.99). Conclusions The results support the trend towards more restrictive use of aspirin in patients with type 2 diabetes and no previous CVD. More research is needed to explore the differences in aspirin's effects in women and men.