Low fructosamine and mortality - A long term follow-up of 215,011 non-diabetic subjects in the Swedish AMORIS study.

BACKGROUND AND AIMS: Both high and low fasting glucose has been associated with an increased mortality among individuals without diabetes. This J-shaped association has also been shown for HbA1c in relation to all-cause mortality. High fructosamine is associated with increased mortality. In this study we aim to evaluate if low fructosamine is also associated with increased mortality in non-diabetic subjects. METHODS AND RESULTS: We included 215,011 subjects from the AMORIS cohort undergoing occupational health screening or primary care in Stockholm, Sweden. Cause specific mortality was obtained from the Swedish Cause-of-Death Register by record linkage. Hazard ratios for the lowest decile of fructosamine were estimated by Cox regression for all-cause (n = 41,388 deaths) and cause-specific mortality during 25 years of follow-up. We observed gradually increased mortality with lower fructosamine in a large segment of the population. In the lowest decile of fructosamine the sex, age, social class and calendar adjusted hazard ratio was 1.20 (95% CI; 1.18-1.27) compared to deciles 2-9. This increased mortality was attenuated after adjustment for six other biomarkers (HR = 1.11 (95% CI; 1.07-1.15)). Haptoglobin, an indicator of chronic inflammation, made the greatest difference in the point estimate. In sensitivity analyses we found an association between low fructosamine and smoking and adjustment for smoking further attenuated the association between low fructosamine and mortality. CONCLUSION: Low levels of fructosamine in individuals without diabetes were found to be associated with increased mortality. Smoking and chronic inflammation seem to at least partially explain this association but an independent contribution by low fructosamine cannot be excluded.

Nurse-led empowerment strategies for patients with hypertension: a questionnaire survey.

BACKGROUND: Hypertension is common and may lead to cerebrovascular and cardiovascular events and mortality. District nurses frequently encounter patients requiring blood pressure monitoring, lifestyle counsel and support. Empowerment as a method enables patients to both increase their control over their health and improve it. AIM: This study aims to describe the effects of the counsel and support from district nurses to patients with hypertension. METHODS: A randomized controlled intervention trial. Questionnaires were answered by patients with hypertension before and after the intervention comprising district nurses' counsel and support based upon empowerment. A specially developed card for blood pressure monitoring was also used. RESULTS: Blood pressure decreased in intervention and the control groups. The intervention group experienced significantly improved health, with better emotional and physical health, and reduced stress. Living habits did not change significantly in either group. Satisfaction with knowledge of hypertension increased significantly in both groups. The intervention group reported that their care was based upon their health needs. LIMITATIONS: Conducting large multi-centre studies with long follow-ups is complicated and results sometimes have a tendency to decline with time. A shorter follow-up might have shown a greater difference between the groups. CONCLUSION: Nursing interventions through district nurses' counsel and support with empowerment improved patients' health. More research is needed to evaluate nursing interventions' effect on hypertension. IMPLICATIONS FOR NURSING AND HEALTH POLICY: This study highlighted that district nurses' counsel and support increased patients' health and decreased stress by focusing on empowerment.

Prevalence of blood lipid disturbances in Swedish and foreign-born 60-year-old men and women in Stockholm, Sweden.

BACKGROUND AND AIMS: Some immigrant groups in Sweden show a higher incidence of cardiovascular diseases, especially coronary heart disease. There is a lack of data of pattern of blood lipids among these. The aim of this study was to estimate the prevalence of dyslipidaemia in men and women of foreign-born origin compared to Swedish-born. METHODS AND RESULTS: A cross-sectional study of a random sample of the population in Stockholm County, Sweden, with total of 4228 60-year-old men and women. Medical, lifestyle and socio-economic data were collected by questionnaires, and anthropometric and laboratory data through medical examination. Outcomes were odds ratios (OR) with 95% confidence interval (95% CI) for dyslipidaemia in different groups, with Swedish-born as reference group, with adjustment for anthropometric, medical, lifestyle and socio-economic factors. Among non-European immigrants, the fully adjusted OR of high cholesterol was 0.57 (95% CI 0.37-0.88), of high LDL-cholesterol was 0.62 (95% CI 0.40-0.96), and of low HDL-cholesterol was 2.06 (95% CI 1.35-3.15). When only adjusting for sex, Finnish-born and non-European immigrants showed higher risk of high triglycerides, OR 1.31 (95% CI 1.01-1.71) and OR 1.98 (95% CI 1.34-2.93), respectively, and of high apoB/apoA-I ratio, OR 1.29 (95% CI 1.00-1.66) and OR 1.57 (95% CI 1.06-2.33), respectively. CONCLUSION: The finding of blood lipid disturbances among immigrants in this study partly explain the higher cardiovascular morbidity shown in previous studies. Non-European immigrants showed a different lipid pattern, with lower HDL-cholesterol, which could possibly be of genetic background.

The association between BMI value and long-term mortality.

OBJECTIVES: To study total mortality in different categories of BMI values, with adjustments for important covariates in a population-based 26-year mortality follow-up. Special interest will be given to gender differences and low BMI values. METHODS: From a stratified sample in 1969 of 32 185 individuals aged 18-64 years from Stockholm County, 2422 underwent a health examination, with complete data obtained for 1020 subjects. BMI was classified as underweight (<20), normal (20-24.9), overweight (25-29.9) or obesity (> or =30). Participants were followed up in the National Cause of Death Register until the end of 1996. Multivariate analysis was performed by Cox regression for men and women separately, with different models, with step-wise adjustment for age, care need category, heart rate, hypertension, blood glucose, alcohol intake and smoking, with hazard ratios (HR) and 95% confidence interval (CI) and with normal weight as reference. RESULTS: Among men, the age-adjusted HR was 1.68 (95% CI 1.10-2.57) for underweight and 1.62 (95% CI 1.08-2.43) for obesity, and among women it was 0.93 (95% CI 0.58-1.51) for underweight and 1.88 (95% CI 1.26-2.82) for obesity. In men, the significantly increased mortality remained when also adjusting for care need category, but not when adjusting for other factors, whereas the opposite was found regarding obesity. For women, underweight was significantly associated with decreased mortality when adjusting for smoking and for all factors together, whereas obesity was associated with increased mortality when adjusting for the different factors except for all factors together. CONCLUSIONS: Underweight was associated with higher mortality among men, but not when adjusting for covariates, whereas underweight was associated with lower mortality among women when adjusting for smoking.

Estimation of diabetes prevalence among immigrants from the Middle East in Sweden by using three different data sources.

AIMS: To estimate diabetes prevalence in immigrants from the Middle East in Sweden compared with Swedish-born subjects. This group accounts for around 15% of Sweden's non-European immigrants. METHODS: Three samples were used: self-reported diabetes in a random sample (SALLS sample) of subjects aged 35-64 years in Sweden (n=22,032); known diabetes among patients aged 35-64 years in primary care (PC) at four primary healthcare centers in Stockholm County (n=30,679); and known and newly diagnosed diabetes in a random population sample of subjects aged 60 years in Stockholm County (n=4106). RESULTS: The odds ratio (OR) for subjects from the Middle East was: 1.69 (95% confidence interval [CI] 0.96-2.99) in the SALLS sample; 4.43 (95% CI 3.38-5.56) in the PC sample; and 3.96 (95% CI 1.98-7.92) in the age-60 sample, compared with native Swedes. Subjects from European and other Organization for Economic Cooperation and Development (OECD) countries showed an excess risk only in the SALLS sample (1.43, 95% CI 1.11-1.83). CONCLUSIONS: Immigrants from the Middle East showed a four-fold higher risk of diabetes compared with Swedish-born subjects in two of the three data sources. More studies are needed to confirm these results, but the findings call for targeted preventative strategies in this population group.

Effects of a short-term intervention with a paleolithic diet in healthy volunteers.

OBJECTIVES: Prevention of cardiovascular diseases by paleolithic or hunter-gatherer diets has been discussed during recent years. METHODS: Our aim was to assess the effect of a paleolithic diet in a pilot study on healthy volunteers during 3 weeks. The intention was to include 20 subjects, of whom 14 fulfilled the study. Complete dietary assessment was available for six subjects. RESULTS: Mean weight decreased by 2.3 kg (P<0.001), body mass index by 0.8 (P<0.001), waist circumference by 0.5 cm (P=0.001), systolic blood pressure by 3 mm Hg (P=0.03) and plasminogen activator inhibitor-1 by 72% (P=0.020). Regarding nutrient intake, intake of energy decreased by 36%, and other effects were also observed, both favourable (fat composition, antioxidants, potassium-sodium rate) and unfavourable (calcium). CONCLUSION: This short-term intervention showed some favourable effects by the diet, but further studies, including control group, are needed.

Increased prevalence of diabetes among immigrants from non-European countries in 60-year-old men and women in Sweden.

AIMS: To estimate the prevalence of risk factors for diabetes in subjects of foreign origin compared to Swedish-born. METHODS: A cross-sectional study with subjects included from a random sample of the population of in Stockholm County, Sweden, among 60-year-old men and women. Number in the analyzed groups were Swedish-born n=3329, immigrants from Europe n=654, and immigrants from non-European countries n=123. The health screening including physical examination, laboratory testing and a questionnaire on medical, socioeconomic and life-style factors. RESULTS: Men showed a higher prevalence of diabetes than women, 9.7% vs. 5.1% (P<0.001). Among European immigrants, no excess risk was present compared to Swedish-born subjects, 7.6% vs. 6.9%, sex-adjusted odds ratio (OR): 1.14 (95% confidence interval (CI) 0.83-1.57). Among non-European immigrants, prevalence of diabetes was two times higher, i.e. 14.6%, sex-adjusted OR: 2.19 (95% CI: 1.30-3.69), compared to Swedish-born subjects. When also adjusting for anthropometrical, socioeconomic and life-style factors, ORs were for European immigrants 0.95 (95% CI: 0.68-1.33), and non-European immigrants OR: 1.21 (95% CI: 0.65-2.26). Beside sex, i.e. female OR: 0.50 (95% CI: 0.38-0.66), the only significant covariate in full model was BMI-category, i.e. overweight OR: 1.83 (95% CI: 1.29-2.59), and obesity OR: 4.64 (95% CI: 3.25-6.63). CONCLUSIONS: The prevalence of diabetes was found to be considerably higher among immigrants from non-European countries in Sweden. The excess risk was associated with above all to a higher BMI.

High intake of alcohol is associated with newly diagnosed diabetes in 60 years old men and women.

BACKGROUND AND AIMS: Low or moderate alcohol intake has been found to be protective against the incidence of diabetes, while conflicting results have been found regarding high alcohol intake. This study aimed at evaluating the effect of alcohol intake on newly diagnosed diabetes among subjects aged 60 years in relation to anthropometric measurements, life-style and socio-economic factors. METHODS AND RESULTS: A population-based cross-sectional study of 4106 individuals, 1973 men and 2133 women, aged 60 years, in Stockholm County, Sweden. Medical history, socio-economic factors and life-style data were collected by a questionnaire and a medical examination including laboratory tests. High total intake of alcohol, i.e. >30 g/day vs. 0-30 g/day, was significantly noted more often in newly diagnosed diabetes in men (OR 2.72, 95% CI 1.70-4.34), even when adjusting for other factors, i.e. anthropometric measurements, life-style, socio-economic and dietary factors (adjusted OR 1.94, 95% CI 1.17-3.23); a high intake of spirits, i.e. >15 g/day vs. 0-15 g/day, was significantly more often observed among women (OR 3.97, 95% CI 1.50-10.50), however, it was not significant after adjustment (OR 2.23, 95% CI 0.67-7.42). CONCLUSION: High intake of alcohol among men was associated with increased risk of diabetes even when adjusting for other factors.

Coping strategies in men and women with type 2 diabetes in Swedish primary care.

Based on findings regarding gender differences in the experience and complications of diabetes, we studied coping strategies in men and women with type 2 diabetes in relation to their demographic, medical, socio-economic and psychosocial situation. Altogether 232 Swedish-born type 2 diabetes patients aged 35-64 years at four primary health care centres in Stockholm County were studied, 121 men and 111 women. Coping strategies were assessed by the General Coping Questionnaire (GCG), which describes five orientations dichotomised into positive and negative opposites: self-trust/fatalism; problem focusing/resignation; cognitive revaluation/protest; social trust/isolation; and minimisation/intrusion. Socio-economic and medical data were taken both from a questionnaire and from medical records. Gender differences for the coping strategies resignation, protest and isolation were found (p<0.05), with higher scores for women. The most important medical factor associated with coping strategies was HbA1c. Other significant factors detected in the multivariate analyses were psychiatric disorder, cohabitation and daily smoking. Thus, coping strategies and gender are important factors that should be addressed more in diabetes health care.

The association between blood glucose value and long-term mortality.

This study aims at estimating the association between different fasting blood glucose levels (FBG) and total mortality during a long-term follow-up. In all 2,300 subjects were health examined, out of a stratified sample of 32,185 individuals aged 18-64 years drawn from the population in Stockholm County from the years 1969-70. FBG values were divided into following groups:<3.0, 3.0-4.4, 4.5-5.5, 5.66.0, 6.1-6.6, and > 6.6 mmol/l (corresponding to fasting plasma glucose, FPG,<3.5, 3.5-4.9, 5.0-6.0, 6.1-6.9, 7.0-7.7 and > 7.7 mmol/l), and known diabetes mellitus. All participants were followed up in the National Cause of Death Register up to the end of 1996. Multivariate analysis was performed by Cox regression, with three models, the first age- and sex-adjusted, the second also adjusted for care need category and hypertension, and the third with added BMI-category, with hazard ratios (HR) and 95% confidence interval (CI). Smoking habits were available for around half of the sample. Compared to the FBG showing the lowest mortality, i.e. FBG 5.6-6.0 mmol/l, we found an age- and sex-adjusted excess risk for subjects with known diabetes (HR 7.39, 95% CI 3.78-14.45), with FBG > 6.6 mmol/l (HR 2.30, 95% CI 1.20-4.39), and with FBG<3.0 mmol/l (HR 3.44, 95% CI 1.47-8.06). The excess risk persisted when adjusting for care need, hypertension, BMI, and also for smoking. The cause of the increased mortality risk with low FBG values is unclear, but low FBG value seems to be a risk marker of poor health.

Drug use in patients with diabetes.

OBJECTIVE: To describe the use of pharmaceutical medications by patients with diabetes in Sweden. RESEARCH DESIGN AND METHODS: We analyzed the computerized Surveys of Living Conditions (SLC), performed regularly in Sweden, for the years 1988 and 1989, among individuals aged 16-84 years. Drug use (during a 2-week period) and the use of health services (during a 3-month period) were registered for subjects with diabetes (n = 361) and compared with age- and gender-standardized figures (using the diabetes group as the standard) in subjects with hypertension but without diabetes (n = 980), in subjects with a musculoskeletal condition but without diabetes (n = 2,187), in healthy subjects free from any medical condition (n = 6,664), and in the general population sample (n = 12,717). RESULTS: The reported use of medication was higher for subjects with diabetes compared with the general population regarding overall use (92.5 vs. 71.9%; P < 0.001), the use of cardiovascular drugs (52.2 vs. 36.3%; P < 0.001), all use of analgesics (43.8 vs. 36.5%; P < 0.05), and use of psychoactive drugs (23.5 vs. 15.3%; P < 0.01). Compared with the hypertension group, the use was lower regarding cardiovascular drugs (52.2 vs. 93.3%; P < 0.001), and compared with the musculoskeletal group, the use was lower regarding all use of analgesics (43.8 vs. 56.5%; P < 0.01) and the use of herbal products (6.8 vs. 11.8%; P < 0.05), but was higher regarding cardiovascular drugs (52.2 vs. 37.8%; P < 0.001). The use was higher compared with the healthy individuals, regarding all groups of drugs with the exception of vitamins and herbal products. CONCLUSIONS: Diabetic subjects have a higher overall use of drugs compared with the general population. Compared with other chronic illnesses, the differences are small except for disease-specific drugs (cardiovascular drugs in the hypertension group and analgesics in the musculoskeletal group). The main difference concerns the comparison with healthy subjects who had a markedly higher drug rate among diabetic subjects, thus signifying a greater impact on health.

Quality of life in relation to comorbidity among diabetic patients followed for three years in Swedish primary health care.

The aim of this study was to follow health-related quality of life (HRQOL) in diabetic subjects over a three-year period in relation to their medical situation. Forty-eight subjects 42-81 years of age in 1992 were identified as those responding to the HRQOL questionnaire on both occasions from a larger study of 341 diabetic patients in 1992 and 413 in 1995 in Stockholm County. Age- and sex-matched controls were taken from randomly collected samples of the general Swedish population. HRQOL was assessed by the SWED-QUAL (the Swedish Health-Related Quality of Life Survey). Medical data were extracted from medical records at community health centres. Pearson's correlation coefficient for SWED-QUAL results over time exceeded 0.60 for seven of the ten scales (p < 0.001). A significant difference between 1992 and 1995 was found only for "Physical functioning" (p < 0.01). The general deterioration in health seen in medical records was accompanied by a decrease in the "Sleep problems" scale. In conclusion, worse outcome was noted only for "Physical functioning", while deterioration in health according to medical records was related to a worse outcome with respect to "Sleep problems". However, as the sample was small and not randomly selected, the results should be interpreted with caution and need confirmation in further studies.

Diabetes mellitus in Turkish immigrants in Sweden.

This study analyses the risk of self-reported diabetes mellitus among Turkish-born immigrants in Sweden. Two simple random samples were used: The Swedish National Board of Health and Welfare Immigrant Survey, and the Swedish Survey of Living Conditions, both from 1996. Totally 526 Turkish immigrants, 285 men and 241 women, were compared with 2854 Swedish controls, 1425 men and 1429 women, all in ages 27-60 years. Data were analysed by sex in an age-adjusted model, and a full model also included education, employment status, BMI and country of birth (logistic regression). Among Turkish men, age-adjusted diabetes prevalence was not higher than among Swedish men, odds ratio (OR) 1.04 (95% confidence interval (CI) 0.35-3.11). Among Turkish women, age-adjusted diabetes prevalence was higher than among Swedish women, OR 3.22 (95% CI 1.36-7.64), but when also adjusting for educational level, employment status and BMI, OR was 1.22 (95% CI 0.41-3.66). We conclude, that age-adjusted presence of known diabetes was higher among Turkish-born women than among Swedish women, but was explained by lower employment rate, lower educational status and a higher level of overweight and obesity.

The quality of life of elderly diabetic patients.

The objective of this study was to evaluate the health-related quality of life (HRQoL) of elderly diabetic patients. A cross-sectional, questionnaire survey of diabetic subjects aged 65-84 years (n=177 respondents) from three community health centers in Stockholm County. 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) and consisting of 67 items covering broad aspects of the HRQoL. Diabetic subjects were compared with age- and gender-matched controls from a random standard population sample (SPS) of the Swedish population. Medical data on the diabetic subjects were extracted from medical records. The HRQoL, as regarded 7 of the 13 scales, was poorer in diabetic subjects than in the SPS controls. These scales were "general health perceptions," "physical functioning," "satisfaction with physical health," "role limitations due to physical health," "pain," "sleep problems," and "role limitations due to emotional health." Atheromatous complications and nonvascular disease were significant predictors of a poor HRQoL. "Cognitive functioning" was the only HRQoL scale on which diabetic subjects with high levels of HbA(1c) (HbA(1c)>7.0%) scored worse than those with acceptable levels (HbA(1c)<7.0%). In our study, elderly diabetic subjects had a poorer HRQoL than the general population, especially regarding physical health. Poor metabolic control was associated with reduced cognitive function.

Effects of tactile massage on metabolic biomarkers in patients with type 2 diabetes.

AIM: Tactile massage (TM) is a gentle and superficial form of massage. A pilot study of patients with type 2 diabetes in primary care reported a reduction of 0.8% in glycosylated haemoglobin (HbA1c), whereas a randomized study comparing the effects of 10 weeks of TM once per week with relaxation exercises performed once per week as per instructions on a CD found no effects of TM on HbA(1c) in an intention-to-treat analysis. However, a significant reduction in waist circumference (WC) was found between the groups. METHODS: This was a secondary per-protocol analysis of the effect of TM (n=21) compared with relaxation (n=25) on other metabolic biomarkers. Anthropometrics (BMI and WC) and metabolic factors (B HbA(1c), S IGF, fS insulin, S adiponectin, S leptin and fP ghrelin) were assessed, insulin resistance (IR) was determined by modified homoeostasis model assessment (HOMA2-IR) using fP glucose and fS insulin, and ratios of adiponectin-to-leptin, adiponectin-to-HOMA-IR, adiponectin-to-WC and adiponectin-to-HbA1c were calculated at baseline, and at 10 weeks and 6 months after the intervention. RESULTS: Significant results adjusted for age, gender and changes in lifestyle and medical factors were shown for WC in women (-6.2 cm [95% CI: -10.4, -1.9]), but not in men. In addition, improvements in the TM group were found for adiponectin and ratios of adiponectin-to-leptin and adiponectin-to-HbA1c levels. CONCLUSION: Our data indicate that TM therapy may affect metabolic markers in type 2 diabetes despite the lack of significant effects on HbA(1c). The clinical implications of our findings need to be evaluated in further studies.

Psychosocial problems among newly diagnosed rheumatoid arthritis patients.

We identified patients with newly diagnosed rheumatoid arthritis (RA) in the ages 18-65 years who needed psychosocial interventions. A total of 123 patients (90 women) were asked to participate, but 19 declined and 4 dropped out early in the study, leaving a total of 100 patients (75 women) in the sample. Questionnaires used were the Epidemiological Investigation on Rheumatoid Arthritis study questionnaire, the Hospital Anxiety and Depression Scale, the Sense of Coherence (SOC) scale, and the General Coping Questionnaire. Interviews showed that 46% of the included 100 patients had psychosocial problems (PSP). One third of them had problems directly related to RA. The rest had problems with their life situation in general, without or reinforced by RA. Compared to patients without psychosocial problems, PSP patients lived in more strained social situations, especially regarding personal finances and social support. More of the PSP patients were anxious, showed lower SOC scores, and also used more emotion-based coping strategies (resignation, protest, isolation and intrusion) and less problem-oriented (minimization). They also had higher scores on depression and more frequently expected that RA would negatively affect their future. PSP patients also experienced a more negative impact of the disease, a finding not confirmed by the sickness activity score judged by the rheumatologist. Thus, early in the course of RA, screening instruments should be used to identify PSP patients. Psychosocial treatment and support by medical social workers skilled in RA care should be offered.

Poor self-rated health is not associated with a high total allostatic load in type 2 diabetic patients--but high blood pressure is.

OBJECTIVE: Allostatic load has been linked to self-rated health (SRH), cardiovascular disease and mortality in non-diabetic individuals. The aim of this study was to construct an allostatic load score and to find any correlations with SRH. METHODS: The subjects included in the study came from a randomized, controlled trial of type 2 diabetes. Blood samples were drawn, urine was collected for 24h, and questionnaires, including SRH, were filled out on three occasions: at baseline; after the 10-week intervention; and at a follow-up 3 months after the intervention. Allostatic load was estimated using a wide range of variables, including systolic and diastolic blood pressure, pulse pressure, cortisol, catecholamines, HbA(1c), insulin, plasma glucose and waist circumference. RESULTS: There was no association between SRH and allostatic load. However, three other components were significantly correlated with allostatic load at the baseline investigation and the two follow-up investigations - namely, systolic blood pressure, diastolic blood pressure and HbA(1c). CONCLUSION: The absence of an association between allostatic load and SRH in diabetic individuals contrasts with previous findings in non-diabetic women, and shows that it is hazardous to apply findings in one population to another, especially diabetic and non-diabetic populations.

Psychosocial problems in patients with newly diagnosed diabetes: number and characteristics.

Early in the course of diabetes, it is important to identify and support patients whose psychosocial situations and reactions to the diagnosis may affect their ability to adjust or take adequate responsibility for self-care. We aimed to identify (a) the number and characteristics of patients, 18-65 years, newly diagnosed with diabetes, who needed psychosocial interventions and (b) the type of psychosocial problems they had. A total of 106 patients (72 men) were included in the study. Interviews showed that 41.5% had psychosocial problems. Fifteen dropped out early in the study; 38% of those remaining had psychosocial problems (PSP). More than half had problems with their life situation; most commonly in relationships. About a third had problems related to diabetes, most commonly, work-related. Compared to other participants, PSP patients lived in more strained social situations, especially regarding personal finances and social support. More of the PSP patients were anxious and depressed. They used negative coping strategies more often and more frequently expected that diabetes would negatively affect their future. In conclusion, early in the course of diabetes, screening instruments should be used to identify PSP patients. Treatment by medical social workers skilled in diabetes care should be offered.