Involving supermarkets in health promotion interventions in the Danish Project SoL. A practice-oriented qualitative study on the engagement of supermarket staff and managers.

BACKGROUND: Supermarkets have been suggested as relevant settings for environmental and educational initiatives encouraging healthier shopping and eating decisions, but in the literature, limited attention has been paid to the context, perspectives, and everyday practices of supermarket staff. The aim of this study was to examine the engagement of supermarket staff in a health promotion project from a practice-oriented perspective. METHODS: The study was based on qualitative data collected in the supermarket setting of Project SoL; a community-based health promotion project in Denmark. We conducted 26 in-depth interviews with store managers and other key staff members in seven participating supermarkets. In addition, we collected data on planning, implementation, and perceptions of supermarket staff of in-store interventions and other project-related activities. These field data included short telephone interviews, observational notes, photos, and audiotapes of meetings. Data were analysed from the perspective of practice theory. RESULTS: Although supermarket staff found community-based health promotion meaningful to engage in, the study observed that their engagement was challenged by a business mindset, practical routines and structural requirements favouring sales promotion over health promotion. Nevertheless, there were also examples of how health promotion activities and ways of thinking were successfully incorporated in everyday staff practices during and after Project SoL. CONCLUSIONS: Our findings point to both potentials and challenges for using supermarkets as settings for health promotion. The voluntary engagement of supermarket staff in community-based health projects cannot stand alone but should be supplemented by more long-lasting strategies and policies regulating this and other food environments. Context-sensitive and practice-oriented analyses in local food environments could inform such strategies and policies to make sure they target unwanted elements and practices and not just individual behavior.

Improving Health and Diabetes Self-Management in Immigrants with Type 2 Diabetes Through a Co-Created Diabetes Self-Management Education and Support Intervention.

To examine the impact of a co-created culturally sensitive diabetes self-management education and support (DSMES) intervention on the physical and mental health of immigrants with type 2 diabetes (T2D). Pre- and post-test among people with T2D whose primary language was Urdu, Arabic or Turkish (n = 97). Participants were offered a six-week intervention based on a person-centred approach using research-based dialogue tools to facilitate learning and reflection, which was developed in co-creation with immigrants and healthcare professionals. Data were collected at baseline, post-intervention and after 6 months and analysed using paired t-tests, Wilcoxon signed-rank tests, chi-square tests and regression models when appropriate. Several clinical outcomes were improved post-intervention, including HbA1c (P < 0.001), body fat percentage (P = 0.002), self-rated general health (P = 0.05), well-being (P = 0.004) and several self-management behaviours, e.g., physical activity (P < 0.001). Most outcomes remained improved after 6 months, but the effect on HbA1c was no longer statistically significant. Some outcomes were improved only at 6 months, including waist circumference (P < 0.001) and diabetes-related emotional distress (P < 0.001). Fatigue did not change. Attendance at more programme sessions was associated with better outcomes. The DSMES intervention developed in a co-creation process was highly effective in improving the health of immigrants with T2D.

Patients' assessment of care for type 2 diabetes: Results of the Patient Assessment of Chronic Illness Care scale in a Danish population.

BACKGROUND: The Patient Assessment of Chronic Illness Care (PACIC) scale is the most appropriate for assessing self-reported experience in chronic care. We aimed to validate the PACIC questionnaire by (1) assess patients' perception of the quality of care for Danish patients with type 2 diabetes, (2) identify which factors are most important to the quality of care designated by the five subscales in PACIC, and (3) the validity of the questionnaire. METHODS: A survey of 7,745 individuals randomly selected from the National Diabetes Registry. Descriptive statistics inter-item and item-rest correlations and factor analysis assessed the PACIC properties. Quality of care was analysed with descriptive statistics; linear and multiple regression assessed the effect of forty-nine covariates on total and subscale scores. RESULTS: In total, 2,696 individuals with type 2 diabetes completed ≥ 50 % of items. The floor effect for individual items was 8.5-74.5 %; the ceiling effect was 4.1-47.8 %. Cronbach's alpha was 0.73-0.86 for the five subscales. The comparative fit index (CFI) and the Tucker-Lewis index (TLI) were 0,87, and 0,84, respectively. Mean PACIC score was 2.44 (± 0.04). Respondents, who receive diabetes care primarily at general practice and outpatient clinics had higher scores compared to those receiving care at a private specialist. Receiving rehabilitation was followed by higher scores in all subscales. Those 70 years or older had lower mean total and subscale scores compared to younger patient groups. A higher number of diabetes visits were associated with higher total scores; a higher number of emergency department visits were associated with lower total scores. The effects of healthcare utilisation on subscale scores varied. CONCLUSIONS: These results provide insight into variations in the quality of provided care and can be used for targeting initiatives towards improving diabetes care. Factors important to the quality of perceived care are having a GP or hospital outpatient clinic as the primary organization. Also having a higher number of visits to the two organizations are perceived as higher quality of care as well as participating in a rehabilitation program. Floor and ceiling effects were comparable to an evaluation of the PACIC questionnaire in a Danish population. Yet, floor effects suggest a need for further evaluation and possible improvement of the PACIC questionnaire in a Danish setting. Total PACIC scores were lower than in other healthcare systems, possible being a result of different contexts and cultures, and of a need for improving diabetes care in Denmark.

Health Technology Readiness Profiles Among Danish Individuals With Type 2 Diabetes: Cross-Sectional Study.

BACKGROUND: Information technologies (IT) are increasingly implemented in type 2 diabetes (T2D) treatment as a resource for remotely supported health care. However, possible pitfalls of introducing IT in health care are generally overlooked. Specifically, the effectiveness of IT to improve health care may depend on the user's readiness for health technology. OBJECTIVE: We aim to investigate readiness for health technology in relation to mental well-being, sociodemographic, and disease-related characteristics among individuals with T2D. METHODS: Individuals with T2D (aged ≥18 years) who had been referred to self-management education, exercise, diet counseling, smoking cessation, or alcohol counseling completed a questionnaire survey covering (1) background information, (2) the 5-item World Health Organization Well-Being Index (WHO-5), (3) receptiveness to IT use in physical activity, and (4) the Readiness and Enablement Index for Health Technology (READHY), constituted by dimensions related to self-management, social support, and eHealth literacy. Individuals were divided into profiles using cluster analysis based on their READHY scores. Outcomes included differences across profiles in mental well-being, sociodemographic, and disease-related characteristics. RESULTS: Participants in the study were 155 individuals with T2D with a mean age of 60.2 (SD 10.7) years, 55.5% (86/155) of which were men and 44.5% (69/155) of which were women. Participants were stratified into 5 health technology readiness profiles based on the cluster analysis: Profile 1, high health technology readiness; Profile 2, medium health technology readiness; Profile 3, medium health technology readiness and high level of emotional distress; Profile 4, medium health technology readiness and low-to-medium eHealth literacy; Profile 5, low health technology readiness. No differences in sociodemographic and disease-related characteristics were observed across profiles; however, we identified 3 vulnerable subgroups of individuals: Profile 3 (21/155, 13.5%), younger individuals (mean age of 53.4 years, SD 8.9 years) with low mental well-being (mean 42.7, SD 14.7) and emotional distress (mean 1.69, SD 0.38); Profile 4 (20/155, 12.9%), older individuals (mean age 66.3 years, SD 9.0 years) with less IT use (50.0% used IT for communication) and low-to-medium eHealth literacy; and Profile 5 (36/155, 23.2%) with low mental well-being (mean 43.4, SD 20.1) and low readiness for health technology. CONCLUSIONS: Implementation of IT in health care of individuals with T2D should be based on comprehensive consideration of mental well-being, emotional distress, and readiness for health technology rather than sociodemographic and disease-related characteristics to identify the individuals in need of social support, self-management education, and extensive IT support. A one-size-fits-all approach to IT implementation in health care will potentially increase the risk of treatment failure among the most vulnerable individuals.

Glucose patterns during an oral glucose tolerance test and associations with future diabetes, cardiovascular disease and all-cause mortality rate.

AIMS/HYPOTHESIS: In addition to blood glucose concentrations measured in the fasting state and 2 h after an OGTT, intermediate measures during an OGTT may provide additional information regarding a person's risk of future diabetes and cardiovascular disease (CVD). First, we aimed to characterise heterogeneity of glycaemic patterns based on three time points during an OGTT. Second, we compared the incidences of diabetes and CVD and all-cause mortality rates among those with different patterns. METHODS: Our cohort study included 5861 participants without diabetes at baseline from the Danish Inter99 study. At baseline, all participants underwent an OGTT with measurements of plasma glucose levels at 0, 30 and 120 min. Latent class mixed-effects models were fitted to identify distinct patterns of glycaemic response during the OGTT. Information regarding incident diabetes, CVD and all-cause mortality rates during a median follow-up time of 11, 12 and 13 years, respectively, was extracted from national registers. Cox proportional hazard models with adjustment for several cardiometabolic risk factors were used to compare the risk of diabetes, CVD and all-cause mortality among individuals in the different latent classes. RESULTS: Four distinct glucose patterns during the OGTT were identified. One pattern was characterised by high 30 min but low 2 h glucose values. Participants with this pattern had an increased risk of developing diabetes compared with participants with lower 30 min and 2 h glucose levels (HR 4.1 [95% CI 2.2, 7.6]) and participants with higher 2 h but lower 30 min glucose levels (HR 1.5 [95% CI 1.0, 2.2]). Furthermore, the all-cause mortality rate differed between the groups with significantly higher rates in the two groups with elevated 30 min glucose. Only small non-significant differences in risk of future CVD were observed across latent classes after confounder adjustment. CONCLUSIONS/INTERPRETATION: Elevated 30 min glucose is associated with increased risk of diabetes and all-cause mortality rate independent of fasting and 2 h glucose levels. Therefore, subgroups at high risk may not be revealed when considering only fasting and 2 h glucose levels during an OGTT.

Does perceived stress increase the risk of atrial fibrillation? A population-based cohort study in Denmark.

BACKGROUND: Psychological stress is associated with increased risk of acute cardiovascular diseases, as myocardial infarction. We recently found a higher risk of atrial fibrillation following an acute stressful life event, but it remains unknown whether this also applies to common and less acute stress exposures. METHODS: We investigated the risk of incident atrial fibrillation in people with high levels of perceived stress by following a population-based cohort of 114,337 participants from the Danish National Health Survey from 2010 to 2014. The survey holds information on lifestyle factors and perceived stress measured by Cohen's 10-item Perceived Stress Scale (PSS). We obtained information on atrial fibrillation, comorbidities and socioeconomic status from Danish nationwide registers. We identified 2172 persons with a first episode of atrial fibrillation during 424,839 person-years of follow-up. The hazard ratio (HR) of atrial fibrillation with 95% confidence interval (CI) was calculated with Cox proportional hazard model. RESULTS: The risk of atrial fibrillation increased with increasing PSS score; persons in the highest perceived stress quintile had 28% (95% CI, 12%-46%) higher risk of atrial fibrillation compared with persons in the lowest perceived stress quintile. However, the association disappeared when adjusting for comorbidities, socioeconomic status and lifestyle factors; HR was 1.01 (95% CI, 0.88-1.16) when comparing persons in the highest and the lowest perceived stress quintile. CONCLUSIONS: This large population-based cohort study did not reveal a higher risk of atrial fibrillation among persons with a high degree of perceived stress after adjustment for participants' baseline characteristics.

Functional and genetic epidemiological characterisation of the FFAR4 (GPR120) p.R270H variant in the Danish population.

BACKGROUND: p.R270H (rs116454156) in the long chain fatty acid 7TM receptor FFAR4 (GPR120) which results in impaired Gαq (Gq) coupled signalling, has been associated with obesity. We aimed to extend the functional in vitro analyses of p.R270H and to investigate the association with obesity and glucose-related traits in the Danish population. METHODS: Surface expression, Gq and Gi coupled signalling as well as ß-arrestin recruitment were examined in vitro. p.R270H was genotyped using the exome chip array in 11 479 Danish adult individuals. Of these 4391 were obese and 4415 were normal weight. Association with quantitative metabolic traits comprised 8720 non-diabetic individuals. RESULTS: p.R270H showed reduced surface expression of FFAR4. Ligand-independent activity was eliminated and strongly impaired through the Gq and Gi signalling pathways, respectively. The ligand-induced maximal signalling efficacy of p.R270H was reduced only through the Gq pathway. The p.R270H variant did not affect ß-arrestin recruitment. p.R270H was not associated with increased risk of obesity nor increased fasting plasma glucose levels in the Danish study populations. Nor was it associated with these two traits in the European Network for Genetic and Genomic Epidemiology consortium data (N=34 901-71 175; p>0.70). It was also not associated with waist-hip ratio, glucose metabolism during an oral glucose tolerance test, lipid levels or with markers of adiposity (leptin, adiponectin), inflammation (high-sensitive C reactive protein; hs-CRP) and liver function (alanine aminotransferase) in the Danish population (p>0.05). CONCLUSIONS: We demonstrate that p.R270H of FFAR4 impairs Gq and Gi signalling of FFAR4 in vitro; however, this impaired signalling for p.R270H does not translate into associations with human metabolic phenotypes in the investigated populations.

Social disparities in the prevalence of multimorbidity - A register-based population study.

BACKGROUND: Prevalences of multimorbidity vary between European studies and several methods and definitions are used. In this study we examine the prevalence of multimorbidity in relation to age, gender and educational attainment and the association between physical and mental health conditions and educational attainment in a Danish population. METHODS: A cross-sectional design was used to study the prevalence of multimorbidity, defined as two or more chronic conditions, and of comorbid physical and mental health conditions across age groups and educational attainment levels among 1,397,173 individuals aged 16 years and older who lived in the Capital Region of Denmark on January 1st, 2012. After calculating prevalence, odds ratios for multimorbidity and mental health conditions were derived from logistic regression on gender, age, age squared, education and number of physical conditions (only for odds ratios for mental health conditions). Odds ratios for having multimorbidity and mental health conditions for each variable were adjusted for all other variables. RESULTS: Multimorbidity prevalence was 21.6%. Half of the population aged 65 and above had multimorbidity, and prevalence was inversely related to educational attainment: 26.9% (95% CI, 26.8-26.9) among those with lower secondary education versus 13.5% (95% CI, 13.5-13.6) among people with postgraduate education. Adjusted odds ratios for multimorbidity were 0.50 (95% CI, 0.49-0.51) for people with postgraduate education, compared to people with lower secondary education. Among all population members, 4.9% (95% CI, 4.9-4.9) had both a physical and a mental health condition, a proportion that increased to 22.6% of people with multimorbidity. Physical and mental health comorbidity was more prevalent in women (6.33%; 95% CI, 6.3-6.4) than men (3.34%; 95% CI, 3.3-3.4) and approximately 50 times more prevalent among older persons than younger ones. Physical and mental health comorbidity was also twice as prevalent among people with lower secondary education than among those with postgraduate education. The presence of a mental health condition was strongly associated with the number of physical conditions; those with five or more physical conditions had an adjusted odds ratio for a mental health condition of 3.93 (95% CI, 3.8-4.1), compared to those with no physical conditions. CONCLUSION: Multimorbidity prevalence and patterns in the Danish population are comparable to those of other European populations. The high prevalence of mental and physical health conditions highlights the need to ensure that healthcare systems deliver care that takes physical and mental comorbidity into account. Further, the higher prevalence of multimorbidity among persons with low educational attainment emphasizes the importance of having a health care system providing care that is beneficial to all regardless of socioeconomic status.

Unravelling networks in local public health policymaking in three European countries - a systems analysis.

BACKGROUND: Facilitating and enhancing interaction between stakeholders involved in the policymaking process to stimulate collaboration and use of evidence, is important to foster the development of effective Health Enhancing Physical Activity (HEPA) policies. Performing an analysis of real-world policymaking processes will help reveal the complexity of a network of stakeholders. Therefore, the main objectives were to unravel the stakeholder network in the policy process by conducting three systems analyses, and to increase insight into the similarities and differences in the policy processes of these European country cases. METHODS: A systems analysis of the local HEPA policymaking process was performed in three European countries involved in the 'REsearch into POlicy to enhance Physical Activity' (REPOPA) project, resulting in three schematic models showing the main stakeholders and their relationships. The models were used to compare the systems, focusing on implications with respect to collaboration and use of evidence in local HEPA policymaking. Policy documents and relevant webpages were examined and main stakeholders were interviewed. RESULTS: The systems analysis in each country identified the main stakeholders involved and their position and relations in the policymaking process. The Netherlands and Denmark were the most similar and both differed most from Romania, especially at the level of accountability of the local public authorities for local HEPA policymaking. The categories of driving forces underlying the relations between stakeholders were formal relations, informal interaction and knowledge exchange. CONCLUSIONS: A systems analysis providing detailed descriptions of positions and relations in the stakeholder network in local level HEPA policymaking is rather unique in this area. The analyses are useful when a need arises for increased interaction, collaboration and use of knowledge between stakeholders in the local HEPA network, as they provide an overview of the stakeholders involved and their mutual relations. This information can be an important starting point to enhance the uptake of evidence and build more effective public health policies.

Ponderal index at birth associates with later risk of gestational diabetes mellitus.

PURPOSE: Low birth weight (BW) and low ponderal index (PI) are associated with increased risk of type 2 diabetes mellitus. This study has two purposes: first to investigate the influence of PI on the risk of gestational diabetes mellitus (GDM); second, to study the association between glucose metabolism and BW in women with previous GDM. METHODS: GDM cohort: 185 women with GDM in 1978-1996, attending a follow-up study in 2000-2002. Control cohort: 1137 women from a population-based diabetes screening study (Inter99) in a neighbouring county in 1999-2001. BW and birth length were collected from the original midwifery records. BW and PI were stratified into tertiles for analysis. RESULTS: PI in the lower tertiles was associated with an increased risk of GDM [odds ratio 1.59 (95% confidence interval 1.07-2.36, p = 0.021)]. Among women with previous GDM, the area under the curve (AUC) for plasma levels of glucose and insulin during an OGTT was highest for the lower tertiles of BW (for AUCglucose p = 0.048, for AUCinsulin p = 0.047 adjusted for age and BMI). CONCLUSIONS: Lower PI is associated with increased risk of GDM. In women with previous GDM, lower BW is associated with a more severe impairment of glucose metabolism one to two decades after the pregnancy complicated by GDM.

Medication overuse, healthy lifestyle behaviour and stress in chronic headache: Results from a population-based representative survey.

AIM: This cross-sectional study investigated associations between chronic headache (CH) with and without medication overuse, healthy lifestyle behaviour, and stress. METHODS: Questionnaires were sent to 129,150 adults. Those with headache ≥15 days per month for three months were classified as having CH then further described as having medication-overuse headache (MOH) or CH without medication overuse. Associations between headache and daily smoking, physical inactivity, obesity, excessive drinking, illicit drug use, and high stress were analysed by logistic regression. RESULTS: CH with and without medication overuse (prevalence 1.8% and 1.6%, respectively) had strong, graded associations with stress. Associations with daily smoking, physical inactivity, and obesity were significant only for MOH. Odds for MOH were highest among people who had all three factors compared to those who had none (OR 2.8 in women and 5.1 in men). High stress plus any of these three factors had synergistic effects in MOH but not clearly in those who had CH without overuse. Associations between CH subtypes and excessive drinking or illicit drug use were not statistically significant. CONCLUSION: Results suggest strong links between healthy lifestyle behaviour and stress in MOH. Stress reduction and promoting healthy behaviour are highly relevant in MOH management.

Ready for a goodbye to tobacco? - Assessment of support for endgame strategies on smoking among adults in a Danish regional health survey.

OBJECTIVES: To assess support for a future ban on smoking and for increasing tobacco taxes in Denmark, and to explore if support differed across sex, age, educational attainment, smoking status and intention to quit. METHODS: Data from a 2013 health survey representative of the population aged ≥16years in the Capital Region of Denmark (N=41,356, response rate=43.5) was linked with data on sex, age and education from central registers. Participants were asked if they supported: 1) a future ban on smoking in Denmark, and 2) increased taxes on tobacco products. Subgroup differences were explored using logistic regression. RESULTS: 30.6% supported a future ban on smoking, while 59.0% supported increased taxes. Women were less supportive of a future ban (OR=0.83 (0.78-0.88)) and more supportive of increasing taxes (OR=1.11 (1.06-1.18)) than men. Support for both measures was higher among the youngest. Only small differences were found in ban support across educational attainment, while support for taxes increased with increasing education. Support for both measures were greatest among never smokers (OR=2.66 (2.40-2.93) and OR=9.69 (8.83-10.63)) compared to daily smokers. Smokers intending to quit were two to three times as likely to support a future ban or increased taxes compared to smokers with no quit intensions. CONCLUSION: One third supported a future ban on smoking, while six out of ten supported increasing taxes. This first Danish study of support for more radical tobacco control adds to the growing literature on tobacco endgame and sets a baseline for future assessments of public support.

Effect of general health screening and lifestyle counselling on incidence of diabetes in general population: Inter99 randomised trial.

We aimed to examine the effect of a large population-based multifactorial screening and lifestyle intervention programme on 10-year incidence of diabetes. In a randomised trial of the general Danish population initiated in 1999-2001 59,616 men and women aged 30-60years were assigned to a five year screening and lifestyle counselling programme (n=11,629) or control group (n=47,987) and followed for ten years in nationwide registers. Intention to treat was applied and risk of diabetes was modeled by Cox regression and expressed as hazard ratios (HRs). We found that 1692 individuals had diabetes at baseline. Among 57,924 individuals without diabetes at baseline, 1267 emigrated, 2593 died and 3369 (Intervention group=684, Control group=2685) developed diabetes. We saw no significant difference in diabetes incidence between the groups after 10-year follow-up (Grey's test: p=0.22). In the first year of follow-up, incidence of diabetes was significantly higher in the intervention group than the control group (HR=1.68, 95%CI 1.29 to 2.29). We observed no difference in incidence of diabetes between the groups in the follow-up intervals from 1 to 6years or after 6-10years (HR=0.94, 0.83 to 1.06; HR=1.03, 0.91 to 1.17). Inviting the general population to participate in a repeated screening and lifestyle counselling programme over five years did not result in lower incidence of diabetes after 10years of follow-up. As expected, significantly more individuals were diagnosed with diabetes in the intervention group during the first year, but this was not followed by a decrease in the following years. TRIALS REGISTRATION: Clinical trials NCT00289237.

Catalog of 199 register-based definitions of chronic conditions.

INTRODUCTION: The aim of the current study was to present and discuss a broad range of register-based definitions of chronic conditions for use in register research, as well as the challenges and pitfalls when defining chronic conditions by the use of registers. MATERIALS AND METHODS: The definitions were defined based on information from nationwide Danish public healthcare registers. Medical and epidemiological specialists identified and grouped relevant diagnosis codes that covered chronic conditions, using the International Classification System version 10 (ICD-10). Where relevant, prescription and other healthcare data were also used to define the chronic conditions. RESULTS: We identified 199 chronic conditions and subgroups, which were divided into four groups according to a medical judgment of the expected duration of the conditions, as follows. Category I: Stationary to progressive conditions (maximum register inclusion time of diagnosis since the start of the register in 1994). Category II: Stationary to diminishing conditions (10 years of register inclusion after time of diagnosis). Category III: Diminishing conditions (5 years of register inclusion after time of diagnosis). Category IV: Borderline conditions (2 years of register inclusion time following diagnosis). The conditions were primarily defined using hospital discharge diagnoses; however, for 35 conditions, including common conditions such as diabetes, chronic obstructive lung disease and allergy, more complex definitions were proposed based on record linkage between multiple registers, including registers of prescribed drugs and use of general practitioners' services. CONCLUSIONS THIS STUDY PROVIDED A CATALOG OF REGISTER-BASED DEFINITIONS FOR CHRONIC CONDITIONS FOR USE IN HEALTHCARE PLANNING AND RESEARCH, WHICH IS, TO THE AUTHORS' KNOWLEDGE, THE LARGEST CURRENTLY COMPILED IN A SINGLE STUDY.

Alcohol consumption among patients with diabetes: a survey-based cross-sectional study of Danish adults with diabetes.

AIMS: To estimate alcohol consumption among Danish adults with diabetes and to investigate whether certain comorbidities are related to a high alcohol intake. METHODS: A total of 162,283 participants responded to the Danish National Health Survey 2013 (questionnaire study, response rate 54.0%). Variables on the participants were extracted from the survey and 6.5% of respondents reported having diabetes. High alcohol consumption was defined as >21 (men) or >14 (women) standard drinks per week. RESULTS: High alcohol consumption was reported by 11.2 % of men and 4.3% of women with diabetes. In the women, this was fewer than among women without diabetes (odds ratio (OR) 0.65, 95% confidence interval (CI) 0.56-0.77, p<0.0001). Patients with diabetes had lower ORs for binge drinking (men OR 0.90, 95% CI 0.84-0.97, p=0.0039; women OR 0.79, 95% CI 0.70-0.89, p<0.0001) and lower ORs for having a problematic alcohol intake (men OR 0.80, 95% CI 0.75-0.86, p<0.0001; women OR 0.56, 95% CI 0.49-0.64, p<0.0001) compared with participants without diabetes. A larger proportion of participants with diabetes had not consumed alcohol within the last year (men 13.5%; women 28.2%) compared with participants without diabetes (men 6.0%; women 11.2%). Men with diabetes and a high consumption of alcohol had significantly lower ORs for myocardial infarction (OR 0.55, 95% CI 0.40-0.76, p =0.0003) and stroke (OR 0.70, 95% CI 0.49-1.00, p=0.0498). CONCLUSIONS THIS STUDY SUGGESTS THAT DANISH PATIENTS WITH DIABETES ARE LESS PRONE TO EXHIBIT ADDICTIVE BEHAVIOUR AND MANY ABSTAIN FROM ALCOHOL FEWER WOMEN WITH DIABETES THAN WITHOUT DIABETES HAVE AN EXCESSIVE DRINKING PATTERN HIGH ALCOHOL CONSUMPTION IN MEN WITH DIABETES CORRELATES TO A LOWER OCCURRENCE OF CARDIOVASCULAR EVENTS.

Substituting sugar confectionery with fruit and healthy snacks at checkout - a win-win strategy for consumers and food stores? a study on consumer attitudes and sales effects of a healthy supermarket intervention.

BACKGROUND: The widespread use of in-store marketing strategies to induce unhealthy impulsive purchases has implications for shopping experience, food choice and possibly adverse health outcomes. The aim of this study was to examine consumer attitudes and evaluate sales effects of a healthy checkout supermarket intervention. The study was part of Project Sundhed & Lokalsamfund (Project SoL); a Danish participatory community-based health promotion intervention. METHODS: Consumer attitudes towards unhealthy snack exposure in supermarkets were examined in a qualitative pre-intervention study (29 short in-store interviews, 11 semi-structured interviews and three focus group interviews). Findings were presented to food retailers and informed the decision to test a healthy checkout intervention. Sugar confectionery at one checkout counter was substituted with fruit and healthy snacking items in four stores for 4 weeks. The intervention was evaluated by 48 short exit interviews on consumer perceptions of the intervention and by linear mixed model analyses of supermarket sales data from the intervention area and a matched control area. RESULTS: The qualitative pre-intervention study identified consumer concern and annoyance with placement and promotion of unhealthy snacks in local stores. Store managers were willing to respond to local consumer concern and a healthy checkout intervention was therefore implemented. Exit interviews found positive attitudes towards the intervention, while intervention awareness was modest. Most participants believed that the intervention could help other consumers make healthier choices, while fewer expected to be influenced by the intervention themselves. Statistical analyses suggested an intervention effect on sales of carrot snack packs when compared with sales before the intervention in Bornholm control stores (P < 0.05). No significant intervention effect on sales of other intervention items or sugar confectionery was found. CONCLUSIONS: The present study finds that the healthy checkout intervention was positively evaluated by consumers and provided a 'responsible' branding opportunity for supermarkets, thus representing a win-win strategy for store managers and consumers in the short term. However, the intervention was too modest to draw conclusions on long-term sales and health implications of this initiative. More research is needed to assess whether retailer-researcher collaborations on health promotion can be a winning strategy for public health.

The association between accessibility of local convenience stores and unhealthy diet.

BACKGROUND: High accessibility of unhealthy food stores may contribute to a poor dietary quality. Research on the link between neighbourhood food environment and consumption is limited, especially in a European context. The objective of this study was to examine the relationship between convenience stores (CS) and dietary quality within the Capital Region of Denmark. METHOD: Cross-sectional study of the geographic food environment in the Capital Region of Denmark based on 47 623 subjects (age 16+ years) with complete information on retail food environment and dietary quality. A categorization procedure to identify CS from a government list of inspected food stores (the Smiley register) was developed. Using GIS network analyses, density of CS within 0.25 km and 0.5 km network buffers from residency was calculated for participants in metropolitan and non-metropolitan areas, respectively. Information on dietary intake and confounders is derived from a questionnaire survey. Multi-level analyses were performed, adjusting for age, sex, individual socio-economic factors and area socio-economic status. RESULTS: In the non-metropolitan population, the odds of having an unhealthy diet increased significantly (P < 0.0001) with increased density of CS. Compared to individuals who did not have a CS within 0.5 km from their home, the odds ratios were 1.20 (95% CI: 1.09-1.33) and 1.37 (95% CI: 1.19-1.57) for individuals having 1 or ≥2 CS, respectively. In the fully adjusted model, the overall association remained significant (P = 0.015) and odds ratios diminished to 1.14 (1.02-1.27) and 1.18 (1.01-1.38). CONCLUSION: High accessibility of CS in neighbourhoods is associated with less healthy dietary habits among residents.

Prescription pain medications and chronic headache in Denmark: implications for preventing medication overuse.

PURPOSE: The aim of the present paper is to study which prescription pain medications are most commonly dispensed to people with chronic headache (CH), particularly those with medication-overuse headache (MOH). METHODS: This cross-sectional study analysed prescription pain medications dispensed within 1 year to 68,518 respondents of a national health survey. Participants with headache ≥ 15 days per month for 3 months were classified as having CH. Those with CH and over-the-counter analgesic use ≥ 15 days per month or purchase of ≥ 20 or ≥ 30 defined daily doses (DDDs) of prescription pain medication per month (depending on the drug) were classified as having MOH. Associations between CH and other chronic pain conditions were analysed by logistic regression. RESULTS: Among those with CH (adjusted prevalence 3.3%, CI 3.2-3.5%), pain medications most commonly dispensed were paracetamol, tramadol, ibuprofen and codeine. CH was associated with osteoarthritis, back pain, and rheumatoid arthritis. Among those with MOH, 32.4% were dispensed an opioid at least once within 1 year. Only 5.1% of people with CH were dispensed triptans. CONCLUSIONS: High prevalence of opioid use among people with CH may be due to inappropriate headache treatment or development of MOH among those treated for other pain conditions. While there were cases of triptan overuse, triptans remain underutilized among those with CH, suggesting that migraine may be under-recognized and inappropriately treated, leading to overuse of other medications. Education of physicians on appropriate headache management is essential for MOH prevention. There is a need to increase universal awareness about MOH as an adverse effect of long-term analgesic use.

The development in body mass index, overweight and obesity in three regions in Denmark.

BACKGROUND: The prevalence of overweight and obesity has increased markedly the past decades. However, recent studies have indicated that the development differ between different socio-economic groups and different geographic regions. The aim of this study was to assess the development in prevalence of overweight and obesity from 2006/2007 to 2010 by age, gender, socio-economic factors and geographical regions. METHODS: Two cross-sectional surveys in three regions in Denmark (The Capital Region of Denmark, The Central Denmark Region and The North Denmark Region) were performed in 2006/2007 and 2010. A random sample of citizens aged more than or equal to 25 years was invited to participate. The overall response rate was 57.5% (n = 177 076). Data from questionnaire and central registers were included. RESULTS: In 2006/2007, the prevalence of overweight, including obesity, was 54.3% and 36.8% among men and women, respectively. Of the overweight men 12.8% were obese and 11.8% women were obese. The prevalence was highest in the Northern region and among those who were older, had short education, was outside labour market, had low income and residents in rural areas. In 2010, the prevalence of overweight had increased to 56.3% and 39.6% in men and women, respectively (P < 0.0001). However, overweight increased the most in the Northern Region whereas no significant increase in body mass index was found among men in the Capital Region. Among women prevalence of overweight increased but not in those retired or above 60 years, and with high income. CONCLUSION: The prevalence of overweight and obesity was high and increased. The development, however, was heterogenic.

The effect of multiple reminders on response patterns in a Danish health survey.

BACKGROUND: Reminders are routinely applied in surveys to increase response rates and reduce the possibility of bias. This study examines the effect of multiple reminders on the response rate, non-response bias, prevalence estimates and exposure-outcome relations in a national self-administered health survey. METHODS: Data derive from the Danish National Health Survey 2010, in which 298,550 individuals (16 years of age or older) were invited to participate in a cross-sectional survey using a mixed-mode approach (paper and web questionnaires). At least two reminders were sent to non-respondents, and 177,639 individuals completed the questionnaire (59.5%). Response patterns were compared between four groups of individuals (first mailing respondents, second mailing respondents, third mailing respondents and non-respondents). RESULTS: Multiple reminders led to an increase in response rate from 36.7 to 59.5%; however, the inclusion of second and third mailing respondents did not change the overall characteristics of respondents compared with non-respondents. Furthermore, only small changes in prevalence estimates and exposure-outcome relationships were observed when including second and third mailing respondents compared with only first mailing respondents. CONCLUSIONS: Multiple reminders were an effective way to increase the response rate in a national Danish health survey. However, when differences do exist between respondents and non-respondents, the results suggest that second and third mailings are unlikely to eliminate these differences. Overall, multiple reminders seemed to have only minor effect on response patterns and study conclusions in the present study.