Barriers and facilitators for sustainable weight loss in the pre-conception period among Danish women with overweight or obesity - a qualitative study.

BACKGROUND: The prevalence of overweight or obesity in women of reproductive age continues to increase. A high pre-pregnancy body mass index (BMI) has been shown to increase the risk of pregnancy complications and predispose offspring to childhood obesity. However, little is known about factors affecting women's ability to achieve sustainable weight management and very few studies have applied behavior change theory to qualitative data. AIM: This study aimed to explore barriers and facilitators for weight management among women with overweight or obesity, who wanted to lose weight before pregnancy. METHODS: We conducted semi-structured interviews with 17 women with a BMI ≥ 27 kg/m2, who planned to become pregnant in the near future. Data were analyzed using an abductive approach and the Capability, Opportunity, Motivation, and Behavior model was applied as a conceptual framework. RESULTS: The women's strongest motivator for pre-conception weight loss was their ability to become pregnant. Barriers to successful weight management included their partners' unhealthy behaviors, mental health challenges, competing priorities, and internalized weight stigmatization. The women described careful planning, partners' health behaviors, social support, and good mental health as facilitators for sustainable weight management. CONCLUSION: Our study provides insights into factors affecting weight management among women with overweight or obesity in the pre-conception period. Future interventions on weight management require a holistic approach, including a focus on social support, especially from the partner, and mental health, as well as an effort to limit internalized weight stigma.

Examining Phenotypic Traits Contributing to the Spread in Northern European Potato Crops of EU_41_A2, a New Clonal Lineage of Phytophthora infestans.

Until recently, genotypes of Phytophthora infestans were regionally distributed in Europe, with populations in western Europe being dominated by clonal lineages and those in northern Europe being genetically diverse because of frequent sexual reproduction. However, since 2013 a new clonal lineage (EU_41_A2) has successfully established itself and expanded in the sexually recombining P. infestans populations of northern Europe. The objective of this study was to study phenotypic traits of the new clonal lineage of P. infestans, which may explain its successful establishment and expansion within sexually recombining populations. Fungicide sensitivity, aggressiveness, and virulence profiles of isolates of EU_41_A2 were analyzed and compared with those of the local sexual populations from Denmark, Norway, and Estonia. None of the phenotypic data obtained from the isolates collected from Denmark, Estonia, and Norway independently explained the invasive success of EU_41_A2 within sexual Nordic populations. Therefore, we hypothesize that the expansion of this new genotype could result from a combination of fitness traits and more favorable environmental conditions that have emerged in response to climate change.

Perceptions of risk and motivation for healthy living among immigrants from non-western countries with prior gestational diabetes mellitus living in Denmark.

OBJECTIVE: To explore perceptions of risk and motivation for healthy living among immigrant women from non-western countries with prior gestational diabetes mellitus (GDM) living in Denmark. DESIGN: Seventeen semi-structured interviews were conducted with 12 female immigrants with prior GDM from non-western countries living in Denmark. The women were recruited through a public hospital and other health services and nongovernmental organisations. The theoretical approach was inspired by Arthur Kleinman's Explanatory Models. Data were analysed using qualitative content analysis. RESULTS: A diagnosis of GDM entailed great worry for the future. Participants' fears were primarily linked to the potential later development of type 2 diabetes (T2D) and poor health. Women's perceptions of GDM reflected their experiences with T2D-related complications and even death among relatives. The risk perception of GDM was also influenced by participants' challenges and trauma unrelated to diabetes. Their motivation for healthy living was strengthened by their experiences with T2D among relatives, while unrelated challenges and trauma generally reduced their capacity for healthier behaviours. CONCLUSION: Among women with a non-western immigrant background and prior GDM living in Denmark, experiences with T2D among family members and their close communities affect their perceptions of risk and motivation to prevent the development of T2D. Furthermore, the challenges of daily life and past trauma were critical factors in their levels of available resources for health. Health promotion in this population should address health in a holistic way by integrating mental and social health with interventions aimed at preventing the development of T2D.

Danish 'add-in' school-based health promotion: integrating health in curriculum time.

Schools provide an important setting for health promotion and health education. In countries where health education is not a specific subject, it is typically undertaken by teachers in health-integrating subjects such as biology, home economics or physical education. More ambitious and holistic frameworks and whole school approaches such as health promoting schools have been considered best practice for the past three decades. Recently, more attention has been given to policy initiatives integrating health activities into school curriculum time. This paper discusses potentials and challenges of school-based health promotion applying an 'add-in' approach, that integrates health activities into teachers' curricular obligations without taking time away from them, based on a presentation of three Danish cases. This may serve as a supplement to health promotion activities that have been initiated over and above the day-to-day teaching (add-on). We contend that an 'add-in' approach to school health promotion provides a potential win-win situation where both health and core education stand to gain; makes it possible to reach a wider range of schools; mobilizes additional resources for health promotion; and leads to more sustainable activities. However, potential limitations including not addressing structural aspects of health promotion and reliance on a relatively limited evidence base should also be considered.

What are the public health implications of the life course perspective?

During the past decades innovative research has shown that exposure to harmful events during pregnancy and early infancy ('the first 1000 days') has an impact on health at subsequent stages of the life course and even across generations. Recently it has been shown that even the pre-conception period is of outmost importance, and other scholars have made the case that the 1000 days should be extended to a period of 8000 days post-conception. The present contribution aims to bridge further the gap between research evidence and public health policy by applying a holistic 'full-cycle' perspective. Thus, a conceptual framework is suggested for guiding public health prioritization, including the variables of 'impact on the next generation', 'plasticity' and 'available interventions with documented impact'. This framework could guide decision makers in selecting at which stages of the life course to invest (and not), and furthermore it points to some pertinent research priorities.

Vitamin D3 supplementation and treatment outcomes in patients with depression (D3-vit-dep).

OBJECTIVE: To examine whether vitamin D supplementation in patients with depression would result in a reduction in Hamilton D-17 depression score (primary outcome) at 3 and 6 months compared to controls and to explore the correlations between serum vitamin D and symptoms of depression, wellbeing, systolic blood pressure, and waist circumference. In this outpatient multicentre study conducted between 2010 and 2013, patients, 18-65 years old, diagnosed with mild to severe depression were randomly assigned to receive D supplementation 70 micrograms daily or placebo on top of standard treatment. Participants, care givers and those assessing the outcomes were blinded to group assignment. RESULTS: At baseline, 23 patients had a normal 25(OH)D level, 22 had insufficiency (< 25 nmol/L), and 17 had deficiency (25-50 nmol/L). No significant reduction in depression was seen after vitamin D supplementation compared to placebo at Hamilton (18.4-18.0; p = 0.73 at 12 weeks). Vitamin D supplementation did not provide a reduction in symptom score among patients with depression. Trial registration The trial was registered in the National Board of Health (EudraCT: 2011-002585-20) and in ClinicalTrials.Gov (NCT01390662).

Perioperative Safety in Patient Under Oral Anticoagulation During Holmium Laser Enucleation of the Prostate.

INTRODUCTION AND OBJECTIVES: To evaluate the safety of holmium laser enucleation of the prostate (HoLEP) in patients on oral anticoagulation (OA) with respect to intra- and postoperative bleeding complications. METHODS: Between January 2013 and October 2016, 2178 patients were included in this study, of whom 94 received direct oral anticoagulants (DOACs) and 151 received vitamin K antagonists (VKAs) before HoLEP. All patients either ceased OA (DOACs) or were bridged subtherapeutically (VKAs, international normalized ratio <2) during surgery. These patients were compared to a sample size of 1933 nonanticoagulated patients. RESULTS: A significant longer postoperative stay was noted for the patients on DOACs (5.2 [4-6] days) and VKAs (5.3 [4-5] days) compared to the control group (4.5 [4-4] days). The mean drop in hemoglobin was significantly higher in the VKA group compared to the DOAC and control group. There was a significantly higher rate of postoperative bladder tamponades/secondary coagulation in patients on OA with 6 (7.9%)/3 (3.9%) patients in the DOAC group, 10 (7.4%)/6 (4.4%) patients in the VKA group compared to 37 (2.2%)/21 (2.1%) patients in the control group, respectively (p < 0.001). Eight patients required blood transfusions with a distribution of 1 (1.3%), 3 (2.2%), and 4 (0.2%) patients in the DOAC, VKA, and control group, respectively (p < 0.001). CONCLUSIONS: Our findings indicate that bridged patients who's DOACs and VKAs were ceased before HoLEP are at higher risk of intra- and postoperative bleeding complications. Nonetheless, HoLEP appears to be a safe and effective procedure in those patients.

Project SoL-A Community-Based, Multi-Component Health Promotion Intervention to Improve Eating Habits and Physical Activity among Danish Families with Young Children. Part 1: Intervention Development and Implementation.

Project SoL was implemented over a period of four years from 2012⁻2015 with the aim to promote healthy eating and physical activity among families with children aged 3⁻8 years, living in selected communities in two Danish municipalities. This was done by applying the supersetting approach to implement complex multi-component interventions in a participatory, coordinated, and integrated manner in childcare centres, schools, and supermarkets in three local communities, as well as in local media during a 19-month period in the Regional Municipality of Bornholm, which served as the intervention site. The matching municipality of Odsherred served as a control site based on its similarity to Bornholm regarding several socio-demographic and health indicators. The present paper describes the design of Project SoL as well as the processes of developing and implementing its complex interventions. Moreover, the theoretical and conceptual framework of the project is described together with its organisational structure, concrete activities, and sustainability measures. The paper discusses some of the key lessons learned related to participatory development and the implementation of a multi-component intervention. The paper concludes that coordinated and integrated health promotion activities that are implemented together with multiple stakeholders and across multiple settings in the local community are much more powerful than individual activities carried out in single settings. The supersetting approach was a useful conceptual framework for developing and implementing a complex multi-component health promotion intervention and for fostering ownership and sustainability of the intervention in the local community. The research and evaluation approach of the project is described in a separate paper (Part 2).

Treatment of adult patients with schizophrenia and complex mental health needs - A national clinical guideline.

BACKGROUND AND AIM: The Danish Health and Medicines Authority assembled a group of experts to develop a national clinical guideline for patients with schizophrenia and complex mental health needs. Within this context, ten explicit review questions were formulated, covering several identified key issues. METHODS: Systematic literature searches were performed stepwise for each review question to identify relevant guidelines, systematic reviews/meta-analyses, and randomized controlled trials. The quality of the body of evidence for each review question was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Clinical recommendations were developed on the basis of the evidence, assessment of the risk-benefit ratio, and perceived patient preferences. RESULTS: Based on the identified evidence, a guideline development group (GDG) recommended that the following interventions should be offered routinely: antipsychotic maintenance therapy, family intervention and assertive community treatment. The following interventions should be considered: long-acting injectable antipsychotics, neurocognitive training, social cognitive training, cognitive behavioural therapy for persistent positive and/or negative symptoms, and the combination of cognitive behavioural therapy and motivational interviewing for cannabis and/or central stimulant abuse. SSRI or SNRI add-on treatment for persistent negative symptoms should be used only cautiously. Where no evidence was available, the GDG agreed on a good practice recommendation. CONCLUSIONS: The implementation of this guideline in daily clinical practice can facilitate good treatment outcomes within the population of patients with schizophrenia and complex mental health needs. The guideline does not cover all available interventions and should be used in conjunction with other relevant guidelines.

Vitamin D supplementation for treatment of seasonal affective symptoms in healthcare professionals: a double-blind randomised placebo-controlled trial.

BACKGROUND: Low serum 25-hydroxyvitamin D levels (25(OH)D) have been associated with a higher likelihood of seasonal affective disorder (SAD) and poor mental well-being, yet firm evidence for either remains lacking. Thus, vitamin D supplementation may alleviate symptoms associated with SAD. METHODS: This study was a randomized, single-centre, double-blind, placebo-controlled trial including healthcare professionals employed in psychiatric and somatic hospitals. 3345 healthcare professionals were invited to participate, 50 participants were screened, and 34 were able to complete the study. The main inclusion criterion was 8 points or more on question no. 2 of the Seasonal Pattern Assessment Questionnaire (SPAQ-SAD). During a 3-month period, the participants received a daily dose of 70 µg vitamin D or placebo. The primary outcome was the sum of the self-reported questionnaire Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders (SIGH-SAD). The secondary outcome was World Health Organization-Five Well-Being Index (WHO-5) of the healthcare professionals during the winter period and the exploratory outcome measures were weight, waist circumference, blood pressure, absenteeism from work and 25(OH)D. RESULTS: There were no significant between-group differences in SIGH-SAD sums at 12 weeks (p = 0.7 (CI: - 3.27 to 4.81)). However, there was a significant improvement of primary SIGH-SAD over time from inclusion (autumn-winter) to the completion of the study (winter-spring) for all participants. The secondary and exploratory outcome measures were all insignificant between groups.The sums of the SIGH-SAD at 12 weeks were not significantly different [p = 0.701 (CI: 4.81-3.27)] between the groups. There was, however, a significant improvement in primary SIGH-SAD sums over time from inclusion (autumn-winter) to the completion of the study (winter-spring) in both groups. The secondary and explorative outcome measures were not significantly different between groups. CONCLUSIONS: There were no significant between-group differences in the primary (SIGH-SAD) and secondary (WH0-5) as well as the exploratory outcome measures (weight, waist circumference, blood pressure, absenteeism from work and 25(OH)D. Thus, the study failed to demonstrate an effect of vitamin D on SAD symptoms, but our findings may be limited by confounders. Furthermore, the study was underpowered and did not allow us to assess the ability of vitamin D to improve mood in those with low 25(OH)D. TRIAL REGISTRATION: ( http://www.clinicaltrials.gov registration number: NCT01462058).

A contemporary update on rates and management of toxicities of targeted therapies for metastatic renal cell carcinoma.

BACKGROUND: To provide an updated review of adverse events associated with sunitinib, pazopanib, bevacizumab, temsirolimus, axitinib, everolimus and sorafenib and their management. MATERIALS AND METHODS: We performed a PubMed and Cochrane-based review of side effects associated with the seven agents including product monographs to provide an outline of treatment measures aiming to reduce their toxicities. Subject and outcome of interest, design type, sample size, pertinence and quality, and detail of reporting were the indicators of manuscript quality. RESULTS: All targeted therapies cause adverse events. Most adverse events may be prevented or tested before they escalate to severe levels. CONCLUSION: Prevention, early recognition, and prompt management of side effects are of key importance and avoid unnecessary dose reductions, which may undermine treatment efficacy.

Blood transfusions in radical prostatectomy: a contemporary population-based analysis.

OBJECTIVE: To examine the homologous blood transfusion (HBT), autologous blood transfusion (ABT) and intraoperative blood conservation technique (IOBCT) rates and trends at open (ORP) and minimally invasive radical prostatectomy (MIRP). METHODS: The Nationwide Inpatient Sample was queried. Multivariable logistic regression models focused on all three transfusion types. Covariables consisted of procedure specific annual hospital caseload (AHC), year of surgery, age, Charlson Comorbidity Index, and region. RESULTS: Overall, 119,966 patients underwent radical prostatectomy between 1998 and 2007. The HBT, ABT, and IOBCT rates were 6.2%, 6.0%, and 1.2%, respectively. HBT rates ranged from 5.1-5.1% between 1998 and 2007 (P=.49) vs 9.4-2.7% (P<.001) for ABT vs 1.9-0.9% (P=.003) for IOBCT in the same time period, respectively. In multivariable analyses, ORP patients treated at intermediate (odds ratio [OR] 1.48, P=.003) and low (OR 2.73, P<.001) AHC institutions were more likely to receive an HBT than ORP patients treated at high AHC institutions. Conversely, MIRP patients treated at high (OR 0.46, P=.040), intermediate (OR 0.27, P=.001), and low (OR 0.59, P=.015) AHC institutions were less likely to receive an HBT than ORP patients treated at high AHC institutions. CONCLUSION: Our results indicate that the overall transfusion rate at radical prostatectomy decreased within the last decade because of a substantial decline in ABT use. Moreover, MIRP protects from HBT, even when performed at low AHC Centers.

Genetic analysis of Phytophthora infestans populations in the Nordic European countries reveals high genetic variability.

Late blight, caused by the oomycete Phytophthora infestans, is the most important disease of potato (Solanum tuberosum). The pathogen is highly adaptable and to get an overview of the genetic variation in the Nordic countries, Denmark, Finland, Norway and Sweden we have analyzed 200 isolates from different fields using nine simple-sequence repeat (SSR) markers. Forty-nine alleles were detected among the nine SSR loci and isolates from all four Nordic countries shared the most common alleles across the loci. In total 169 multilocus genotypes (based on seven loci) were identified among 191 isolates. The genotypic diversities, quantified by a normalized Shannon's diversity index (H(s)), were 0.95 for the four Nordic countries. The low F(ST) value of 0.04 indicates that the majority of variation is found within the four Nordic countries. The large number of genotypes and the frequency distribution of mating types (60% A1) support the hypothesis that sexual reproduction is contributing notably to the genetic variation of P. infestans in the Nordic countries.

Regime shift in a coastal marine ecosystem.

We demonstrate changes in ecosystem stable states in a coastal lagoon that are consistent with what a regime shift would hypothesize. In the nutrient-stressed Ringkøbing Fjord, Denmark, a small change in one variable (salinity) facilitated by a change in sluice management, caused a sudden regime shift from a bottom-up controlled turbid state, into a top-down controlled clear-water state. The change in dominating pathway of organic matter production from pelagic turnover to benthic-pelagic coupling was facilitated by new recruitment and growth of existing suspension-feeding clams, Mya arenaria. With the invasion of clams, benthic grazing became the key feature of the biological structure. Phytoplankton composition and zooplankton abundance were also affected by the change in biological structure. The small, but sudden, increase in salinity caused by the change in sluice management led to a dramatic reduction in biomass and coverage of benthic vegetation and thus affected herbivorous waterbird populations. In recent years, plant coverage has been increasing, as can be expected with increased water transparency. The regime shift has some major implications for coastal water management and revealed some conflicts between different types of nature and environmental protection legislation.

Traditional Bhutanese medicine (gSo-BA Rig-PA): an integrated part of the formal health care services.

Traditional medicine in Bhutan is known as gSo-ba Rig-pa and is one of the oldest surviving medical traditions in the world. Other medical systems, such as Chinese medicine, Indian Ayurvedic medicine, Unani medicine, Greco-Roman medicine and the country's rich cultures and traditions have greatly influenced the way traditional Bhutanese medicine evolved. However, Buddhist philosophy remains the mainstream of this medical system. gSo-ba Rig-pa's principles are based on the perception the human body is composed of three main elements: rLung ('Air'), mKhris-pa ('Bile') and Bad-kan ('Phlegm'). When these three elements are balanced in the body a person is said to be healthy. The pathophysiology is also different from other medical systems, and the close link to Buddhism is reflected in the spiritual dimensions and the perception that all suffering is caused by ignorance. The treatment of diseases includes behavioral modification, physiotherapy, herbal medicines, minor surgery and spiritual healing. This makes the traditional Bhutanese medicine a unique and holistic health care system. The traditional medicine is an integrated and recognized part of the formal health care services in Bhutan under the auspices of the Ministry of Health. The article highlights three main points which can be learned from the Bhutanese experience: (1) the strong tradition of herbal medicines within gSo-ba Rig-pa forms a unique opportunity to prospect for new leads for development of pharmaceuticals, (2) the availability of the traditional medicine along with biomedicine broadens the health care choices for patients, and (3) the experiences of integrating two conceptually very different health care systems within one ministry contains important managerial lessons to be learned.

Human accumulation of mercury in Greenland.

In the Arctic, the traditional diet exposes its people to a high intake of mercury especially from marine mammals. To determine whether the mercury is accumulated in humans, we analyzed autopsy samples of liver, kidney and spleen from adult ethnic Greenlanders who died between 1990 and 1994 from a wide range of causes, natural and violent. Liver, kidney and spleen samples from between 33 and 71 case subjects were analyzed for total mercury and methylmercury, and liver samples also for selenium. Metal levels in men and women did not differ and were not related to age except in one case, i.e. for total mercury in liver, where a significant declining concentration with age was observed. The highest total mercury levels were found in kidney followed by liver and spleen. Methylmercury followed the same pattern, but levels were much lower, constituting only 19% of the total mercury concentration in liver and spleen and as little as 3% in kidney. In liver selenium was found in surplus to mercury on a molar basis. Mercury concentrations in the liver and kidneys of Greenlanders were elevated compared to levels in the general population in Japan, Korea and several European countries, except in the Faroe Islands where mercury levels were 2-3 times higher. This is in accordance with the expected exposure of mercury in the diet.

Entomophagy among the Luo of Kenya: a potential mineral source?

Primary objective To determine the iron, zinc, and calcium content in different insects commonly eaten among the Luo of Kenya. Research design A cross-sectional design was chosen for the study in order to determine the insects eaten and their mineral content during a specific season.Methods and procedures Five different insect species were identified and collected with the help of local informants in the Nyang'oma sublocation of the Bondo district in western Kenya, and were analysed for iron, zinc and calcium contents. Main outcomes and results The iron content ranged from 18 to 1562 mg/100 g dry matter, the zinc content from 8 to 25 mg/100 g, and the calcium content from 33 to 341 mg/100 g in five different insects, onyoso mammon (ant), oyala (termite), ogawo (termite), agaor (termite), onjiri mammon (cricket). Conclusions Insect eating could prove to be a valuable measure to combat, especially, iron and zinc deficiency in developing countries.

Selenium status in Greenland Inuit.

In Greenland, the human intake of selenium has always been relatively high and is closely connected to intake of the traditional food of marine origin. Analyses of historic and present day human and animal hair samples have indicated that the selenium level in the marine environment has been constant over time, while the levels in humans have declined corresponding to a decrease in intake of traditional food. The Inuit population in Greenland is in dietary transition where western-style food will increasingly dominate. As a consequence, the ample supply of selenium may not be sustained in the future. We report here the selenium status in three Greenlandic population groups, Ittoqqortoormiit and Tasiilaq on the east coast and Uummannaq on the west coast. Mean whole blood concentrations ranged from 178 microg/l in Tasiilaq men to 488 microg/l in Uummannaq men. Plasma concentrations ranged from 79 microg/l in Tasiilaq women to 113 microg/l in Uummannaq men. With increasing Se concentrations in whole blood, the plasma concentrations increased but tended to stabilise a level approximately 140 microg/l. Selenium blood levels were highly significantly correlated with long chain marine fatty acids. Dietary survey and food composition data from the west coast showed that whale skin, muktuk, is the main source of Se followed by birds, seal meat and organs, and fish. Terrestrial animals contributed only insignificantly to the selenium intake. In West Greenland, daily Se intake (235 microg/day) was estimated by dietary survey; it corresponded well with a calculated intake (220 microg/day) based on the mean blood concentration.

Elements in autopsy liver tissue samples from Greenlandic Inuit and Danes. V. Selenium measured by X-ray fluorescence spectrometry.

The content of selenium in normal liver tissue samples from Greenlandic Inuit was measured and the results compared with those obtained in normal liver tissue samples from Danes. Normal liver tissue samples were obtained at autopsy from 50 Greenlandic Inuit (27 men, 23 women) with a median age of 61 years (range 23-83) and from 74 Danes (44 men, 30 women) with a median age of 60 years (range 15-87). Total liver selenium content was measured by X-ray fluorescence spectrometry. The content of selenium (median) was in Inuit 26.6 micromol/kg dry liver (5-95 percentile: 15.2-49.4) and in Danes 17.7 micromol/kg dry liver (5-95 percentile: < 3.8-36.5) (p < 0.0001). Liver selenium content displayed no significant gender difference, either in Inuit or Danes. In Inuit men, there was a negative correlation between liver selenium content and age (rs = -0.39, p < 0.05), whereas Danish men displayed a positive correlation between liver selenium content and age (rs = 0.37, p = 0.02). There was no correlation in Inuit or Danish women. In Inuit, the median hepatic selenium index (liver selenium content divided by age) was 0.48 and in Danes 0.33 (p = 0.001). There was an inverse correlation between hepatic selenium index and age both in Inuit (rs = -0.77, p < 0.0001) and in Danes (rs = -0.47, p < 0.0001). In conclusion, Inuit had a higher liver content of selenium and a higher hepatic selenium index compared with Danes. The more favourable selenium status is due to a higher nutritional selenium intake with fish and meat from sea mammals.