Risk of leukaemia or cancer in the central nervous system among children living in an area with high indoor radon concentrations: results from a cohort study in Norway.

BACKGROUND: Over the past few years, there has been growing interest in assessing the relationship between exposure to radon at home and the risk of childhood cancer. Previous studies have produced conflicting results, probably because of limitations assessing radon exposure, too few cancer cases and poorly documented health statistics. METHODS: We used a cohort approach of 0-15-year-old children to examine whether residential radon exposure was associated with childhood leukaemia and cancer in the central nervous system in the Oslo region. The study was based on Norwegian population registers and identified cancer cases from The Cancer Registry of Norway. The residence of every child was geo-coded and assigned a radon exposure. RESULTS: In all, 712 674 children were followed from 1967 to 2009 from birth to date of cancer diagnosis, death, emigration or 15 years of age. A total of 864 cancer cases were identified, 437 children got leukaemia and 427 got cancer in the central nervous system.Conclusions or interpretation:No association was found for childhood leukaemia. An elevated nonsignificant risk for cancer in the central nervous system was observed. This association should be interpreted with caution owing to the crude exposure assessment and possibilities of confounding.

Take action to prevent diabetes--the IMAGE toolkit for the prevention of type 2 diabetes in Europe.

When we ask people what they value most, health is usually top of the list. While effective care is available for many chronic diseases, the fact remains that for the patient, the tax payer and the whole of society: prevention is better than cure. Diabetes and its complications are a serious threat to the survival and well-being of an increasing number of people. It is predicted that one in ten Europeans aged 20-79 will have developed diabetes by 2030. Once a disease of old age, diabetes is now common among adults of all ages and is beginning to affect adolescents and even children. Diabetes accounts for up to 18 % of total healthcare expenditure in Europe. The good news is that diabetes is preventable. Compelling evidence shows that the onset of diabetes can be prevented or delayed greatly in individuals at high risk (people with impaired glucose regulation). Clinical research has shown a reduction in risk of developing diabetes of over 50 % following relatively modest changes in lifestyle that include adopting a healthy diet, increasing physical activity, and maintaining a healthy body weight. These results have since been reproduced in real-world prevention programmes. Even a delay of a few years in the progression to diabetes is expected to reduce diabetes-related complications, such as heart, kidney and eye disease and, consequently, to reduce the cost to society. A comprehensive approach to diabetes prevention should combine population based primary prevention with programmes targeted at those who are at high risk. This approach should take account of the local circumstances and diversity within modern society (e.g. social inequalities). The challenge goes beyond the healthcare system. We need to encourage collaboration across many different sectors: education providers, non-governmental organisations, the food industry, the media, urban planners and politicians all have a very important role to play. Small changes in lifestyle will bring big changes in health. Through joint efforts, more people will be reached. The time to act is now.

A European evidence-based guideline for the prevention of type 2 diabetes.

BACKGROUND: The prevalence and socioeconomic burden of type 2 diabetes (T2DM) and associated co-morbidities are rising worldwide. AIMS: This guideline provides evidence-based recommendations for preventing T2DM. METHODS: A European multidisciplinary consortium systematically reviewed the evidence on the effectiveness of screening and interventions for T2DM prevention using SIGN criteria. RESULTS: Obesity and sedentary lifestyle are the main modifiable risk factors. Age and ethnicity are non-modifiable risk factors. Case-finding should follow a step-wise procedure using risk questionnaires and oral glucose tolerance testing. Persons with impaired glucose tolerance and/or fasting glucose are at high-risk and should be prioritized for intensive intervention. Interventions supporting lifestyle changes delay the onset of T2DM in high-risk adults (number-needed-to-treat: 6.4 over 1.8-4.6 years). These should be supported by inter-sectoral strategies that create health promoting environments. Sustained body weight reduction by >or= 5 % lowers risk. Currently metformin, acarbose and orlistat can be considered as second-line prevention options. The population approach should use organized measures to raise awareness and change lifestyle with specific approaches for adolescents, minorities and disadvantaged people. Interventions promoting lifestyle changes are more effective if they target both diet and physical activity, mobilize social support, involve the planned use of established behaviour change techniques, and provide frequent contacts. Cost-effectiveness analysis should take a societal perspective. CONCLUSIONS: Prevention using lifestyle modifications in high-risk individuals is cost-effective and should be embedded in evaluated models of care. Effective prevention plans are predicated upon sustained government initiatives comprising advocacy, community support, fiscal and legislative changes, private sector engagement and continuous media communication.

Quality indicators for the prevention of type 2 diabetes in Europe--IMAGE.

BACKGROUND: The marked increase of type 2 diabetes necessitates active development and implementation of efficient prevention programs. A European level action has been taken by launching the IMAGE project to unify and improve the various prevention management concepts, which currently exist within the EU. This report describes the background and the methods used in the development of the IMAGE project quality indicators for diabetes primary prevention programs. It is targeted to the persons responsible for diabetes prevention at different levels of the health care systems. METHODS: Development of the quality indicators was conducted by a group of specialists representing different professional groups from several European countries. Indicators and measurement recommendations were produced by the expert group in consensus meetings and further developed by combining evidence and expert opinion. RESULTS: The quality indicators were developed for different prevention strategies: population level prevention strategy, screening for high risk, and high risk prevention strategy. Totally, 22 quality indicators were generated. They constitute the minimum level of quality assurance recommended for diabetes prevention programs. In addition, 20 scientific evaluation indicators with measurement standards were produced. These micro level indicators describe measurements, which should be used if evaluation, reporting, and scientific analysis are planned. CONCLUSIONS: We hope that these quality tools together with the IMAGE guidelines will provide a useful tool for improving the quality of diabetes prevention in Europe and make different prevention approaches comparable.

Life course influence of residential area on cause-specific mortality.

OBJECTIVE: To examine the relative influence of area of residence on mortality risk along the life course in different age groups and to see if this differs for causes known to be related differently to various models of the life course. METHODS: Individual data from the Censuses in 1960, 1970, 1980 and 1990 from Oslo, Norway, were linked to the death register 1990-1998. All male inhabitants living in Oslo in 1990 aged 30-69 years who had lived in Oslo at the three previous Censuses were included. RESULTS: In the youngest age group, area of residence closest to the time of death is most important for violent and psychiatric causes. In older age groups, area of residence at all time points in the period studied seemed to have a similar influence. Cardiovascular deaths were related to earlier as well as later area of residence in both young and old age groups. For violent and psychiatric causes, the most recent area may be the most important. CONCLUSION: This paper explores a research strategy to investigate how the area of residence through the life course influences mortality. The associations seem to vary according to age at, and cause of, death.

Prevention of type 2 diabetes: a review.

One of the major public health challenges of the 21st century is type 2 diabetes. WHO estimates that by 2025 as many as 200-300 million people worldwide will have developed the disease. A distressing increase in children is perhaps the most alarming sign of something going wrong. Roughly half of the risk of type 2 diabetes can be attributed to environmental exposure and the other half to genetics. Central themes for prevention are the risk factors overweight, sedentary lifestyle, certain dietary components and perinatal factors. Overweight is the most critical risk factor, and should be targeted for prevention of type 2 diabetes especially among children and youths. Ethnicity and perinatal factors are also worth considering. Today we know that prevention helps. In the US Diabetes Prevention Programme for high risk individuals, there was a 58% relative reduction in the progression to diabetes in the lifestyle group compared with the controls. Within the lifestyle group, 50% achieved the goal of more than 7% weight reduction, and 74% maintained at least 150 min of moderately intense activity each week. This review discusses different forms of prevention, and proposes first of all to target people with Impaired Glucose Tolerance with increasing activity and altering dietary factors. And secondly, population-based measures to encourage increased physical activity and decreased consumption of energy-dense foods are important, and may target school children and young people, certain ethnic groups and women with gestational diabetes.

Evaluation of memory dysfunction following experimental brain injury using the Morris water maze.

Memory dysfunction, a common clinical feature of traumatic brain injury (TBI), is thought to be related to secondary damage of key anatomic structures in the brain, including the hippocampus. In the present study, we have characterized and evaluated a novel experimental paradigm using the Morris water maze (MWM) technique, to measure post-TBI memory retention after lateral (parasagittal) fluid percussion (FP) brain injury in rats. Male Sprague-Dawley rats (n = 37) received a total of 20 training trials over 2 days in the MWM. Two and a half hours after the last training trial, the animals received FP brain injury of moderate severity (2.3 atmospheres, n = 12), high severity (2.6 atm, n = 13), or no injury (n = 12). Forty-two hours after FP brain injury, we observed a highly sufficient memory dysfunction in animals from both injury groups compared to the uninjured group (p less than 0.001). The degree of memory dysfunction was found to be directly related to the severity of injury, with the high severity group scoring significantly worse than the moderately injured group (p = 0.15). In addition, hippocampal cell loss was observed after brain injury, but only unilaterally. These data suggest that lateral FP brain injury causes memory dysfunction possibly related to concurrent hippocampal cell loss and that posttraumatic memory deficits may be sensitively quantitated using the memory testing paradigm described.

Alcohol disorders and re-employment in a 5-year follow-up of long-term unemployed.

AIMS: To establish whether the high prevalence of alcohol abuse among unemployed people is explained by alcohol abuse causing unemployment, or vice versa. DESIGN: A 5-year postal follow-up survey of a community sample of unemployed from Grenland, southern Norway. PARTICIPANTS: Two hundred and twenty-eight unemployed people, registered for more than 12 weeks, aged 16 to 63 years. Response rate 74%. MEASUREMENTS: The Alcohol Use Disorder Identification Test (AUDIT) and DSM-III diagnoses of alcohol disorders in medical examinations. FINDINGS: At the 5-year follow up, 23% of those still unemployed and 12% of those re-employed scored higher than the AUDIT cut-point of 10. Re-employment reduced the chance of scoring positive on the AUDIT to 34% of the chance for those still unemployed. Significant selection to long-term unemployment according to AUDIT score was not demonstrated. None of the 7% who had a DSM-III diagnosis of an alcohol disorder had a job 5 years later, however, suggesting that alcohol-related selection to unemployment does occur. CONCLUSION: The high prevalence of harmful drinking among Norwegian unemployed is explained mainly by unemployment causing alcohol abuse rather than vice versa. Reducing unemployment should contribute to reduced alcohol problems in Norway.

The Alcohol Use Disorders Identification Test (AUDIT) in a routine health examination of long-term unemployed.

A representative sample of 310 long-term unemployed in Norway was followed for 2 years with clinical examinations and the AUDIT questionnaire. 30% of the men and 8% of the women scored over the cut-off point for an alcohol use disorder. This gives a probable prevalence of 16%. The test predicted return to employment in this sample. The AUDIT answers were also used as a basis for dividing into three groups: 'normal', 'hazardous' and 'harmful'. At 2 year follow-up, 27% had changed group, 32 respondents to the worse and 24 to the better. This 'unstable' group was characterized by weaker social network and more frequent drinking. The AUDIT was judged as a useful instrument both in a routine health examination and as an epidemiological tool.

Health and re-employment in a two year follow up of long term unemployed.

STUDY OBJECTIVE: The aim was to examine re-employment and changes in health during a two year follow up of a representative sample of long term unemployed. DESIGN: This was a cross sectional study and a two year follow up. Health was measured by psychometric testing, Hopkins symptom checklist, General health questionnaire, and medical examination. Health related selection to continuous unemployment and recovery by re-employment was estimated by logistic regression with covariances deduced from the labour market theories of human capital and segmented labour market. SETTING: Four municipalities in Greenland, southern Norway. SUBJECTS: Participants were a random sample of 17 to 63 year old people registered as unemployed for more than 12 weeks. MAIN RESULTS: In the cross sectional study, the prevalence of depression, anxiety, and somatic illness was from four to 10 times higher than in a control group of employed people. In the follow up study, there was considerable health related selection to re-employment. A psychiatric diagnosis was associated with a 70% reduction in chances of obtaining a job. Normal performance on psychometric testing showed a two to three times increased chance of re-employment. Recovery of health following re-employment was less than expected from previous studies. CONCLUSIONS: Health related selection to long term unemployment seems to explain a substantial part of the excess mental morbidity among unemployed people. An increased proportion of the long term unemployed will be vocationally handicapped as years pass, putting a heavy burden on social services.

Impact of childhood and adulthood socioeconomic position on cause specific mortality: the Oslo Mortality Study.

OBJECTIVE: To study the impact of childhood and adulthood social circumstances on cause specific adult mortality. DESIGN: Census data on housing conditions from 1960 and Personal Register income data for 1990 were linked to 1990-94 death registrations, and relative indices of inequality were computed for housing conditions in 1960 and for household income in 1990. PARTICIPANTS: The 128 723 inhabitants in Oslo aged 31-50 years in 1990. MAIN RESULTS: Adulthood mortality was strongly associated with both childhood and adulthood social circumstances among both men and women. Cardiovascular disease mortality was more strongly associated with childhood than with adulthood social circumstances, while the opposite was found for psychiatric and accidental/violent mortality. Smoking related cancer mortality was related to both adulthood and childhood social circumstances in men, but considerably more strongly to adult social circumstances. CONCLUSIONS: Childhood social circumstances have an important influence on cardiovascular disease risk in adulthood. Current increases in child poverty that have been seen in Norway over the past two decades could herald unfavourable future trends in adult health.

Rehabilitation efforts before and after tightening eligibility for disability benefits in Norway.

This paper reports the use of vocational rehabilitation among applicants for disability benefits in Norway before and after the eligibility criteria were tightened in 1991. The data sources were documents of 668 applicants from 1990 and 1993 in two countries. Vocational rehabilitation is the preferred benefit in the National Insurance Act, and was a core issue in the restriction reform. Nevertheless, rehabilitation was tried by only 14% of the applicants in 1990, and by no more than 19% in 1993. Eight per cent of the applicants were referred to an employment officer before determination in 1990, and 14% in 1993. In order to study different pathways from work to applying for disability benefits, six types of 'social security careers' were constructed. The commonest comprised sick pay only, the second led through unemployment, and the third included rehabilitation. Rehabilitation may also be offered to applicants who are refused disability benefits. This was the alternative determination for 4% of the refused cases in 1990, a proportion that increased to 12% after the reform. The main reason for the relatively infrequent use of rehabilitation is probably the continuous downgrading over many years of resources and institutions for this task.

A clinical follow up of unemployed. I: Lifestyle, diagnoses, treatment and re-employment.

OBJECTIVE: To describe morbidity, lifestyle and re-employment in a representative sample of unemployed people. DESIGN: A two-year follow up of a routine health examination consisting of a structured interview, a clinical examination and the doctor's conclusions and advice. SETTING: Four municipalities in Greenland, southern Norway. PARTICIPANTS: A representative sample aged 16 to 63 who had been registered with the labour market authorities for more than 12 weeks. RESULTS: Self-reported diseases were more common in the study group than were found in employed people, especially musculoskeletal and mental disorders. The prevalence of medical diagnoses was high. Smoking was reported by nearly twice as many unemployed as the reference population. Heavy alcohol consumption was more prevalent in the unemployed men. Blood pressure was lower than in the reference population. Cholesterol was higher in the unemployed women. Many needed counselling or referrals. Having a medical diagnosis reduced the chances of re-employment two years later. Thus, health-related selection for re-employment seems to explain some of the excess morbidity among unemployed people. CONCLUSION: The long-term unemployed is a group with high morbidity and unhealthy lifestyle. General practitioners should be aware of this pattern in clinical and preventive work.

A clinical follow up of unemployed. II: Sociomedical evaluations as predictors of re-employment.

OBJECTIVE: To frame and study sociomedical evaluations in clinical work with unemployed people. DESIGN: In a two-year follow up of routine health examinations, three sociomedical evaluations were set up. The first was the direct conclusion of the check-up, based on sickness and possibilities of treatment. The second dealt with work identity, and the last was a diagnostic set of main unemployment problem. SETTING: The four municipalities of Grenland, Norway. PARTICIPANTS: A representative sample aged 16 to 63 who had been registered with the labour market authorities for more than 12 weeks. RESULTS: 21% of the unemployed needed further treatment. 7% were classified as "discouraged", being on their way out of the labour market, while the majority of the study group was healthy job seekers. Work identity seemed to be wage earning for 83%, homemaking for 9%, cultural work for 3%, and being a pensioner for 5%. The main unemployment problem was lack of work for 46% of the examined. Other problems were poor health, being less attractive workers, or having little courage for job search. The evaluations predicted re-employment after two years. They divided the unemployed in groups with from five to seven times difference in re-employment rate. CONCLUSION: These standardized sociomedical evaluations seen to be useful in clinical work with unemployed people.

[The physician's role in dealing with patients unemployed for a long time]. / Legeoppgaver overfor langtidsarbeidsløse.

When medical practitioners examine unemployed persons, important considerations are medical and social diagnoses, risk factors and a possible need for counselling. Certification of illness and applications for rehabilitation or a disability pension are ambiguous and difficult tasks in the Norwegian health insurance system. Important measures are better unemployment benefits, more activation of unemployed persons, better educational opportunities, more information on health and unemployment, and a special health maintenance programme for long-term unemployed.

[A health survey of persons unemployed for a long time in Greenland]. / En helseundersøkelse av lengre tids arbeidsløse i Grenland.

In 1988 a random sample of 310 unemployed aged 16 to 63 years who had been registered for more than 12 weeks and lived in the four municipalities of Greenland was examined by a doctor and a nurse. Self-reported health and psychometric tests produced higher prevalences of disease than in a reference population of employed persons. On the basis of both clinical examination and the testing, 22% of the unemployed, were judged to be depressed, as against 2% in the reference group. 17% of the unemployed were scored as "morbidly anxious" and 17% as psychosomatically sick, as against 2% and 4% of the references. The health and social services which the group had received were regarded as unsatisfactory, both by the doctor and by the unemployed themselves. A special health maintenance programme is proposed for long-term unemployed.

Suicidal ideation among the long-term unemployed: a 5-year follow-up.

Suicidal ideation was monitored in a 5-year follow-up of a representative sample of long-term unemployed Norwegians. Four items from the General Health Questionnaire-28 were used as a Suicidal Ideation Index, which showed a prevalence of 17% in the present sample of unemployed subjects, higher than the value of 11% in a sample of Australian students used to construct the Index. Five years later, suicidal ideation was found in 6% of those who had been re-employed and 22% of those still unemployed, indicating that the high prevalence of suicidal ideation may be due to unemployment. Routine clinical examination was also tried for preventive purposes. In total, 8% of the unemployed subjects showed clinically significant suicidal ideation. They were referred to a psychologist or their GP, and were given the standard advice about suicide prevention. A Resource Centre, which many employees at the Labour Office have missed, has now been set up in the area under the National Plan for Suicide Prevention.

Physicians as gatekeepers: will they contribute to restrict disability benefits?

OBJECTIVE: To study how general practitioners (GPs), specialists, and National Insurance Administration (NIA) medical consultants reacted to the narrowed eligibility criteria for disability benefits in Norway from 1991. DESIGN: Records of first-time applicants for disability benefits from the first quarters of 1990 and 1993 were analysed for proposals from the physicians in relation to the decision. SETTING: Two Norwegian counties, Ostfold and Møre and Romsdal. SUBJECTS: 668 applicants--half the granted cases, and all the refused ones. RESULTS: The number of applicants fell by 39% from 1990 to 1993 and the refusal frequency increased from 8 to 21%. Nevertheless, GPs recommended refusal to about the same extent as before, 8-9% of all cases, with probably a minor fall from 52 to 42% of the refused ones (p = 0.19). Specialists did not recommend more refusals than the GPs. Cases evaluated by the NIA medical consultants increased from 29 to 41%, and their concordance with the patients' GPs seemed to be approximately 50%. GPs did not give more detailed medical descriptions in 1993 than in 1990, and discussed eligibility criteria but slightly more comprehensively. CONCLUSION: GPs are willing to act as gatekeepers for social insurance benefits for their patients, also when eligibility criteria become restricted.

Restricting the influx of disability beneficiaries by means of law: experiences in Norway.

OBJECTIVES: To study effects of restricting eligibility criteria for disability pension in Norway 1991. METHODS: Documents of 288 applicants from 1990 and 1993 in one county were analysed for social and medical variables as well as for the determination and its causes. RESULTS: Incidence of applications for disability benefits during a three-month period was 223 per 100,000 inhabitants in 1990. The focused group of 'medically imprecise' musculoskeletal diagnoses concerned 26% of all applicants, while 'precise' musculoskeletal diagnoses were given to 15%, 'imprecise' psychiatric diagnoses to 7% and 'precise' ones to 6%. The number of applicants fell by 39%, surprisingly about the same in all social and diagnostic groups. Denial rate increased from 8% to 21%. Denials mostly struck women, middle-aged, those living alone, those with short education, and applicants with 'medically imprecise' diagnoses. CONCLUSIONS: Restriction of disability benefits affected applicants with the least resources the hardest, and seems to contribute to the on-going process of marginalizing the weaker part of the population.

Health and re-employment in a five-year follow-up of long-term unemployed.

OBJECTIVES: To study health and re-employment in a five-year follow-up of a community sample of long-term unemployed people. METHODS: A random sample registered for more than 12 weeks at the labour offices in Grenland, Norway, were given medical check-ups in 1988 and 1990, and a postal questionnaire in 1993. RESULTS: Only 37% were employed five years after the first spell of long-term unemployment. Recovery after re-employment was demonstrated, indicating that unemployment causes poor mental health. Health-related selection to continuous unemployment was only found for medical diagnoses. The unemployed who might be selected to continuous unemployment because of poor health at the two-year follow-up seemed to deteriorate most. CONCLUSION: The high morbidity of mental health problems among unemployed people is mostly explained by the causal hypothesis. This is a challenge to preventive medicine. Sick unemployed people should be given special attention.