Associations of dietary choline and betaine with all-cause mortality: a prospective study in a large Swedish cohort.

PURPOSE: Investigate the association between choline and betaine intake and all-cause mortality in a large Swedish cohort. METHODS: Women (52,246) and men (50,485) attending the Västerbotten Intervention Programme 1990-2016 were included. Cox proportional hazard regression models adjusted for energy intake, age, BMI, smoking, education, and physical activity were used to estimate mortality risk according to betaine, total choline, phosphatidylcholine, glycerophosphocholine, phosphocholine, sphingomyelin, and free choline intakes [continuous (per 50 mg increase) and in quintiles]. RESULTS: During a median follow-up of 16 years, 3088 and 4214 deaths were registered in women and men, respectively. Total choline intake was not associated with all-cause mortality in women (HR 1.01; 95% CI 0.97, 1.06; P = 0.61) or men (HR 1.01; 95% CI 0.98, 1.04; P = 0.54). Betaine intake was associated with decreased risk of all-cause mortality in women (HR 0.95; 95% CI 0.91, 0.98; P < 0.01) but not in men. Intake of free choline was negatively associated with risk of all-cause mortality in women (HR 0.98; 95% CI 0.96, 1.00; P = 0.01). No other associations were found between intake of the different choline compounds and all-cause mortality. In women aged ≥ 55 years, phosphatidylcholine intake was positively associated with all-cause mortality. In men with higher folate intake, total choline intake was positively associated with all-cause mortality. CONCLUSION: Overall, our results do not support that intake of total choline is associated with all-cause mortality. However, some associations were modified by age and with higher folate intake dependent on sex. Higher intake of betaine was associated with lower risk of all-cause mortality in women.

Toward a More Climate-Sustainable Diet: Possible Deleterious Impacts on Health When Diet Quality Is Ignored.

BACKGROUND: Nutritional quality, and health and climate impacts are important considerations in the design of sustainable diets. OBJECTIVES: To investigate the association between diets varying in nutrient density and climate impact and MI and stroke HRs. METHODS: Dietary data of 41,194 women and 39,141 men (35-65 y) who participated in a Swedish population-based cohort study were employed. Nutrient density was calculated using the Sweden-adapted Nutrient Rich Foods 11.3 index. Dietary climate impact was calculated with data from life cycle assessments, including greenhouse gas emissions from primary production to industry gate. HRs and 95% CIs for MI and stroke were assessed with multivariable Cox proportional hazards regression, comparing a least-desirable diet scenario reference group (lower nutrient density, higher climate impact) with three diet groups that varied with respect to higher/lower nutrient density and higher/lower climate impact. RESULTS: Median follow-up time from the baseline study visit to MI or stroke diagnosis was 15.7 y for women and 12.8 y for men. The MI hazard was significantly higher for the men with diets of lower nutrient density and lower climate impact (HR: 1.19; 95% CI: 1.06, 1.33; P = 0.004), compared with the reference group. No significant association with MI was observed for any of the diet groups of women. No significant association with stroke was observed among any of the diet groups of women or men. CONCLUSIONS: The results among men suggest some adverse health effects for men when diet quality is not considered in the pursuit of more climate-sustainable diets. For women, no significant associations were detected. The mechanism underlying this association for men needs further investigation.

Healthy Nordic diet and associations with plasma concentrations of metabolites in the choline oxidation pathway: a cross-sectional study from Northern Sweden.

BACKGROUND: The choline oxidation pathway and metabolites involved have been linked to diseases including cardiovascular disease, type 2 diabetes and cancer. A healthy Nordic diet is a recently defined dietary pattern associated with decreased risk for these diseases. Our aim was to explore associations between adherence to a healthy Nordic diet and plasma concentrations of metabolites of the choline oxidation pathway. METHODS: The Healthy Nordic Food Index (HNFI) and Baltic Sea Diet Score (BSDS) were applied to cross-sectional data (n = 969) from the Västerbotten Intervention Programme in Northern Sweden to score adherence to a healthy Nordic diet. Data included responses to a dietary questionnaire and blood sample analyses (1991-2008). Associations of diet scores with plasma concentrations of metabolites of the choline oxidation pathway and total homocysteine (tHcy), seven metabolites in total, were evaluated with linear regression, adjusting for age, BMI, education and physical activity. RESULTS: HNFI scores showed linear relationships with plasma choline (ß = 0.11), betaine (ß = 0.46), serine (ß = 0.98) and tHcy (ß = - 0.38), and BSDS scores with betaine (ß = 0.13) and tHcy (ß = - 0.13); unstandardized beta coefficients, all significant at P < 0.05. The regression models predicted changes in plasma metabolite concentrations (± 1 SD changes in diet score) in the range of 1-5% for choline, betaine, serine and tHcy. No other statistically significant associations were observed. CONCLUSIONS: A healthy Nordic diet was associated with plasma concentrations of several metabolites of the choline oxidation pathway. Although relationships were statistically significant, effect sizes were moderate. Further research is warranted to explore the underlying mechanisms and associations with health outcomes.

Adherence to the Swedish dietary guidelines and the impact on mortality and climate in a population-based cohort study.

OBJECTIVE: To assess the associations between adherence to the Swedish dietary guidelines and all-cause mortality (i.e. assessing the index' ability to predict health outcomes), as well as levels of dietary greenhouse gas emissions (GHGEs). DESIGN: A longitudinal study 1990-2016 within the population-based cohort Västerbotten Intervention Programme. Dietary data were based on FFQs. Diet quality was assessed by the Swedish Healthy Eating Index for Adults 2015 (SHEIA15), based on the 2015 Swedish dietary guidelines. Dietary GHGEs were estimated from life cycle assessment data including emissions from farm to industry gate. Hazard ratios (HR) and 95 % CI of all-cause mortality were evaluated with Cox proportional hazards regression, and differences in median GHGEs were tested between quintiles of SHEIA15 score using the Kruskal-Wallis one-way ANOVA test. SETTING: Northern Sweden. PARTICIPANTS: In total, 49 124 women and 47 651 men, aged 35-65 years. RESULTS: Median follow-up times were 16·0 years for women and 14·7 years for men, during which time 3074 women and 4212 men died. A consistent trend of lower all-cause mortality HR for both sexes with higher SHEIA15 scores was demonstrated. For women, the all-cause mortality HR was 0·81 ((95 % CI 0·71, 0·92); P = 0·001) and for men 0·90 ((95 % CI 0·81, 0·996); P = 0·041) between the quintile with the highest SHEIA15 score compared with the quintile with the lowest SHEIA15 score. A consistent trend of lower estimated dietary GHGEs among both sexes with higher SHEIA15 scores was also found. CONCLUSIONS: Adherence to Swedish dietary guidelines, estimated by SHEIA15, seems to promote longevity and reduce dietary climate impact.

Effects of a palaeolithic diet on obstructive sleep apnoea occurring in females who are overweight after menopause-a randomised controlled trial.

BACKGROUND/OBJECTIVES: Obesity is the main risk factor for obstructive sleep apnoea, commonly occurring in females who are overweight after menopause. We aimed to study the effect of a palaeolithic diet on sleep apnoea in females with overweight after menopause from the population. METHODS: Seventy healthy, non-smoking females with a mean age of 60 years and a mean BMI of 33 kg/m2 were randomised to a palaeolithic diet or to a control low-fat diet according to Nordic Nutritional Recommendations, for 2 years. The apnoea-hypopnoea index was measured and daytime sleepiness was estimated during the intervention. RESULTS: The mean apnoea-hypopnoea index at baseline was 11.6 (95% CI 8.6-14.5). The mean weight loss was 7.2 kg (95% CI 5.3-9.2 kg) in the palaeolithic diet group and 3.9 kg in the control group (95% CI 1.9-5.9 kg); p < 0.021 for the group difference. The reduction in weight corresponded to a reduction in the apnoea-hypopnoea index in the palaeolithic diet group (r = 0.38, p = 0.034) but not in the control group (r = 0.08, p = 0.69). The apnoea-hypopnoea index was reduced in the palaeolithic diet group when the weight was reduced by more than 8 kg. Daytime sleepiness according to the Epworth Sleepiness Scale score and the Karolinska Sleepiness Scale score was unaffected by dietary group allocation. CONCLUSIONS: A substantial decrease in body weight of 8 kg was needed to achieve a reduction in sleep apnoea in this small trial of women who are overweight after menopause. The palaeolithic diet was more effective for weight reduction than a control low-fat diet and the reduction in sleep apnoea was related to the degree of weight decrement within this diet group. TRIAL REGISTRATION: Clinicaltrials.gov: NCT00692536.

Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial.

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention. METHODS: Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) is a pragmatic, open-label, randomised controlled trial that was integrated within the Västerbotten Intervention Programme, an ongoing population-based cardiovascular disease prevention programme in northern Sweden. Individuals aged 40, 50, or 60 years with one or more conventional risk factors were eligible to participate. Participants underwent clinical examination, blood sampling, and ultrasound assessment of carotid intima media wall thickness and plaque formation. Participants were randomly assigned 1:1 with a computer-generated randomisation list to an intervention group (pictorial representation of carotid ultrasound plus a nurse phone call to confirm understanding) or a control group (not informed). The primary outcomes, Framingham risk score (FRS) and European systematic coronary risk evaluation (SCORE), were assessed after 1 year among participants who were followed up. This study is registered with ClinicalTrials.gov, number NCT01849575. FINDINGS: 3532 individuals were enrolled between April 29, 2013, and June 7, 2016, of which 1783 were randomly assigned to the control group and 1749 were assigned to the intervention group. 3175 participants completed the 1-year follow-up. At the 1-year follow-up, FRS and SCORE differed significantly between groups (FRS 1·07 [95% CI 0·11 to 2·03, p=0·0017] and SCORE 0·16 [0·02 to 0·30, p=0·0010]). FRS decreased from baseline to the 1-year follow-up in the intervention group and increased in the control group (-0·58 [95% CI -0·86 to -0·30] vs 0·35 [0·08 to 0·63]). SCORE increased in both groups (0·13 [95% CI 0·09 to 0·18] vs 0·27 [0·23 to 0·30]). INTERPRETATION: This study provides evidence of the contributory role of pictorial presentation of silent atherosclerosis for prevention of cardiovascular disease. It supports further development of methods to reduce the major problem of low adherence to medication and lifestyle modification. FUNDING: Västerbotten County Council, the Swedish Research Council, the Heart and Lung Foundation, the Swedish Society of Medicine, and Carl Bennet Ltd, Sweden.

Changes in food intake patterns during 2000-2007 and 2008-2016 in the population-based Northern Sweden Diet Database.

BACKGROUND: Food intake patterns provide a summary of dietary intake. Few studies have examined trends in food intake patterns over time in large, population-based studies. We examined food intake patterns and related sociodemographic and individual characteristics in the large Northern Sweden Diet Database during the two time windows 2000-2007 and 2008-2016. METHODS: In total, 100 507 participants (51% women) who had filled in a 64-item food frequency questionnaire and provided background and sociodemographic data between 2000 and 2016 were included. Food intake patterns were evaluated for women and men separately for the two time windows 2000-2007 and 2008-2016, respectively. Latent class analysis was used to identify distinct, latent clusters based on 40 food groups. RESULTS: Among both women and men, a greater proportion of participants were classified into food intake patterns characterized by high-fat spread and high-fat dairy during 2008-2016 compared to 2000-2007. In the earlier time window, these high-fat clusters were related to lower educational level and smoking. Simultaneously, the proportion of women and men classified into a cluster characterized by high intake of fruit, vegetables, and fibre decreased from the earlier to the later time window. CONCLUSION: From a public health perspective, the increase in clusters with a high conditional mean for high-fat spread and high-fat dairy and decrease in clusters with a high conditional mean for fruit and vegetables, during the time period 2008-2016 compared to 2000-2007, is worrisome as it indicates a shift away from the recommended food habits. Subgroups of women and men with less healthy dietary patterns in the time window 2008-2016 with lower education, lower age, higher body mass index, lower levels of physical activity and more smoking were identified and future interventions may be targeted towards these groups.

Climate impact from diet in relation to background and sociodemographic characteristics in the Västerbotten Intervention Programme.

OBJECTIVE: The objective of this study was to examine climate impact from diet across background and sociodemographic characteristics in a population-based cohort in northern Sweden. DESIGN: A cross-sectional study within the Västerbotten Intervention Programme. Dietary data from a 64-item food frequency questionnaire collected during 1996-2016 were used. Energy-adjusted greenhouse gas emissions (GHGE) for all participants, expressed as kg carbon dioxide equivalents/day and 4184 kJ (1000 kcal), were estimated using data from life cycle analyses. Differences in background and sociodemographic characteristics were examined between participants with low and high GHGE from diet, respectively. The variables evaluated were age, BMI, physical activity, marital status, level of education, smoking, and residence. SETTING: Västerbotten county in northern Sweden. PARTICIPANTS: In total, 46 893 women and 45 766 men aged 29-65 years. RESULTS: Differences in GHGE from diet were found across the majority of examined variables. The strongest associations were found between GHGE from diet and age, BMI, education, and residence (all P < 0·001), with the highest GHGE from diet found among women and men who were younger, had a higher BMI, higher educational level, and lived in urban areas. CONCLUSIONS: This study is one of the first to examine climate impact from diet across background and sociodemographic characteristics. The results show that climate impact from diet is associated with age, BMI, residence and educational level amongst men and women in Västerbotten, Sweden. These results define potential target populations where public health interventions addressing a move towards more climate-friendly food choices and reduced climate impact from diet could be most effective.

Occupational stress is associated with major long-term weight gain in a Swedish population-based cohort.

PURPOSE: Occupational stress and obesity are both increasing in prevalence, but prospective findings relating these conditions are inconsistent. We investigated if baseline as well as prolonged exposure to high job demands and low decision latitude were associated with major weight gain (≥ 10% of baseline weight) in 3872 Swedish women and men examined three times over 20 years in the population-based Västerbotten Intervention Program. METHODS: Anthropometry was measured and participants completed questionnaires on job strain, diet, and other lifestyle factors. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI), adjusting for confounders. RESULTS: Adjusting for age, baseline low decision latitude was associated with major weight gain over 10- and 20-year OR (95% CI) 1.16 (1.00-1.33) and 1.29 (1.13-1.47), respectively (both sexes combined). After adjustment for diet quality and other confounders, the effect over 20 years remained 1.30 (1.13-1.50). Sex modified the effect of prolonged exposure to high job demands over at least 10 years (interaction p = 0.02), showing that high job demands was a risk factor of major weight gain over 20 years in women [1.54 (1.14-2.07)], but not in men [0.87 (0.63-1.19)]. Neither diet nor other lifestyle factors explained these associations. CONCLUSIONS: In conclusion, low decision latitude predicted major weight gain in women and men. In women, the results suggest an additional contribution to major weight gain from high job demands.

Coffee consumption and risk of rare cancers in Scandinavian countries.

Studies on the association between heavy coffee consumption and risk of less frequently diagnosed cancers are scarce. We aimed to quantify the association between filtered, boiled, and total coffee consumption and the risk of bladder, esophageal, kidney, pancreatic, and stomach cancers. We used data from the Norwegian Women and Cancer Study and the Northern Sweden Health and Disease Study. Information on coffee consumption was available for 193,439 participants. We used multivariable Cox proportional hazards models to calculate hazard ratios (HR) with 95% confidence intervals (CI) for the investigated cancer sites by category of total, filtered, and boiled coffee consumption. Heavy filtered coffee consumers (≥ 4 cups/day) had a multivariable adjusted HR of 0.74 of being diagnosed with pancreatic cancer (95% CI 0.57-0.95) when compared with light filtered coffee consumers (≤ 1 cup/day). We did not observe significant associations between total or boiled coffee consumption and any of the investigated cancer sites, neither in the entire study sample nor in analyses stratified by sex. We found an increased risk of bladder cancer among never smokers who were heavy filtered or total coffee consumers, and an increased risk of stomach cancer in never smokers who were heavy boiled coffee consumers. Our data suggest that increased filtered coffee consumption might reduce the risk of pancreatic cancer. We did not find evidence of an association between coffee consumption and the risk of esophageal or kidney cancer. The increased risk of bladder and stomach cancer was confined to never smokers.

Decreased lipogenesis-promoting factors in adipose tissue in postmenopausal women with overweight on a Paleolithic-type diet.

PURPOSE: We studied effects of diet-induced postmenopausal weight loss on gene expression and activity of proteins involved in lipogenesis and lipolysis in adipose tissue. METHODS: Fifty-eight postmenopausal women with overweight (BMI 32.5 ± 5.5) were randomized to eat an ad libitum Paleolithic-type diet (PD) aiming for a high intake of protein and unsaturated fatty acids or a prudent control diet (CD) for 24 months. Anthropometry, plasma adipokines, gene expression of proteins involved in fat metabolism in subcutaneous adipose tissue (SAT) and lipoprotein lipase (LPL) activity and mass in SAT were measured at baseline and after 6 months. LPL mass and activity were also measured after 24 months. RESULTS: The PD led to improved insulin sensitivity (P < 0.01) and decreased circulating triglycerides (P < 0.001), lipogenesis-related factors, including LPL mRNA (P < 0.05), mass (P < 0.01), and activity (P < 0.001); as well as gene expressions of CD36 (P < 0.05), fatty acid synthase, FAS (P < 0.001) and diglyceride acyltransferase 2, DGAT2 (P < 0.001). The LPL activity (P < 0.05) and gene expression of DGAT2 (P < 0.05) and FAS (P < 0.05) were significantly lowered in the PD group versus the CD group at 6 months and the LPL activity (P < 0.05) remained significantly lowered in the PD group compared to the CD group at 24 months. CONCLUSIONS: Compared to the CD, the PD led to a more pronounced reduction of lipogenesis-promoting factors in SAT among postmenopausal women with overweight. This could have mediated the favorable metabolic effects of the PD on triglyceride levels and insulin sensitivity.

Dietary inflammatory index and risk of first myocardial infarction; a prospective population-based study.

BACKGROUND: Chronic, low-grade inflammation is an established risk factor for cardiovascular disease. The inflammatory impact of diet can be reflected by concentrations of inflammatory markers in the bloodstream and the inflammatory potential of diet can be estimated by the dietary inflammatory index (DIITM), which has been associated with cardiovascular disease risk in some previous studies. We aimed to examine the association between the DII and the risk of first myocardial infarction (MI) in a population-based study with long follow-up. METHOD: We conducted a prospective case-control study of 1389 verified cases of first MI and 5555 matched controls nested within the population-based cohorts of the Northern Sweden Health and Disease Study (NSHDS), of which the largest is the ongoing Västerbotten Intervention Programme (VIP) with nearly 100 000 participants during the study period. Median follow-up from recruitment to MI diagnosis was 6.4 years (6.2 for men and 7.2 for women). DII scores were derived from a validated food frequency questionnaire (FFQ) administered in 1986-2006. Multivariable conditional logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI), using quartile 1 (most anti-inflammatory diet) as the reference category. For validation, general linear models were used to estimate the association between the DII scores and two inflammatory markers, high-sensitivity C-reactive protein (hsCRP) and interleukin 6 (IL-6) in a subset (n = 605) of the study population. RESULTS: Male participants with the most pro-inflammatory DII scores had an increased risk of MI [ORQ4vsQ1 = 1.57 (95% CI 1.21-2.02) P trend = 0.02], which was essentially unchanged after adjustment for potential confounders, including cardiovascular risk factors [ORQ4vsQ1 = 1.50 (95% CI 1.14-1.99), P trend = 0.10]. No association was found between DII and MI in women. An increase of one DII score unit was associated with 9% higher hsCRP (95% CI 0.03-0.14) and 6% higher IL-6 (95% CI 0.02-0.11) in 605 controls with biomarker data available. CONCLUSION: A pro-inflammatory diet was associated with an elevated risk of first myocardial infarction in men; whereas for women the relationship was null. Consideration of the inflammatory impact of diet could improve prevention of cardiovascular disease.

Engagement in New Dietary Habits-Obese Women's Experiences from Participating in a 2-Year Diet Intervention.

BACKGROUND: Dietary weight loss interventions most often result in weight loss, but weight maintenance on a long-term basis is the main problem in obesity treatment. There is a need for an increased understanding of the behaviour patterns involved in adopting a new dietary behavior and to maintain the behaviour over time. PURPOSE: The purpose of this paper is to explore overweight and obese middle-aged women's experiences of the dietary change processes when participating in a 2-year-long diet intervention. METHODS: Qualitative semi-structured interviews with 12 overweight and obese women (54-71 years) were made after their participation in a diet intervention programme. The programme was designed as a RCT study comparing a diet according to the Nordic nutrition recommendations (NNR diet) and a Palaeolithic diet (PD). Interviews were analysed according to Grounded Theory principles. RESULTS: A core category "Engagement phases in the process of a diet intervention" concluded the analysis. Four categories included the informants' experiences during different stages of the process of dietary change: "Honeymoon phase", "Everyday life phase", "It's up to you phase" and "Crossroads phase". The early part of the intervention period was called "Honeymoon phase" and was characterised by positive experiences, including perceived weight loss and extensive support. The next phases, the "Everyday life phase" and "It's up to you phase", contained the largest obstacles to change. The home environment appeared as a crucial factor, which could be decisive for maintenance of the new dietary habits or relapse into old habits in the last phase called "Crossroads phase". CONCLUSION: We identified various phases of engagement in the process of a long-term dietary intervention among middle-aged women. A clear personal goal and support from family and friends seem to be of major importance for long-term maintenance of new dietary habits. Gender relations within the household must be considered as a possible obstacle for women engaging in diet intervention.

Health-related quality of life and prospective caries development.

BACKGROUND: The present study was conducted to prospectively assess the association between health-related quality of life (HRQoL) and the development of dental caries in adults in northern Sweden. The SF-36 questionnaire was used to estimate HRQoL. METHODS: Adults who had (i) participated in a population-based health screening in northern Sweden between 2003 and 2009 and had completed the SF-36 questionnaire, and (ii) received a dental check-up within 1 year (n = 15,615) were included in the study. Of these, 9,838 had a second caries examination 2-7 years after the baseline recording. Information regarding SF-36, lifestyle factors and medical conditions was retrieved by questionnaires, and anthropometric status and blood lipid levels were measured. The association between dental caries (outcome) and SF-36 scores (exposure) with the inclusion of potential confounders was analysed by linear and logistic regression. RESULTS: Caries increment increased significantly with decreasing scores for both physical and mental dimensions of SF-36 in women, but no association was seen in men. However, lifelong caries experience (DMFS) increased linearly with decreasing physical HRQoL in both men and women; this was also observed for the single dimension of mental HRQoL. The crude odds ratio for being in the highest caries quintile compared to the lowest when having the poorest physical HRQoL compared with the best physical HRQoL was 1.88 (95 % CI: 1.54-2.3). Several factors were identified as potential confounders in the associations between DMFS and SF-36 scores, including education level, smoking, age, medications, higher levels of total cholesterol, triglycerides, systolic blood pressure, body mass index and sugar intake. Except for education level and smoking, the effect sizes for the association between gradually decreasing SF-36 scores and increasing caries were generally moderate. CONCLUSIONS: Increased development of caries was associated with low physical HRQoL and some aspects of mental HRQoL. The mechanisms underlying these associations, which are likely confounded by both biological and lifestyle factors, remain to be elucidated. The study implies that, when possible, subjects with poor HRQoL would benefit from caries prevention measures meeting the underlying situation.

Experiences of barriers and facilitators to weight-loss in a diet intervention - a qualitative study of women in northern Sweden.

BACKGROUND: There is a lack of research about the experiences of participating in weight-reducing interventions. The aim of this study was to explore barriers and facilitators to weight-loss experienced by participants in a diet intervention for middle-aged to older women in the general population in Northern Sweden. METHOD: In the intervention the women were randomised to eat either a Palaeolithic-type diet or a diet according to Nordic Nutrition recommendations for 24 months. A strategic selection was made of women from the two intervention groups as well as from the drop-outs in relation to social class, civil status and age. Thematic structured interviews were performed with twelve women and analysed with qualitative content analyses. RESULTS: The results showed that the women in the dietary intervention experienced two main barriers - struggling with self (related to difficulties in changing food habits, health problems, lack of self-control and insecurity) and struggling with implementing the diet (related to social relations and project-related difficulties) - and two main facilitators- striving for self-determination (related to having clear goals) and receiving support (from family/friends as well as from the project) - for weight-loss. There was a greater emphasis on barriers than on facilitators. CONCLUSION: It is important to also include drop-outs from diet interventions in order to fully understand barriers to weight-loss. A gender-relational approach can bring new insights into understanding experiences of barriers to weight-loss. TRIAL REGISTRATION: ClinicalTrials gov NCT00692536.

Low-carbohydrate, high-protein diet score and risk of incident cancer; a prospective cohort study.

BACKGROUND: Although carbohydrate reduction of varying degrees is a popular and controversial dietary trend, potential long-term effects for health, and cancer in specific, are largely unknown. METHODS: We studied a previously established low-carbohydrate, high-protein (LCHP) score in relation to the incidence of cancer and specific cancer types in a population-based cohort in northern Sweden. Participants were 62,582 men and women with up to 17.8 years of follow-up (median 9.7), including 3,059 prospective cancer cases. Cox regression analyses were performed for a LCHP score based on the sum of energy-adjusted deciles of carbohydrate (descending) and protein (ascending) intake labeled 1 to 10, with higher scores representing a diet lower in carbohydrates and higher in protein. Important potential confounders were accounted for, and the role of metabolic risk profile, macronutrient quality including saturated fat intake, and adequacy of energy intake reporting was explored. RESULTS: For the lowest to highest LCHP scores, 2 to 20, carbohydrate intakes ranged from median 60.9 to 38.9% of total energy intake. Both protein (primarily animal sources) and particularly fat (both saturated and unsaturated) intakes increased with increasing LCHP scores. LCHP score was not related to cancer risk, except for a non-dose-dependent, positive association for respiratory tract cancer that was statistically significant in men. The multivariate hazard ratio for medium (9-13) versus low (2-8) LCHP scores was 1.84 (95% confidence interval: 1.05-3.23; p-trend = 0.38). Other analyses were largely consistent with the main results, although LCHP score was associated with colorectal cancer risk inversely in women with high saturated fat intakes, and positively in men with higher LCHP scores based on vegetable protein. CONCLUSION: These largely null results provide important information concerning the long-term safety of moderate carbohydrate reduction and consequent increases in protein and, in this cohort, especially fat intakes. In order to determine the effects of stricter carbohydrate restriction, further studies encompassing a wider range of macronutrient intakes are warranted.

Patient experiences of a theory-based lifestyle-focused group treatment in the prevention of cardiovascular diseases and type 2 diabetes.

BACKGROUND: Cardiovascular disease and type 2 diabetes are two of the most common public health diseases, and up to 80 % of the cases may be prevented by lifestyle modification. The physiological effects of lifestyle-focused treatment are relatively well studied, but how patients actually experience such treatments is still rather unclear. PURPOSE: The aim of this study was to explore how patients experience lifestyle-focused group treatment in primary and secondary prevention of cardiovascular disease and type 2 diabetes. METHOD: Qualitative interviews were conducted with 19 patients attending lifestyle-focused group treatment based on social cognitive theory at a behavioral medicine clinic in northern Sweden. The interviews were transcribed verbatim and analyzed according to Malterud's systematic text condensation. RESULTS: The study shows that patients participating in this kind of group-based lifestyle treatment went through a process of self-development which deepened their understanding of own responsibility for health and improved their skills in finding support in others. The process could be tracked through three different themes (the holistic view, personal responsibility, and group treatment) which together reflected the most essential parts of the informants' experience and showed the patient as an active decision maker struggling to adopt the principles of behavioral change. CONCLUSION: Lifestyle-focused group treatment, based on social cognitive theory, was shown to stimulate different components that strengthen patients' self-efficacy for long-term behavioral change.

Associations between emotional support and cardiovascular risk factors and subclinical atherosclerosis in middle-age.

OBJECTIVE: To test the hypothesis of low emotional support being associated with lifestyle and biomedical cardiovascular disease (CVD) risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults. METHODS AND MEASURES: Cross-sectional data were obtained from participants aged 40-60 years who had one or more conventional CVD risk factor. They underwent assessment based on questionnaires, clinical examination, blood sampling, and carotid ultrasound of plaque formation and carotid intima-media wall thickness (cIMT). Based on the Interview Schedule for Social Interaction, the participants were categorised as either low in emotional support (n = 884) or as a referent (n = 2570). Logistic regression analyses were conducted to study the associations. RESULTS: Logistic regression analyses showed that low emotional support was significantly associated with smoking, alcohol consumption and physical inactivity (OR = 1.53 - 1.94), estimated risk of CVD morbidity and mortality (OR = 1.56 - 1.68), and plaque formation (OR = 1.39). No significant associations were found regarding biomedical CVD risk factors or cIMT. CONCLUSION: The findings suggest that low social support is associated with lifestyle CVD risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults, encouraging causal evaluation with longitudinal data investigating an impact of emotional support on mechanisms underlying CVD.

Signs of dysregulated fibrinolysis precede the development of type 2 diabetes mellitus in a population-based study.

BACKGROUND: Diabetic patients experience stimulated coagulation and dysfibrinolysis, which is associated with an increased risk of cardiovascular events. This imbalance may precede the manifest diagnosis. We investigated whether elevated antigen levels of tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1), the tPA/PAI-1 complex, or von Willebrand Factor (VWF) precede type 2 diabetes mellitus (T2DM) diagnosis, and whether this elevation occurs before increased fasting plasma glucose (FPG) or 2-hour plasma glucose (2hPG) in individuals who later develop T2DM. METHODS: We conducted a prospective incident case-referent study within the Västerbotten Intervention Programme. Cardiovascular risk factor data as well as FPG and 2hPG and blood samples for future research were collected at a baseline health examination between 1989 and 2000, (n= 28 736). During follow-up in January 2001, 157 cases had developed T2DM. Referents without T2DM were matched for sex, age, and year of participation (n=277). Subgroup analysis was performed for cases with normal baseline glucose levels (FPG <6.1 mmol/L and 2hPG < 8.9 mmol/L) and cases with elevated levels (FPG 6.1-6.9 mmol/L and/or 2hPG 8.9-12.1 mmol/L). RESULTS: After adjusting for BMI, family history of diabetes, physical activity, smoking, systolic blood pressure and levels of C-reactive protein and triglycerides, independent associations were found between incident T2DM and elevated levels of tPA (OR=1.54, 95% CI 1.06-2.23), PAI-1 (OR=1.61, 95% CI 1.14-2.28), and tPA/PAI-1 complex (OR=2.45, 95% CI 1.56-3.84). In participants with normal glucose levels, PAI-1 (OR=2.06, 95% CI 1.10 - 3.86) exhibited an independent relationship with incident T2DM after the adjustments. CONCLUSIONS: Elevated levels of fibrinolytic variables precede the manifestation of T2DM after adjusting for metabolic and cardiovascular risk factors and can be detected several years before changes in glucose tolerance.

The Mediterranean diet score and mortality are inversely associated in adults living in the subarctic region.

The Mediterranean diet has been widely promoted and may be associated with chronic disease prevention and a better overall health status. The aim of this study was to evaluate whether the Mediterranean diet score inversely predicted total or cause-specific mortality in a prospective population study in Northern Sweden (Västerbotten Intervention Program). The analyses were performed in 77,151 participants (whose diet was measured by means of a validated FFQ) by Cox proportional hazard models adjusted for several potential confounders. The Mediterranean diet score was inversely associated with all-cause mortality in men [HR = 0.96 (95% CI = 0.93, 0.99)] and women [HR = 0.95 (95% CI = 0.91, 0.99)], although not in obese men. In men, but not in women, the score was inversely associated with total cancer mortality [HR = 0.92 (95% CI = 0.87, 0.98)], particularly for pancreas cancer [HR = 0.82 (95% CI = 0.68, 0.99)]. Cardiovascular mortality was inversely associated with diet only in women [HR = 0.90 (95% CI = 0.82, 0.99)]. Except for alcohol [HR = 0.83 (95% CI = 0.76, 0.90)] and fruit intake [HR = 0.90 (95% CI = 0.83, 0.98)], no food item of the Mediterranean diet score independently predicted mortality. Higher scores were associated with increasing age, education, and physical activity. Moreover, healthful dietary and lifestyle-related factors additively decreased the mortality likelihood. Even in a subarctic region, increasing Mediterranean diet scores were associated with a longer life, although the protective effect of diet was of small magnitude compared with other healthful dietary and lifestyle-related factors examined.