Visit Experience and Fulfillment of Care Needs in Primary Care Differs for Video Visits Compared to In-person and Chat Visits.

BACKGROUND: There is a lack of research comparing patient experience and to what extent patients' care needs are fulfilled in telemedicine compared to in-person care. OBJECTIVE: To investigate if patient experience and fulfillment of care needs differ between video and chat visits with direct to consumer telemedicine providers compared to in-person visits. DESIGN: Cross-sectional study. PARTICIPANTS: Adults visiting a primary care physician in person or via chat or video in Region Stockholm, Sweden, October 2020-May 2021. MAIN MEASURES: Patient-reported visit experience and fulfillment of care needs. KEY RESULTS: The sample included 3315 patients who had an in-person (1950), video (844), or chat (521) visit. Response rates were 42% for in-person visitors and 41% for telemedicine visitors. Patients were 18-97 years old, mean age of 51 years, and 66% were female. In-person visitors reported the most positive patient experience ("To a very high degree" or "Yes, completely") for being listened to (64%), being treated with care (64%), and feeling trust and confidence in the health care professional (76%). Chat visitors reported the most positive patient experience for being given enough time (61%) and having care needs fulfilled during the care visit (76%). Video visitors had the largest proportion of respondents choosing "To a very low degree" or "No, not at all" for all visit experience measures. There were statistically significant differences in the distribution of visit experiences between in-person, video, and chat visits for all visit experience measures (P < 0.001). CONCLUSIONS: Video visits were associated with a more negative visit experience and lower fulfillment of care needs than in-person visits. Chat visits were associated with a similar patient experience and fulfillment of care needs as in-person visits. Chat visits may be a viable alternative to in-person visits for selected patients.

Individual Patient Factors Associated with the Use of Physical or Digital Primary Care in Sweden.

Introduction: Little is known about factors that influence patients' choice to use physical or digital primary care. This study aimed to compare self-rated health, internet habits, and what patients deem important when choosing health care between users of physical and digital primary health care. Methods: We recruited 2,716 adults visiting one of six physical or four digital primary health care providers in Stockholm, Sweden, October 2020 to May 2021. Participants answered a questionnaire with questions about sociodemography, self-rated health, internet habits, and what they considered important when seeking care. We used logistic regression and estimated odds ratios (ORs) for choosing digital care. Results: Digital users considered themselves healthier and used the internet more, compared with physical users (p < 0.001). Competence of health care staff was the most important factor when seeking care to both physical and digital users (90% and 78%, respectively). Patients considering it important to avoid leaving home were more likely to seek digital care (OR 29.55, 95% confidence interval [CI] 12.65-69.06), while patients valuing continuity were more likely to seek physical care (OR 0.25, 95% CI 0.19-0.32). These factors were significant also when adjusting for self-rated health and sociodemographic characteristics. Conclusion: What patients considered important when seeking health care was associated with what type of care they sought. Patient preferences should be considered when planning health care to optimize resource allocation.

The effect of an app-based dietary intervention on diet-related greenhouse gas emissions - results from a randomized controlled trial.

BACKGROUND: Dietary change towards a diet low in greenhouse gas emissions (GHGEs) can reduce climate impact and improve individual-level health. However, there is a lack of understanding if diet interventions can achieve low-GHGE diets. METHODS: A randomized controlled trial was conducted to assess the effects of an app-based intervention. The intervention was designed to improve dietary intake of people with Type 2 diabetes, and was delivered via an app over 12 weeks, with each week covering one diet-related topic. Dietary intake was assessed at baseline and 3-month follow up by a 95-item food frequency questionnaire and linked to GHGE values. A total of n = 93 participants (n = 46 and n = 47 for the intervention and control group, respectively) were included in the analysis. Changes to GHGEs within and between the groups were analysed with inferential statistics. RESULTS: The majority (60%) of participants were male, with a mean age of 63.2 years and body mass index of 30 kg/m2. At baseline, diet-related GHGEs were 4.8 and 4.9 kg CO2-eq/day in the intervention and control group, respectively. At 3-month follow up the corresponding GHGEs were 4.7 and 4.9 kg CO2-eq/day. We found no statistically significant changes to diet-related GHGEs within or between groups, or within food categories, from baseline to 3-month follow up. CONCLUSION: No evidence was found for the effectiveness of the app-based intervention to generate changes to diet-related GHGEs in a population of people with Type 2 diabetes. However, future interventions that target reducing meat consumption specifically may have the potential to result in a reduction of individual-level diet-related GHGEs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03784612. Registered 24 December 2018. www. CLINICALTRIALS: gov/ct2/show/NCT03784612 .

Appetite and its association with mortality in patients with advanced cancer - a Post-hoc Analysis from the Palliative D-study.

BACKGROUND: Loss of appetite is a common nutrition symptom in patients with cancer. Understanding the trajectory of appetite could be of clinical use for prognostication in palliative cancer care. Our primary aim was to explore the association between self-assessed appetite and mortality in patients suffering from advanced cancer. Secondary aims included the relation between fatigue, albumin levels and CRP/albumin ratio and mortality. We also aimed to study potential sex-differences in the associations. METHODS: Post-hoc analyses were performed using data from the Palliative D-study comprising 530 patients with cancer admitted to palliative care. Appetite and fatigue were assessed with the Edmonton Symptom Assessment System (ESAS). Cox proportional hazards models were used to calculate Hazard ratios (HR) with 95% confidence intervals (CI) for exposures of appetite, fatigue, albumin and CRP/albumin ratio, and time from study inclusion to death or censoring. Analyses were also performed stratified by sex. RESULTS: The follow-up time ranged between 7 to 1420 days. Moderate and poor appetite were significantly associated with a higher mortality rate compared to reporting a good appetite; HR 1.44 (95%CI: 1.16-1.79) and HR 1.78 (95%CI: 1.39-2.29), respectively. A higher mortality rate was also seen among participants reporting severe fatigue compared to those reporting no fatigue; HR 1.84 (95%CI:1.43-2.36). Participants with low albumin levels (< 25 g/L) and those in the highest tertile of CRP/albumin ratio, had higher mortality rates, HR 5.35 (95%CI:3.75-7.63) and HR 2.66 (95%CI:212-3.35), compared to participants with high albumin levels (> 36 g/L) and those in lowest tertile of CRP/albumin ratio. These associations were more pronounced in men than in women. CONCLUSION: Poor appetite, severe fatigue, low albumin level and a high CRP/albumin ratio were associated with increased mortality rates among patients with advanced cancer. All these variables might be clinically useful for prognostication in palliative cancer care. TRIAL REGISTRATION: Clinicaltrial.gov. Identifier: NCT03038516;31, January 2017.

Does eating behaviour among adolescents and young adults seeking obesity treatment differ depending on sex, body composition, and parental country of birth?

BACKGROUND: Adolescents and young adults around the world experience high rates of weight gain. The underlying eating behaviours that may lead to overconsumption of energy are complex and can depend on a number of factors. The aim of this study was to explore if eating behaviour among adolescents and young adults referred to specialized obesity treatment differed depending on sex, body composition, and parental country of birth. METHODS: Adolescents and young adults aged 16-25 years, referred for obesity treatment in 2018-2021 were included in the study. Eating behaviour was assessed using the Three Factor Eating Questionnaire, comprising domains of uncontrolled-, emotional- and cognitive restraint eating. Student's t-test was used to compare differences in eating behaviour scores between males and females, and between those having at least one parent born in a Nordic country and those with both parents born outside the Nordic countries. Associations between BMI, waist circumference, and body fat percentage, and eating behaviour as the dependent variable, were examined using linear regression. RESULTS: A total of 463 participants, mean age 21 years and mean BMI 41.3 kg/m2, were included in the analysis. Females scored statistically significantly higher than males on emotional eating (45.8 vs. 35.4, p = 0.002) and cognitive restraint eating (45.4 vs. 39.2, p = 0.009). Participants with at least one parent born in a Nordic country reported a statistically significantly lower score of uncontrolled eating (45.7 vs. 51.3, p = 0.02) compared to participants with both parents born outside the Nordic countries. Further, there were statistically significant inverse associations between cognitive restraint eating scores and BMI (ß=-0.64, 95%CI: -0.97 to -0.31), waist circumference (ß=-0.44, 95%CI: -0.61 to -0.27) and body fat percentage (ß=-0.57, 95%CI: -1.01 to -0.14) in models adjusted for age, sex, smoking, and civil status. CONCLUSION: Our findings suggest that sex and parental country of birth may influence eating behaviours among adolescents and young adults referred for specialist obesity treatment. We also found that cognitive restraint eating decreased with increasing BMI, waist circumference, and body fat percentage. This indicates that there may be an inverse association between the ability to restrain oneself from eating and gaining weight, however, the direction of the association must be investigated further. Increased knowledge about eating behaviours may be valuable in the clinical setting.

App-technology to improve lifestyle behaviors among working adults - the Health Integrator study, a randomized controlled trial.

BACKGROUND: Mobile health, mHealth is recognized as a strategy to improve lifestyle behaviors. Research targeting specific lifestyle behaviors has shown that interventions using smartphones can be effective. However, few studies have evaluated solutions with multicomponent interventions, tailoring the intervention to the specific needs of the participant using a combination of mHealth and conventional treatment. To accomplish this, we developed Health Integrator, an mHealth platform with services and offers in the areas of diet, physical activity, sleeping habits, stress, alcohol and tobacco use. In the system, the user selects an area of intervention together with a health coach and set weekly goals. This study protocol presents the design and methodology of the Health Integrator Study, a randomized controlled trial to promote improved lifestyle behaviors. METHODS: A three-arm parallel randomized controlled trial (1:1:1) is conducted in the Stockholm County, Sweden. In total, 209 employees at a four different companies representing both white and blue collar workers, have been recruited. Participants are randomized to either a control group or to one of two intervention groups receiving a 3-month lifestyle behavior change program including either 1) use of Health Integrator and monthly health coaching sessions or 2) only Health Integrator. At baseline and follow-up after 3- and 6-months, all participants answer questionnaires assessing lifestyle behaviors and quality of life. At baseline and the 3-month follow-up (end of intervention period), weight, height, waist circumference and blood pressure are measured, and all participants wear an Actigraph accelerometer for 7 days to assess physical activity. Blood lipid profile and HbA1c are measured among all participants at baseline. If baseline measures fall outside the normal range, a second measurement is done after 3 months. DISCUSSION: The Health Integrator Intervention Study will evaluate if a personalized intervention combining mHealth and conventional programs for lifestyle change, with or without additional health coach sessions, can improve lifestyle behaviors and quality of life. Based on the results from this trial, Health Integrator can easily be implemented within a broad public. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03579342 . Retrospectively registered, first submitted May 8, 2018.

App-technology to increase physical activity among patients with diabetes type 2 - the DiaCert-study, a randomized controlled trial.

BACKGROUND: Physical activity can decrease the risk of complications related to diabetes type 2. Feasible and scalable strategies to implement support for a healthy lifestyle for patients in primary care are needed. The aim of the DiaCert-study is to evaluate a digital healthcare platform and the effect of a 12-week long smartphone-app physical activity intervention aiming at increasing physical activity (primary outcome) and improve levels of HbA1c (glycated hemoglobin), blood lipids, blood pressure, body composition, as well as other lifestyle factors and overall health in patients with diabetes type 2. METHODS/DESIGN: The DiaCert-study is a two-arm, randomized controlled trial that will include 250 patients with diabetes type 2. At baseline, participants are randomized 1:1 to intervention, i.e. use of the smartphone-app, during 12 weeks, or to a control group receiving only standard care. Physical activity and sedentary behavior, is objectively measured using the Actigraph GT3X. Biomarkers including HbA1c and blood lipids are measured in fasting blood samples. Anthropometrics include height, weight, waist circumference and body composition, and a number of lifestyle factors including sleep, diet, self-efficacy, and quality of life, are assessed through an extensive questionnaire. Measurements are made at baseline and at follow-up after 3, 6 and 12 months. DISCUSSION: Using new technology, is one way to bridge the gap between what patients need and what health care can offer. This study evaluates a new digital health care platform and will show if use of a smartphone-app to promote daily steps is an effective and feasible method to increase physical activity and improve clinical markers in patients with diabetes type 2. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03053336 ; 7 Feb, 2017.

Body mass index in relation to serum prostate-specific antigen levels and prostate cancer risk.

High Body mass index (BMI) has been directly associated with risk of aggressive or fatal prostate cancer. One possible explanation may be an effect of BMI on serum levels of prostate-specific antigen (PSA). To study the association between BMI and serum PSA as well as prostate cancer risk, a large cohort of men without prostate cancer at baseline was followed prospectively for prostate cancer diagnoses until 2015. Serum PSA and BMI were assessed among 15,827 men at baseline in 2010-2012. During follow-up, 735 men were diagnosed with prostate cancer with 282 (38.4%) classified as high-grade cancers. Multivariable linear regression models and natural cubic linear regression splines were fitted for analyses of BMI and log-PSA. For risk analysis, Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) and natural cubic Cox regression splines producing standardized cancer-free probabilities were fitted. Results showed that baseline Serum PSA decreased by 1.6% (95% CI: -2.1 to -1.1) with every one unit increase in BMI. Statistically significant decreases of 3.7, 11.7 and 32.3% were seen for increasing BMI-categories of 25 < 30, 30 < 35 and ≥35 kg/m(2), respectively, compared to the reference (18.5 < 25 kg/m(2)). No statistically significant associations were seen between BMI and prostate cancer risk although results were indicative of a positive association to incidence rates of high-grade disease and an inverse association to incidence of low-grade disease. However, findings regarding risk are limited by the short follow-up time. In conclusion, BMI was inversely associated to PSA-levels. BMI should be taken into consideration when referring men to a prostate biopsy based on serum PSA-levels.

Background risk of breast cancer and the association between physical activity and mammographic density.

INTRODUCTION: High physical activity has been shown to decrease the risk of breast cancer, potentially by a mechanism that also reduces mammographic density. We tested the hypothesis that the risk of developing breast cancer in the next 10 years according to the Tyrer-Cuzick prediction model influences the association between physical activity and mammographic density. METHODS: We conducted a population-based cross-sectional study of 38,913 Swedish women aged 40-74 years. Physical activity was assessed using the validated web-questionnaire Active-Q and mammographic density was measured by the fully automated volumetric Volpara method. The 10-year risk of breast cancer was estimated using the Tyrer-Cuzick (TC) prediction model. Linear regression analyses were performed to assess the association between physical activity and volumetric mammographic density and the potential interaction with the TC breast cancer risk. RESULTS: Overall, high physical activity was associated with lower absolute dense volume. As compared to women with the lowest total activity level (<40 metabolic equivalent hours [MET-h] per day), women with the highest total activity level (≥50 MET-h/day) had an estimated 3.4 cm(3) (95% confidence interval, 2.3-4.7) lower absolute dense volume. The inverse association was seen for any type of physical activity among women with <3.0% TC 10-year risk, but only for total and vigorous activities among women with 3.0-4.9% TC risk, and only for vigorous activity among women with ≥5.0% TC risk. The association between total activity and absolute dense volume was modified by the TC breast cancer risk (P interaction = 0.05). As anticipated, high physical activity was also associated with lower non-dense volume. No consistent association was found between physical activity and percent dense volume. CONCLUSIONS: Our results suggest that physical activity may decrease breast cancer risk through reducing mammographic density, and that the physical activity needed to reduce mammographic density may depend on background risk of breast cancer.

Body mass index and mortality in men with prostate cancer.

BACKGROUND: Body Mass index (BMI) has been shown to affect risk and mortality of several cancers. Prostate cancer and obesity are major public health concerns for middle-aged and older men. Previous studies of pre-diagnostic BMI have found an increased risk of prostate cancer mortality in obese patients. OBJECTIVE: To study the associations between BMI at time of prostate cancer diagnosis and prostate cancer specific and overall mortality. METHODS: BMI was analyzed both as a continuous variable and categorized into four groups based on the observed distribution in the cohort (BMI < 22.5, 22.5 < 25, 25 < 27.5 and ≥27.5 kg/m2). The association between BMI and mortality was assessed using stratified Cox proportional hazards models and by fitting regression splines for dose response analysis in 3,161 men diagnosed with prostate cancer. After 11 years of follow up via linkage to the population-based cause of death registry, we identified 1,161 (37%) deaths off which 690 (59%) were due to prostate cancer. RESULTS: High BMI (BMI ≥ 27.5 kg/m2) was associated with a statistically significant increased risk of prostate cancer specific mortality (HR:1.44, 95% CI: 1.09-1.90) and overall mortality (HR:1.33, 95% CI: 1.09-1.63) compared to the reference group (BMI 22.5 < 25 kg/m2). Additionally, men with a low BMI (<22.5 kg/m2 ), had a statistically significant increased risk of prostate cancer specific mortality (HR:1.33, 95% CI: 1.02-1.74) and overall mortality (HR:1.36, 95% CI: 1.11-1.67) compared to the reference. However, this effect disappeared when men who died within the first two years of follow-up were excluded from the analyses while the increased risk of prostate cancer specific mortality and overall mortality remained statistically significant for men with a BMI ≥ 27.5 kg/m2 (HR:1.44, 95% CI: 1.09-1.90 and HR: 1.33, 95% CI: 1.09-1.63, respectively). CONCLUSION: This study showed that a high BMI at time of prostate cancer diagnosis was associated with increased overall mortality.

Body mass index and weight change in men with prostate cancer: progression and mortality.

PURPOSE: Body mass index (BMI) is a modifiable lifestyle factor that has been associated with an increased risk of fatal prostate cancer and biochemical recurrence. The main purpose of the present study was to investigate the association between the exposure BMI at the time of a prostate cancer diagnosis and weight change after diagnosis, and the outcomes of prostate cancer progression and mortality in a large cohort study. METHODS: Data from 4,376 men diagnosed with clinically localized prostate cancer between 1997 and 2002 were analyzed. BMI and weight change were self-reported in 2007. Hazard ratios (HRs) with 95 % confidence intervals (CIs) were estimated in complete-case analysis (n = 3,214) using Cox proportional hazards models. RESULTS: Progression was experienced among 639 (14.6 %) of the study participants, and in total, 450 (10.3 %) deaths of any cause and 134 (3.1 %) prostate cancer-specific deaths were recorded during follow-up. Obese men had a 47 % increased rate of overall mortality compared to normal weight men (HR 1.47, 95 % CI 1.03-2.10). No statistically significant associations were found for BMI and prostate cancer progression or prostate cancer-specific mortality. A weight loss >5 % after diagnosis almost doubled the rate of overall mortality compared to maintaining a stable weight (HR 1.94, 95 % CI 1.41-2.66), while a weight gain >5 % was associated with an almost doubled increased rate of prostate cancer-specific mortality (HR 1.93, 95 % CI 1.18-3.16). CONCLUSIONS: Being obese was associated with an increased rate of overall mortality, and gaining weight after a prostate cancer diagnosis was associated with an increased rate of prostate cancer-specific mortality.

Relative validity of micronutrient and fiber intake assessed with two new interactive meal- and Web-based food frequency questionnaires.

BACKGROUND: The meal- and Web-based food frequency questionnaires, Meal-Q and MiniMeal-Q, were developed for cost-efficient assessment of dietary intake in epidemiological studies. OBJECTIVE: The objective of this study was to evaluate the relative validity of micronutrient and fiber intake assessed with Meal-Q and MiniMeal-Q. The reproducibility of Meal-Q was also evaluated. METHODS: A total of 163 volunteer men and women aged between 20 and 63 years were recruited from Stockholm County, Sweden. Assessment of micronutrient and fiber intake with the 174-item Meal-Q was compared to a Web-based 7-day weighed food record (WFR). Two administered Meal-Q questionnaires were compared for reproducibility. The 126-item MiniMeal-Q, developed after the validation study, was evaluated in a simulated validation by using truncated Meal-Q data. RESULTS: The study population consisted of approximately 80% women (129/163) with a mean age of 33 years (SD 12) who were highly educated (130/163, 80% with >12 years of education) on average. Cross-classification of quartiles with the WFR placed 69% to 90% in the same/adjacent quartile for Meal-Q and 67% to 89% for MiniMeal-Q. Bland-Altman plots with the WFR and the questionnaires showed large variances and a trend of increasing underestimation with increasing intakes. Deattenuated and energy-adjusted Spearman rank correlations between the questionnaires and the WFR were in the range ρ=.25-.69, excluding sodium that was not statistically significant. Cross-classifications of quartiles of the 2 Meal-Q administrations placed 86% to 97% in the same/adjacent quartile. Intraclass correlation coefficients for energy-adjusted intakes were in the range of .50-.76. CONCLUSIONS: With the exception of sodium, this validation study demonstrates Meal-Q and MiniMeal-Q to be useful methods for ranking micronutrient and fiber intake in epidemiological studies with Web-based data collection.

Wrist-worn accelerometers: Influence of decisions during data collection and processing: A cross-sectional study.

Background and Aims: Accelerometers collect data in an objective way, however, a number of decisions must be done during data collection, processing and output-interpretation. The influence of those decisions is seldom investigated, reported, or discussed. Herein, we examined the influence of different decisions on the outcomes: daily minutes of moderate-to-vigorous physical activity (MVPA), inactivity and light physical activity (LPA). Methods: In total, 156 participants wore an accelerometer (ActiGraph wGT3X-BT) on their nondominant wrist for 7 days. Data collection was conducted from February 2017 to June 2018. Data was processed using the R-package GGIR and default settings were compared to by-the-literature-suggested options. The output was examined using paired t-tests. Results: When comparing two commonly used MVPA-cut-points, default and Hildebrand et al. we found a marginal difference (0.4 min, 1.0%, p < 0.001) in MVPA/day. When no bout criteria for MVPA/day was applied, MVPA/day was twice as high as bouted MVPA/day. Further, when we changed the epoch-length from 5 to 1 s, statistically significant changes were seen for MVPA/day (-6.6 min, 19%, p < 0.001), inactivity/day (-22 min, 3.0%, p < 0.001) and LPA/day (28 min, 81%, p < 0.001). Conclusion: Decisions made during data processing of wrist-worn accelerometers has an influence on the output and thus, may influence the conclusions drawn. However, there may be situations when these settings are changed. If so, we recommend examining if the variables of interest are affected. We encourage researchers to report decisions made during data collection, processing and output-interpretation, to facilitate comparisons between different studies.

A validation study comparing energy and nutrient intake between a web-based food frequency questionnaire and a 4-d dietary record.

OBJECTIVE: Reliable assessments of dietary intake is crucial when examining associations between dietary factors and different outcomes. Today, web-based instead of paper-based food frequency questionnaires (FFQs) are common. A web-based FFQ implies a different experience (including design differences, the possibility only to show relevant questions, and automatic checks for completeness) and may capture dietary intake differently. The aim of this study was to validate a well-used paper-based FFQ transferred to a web-based version against a 4-d dietary record. METHODS: Baseline data from a dietary intervention study comprising women and men with type 2 diabetes were used. Diet was assessed with the web-based FFQ and a 4-d dietary record. Energy intake and energy-adjusted nutrient intakes were assessed and compared using Spearman's rank correlation and Bland-Altman analysis. The analysis included 101 participants. RESULTS: The average energy intake with the FFQ was 2068 kcal, 157 kcal higher than the average from the dietary record. Significant deattenuated correlations were found for intake of energy (r = 0.37; 95% confidence interval [CI],0.19-0.53), carbohydrates (r = 0.85; 95% CI, 0.78-0.89), protein (r = 0.53; 95% CI, 0.38-0.66) and fat (r = 0.59; 95% CI, 0.44-0.70). Significant deattenuated correlations (ranging r = 0.26-0.73) were found for intake of alcohol, whole grain, fiber, saturated fat, monounsaturated fat, polyunsaturated fat, cholesterol, vitamins A, B12, C, D, and E, folate, iron, potassium, magnesium, and calcium. Bland-Altman analyses showed no clear trends but wide limits of agreement. CONCLUSION: Overall, the web-based FFQ performed well and is similar to the paper-based version. It can be a useful tool for dietary assessments.

Effectiveness of a Smartphone App to Promote Physical Activity Among Persons With Type 2 Diabetes: Randomized Controlled Trial.

BACKGROUND: Physical activity is well known to have beneficial effects on glycemic control and to reduce risk factors for cardiovascular disease in persons with type 2 diabetes. Yet, successful implementation of lifestyle interventions targeting physical activity in primary care has shown to be difficult. Smartphone apps may provide useful tools to support physical activity. The DiaCert app was specifically designed for integration into primary care and is an automated mobile health (mHealth) solution promoting daily walking. OBJECTIVE: This study aimed to investigate the effect of a 3-month-long intervention promoting physical activity through the use of the DiaCert app among persons with type 2 diabetes in Sweden. Our primary objective was to assess the effect on moderate to vigorous physical activity (MVPA) at 3 months of follow-up. Our secondary objective was to assess the effect on MVPA at 6 months of follow-up and on BMI, waist circumference, hemoglobin A1c, blood lipids, and blood pressure at 3 and 6 months of follow-up. METHODS: We recruited men and women with type 2 diabetes from 5 primary health care centers and 1 specialized center. Participants were randomized 1:1 to the intervention or control group. The intervention group was administered standard care and access to the DiaCert app at baseline and 3 months onward. The control group received standard care only. Outcomes of objectively measured physical activity using accelerometers, BMI, waist circumference, biomarkers, and blood pressure were assessed at baseline and follow-ups. Linear mixed models were used to assess differences in outcomes between the groups. RESULTS: A total of 181 study participants, 65.7% (119/181) men and 34.3% (62/181) women, were recruited into the study and randomized to the intervention (n=93) or control group (n=88). The participants' mean age and BMI were 60.0 (SD 11.4) years and 30.4 (SD 5.3) kg/m2, respectively. We found no significant effect of the intervention (group by time interaction) on MVPA at either the 3-month (ß=1.51, 95% CI -5.53 to 8.55) or the 6-month (ß=-3.53, 95% CI -10.97 to 3.92) follow-up. We found no effect on any of the secondary outcomes at follow-ups, except for a significant effect on BMI at 6 months (ß=0.52, 95% CI 0.20 to 0.84). However, mean BMI did not differ between the groups at the 6-month follow-up. CONCLUSIONS: We found no evidence that persons with type 2 diabetes being randomized to use an app promoting daily walking increased their levels of MVPA at 3 or 6 months' follow-up compared with controls receiving standard care. The effect of the app on BMI was unclear, and we found nothing to support an effect on secondary outcomes. Further research is needed to determine what type of mHealth intervention could be effective to increase physical activity among persons with type 2 diabetes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03053336; https://clinicaltrials.gov/study/NCT03053336.

Two new meal- and web-based interactive food frequency questionnaires: validation of energy and macronutrient intake.

BACKGROUND: Meal-Q and its shorter version, MiniMeal-Q, are 2 new Web-based food frequency questionnaires. Their meal-based and interactive format was designed to promote ease of use and to minimize answering time, desirable improvements in large epidemiological studies. OBJECTIVE: We evaluated the validity of energy and macronutrient intake assessed with Meal-Q and MiniMeal-Q as well as the reproducibility of Meal-Q. METHODS: Healthy volunteers aged 20-63 years recruited from Stockholm County filled out the 174-item Meal-Q. The questionnaire was compared to 7-day weighed food records (WFR; n=163), for energy and macronutrient intake, and to doubly labeled water (DLW; n=39), for total energy expenditure. In addition, the 126-item MiniMeal-Q was evaluated in a simulated validation using truncated Meal-Q data. We also assessed the answering time and ease of use of both questionnaires. RESULTS: Bland-Altman plots showed a varying bias within the intake range for all validity comparisons. Cross-classification of quartiles placed 70%-86% in the same/adjacent quartile with WFR and 77% with DLW. Deattenuated and energy-adjusted Pearson correlation coefficients with the WFR ranged from r=0.33-0.74 for macronutrients and was r=0.18 for energy. Correlations with DLW were r=0.42 for Meal-Q and r=0.38 for MiniMeal-Q. Intraclass correlations for Meal-Q ranged from r=0.57-0.90. Median answering time was 17 minutes for Meal-Q and 7 minutes for MiniMeal-Q, and participants rated both questionnaires as easy to use. CONCLUSIONS: Meal-Q and MiniMeal-Q are easy to use and have short answering times. The ranking agreement is good for most of the nutrients for both questionnaires and Meal-Q shows fair reproducibility.

A Digital Platform and Smartphone App to Increase Physical Activity in Patients With Type 2 Diabetes: Overview Of a Technical Solution.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-018-5026-4.

Weight Loss History and Its Association with Self-Esteem and Eating Behaviors in Adolescents and Young Adults with Obesity.

INTRODUCTION: Previous weight loss attempts in young people with obesity may have influenced their beliefs about themselves and contributed to maladaptive eating behaviors. Therefore, we aimed to investigate the association between previous weight loss with self-esteem and different eating behaviors in adolescents and young adults with obesity seeking specialty obesity care. METHODS: We performed a cross-sectional study, where a total of 224 participants with obesity, aged 16-25, self-reported the amount and the frequency of previous weight loss of 5 kg or more. Self-esteem was assessed with Rosenberg's Self-Esteem Scale and eating behavior with the Three-Factor Eating Questionnaire-Revised21. Linear regression was used to analyze associations between the amount of weight loss (no weight loss, 5-10 kg, and >10 kg) and the frequency of weight loss ≥5 kg (0, 1, and ≥2 times) with self-esteem and eating behaviors. RESULTS: We found that both those who had lost 5-10 kg and those who had lost ≥5 kg twice or more, had statistically significantly higher cognitive restraint eating scores ß = 7.03 (95% CI: 0.004-14.05) and ß = 8.32 (95% CI: 1.20-15.43), respectively, compared to those who reported no previous weight loss. No other statistically significant associations were found. CONCLUSION: Previous weight loss in adolescents and young adults with obesity may be associated with a higher cognitive restraint eating behavior. Therefore, assessing weight loss history and eating behavior may be beneficial to better individualize obesity treatment.

Patients' Perspectives on Dietary Patterns and Eating Behaviors During Weight Regain After Gastric Bypass Surgery.

PURPOSE: Food quality, energy intake, and various eating-related problems have been highlighted as some of the components influencing weight after bariatric surgery. This study aimed to increase our knowledge of patients' perspectives on dietary patterns and eating behaviors during weight regain after bariatric surgery. MATERIALS AND METHODS: We recruited 4 men and 12 women with obesity and the experience of weight regain after bariatric surgery at an obesity clinic in Stockholm, Sweden. Data were collected during 2018-2019. We conducted a qualitative study, carried out individual semi-structured interviews, and analyzed the recorded and transcribed interview data with thematic analysis. RESULTS: Participants had regained 12 to 71% from their lowest weight after gastric bypass surgery performed 3 to 15 years before. They perceived their dietary challenges as overwhelming and had not expected weight management, meal patterns, increasing portion sizes, and appealing energy-dense foods to be problematic after surgery. In addition, difficulties with disordered eating patterns, emotional eating, and increased alcohol intake further contributed to the weight management hurdles. Insufficient nutritional knowledge and lack of support limited participants' ability to avoid weight regain, leading to restrictive eating and dieting without sustained weight loss. CONCLUSION: Eating behavior and dietary factors such as lack of nutritional knowledge, emotional eating, or disorganized meal patterns contribute to difficulties with weight management after gastric bypass surgery. Improved counseling may help patients prepare for possible weight regain and remaining challenges with food and eating. The results highlight the importance of regular medical nutrition therapy after gastric bypass surgery.

The Swedish Youth with Obesity cohort: Profile of an ongoing prospective study.

OBJECTIVE: As there is a lack of studies on adolescents and young adults with obesity, the Swedish Youth with Obesity cohort was set up to describe the long-term results of medical, as well as surgical, obesity interventions in youth. This article describes the study protocol. METHODS: Since 2018, the study has continuously recruited patients aged between 16 and 25 years who have been admitted for obesity treatment at a specialist obesity clinic in Stockholm, Sweden. Participants provide data from blood tests, questionnaires, and anthropometric measurements. Data are collected longitudinally at enrollment and after 18 months and 3, 4, 5, and 10 years. RESULTS: In the first 500 participants (76% female), the mean age was 21 (SD 3.0) years and the mean BMI was 41.3 (SD 6.1) kg/m2 at enrollment. Almost half of the participants (44.4%) reported that both parents were born outside the Nordic countries. The proportion of participants who smoked at least sometimes was 28.4%. CONCLUSIONS: The longitudinally collected data from the Swedish Youth with Obesity cohort will become a valuable source for answering various research questions regarding long-term results of medical and surgical obesity treatment in adolescents and young adults with obesity.