Rapid changes in the prevalence of obesity and known diabetes in an adult Norwegian population. The Nord-Trøndelag Health Surveys: 1984-1986 and 1995-1997

Inflammatory markers and risk of cardiovascular mortality in relation to diabetes status in the HUNT study

Inflammatory markers have been associated with increased risk of cardiovascular mortality in general populations. We assessed whether these associations differ by diabetes status. From a population-based cohort study (n = 62,237) we included all participants with diabetes (n = 1753) and a control group without diabetes (n = 1818). Cox regression models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CI) for possible associations with cardiovascular mortality of 4 different inflammatory markers; C-reactive protein (CRP), calprotectin, neopterin and lactoferrin. During a median follow-up of 13.9 years, 728 (20.4%) died from cardiovascular disease (CVD). After adjustment for age, sex and diabetes, the associations of all inflammatory markers with risk of cardiovascular mortality were log-linear (all P ≤ 0.017 for trend) and did not differ according to diabetes status (all P ≥ 0.53 for interaction). After further adjustments for established risk factors, only CRP remained independently associated with cardiovascular mortality. HRs were 1.22 (1.12–1.32) per standard deviation higher log_e CRP concentration and 1.91 (1.50–2.43) when comparing individuals in the top versus bottom quartile. The associations of CRP, calprotectin, lactoferrin and neopterin with cardiovascular mortality did not differ by diabetes, suggesting that any potential prognostic value of these markers is independent of diabetes status.

Warning signals of elevated prediabetes prevalence in the modern Iranian urban population

BACKGROUND

We sought to estimate the prevalence of diabetes mellitus (DM) and pre-DM and their associated factors among a sample of the Iranian urban population between 2017 and 2019.

METHODS

The present investigation is a sub-study on the HAMRAH cohort study, a longitudinal population-based cohort study to assess the 10-year risk of cardiovascular diseases and their related risk factors in the adult population of the Iranian capital, Tehran. Via a multistage cluster randomized sampling method, 2123 adults aged between 30 and 75 years who had no history of cardiovascular diseases were selected for the study. With the aid of the 2010 American Diabetes Association criteria for the definition of DM and pre-DM, age and sex-specific prevalence rates were estimated.

RESULTS

The estimated overall prevalence of DM was 14.3% (95% CI: 13.1%-15.8%): 10.4% known DM (95% CI: 9.1%-11.8%) and 4% newly diagnosed DM (95% CI: 3.1%-5.1%). Pre-DM was detected in about 29.2% of the study participants (95% CI: 22.9-36.3%). Our logistic regression analysis revealed that increasing age, higher systolic blood pressure, higher levels of triglycerides, and lower levels of high-density lipoprotein were significantly associated with DM.

CONCLUSIONS

DM and pre-DM follow a notable incremental pattern among the Iranian urban population. This finding underscores the significance of the need to improve prevention and screening strategies in the Iranian urban population.

Temporal trends in age at menarche and age at menopause: a population study of 312 656 women in Norway

STUDY QUESTION

Have mean age at menarche or mean age at natural menopause changed from the 1939 birth cohort to the 1964 birth cohort?

SUMMARY ANSWER

We estimated a minor decrease in mean age at menarche and an increase by nearly 3 years in mean age at natural menopause.

WHAT IS KNOWN ALREADY

In the Western world, age at menarche decreased across birth cohorts from the early 1800s until the 1950s. Whether mean age at menarche has continued to decrease in birth cohorts after the 1950s remains uncertain. It is also uncertain whether mean age at natural menopause has changed across birth cohorts.

STUDY DESIGN, SIZE, DURATION

We performed a retrospective population study of 312 656 women who were born in Norway during the years 1936–1964.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The data were obtained by two self-administered questionnaires from women who participated in the Norwegian breast cancer screening program (BreastScreen Norway) during the years 2006–2014. We used flexible parametric survival models with restricted cubic splines to estimate mean age at menarche, mean age at menopause and mean number of years between menarche and menopause according to the women’s year of birth. The women who were still having menstrual periods contributed with follow-up time until the time of data collection, and the women who had reported surgical removal of the uterus and/or both ovaries prior to natural menopause contributed with follow-up time until the time of surgery.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean age at menarche was 13.42 years (95% CI: 13.40–13.44 years) among women born during 1936–1939, and it was 13.24 years (95% CI: 13.22–13.25 years) among women born during 1960–1964. The mean age at natural menopause increased from 50.31 years (95% CI: 50.25–50.37 years) among women born during 1936–1939 to 52.73 years (95% CI: 52.64–52.82 years) among women born during 1960–1964. The mean number of years between menarche and menopause increased from 36.83 years (95% CI: 36.77–36.89 years) to 40.22 years (95% CI: 40.11–40.34 years).

LIMITATIONS, REASONS FOR CAUTION

Information about age at menarche and age at menopause was based on self-reports.

WIDER IMPLICATIONS OF THE FINDINGS

Late menopause is associated with increased risk of breast cancer but also with increased life expectancy. Thus, higher mean age at menopause may partly explain the increase in breast cancer incidence after menopause and the increase in life expectancy in recent time. Also, a longer interval between menarche and menopause could suggest that the number of years of female fecundity has increased.

STUDY FUNDING/COMPETING INTEREST(S)

This work was funded by the South-Eastern Norway Regional Health Authority [grant number 2016112 to M.S.G.] and by the Norwegian Cancer Society [grant number 6863294-2015 to E.K.B.]. The authors declare no conflicts of interest.

Concentration/activity of superoxide dismutase isozymes and the pro-/antioxidative status, in context of type 2 diabetes and selected single nucleotide polymorphisms (genes: INS, SOD1, SOD2, SOD3) - Preliminary findings

The alterations in concentration/activity of superoxide dismutase isozymes in the context of type 2 diabetes or obesity are well-described. Moreover, many hereditary factors, including single-nucleotide polymorphisms (SNPs) of genes for coding insulin, insulin receptors, or insulin receptor substrates (INS, INSR, IRS1, IRS2) or superoxide dismutase isozymes (SOD1, SOD2, SOD3), have been linked with the incidence of obesity and diabetes. However, the underlying changes in the plasma concentration/activity of superoxide dismutase isozymes and their potential connection with the said hereditary factors remain unexplored. Previously, we have observed that the plasma concentration/activity of superoxide dismutase isozymes differs in the context of obesity and/or rs2234694 (SOD1) and rs4880 (SOD2) and that the concentrations of SOD1, SOD2, SOD3 are correlated with each other. Intersexual variability of SOD1 concentration was detected regardless of obesity. In this study, the variability of concentration/activity of superoxide dismutase isozymes in plasma is considered in the context of type 2 diabetes and/or SNPs: rs2234694 (SOD1), rs5746105 (SOD2), rs4880 (SOD2), rs927450 (SOD2), rs8192287 (SOD3). Genotypic variability of SNP rs3842729 (INS), previously studied in the context of insulin-dependent diabetes, is investigated in terms of selected clinical parameters associated with type 2 diabetes. This study revealed higher SOD1 concentration in diabetic men compared to women, and extremely high SOD1 concentration, higher total superoxide dismutase, and copper-zinc superoxide dismutase activity, and lower superoxide dismutase and copper-zinc superoxide dismutase activity (when adjusted for the concentration of SODs) in the diabetic group regardless of sex. Multiple logistic regression, applied to explore possible links between the studied SNPs and other factors with the odds of type 2 diabetes or obesity, revealed that the genotypic variability of rs4880 (SOD2) could affect these odds, supporting the findings of several other studies.

Long-term trends in colorectal cancer: incidence, localization, and presentation

Background

The purpose of this study was to assess trends in incidence and presentation of colorectal cancer (CRC) over a period of 37 years in a stable population in Mid-Norway. Secondarily, we wanted to predict the future burden of CRC in the same catchment area.

Methods

All 2268 patients diagnosed with CRC at Levanger Hospital between 1980 and 2016 were included in this study. We used Poisson regression to calculate the incidence rate ratio (IRR) and analyse factors associated with incidence.

Results

The incidence of CRC increased from 43/100,000 person-years during 1980–1984 to 84/100,000 person-years during 2012–2016. Unadjusted IRR increased by 1.8% per year, corresponding to an overall increase in incidence of 94.5%. Changes in population (ageing and sex distribution) contributed to 28% of this increase, whereas 72% must be attributed to primary preventable factors associated with lifestyle. Compared with the last observational period, we predict a further 40% increase by 2030, and a 70% increase by 2040. Acute colorectal obstruction was associated with tumours in the left flexure and descending colon. Spontaneous colorectal perforation was associated with tumours in the descending colon, caecum, and sigmoid colon. The incidence of obstruction remained stable, while the incidence of perforation decreased throughout the observational period. The proportion of earlier stages at diagnosis increased significantly in recent decades.

Conclusion

CRC incidence increased substantially from 1980 to 2016, mainly due to primary preventable factors. The incidence will continue to increase during the next two decades, mainly due to further ageing of the population.

Validity of the FINDRISC as a prediction tool for diabetes in a contemporary Norwegian population: a 10-year follow-up of the HUNT study

OBJECTIVE

The Finnish Diabetes Risk Score (FINDRISC) is a recommended tool for type 2 diabetes prediction. There is a lack of studies examining the performance of the current 0-26 point FINDRISC scale. We examined the validity of FINDRISC in a contemporary Norwegian risk environment.

RESEARCH DESIGN AND METHODS

We followed 47 804 participants without known diabetes and aged ≥20 years in the HUNT3 survey (2006-2008) by linkage to information on glucose-lowering drug dispensing in the Norwegian Prescription Database (2004-2016). We estimated the C-statistic, sensitivity and specificity of FINDRISC as predictor of incident diabetes, as indicated by incident use of glucose-lowering drugs. We estimated the 10-year cumulative diabetes incidence by categories of FINDRISC.

RESULTS

The C-statistic (95% CI) of FINDRISC in predicting future diabetes was 0.77 (0.76 to 0.78). FINDRISC ≥15 (the conventional cut-off value) had a sensitivity of 38% and a specificity of 90%. The 10-year cumulative diabetes incidence (95% CI) was 4.0% (3.8% to 4.2%) in the entire study population, 13.5% (12.5% to 14.5%) for people with FINDRISC ≥15 and 2.8% (2.6% to 3.0%) for people with FINDRISC <15. Thus, FINDRISC ≥15 had a positive predictive value of 13.5% and a negative predictive value of 97.2% for diabetes within the next 10 years. To approach a similar sensitivity as in the study in which FINDRISC was developed, we would have to lower the cut-off value for elevated FINDRISC to ≥11. This would yield a sensitivity of 73%, specificity of 67%, positive predictive value of 7.7% and negative predictive value of 98.5%.

CONCLUSIONS

The validity of FINDRISC and the risk of diabetes among people with FINDRISC ≥15 is substantially lower in the contemporary Norwegian population than assumed in official guidelines. To identify ~3/4 of those developing diabetes within the next 10 years, we would have to lower the threshold for elevated FINDRISC to ≥11, which would label ~1/3 of the entire adult population as having an elevated FINDRISC necessitating a glycemia assessment.

Is chronic low back pain a risk factor for diabetes? The Nord-Trøndelag Health Study

OBJECTIVE

The purpose of this study was to examine the risk of diabetes associated with the presence or absence of chronic low back pain, considering both cross-sectional and cohort data.

RESEARCH DESIGN AND METHODS

Analyses were based on the Norwegian HUNT2 and HUNT3 surveys of Nord-Trøndelag County. The prevalence of diabetes was compared in groups with and without chronic low back pain among 45 157 participants aged 30-69 years. Associations between low back pain at baseline and risk of diabetes were examined in an 11-year follow-up of 30 380 individuals with no baseline diagnosis of diabetes. The comorbidity between diabetes and low back pain was assessed at the end of follow-up. All analyses were carried out considering generalized linear models incorporating adjustment for other relevant risk factors.

RESULTS

Cross-sectional analyses did not reveal any association between low back pain and diabetes. With adjustment for age, body mass index, physical activity and smoking, the cohort study of women showed a significant association between low back pain at baseline and risk of diabetes (RR 1.30; 95%  CI 1.09 to 1.54, p=0.003). The association differed between age groups (p=0.015), with a stronger association in relatively young women. In men, no association was found in the whole age range (RR 1.02; 95%  CI 0.86 to 1.21, p=0.82). No association was observed between diabetes and chronic low back pain at the end of follow-up.

CONCLUSION

Among younger women, those with chronic low back pain may have an increased risk of diabetes.

Individuals at high risk for type 2 diabetes invited to a lifestyle program: characteristics of participants versus non-participants (the HUNT Study) and 24-month follow-up of participants (the VEND-RISK Study)

OBJECTIVE

Prevention of type 2 diabetes mellitus is possible through lifestyle programs, but the effect depends on the program's content, resources, and setting. Lifestyle programs are often confronted with high rates of non-participation and attrition. This study invited individuals at high risk for type 2 diabetes to a lifestyle program in the Norwegian primary healthcare setting. The aims were to investigate possible differences in characteristics between participants and non-participants and to study the effect of the lifestyle program at 24-month follow-up for participants.

RESEARCH DESIGN AND METHODS

Individuals identified at high risk for type 2 diabetes during the third survey of the Nord-Trøndelag Health Study (HUNT3) from two municipalities (n=332) were invited to a lifestyle program (the VEND-RISK Study). A cross-sectional design was used to explore if the participants' characteristics differed from non-participants. A non-randomized, single-arm, pre-post examination was used to examine the effect of the lifestyle program on participants' characteristics at 24-month follow-up.

RESULTS

Of all individuals at high risk for type 2 diabetes invited to the lifestyle program, 86% (287/332) declined to participate. Non-participating women had fewer years of education (p<0.001), compared with participating women. For men, no differences were seen between non-participants and participants. Among all participants (n=45) at 24-month follow-up, none had developed type 2 diabetes, and HbA_1c (p<0.001) had decreased significantly. There was a small reduction in mean body mass index from baseline to 24 months that was not statistically significant. For women, waist circumference (-4.0 cm, p<0.001) decreased significantly.

CONCLUSIONS

Future research regarding individuals at high risk for type 2 diabetes in the primary healthcare lifestyle program should focus on how to promote recruitment of women with low education. Participants attending this study's lifestyle program improved their cardiometabolic markers.

CLINICAL TRIALS REGISTRATION

NCT01135901; Results.

Diabetes and obesity in Northern Sweden: occurrence and risk factors for stroke and myocardial infarction

Aims: The authors describe the occurrence of diabetes and obesity in the population of Northern Sweden and the role of diabetes in cardiovascular disease. Methods: Four surveys of the population aged 25 to 64 years were undertaken during a 14-year time span. Stroke events in subjects 35 - 74 years during 1985 - 92 and myocardial infarction in subjects 25 - 64 years 1989 - 93 were registered. Results: The prevalence of diagnosed diabetes was 3.1 and 2.0% in men and women, respectively, and 2.6 and 2.7% for previously undiagnosed diabetes. During the 13-year observation period, BMI increased 0.96 kg/m2 in men and 0.87 in women. The proportion of subjects with obesity (BMI≥30) increased from 10.3% to 14.6% in men and from 12.5% to 15.7% in women. Hip circumference increased substantially more than waist circumference, leading to a decreasing waits-to-hip ratio (WHR). The relative risk for stroke or myocardial infarction was four to six times higher in a person with diabetes than in those without diabetes. The 28-day case fatality for myocardial infarction, but not for stroke, was significantly higher in both men and women with diabetes. Population-attributable risk for diabetes and stroke was 18% in men and 22% in women and for myocardial infarction it was 11% in men and 17% in women. Conclusion: Obesity is becoming more common, although of a more distal than central distribution. The burden of diabetes in cardiovascular diseases in Northern Sweden is high.

Health inequalities by socioeconomic status among men in the Nord-Trøndelag Health Study, Norway

Aims: This study describes inequalities and trends in health according to socioeconomic status in the Nord-Trøndelag Health Study (HUNT I and II) and contribute to the ongoing discussion on the magnitude of inequalities in health in the Nordic welfare states. To produce data comparable to recent European studies, occupational data in the HUNT Study were reclassifi ed according to the international Erikson Goldthorpe Portocarero (EGP) social class scheme. Methods: Two cross-sectional health surveys were undertaken with a 10-year interval, HUNT I (1984-86) and HUNT II (1995-97). This was a primary healthcare, total-county population study, participants for this analysis being men aged 25-69 years. Results: A consistent pattern was found of increasing health problems with decreasing socioeconomic status for four health variables: self-perceived health, temporary disability, any long-standing health problem, and chronic conditions. The prevalence ratio between the highest and lowest status groups for ``perceived health less than good'' was 2.0 in the first survey and 2.1 in the second 10 years later. The magnitude of differences for the other health outcomes was at this level or smaller, with no signifi cant overall time trend from the mid-1980s to the mid-1990s. Conclusions: The magnitude of socioeconomic gradients in health in this study seemed somewhat smaller than results from national studies, and on the average compared to studies from other European countries; there was no detectable time trend in health differentials. International comparative studies have suggested considerably larger inequalities in health according to social class in Norway using national data.

Telemedicine Versus Standard Follow-Up Care for Diabetes-Related Foot Ulcers: Protocol for a Cluster Randomized Controlled Noninferiority Trial (DiaFOTo)

Background

This paper presents the protocol for an ongoing study to evaluate a telemedicine follow-up intervention for patients with diabetes-related foot ulcers. Diabetes-related foot ulcers represent challenges for patients and the health services. The large increase in the prevalence of diabetes, combined with the aging population, means that the absolute number of patients with diabetes-related foot ulcers is likely to continue to increase. Health care services therefore need to provide close clinical follow-up care for people with diabetes both in primary and specialist care. Information and communication technologies may enable more integrated treatment and care pathways across organizational boundaries. However, we lack knowledge about the effect of telemedicine follow-up and how such services can be optimally organized.

Objective

To present the design and methods of a study evaluating a telemedicine follow-up intervention for patients with diabetes-related foot ulcers.

Methods

The study is designed as a cluster randomized controlled trial (noninferiority trial) involving municipalities or municipality districts (clusters) belonging to one clinical site in Western Norway. The study includes patients with type 1 and type 2 diabetes presenting with a new foot ulcer at the initial visit to the clinic. Patients in the intervention group receive telemedicine follow-up care in the community. The key ingredient in the intervention is the close integration between health care levels. The intervention is facilitated by the use of an interactive wound platform consisting of a Web-based ulcer record combined with a mobile phone, enabling counseling and communication between nurses in the community and specialist health care. Patients in the control group receive standard hospital outpatient care. The primary endpoint in the trial is healing time; secondary outcomes include amputation and death, patient-reported outcome measures, and follow-up data on the recurrence of foot ulcers. In addition, qualitative substudies are being performed to provide a more comprehensive evaluation of the ongoing processes during the trial with the patients in the intervention and control groups and those health care professionals either working in primary care or in specialist care delivering the intervention.

Results

The project has been funded. The inclusion of patients started in September 2012. Because recruitment goals were not met in the initial period, two more clinical sites have been included to meet sample size requirements. Patient recruitment will continue until June 2016. Data collection in the qualitative substudies has been completed.

Conclusions

This telemedicine trial operates in a novel setting and targets patients with diabetes-related foot ulcers during a 12-month follow-up period. The trial addresses whether integrated care using telemedicine between primary and specialist health care can be an equivalent alternative to standard outpatient care.

Trial Registration

ClinicalTrials.gov NCT01710774; https://clinicaltrials.gov/ct2/show/NCT01710774 (Archived by WebCite at http://www.webcitation.org/6im6KfFov).

Prevalence and incidence of diabetes mellitus: a nationwide population-based pharmaco-epidemiological study in Sweden

AIM

To investigate the changes in prevalence and incidence of pharmacologically and non-pharmacologically treated diabetes in Sweden during 2005 to 2013.

METHODS

We obtained data on gender, date of birth and pharmacologically and non-pharmacologically treated diabetes from national registers for all Swedish residents.

RESULTS

During the study period a total of 240 871 new cases of pharmacologically treated diabetes was found. The age-standardized incidence during the follow-up was 4.34 and 3.16 per 1000 individuals in men and women, respectively. A decreasing time trend in incidence for men of 0.6% per year (0.994, 95% CI 0.989-0.999) and for women of 0.7% per year (0.993, 95% CI 0.986-0.999) was observed. The age-standardized prevalence increased from 41.9 and 29.9 per 1000 in 2005/2006 to 50.8 and 34.6 in 2012/2013 in men and women, respectively. This corresponds to an annually increasing time trend for both men (1.024, 95% CI 1.022-1.027) and women (1.019, 95% CI 1.016-1.021). The total age-standardized prevalence of pharmacologically and non-pharmacologically treated diabetes (2012) was 46.9 per 1000 (55.6 for men and 38.8 for women). This corresponds to an annually increasing time trend (2010-2012) for both men (1.017, 95% CI 1.013-1.021) and women (1.012, 95% CI 1.008-1.016).

CONCLUSIONS

The prevalence of pharmacologically treated diabetes increased moderately during 8 years of follow-up, while the incidence decreased modestly. This is in contrast to the results reported by most other studies. The total prevalence of diabetes (both pharmacologically and non-pharmacologically treated) in Sweden is relatively low, from a global viewpoint.

Changes in body mass index and the prevalence of obesity during 1994-2008: repeated cross-sectional surveys and longitudinal analyses. The Tromsø Study

OBJECTIVES

To determine the mean body mass index (BMI, kg/m(2)) and prevalence of low weight (BMI<20) and obesity (BMI ≥ 30) in 3 population-based surveys, and to describe the longitudinal changes during 1994-2008 in mean BMI, and the prevalence of low weight and obesity.

SETTING

A population study in Tromsø, Norway.

PARTICIPANTS

A total of 29,688 different participants in 1 or more of 3 surveys (1994-1995, 2001-2002 and 2007-2008). Longitudinal analyses comprised 9845 participants aged 25-69 in 1994 who participated in the 1994-1995 and 2007-2008 surveys and 4202 men and women who participated in all 3 surveys.

OUTCOME MEASURES

Mean age-specific and sex-specific BMI, prevalence of low weight and obesity, and changes in BMI and prevalence of low weight and obesity during 1994-2008, according to sex and birth cohort.

RESULTS

The age-adjusted (ages 30-84) prevalence of obesity increased from 9.8% and 11.8% in men and women, respectively, in 1994-1995 to 20.9% and 18.5%, respectively, in 2007-2008. The increase in mean age-adjusted BMI was stronger from 1994-1995 to 2001-2002 than from 2001-2002 to 2007-2008. Longitudinal results confirmed that the change in BMI from 1994-1995 to 2001-2002 was larger (0.9 kg/m(2) (95% CI 0.8 to 1.0) in men and 1.3 kg/m(2) (95% CI 1.2 to 1.4) in women) than from 2001-2002 to 2007-2008 (0.2 kg/m(2) (95% CI 0.1 to 0.3) in men and women). The most recently born had the largest increase (p<0.001).

CONCLUSIONS

The mean BMI and the prevalence of obesity are still increasing in Tromsø, and the increase is strongest in the youngest age groups. However, the increase in BMI was less marked in the last period (from 2001-2002 to 2007-2008) than in the first period (1994-1995 to 2001-2002).

The predictive effect of body mass index on type 2 diabetes in the Norwegian women and cancer study

Background

Several studies have analyzed the association of body mass index (BMI) with either the prevalence or incidence of type 2 diabetes (T2D), but no study from Europe or North America has yet analyzed and compared the association of BMI with both incident and prevalent T2D cases.

Methods

Stratified logistic regression was used to calculate odds ratios (OR), and stratified Cox proportional hazards regression was used to calculate hazard ratios (HR) of the effect of BMI on the prevalence, and incidence of T2D. Wald chi-square statistics were applied when comparing the risk estimates.

Results

Among prevalent T2D cases, overweight women (BMI 25–29.9 kg/m²) had an OR of 2.83 (95% confidence interval [CI], 1.92-4.18) and obese women (BMI ≥30 kg/m²) had an OR of 12.12 (95% CI, 8.32-17.68) when compared with normal weight women (BMI <25 kg/m²). Among incident T2D cases, overweight women had a HR of 5.01 (95% CI, 3.59-6.98) and obese women had a HR of 15.99 (95% CI, 11.39-22.46) when compared with normal weight women. After stratification by level of physical activity, and adjustment for age, smoking status, and education level, the Wald chi-square statistic for BMI was 180.90 for prevalent T2D cases, and 262.03 for incident T2D cases.

Conclusion

The predictive effect of BMI was found to be stronger for T2D incidence than T2D prevalence.

Weight gain and the risk of knee replacement due to primary osteoarthritis: a population based, prospective cohort study of 225,908 individuals

OBJECTIVE

To study the association between weight gain and the risk of knee replacement (KR) due to primary osteoarthritis (OA), and to evaluate whether the association differs by age.

DESIGN

225,908 individuals from national health screenings with repeated measurements of height and weight were followed prospectively with respect to KR identified by linkage to the Norwegian Arthroplasty Register. Cox proportional hazard regression was used to calculate sex-specific relative risks (RR) of KR according to change in Body Mass Index (BMI) and weight, corresponding analyses were done for age categories at first screening.

RESULTS

During 12 years of follow up, 1591 participants received a KR due to primary OA. Men in the highest quarter of yearly change in BMI had a RR of 1.5 (95% confidence interval (CI) 1.1-1.9) of having a KR compared to those in the lowest quarter. For women the corresponding RR was 2.4 (95% CI 2.1-2.7). Men under the age of 20 at the first screening had a 26% increased risk for KR per 5 kg weight gain, for women the corresponding increase was 43%. At older age the association became weaker, and in the oldest it was lost.

CONCLUSIONS

Weight gain increases the risk for later KR both in men and women. The impact of weight gain is strongest in the young, at older age the association is weak or absent. Our study suggests that future OA may be prevented by weight control and that preventive measures should start at an early age.

Appetite Response among Those Susceptible or Resistant to Obesity

An alternative approach in determining cause, treatment, and prevention of obesity is to study those who appear resistant to the obesogenic environment. We examined appetite responses in 33 obesity resistant individuals (ORI) versus 28 obesity susceptible individuals (OSI). Fingerprick blood samples to measure ghrelin, total peptide YY (PYY), leptin, glucose, and insulin along with appetite ratings were collected at baseline and 15, 30, 60, 120, and 180 min following consumption of a standardized meal. Fasting, area under the curve (AUC), peak/nadir, and time to peak/nadir were compared. Participants completed the three factor eating questionnaire (TFEQ). No significant differences were observed for ghrelin or PYY. Higher leptin concentrations in the OSI disappeared after controlling for percent body fat (%BF). Significant differences in appetite ratings included a lower hunger nadir among OSI compared with ORI (P = 0.017). Dietary restraint (P < 0.001) and disinhibition (P < 0.001) were lower in ORI compared with OSI, with and without adjustment for %BF. Given the differential body weight of the study groups, similar observed ghrelin concentrations were unexpected, perhaps indicating OSI and ORI respond differently to the same ghrelin concentration. Also ORI response to hunger appears different as they exhibit lower levels of dietary restraint and disinhibition compared with OSI.

Does diabetes have a protective effect on migraine?

BACKGROUND

Diabetes is associated with an increased risk of several other chronic diseases. In contrast, a previous study found an inverse relation between diabetes and migraine, whereas another large population-based study showed that the prevalence of migraine among patients with diabetes varied strongly depending on age. We aimed to investigate how the prevalence of medically treated migraine in patients with diabetes varied depending on diabetic drug treatment, sex, and age in the complete Norwegian population.

METHODS

Data on all persons in Norway being prescribed medication for diabetes (n =124,649) or migraine (n = 81,225) in 2006 were obtained from the National Register of Prescriptions and analyzed in a cross-sectional design.

RESULTS

Persons using diabetic drugs had an overall reduced prevalence of medically treated migraine when compared with the nondiabetic population (odds ratio [OR] = 0.72 [95% confidence interval = 0.68-0.75]). The OR was strongly associated with age. Although young persons receiving oral diabetic medication had, in fact, an increased prevalence of medically treated migraine, the prevalence declined with increasing age to about the same reduced prevalence (OR = 0.4-0.6) for all types of diabetes treatment in patients 60 to 69 years of age. The prevalence was equally decreased between men and women.

CONCLUSIONS

The results suggest a markedly reduced prevalence of migraine among older patients with diabetes, when compared with the general population. One may speculate that the seemingly protective effect of diabetes on migraine could be a result of neuropathy.

Trans-ethnic fine-mapping of lipid loci identifies population-specific signals and allelic heterogeneity that increases the trait variance explained

Genome-wide association studies (GWAS) have identified ∼100 loci associated with blood lipid levels, but much of the trait heritability remains unexplained, and at most loci the identities of the trait-influencing variants remain unknown. We conducted a trans-ethnic fine-mapping study at 18, 22, and 18 GWAS loci on the Metabochip for their association with triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C), respectively, in individuals of African American (n = 6,832), East Asian (n = 9,449), and European (n = 10,829) ancestry. We aimed to identify the variants with strongest association at each locus, identify additional and population-specific signals, refine association signals, and assess the relative significance of previously described functional variants. Among the 58 loci, 33 exhibited evidence of association at P<1×10⁻⁴ in at least one ancestry group. Sequential conditional analyses revealed that ten, nine, and four loci in African Americans, Europeans, and East Asians, respectively, exhibited two or more signals. At these loci, accounting for all signals led to a 1.3- to 1.8-fold increase in the explained phenotypic variance compared to the strongest signals. Distinct signals across ancestry groups were identified at PCSK9 and APOA5. Trans-ethnic analyses narrowed the signals to smaller sets of variants at GCKR, PPP1R3B, ABO, LCAT, and ABCA1. Of 27 variants reported previously to have functional effects, 74% exhibited the strongest association at the respective signal. In conclusion, trans-ethnic high-density genotyping and analysis confirm the presence of allelic heterogeneity, allow the identification of population-specific variants, and limit the number of candidate SNPs for functional studies.

Lipid traits are heritable, but many of the DNA variants that influence lipid levels remain unknown. In a genomic region, more than one variant may affect gene expression or function, and the frequencies of these variants can differ across populations. Genotyping densely spaced variants in individuals with different ancestries may increase the chance of identifying variants that affect gene expression or function. We analyzed high-density genotyped variants for association with TG, HDL-C, and LDL-C in African Americans, East Asians, and Europeans. At several genomic regions, we provide evidence that two or more variants can influence lipid traits; across loci, these additional signals increase the proportion of trait variation that can be explained by genes. At some association signals shared across populations, combining data from individuals of different ancestries narrowed the set of likely functional variants. At PCSK9 and APOA5, the data suggest that different variants influence trait levels in different populations. Variants previously reported to alter gene expression or function frequently exhibited the strongest association at those signals. The multiple signals and population-specific characteristics of the loci described here may be shared by genetic loci for other complex traits.

The combined effect of leisure-time physical activity and diabetes on cardiovascular mortality: the Nord-Trondelag Health (HUNT) cohort study, Norway

OBJECTIVE

To examine if leisure-time physical activity could cancel out the adverse effect of diabetes on cardiovascular mortality.

RESEARCH DESIGN AND METHODS

This study prospectively examined the combined effect of clinical diabetes and reported leisure-time physical activity on cardiovascular mortality. Data on 53,587 Norwegian men and women participating in the population-based Nord-Trøndelag Health (HUNT) Study (1995-1997) were linked with the Cause of Death Registry at Statistics Norway.

RESULTS

Overall, 1,716 people died of cardiovascular disease during follow-up through 2008. Compared with the reference group of 3,077 physically inactive people without diabetes, 121 inactive people with diabetes had an adjusted hazard ratio (HR) of 2.81 (95% CI 1.93-4.07). The HR (95% CI) among people who reported ≥3 h of light activity per week was 0.89 (0.48-1.63) if they had diabetes (n = 403) and 0.78 (0.63-0.96) if they did not (n = 17,714). Analyses stratified by total activity level showed a gradually weaker association of diabetes with mortality with increasing activity level (P(interaction) = 0.003).

CONCLUSIONS

The data suggest that even modest physical activity may cancel out the adverse impact of diabetes on cardiovascular mortality.

Trends in overweight and obesity over 22 years in a large adult population: the HUNT Study, Norway

Some reports indicate that the obesity epidemic may be slowing down or halting. We followed body mass index (BMI) and waist circumference (WC) in a large adult population in Norway (n = 90 000) from 1984-1986 (HUNT1) through 1995-1997 (HUNT2) to 2006-2008 (HUNT3) to study whether this is occurring in Norway. Height and weight were measured with standardized and identical methods in all three surveys; WC was also measured in HUNT2 and HUNT3. In the three surveys, mean BMI increased from 25.3 to 26.5 and 27.5 kg m-2 in men and from 25.1 to 26.2 and 26.9 kg m-2 in women. Increase in prevalence of obesity (BMI ≥ 30 kg m-2) was greater in men (from 7.7 to 14.4 and 22.1%) compared with women (from 13.3 to 18.3 and 23.1%). In contrast, women had a greater increase in abdominal obesity (WC ≥ 102 cm for men and WC ≥ 88 cm for women). There was a continuous shift in the distribution curve of BMI and WC to the right, demonstrating that the increase in body weight was occurring in all weight groups, but the increase of obesity was greatest in the youngest age groups. Our data showed no signs of a halt in the increase of obesity in this representative Norwegian population.

Gender disparity in the secular trends for obesity prevalence in Korea: analyses based on the KNHANES 1998-2009

BACKGROUND/AIMS

A similar gender-associated trend in obesity is observed worldwide. Nevertheless, systematic analyses of gender-specific characteristics in the general Korean population are rare.

METHODS

We analyzed the prevalence of obesity in Korean adults aged ≥ 19 years based on data collected from the Korea Health and Nutrition Examination Surveys I to IV, and verified the obesity prevalence characteristics by gender.

RESULTS

The prevalence of obesity in Korean males increased during the past 12 years from 25.1% to 35.7%, and the trend for an increase in obesity was significant in all age groups (p < 0.001). In contrast, no significant trend over the past 12 years was identified for females, but the prevalence of obesity in the 30- to 39-year, 40- to 49-year, and 50- to 59-year subgroups decreased significantly (p < 0.05). However, the obesity prevalence in the 60- to 69-year and > 70-year female subgroups increased significantly (p < 0.05).

CONCLUSIONS

We observed a gradually widening gender disparity due to an increase in the prevalence of male obesity and a decrease in the obesity prevalence among young and middle-aged women.

Cohort Profile: the HUNT Study, Norway

The HUNT Study includes large total population-based cohorts from the 1980ies, covering 125 000 Norwegian participants; HUNT1 (1984-86), HUNT2 (1995-97) and HUNT3 (2006-08). The study was primarily set up to address arterial hypertension, diabetes, screening of tuberculosis, and quality of life. However, the scope has expanded over time. In the latest survey a state of the art biobank was established, with availability of biomaterial for decades ahead. The three population based surveys now contribute to important knowledge regarding health related lifestyle, prevalence and incidence of somatic and mental illness and disease, health determinants, and associations between disease phenotypes and genotypes. Every citizen of Nord-Trøndelag County in Norway being 20 years or older, have been invited to all the surveys for adults. Participants may be linked in families and followed up longitudinally between the surveys and in several national health- and other registers covering the total population. The HUNT Study includes data from questionnaires, interviews, clinical measurements and biological samples (blood and urine). The questionnaires included questions on socioeconomic conditions, health related behaviours, symptoms, illnesses and diseases. Data from the HUNT Study are available for researchers who satisfy some basic requirements (www.ntnu.edu/hunt), whether affiliated in Norway or abroad.

Evaluation of a risk factor scoring model in screening for undiagnosed diabetes in China population

OBJECTIVE

To develop a risk scoring model for screening for undiagnosed type 2 diabetes in Chinese population.

METHODS

A total of 5348 subjects from two districts of Jinan City, Shandong Province, China were enrolled. Group A (2985) included individuals from east of the city and Group B (2363) from west of the city. Screening questionnaires and a standard oral glucose tolerance test (OGTT) were completed by all subjects. Based on the stepwise logistic regression analysis of Group A, variables were selected to establish the risk scoring model. The validity and effectiveness of this model were evaluated in Group B.

RESULTS

Based on stepwise logistic regression analysis performed with data of Group A, variables including age, body mass index (BMI), waist-to-hip ratio (WHR), systolic pressure, diastolic pressure, heart rate, family history of diabetes, and history of high glucose were accepted into the risk scoring model. The risk for having diabetes increased along with aggregate scores. When Youden index was closest to 1, the optimal cutoff value was set up at 51. At this point, the diabetes risk scoring model could identify diabetes patients with a sensitivity of 83.3% and a specificity of 66.5%, making the positive predictive value 12.83% and negative predictive value 98.53%. We compared our model with the Finnish and Danish model and concluded that our model has superior validity in Chinese population.

CONCLUSIONS

Our diabetes risk scoring model has satisfactory sensitivity and specificity for identifying undiagnosed diabetes in our population, which might be a simple and practical tool suitable for massive diabetes screening.

No increase in prevalence of Barrett's oesophagus in a surgical series of obese patients referred for laparoscopic gastric banding

INTRODUCTION

Obesity is a risk factor for gastroesophageal reflux and oesophageal adenocarcinoma. However, only a few studies have examined obesity and lifestyle risk factors in relation to Barrett's oesophagus. In this prospective study we assessed the presence of oesophagitis and Barrett's oesophagus in obese patients selected for laparoscopic gastric banding.

METHODS

1049 obese patients were referred for laparoscopic gastric banding (233 males; mean age 41.0±10.7 years). oesophagogastroduodenoscopy was performed before surgery to check for upper gastrointestinal tract disorders, especially hiatal hernia, signs of inflammation and/or erosions and/or ulcers of the oesophageal mucosa, and Barrett's epithelium.

RESULTS

Mean body mass index was 45.15±6.46 kg/m(2). Overall 86/1049 (8.2%) patients had endoscopic signs of oesophagitis: 84 grade A, 1 grade B and 1 grade C, according to the Los Angeles classification. Hiatal hernia was detected in 127 patients (12.1%), with a mean size of 2.1±0.7 cm (range 1-4 cm); of these, 38 (29.9%) had oesophagitis (37 grade A and 1 grade B). No patients had any visible length of columnar epithelium.

CONCLUSIONS

We could not confirm a high prevalence of Barrett's oesophagus in this series of obese patients.

Fine mapping of five loci associated with low-density lipoprotein cholesterol detects variants that double the explained heritability

Complex trait genome-wide association studies (GWAS) provide an efficient strategy for evaluating large numbers of common variants in large numbers of individuals and for identifying trait-associated variants. Nevertheless, GWAS often leave much of the trait heritability unexplained. We hypothesized that some of this unexplained heritability might be due to common and rare variants that reside in GWAS identified loci but lack appropriate proxies in modern genotyping arrays. To assess this hypothesis, we re-examined 7 genes (APOE, APOC1, APOC2, SORT1, LDLR, APOB, and PCSK9) in 5 loci associated with low-density lipoprotein cholesterol (LDL-C) in multiple GWAS. For each gene, we first catalogued genetic variation by re-sequencing 256 Sardinian individuals with extreme LDL-C values. Next, we genotyped variants identified by us and by the 1000 Genomes Project (totaling 3,277 SNPs) in 5,524 volunteers. We found that in one locus (PCSK9) the GWAS signal could be explained by a previously described low-frequency variant and that in three loci (PCSK9, APOE, and LDLR) there were additional variants independently associated with LDL-C, including a novel and rare LDLR variant that seems specific to Sardinians. Overall, this more detailed assessment of SNP variation in these loci increased estimates of the heritability of LDL-C accounted for by these genes from 3.1% to 6.5%. All association signals and the heritability estimates were successfully confirmed in a sample of ∼10,000 Finnish and Norwegian individuals. Our results thus suggest that focusing on variants accessible via GWAS can lead to clear underestimates of the trait heritability explained by a set of loci. Further, our results suggest that, as prelude to large-scale sequencing efforts, targeted re-sequencing efforts paired with large-scale genotyping will increase estimates of complex trait heritability explained by known loci.

Despite the striking success of genome-wide association studies in identifying genetic loci associated with common complex traits and diseases, much of the heritable risk for these traits and diseases remains unexplained. A higher resolution investigation of the genome through sequencing studies is expected to clarify the sources of this missing heritability. As a preview of what we might learn in these more detailed assessments of genetic variation, we used sequencing to identify potentially interesting variants in seven genes associated with low-density lipoprotein cholesterol (LDL-C) in 256 Sardinian individuals with extreme LDL-C levels, followed by large scale genotyping in 5,524 individuals, to examine newly discovered and previously described variants. We found that a combination of common and rare variants in these loci contributes to variation in LDL-C levels, and also that the initial estimate of the heritability explained by these loci doubled. Importantly, our results include a Sardinian-specific rare variant, highlighting the need for sequencing studies in isolated populations. Our results provide insights about what extensive whole-genome sequencing efforts are likely to reveal for the understanding of the genetic architecture of complex traits.

Risk factors for type 2 diabetes among female Pakistani immigrants: the InvaDiab-DEPLAN study on Pakistani immigrant women living in Oslo, Norway

The risk for type 2 diabetes (T2D) in Pakistani immigrants is high. The aim of this study was to provide an update of the risk of T2D and the metabolic syndrome (MetS) in female Pakistani immigrants living in Oslo, Norway. Female Pakistani immigrants (n = 198, age 25-63) were interviewed, and data related to T2D, including anthropometric measurements, blood data, heart rate, and level of physical activity, were determined. Ninety-eight percentage had body mass index (BMI > 23 kg m(-2)) and 39% were obese (BMI ≥ 30). Impaired glucose tolerance (IGT) was found in 37%, MetS in 41%, and T2D in 13%, using fasting glucose. By score evaluation, approximately 90% had risk of T2D. The participants had low energy expenditure, despite acceptable number of steps walked during a day. The risk of T2D is very high in female Pakistani immigrants in Oslo.

The prevalence of peripheral neuropathy in a population-based study of patients with type 2 diabetes in Sweden

AIMS

To assess peripheral neuropathy following a standardized foot examination protocol in a representative population-based cohort of subjects with type 2 diabetes.

METHODS

In a geographically defined population, aged 40-70 years with diabetes prevalence of 3.5% according to medical records, we investigated 156 type 2 diabetic subjects, 95% Caucasian, mean age 61.7±7.2 years, duration of diabetes 7.0±5.7 years, and HbA(1c) 7.3±2.4% (6.4% Mono-S), by questionnaires, clinical examinations, blood sampling, and review of medical records. Foot examination included clinical signs of peripheral neuropathy and tests of sensibility with monofilament, tuning fork, and assessments of the vibration perception thresholds (VPT).

RESULTS

Peripheral autonomic neuropathy (PAN) as judged by two or more signs of dysfunction was the most common and affected 43%. The prevalence of peripheral sensory neuropathy (PSN) was 15% by monofilament, 24% by tuning fork, and 28% by VPT expressed as ZscoreVPT ≥2.0 S.D. Twenty-nine percent had a VPT ≥25 V. Signs of peripheral motor neuropathy (PMN) affected 15%. Peripheral neuropathy, at least one variable, affected 67%, whereas 25% were affected by more than one variable of neuropathy, i.e., polyneuropathy. Exclusion of other identified causes for neuropathy than diabetes reduced the prevalence of diabetic polyneuropathy to 23%. Concurrent diabetic complications were 29% for retinopathy, 14% for incipient nephropathy, and 8% for overt nephropathy. The prevalence of macrovascular complications was 62% for CVD, 26% for PVD, and 11% for cerebrovascular lesion (CVL).

CONCLUSION

Peripheral neuropathy was common in this representative type 2 diabetes population. Clinical signs of PAN were the most frequent followed by diminished perception of vibration and touch.

Lower limb amputations in Trondheim, Norway

BACKGROUND AND PURPOSE

In the city of Trondheim, Norway, diabetic lower-limb amputations accounted for one-third of all lower-limb amputations (LLAs). In an attempt to reduce this rate, a diabetic foot team was established in 1996. We present the incidence of LLA in Trondheim as measured 10 years later.

PATIENTS AND METHODS

In 2004-07, we registered all LLAs performed in Trondheim and then compared the data with previously published data from 1994-1997. From 1996 through 2006, we registered the activity of the diabetic foot team and we also registered the number of vascular procedures performed on citizens of Trondheim from 1998 through 2006.

RESULTS

Comparing the two 3-year periods 1994-97 and 2004-07, we observed a decrease in all non-traumatic LLAs. The incidence of diabetic major LLAs per 10³ diabetics per year decreased from 4.0 to 2.4, and in patients with peripheral vascular disease we observed a decrease in LLAs from 18 to 12 per 10⁵ inhabitants per year. 5,915 consultations on diabetic subjects were conducted by the diabetic foot team during the period 1996-2006. From 1998 to 2006, the rate of vascular procedures decreased in the non-diabetic population, and was unchanged in diabetic subjects.

INTERPRETATION

In the population of Trondheim city there appears to have been a reduction in the rate of vascular obstructive lower-limb disease between the two 3-year periods 1994-97 and 2004-07. In our judgment, the decline in diabetic LLA also reflects better care of the diabetic foot.

Increasing glucose concentrations and prevalence of diabetes mellitus in northern Sweden, 1990-2007

Background

The prevalence of diabetes in the world is projected to rise from 2.8% in the year 2000 to 4.4% in 2030, an increase suggesting an ongoing global epidemic of diabetes.

Objective

To examine time trends in fasting and 2-h glucose concentrations, prevalence and 10-year cumulative incidence of diabetes, and the role of education in these trends.

Design

Each year the Västerbotten Intervention Programme invites all 40, 50, and 60-year-old individuals to a health survey, which includes a cardiovascular risk factor screening and oral glucose tolerance test. The cross-sectional part of the study is based on health examinations conducted between 1990 and 2007 (n = 102,822). The prospective subset (panel dataset) of the study is based on individuals who have had two health examinations 10 years apart and were not defined as having diabetes at their first health examination (n = 23,546).

Results

Between 1990 and 2007, the mean population fasting glucose concentration increased 0.5 mmol/L. Comparing the prevalence in 1990–1995 with 2002–2007 demonstrated a significant 44% increase in men (p < 0.001) and a significant 17% increase in women (p<0.001). Socioeconomic status, here represented by education, clearly influenced both prevalence and incidence of diabetes and glucose concentration. In all time periods and in all age groups, individuals with low education were more likely to have or get diabetes. The 10-year risk of developing diabetes was four to five times higher in the oldest age group (50–60 years) compared with the youngest (30–40 years). A 30% reduction in the 10-year risk of developing diabetes was found in women (p<0.001) between 2000–2003 and 2004–2007.

Conclusions

Despite a clear increase in glucose concentrations and diabetes prevalence between 1990 and 2007, especially in men, there was a decline in the 10-year risk of developing diabetes in women between 2000–2003 and 2004–2007.

Suggestive evidence of associations between liver X receptor β polymorphisms with type 2 diabetes mellitus and obesity in three cohort studies: HUNT2 (Norway), MONICA (France) and HELENA (Europe)

BACKGROUND

The liver X receptors (LXR) α and β regulate lipid and carbohydrate homeostasis and inflammation. Lxrβ⁻/⁻ mice are glucose intolerant and at the same time lean. We aimed to assess the associations between single nucleotide polymorphisms (SNPs) in LXRβ and risk of type 2 diabetes mellitus (T2DM), obesity and related traits in 3 separate cohort studies.

METHODS

Twenty LXRβ SNPs were identified by sequencing and genotyped in the HUNT2 adult nested case-control study for T2DM (n = 835 cases/1986 controls). Five tag-SNPs (rs17373080, rs2695121, rs56151148, rs2303044 and rs3219281), covering 99.3% of the entire common genetic variability of the LXRβ gene were identified and genotyped in the French MONICA adult study (n = 2318) and the European adolescent HELENA cross-sectional study (n = 1144). In silico and in vitro functionality studies were performed.

RESULTS

We identified suggestive or significant associations between rs17373080 and the risk of (i) T2DM in HUNT2 (OR = 0.82, p = 0.03), (ii) obesity in MONICA (OR = 1.26, p = 0.05) and (iii) overweight/obesity in HELENA (OR = 1.59, p = 0.002). An intron 4 SNP (rs28514894, a perfect proxy for rs17373080) could potentially create binding sites for hepatic nuclear factor 4 alpha (HNF4α) and nuclear factor 1 (NF1). The C allele of rs28514894 was associated with ~1.25-fold higher human LXRβ basal promoter activity in vitro. However, no differences between alleles in terms of DNA binding and reporter gene transactivation by HNF4α or NF1 were observed.

CONCLUSIONS

Our results suggest that rs17373080 in LXRβ is associated with T2DM and obesity, maybe via altered LXRβ expression.

Diabetes: cost of illness in Norway

BACKGROUND

Diabetes mellitus places a considerable burden on patients in terms of morbidity and mortality and on society in terms of costs. Costs related to diabetes are expected to increase due to increasing prevalence of type 2 diabetes. The aim of this study was to estimate the health care costs attributable to type 1 and type 2 diabetes in Norway in 2005.

METHODS

Data on inpatient hospital services, outpatient clinic visits, physician services, drugs, medical equipment, nutrition guidance, physiotherapy, acupuncture, foot therapy and indirect costs were collected from national registers and responses to a survey of 584 patients with diabetes. The study was performed with a prevalence approach. Uncertainty was explored by means of bootstrapping.

RESULTS

When hospital stays with diabetes as a secondary diagnosis were excluded, the total costs were €293 million, which represents about 1.4% of the total health care expenditure. Pharmaceuticals accounted for €95 million (32%), disability pensions €48 million (16%), medical devices €40 million (14%) and hospital admissions €21 million (7%). Patient expenditures for acupuncture, physiotherapy and foot therapy were many times higher than expenditure for nutritional guidance. Indirect costs (lost production from job absenteeism) accounted for €70.1 million (24% of the €293 million) and included sick leave (€16.7 million), disability support and disability pensions (€48.2 million) and other indirect costs (€5.3 million). If all diabetes related hospital stays are included (primary- and secondary diagnosis) total costs amounts to €535 million, about 2.6% of the total health care expenditure in Norway.

CONCLUSIONS

Diabetes represents a considerable burden to society in terms of health care costs and productivity losses.

Past and current weight change and forearm bone loss in middle-aged women: the Nord-Trøndelag Health Study, Norway

OBJECTIVE

The aim of this study was to investigate the association between bone loss and weight change before and concurrently to the assessment of forearm bone loss over 4.6 years in a population-based cohort of middle-aged women followed for more than 15 years.

METHODS

Among 8,856 women aged 45 to 60 years attending the first Nord-Trøndelag Health Study study, Norway (1984-1986), a 35% random sample was invited for forearm densitometry at Nord-Trøndelag Health Study 2 (1995-1997), and 2,188 women (78%) attended. After an average period of 4.6 years, they were subsequently invited for follow-up densitometry in 2001, and 1,421 women (67.8%) met. Weight and height were measured on all three occasions.

RESULTS

During the total period of observation since baseline (15.5 y), the mean weight had increased by 3.4 kg, mostly in the youngest women. Weight loss had an accelerating and weight gain a decelerating effect on bone loss, and this was observed both for weight change occurring before the bone mineral density follow-up and for concurrent weight change. The relationship between prior weight gain or loss and bone loss seemed to persist, independent of the weight change observed during the period of bone loss assessment.

CONCLUSIONS

Despite no mechanical impact of body weight on the forearm, weight loss in midlife women seems to be associated with a long-lasting negative effect on bone and vice versa for weight gain. This is presumably explained by humoral factors.

Ethnic differences in the prevalence of general and central obesity among the Sami and Norwegian populations: the SAMINOR study

AIMS

To estimate the prevalence of general (body mass index) and central (waist circumference and waist/hip ratio) obesity in an area with a mixed Sami and Norwegian population.

METHODS

A cross-sectional population-based study carried out in 2003- 2004, the SAMINOR study. The attendance rate was 60.6%. A total of 7,301 men and 7,841 women, aged 36-79, were included in the analyses. Height, weight, waist and hip circumference were measured, body mass index (BMI) calculated and information concerning lifestyle was collected by questionnaire.

RESULTS

The prevalence of general obesity (BMI > or = 30 kg/m(2)) in participants who had Sami as their home language for three generations (Sami I) and Norwegian participants was 38.7% and 24.3% for women respectively; and for men 26.9% and 23.4% respectively. More than 40% of the women had central obesity (waist circumference > or = 88 cm), and the highest prevalence was found in Sami I women (45%). The highest prevalence of central obesity (waist circumference > or = 102 cm) was found in Norwegian men (24.2%). The ethnic differences persisted after adjustment for age, education, physical activity in leisure time, and smoking habits.

CONCLUSIONS

The prevalence of obesity was high in this population and central obesity was most pronounced in women, particularly in Sami women. Sami men were less obese than Norwegian men. Further studies are necessary to examine a possible explanation for these findings, especially to elaborate on the impact of diet.

Diabetes related risk factors did not explain the increased risk for urinary incontinence among women with diabetes. The Norwegian HUNT/EPINCONT study

BACKGROUND

Previous studies have shown an association between diabetes mellitus (DM) and urinary incontinence (UI) in women, especially severe UI. The purpose of this study was to investigate whether diabetes related variables could explain this association.

METHODS

The study is part of the EPINCONT study, which is based on the large Nord-Trøndelag Health Study 2 (HUNT 2), performed in the county of Nord-Trøndelag, Norway, during the years 1995 - 1997. Questions on diabetes and UI were answered by a total of 21 057 women aged 20 years and older. Of these 685 were identified as having diabetes, and thus comprise the population of our study. A variety of clinical and biochemical variables were recorded from the participants.

RESULTS

Blood-glucose, HbA1c, albumine:creatinine ratio (ACR), duration of diabetes, diabetes treatment, type of diabetes, cholesterol and triglycerides did not significantly differ in women with and without UI in crude analyses. However, the diabetic women with UI had more hospitalizations during the last 12 months, more homecare, and a higher prevalence of angina and use of oestrogene treatment (both local and oral/patch). After adjusting for age, BMI, parity and smoking, there were statistically significant associations between any UI and angina (OR 1.89; 95% CI: 1.22 - 2.93), homecare (OR 1.72; 95% CI: 1.02 - 2.89), and hospitalization during the last 12 months (OR 1.67; 95% CI: 1.18 - 2.38). In adjusted analyses severe UI was also significantly associated with the same variables, and also with diabetes drug treatment (OR 2.10; 95% CI: 1.07 - 4.10) and stroke (OR 2.47; 95% CI: 1.09 - 5.59).

CONCLUSION

No single diabetes related risk factor seems to explain the increased risk for UI among women with diabetes. However, we found associations between UI and some clinical correlates of diabetes.

Age, period and cohort effects on body weight and body mass index in adults: The Doetinchem Cohort Study

Objective

To study the development of body weight with ageing, in a general adult population, taking into account possible period and cohort effects.

Design

A prospective cohort study with 11 years of follow-up. At baseline and after 6 and 11 years, body weight and height were measured.

Setting

The Doetinchem Cohort Study, consisting of inhabitants of Doetinchem, a town in a rural area of The Netherlands.

Subjects

In total, 4070 healthy men and women aged 20–59 years at baseline.

Results

Increase in BMI with ageing was less profound based on cross-sectional data than based on longitudinal data. More recent-born cohorts had a higher BMI at a given age than cohorts who were born earlier. Increase in mean BMI with ageing was observed in all age groups and was similar for groups with a different educational level. Highest increase in BMI over 11 years was observed in the youngest group, aged 20–29 years at baseline (2·2 [95 % CL 2·0, 2·3] kg/m2), and lowest increase in the oldest group, aged 50–59 years at baseline (1·1 [1·0, 1·3] kg/m2).

Conclusions

Findings of the present study using longitudinal data suggest that increase in BMI with ageing is underestimated in all age groups by studying cross-sectional data only. Further, weight gain is present in all educational levels and does not stop at middle age.

Comparison of genetic risk in three candidate genes (TCF7L2, PPARG, KCNJ11) with traditional risk factors for type 2 diabetes in a population-based study--the HUNT study

We studied the impact of genetic and traditional risk factors for type 2 diabetes in a large, population-based study from Nord-Trøndelag county in Norway (HUNT), in both cross-sectional and prospective design.

MATERIAL AND METHODS

65,905 individuals participated in the HUNT study. We studied a randomly selected group of 869 individuals with self-reported diabetes or non-fasting serum glucose >or=11.1 mmol/L and 2,080 non-diabetic control subjects with non-fasting serum glucose <5.5 mmol/L. Four candidate polymorphisms in the three genes TCF7L2 (rs12255372 and rs7903146), PPARG (rs1801282), KCNJ11 (rs5219) and traditional risk factors were studied.

RESULTS

Risk alleles of the TCF7L2 gene showed increased risk of diabetes even when controlled for traditional diabetes risk factors (diabetes in family, waist circumference, physical activity, BMI, SBP and total and HDL-cholesterol) in both a cross-sectional and prospective setting (cross-sectional: rs12255372 OR 1.61 (1.31-1.99), rs7903146 OR 1.48 (1.20-1.83) and prospective: rs12255372 OR 1.59 (1.22-2.07), rs7903146 OR 1.47 (1.11-1.93)). The risk alleles of TCF7L2 indicated impaired beta-cell function in patients and control subjects. The population attributable risks for diabetes with TCF7L2 risk alleles were 15 % and with diabetes in a first-degree relative 31 %.

CONCLUSION

The risk alleles of the TCF7L2 gene (rs12255372 and rs7903146) were strongly associated with type 2 diabetes, even after controlling for traditional risk factors in both a cross-sectional and prospective setting. These risk alleles were associated with indices of reduced beta-cell function.

Can individuals with a significant risk for cardiovascular disease be adequately identified by combination of several risk factors? Modelling study based on the Norwegian HUNT 2 population

RATIONALE, AIMS AND OBJECTIVES

Clinicians are generally advised to consider several risk factors when evaluating patients' cardiovascular disease (CVD) risk. Our aim was to study whether combined assessment of five traditional risk factors might help doctors demarcate a relatively distinct and manageable group of high-risk individuals. We selected five modifiable risk factors and estimated the proportion of a well-defined population with 'unfavourable' levels of at least two of them, as defined by four internationally renowned guidelines. The impact of including so-called 'prehypertension' among the risk factors was specifically addressed, and the results are discussed in a wider perspective.

MATERIAL AND METHODS

Guideline implementation was modelled on data from a cross-sectional Norwegian population study comprising 62 104 adults aged 20-79 years (The Nord-Tröndelag Health Study 1995-7). Total, age- and gender-specific point prevalences of individuals with zero, one, two, three or more factors, in addition to established disease, were calculated.

RESULTS

One single CVD risk factor was exhibited by 12.4% of the population; two factors by 21.5%; and three or more by 49.7%. Established CVD or diabetes mellitus was reported by 12.5%. In total, 83.7% of the population exhibited a risk or disease profile with at least two factors, if prehypertension was included.

CONCLUSIONS

If guideline recommendations are literally applied, as many as 84% of adults in Norway could exhibit two or more CVD or risk factors and thus be considered in need of individual, clinical attention. This challenges the widely held presumption that 'the net will close' around a manageable group of individuals-at-risk if several risk factors are jointly considered. As the finding of this study arises in one of the world's most long- and healthy-living populations, it raises several practical as well as ethical questions.

Prevalence and incidence of Type 2 diabetes and its complications 1996-2003--estimates from a Swedish population-based study

AIMS

To determine the prevalence and incidence of Type 2 diabetes and its complications in Uppsala county, Sweden between 1996 and 2003.

METHODS

Retrospective population-based study of patients with Type 2 diabetes identified in computerized medical records at 26 county primary care centres. Prevalence and incidence of Type 2 diabetes were estimated in the population aged 30-39, 40-49, 50-59, 60-69, 70-79 and > or = 80 years. Mortality, prevalence and incidence of complications in patients with Type 2 diabetes were determined through linkage to national inpatient, uraemia and cause-of-death registers.

RESULTS

Crude prevalence of Type 2 diabetes increased from 2.2 to 3.5% between 1996 and 2003. In the population aged > or = 30 years, the age- and sex-adjusted period increase was 53%[odds ratio (OR) 1.53, 95% confidence interval (CI) 1.47-1.58]. Crude population incidence was approximately stable after 1997 (3.7 cases/1000 residents in 1997 compared with 3.8/1000 in 2003). Age- and sex-adjusted mortality rates in Type 2 diabetic patients decreased by 4% per year (OR 0.96, 95% CI 0.94-0.97). Prevalence rates of cardiovascular disease in Type 2 diabetic patients were essentially stable, affecting 13.8% of females and 18.0% of males in 2003. No trend was detected for prevalence of renal failure or incidence of acute myocardial infarction, stroke and amputation.

CONCLUSIONS

Prevalence of Type 2 diabetes increased in Uppsala county between 1996 and 2003 as a consequence of approximately stable incidence since 1997 and declining mortality. Rates of diabetes-related complications, notably cardiovascular disease, continued to impose a substantial burden.

An increase in prevalence of diabetes mellitus in Jordan over 10 years

OBJECTIVE

This study aimed to determine the prevalence of type 2 diabetes mellitus (DM) and impaired fasting glycemia (IFG), identify their associated factors, determine how the prevalence of type 2 DM has changed over 10 years, and assess the awareness and state of control of diabetes in Jordan.

METHODS

Data were analyzed from a cross-sectional study that included a random sample of 1121 Jordanians aged 25 years and above. A subject was deemed affected by DM if this diagnosis was known to the patient or if his or her condition complies with the American Diabetes Association definition. IFG was defined as a fasting serum glucose level of >or=6.1 mmol/l (110 mg/dl) but <7 mmol/l. HbA(1c) >7.5% was defined as "unsatisfactory" metabolic control.

RESULTS

The age-standardized prevalence of diabetes and IFG was 17.1% and 7.8%, respectively, with no significant differences between women and men. Of the 195 diabetic subjects, 146 (74.9%) had been previously diagnosed. More than half (54%) of those previously diagnosed were found to be with unsatisfactory glycemic control. Compared to the 1994 survey, there was a significant increase in the prevalence of diabetes by 31.5%. Increase in age, increase in body mass index, and having a family history of diabetes were associated with increased odds of diabetes and IFG. While the level of education had no effect on IFG, higher level of education was associated with a decrease in the odds of having diabetes.

CONCLUSION

The prevalence of type 2 diabetes and IFG is high in Jordan and is increasing. More than half of the patients with diabetes have unsatisfactory control. Therefore, they are likely to benefit from programs aimed at encouraging behaviors toward achieving optimum weight as well as physical activity behaviors. Physicians caring for patients with diabetes may need to adopt a more vigorous approach for diabetes control.