Holger Theobald

Gender differences in risk factor control and treatment profile in diabetes: a study in 229 swedish primary health care centres.

Objective To measure the risk factors and treatment profile of diabetes patients treated in primary health care (PHC) in order to evaluate potential gender differences. Design Cross-sectional survey of consecutive diabetes patients. Setting 229 PHC centres in Sweden. Subjects 5082 men and 4293 women with diabetes were investigated (1998–2001). Main outcome measures Glycaemic control (HbA1c), blood pressure, lipid levels, prevalence of left ventricular hypertrophy and microalbuminuria. Proportions of patients with previous ischaemic heart disease (IHD) and specific drug treatment. Results Male patients generally had better blood pressure (<140 and/or 85 mmHg) and glycaemic (HbA1c <6.5%) control than corresponding female patients (44% and 59%, versus 40% and 54% in the 60–75 year age group; p<0.01). Females showed higher levels of total (p<0.01) and HDL cholesterol (p<0.05) than males in all age groups. No gender difference was detected for LDL cholesterol levels in the younger or elderly patients, but in the age group 60–75 years female patients had significantly higher mean LDL cholesterol level than male patients (3.3 vs 3.2 mmol/L; p<0.05). Previously known manifestations of IHD were more common (p<0.01) in male patients. Conclusion Elderly male patients with diabetes had a more favourable risk factor control than corresponding female patients.

The association between BMI value and long-term mortality

Objectives:To study total mortality in different categories of BMI values, with adjustments for important covariates in a population-based 26-year mortality follow-up. Special interest will be given to gender differences and low BMI values.Methods:From a stratified sample in 1969 of 32 185 individuals aged 18–64 years from Stockholm County, 2422 underwent a health examination, with complete data obtained for 1020 subjects. BMI was classified as underweight (<20), normal (20–24.9), overweight (25–29.9) or obesity (⩾30). Participants were followed up in the National Cause of Death Register until the end of 1996. Multivariate analysis was performed by Cox regression for men and women separately, with different models, with step-wise adjustment for age, care need category, heart rate, hypertension, blood glucose, alcohol intake and smoking, with hazard ratios (HR) and 95% confidence interval (CI) and with normal weight as reference.Results:Among men, the age-adjusted HR was 1.68 (95% CI 1.10–2.57) for underweight and 1.62 (95% CI 1.08–2.43) for obesity, and among women it was 0.93 (95% CI 0.58–1.51) for underweight and 1.88 (95% CI 1.26–2.82) for obesity. In men, the significantly increased mortality remained when also adjusting for care need category, but not when adjusting for other factors, whereas the opposite was found regarding obesity. For women, underweight was significantly associated with decreased mortality when adjusting for smoking and for all factors together, whereas obesity was associated with increased mortality when adjusting for the different factors except for all factors together.Conclusions:Underweight was associated with higher mortality among men, but not when adjusting for covariates, whereas underweight was associated with lower mortality among women when adjusting for smoking.

Sex differences in risk factor control of treated hypertensives: a national primary healthcare-based study in Sweden.

Background To evaluate potential sex differences, this study aimed to investigate blood pressure and lipid control and other risk factors for cardiovascular disease in treated hypertensive (tHT) patients from primary healthcare. Design and methods This cross-sectional survey of tHT patients was carried out between 2002 and 2005 by 264 primary care physicians from Sweden who consecutively recruited 6537 tHT patients (48% men and 52% women) from medical records. Results tHT men more often reached the treatment goal for systolic/diastolic blood pressure, less than 140/90 mmHg, than tHT women (30 vs. 26%, P < 0.01). Men had lower systolic blood pressure than women, however, women had lower diastolic blood pressure and higher pulse pressure. More tHT women had total cholesterol ≥ 5.0 mmol/l than corresponding men (75 vs. 64% P < 0.001). Men more often had diabetes (25 vs. 20% P < 0.001), left ventricular hypertrophy (20 vs. 16% P < 0.001), and microalbuminuria (24 vs. 16% P < 0.001). Women were more often treated with diuretics (64 vs. 48%) and β-receptor blockers (54 vs. 51%), and men more often treated with angiotensin-converting enzyme inhibitors (27 vs. 18%), calcium channel blockers (34 vs. 26%), and lipid-lowering drugs (34 vs. 29%). Conclusion A need still exists for more intensified treatment of elevated blood pressure and hypercholesterolemia, especially in women. In hypertensives of both sexes, smoking and other risk factors also need to be addressed to reduce the risk of cardiovascular disease.

Validity of the 12-item version of the General Health Questionnaire in detecting depression in the general population

OBJECTIVES The 12-item version of the General Health Questionnaire (GHQ-12) is frequently used to measure common mental disorder in public health surveys, but few population-based validations have been made. We validated the GHQ-12 against structured psychiatric interviews of depression using a population-based cohort in Stockholm, Sweden. METHODS We used a population-based cohort of 484 individuals in Stockholm, Sweden (participation rate 62%). All completed the GHQ-12 and a semi-structured psychiatric interview. Last month DSM-III-R symptoms were used to classify major and minor depression. Three scoring methods for GHQ-12 were assessed, the Standard, Likert and Corrected method. Discriminatory ability was assessed with area under the receiver operating characteristic (ROC) curve. RESULTS A total of 9.5% had a major or minor depression. The area under the ROC curve was for the Standard method 0.73 (0.65-0.82), the Likert method 0.80 (0.72-0.87) and the Corrected method 0.80 (0.73-0.87) when using major or minor depression as standard criterion. Adequate sensitivity and specificity for separating those with or without a depressive disorder was reached at ≥12 Likert scored points (80.4 and 69.6%) or ≥6 Corrected GHQ points (78.3 and 73.7%). Sensitivity and specificity was at ≥2 Standard scored points 67.4% and 74.2%. CONCLUSION When scored using the Likert and Corrected methods, the GHQ-12 performed excellently. When scored using the Standard method, performance was acceptable in detecting depressive disorder in the general population. The GHQ-12 appears to be a good proxy for depressive disorder when used in public health surveys.

Effects of drop out in a longitudinal study of musculoskeletal disorders

OBJECTIVES The drop out rates in different longitudinal studies of musculoskeletal disorders range between 7% and 57%, and little is known about the characteristics of the subjects who dropped out. The aim was to analyse various consequences of drop out in a longitudinal study of musculoskeletal disorders and occupational risk factors during 1969–97. METHOD Data about occupational conditions and health in 1969 and in 1993 were analysed. Differences between those who participated throughout (participants) and drop out subjects in these analyses formed the basis for recalculations of earlier reported analyses of associations between occupational conditions and low back pain. In the recalculation the data were weighted to compensate for the differences. RESULTS More female and male drop out subjects than participants in 1993 had monotonous work, fewer women and more male drop out subjects had heavy lifting in 1969. In 1997, more female and male drop out subjects had had heavy lifting and low stimulation at work in 1993. At both occasions, there were differences between the drop out subjects and participants in occurrence of musculoskeletal disorders. The weighted analyses resulted in changes in risk ratio of 0.1–0.2. CONCLUSIONS Differences in occupational conditions and health among participants and drop out subjects in a longitudinal study of musculoskeletal disorders and occupational risk factors during 1969–97 did not markedly influence the risk ratios.

Hypertensive smokers have a worse cardiovascular risk profile than non‐smokers in spite of treatment – A national study in Sweden

Smoking is a well‐established risk factor for cardiovascular disease. Studies have indicated that smoking may outweigh the benefit of blood pressure (BP) control. Our aim was to compare cardiovascular risk factors in smokers vs non‐smokers from a national sample of treated hypertensives. Data were collected on smoking habits, BP control, total and low‐density lipoprotein (LDL) cholesterol, diabetes, left ventricular hypertrophy (LVH), and microalbuminuria (MA), from records of 4424 consecutive patients by 189 physicians. All technical methods were local. Treated hypertensives who smoked had microalbuminuria significantly more often than non‐smokers, 26.2% vs 20.5% (p<0.05), and a higher proportion of smokers were suboptimally controlled (DBP⩾90 mmHg), 32.7% vs 25.0% (p<0.01). Smoking males had a higher prevalence of LVH (25.7% vs 20.1; p<0.05), microalbuminuria (29.7% vs 24.7%; p<0.01), and a higher proportion of subjects with uncontrolled systolic BP (⩾140 mmHg) (72.8% vs 68.9%; p<0.01). Both DBP and total cholesterol were higher in smoking vs non‐smoking females. An increased prevalence of LVH and microalbuminuria was independently associated with smoking. In summary, smokers with treated hypertension show a higher proportion of LVH (men), microalbuminuria and worse diastolic BP control than non‐smokers. This may hypothetically reflect either less compliance with drug treatment in smokers or that smoking impairs the pharmacological effects of antihypertensive drugs.

Validity of two questions on alcohol use in a health survey questionnaire

The aim of this study was to investigate whether consumers of high and low levels of alcohol could be identified by two questions about alcohol use in a postal questionnaire survey. A sample of 2,300 persons aged 18 - 64 years from Stockholm county were sent a masked postal questionnaire comprising 30 questions about their health and functioning. Two questions concerned their alcohol consumption. One year later the subjects underwent a psychiatric health examination, which included an assessment of their alcohol use. The two questions about alcohol consumption identified high alcohol consumers with a relatively high sensitivity and specificity, of 64% and 87%, respectively, and thus are useful for identifying high alcohol consumers in health surveys using questionnaires.

Effect of heart rate on long-term mortality among men and women.

Objective — This study aims at estimating the effect of high heart rate on total mortality during a long-term follow-up among men and women. During the years 1969-70, a stratified sample of 32,185 individuals aged 18-64 years was drawn from the population in Stockholm County (response rate 87%). A sub-sample, stratified by predicted health care needs, was invited to the health-screening program, and an extensive health examination performed on 2445 individuals out of 3064 individuals. An exercise test was performed on 1054 subjects. Complete data were available for 989 subjects, 490 men and 499 women. Methods — Participants were followed up in the National Cause of Death Register up to the end of 1996. Multivariate analysis was performed adjusting for cardio-respiratory fitness, expected level of care need, obesity, smoking and hypertension. Results — Among men, high heart rate (above 75 beats/minute) was associated with excess mortality, HR 1.63 (95% CI 1.30-2.03) in the age-adjusted model, and HR 1.57 (95% CI 1.05-2.35) in the full model. Among women, no significant excess risk was found, HR 1.18 (95% CI 0.89-1.58) in the age-adjusted model. Conclusions — High heart rate is an independent mortality risk marker for men but not for women.

Cardiovascular and total mortality in men and women with different blood pressure levels – A 26-year follow-up

Abstract Aim. Our aim was to study different levels of high blood pressure and normal blood pressure (reference) to calculate the hazard ratios (HRs) for cardiovascular and total mortality in men and women with adjustments for many covariates. Methods. A health-screening program was offered to a population-based sample in Stockholm County to estimate healthcare needs (a proxy for co-morbidity). Blood pressure measurements (mmHg systolic/diastolic) were available for 2280 participants (74%). Mortality was followed up for 26 years. Results. HRs with confidence intervals (CI) were calculated. The HR for all-cause mortality in those with very high blood pressure, ≥160and/or 95, was 1.93 (1.38–2.70) in men and 2.29 (1.42–3.69) in women. High blood pressure (≥ 140 and/or 90 but <160 and 95cmHg) and prehypertension (≥ 130 and/or 85 but <140 and 90) were significant in women but not in men. Diagnosed hypertension with antihypertensive treatment adjusted for blood pressure level was non-significant in all models. Conclusion. Very high blood pressure was an independent risk factor for both total and cardiovascular mortality in both men and women after adjustments for all covariates including healthcare need. Hypertension seems just as important to treat in individuals with co-morbidities.

The Association Between Low Fasting Blood Glucose Value and Mortality

Earlier studies and reviews have shown an association between high fasting blood glucose levels (FBG) and increased mortality. Less is known about the association between low FBG and mortality. This study aimed at reviewing the literature on this topic. A search was performed primarily of Medline through PubMed, and secondarily by searching other databases and using the information from articles already found. Altogether 5 articles meeting the quality demands of the search were found, all supporting the association between low FBG and increased all-cause mortality, with multivariate adjusted hazard ratios between 1.2 and 3.2. Another 22 articles not fulfilling the quality criteria were studied, and actually no study contradicted this association. Most studies were focused on the relation between high FBG and mortality, and did not analyze the association between low FBG and mortality specifically, hence explaining the low number of conclusive articles focusing on this. Thus we conclude, that low FBG is associated with increased mortality, but the cause of this association is unclear. We hypothesize, that low FBG could be a marker of low fat-free mass and low nutrition intake. This topic needs further studies.