Mats Eliasson

Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged men

OBJECTIVES To explore whether the use of snuff affects the risk of myocardial infarction (MI). BACKGROUND Snuff and other forms of smokeless tobacco are widely used in some populations. Possible health hazards associated with the use of smokeless tobacco remain controversial. METHODS In a population-based study within the framework of the Northern Sweden center of the World Health Organization Multinational Monitoring of Trend and Determinants in Cardiovascular Disease (WHO MONICA) Project, tobacco habits were compared in 25- to 64-year-old men with first-time fatal or nonfatal MI and referent subjects matched for age and place of living (687 cases, 687 referents). RESULTS The unadjusted odds ratio (OR) for MI in regular cigarette smokers as compared with men who never used tobacco was 3.65 (95% confidence interval [CI] 2.67 to 4.99). When nonsmoking regular snuff dippers were compared with never-users of tobacco, the unadjusted OR was 0.96 (0.65 to 1.41). After adjustment for multiple cardiovascular risk factors, the OR was 3.53 (95% CI 2.48 to 5.03) for regular smoking and 0.58 (95% CI 0.35 to 0.94) for regular snuff dipping. Restricting the analyses to fatal cases of myocardial (including sudden death) showed a tendency towards increased risk among snuff dippers 1.50 (95% CI 0.45 to 5.03). CONCLUSIONS The risk of MI is not increased in snuff dippers. Nicotine is probably not an important contributor to ischemic heart disease in smokers. A possible small or modest detrimental effect of snuff dipping on the risk for sudden death could not be excluded in this study due to a limited number of fatal cases.

A randomized trial of lifestyle intervention in primary healthcare for the modification of cardiovascular risk factors The Björknäs study

Aims: To evaluate the effects of a lifestyle intervention programme in primary healthcare, targeted to patients with moderate to high risk of cardiovascular disease in terms of cardiovascular risk factors, physical activity, and quality of life. Method: Randomized controlled trial with one-year follow-up, carried out in a primary healthcare centre in Northern Sweden. A total of 151 middle-aged men and women, with hypertension, dyslipidemia, type 2 diabetes, or obesity were enrolled. The subjects were randomized to either the intervention (n=75) or the control group (n=76). A total of 123 subjects completed the one-year follow-up. Interventions: Exercise: supervised endurance and circuit training in groups three times a week for three months. Diet: five group sessions of diet counselling with a dietitian. Follow- up meetings with a physiotherapist were conducted monthly thereafter. Primary outcomes were changes in anthropometry, maximal oxygen uptake, health-related quality of life, and self-reported physical activity. The secondary outcomes were changes in blood pressure and metabolic variables. Results: After one year the intervention group significantly increased maximal oxygen uptake, physical activity, and quality of life and significantly decreased body weight, waist and hip circumference, body mass index, waist—hip ratio, systolic and diastolic blood pressure, triglycerides, and glycosylated haemoglobin. There were significant differences between groups, mean changes (and their 95% confidence intervals, CI) in waist circumference -1.9 cm (-2.80 to -0.90; p<0.001), in waist—hip ratio -0.01 (-.02 to -0.004; p<0.01) and in diastolic blood pressure -2.3 mmHg (-4.04 to -0.51; p<0.05). Conclusion: A prevention programme in primary healthcare with a focus on physical activity and diet counselling followed by structured follow-up meetings can favourably influence several risk factors for cardiovascular diseases and quality of life in high-risk subjects for at least one year.

Telomere Length Is Associated With Obesity Parameters but With a Gender Difference

Cardiovascular disease (CVD) and obesity have been coupled to short telomere length in peripheral blood. The biological background to this observation is not obvious from the literature. In this study we have analyzed a large set of known risk factors for CVD in relation to telomere length in blood cells on a merged cohort of 989 individuals recruited in the Malmö Diet and Cancer Cohort (MDCC) and the Northern Sweden MONICA project. We found a significant or borderline association between obesity parameters and telomere length in women after age and center adjustments (BMI: r = −0.106, P = 0.021, weight: r = −0.087, P = 0.060, waist circumference: r = −0.099, P = 0.032, hip circumference: r = −0.128, P = 0.005). In men, a positive borderline correlation to high‐density lipoprotein (HDL) (r = 0.111, P = 0.053) and a negative correlation to 2‐h post‐oral glucose‐tolerance test (OGTT) was observed (r = −0.202, P = 0.045). In neither group any association was found between telomere length and cholesterol, serum triglycerides, serum low‐density lipoprotein, plasma insulin, blood pressure, pulse pressure, or smoking habits. Our data indicate that telomere length is associated with an “obesity‐phenotype” but only in women.

Diabetes as a risk factor for myocardial infarction: population and gender perspectives

Abstract. Lundberg V, Stegmayr B, Asplund K, Eliasson M, Huhtasaari F (Kalix Hospital, Umel University Hospital and Lulei‐Boden Hospital, Sweden). Diabetes as a risk factor for myocardial infarction: population and gender perspectives.

Relationship of cigarette smoking and snuff dipping to plasma fibrinogen, fibrinolytic variables and serum insulin. The Northern Sweden MONICA study

The influence of cigarette smoking and use of smokeless tobacco on plasma fibrinogen level, fibrinolytic variables, glucose tolerance and serum insulin was studied in a randomly selected population sample consisting of 604 men and 662 females between 25 and 64 years. Subjects were grouped according to tobacco habits as follows: regular smokers (> 1 cig/day), ex-smokers, snuff dippers, and non-tobacco users. An oral glucose tolerance test was performed on 54% of the participants. Tissue plasminogen activator (tPA) activity and plasminogen activator inhibitor type 1 (PAI-1) activity were used to study fibrinolysis. Men who smoked had 0.34 g/l (95% CI 0.17 to 0.49) higher fibrinogen level than non-tobacco users and numbers of cigarettes smoked correlated with plasma fibrinogen levels (r = 0.21, P = 0.006). Female smokers had significantly higher fibrinogen levels than ex-smokers but the difference compared with non-smokers was not significant. Snuff dipping did not affect fibrinogen levels. We found no relationship between tPA activity, PAI-1 activity and tobacco use. Post-load plasma glucose was lower in women who smoked, otherwise no influence of tobacco use on glucose levels was seen. Lower post-load insulin levels (-8.8 mU/ml, 95% CI -2.4 to -16.3) than in non-smokers were also found in women who smoked. This was only partially explained by a lower body mass index in smokers. We conclude that cigarette smoking is associated with increased fibrinogen levels, unaltered fibrinolysis, normal glucose tolerance and insulin levels. The use of smokeless tobacco, as moist oral snuff, does not appear to affect these potential cardiovascular risk factors.

Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986–2009

Abstract.  Eriksson M, Holmgren L, Janlert U, Jansson J‐H, Lundblad D, Stegmayr B, Söderberg S, Eliasson M (Department of Public Health and Clinical Medicine, Umeå University, Umeå; Research Department, Norrbotten County Council, Luleå; Department of Medicine, Skellefteå Hospital, Skellefteå; Department of Medicine, Sunderby Hospital, Luleå; and National Board of Health and Welfare, Stockholm, Sweden). Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986–2009. J Intern Med 2011; 269: 219–231.

A 3-Year Randomized Trial of Lifestyle Intervention for Cardiovascular Risk Reduction in the Primary Care Setting: The Swedish Björknäs Study

Background Successfully transferring the findings of expensive and tightly controlled programmes of intensive lifestyle modification to the primary care setting is necessary if such knowledge is to be of clinical utility. The objective of this study was to test whether intensive lifestyle modification, shown previously in tightly-controlled clinical trials to be efficacious for diabetes risk-reduction among high-risk individuals, can reduce cardiovascular risk factor levels in the primary care setting. Methodology / Principal Findings The Swedish Björknäs study was a randomized controlled trial conducted from 2003 to 2006 with follow-up on cardiovascular risk factors at 3, 12, 24 and 36 months. A total of 151 middle-aged men and women at moderate- to high-risk of cardiovascular disease from northern Sweden were randomly assigned to either an intensive lifestyle intervention (n = 75) or control (n = 76) group. The intervention was based broadly on the protocol of the Diabetes Prevention Program. The three-month intervention period was administered in the primary care setting and consisted of supervised exercise sessions and diet counselling, followed by regular group meetings during three years. The control group was given general advice about diet and exercise and received standard clinical care. Outcomes were changes in anthropometrics, aerobic fitness, self-reported physical activity, blood pressure, and metabolic traits. At 36 months post-randomisation, intensive lifestyle modification reduced waist circumference (−2.2 cm: p = 0.001), waist-hip ratio (−0.02: p<0.0001), systolic blood pressure (−4.9 mmHg: p = 0.036), and diastolic blood pressure (−1.6 mmHg: p = 0.005), and improved aerobic fitness (5%; p = 0.038). Changes in lipid or glucose values did not differ statistically between groups. At 36 months, self-reported time spent exercising and total physical activity had increased more in the intervention group than in the control group (p<0.001). Conclusion / Significance A program of intensive lifestyle modification undertaken in the primary health care setting can favourably influence cardiovascular risk-factor profiles in high-risk individuals. Trial Registration ClinicalTrials.gov NCT00486941

Fibrinogen and fibrinolytic variables in relation to anthropometry, lipids and blood pressure. The Northern Sweden MONICA Study.

Fibrinolysis is dependent upon plasminogen activator (tPA) activity while high fibrinogen levels increase the risk of thromboembolic events. From a cross-sectional population sample of 1558 men and women aged 25 to 64 years, plasma fibrinogen, tPA activity and plasminogen activator inhibitor-1 (PAI) activity were determined using specific assays. Associations with body mass index (BMI), waist-hip ratio (WHR), serum lipids and blood pressure were calculated with uni- and multivariate models where age and smoking were also introduced. In men age, truncal obesity, short height and low HDL cholesterol independently predicted fibrinogen (R2 0.20) while in women obesity per se, total cholesterol, systolic blood pressure, smoking and age were predictors (R2 0.29). tPA activity was negatively associated with BMI and serum triglyceride levels and positively with age in both sexes. In men diastolic blood pressure (R2 0.22) and in women WHR further independently predicted low fibrinolytic activity. HDL was associated with greater fibrinolysis in women (R2 0.15). Relationships with PAI-1 activity were essentially the reverse of tPA but stronger. Prospective interventional studies are needed to answer the question of causality.

No increase in the prevalence of known diabetes between 1986 and 1999 in subjects 25-64 years of age in northern Sweden.

Aims A global increase in diabetes is predicted due to higher body weight and less physical activity. Over the period 1986–1999, the body mass index (BMI) of the adult population of northern Sweden increased from 25.3 to 26.2 and the prevalence of obesity (BMI ≥ 30) from 11% to 15%, although this was more distal than central adiposity. Our hypothesis was that this would lead to a higher prevalence of diabetes.

Biomarkers of milk fat and the risk of myocardial infarction in men and women: a prospective, matched case-control study

BACKGROUND High intakes of saturated fat have been associated with cardiovascular disease, and milk fat is rich in saturated fat. OBJECTIVE The objective of this study was to investigate the association between the serum milk fat biomarkers pentadecanoic acid (15:0), heptadecanoic acid (17:0), and their sum (15:0+17:0) and a first myocardial infarction (MI). DESIGN The study design was a prospective case-control study nested within a large population-based cohort in Sweden. Included in the study were 444 cases (307 men) and 556 controls (308 men) matched on sex, age, date of examination, and geographic region. Clinical, anthropometric, biomarker fatty acid, physical activity, and dietary data were collected. The odds of a first MI were investigated by using conditional logistic regression. RESULTS In women, proportions of milk fat biomarkers in plasma phospholipids were significantly higher (P < 0.05) in controls than in cases and were, in general, negatively, albeit weakly, correlated with risk factors for metabolic syndrome. The crude standardized odds ratios of becoming an MI case were 0.74 (95% CI: 0.58, 0.94) in women and 0.91 (95% CI: 0.77, 1.1) in men. After multivariable adjustment for confounders, the inverse association remained in both sexes and was significant in women. In agreement with biomarker data, quartiles of reported intake of cheese (men and women) and fermented milk products (men) were inversely related to a first MI (P for trend < 0.05 for all). CONCLUSIONS Milk fat biomarkers were associated with a lower risk of developing a first MI, especially in women. This was partly confirmed in analysis of fermented milk and cheese intake. Components of metabolic syndrome were observed as potential intermediates for the risk relations.