Per Wändell

Quality of life of patients with diabetes mellitus. An overview of research in primary health care in the Nordic countries.

Objective A review of articles on health-related quality of life (HRQoL) among diabetes patients in primary health care in the Nordic countries. Design Search in PubMed and related sources. Used MeSH terms were: “Diabetes Mellitus”, “Quality of Life”, “Primary Health Care”, and “Scandinavia” or “Denmark”, “Finland”, “Iceland”, “Norway”, or “Sweden”. Results In total, 19 relevant articles were found, 9 from Finland and 10 from Sweden. HRQoL questionnaires used were from the Medical Outcomes Study, i.e. the SWED-QUAL in seven, SF-20 in four and SF-36 in one, NHP in two, GQL in two, GHQ in one, and own questionnaires in two. HRQoL was moderately affected in diabetic patients, with macrovascular diseases, especially coronary heart disease, and non-vascular diseases as the most consistently found and strongest predictors. Weaker predictors were microvascular complications, age, sex, metabolic level, and education. Other groups at higher risk of worse HRQoL were diabetes patients with psychiatric disorders, especially depression, and foreign-born patients. Good continuity of care was associated with better HRQoL. Conclusion Diabetes affects the HRQoL through macrovascular complications and associated non-vascular comorbidity, and also by adding to the total burden of disease. Future research areas include transcultural and ethnic aspects, and effects of lifestyle interventions.

The epidemiology of heart failure, based on data for 2.1 million inhabitants in Sweden.

The epidemiology of congestive heart failure (CHF) is likely to have changed due to changes in demography, risk factors, diagnostic procedures, and medical care. Prevailing information is in part old, incomplete, and to some extent contradictory. We determined the current prevalence, incidence, mortality, and 5‐year survival rate of CHF, and possible temporal changes in Sweden.

Do immigrants have an increased prevalence of unhealthy behaviours and risk factors for coronary heart disease

Background Although previous research has demonstrated a high risk of coronary disease in immigrants, the prevalence of unhealthy behaviours and risk factors is less known. The aim of this study was to investigate whether unhealthy behaviours and risk factors for coronary disease are more common in immigrants than in Swedish-born individuals. Methods Between 1 January 1996 and 31 December 2002 a simple random sample of the population was drawn and interviewed face to face. Eight immigrant groups in Sweden and a Swedish-born reference group, aged between 27 and 60 years, were studied. A log-binomial model was used to analyse the cross-sectional association between country of birth and unhealthy behaviours as well as coronary disease risk factors. Results Many of the immigrant groups showed higher risks of smoking, of physical inactivity and of obesity than Swedish-born individuals in age-adjusted models. On also adjusting for the level of education, occupational status and social network, the differences in risk persisted in the majority of groups. However, the over-risks of physical inactivity in Finnish and south European immigrant men and of diabetes in Finnish and Turkish immigrant women disappeared. Conclusions The high prevalence of unhealthy behaviours and risk factors for coronary disease in many immigrant groups might be a lifestyle remnant from their country of birth or might be brought about by a stressful migration and acculturation into a new social and cultural environment. Nevertheless, it is important in primary healthcare to be aware of a possible preventable increased risk of unhealthy behaviours and risk factors for coronary disease in some immigrants.

Morbidity in cardiovascular diseases in immigrants in Sweden.

Abstract. Gadd M, Johansson S‐E, Sundquist J, Wändell P (Family Medicine Stockholm, Karolinska Institutet, Huddinge, Sweden). Morbidity in cardiovascular diseases in immigrants in Sweden. J Intern Med 2003; 254: 236–243.

Are there differences in all-cause and coronary heart disease mortality between immigrants in Sweden and in their country of birth? A follow-up study of total populations

BackgroundMortality from cardiovascular diseases is higher among immigrants than native Swedes. It is not clear whether the high mortality persists from the country of birth or is a result of migration. The purpose of the present study was to analyse whether all-cause and coronary heart disease mortality differ between immigrants in Sweden and in the country of birth.MethodsTwo cohorts including the total population from Swedish national registers and WHO were defined. All-cause and CHD mortality are presented as age-adjusted incidence rates and incidence density ratios (IDR) in eight immigrant groups in Sweden and in their country of birth. The data were analysed using Poisson regression.ResultsThe all-cause mortality risk was lower among seven of eight male immigrant groups (IDR 0.39–0.97) and among six of eight female immigrant groups (IDR 0.42–0.81) than in their country of birth. The CHD mortality risk was significantly lower in male immigrants from Norway (IDR = 0.84), Finland (IDR = 0.91), Germany (IDR = 0.84) and Hungary (IDR = 0.59) and among female immigrants from Germany (IDR = 0.66) and Hungary (IDR = 0.54) than in their country of birth. In contrast, there was a significantly higher CHD mortality risk in male immigrants from Southern Europe (IDR = 1.23) than in their country of birth.ConclusionThe all-cause mortality risk was lower in the majority of immigrant groups in Sweden than in their country of birth. The differences in CHD mortality risks were more complex. For countries with high CHD mortality, such as Finland and Hungary, the risk was lower among immigrants in Sweden than in their country of birth. For low-risk countries in South Europe, the risk was higher in immigrants in Sweden than in South Europe.

Diagnostic tests, treatment and follow-up in heart failure patients — is there a gender bias in the coherence to guidelines?

To relate clinical data in a consecutive cohort of patients admitted with heart failure in Sweden to demographic data and the use of diagnostic tests, medical treatment, care process and mortality.

Seven modifiable lifestyle factors predict reduced risk for ischemic cardiovascular disease and all-cause mortality regardless of body mass index: A cohort study

OBJECTIVES A healthy lifestyle has an impact on cardiovascular health. Yet, the importance of body mass index (BMI) and gender remains less clear. The aim of this study was to investigate whether healthy lifestyle factors can predict incident cardiovascular disease (CVD) and all-cause mortality. METHODS Representative population-based prospective cohort study of 60-year-old women (n=2193) and men (n=2039). The following factors related to a healthy lifestyle were assessed using a questionnaire: non-smoking, alcohol intake of 0.6-30 g/day, moderate physical activity at least once a week, low intake of processed meats, weekly intake of fish, daily intake of fruit, and daily intake of vegetables. These factors were combined to produce a total score of healthy lifestyle factors (0-7) and classified into four groups: unhealthy (0-2 lifestyle factors), intermediate (3), healthy (4-5), and very healthy (6-7). National registers enabled identification of incident CVD (n=375) and all-cause mortality (n=427) over a follow-up of 11 years. RESULTS Very healthy women and men exhibited a decreased risk for incident CVD compared with unhealthy individuals, with hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for educational level and BMI of 0.44 (0.26-0.75) and 0.39 (0.25-0.61), respectively. The corresponding HRs (95% CIs) for all-cause mortality for very healthy women and men were 0.25 (0.15-0.44) and 0.35 (0.23-0.54), respectively. CONCLUSION With seven healthy lifestyle factors, it was possible to identify men and women with substantially lower relative risks of incident CVD and death, regardless of BMI and educational level.

Quality of life in diabetic patients registered with primary health care services in Sweden

OBJECTIVE To evaluate the health-related quality of life in diabetic subjects in primary health care. DESIGN A cross-sectional, questionnaire survey of diabetic patients registered with primary health services, compared with a standard population sample. SETTING Three community health centres in the Metropolitan Stockholm area. SUBJECTS 341 diabetic individuals aged 21-84 years, with 229 respondents, i.e. 67%. Matched controls of the same age and sex from a standard population sample of 2366 individuals. MAIN OUTCOME MEASURES Quality of life was assessed by the Swedish Health-Related Quality of Life Survey (SWEDQUAL), adopted from the Medical Outcomes Study and consisting of 61 items covering aspects of physical, mental, social, and general health. Medical data were extracted from the medical records. RESULTS Diabetic patients had significantly lower scores on all scales (p < 0.001 for ten, and p < 0.01 for one), except for social health, when compared with the standard population sample. Outcomes were correlated with vascular and non-vascular comorbidity, age, and income, but not with level of metabolic control. CONCLUSIONS Diabetic patients in primary health care have a markedly lower health-related quality of life, compared with a standard population.

Quality of life among diabetic patients in Swedish primary health care and in the general population: comparison between 1992 and 1995

To assess change over time in health-related quality of life (HRQoL) in diabetic patients in primary health care and differences to general Swedish population samples, 341 diabetic subjects in 1992 and 413 in 1995, aged 20–84 years, were chosen from three community health centres (CHCs) in the Metropolitan Stockholm area and compared to controls matched by age and sex in randomly selected samples of 2,366 subjects in 1991 and 2,500 in 1995 from the general population. HRQoL was assessed by the Swedish Health-Related Quality of Life Survey (SWED-QUAL), adapted from the Medical Outcomes Study, which measures aspects of physical, mental, social and general health in 13 scales. Information on diabetic and general medical data were extracted from the medical records at the CHCs. HRQoL was lower in diabetic subjects compared with the general population in both 1992 and 1995 in all scales except family functioning and marital functioning. The level of HRQoL did not change significantly between the diabetic samples, but decreased in the population samples, making the difference compared to diabetic patients smaller in five of the scales. The most significant predicting factors for the SWED-QUAL results in diabetic patients in 1995 were the vascular and non-vascular co-morbidity.

Risk Factors Associated With Newly Diagnosed High Blood Pressure in Men and Women

BACKGROUND Hypertension is a major risk factor for cardiovascular diseases. Early diagnosis and prevention of hypertension are of great importance in reducing overall mortality. The objective was to determine which potential risk factors are associated with newly diagnosed high blood pressure in women and men. METHODS This study is part of a population-based, cross-sectional study including 4,228 women and men aged 60 years in Stockholm County, Sweden. Newly diagnosed high blood pressure was defined as systolic and/or diastolic blood pressure exceeding 140/90 measured on one occasion. Subjects with known hypertension were excluded, leaving 3,156 individuals. RESULTS Waist circumference > or =95 cm (quintiles 3-5) in men and > or =88.5 cm (quintiles 4-5) in women was associated with newly diagnosed high blood pressure. Secondary school was a protective factor in men (odds ratio (OR), men = 0.73, 95% confidence interval (CI) = 0.54-0.99) and university education was protective in both men (OR = 0.66, 95% CI = 0.52-0.85) and women (OR = 0.45, 95% CI = 0.34-0.59). Regular physical activity was negatively associated in women (OR = 0.77, 95% CI = 0.61-0.99), and high alcohol consumption (>30 g/day) was positively associated in men (OR = 1.60, 95% CI = 1.22-2.09). Women were negatively associated with newly diagnosed high blood pressure (OR = 0.50, 95% CI = 0.41-0.61). An interaction between college/university and gender was found in multivariate analysis (OR = 0.67, 95% CI = 0.47-0.97). CONCLUSION Gender differences in risk profile for newly diagnosed high blood pressure might explain part of the differences in hypertension found between men and women. These findings should be considered when planning preventive actions against hypertension at the community level.