Stig Wall

Celiac disease revealed in 3% of Swedish 12-year-olds born during an epidemic

Objective: Sweden experienced a marked epidemic of celiac disease between 1984 and 1996 in children younger than 2 years of age, partly explained by changes in infant feeding. The objective of this study was to determine the prevalence of celiac disease in 12-year-olds born during the epidemic (1993), including both symptomatic and screening detected cases. Patients and Methods: All sixth-grade children in participating schools were invited (n = 10,041). Symptomatic and, therefore, previously diagnosed celiac disease cases were ascertained through the National Swedish Childhood Celiac Disease Register and/or medical records. All serum samples were analyzed for antihuman tissue transglutaminase (tTG)-IgA (Celikey), and serum-IgA, and some for tTG-IgG and endomysial antibodies. A small intestinal biopsy was recommended for all children with suspected undiagnosed celiac disease. Results: Participation was accepted by 7567 families (75%). Previously diagnosed celiac disease was found in 67 children; 8.9/1000 (95% confidence interval [CI] 6.7–11). In another 192 children, a small intestinal biopsy was recommended and was performed in 180. Celiac disease was verified in 145 children, 20/1000 (95% CI 17–23). The total prevalence was 29/1000 (95% CI 25–33). Conclusions: The celiac disease prevalence of 29/1000 (3%)—with two thirds of cases undiagnosed before screening—is 3-fold higher than the usually suggested prevalence of 1%. When these 12-year-olds were infants, the prevailing feeding practice was to introduce gluten abruptly, often without ongoing breast-feeding, which might have contributed to this unexpectedly high prevalence.

The epidemiology of diabetes in Swedish children 0-14 years--a six-year prospective study.

SummarySince 1 July 1977, all newly diagnosed diabetic children in Sweden aged 0–14 years have been reported to a central register. During the first 6 years, 2300 newly diagnosed diabetic children out of a population of 1.6 million children were registered. The degree of certainty was close to 100%. The mean of the yearly incidence rate for the whole 6 year period was 23.6 per 100000. The prevalence of insulin dependent diabetes mellitus on 1 July 1980 was 1.48 per 1000 and 1.52 on 1 July 1983. Comparing the first and second 3-year periods, an increase was found (22.7–25.1 per 100000). This increase was consistent when analyzing incidence rates by age, sex, and geographical distribution. Cumulative incidence rates revealed a risk of developing diabetes by the age of 15 years of 3.6 per thousand for boys and 3.2 per thousand for girls. The higher incidence for boys was consistent throughout the study period. Seasonal variations in the incidence rate were also consistent, showing yearly incidence peaks in the autumn and winter months. Incidence peaks were noted for both sexes in the pubertal ages. Age- and sex-standardized morbidity ratios varied significantly within the country. 12.8% of the probands had a first degree relative with Type 1 diabetes, and it was twice as common that this relative was a father as a mother. The high and rapidly increasing incidence of Type 1 diabetes in a genetically stable population such as Sweden calls for case-control studies directed towards the identification of environmental pathogens.

Health in Sweden : the National Public Health Report 2005.

Health in Sweden – The National Public Health Report 2005 : Scandinavian Journal of Public Health

The Swedish childhood diabetes study — results from a nine year case register and a one year case-referent study indicating that Type 1 (insulin-dependent) diabetes mellitus is associated with both Type 2 (non-insulin-dependent) diabetes mellitus and autoimmune disorders

SummaryFrom July 1, 1977 to July 1, 1986, 3,503 incident cases of Type 1 (insulin-dependent) diabetes mellitus were registered in the Swedish childhood diabetes study. Using data from this register and from a case-referent study, including all incident Type 1 diabetic children in Sweden during one year and, for each patient, two referent children matched according to age, sex and county, we have studied the associations between Type 1 diabetes and familial Type 1 and Type 2 (non-insulin-dependent) diabetes, thyroid, adrenal, allergic, rheumatic, heart and bowel disease. The mean annual incidence per 100,000 during the nine year period was 25.1 for boys and 23.5 for girls. In 8.5% of the patients, one parent had Type 1 diabetes, 73% of whom were fathers. Fifty-six of the patients (1.7%) had a parent with Type 2 diabetes. The prevalence of parental Type 1 diabetes tended to be higher in patients with younger age at onset; whereas, the opposite was found for patients with parental Type 2 diabetes. In the case-referent study, the age-adjusted odds ratio for Type 1 diabetes when a first and/or second degree relative had Type 1 diabetes was 5.5 (95% confidence limits 4.0–7.7), and in accordance with the findings of the case register, the odds ratio tended to be highest in patients with the youngest age at onset. Season at onset of the patients was not associated with parental Type 1 diabetes. The odds ratio for Type 1 diabetes was significantly increased 3.3 (95% confidence limits: 2.3–4.6) when Type 2 diabetes was reported in relatives (three generations). Odds ratios were also significantly increased (p(0.05) when thyroid or rheumatic diseases were reported among relatives.It is concluded that although the majority of incident Type 1 diabetic children lack family history, parental Type 1 diabetes may influence the age at onset of the disease but has no effect on sex distribution of these children. An increased risk for Type 1 diabetes in children is also indicated when Type 2 diabetes, (non-insulin-treated) thyroid or rheumatic disease is reported in relatives.

ASSOCIATION BETWEEN BODY MASS INDEX AND BLOOD PRESSURE ACROSS THREE POPULATIONS IN AFRICA AND ASIA

Despite a growing burden of obesity and hypertension in developing countries, there is limited information on the contribution of body mass index (BMI) to blood pressure (BP) in these populations. This study examines the association between BMI and BP in three populations across Africa and Asia. Data on BMI, BP and other background characteristics of study participants were generated using the World Health Organization STEPwise approach to surveillance (STEPS), at three demographic surveillance sites in Ethiopia, Vietnam and Indonesia. BMI and BP increased along the socioeconomic gradient across the three countries. Mean (s.d.) BMI in men varied between 19.41 (2.28) in Ethiopia to 21.17 (2.86) in Indonesia. A high prevalence of overweight/obesity was noted among Indonesian women (25%) and men (10%), whereas low BMI was widely prevalent in Ethiopia and Vietnam, ranging from 33 to 43%. Mean (s.d.) systolic BP (SBP) among men varied between 117.15 (15.35) in Ethiopia to 127.33 (17.80) in Indonesia. The prevalence of hypertension was highest among women (25%) and men (24%) in Indonesia. Mean BP levels increased with increasing BMI. The risk of hypertension was higher among population groups with overweight and obesity (BMI⩾25 kg/m2); odds ratio (95% confidence interval); 2.47 (1.42, 4.29) in Ethiopia, 2.67 (1.75, 4.08) in Vietnam and 7.64 (3.88, 15.0) in Indonesia. BMI was significantly and positively correlated with both SBP and DBP in all the three populations, correlation coefficient (r) ranging between 0.23 and 0.27, P<0.01. High BP exists in a background of undernutrition in populations at early stages of the epidemiologic transition.

Reduction of selection bias in primary prevention of cardiovascular disease through involvement of primary health care

OBJECTIVE To examine selection bias in social and health factors in a community intervention programme for the prevention of cardiovascular disease by comparing programme data with both census data and a random sample of the same population. DESIGN Cross sectional studies. SETTING All 35 primary health care centres in Västerbotten County, Sweden. SUBJECTS 24,870 individuals who during 1992 and 1993 became 30, 40, 50 or 60 years of age. MAIN OUTCOME MEASURES Total income, socio-economic group, employment, education, body mass index (BMI), total cholesterol, systolic and diastolic blood pressure, and daily smoking. RESULTS The differences in social characteristics between participants and non-participants were marginal, indicating that the social selection bias was small. However, unemployment, low income, and younger age tended to be associated with somewhat lower preference to participate. The overall pattern of health status, as measured by risk factors, was similar rather than dissimilar. While the participants in the intervention health survey had lower mean total cholesterol, their blood pressure was generally higher compared with the reference random sample. CONCLUSIONS The primary health care system in Sweden might serve as a useful base for educational health counselling, at least within a community intervention programme, for all levels of society.

The Västerbotten Intervention Programme: background, design and implications.

Background and objective: In Sweden, mortality from cardiovascular diseases (CVD) increased steadily during the 20th century and in the mid-1980s it was highest in the county of Västerbotten. Therefore, a community intervention programme was launched – the Västerbotten Intervention Programme (VIP) – with the aim of reducing morbidity and mortality from CVD and diabetes. Design : The VIP was first developed in the small municipality of Norsjö in 1985. Subsequently, it was successively implemented across the county and is now integrated into ordinary primary care routines. A population-based strategy directed towards the public is combined with a strategy to reach all middle-aged persons individually at ages 40, 50 and 60 years, by inviting them to participate in systematic risk factor screening and individual counselling about healthy lifestyle habits. Blood samples for research purposes are stored at the Umeå University Medical Biobank. Results: Overall, 113,203 health examinations have been conducted in the VIP and 6,500–7,000 examinations take place each year. Almost 27,000 subjects have participated twice. Participation rates have ranged between 48 and 67%. A dropout rate analysis in 1998 indicated only a small social selection bias. Cross-sectional, nested case-control studies and prospective studies have been based on the VIP data. Linkages between the VIP and local, regional and national databases provide opportunities for interdisciplinary research, as well as national and international collaborations on a wide range of disease outcomes. A large number of publications are based on data that are collected in the VIP, many of which also use results from analysed stored blood samples. More than 20 PhD theses have been based primarily on the VIP data. Conclusions: The concept of the VIP, established as a collaboration between politicians and health care providers on the one hand and primary care, functioning as the operating machinery, and the public on the other, forms the basis for effective implementation and endurance over time. After more than 20 years of the VIP, there is a large comprehensive population-based database, a stable organisation to conduct health surveys and collect data, and a solid structure to enable widespread multidisciplinary and scientific collaborations.

The swedish childhood diabetes study: social and perinatal determinants for diabetes in childhood

SummaryUsing the Swedish childhood diabetes register, a nationwide, case-referent study was performed from September 1, 1985 to August 31, 1986. Based on the information from a mailed questionnaire sent to all incident diabetic children and for each diabetic child — two referent children matched according to age, sex, and county, we have analysed perinatal events and aspects of the social environment as possible risk factors for Type 1 (insulin-dependent) diabetes in childhood. A significantly larger proportion of the mothers of the diabetic children were older than 40 years compared to those of the referent children (33% and 24%, p=0.01 respectively). A smaller percentage of mothers of the diabetic children had a high educational level compared to mothers of referent children (10% and 15%, p=0.03 respectively) and 39% of the fathers of the diabetic children were manual workers compared to 31% of the fathers of referent children (p=0.03). Perinatal events did not differ between diabetic and referent children. In children 0–6 years, the duration of breast-feeding was significantly shorter in diabetic children than among referent children (median duration for diabetic children 5 months compared to 6 months for referent children p=0.03). When considering the presence of Type 1 diabetes among relatives, maternal age over 40 years, low educational level of the mother, and the father being a manual worker as risk factors, the presence of 1 to 4 of any of these risk factors increased the relative risk for Type 1 diabetes cumulatively from 1.2–7.5. In conclusion, breast-feeding habits and probably other factors dependent on maternal age and the social status of the family may further increase the risk for Type 1 diabetes in genetically susceptible individuals.

Ageing and adult health status in eight lower-income countries : the INDEPTH WHO-SAGE collaboration

Background: Globally, ageing impacts all countries, with a majority of older persons residing in lower- and middle-income countries now and into the future. An understanding of the health and well-being of these ageing populations is important for policy and planning; however, research on ageing and adult health that informs policy predominantly comes from higher-income countries. A collaboration between the WHO Study on global AGEing and adult health (SAGE) and International Network for the Demographic Evaluation of Populations and Their Health in developing countries (INDEPTH), with support from the US National Institute on Aging (NIA) and the Swedish Council for Working Life and Social Research (FAS), has resulted in valuable health, disability and well-being information through a first wave of data collection in 2006–2007 from field sites in South Africa, Tanzania, Kenya, Ghana, Viet Nam, Bangladesh, Indonesia and India. Objective: To provide an overview of the demographic and health characteristics of participating countries, describe the research collaboration and introduce the first dataset and outputs. Methods: Data from two SAGE survey modules implemented in eight Health and Demographic Surveillance Systems (HDSS) were merged with core HDSS data to produce a summary dataset for the site-specific and cross-site analyses described in this supplement. Each participating HDSS site used standardised training materials and survey instruments. Face-to-face interviews were conducted. Ethical clearance was obtained from WHO and the local ethical authority for each participating HDSS site. Results: People aged 50 years and over in the eight participating countries represent over 15% of the current global older population, and is projected to reach 23% by 2030. The Asian HDSS sites have a larger proportion of burden of disease from non-communicable diseases and injuries relative to their African counterparts. A pooled sample of over 46,000 persons aged 50 and over from these eight HDSS sites was produced. The SAGE modules resulted in self-reported health, health status, functioning (from the WHO Disability Assessment Scale (WHODAS-II)) and well-being (from the WHO Quality of Life instrument (WHOQoL) variables). The HDSS databases contributed age, sex, marital status, education, socio-economic status and household size variables. Conclusion: The INDEPTH WHO–SAGE collaboration demonstrates the value and future possibilities for this type of research in informing policy and planning for a number of countries. This INDEPTH WHO–SAGE dataset will be placed in the public domain together with this open-access supplement and will be available through the GHA website (www.globalhealthaction.net) and other repositories. An improved dataset is being developed containing supplementary HDSS variables and vignette-adjusted health variables. This living collaboration is now preparing for a next wave of data collection. Access the supplementary material to this article: INDEPTH WHO-SAGE questionnaire (including variants of vignettes), a data dictionary and a password-protected dataset (see Supplementary files under Reading Tools online). To obtain a password for the dataset, please send a request with ‘SAGE data’ as its subject, detailing how you propose to use the data, to global.health@epiph.umu.se

Population based prevalence of high blood pressure among adults in Addis Ababa: uncovering a silent epidemic.

BackgroundThe prevention and control of high blood pressure or other cardiovascular diseases has not received due attention in many developing countries. This study aims to describe the epidemiology of high blood pressure among adults in Addis Ababa, so as to inform policy and lay the ground for surveillance interventions.MethodsAddis Ababa is the largest urban centre and national capital of Ethiopia, hosting about 25% of the urban population in the country. A probabilistic sample of adult males and females, 25–64 years of age residing in Addis Ababa city participated in structured interviews and physical measurements. We employed a population based, cross sectional survey, using the World Health Organization instrument for stepwise surveillance (STEPS) of chronic disease risk factors. Data on selected socio-demographic characteristics and lifestyle behaviours, including physical activity, as well as physical measurements such as weight, height, waist and hip circumference, and blood pressure were collected through standardized procedures. Multiple linear regression analysis was performed to estimate the coefficient of variability of blood pressure due to selected socio-demographic and behavioural characteristics, and physical measurements.ResultsA total of 3713 adults participated in the study. About 20% of males and 38% of females were overweight (body-mass-index ≥ 25 kg/m2), with 10.8 (9.49, 12.11)% of the females being obese (body-mass-index ≥ 30 kg/m2). Similarly, 17% of the males and 31% of the females were classified as having low level of total physical activity. The age-adjusted prevalence (95% confidence interval) of high blood pressure, defined as systolic blood pressure (SBP) ≥ 140 mmHg (millimetres of mercury) or diastolic blood pressure (DBP) ≥ 90 mmHg or reported use of anti-hypertensive medication, was 31.5% (29.0, 33.9) among males and 28.9% (26.8, 30.9) among females.ConclusionHigh blood pressure is widely prevalent in Addis Ababa and may represent a silent epidemic in this population. Overweight, obesity and physical inactivity are important determinants of high blood pressure. There is an urgent need for strategies and programmes to prevent and control high blood pressure, and promote healthy lifestyle behaviours primarily among the urban populations of Ethiopia.