Sven-Erik Johansson

High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: A Kalixanda study report

Objective. Gastroesophageal reflux disease has been reported to be a common burden on health-care resources in the Western world, but its manifestations in the general population are as yet unclear. The aim of this study was to estimate the prevalence of, and to identify the risk factors for gastroesophageal reflux symptoms (GERS) and erosive esophagitis (EE) in the adult population of two Swedish municipalities. Material and methods. A random sample (n=3000) of the adult population (20–81 years of age) of two Swedish municipalities (n=21,610) was surveyed using a validated postal questionnaire assessing gastrointestinal symptoms. The response rate was 74%. A subsample (n=1000) of the responders was subsequently invited, in random order, for esophago-gastro-duodenoscopy with evaluation of GERS, risk factors and tests for Helicobacter pylori. Results. GERS were reported by 40.0% and EE was found in 15.5% of the population that had undergone endoscopy. Of those with GERS, 24.5% had EE while 36.8% of those with EE reported no GERS. Hiatus hernia and obesity remained significant risk factors for GERS and/or EE, with or without symptoms in a main effect model (OR up to 14 at EE). Those with active H. pylori infection had a higher risk of GERS without EE than those without H. pylori infection (OR=1.71 (1.23–2.38)). Conclusions. GERS and EE (of which one-third is asymptomatic) are highly prevalent in the Swedish adult population. H. pylori infection seems to play a role in the manifestations of gastroesophageal reflux.

Prevalence of oesophageal eosinophils and eosinophilic oesophagitis in adults: The population-based Kalixanda study

Background: Eosinophilic oesophagitis may be increasing but the prevalence in the general population remains unknown. Our aim was to assess this and the presence of eosinophils in the distal oesophageal epithelium in the community. Methods: Oesophagogastroduodenoscopy was performed in a random sample (n = 1000) of the adult Swedish population (mean age 54 years, 49% men). Oesophageal biopsy samples were obtained from 2 cm above, and at, the Z-line. Any eosinophil infiltration of the epithelium was defined as “eosinophils present”. Definite eosinophilic oesophagitis was defined as ⩾20, probable as 15–19, and possible as 5–14 eosinophils/high-power field (HPF, at magnification ×40) in oesophageal biopsy specimens. Results: Eosinophils were present in 48 subjects (4.8%, 95% CI 3.5 to 6.1%, mean age 54 years, 63% men), in 54% without troublesome reflux symptoms. Definite eosinophilic oesophagitis was present in four subjects (0.4%, 95% CI 0.01 to 0.8%, mean age 51 years, 75% men) and probable eosinophilic oesophagitis in seven subjects (0.7%, 95% CI 0.2 to 1.2%, mean age 58 years, 43% men). Erosive oesophagitis (OR = 2.99, 95% CI 1.58 to 5.66) and absence of dyspepsia (OR = 0.23, 95% CI 0.07 to 0.75) and Helicobacter pylori infection (OR = 0.41, 95% CI 0.19 to 0.92) were independent predictors for “eosinophils present”. Definite eosinophilic oesophagitis was associated with dysphagia (2/66 vs 2/926, p = 0.025), and probable eosinophilic oesophagitis with narrowing of the oesophageal lumen (2/15 vs 5/978, p = 0.005). Conclusions: Oesophageal eosinophils were present in nearly 5% of the general population; approximately 1% had definite or probable eosinophilic oesophagitis. Oesophageal eosinophils may be a manifestation of reflux disease in adults, but the condition is as likely to be asymptomatic and go unrecognised.

Ethnicity, acculturation, and self reported health. A population based study among immigrants from Poland, Turkey, and Iran in Sweden

Study objective: To analyse the association between ethnicity and poor self reported health and explore the importance of any mediators such as acculturation and discrimination. Design: A simple random sample of immigrants from Poland (n = 840), Turkey (n = 840), and Iran (n = 480) and of Swedish born persons (n = 2250) was used in a cross sectional study in 1996. The risk of poor self reported health was estimated by applying logistic models and stepwise inclusion of the explanatory variables. The response rate was about 68% for the immigrants and 80% for the Swedes. Explanatory variables were: age, ethnicity, educational status, marital status, poor economic resources, knowledge of Swedish, and discrimination. Main results: Among men from Iran and Turkey there was a threefold increased risk of poor self reported health than Swedes (reference) while the risk was five times higher for women. When socioeconomic status was included in the logistic model the risk decreased slightly. In an explanatory model, Iranian and Turkish women and men had a higher risk of poor health than Polish women and men (reference). The high risks of Turkish born men and women and Iranian born men for poor self reported health decreased to non-significance after the inclusion of SES and low knowledge of Swedish. The high risks of Iranian born women for poor self reported health decreased to non-significance after the inclusion of low SES, low knowledge of Swedish, and discrimination. Conclusions: The strong association between ethnicity and poor self reported health seems to be mediated by socioeconomic status, poor acculturation, and discrimination.

Visual rating and volumetry of the medial temporal lobe on magnetic resonance imaging in dementia: a comparative study

OBJECTIVES It has been shown that atrophy of medial temporal lobe structures such as the hippocampus and entorhinal cortex shown on MRI may distinguish patients with Alzheimers disease from healthy controls. However, the diagnostic value of visual inspection and volumetry of medial temporal lobe atrophy (MTA) on MRI in a clinical setting is insufficiently known. METHODS Medial temporal lobe atrophy in 143 patients was visually rated from hard copies, using a 0–4 rating scale and a comparison was made with the volumes (cm3) of the medial temporal lobe as estimated with volumetry, using a stereological method. All patients were recruited in an unselected way in a clinical setting in the centre for memory impairments at the Huddinge University Hospital. Patients with Alzheimers disease (n=41), patients with other dementias (vascular dementia, frontotemporal dementia, and unspecified dementia; n=36) as well as non-demented subjects (n=66) were included. Medial temporal atrophy and volumetry were evaluated as a diagnostic tool by performing logistic regression analysis including age, sex, and mini mental state examination (MMSE) score and calculating the sensitivity and specificity and percentage correct classification. RESULTS Visual and volumetric analysis yielded statistically significant differences between patients with Alzheimers disease and non-demented subjects, as well as between those with other dementias and non-demented subjects. Combining MMSE scores and visually rated MTA ratings yielded a sensitivity of 95% for Alzheimers disease, 85% for other dementias. Non-demented subjects were identified with a specificity of 96%. Volumetry did not have an added value over the MMSE score alone. CONCLUSIONS Visual rating of MTA is a clinically useful method for differentiating Alzheimers disease from controls and is both quicker and more accurate than volumetry.

Social mapping of the obesity epidemic in Sweden

OBJECTIVE: The aim of the present study is to describe the evolution of the obesity epidemic in Sweden, with specific attention to the socioeconomic gradient.DESIGN: Data from the Swedish Surveys of Living Conditions were used. Three such surveys were undertaken in 1980/81, 1988/89, and 1996/97, each of which was based on a simple random sample from the national population registry.SUBJECTS: A total of 38,284 observations are used in this analysis, including males and females aged 16–84. The sample is approximately equally divided among the 3 survey periods and by gender.MEASUREMENTS: The following body weight categories are used to describe changing prevalences: overweight (BMI≥25), obesity (BMI≥30) and underweight (BMI<18.5). Because body weight and heights were self-reported, recorded values were adjusted for estimating gender-specific obesity prevalences. Education was used as a proxy for socioeconomic status.RESULTS AND CONCLUSIONS: The prevalence of BMI≥30 increased significantly over the 16-year observation period. At the time of the 1980/81 survey, the adjusted estimates were 8.8% in women and 6.6% in men, compared to 11.9% and 10.0% respectively, in 1996/97. The prevalence of BMI≥25 was also analyzed for time trends, with specific attention to populations at risk. The largest proportionate changes occurred in women aged 16–44, among whom the prevalence of overweight doubled. The inverse educational gradient with respect to obesity is still present in both sexes, but there is no indication that it has increased in magnitude between 1980/81–1996/97.

Neighbourhood deprivation and incidence of coronary heart disease: a multilevel study of 2.6 million women and men in Sweden

Study objective: To examine whether neighbourhood deprivation predicts incidence rates of coronary heart disease, beyond age and individual income. Design: Follow up study from 31 December 1995 to 31 December 1999. Women and men were analysed separately with respect to incidence rates of coronary heart disease. Multilevel logistic regression was used in the analysis with individual level characteristics (age, individual income) at the first level and level of neighbourhood deprivation at the second level. Neighbourhood deprivation was measured at small area market statistics level by the use of Care Need Index. Setting: Sweden. Participants: All women and men aged 40–64 in the Swedish population, in total 2.6 million people. Main results: There was a strong relation between level of neighbourhood deprivation and incidence rates of coronary heart disease for both women and men. In the full model, which took account of individual income, the risk of developing coronary heart disease was 87% higher for women and 42% higher for men in the most deprived neighbourhoods than in the most affluent neighbourhoods. For both women and men the variance at neighbourhood level was over twice the standard error, indicating significant differences in coronary heart disease risk between neighbourhoods. Conclusions: High levels of neighbourhood deprivation independently predict coronary heart disease for both women and men. Both individual and neighbourhood level approaches are important in health care policies.

Self reported poor health and low educational level predictors for mortality: a population based follow up study of 39,156 people in Sweden.

OBJECTIVE: To analyse the relative risk (RR) of mortality for people who reported poor health or had low educational level. SETTING: Sweden. DESIGN: A random sample of 39156 people was interviewed face to face by Statistics Sweden from 1979-85. The dependent variable was total mortality. Independent variables were sex, age, marital status, and socioeconomic position, defined as educational level, type of housing tenure, and health status. This study was designed as a follow up study ranging from 1 January 1979 to 31 December 1993. Information on the dependent variables was obtained from the central cause of death register. Respondents were linked to the register by the Swedish personal registration number. Person-years at risk were calculated from the date of the interview until death, or for those who survived, until the end of the follow up period. Data were analysed in relation to gender and age (25-29 years and 60-74 years) in a proportional hazard model in order to estimate RR. RESULTS: During follow up 2656 men and 1706 women died. Men and women in both age groups who reported poor health status at the interview had a strongly increased risk of dying during the follow up period (RR = 2.05 (95% confidence interval 1.72, 2.31) and RR = 1.91 (1.74, 2.10) for men, and RR = 2.34 (1.94, 2.83) and RR = 1.80 (1.61, 2.02) for women for the younger and older age groups respectively) when simultaneously controlled for age, marital status, education, and housing tenure. Living alone, renting an apartment, and low educational level (< or = 9 years) were also associated with increased mortality risks for men and women in both age groups. CONCLUSION: Poor self reported health was a strong predictor for total mortality. Furthermore, in Sweden, a country well known for the equality of its income distribution, there are inequalities in health with higher total mortality risks for people with a low educational level and those who are not owner-occupiers.

Neighborhood deprivation and cardiovascular disease risk factors: Protective and harmful effects

Aims: To determine whether neighborhood-level deprivation is independently associated with cardiovascular disease (CVD) health behaviors/risk factors in the Swedish population. Methods: Pooled cross-sectional data, Swedish Annual Level of Living Survey (1996—2000) linked with indicators of neighborhood-level (i.e. Small Area Market Statistics areas) deprivation (1997), to examine the association between neighborhood-level deprivation and individual-level smoking, physical inactivity, obesity, diabetes, and hypertension among women and men, aged 25—64 (n=18,081). Data were analyzed with a series of logistic regression models that adjusted for individual-level age, gender, marital status, immigration status, urbanization, and a comprehensive measure of socioeconomic status (SES). Interactions were tested to determine whether neighborhood effects varied by SES or length of neighborhood exposure. Results: Living in a neighborhood with low deprivation was protective (i.e. lower odds) for smoking, while living in a neighborhood with high deprivation was harmful (i.e. higher odds) for smoking, physical inactivity, and obesity (compared with living in a neighborhood with moderate deprivation). These associations were significant after adjustment for individual-level characteristics. There was no evidence that the neighborhood deprivation associations varied by individual-level SES or length of neighborhood exposure. Conclusions: Neighborhood-level deprivation exerted important protective and harmful associations with health behaviors/ risk factors related to CVD. The significance to public health is substantial because of the number of persons at risk as well as the serious health consequences of CVD. These results suggest that interventions focusing on changing contextual aspects of neighborhoods, in addition to changing individual behaviors, may have a greater impact on CVD than a sole focus on individuals.

Impact of ethnicity, violence and acculturation on displaced migrants: psychological distress and psychosomatic complaints among refugees in Sweden.

This study uses data collected in 1996 by the Swedish National Board of Health and Welfare. By means of interviews with 1980 foreign-born immigrants, an attempt was made to determine the impact of a) migration status (country of birth/ethnicity), b) exposure to violence, c) Antonovskys sense of coherence, d) acculturation status (knowledge of Swedish), e) sense of control over ones life, f) economic difficulties, and g) education, both on psychological distress (using General Health Questionnaire 12) and psychosomatic complaints (daytime fatigue, sleeping difficulties, and headache/migraine). Iranians and Chileans (age-adjusted) were at great risk for psychological distress as compared with Poles, whereas Turks and Kurds exhibited no such risk. When the independent factors were included in the model, the migration status effect decreased to insignificance (with the exception of Iranian men). A low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties were strongly associated with the outcomes, generally accounting for a convincing link between migration status and psychological distress. Furthermore, a low sense of coherence, poor acculturation (men only), poor sense of control, and economic difficulties in exile seemed to be stronger risk factors for psychological distress in this group than exposure to violence before migration.

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.