Ulla Toft

The Dietary Quality Score: validation and association with cardiovascular risk factors: the Inter99 study.

Objective:To develop and assess the validity of the Dietary Quality Score (DQS) and investigate the association with cardiovascular risk factors.Design:Cross-sectional population-based study.Setting:Copenhagen County, Glostrup, Denmark.Subjects:A random sample of 12 934 men and women aged 30–60 years were invited to a health examination. A total of 6542 participants were included in the statistical analysis.Methods:The DQS was developed using eight questions from a 48-item food frequency questionnaire (FFQ) and validated using a 198-item FFQ. Associations between the DQS and fasting serum lipids, homocysteine, blood pressure and the absolute risk of ischaemic heart disease (IHD) were explored.Results:A higher DQS was shown to be associated with higher dietary quality in general, including a low intake of fat, especially saturated fat; a high intake of fibre; various vitamins and minerals; and fruit, fish, vegetables and whole–grain products. A higher score according to the DQS was significantly negatively associated with total cholesterol (P=0.0031), triglyceride (P=0.0406), low-density lipoprotein-cholesterol (P=0.0071), homocysteine (P<0.0001) and the absolute risk of IHD (P<0.0001), adjusted for sex, age, smoking habits and physical activity level.Conclusions:The DQS is a simple, valid and quick tool to make a rough classification of individuals into groups with high, average and low dietary quality. The DQS is negatively associated with serum lipids, homocysteine and the absolute risk of IHD.Sponsorship:The Inter99 study is supported economically by The Danish Medical Research Council, The Danish Centre for Evaluation and Health Technology Assessment, Novo Nordisk, Copenhagen County, The Danish Heart Foundation, The Danish Pharmaceutical Association, Augustinus Foundation, Ib Henriksen Foundation and Becket Foundation, Copenhagen County.

Determinants of vitamin D status in a general population of Danish adults

BACKGROUND AND AIMS Danish legislation regarding food fortification has been very restrictive and vitamin D deficiency is thought to be common in Denmark due to inadequate dietary intakes and the fact that in Denmark (latitude 56°N) vitamin D is only synthesized in the skin after exposure to solar radiation during summertime (April-September). The purpose of this study was to evaluate the vitamin D status of a general adult population in Denmark and, in addition, associations between vitamin D status and distinct lifestyle factors were studied. METHODS A random sample of 6784 persons from a general population aged 30-60 years participated in a health examination in 1999-2001. Serum samples from all participants were stored and levels of 25-hydroxyvitamin D (25(OH)D) were measured by HPLC in 2009. The method was compared to another HPLC method. Information on dietary intake of vitamin D and other lifestyle factors were obtained by questionnaires. A total of 6146 persons defined as ethnic Danes and with successful measurements of 25(OH)D were included in the analyses. RESULTS The overall prevalence of vitamin D deficiency (25(OH)D<25 nmol/l) and insufficiency (25(OH)D<50 nmol/l) were 13.8% and 52.2%, respectively. A marked seasonal fluctuation was seen in serum levels of 25(OH)D - median values of 25(OH)D were lowest in February and highest in August. In multiple logistic regression models (n=5506), low vitamin D status was significantly associated with obesity (BMI≥30), daily smoking and a sedentary lifestyle. However, measurements of 25(OH)D were not associated with the estimated dietary intake of vitamin D. Comparison of two HPLC methods demonstrated considerable differences in accuracy. DISCUSSION AND CONCLUSIONS Our results suggest that poor vitamin D status is common among adults in a Northern European country without food fortification with vitamin D. Methodological issues are, however, of great importance when using cut-off values to define poor vitamin D status. In addition, we demonstrated that low serum levels of 25(OH)D were associated with several lifestyle factors.

Effect of screening and lifestyle counselling on incidence of ischaemic heart disease in general population: Inter99 randomised trial

Objective To investigate the effect of systematic screening for risk factors for ischaemic heart disease followed by repeated lifestyle counselling on the 10 year development of ischaemic heart disease at a population level. Design Randomised controlled community based trial. Setting Suburbs of Copenhagen, Denmark Participants 59 616 people aged 30-60 years randomised with different age and sex randomisation ratios to an intervention group (n=11 629) and a control group (n=47 987). Intervention The intervention group was invited for screening, risk assessment, and lifestyle counselling up to four times over a five year period. All participants with an unhealthy lifestyle had individually tailored lifestyle counselling at all visits (at baseline and after one and three years); those at high risk of ischaemic heart disease, according to predefined criteria, were furthermore offered six sessions of group based lifestyle counselling on smoking cessation, diet, and physical activity. After five years all were invited for a final counselling session. Participants were referred to their general practitioner for medical treatment, if relevant. The control group was not invited for screening. Main outcome measures The primary outcome measure was incidence of ischaemic heart disease in the intervention group compared with the control group. Secondary outcome measures were stroke, combined events (ischaemic heart disease, stroke, or both), and mortality. Results 6091 (52.4%) people in the intervention group participated at baseline. Among 5978 people eligible at five year follow-up (59 died and 54 emigrated), 4028 (67.4%) attended. A total of 3163 people died in the 10 year follow-up period. Among 58 308 without a history of ischaemic heart disease at baseline, 2782 developed ischaemic heart disease. Among 58 940 without a history of stroke at baseline, 1726 developed stroke. No significant difference was seen between the intervention and control groups in the primary end point (hazard ratio for ischaemic heart disease 1.03, 95% confidence interval 0.94 to 1.13) or in the secondary endpoints (stroke 0.98, 0.87 to 1.11; combined endpoint 1.01, 0.93 to 1.09; total mortality 1.00, 0.91 to 1.09). Conclusion A community based, individually tailored intervention programme with screening for risk of ischaemic heart disease and repeated lifestyle intervention over five years had no effect on ischaemic heart disease, stroke, or mortality at the population level after 10 years. Trial registration Clinical trials NCT00289237.

Cohort Profile: The Health2006 cohort, Research Centre for Prevention and Health

Research Centre for Prevention and Health, Copenhagen University Hospital Glostrup, The Capital Region of Denmark, Denmark, National Allergy Research Centre, Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Denmark, Danish Research Centre for Chemical Sensitivities, Gentofte University Hospital, University of Copenhagen, Copenhagen, Denmark, Hagedorn Research Institute and Steno Diabetes Centre, Gentofte, Denmark, The Novo Nordisk Foundation Centre for Basic Metabolic Research, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark and Faculty of Health Sciences, University of Aarhus, Aarhus, Denmark

Combined Analyses of 20 Common Obesity Susceptibility Variants

OBJECTIVE Genome-wide association studies and linkage studies have identified 20 validated genetic variants associated with obesity and/or related phenotypes. The variants are common, and they individually exhibit small-to-modest effect sizes. RESEARCH DESIGN AND METHODS In this study we investigate the combined effect of these variants and their ability to discriminate between normal weight and overweight/obese individuals. We applied receiver operating characteristics (ROC) curves, and estimated the area under the ROC curve (AUC) as a measure of the discriminatory ability. The analyses were performed cross-sectionally in the population-based Inter99 cohort where 1,725 normal weight, 1,519 overweight, and 681 obese individuals were successfully genotyped for all 20 variants. RESULTS When combining all variants, the 10% of the study participants who carried more than 22 risk-alleles showed a significant increase in probability of being both overweight with an odds ratio of 2.00 (1.47–2.72), P = 4.0 × 10−5, and obese with an OR of 2.62 (1.76–3.92), P = 6.4 × 10−7, compared with the 10% of the study participants who carried less than 14 risk-alleles. Discrimination ability for overweight and obesity, using the 20 single nucleotide polymorphisms (SNPs), was determined to AUCs of 0.53 and 0.58, respectively. When combining SNP data with conventional nongenetic risk factors of obesity, the discrimination ability increased to 0.64 for overweight and 0.69 for obesity. The latter is significantly higher (P < 0.001) than for the nongenetic factors alone (AUC = 0.67). CONCLUSIONS The discriminative value of the 20 validated common obesity variants is at present time sparse and too weak for clinical utility, however, they add to increase the discrimination ability of conventional nongenetic risk factors.

The relationship between lifestyle and self-reported health in a general population: The Inter99 study

OBJECTIVES The aim of this paper is to describe the relationship between smoking status, dietary habits, physical activity and alcohol intake, and mental and physical self-reported health in a general population. MEASURES A large population-based study Inter99, Copenhagen, Denmark, 1999-2006. Self-reported health-related quality of life was measured by Short Form 12 (SF-12). Mental and physical health component scores were computed. RESULTS At baseline, SF-12 was completed by 6305 (92.3%) participants in the intervention groups, and 3017 (72.4%) persons in the control group. In cross-sectional analyses, persons with an unhealthy lifestyle reported significantly worse physical and mental health than persons with a healthier lifestyle. In longitudinal data, using adjusted multivariate analyses (N=3,084), we found an association between increased physical activity at five-year follow-up and improvement in physical health ( odds ratio=2.30 (95% confidence interval=1.7-3.2)) in the high-intensity intervention group. Improvement in mental health was associated with a much healthier diet at 5-year follow-up than at baseline ( odds ratio=1.68 (95% confidence interval=1.1-2.5)). CONCLUSIONS This study describes the negative relationship between unhealthy lifestyle and self-reported mental and physical health in a general population. Also, it shows the impact of improvements in lifestyle on self-reported health in a general population, which has not been investigated before.

High risk strategy in smoking cessation is feasible on a population-based level. The Inter99 study.

INTRODUCTION A high risk strategy is one of more strategies in public health. Smoking remains the most important contributor to the burden of disease in developed countries. METHODS A population-based multi-factorial intervention study, Inter99 (1999-2006), Copenhagen, Denmark, using a high risk strategy. All 2408 daily smokers were repeatedly offered individual face-to-face lifestyle counselling. Smokers in the high-intensity group were offered participation in smoking cessation groups. We measured point abstinence at 1, 3 and 5-year follow-up and compared with a control group, using adjusted intention-to treat analyses. RESULTS Compared with the control group it was twice as likely to be self-reported abstinent at 5-year follow-up in the high-intensity intervention group (OR: 2.19; 95%CI: 1.7-2.8; p<0.001). The effect of the intervention was significant, even when comparing validated abstinence in the intervention groups with self-reported abstinence in the control group (OR: 1.38; 95%CI: 1.1-1.8; p=0.014). Male gender, vocational training, higher age at onset of smoking, high knowledge of harm of smoking and lower tobacco consumption predicted abstinence. CONCLUSION A high risk strategy showed a significant effect on smoking in the long term. Proactive recruitment, face-to-face setting, repeated offer of assistance to quit and a multi-factorial approach may explain the success of the intervention.

The rise and fall of the world's first fat tax

In 2011, Denmark introduced the worlds first tax on saturated fat, but only 15 months later the fat tax was abolished. The aim of this article is to investigate the political processes surrounding the implementation and rapid abolition of the fat tax. Our findings suggest that industry and trade associations were heavily involved in the political process of formulating the fat tax. Industry representatives used certain tactics to oppose the fat tax: threatening lawsuits, predicting welfare losses, casting doubt on evidence, diverting focus and requesting postponement. After the fat tax was implemented, the food industry continued their opposition through intensified lobbyism and juridical actions at EU level. However, other factors seem to have contributed to the fall of the fat tax. The tax received criticism for being poorly designed and gradually lost popularity among health professionals, politicians and the public. In the end, the fat tax was abolished for financial reasons. This study demonstrates how politicians considered the fat tax as a funding source rather than a public health initiative, which resulted in significant shortcomings. Furthermore, we demonstrate that the massive influence by industry stakeholders was not balanced with inputs from public health professionals, who should assume a more proactive role in policy-making.

The impact of a population-based multi-factorial lifestyle intervention on changes in long-term dietary habits: the Inter99 study.

OBJECTIVE To evaluate the effectiveness of a population-based multi-factorial lifestyle intervention on long-term changes in dietary habits compared to a non-intervention control group. METHODS The study was a randomized controlled lifestyle intervention study, Inter99 (1999-2006), Copenhagen, Denmark, using a high-risk strategy. Participants in the intervention group (n=6 091) had at baseline a medical health-examination and a face-to-face lifestyle counselling. Individuals at high risk of ischemic heart disease were repeatedly offered both individual and group-based counselling. The control group (n=3 324) was followed by questionnaires. Dietary habits were measured by a validated 48-item food frequency questionnaire and changes were analyzed by multilevel analyses. RESULTS At the 5-year follow-up the intervention group compared to the control group had significantly increased their intake of vegetables (men: net-change: 23 g/week; p=0.04; women: net-change: 27 g/week; p=0.005) and decreased the intake of highly saturated fats used on bread and for cooking (men: OR=0.59 (0.41-0.86); women: OR=0.42 (0.30-0.59)). Significant effects on fruit and fish intake were found at the 3-year follow-up but the effect attenuated at the 5-year follow-up. CONCLUSION A population-based multi-factorial lifestyle intervention promoted significant greater beneficial long-term dietary changes compared to the control group, especially the intake of vegetables and saturated fat was improved.

Motives to quit smoking and reasons to relapse differ by socioeconomic status

OBJECTIVE To investigate motives, strategies and experiences to quit smoking and reasons to relapse as a function of socioeconomic status. METHODS A population-based study, Inter99, Denmark. Two thousand six hundred twenty-one daily smokers with a previous quit attempt completed questionnaires at baseline. Cross-sectional baseline-data (1999-2001) were analysed in adjusted regression analyses. RESULTS Consistent findings across the three indicators of socioeconomic status (employment, school education, higher education/vocational training): smokers with low socioeconomic status were significantly more likely than smokers with high socioeconomic status to report that they wanted to quit because smoking was too expensive (OR: 1.85 (1.4-2.4), for school education) or because they had health related problems (OR: 1.75 (1.4-2.2)). When looking at previous quit attempts, smokers with low socioeconomic status were significantly more likely to report that it had been a bad experience (OR: 1.41 (1.1-1.8)) and that they had relapsed because they were more nervous/restless/depressed (OR: 1.43 (1.1-1.8)). CONCLUSIONS This study shows that smokers with low socioeconomic status have other motives to quit and other reasons to relapse than smokers with high socioeconomic status. Future tobacco prevention efforts aimed at smokers with low socioeconomic status should maybe focus on current advantages of quitting smoking, using high cost of smoking and health advantages of quitting as motivating factors and by including components of mental health as relapse prevention.