Changes in lung cancer incidence and mortality in Estonia were studied for 20 years (1968-87). A steady upward trend was observed for men and women. The 1983-87/1968-72 age-standardized incidence rate ratio was 1.22 (95% confidence interval (CI) 1.15-1.29) in men and 1.34 (95% CI 1.16-1.54) in women. The corresponding mortality rate ratio was 1.26 (95% CI 1.18-1.34) in men and 1.35 (95% CI 1.16-1.57) in women. The age-specific incidence and mortality rates increased clearly towards the younger birth cohorts. For men and women, the increase was most evident for the age group 45-64 years. In women there was a more rapid increase in incidence and mortality than in men. It may be a result of a substantial increase of tobacco smoking, particularly among women, after the World War II. The high and still rising occurrence of lung cancer is closely related to the high prevalence of smoking; in addition, high tar yields in domestic cigarettes could have been responsible for an elevated lung cancer risk during the past decades. There is not tobacco control programme in Estonia, and existing legislation and regulations do not defend the non-smoking population.

Importance: Higher Mediterranean diet (MED) intake has been associated with reduced risk of type 2 diabetes, but underlying biological mechanisms are unclear.

Objective: To characterize the relative contribution of conventional and novel biomarkers in MED-associated type 2 diabetes risk reduction in a US population.

Design, Setting, and Participants: This cohort study was conducted among 25 317 apparently healthy women. The participants with missing information regarding all traditional and novel metabolic biomarkers or those with baseline diabetes were excluded. Participants were invited for baseline assessment between September 1992 and May 1995. Data were collected from November 1992 to December 2017 and analyzed from December 2018 to December 2019.

Exposures: MED intake score (range, 0 to 9) was computed from self-reported dietary intake, representing adherence to Mediterranean diet intake.

Main Outcomes and Measures: Incident cases of type 2 diabetes, identified through annual questionnaires; reported cases were confirmed by either telephone interview or supplemental questionnaire. Proportion of reduced risk of type 2 diabetes explained by clinical risk factors and a panel of 40 biomarkers that represent different physiological pathways was estimated.

Results: The mean (SD) age of the 25 317 female participants was 52.9 (9.9) years, and they were followed up for a mean (SD) of 19.8 (5.8) years. Higher baseline MED intake (score ≥6 vs ≤3) was associated with as much as a 30% lower type 2 diabetes risk (age-adjusted and energy-adjusted hazard ratio, 0.70; 95% CI, 0.62-0.79; when regression models were additionally adjusted with body mass index [BMI]: hazard ratio, 0.85; 95% CI, 0.76-0.96). Biomarkers of insulin resistance made the largest contribution to lower risk (accounting for 65.5% of the MED–type 2 diabetes association), followed by BMI (55.5%), high-density lipoprotein measures (53.0%), and inflammation (52.5%), with lesser contributions from branched-chain amino acids (34.5%), very low-density lipoprotein measures (32.0%), low-density lipoprotein measures (31.0%), blood pressure (29.0%), and apolipoproteins (23.5%), and minimal contribution (≤2%) from hemoglobin A1c. In post hoc subgroup analyses, the inverse association of MED diet with type 2 diabetes was seen only among women who had BMI of at least 25 at baseline but not those who had BMI of less than 25 (eg, women with BMI <25, age- and energy-adjusted HR for MED score ≥6 vs ≤3, 1.01; 95% CI, 0.77-1.33; P for trend = .92; women with BMI ≥25: HR, 0.76; 95% CI, 0.67-0.87; P for trend < .001).

Conclusions and Relevance: In this cohort study, higher MED intake scores were associated with a 30% relative risk reduction in type 2 diabetes during a 20-year period, which could be explained in large part by biomarkers of insulin resistance, BMI, lipoprotein metabolism, and inflammation.

The rapid rise of obesity, type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) during the last few decades among South Asians has been largely attributed to a major shift in lifestyles including physical inactivity, unhealthy dietary patterns, and an overall pattern of sedentary lifestyle. Genetic predisposition to these cardiometabolic risk factors may have interacted with these obesogenic environments in determining the higher cardiometabolic disease prevalence. Based on the premise that gene-environment interactions cause obesity and cardiometabolic diseases, we systematically searched the literature and considered the knowledge gaps that future studies might fulfill. We identified only seven published studies that focused specifically on gene-environment interactions for cardiometabolic traits in South Asians, most of which were limited by relatively small sample and lack of replication. Some studies reported that the differences in metabolic response to higher physical activity and low caloric diet might be modified by genetic risk related to these cardiometabolic traits. Although studies on gene lifestyle interactions in cardiometabolic traits report significant interactions, future studies must focus on more precise assessment of lifestyle factors, investigation of a larger set of genetic variants and the application of powerful statistical methods to facilitate translatable approaches. Future studies should also be integrated with findings both using mechanistic studies through laboratory settings and randomized clinical trials for clinical outcomes.

Obesity is associated with adverse health outcomes, but the metabolic effects have not yet been fully elucidated. We aimed to investigate the association between adiposity and circulating metabolites and to address causality with Mendelian randomization (MR). Metabolomics data were generated with nontargeted ultraperformance liquid chromatography coupled to time-of-flight mass spectrometry in plasma and serum from three population-based Swedish cohorts: ULSAM (N = 1,135), PIVUS (N = 970), and TwinGene (N = 2,059). We assessed associations of general adiposity measured as BMI and central body fat distribution measured as waist-to-hip ratio adjusted for BMI (WHRadjBMI) with 210 annotated metabolites. We used MR analysis to assess causal effects. Lastly, we attempted to replicate the MR findings in the KORA and TwinsUK cohorts (N = 7,373), the CHARGE Consortium (N = 8,631), the Framingham Heart Study (N = 2,076), and the DIRECT Consortium (N = 3,029). BMI was associated with 77 metabolites, while WHRadjBMI was associated with 11 and 3 metabolites in women and men, respectively. The MR analyses in the Swedish cohorts suggested a causal association (P value <0.05) of increased general adiposity and reduced levels of arachidonic acid, dodecanedioic acid, and lysophosphatidylcholine (P-16:0) as well as with increased creatine levels. The results of the replication effort provided support for a causal association of adiposity with reduced levels of arachidonic acid (P value = 0.03). Adiposity is associated with variation of large parts of the circulating metabolome; however, further investigation of causality is required in well-powered cohorts.

Aims: Skeletal muscle is a major metabolic organ and plays important roles in glucose metabolism, insulin sensitivity and insulin action. Muscle telomere length reflects the myocyte’s exposure to harmful environmental factors. Leukocyte telomere length is considered a marker of muscle telomere length and is used in epidemiologic studies to assess associations with ageing-related diseases where muscle physiology is important. However, the extent to which leucocyte and muscle telomere length are correlated is unknown, as are their relative correlations with glucose and insulin concentrations. The purpose of this study was to determine the extent of these relationships.

Methods: Leucocyte and muscle telomere length were measured by quantitative real-time polymerase chain reaction in participants from the Malmö Exercise Intervention (n = 27) and the Prevalence, Prediction and Prevention of Diabetes—Botnia studies (n = 31). Participants in both studies were free from Type 2 diabetes. We assessed the association between leucocyte telomere length, muscle telomere length and metabolic traits using Spearmen correlations and multivariate linear regression. Bland–Altman analysis was used to assess agreement between leucocyte and muscle telomere length.

Results: In age-, study-, diabetes family history- and sex-adjusted models, leucocyte and muscle telomere length were positively correlated (r = 0.39, 95% CI 0.15–0.59). Leucocyte telomere length was inversely associated with 2-h glucose concentrations (r = −0.58, 95% CI −1.0 to −0.16), but there was no correlation between muscle telomere length and 2-h glucose concentrations (r = 0.05, 95% CI −0.35 to 0.46) or between leucocyte or muscle telomere length with other metabolic traits.

Conclusions: In summary, the current study supports the use of leucocyte telomere length as a proxy for muscle telomere length in epidemiological studies of Type 2 diabetes aetiology.

Importance: Higher Mediterranean diet (MED) intake has been associated with lower risk of cardiovascular disease (CVD), but limited data are available about the underlying molecular mechanisms of this inverse disease association in human populations.

Objective: To better characterize the relative contribution of traditional and novel factors to the MED-related risk reduction in CVD events in a US population.

Design, setting, and participants: Using a prospective cohort design, baseline MED intake was assessed in 25 994 initially healthy US women in the Women's Health Study who were followed up to 12 years. Potential mediating effects of a panel of 40 biomarkers were evaluated, including lipids, lipoproteins, apolipoproteins, inflammation, glucose metabolism and insulin resistance, branched-chain amino acids, small-molecule metabolites, and clinical factors. Baseline study information and samples were collected between April 30, 1993, and January 24, 1996. Analyses were conducted between August 1, 2017, and October 30, 2018.

Exposures: Intake of MED is a 9-category measure of adherence to a Mediterranean dietary pattern. Participants were categorized into 3 levels based on their adherence to the MED.

Main outcomes and measures: Incident CVD confirmed through medical records and the proportion of CVD risk reduction explained by mediators.

Results: Among 25 994 women (mean [SD] age, 54.7 [7.1] years), those with low, middle, and upper MED intakes composed 39.0%, 36.2%, and 24.8% of the study population and experienced 428 (4.2%), 356 (3.8%), and 246 (3.8%) incident CVD events, respectively. Compared with the reference group who had low MED intake, CVD risk reductions were observed for the middle and upper groups, with respective HRs of 0.77 (95% CI, 0.67-0.90) and 0.72 (95% CI, 0.61-0.86) (P for trend < .001). The largest mediators of the CVD risk reduction of MED intake were biomarkers of inflammation (accounting for 29.2% of the MED-CVD association), glucose metabolism and insulin resistance (27.9%), and body mass index (27.3%), followed by blood pressure (26.6%), traditional lipids (26.0%), high-density lipoprotein measures (24.0%) or very low-density lipoprotein measures (20.8%), with lesser contributions from low-density lipoproteins (13.0%), branched-chain amino acids (13.6%), apolipoproteins (6.5%), or other small-molecule metabolites (5.8%).

Conclusions and relevance: In this study, higher MED intake was associated with approximately one-fourth relative risk reduction in CVD events, which could be explained in part by known risk factors, both traditional and novel.

Importance  Higher adherence to the Mediterranean diet has been associated with reduced risk of all-cause mortality, but data on underlying molecular mechanisms over long follow-up are limited.

Objectives  To investigate Mediterranean diet adherence and risk of all-cause mortality and to examine the relative contribution of cardiometabolic factors to this risk reduction.

Design, Setting, and Participants  This cohort study included initially healthy women from the Women’s Health Study, who had provided blood samples, biomarker measurements, and dietary information. Baseline data included self-reported demographics and a validated food-frequency questionnaire. The data collection period was from April 1993 to January 1996, and data analysis took place from June 2018 to November 2023.

Exposures  Mediterranean diet score (range, 0-9) was computed based on 9 dietary components.

Main Outcome and Measures  Thirty-three blood biomarkers, including traditional and novel lipid, lipoprotein, apolipoprotein, inflammation, insulin resistance, and metabolism measurements, were evaluated at baseline using standard assays and nuclear magnetic resonance spectroscopy. Mortality and cause of death were determined from medical and death records. Cox proportional hazards regression was used to calculate hazard ratios (HRs) for Mediterranean diet adherence and mortality risk, and mediation analyses were used to calculate the mediated effect of different biomarkers in understanding this association.

Results  Among 25 315 participants, the mean (SD) baseline age was 54.6 (7.1) years, with 329 (1.3%) Asian women, 406 (1.6%) Black women, 240 (0.9%) Hispanic women, 24 036 (94.9%) White women, and 95 (0.4%) women with other race and ethnicity; the median (IQR) Mediterranean diet adherence score was 4.0 (3.0-5.0). Over a mean (SD) of 24.7 (4.8) years of follow-up, 3879 deaths occurred. Compared with low Mediterranean diet adherence (score 0-3), adjusted risk reductions were observed for middle (score 4-5) and upper (score 6-9) groups, with HRs of 0.84 (95% CI, 0.78-0.90) and 0.77 (95% CI, 0.70-0.84), respectively (P for trend < .001). Further adjusting for lifestyle factors attenuated the risk reductions, but they remained statistically significant (middle adherence group: HR, 0.92 [95% CI, 0.85-0.99]; upper adherence group: HR, 0.89 [95% CI, 0.82-0.98]; P for trend = .001). Of the biomarkers examined, small molecule metabolites and inflammatory biomarkers contributed most to the lower mortality risk (explaining 14.8% and 13.0%, respectively, of the association), followed by triglyceride-rich lipoproteins (10.2%), body mass index (10.2%), and insulin resistance (7.4%). Other pathways, including branched-chain amino acids, high-density lipoproteins, low-density lipoproteins, glycemic measures, and hypertension, had smaller contributions (<3%).

Conclusions and Relevance  In this cohort study, higher adherence to the Mediterranean diet was associated with 23% lower risk of all-cause mortality. This inverse association was partially explained by multiple cardiometabolic factors.

Background: Previous results from Scandinavian cohorts have shown that obesity accentuates the effects of common genetic susceptibility variants on increased triglycerides (TG). Whether such interactions are present in the US population and further selective for particular TG-rich lipoprotein subfractions is unknown.

Methods: We examined these questions using body mass index (BMI) and waist circumference (WC) among women of European ancestry from the Women's Genome Health Study (WGHS) (n = 21840 for BMI; n = 19313 for WC). A weighted genetic risk score (TG-wGRS) based on 40 published TG-associated single-nucleotide polymorphisms was calculated using published effect estimates.

Results: Comparing overweight (BMI ≥ 25 kg/m2) and normal weight (BMI < 25 kg/m2) WGHS women, each unit increase of TG-wGRS was associated with TG increases of 1.013% and 1.011%, respectively, and this differential association was significant (Pinteraction = 0.014). Metaanalyses combining results for WGHS BMI with the 4 Scandinavian cohorts (INTER99, HEALTH2006, GLACIER, MDC) (total n = 40026) yielded a more significant interaction (Pinteraction = 0.001). Similarly, we observed differential association of the TG-wGRS with TG (Pinteraction = 0.006) in strata of WC (<80 cm vs ≥80 cm). Metaanalysis with 2 additional cohorts reporting WC (INTER99 and HEALTH2006) (total n = 27834) was significant with consistent effects (Pinteraction = 0.006). We also observed highly significant interactions of the TG-wGRS across the strata of BMI with very large, medium, and small TG-rich lipoprotein subfractions measured by nuclear magnetic resonance spectroscopy (all Pinteractions < 0.0001). The differential effects were strongest for very large TG-rich lipoprotein.

Conclusions: Our results support the original findings and suggest that obese individuals may be more susceptible to aggregated genetic risk associated with common TG-raising alleles, with effects accentuated in the large TG-rich lipoprotein subfraction.

Objective- Higher triglyceride (TG) is a risk factor for incident type 2 diabetes mellitus (T2DM), but paradoxically, genetic susceptibility for higher TG has been associated with lower T2DM risk. There is also evidence that the genetic association may be modified by baseline TG. Whether such associations can be replicated and the interaction is selective for certain TG-rich lipoprotein particles remains to be explored. Approach and Results- Cox regression involving TG, TG-rich lipoprotein particles, and genetic determinants of TG was performed among 15 813 participants with baseline fasting status in the WGHS (Women's Genome Health Study), including 1453 T2DM incident cases during a mean 18.6 (SD=5.3) years of follow-up. A weighted, 40-single-nucleotide polymorphism TG genetic risk score was inversely associated with incident T2DM (hazard ratio [95% CI], 0.66 [0.58-0.75]/10-TG risk alleles; P<0.0001) with adjustment for baseline body mass index, HDL (high-density lipoprotein) cholesterol, and TG. TG-associated risk was higher among individuals in the low compared with the high 40-single-nucleotide polymorphism TG genetic risk score tertile (hazard ratio [95% CI], 1.98 [1.83-2.14] versus 1.68 [1.58-1.80] per mmol/L; Pinteraction=0.0007). In TG-adjusted analysis, large and medium but not small TG-rich lipoprotein particles were associated with higher T2DM incidence for successively lower 40-single-nucleotide polymorphism TG genetic risk score tertiles, Pinteraction=0.013, 0.012, and 0.620 across tertiles, respectively. Conclusions- Our results confirm the previous observations of the paradoxical associations of TG with T2DM while focusing attention on the larger TG-rich lipoprotein particle subfractions, suggesting their importance in clinical profiling of T2DM risk.

Background: Recent cross-sectional genome-wide scans have reported associations of 97 independent loci with body mass index (BMI). In 3541 middle-aged adult participants from the GLACIER Study, we tested whether these loci are associated with 10-year changes in BMI and other cardiometabolic traits (fasting and 2-h glucose, triglycerides, total cholesterol, and systolic and diastolic blood pressures).

Methods: A BMI-specific genetic risk score (GRS) was calculated by summing the BMI-associated effect alleles at each locus. Trait-specific cardiometabolic GRSs comprised only the loci that show nominal association (P⩽0.10) with the respective trait in the original cross-sectional study. In longitudinal genetic association analyses, the second visit trait measure (assessed ~10 years after baseline) was used as the dependent variable and the models were adjusted for the baseline measure of the outcome trait, age, age2, fasting time (for glucose and lipid traits), sex, follow-up time and population substructure.

Results: The BMI-specific GRS was associated with increased BMI at follow-up (β=0.014 kg m−2 per allele per 10-year follow-up, s.e.=0.006, P=0.019) as were three loci (PARK2 rs13191362, P=0.005; C6orf106 rs205262, P=0.043; and C9orf93 rs4740619, P=0.01). Although not withstanding Bonferroni correction, a handful of single-nucleotide polymorphisms was nominally associated with changes in blood pressure, glucose and lipid levels.

Conclusions: Collectively, established BMI-associated loci convey modest but statistically significant time-dependent associations with long-term changes in BMI, suggesting a role for effect modification by factors that change with time in this population.

Numerous obesity loci have been identified using genome-wide association studies. A UK study indicated that physical activity may attenuate the cumulative effect of 12 of these loci, but replication studies are lacking. Therefore, we tested whether the aggregate effect of these loci is diminished in adults of European ancestry reporting high levels of physical activity. Twelve obesity-susceptibility loci were genotyped or imputed in 111,421 participants. A genetic risk score (GRS) was calculated by summing the BMI-associated alleles of each genetic variant. Physical activity was assessed using self-administered questionnaires. Multiplicative interactions between the GRS and physical activity on BMI were tested in linear and logistic regression models in each cohort, with adjustment for age, age2, sex, study center (for multicenter studies), and the marginal terms for physical activity and the GRS. These results were combined using meta-analysis weighted by cohort sample size. The meta-analysis yielded a statistically significant GRS × physical activity interaction effect estimate (Pinteraction = 0.015). However, a statistically significant interaction effect was only apparent in North American cohorts (n = 39,810, Pinteraction = 0.014 vs. n = 71,611, Pinteraction = 0.275 for Europeans). In secondary analyses, both the FTO rs1121980 (Pinteraction = 0.003) and the SEC16B rs10913469 (Pinteraction = 0.025) variants showed evidence of SNP × physical activity interactions. This meta-analysis of 111,421 individuals provides further support for an interaction between physical activity and a GRS in obesity disposition, although these findings hinge on the inclusion of cohorts from North America, indicating that these results are either population-specific or non-causal.

Background/Aims: Obesity is a pervasive and highly prevalent disease that poses substantial health risks to those it affects. The rapid emergence of obesity as a global epidemic and the patterns and distributions of the condition within and between populations suggest that interactions between inherited biological factors (e.g. genes) and relevant environmental factors (e.g. diet and physical activity) may underlie the current obesity epidemic. Methods: We discuss the rationale for the assertion that gene × lifestyle interactions cause obesity, systematically appraise relevant literature, and consider knowledge gaps future studies might seek to bridge. Results: We identified >200 relevant studies, of which most are relatively small scale and few provide replication data. Conclusion: Although studies on gene × lifestyle interactions in obesity point toward the presence of such interactions, improved data standardization, appropriate pooling of data and resources, innovative study designs, and the application of powerful statistical methods will be required if translatable examples of gene × lifestyle interactions in obesity are to be identified. Future studies, of which most will be observational, should ideally be accompanied by appropriate replication data and, where possible, by analogous findings from experimental settings where clinically relevant traits (e.g. weight regain and weight cycling) are outcomes.

Background: Obesity is a complex disease caused by the interplay of genetic and lifestyle factors, but identification of gene–lifestyle interactions in obesity has remained challenging. Few large-scale studies have reported use of genome-wide approaches to investigate gene–lifestyle interactions in obesity.

Methods: In the Pakistan Risk of Myocardial Infraction Study, a cross-sectional study based in Pakistan, we calculated body mass index (BMI) variance estimates (square of the residual of inverse-normal transformed BMI z-score) in 14 131 participants and conducted genome-wide heterogeneity of variance analyses (GWHVA) for this outcome. All analyses were adjusted for age, age2, sex and genetic ancestry.

Results: The GWHVA analyses identified an intronic variant, rs140133294, in the FLJ33544 gene in association with BMI variance (P-value=3.1 × 10−8). In explicit tests of gene × lifestyle interaction, smoking was found to significantly modify the effect of rs140133294 on BMI (Pinteraction=0.0005), whereby the minor allele (T) was associated with lower BMI in current smokers, while positively associated with BMI in never smokers. Analyses of ENCODE data at the FLJ33534 locus revealed features indicative of open chromatin and high confidence DNA-binding motifs for several transcription factors, providing suggestive biological support for a mechanism of interaction.

Conclusions: In summary, we have identified a novel interaction between smoking and variation at the FLJ33534 locus in relation to BMI in people from Pakistan.

Background: Multiple genetic variants have been reliably associated with obesity-related traits in Europeans, but little is known about their associations and interactions with lifestyle factors in South Asians.

Methods: In 16,157 Pakistani adults (8232 controls; 7925 diagnosed with myocardial infarction [MI]) enrolled in the PROMIS Study, we tested whether: a) BMI-associated loci, individually or in aggregate (as a genetic risk score - GRS), are associated with BMI; b) physical activity and smoking modify the association of these loci with BMI. Analyses were adjusted for age, age2, sex, MI (yes/no), and population substructure.

Results: Of 95 SNPs studied here, 73 showed directionally consistent effects on BMI as reported in Europeans. Each additional BMI-raising allele of the GRS was associated with 0.04 (SE = 0.01) kg/m2 higher BMI (P = 4.5 × 10−14). We observed nominal evidence of interactions of CLIP1 rs11583200 (P interaction = 0.014), CADM2 rs13078960 (P interaction = 0.037) and GALNT10 rs7715256 (P interaction = 0.048) with physical activity, and PTBP2 rs11165643 (P interaction = 0.045), HIP1 rs1167827 (P interaction = 0.015), C6orf106 rs205262 (P interaction = 0.032) and GRID1 rs7899106 (P interaction = 0.043) with smoking on BMI.

Conclusions: Most BMI-associated loci have directionally consistent effects on BMI in Pakistanis and Europeans. There were suggestive interactions of established BMI-related SNPs with smoking or physical activity.

Elevated circulating copper levels have been associated with chronic kidney disease (CKD), kidney damage, and decline in kidney function. Using a two sample Mendelian randomization approach where copper-associated genetic variants were used as instrumental variables, genetically predicted higher circulating copper levels were associated with higher CKD prevalence (odds ratio 1.17; 95% confidence interval 1.04, 1.32; p-value = 0.009). There was suggestive evidence that genetically predicted higher copper was associated with a lower estimated glomerular filtration rate and a more rapid kidney damage decline. In conclusion, we observed that elevated circulating copper levels may be a causal risk factor for CKD.

Sweden has for many decades witnessed a decrease of the spread of tuberculosis (TB), but between the years of 2003-2012 a new pattern has emerged with refugees carrying TB entering the country and contributing to a situation where the infection has slowly begun to spread again. The communication between the refugees and the health professionals has been inefficient, which inevitably results in fewer refugees undergoing health examinations. This in turn can lead to an increase of infections and diseases.

The purpose of this study is to examine the current health communication between Swedish health professionals and immigrants, asylum seekers and refugees, and to give an overview of what type of health care currently exist for refugees with a high risk of TB. This is done to understand what is missing in the communication process, what has been done in order to improve the situation, and how it can be further improved in order to prevent TB. In order to fulfill the purpose of this study, a qualitative method has been used combining text analysis of interviews and secondary sources.

This study has shown based on the interviews and secondary sources that the Swedish prevention work regarding TB is developing positively in general, but the communication between newly arrived refugees, health professionals and authorities in Sweden is lacking due to the fact that most of what is written and said in this communication process is in Swedish. This makes it difficult for the refugees to understand what is communicated and is stated as one of the main reasons why many refugees do not undergo health examinations, combined with the lack of awareness. Therefore a better functioning health communication between refugees, authorities and health professionals is required to support refugees seeking health care, as well as co-operating with health professionals to prevent the spread of not only TB but other infections and diseases in Sweden.

Aims: To determine whether obesity-associated metabolites are associated with type 2 diabetes (T2DM) risk among South Asians.

Materials and methods: Serum-based nuclear magnetic resonance imaging metabolomics data were generated from two South Asian population-based prospective cohorts from Karachi, Pakistan: CARRS1 (N = 4017) and CARRS2 (N = 4802). Participants in both cohorts were followed up for 5 years and incident T2DM was ascertained. A nested case-control study approach was developed to select participants from CARRS1 (Ncases = 197 and Ncontrols = 195) and CARRS2 (Ncases = 194 and Ncontrols = 200), respectively. First, we investigated the association of 224 metabolites with general obesity based on body mass index and with central obesity based on waist-hip ratio, and then the top obesity-associated metabolites were studied in relation to incident T2DM.

Results: In a combined sample of the CARRS1 and CARRS2 cohorts, out of 224 metabolites, 12 were associated with general obesity and, of these, one was associated with incident T2DM. Fifteen out of 224 metabolites were associated with central obesity and, of these, 10 were associated with incident T2DM. The higher level of total cholesterol in high-density lipoprotein (HDL) was associated with reduced T2DM risk (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.53, 0.86; P = 1.2 × 10-3 ), while higher cholesterol esters in large very-low-density lipoprotein (VLDL) particles were associated with increased T2DM risk (OR 1.90, 95% CI 1.40, 2.58; P = 3.5 × 10-5 ).

Conclusion: Total cholesterol in HDL and cholesterol esters in large VLDL particles may be an important biomarker in the identification of early development of obesity-associated T2DM risk among South Asian adults.

Waterborne diseases are illnesses caused by microscopic organisms, like viruses, bacteria and  parasites, that transmitted via the fecal-oral route through ingestion of contaminated water or food or by direct person to person contact. The transmission cycle can be broken through safe water supplies, maintaining standards of sanitation and proper handwashing practices. Two waterborne diseases are considered in this study: hepatitis A and amebic dysentery. The study aimed to understand the important factors for preventing waterborne diseases in order to improve public health. A descriptive cross-sectional study was conducted to assess the effect of different drinking water sources, sewage systems and different active practices of soap use for hand washing on incidence of waterborne diseases in different regions in Saudi Arabia. Data was obtained from Ministry of Health and Household Environment Survey provided by General Authority for Statistics. Statistical analysis performed by using general linear model and type II Analysis of Variance. In comparison of different drinking water sources, this study showed borderline rise in incidence of waterborne diseases with the use of private well water. Whereas different sewage systems had no clear effect on the incidence of waterborne diseases. The study also revealed that not using soap for hand washing would increase the risk for hepatitis A infection. Moreover, the study showed significant decline in waterborne diseases incidence when access to filtered water combined with regular soap use in the same linear model.

OBJECTIVE: To describe the magnitude of socioeconomic inequalities in tuberculosis (TB) mortality by level of education in male, female, urban and rural populations in several European countries. DESIGN: Data were obtained from the Eurothine Project, covering 16 populations between 1990 and 2003. Age- and sex-standardised mortality rates, the relative index of inequality and the slope index of inequality were used to assess educational inequalities. RESULTS: The number of TB deaths reported was 8530, with a death rate of 3 per 100000 per year, of which 73% were males. Educational inequalities in TB mortality were present in all European populations. Inequalities in TB mortality were greater than in total mortality. Relative and absolute inequalities were large in Eastern European and Baltic countries but relatively small in Southern European countries and in Norway, Finland and Sweden. Inequalities in mortality were observed among both men and women, and in both rural and urban populations. CONCLUSIONS: Socio-economic inequalities in TB mortality exist in all European countries. Firm political commitment is required to reduce inequalities in the social determinants of TB incidence. Targeted public health measures are called for to improve access to treatment of vulnerable groups and thereby reduce TB mortality.

This paper uses secondary data analysis and a literature review to explore a “Swedish Dilemma”: Can Sweden continue to provide a high level of comprehensive health services for all regardless of ability to pay — a policy emphasizing “solidarity” — or must it decide to impose increasing constraints on health services spending and service delivery — a policy emphasizing “cost containment?” It examines recent policies and longer term trends including: changes in health personnel and facilities; integration of health and social services for older persons; introduction of competition among providers; cost sharing for patients; dismantling of dental insurance; decentralization of government responsibility; priority settings for treatment; and encouragement of the private sector. It is apparent that the Swedes have had considerable success in attaining cost containment — not primarily through “market mechanisms” but through government budget controls and service reduction. Further, it appears that equal access to care, or solidarity, may be adversely affected by some of the system changes.

Deliberate fire-setting, such as the crime of arson, can have devastating, even lethal, consequences. This study compared factors at the time of arson by female and male offenders in Sweden between 2000–2010. The women (n = 100), and men (n = 100) included in this study were randomly chosen from among all individuals who had been convicted for arson during this period and who underwent forensic psychiatric investigations. Information regarding psychiatric and somatic characteristics, their psychosocial situation, and whether they were in contact with health or social services before the arsons were examined. The results showed that both women and men have complex psychiatric and somatic characteristics, as well as psychosocial situations. Women showed more self-destructive behaviour, lower Global Assessment of Functioning scores, and had been in contact with psychiatric health services to a greater extent than men. More women than men had children. These findings suggest that specific actions may be needed for preventing and treating women compared with men at risk for committing arson. 

This study examines global incentives to reduce maternal mortality, namely the fifth Millenium Developmnet Goal to reduce maternal mortality with 75% by 2015. More specifically it examines maternal mortality and obstetric care in situations of emergency. When exposed to extreme situations the risks of negative pregnancy- and delivey outcomes are increased. Data was collected from seconday sources and from interviews with health staff with experiences from humanitarian work in the field. The findings were analyzed using a theoretical framework explaining maternal mortality be referring to both direct and indirect causes. The two theoretical models used in the study are similar and reminds of each other when explaining maternal mortality. One is based on the assumption that an obstetric complication has occurred and differnt delays in recieving care is the main cause maternal mortality, whilst the other theory is more in depth and elaborates the underlying causes. The first theory is used a base tto analyze the data after which the other theory is applied in order to introdue a deeper dimension to the analysis. The findings suggest that direct causes accounts for 80 per cent of all maternal deaths, homorrhage being the largest, including in disasters. Further causes are infections, unsafe abortions, eclampsia and obstructed labor. Also, underlying socail factors such as gender inequality indirectly has a negative impact on maternal mortality. Moreover, findings suggest that obstetric care is prioritized in disaster relief response.

Coordinators may play a key role during the return-to-work (RTW) process for people on sickness absence. There are still few studies on the newly implemented rehabilitation coordinators (RECO) within Swedish healthcare, and none focus on their competence. The aim of this study was to explore how persons with multimorbidity and psychosocial difficulties describe the professional competence of the RECO they encountered during their RTW process. The study takes a relational and practical approach in defining professional competence, including both what professionals do and what they possess. Interviews with 12 people with multimorbidity and psychosocial difficulties who had encountered a RECO during their RTW process were analysed using thematic analysis. Six different themes were found: communicative and coordinating skills; advisory and guidance skills; engagement and advocacy skills; being persistent and flexible; being empathic and therapeutic; being professional and trustworthy. Most of these are found in research on RTW coordinators, but being persistent, and having advisory, guidance, advocacy and therapeutic skills have not been recognised as important competences previously. This study adds patients’ views on important professional competence that support the RTW process, which should be regarded in further developments of RECOs’ functions and their competence descriptions.

OBJECTIVES: To assess to what extent educational differences in total life expectancy (TLE) and disability-free life expectancy (DFLE) could be reduced by improving fruit and vegetable consumption in ten European countries.

METHODS: Data from national census or registries with mortality follow-up, EU-SILC, and ESS were used in two scenarios to calculate the impact: the upward levelling scenario (exposure in low educated equals exposure in high educated) and the elimination scenario (no exposure in both groups). Results are estimated for men and women between ages 35 and 79 years.

RESULTS: Varying by country, upward levelling reduced inequalities in DFLE by 0.1-1.1 years (1-10%) in males, and by 0.0-1.3 years (0-18%) in females. Eliminating exposure reduced inequalities in DFLE between 0.6 and 1.7 years for males (6-15%), and between 0.1 years and 1.8 years for females (3-20%).

CONCLUSIONS: Upward levelling of fruit and vegetable consumption would have a small, positive effect on both TLE and DFLE, and could potentially reduce inequalities in TLE and DFLE.

OBJECTIVES: A considerable increase in social inequalities in mortality was observed in Eastern Europe during the post-communist transition. This study evaluated the contribution of avoidable causes of death to the difference in life expectancy between Estonians and non-Estonians in Estonia.

STUDY DESIGN: Descriptive study.

METHODS: Temporary life expectancy (TLE) was calculated for Estonian and non-Estonian men and women aged 0-74 years in 2005-2007. The ethnic TLE gap was decomposed by age and cause of death (classified as preventable or treatable).

RESULTS: The TLE of non-Estonian men was 3.53 years less than that of Estonian men, and the TLE of non-Estonian women was 1.36 years less than that of Estonian women. Preventable causes of death contributed 2.19 years to the gap for men and 0.78 years to the gap for women, while treatable causes contributed 0.67 and 0.33 years, respectively. Cardiorespiratory conditions were the major treatable causes of death, with ischaemic heart disease alone contributing 0.29 and 0.08 years to the gap for men and women, respectively. Conditions related to alcohol and substance use represented the largest proportion of preventable causes of death.

CONCLUSIONS: Inequalities in health behaviours underlie the ethnic TLE gap in Estonia, rather than inequalities in access to health care or the quality of health care. Public health interventions should prioritize primary prevention aimed at alcohol and substance use, and should be implemented in conjunction with wider social policy measures.

Background Previous population -based studies investigating the relationship between physical activity and the gut microbiota have relied on self -reported activity, prone to reporting bias. Here, we investigated the associations of accelerometer -based sedentary (SED), moderate -intensity (MPA), and vigorous -intensity (VPA) physical activity with the gut microbiota using cross-sectional data from the Swedish CArdioPulmonary bioImage Study. Methods In 8416 participants aged 50-65, time in SED, MPA, and VPA were estimated with hip -worn accelerometer. Gut microbiota was profiled using shotgun metagenomics of faecal samples. We applied multivariable regression models, adjusting for sociodemographic, lifestyle, and technical covariates, and accounted for multiple testing. Findings Overall, associations between time in SED and microbiota species abundance were in opposite direction to those for MPA or VPA. For example, MPA was associated with lower, while SED with higher abundance of Escherichia coli. MPA and VPA were associated with higher abundance of the butyrate -producers Faecalibacterium prausnitzii and Roseburia spp. We observed discrepancies between specific VPA and MPA associations, such as a positive association between MPA and Prevotella copri, while no association was detected for VPA. Additionally, SED, MPA and VPA were associated with the functional potential of the microbiome. For instance, MPA was associated with higher capacity for acetate synthesis and SED with lower carbohydrate degradation capacity. Interpretation Our findings suggest that sedentary and physical activity are associated with a similar set of gut microbiota species but in opposite directions. Furthermore, the intensity of physical activity may have specific effects on certain gut microbiota species.

Background: OSA is a common sleep-breathing disorder linked to increased risk of cardiovascular disease. Intermittent upper airway obstruction and hypoxia, hallmarks of OSA, have been shown in animal models to induce substantial changes to the gut microbiota composition, and subsequent transplantation of fecal matter to other animals induced changes in BP and glucose metabolism.

Research question: Does OSA in adults associate with the composition and functional potential of the human gut microbiota?

Study design and methods: We used respiratory polygraphy data from up to 3,570 individuals 50 to 64 years of age from the population-based Swedish Cardiopulmonary bioimage Study combined with deep shotgun metagenomics of fecal samples to identify cross-sectional associations between three OSA parameters covering apneas and hypopneas, cumulative sleep time in hypoxia, and number of oxygen desaturation events with gut microbiota composition. Data collection about potential confounders was based on questionnaires, onsite anthropometric measurements, plasma metabolomics, and linkage with the Swedish Prescribed Drug Register.

Results: We found that all three OSA parameters were associated with lower diversity of species in the gut. Furthermore, in multivariable-adjusted analysis, the OSA-related hypoxia parameters were associated with the relative abundance of 128 gut bacterial species, including higher abundance of Blautia obeum and Collinsella aerofaciens. The latter species was also independently associated with increased systolic BP. Furthermore, the cumulative time in hypoxia during sleep was associated with the abundance of genes involved in nine gut microbiota metabolic pathways, including propionate production from lactate. Finally, we observed two heterogeneous sets of plasma metabolites with opposite association with species positively and negatively associated with hypoxia parameters, respectively.

Interpretation: OSA-related hypoxia, but not the number of apneas/hypopneas, is associated with specific gut microbiota species and functions. Our findings lay the foundation for future research on the gut microbiota-mediated health effects of OSA.

Hepatitis C virus (HCV) affects up to 45,000 people in Sweden today. Although it is a very treatable disease, the prevalence of HCV is extremely high within the population of people who inject drugs (PWID). This study examines the direct effect of needle exchange programs (NEPs) on HCV rates in Sweden. Previous research has shown that NEPs reduce the transmission of other blood-borne diseases among PWID. Using an interrupted time series (ITS) analysis, this study investigates if there are statistically significant differences between HCV rates in Swedish counties before and after the implementation of NEPs. The study also investigates via linear regression to see if there is a relationship between sterile injecting equipment (needles and syringes) dispensed and HCV rates in the counties where NEPs exist. While there has been a steady decrease in HCV rates across the country as a whole, the ITS analyses show no statistically significant differences in HCV rates due to the opening of NEPs. Because of the relatively recent introduction of NEPs in Sweden, more data points post-intervention may be needed before we can truly see the effect they have on regional HCV rates. There is also no relationship between the number of needles and syringes dispensed and county HCV rates. However, Sweden falls far short of the 300 syringes/needles per user per year recommendation of the World Health Organization at this time. Standardized data collection and further research can help answer these questions more clearly. 

An aim of committing terror is to instill fear in the population. This article explores to what extent Swedish citizens were cognitively, emotionally, and behaviorally affected by the 2017 terrorist attack in Stockholm and how the citizens perceived that the authorities handled the situation. The study is based on data from a survey with 1996 participants, consisting of a random sample of people living in Sweden, aged 18-79 years. Our results show that exposure to terrorist acts has a significant negative psychological impact on the population in general and on those who do not feel part of Swedish society in particular. The attack’s negative effect was despite the fact that the vast majority of respondents felt that society had handled the attack well and almost half of the respondents stated that they had gained increased confidence in the authorities.

The hypotheses of this study are that reduction and rational usage of antibiotics reduces development of antibiotic resistance. In Sweden, the trends do not follow this pattern. Despite a decrease in prescriptions of antibiotics, there is an increase in the number of patients infected with Methicillin-resistant Staphylococcus Aureus (MRSA), Extended Spectrum Beta-Lactamases (ESBL) and ESBL selecting for carbapenem-resistance (ESBLCARBA). This study aims to study factors affecting antibiotic resistance management. An additional aim is to use a multidisciplinary approach for a subject that has mostly been studied with quantitative methods. First, linear regressions investigated any possible significant changes of prescription rates in outpatient care, hospital usage of antibiotic groups and antibiotic resistance. After this, nine interviews were conducted with physicians in outpatient care, hospital care and with representatives from the Swedish Strategic Programme for the Rational Use of Antimicrobial Agents and Surveillance of Resistance (Strama), a network working for Swedish prevention against antibiotics resistance. There was a significant decrease in the number of prescriptions of antibiotics in outpatient care among all Swedish counties and a small, but significant increase of antibiotics used in hospitals. The number of patients infected with multidrug resistant bacteria also show a significant increase. The interviews revealed that health care workers in all counties follow the same guidelines and try to be as specific as possible in choosing antibiotics to hit specific bacteria. The respondents suggested migration and extended travelling as explanations to the growing number of cases of multidrug resistant bacteria. Further, two major factors emerged as important for an efficient antibiotic resistance management; Education/knowledge and Discussion. The results indicate a need for further research on rational usage of antibiotics and the use of broad-spectrum antibiotics in hospital care, rather than the reduction through prescriptions. The results indicate that rational usage has a bigger impact than reduction. Using a multidisciplinary approach gave a broader perspective on the issue and future studies should see the possibilities of mixing quantitative and qualitative studies.

Purpose: Return-to-work coordinators (RTWCs) give people on sick leave individualized support and coordinate between different stakeholders, including physicians.  The aim of this study was to explore physicians’ experience of RTWCs and investigate factors that influence how much physicians collaborate with RTWCs, or refer patients to them, in primary, orthopaedic, and psychiatric care clinics.

Materials and methods: Of the 1229 physicians responding to a questionnaire, 629 physicians who had access to a RTWC in their clinic answered to questions about collaborating with RTWCs.

Results: Among physicians who had access to a RTWC, 29.0% collaborated with a RTWC at least once a week. Physicians with a more favourable experience of RtWcs reported more frequent collaboration (adjusted OR 2.92, 95% CI 2.06–4.15). Physicians also collaborated more often with RTWCs if they reported to often deal with problematic sick-leave cases, patients with multiple diagnoses affecting work ability, and conflicts with patients over sickness certification.

Conclusions: Physicians who had more problematic sick-leave cases to handle and a favourable experience of RTWCs, also reported collaborating more often with RTWCs. The results indicate that RTWCs’ facilitation of contacts with RtW stakeholders and improvements in the sickness certification process may be of importance for physicians.

Experiences of, and access and barriers to, physical activity (PA) differ between individuals. This becomes perpetuated in a migration context. Although there is super-diversity between migrant groups, health research rarely accounts for this cultural diversity. More concerningly, the matter of context is rarely scrutinized or juxtaposed with the specifics of certain ethnic groups. This integrative review assessed the evidence on post-socialist migrants’ PA levels, constraints, and enablers for PA in the Nordic region. The results show that post-socialist female migrants have an especially high risk of being physically inactive. The qualitative work elucidates socio-cultural factors that impose specific constraints on females when attempting to engage in PA. Furthermore, in scrutinizing the context, Nordic nature (Friluftsliv) is a viable way for migrants to access PA with additional health benefits (e.g., mental). However, the Nordic environment also poses specific PA challenges, such as harsh winters. This can be understood by considering post-socialist migrants’ prior use of, and attitude to, nature. The review highlights the importance of understanding specifics about both migrant groups and contexts through a critical-realist lens in the pursuit of providing PA opportunities. Future PA programs need to understand the contextual, sociohistorical, and cultural settings in which they and migrants are embedded.

BACKGROUND: At the end of the 19th century, infant mortality was high in urban and rural areas in Sweden. In Stockholm, the mortality rate was particularly high among foster children. This study addresses the importance for health of targeted public policies and their local implementation in the reduction of excess mortality among foster children in Stockholm at the turn of the 19th century. In response to public concern, a law was passed in 1902 on inspections of foster homes. Stockholm city employed a handful of inspectors who visited foster homes and advised parents on child care and feeding. METHODS: Analysis of historical records from the City of Stockholm was combined with epidemiological analysis of mortality rates and hazard ratios on individual-level data for 112 746 children aged <1 year residing in one part of Stockholm between 1878 and 1925. Hazard ratios of mortality were calculated using Cox' regression analysis. RESULTS: Mortality rates of foster infants exceeded 300/1000 before 1903. Ten years later the mortality rates among foster children had declined and were similar to other children born in and out of wedlock. Historical accounts and epidemiological analysis of individual-level data over a longer time period showed similar results. CONCLUSIONS: Targeted policy measures to foster children may have potentiated the positive health effects of other universal policies, such as improved living conditions, clean water and sanitation for the whole population in the city, contributing to an equalization of mortality rates between different groups.

Study objective: To investigate whether the income distribution in a Russian region has a "contextual" effect on individuals' self rated health, and whether the regional income distributions are related to regional health differences. Methods: The Russia longitudinal monitoring survey (RLMS) is a survey (n = 7696) that is representative of the Russian population. With multilevel regressions both individual as well as contextual effects on self rated health were estimated. Main results: The effect of income inequality is not negative on men's self rated health as long as the level of inequality is not very great. When inequality levels are high, however, there is a tendency for men's health to be negatively affected. Regional health differences among men are in part explained by regional income differences. On the other hand, women do not seem to be affected in the same way, and individual characteristics like age and educational level seem to be more important. Conclusions: It seems that a rise in income inequality has no negative effect on men's self rated health as long as the level of inequality is not very great. On the other hand, when inequality levels are higher a rise tends to affect men's health negatively. A curvilinear relation between self rated health and income distribution is an interesting hypothesis. It could help to explain the confusing results that arise when you look at countries with a high degree of income inequality (USA) and those with lower income inequality (for example, Japan and New Zealand).

Sexual harassment and other forms of transit crime are everyday occurrences for women and girls around the world. The absence of safety hampers the ability of numerous women to engage freely in school, employment, and public activities without being alert. This research explores women's safety experiences, particularly focusing on young women in diverse rural and urban environments. We utilized chi-square analysis and regression models to analyze data obtained from a survey distributed to railway passengers in 2022 across neighboring municipalities in southern central Sweden. Findings show that being young makes women more likely to be victimized. Although rural women feel safer than their urban counterparts, they are more often willing to take precautionary measures before taking a trip (e.g., more often traveling with someone in the evening or avoiding certain stations). These findings call for gender-age-sensitive mobility policies, taking into account the intersectionality of transit safety, and reflecting women's and girls' safety needs in particular rural contexts.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is a pandemic and leading cause of death. Beyond the deaths directly caused by the virus and the suicides related to the psychological response to the dramatic changes as socioeconomic related to the pandemic, there might also be suicides related to the inflammatory responses of the infection. Infection induces inflammation as a cytokine storm, and there is an increasing number of studies that report a relationship between infection and suicide. MATERIALS AND METHODS: We searched the World Health Organization status report and the PubMed database for keywords (COVID-19, suicide, infection, inflammation, cytokines), and reviewed five cytokine pathways between suicide and inflammation using two meta-analyses and two observational studies starting from November 31, 2020, focusing on the relationship between suicide and inflammation by infection. First, we discussed existing evidence explaining the relationship between suicidal behaviors and inflammation. Second, we summarized the inflammatory features found in COVID-19 patients. Finally, we highlight the potential for these factors to affect the risk of suicide in COVID-19 patients. RESULTS: Patients infected with COVID-19 have high amounts of IL-1 beta, IFN-gamma, IP10, and MCP1, which may lead to Th1 cell response activation. Also, Th2 cytokines (e.g., IL-4 and IL-10) were increased in COVID-19 infection. In COVID-19 patients, neurological conditions, like headache, dizziness, ataxia, seizures, and others have been observed. CONCLUSIONS: COVID-19 pandemic can serve as a significant environmental factor contributing directly to increased suicide risk; the role of inflammation by an infection should not be overlooked.

Abortion stigma, while observable as a global phenomenon, is constructed locally through various pathways and institutions, and at the intersection of transnational and local discourses. Stigmatisation of abortion has been challenged in varied ways by pro-choice adherents. This article investigates strategies for identifying and opposing stigmatisation of abortion in Ireland and Poland, focusing on campaigns aimed in one context, at repealing a near total prohibition of abortion, and in another, on resisting further restrictions concerning reproductive rights. We examine how mobilisation on sexual and reproductive health (SRH) in both contexts worked to address stigma and discrimination in SRH, drawing on the concept of framing and showing similarities between these two national contexts. Our analysis explains how the logic of inclusion and exclusion works in efforts at destigmatising abortion.

Background: On 1 January 2020, the UNCRC was incorporated into the Swedish national law. The Convention argues that all children have the right to health, life, survival and development. The Articles of the UNCRC require higher authorities, health facilities and parents to act in the best interest of children, and to do everything to secure children’s rights. Interpreting the Convention, it is possible to conclude that all children have the right to safe and effective vaccines. Even though vaccines are accessible and free of charge to all children in Sweden, vaccination coverage for multiple vaccine-preventable diseases in Sweden has dropped. As one of the reasons for this drop in vaccination coverage is proposed vaccination hesitancy. To fulfil children’s rights as proposed in the UNCRC, vaccination hesitancy needs to be understood and addressed. 

Aim: The objective of the study is to understand causes of vaccination hesitancy among parents living in Stockholm, Sweden and to examine how healthcare professionals in Stockholm County are working to eliminate vaccination hesitancy, in goal to promote children’s rights to health, life, survival and development after the UNCRC became a Swedish law on 1 January 2020. Additionally, to analyze if strategies applied by Stockholm County are truly addressing identified causes of vaccination hesitancy among parents living in Stockholm, Sweden and in that way increasing vaccination rates this year.

Method: This study used a qualitative research strategy. Vaccination hesitancy in Sweden was studied using 20 semi-structured interviews with parents living in Stockholm, while effect of the UNCRC incorporation into Swedish law on vaccination hesitancy was studied using a semi-structured interview with one health professional working in Stockholm County. The gathered data was summarized, categorized and analyzed according to the proposed themes of two theories. The theoretical framework consisted of the Health Belief Model and Social-Ecological Model.

Conclusion: It was possible to conclude that the choice of immunization among parents is shaped by; 1) sources and type of the received information on vaccines, vaccination and vaccine-preventable diseases included in the general Swedish child vaccination program, 2) their views on vaccine quality, safety, effectiveness and necessity for satisfying children’s rights to health, life, survival and development, 3) the level of knowledge of epidemiological concepts, mechanisms, infectious diseases and vaccines included in the vaccination program, and 4) the level of trust in the Swedish Government and healthcare, and belief if they are acting in the best interest of children. After the UNCRC incorporation into Swedish law, there have not been observed any changes in the strategic work of Stockholm County against vaccination hesitancy. For the past ten years, they are applying methods at the individual- and interpersonal level, which are not quite reaching vaccine hesitant parents living in Stockholm. Other methods at the community- and public policy level are needed. Due to unclear implications of the UNCRC entrance as a national law and COVID-19 pandemic, it is not possible to estimate if there are any changes in the vaccination rates this year.

Human gut microbiota produce a variety of molecules, some of which enter the bloodstream and impact health. Conversely, dietary or pharmacological compounds may affect the microbiota before entering the circulation. Characterization of these interactions is an important step towards understanding the effects of the gut microbiota on health. In this cross-sectional study, we used deep metagenomic sequencing and ultra-high-performance liquid chromatography linked to mass spectrometry for a detailed characterization of the gut microbiota and plasma metabolome, respectively, of 8583 participants invited at age 50 to 64 from the population-based Swedish CArdioPulmonary bioImage Study. Here, we find that the gut microbiota explain up to 58% of the variance of individual plasma metabolites and we present 997 associations between alpha diversity and plasma metabolites and 546,819 associations between specific gut metagenomic species and plasma metabolites in an online atlas ( https://gutsyatlas.serve.scilifelab.se/ ). We exemplify the potential of this resource by presenting novel associations between dietary factors and oral medication with the gut microbiome, and microbial species strongly associated with the uremic toxin p-cresol sulfate. This resource can be used as the basis for targeted studies of perturbation of specific metabolites and for identification of candidate plasma biomarkers of gut microbiota composition.

OBJECTIVE: To assess whether recent declines in cardiovascular mortality have benefited all socioeconomic groups equally and whether these declines have narrowed or widened inequalities in cardiovascular mortality in Europe.

METHODS: In this prospective registry-based study, we determined changes in cardiovascular mortality between the 1990s and the early 2010s in 12 European populations by gender, educational level and occupational class. In order to quantify changes in the magnitude of differences in mortality, we calculated both ratio measures of relative inequalities and difference measures of absolute inequalities.

RESULTS: Cardiovascular mortality has declined rapidly among lower and higher socioeconomic groups. Relative declines (%) were faster among higher socioeconomic groups; absolute declines (deaths per 100 000 person-years) were almost uniformly larger among lower socioeconomic groups. Therefore, although relative inequalities increased over time, absolute inequalities often declined substantially on all measures used. Similar trends were seen for ischaemic heart disease and cerebrovascular disease mortality separately. Best performer was England and Wales, which combined large declines in cardiovascular mortality with large reductions in absolute inequalities and stability in relative inequalities in both genders. In the early 2010s, inequalities in cardiovascular mortality were smallest in Southern Europe, of intermediate magnitude in Northern and Western Europe and largest in Central-Eastern European and Baltic countries.

CONCLUSIONS: Lower socioeconomic groups have experienced remarkable declines in cardiovascular mortality rates over the last 25 years, and trends in inequalities can be qualified as favourable overall. Nevertheless, further reducing inequalities remains an important challenge for European health systems and policies.

We examined interactions between lifestyle factors and genetic risk of type 2 diabetes (T2D-GR), captured by genetic risk score (GRS) and family history (FH). Our initial study cohort included 20,524 European-ancestry participants, of whom 1,897 developed incident T2D, in the Nurses' Health Study (1984-2016), Nurses' Health Study II (1989-2016), and Health Professionals Follow-up Study (1986-2016). The analyses were replicated in 19,183 European-ancestry controls and 2,850 incident T2D cases in the Women's Genome Health Study (1992-2016). We defined 2 categories of T2D-GR: high GRS (upper one-third) with FH and low GRS or without FH. Compared with participants with the healthiest lifestyle and low T2D-GR, the relative risk of T2D for participants with the healthiest lifestyle and high T2D-GR was 2.24 (95% confidence interval (CI): 1.76, 2.86); for participants with the least healthy lifestyle and low T2D-GR, it was 4.05 (95% CI: 3.56, 4.62); and for participants with the least healthy lifestyle and high T2D-GR, it was 8.72 (95% CI: 7.46, 10.19). We found a significant departure from an additive risk difference model in both the initial and replication cohorts, suggesting that adherence to a healthy lifestyle could lead to greater absolute risk reduction among those with high T2D-GR. The public health implication is that a healthy lifestyle is important for diabetes prevention, especially for individuals with high GRS and FH of T2D.

Background: The stressful and complex nature of police work and its adverse effects on mental health are well-documented in police research. The mental health of police students however, has not been given the same attention. To the best of our knowledge, studies on the mental health of Swedish police recruits have not been undertaken since 2010.

Objectives: The present study aims to examine whether there are differences in the mental health between two cohorts (2009 and 2020) of Swedish police recruits, as well as to compare the mental health of both cohorts with the general population data collected in 2002.

Methods: Data was collected using the SCL-90-R survey. Data was analyzed using multivariate analysis of variance (MANOVA) and independent sample T-tests. Bi-variate analyses including t-test and chi-square were used to examine differences in sociodemographic variables between the two cohorts.

Results: A total of 376 police recruits participated in the study. Results indicated no significant differences between the cohorts with regards to the three global indices of the SCL-90-R: Global Severity Index (GSI), Positive Symptom Total (PST), and Positive Symptom Distress Index (PSDI). Recruits with a college degree had lower scores on GSI and PSDI, similar to respondents that where in a relationship vs. singles. A total of 15 (four female) recruits had GSI scores above the Swedish patient mean. Compared with the general population, males and females from the 2009, as well as females from the 2020 cohorts had lower or insignificantly different mean scores on all global indices, with males from the 2020 cohort having a significantly lower PST score.

Conclusions: While the vast majority of recruits had results that where indicative of a low prevalence and intensity with regards to mental health disorders, some recruits did score above the Swedish patient mean. While mental preparedness is part of the curriculum for Swedish police recruits, interventions targeting the stigmas of poor mental health could be of value. The fact that educational attainment appears to have a positive impact on the mental health of police recruits, could be taken in to consideration when recruiting future police officers.

In Europe, educational attainment and diabetes are inversely related, in terms of both morbidity and mortality rates. This underlines the importance of targeting interventions towards low SEP groups. Access and use of healthcare services by people with diabetes also need to be improved.

Countries of the Baltic Sea region differ strongly with regard to the magnitude and pattern of the educational inequalities in cancer mortality.

The specific health benefits achieved from different formsand patterns of leisure-time physical activity are not established.We analyzed the mortality in a cohort of Swedishgolf players. We used the Swedish Golf Federation’s membershipregistry and the nationwide Mortality Registry. Wecalculated standardized mortality ratios (SMR) with stratificationfor age, sex, and socioeconomic status. The cohortincluded 300 818 golfers, and the total number of deaths was1053. The overall SMR was 0.60 [95% confidence intervals(CIs): 0.57–0.64]. The mortality reduction was observed inmen and women, in all age groups, and in all socioeconomiccategories. Golfers with the lowest handicap (the mostskilled players) had the lowest mortality; SMR50.53(95% CI: 0.41–0.67) compared with 0.68 (95% CI: 0.61–0.75) for those with the highest handicap. While we cannotconclude with certainty that all the 40% decreased mortalityrates are explained by the physical activity associatedwith playing golf, we conclude that most likely this is part ofthe explanation. To put the observed mortality reduction incontext, it may be noted that a 40% reduction of mortalityrates corresponds to an increase in life expectancy of about5 years.

The World Health Organization (WHO), concludes that child maltreatment is a global concern calling for a multi sectoral interdisciplinary approach. School professionals, such as social workers, teachers, and health care professionals are in positions to discover and report maltreatment enabling social workers to intervene. However, a variety of reports reveal an evident gap between incidences and frequency of number of cases reported. A review of relevant research indicates that the problem of “not reporting” suggests that moral conflicts are activated in the process of decision-making. The aim was to gain a deeper understanding of school professionals’ experiences of reporting suspected neglect and abuse to the Social Welfare Board. In a mixed method approach 32 school professionals, such as teachers, social workers, nurses and psychologists participated in interviews and responded to questionnaires. Findings from the qualitative content analysis were compared to the quantitative analysis in a meta-analysis. Moral conflicts occur when faced with making decisions about how to best deal with a child’s situation. Thoughts about the child’s best interest and relationship with his/her parents as well as the informants´ own safety, were central. The comparative meta- analysis of both data sets revealed these conflicts commence with a moral sensitivity of possible negative consequences for the child. Moral sensitivity can be viewed as a “good” personal attribute, it paradoxically might lead to moral stress despite an open ethical climate. Based on the results of this study, further research on the interpersonal aspects of dealing with moral conflicts involved in reporting suspected child abuse is indicated.