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Screening for Cardiovascular Risk and Diabetes in Primary Health Care: The Söderåkra Risk Factor Screening Study
Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Screening för hjärtkärlrisk och diabetes i primärvården : Söderåkrastudien (Swedish)
Abstract [en]

Background: Cardiovascular disease (CVD) has been the predominant cause of morbidity and mortality for many decades in Sweden. Preventive work in primary health care through individual approach and community-based programmes has shown some success. Still, we need better risk assessment tools and health strategies to lessen the burden of CVD in our population.

Methods: This thesis is based on four studies that explore the cardiovascular risk factor pattern and its development to CVD morbidity and mortality in the middle-aged (40-59 years) population in Söderåkra, southern Sweden, 1989-2006. At a single physician consultation in 1989-1990 the participants provided information about lifestyle in a self-administered questionnaire, underwent a physical examination and received medical advice after a laboratory investigation. The laboratory tests consisted mainly of blood glucose, serum lipids and thyroid function tests. Blood samples were also frozen for later analyses. A telephone interview on self-reported lifestyle changes was conducted ten years later. In 2006, primary health care medical records were studied for incident diabetes and also for impaired glucose tolerance (IGT). Finally, national registers were studied for incident fatal or nonfatal cardiovascular disease until 2006. Cardiovascular risk assessments using three separate risk algorithms were applied on the population.

Results: The participation rate was high with 90% attendance. The conclusion of this cross-sectional baseline analysis was that it is meaningful to check for a secondary cause of hyperlipidemia, hypothyroidism, in women with a cholesterol value above 7.0 mmol/L. After 10 years follow-up women reported significantly more lifestyle changes than men, odds ratio (OR) 1.56 (95% CI: 1.11- 2.18; p= 0.010). Men with a history of smoking or CVD at baseline and women with treated hypertension at baseline made successful lifestyle changes, OR 4.77 (95% CI: 2.18-10.5; p<0.001 and OR 1.84 (95% CI: 1.12-3.02; p= 0.016), respectively, than those without these characteristics. Until 2006, 38 participants had developed diabetes and four subjects IGT out of 664 participants, excluding 10 with diabetes at baseline. A low level of IGFBP-1 at baseline was associated with the development of type 2 diabetes/IGT, hazard ratio (HR) 3.54 (95% CI: 1.18-10.6, p=0.024). This was independent of abdominal obesity or inflammation (CRP). After excluding 16 participants with prevalent CVD at baseline, 71 first fatal or nonfatal CVD events in 689 men and women were registered. Several known risk factors and risk markers were applied on this population.

Those that turned out to be significantly associated with development of incident CVD in univariate Cox´s regression proportional hazard analyses where used in three different risk assessment models: the consultation model, SCORE and the extensive model. A non-laboratory-based risk assessment model, including variables easily obtained during one consultation visit to a general practitioner (GP), predicted cardiovascular events as accurately, HR 2.72; (CI 95% 2.18-3.39, p<0.001), as the established SCORE algorithm, HR 2.73; (CI 95% 2.10-3.55, p<0.001), which requires laboratory testing. Furthermore, adding laboratory measurements covering lipids, inflammation and endothelial dysfunction, did not confer any additional value to the prediction of CVD risk, HR 2.72; (CI 95% 2.19-3.37, p<0.001). The c-statistics for the consultation model (0.794; CI 95% 0.762-0.823) was not significantly different from SCORE (0.767; CI 95% 0.733-0.798, p=0.12) or the extended model (0.806; CI 95% 0.774-0.835, p=0.55).

Conclusions: Our study showed that it is worth searching for hypothyroidism, in women with a cholesterol value above 7 mmol/L. The study identified female gender, previous CVD, hypertension and smoking as predictors of positive lifestyle change during follow-up. A low level of IGFBP-1 predicted future diabetes/IGT in this population as did increased waist and CRP. Finally, data on nonlaboratory risk factors obtained during one GP visit predicted future cardiovascular risk as accurately as SCORE or a laboratory-based risk algorithm.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2009. , 70 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1110
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-17692ISBN: 978-91-7393-673-6 (print)OAI: oai:DiVA.org:liu-17692DiVA: diva2:211338
Public defence
2009-04-29, Aulan, Hälsans Hus (ingång 16), Campus US, Linköpings Universitet, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2009-04-14 Created: 2009-04-14 Last updated: 2009-08-21Bibliographically approved
List of papers
1. Thyroid function tests, serum lipids and gender interrelations in a middle-aged population
Open this publication in new window or tab >>Thyroid function tests, serum lipids and gender interrelations in a middle-aged population
2001 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, Vol. 19, no 3, 183-185 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: To study the value of screening for thyroid function in a screening program for hyperlipidaemia.

DESIGN: A screening study in primary health care.

SETTING: All individuals in a defined rural area, Söderåkra, Sweden, aged 40-59 years were invited to a screening programme at the local primary health care centre.

PARTICIPANTS: 782 individuals were invited for screening. Blood samples were obtained from 88% of the invited males and from 92% of the females.

MAIN OUTCOME MEASURES: Thyroid function tests (thyroid stimulating hormone (TSH) and free T4), serum lipids (total-cholesterol, HDL-cholesterol, LDL-cholesterol and s-triglycerides), b-glucose and body anthropometry (body mass index and waist to hip circumference) were measured.

RESULTS: 0.57% of males and 1.13% of females showed evidence of hypothyroidism as defined by a TSH value greater than 3.75 mU/l of those with s-cholesterol concentration above 7 mmol/l. In addition, higher TSH values in females were associated with higher s-cholesterol, s-LDL-cholesterol and s-triglycerides.

CONCLUSION: It seems appropriate to screen for hypothyroidism in females with s-cholesterol above 7.0 mmol/l.

Keyword
Free, T4, Serum, Lipids, Gender, Primary-CARE, Thyroid; Function, Tsh
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17688 (URN)10.1080/028134301316982432 (DOI)11697562 (PubMedID)
Available from: 2009-04-14 Created: 2009-04-14 Last updated: 2009-04-14Bibliographically approved
2. Predictors of successful, self-reported lifestyle changes in a defined middle-aged population: the Soderakra Cardiovascular Risk Factor Study, Sweden
Open this publication in new window or tab >>Predictors of successful, self-reported lifestyle changes in a defined middle-aged population: the Soderakra Cardiovascular Risk Factor Study, Sweden
Show others...
2008 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, Vol. 36, no 4, 389-396 p.Article in journal (Refereed) Published
Abstract [en]

Aims: It is well established that the main cause of the development of cardiovascular disease can be found in unhealthy lifestyle habits. In our study, we wanted to explore the long-term predictors of self-reported lifestyle changes in a middle-aged population after screening for cardiovascular risk factors 10 years earlier.

Methods: We conducted a 10-year follow-up telephone interview on self-reported lifestyle changes in a rural population in south-eastern Sweden, after a cardiovascular screening programme. The population comprised 90% of all inhabitants (n=705) aged 40-59 years at baseline, and 90% of these (n=629) were reached for the telephone interview.

Results: When multivariate logistic regression was used, a higher success rate for lifestyle changes was independently associated with female gender (odds ratio (OR)=1.56, 95% confidence interval (CI) 1.11-2.18). When stratified for gender, significant predictors for success in men were prevalent cardiovascular risk conditions (OR=4.77, 95% CI 2.18-10.5; p<0.001) and previous myocardial infarction (OR=22.8, 95% CI 4.73-110; p<0.001) at baseline. For women, elevated blood pressure (> or = 160 and/or > or = 90 mmHg) measured at baseline (OR=1.84, 95% CI 1.12-3.02; p=0.016) was significantly associated with successful lifestyle changes. Smoking at baseline was also associated with significant success: OR=3.36 (95% CI:2.05-5.51; p<0.001) and OR=1.81 (95% CI 1.11-2.95; p=0.017) for men and women, respectively.

Conclusions: Female gender was associated with significant improvements in self-reported lifestyle changes. Furthermore, smoking, a medical history of diabetes, hypertension, angina pectoris or myocardial infarction at baseline predicted success in lifestyle change in this 10-year follow-up study.

Keyword
Cardiovascular, lifestyle change, population-based, risk factors
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17689 (URN)10.1177/1403494808089561 (DOI)18539693 (PubMedID)
Available from: 2009-04-14 Created: 2009-04-14 Last updated: 2009-08-20Bibliographically approved
3. Low levels of insulin-like growth-factor-binding protein-1 (IGFBP-1) are prospectively associated with the incidence of type 2 diabetes and impaired glucose tolerance (IGT): The Söderåkra Cardiovascular Risk Factor Study
Open this publication in new window or tab >>Low levels of insulin-like growth-factor-binding protein-1 (IGFBP-1) are prospectively associated with the incidence of type 2 diabetes and impaired glucose tolerance (IGT): The Söderåkra Cardiovascular Risk Factor Study
Show others...
2009 (English)In: Diabetes & Metabolism, ISSN 1262-3636, Vol. 35, no 3, 198-205 p.Article in journal (Refereed) Published
Abstract [en]

AIM: To explore the association between baseline levels of insulin-like growth-factor-binding protein-1 (IGFBP-1), a marker of insulin sensitivity, and the development of type 2 diabetes or impaired glucose tolerance (IGT) in a specifically defined middle-aged population.

METHODS: This cross-sectional population-based screening study was conducted in 1989-1990 and included baseline data for 664 non-diabetic subjects aged 40-59 years. Clinical data were collected and blood samples analyzed for blood glucose, serum lipids and insulin. Blood specimens were frozen at baseline and later analyzed for IGF-I, IGFBP-1 and C-reactive protein (CRP). At the follow-up in 2006, the incidence of type 2 diabetes and IGT was reported based on primary-care medical records.

RESULTS: During the 17-year observation period, 42 subjects (6.3%) developed type 2 diabetes/IGT. Those in the lowest quintile of IGFBP-1 (/=59mug/L), the incidence was 1.5%. Cox's proportional-hazards model regression analyses were used to determine the incidence of type 2 diabetes/IGT, corrected for age and gender, in relation to IGFBP-1, CRP and waist circumference. Subjects in the lowest IGFBP-1 quintile showed an independently increased risk of type 2 diabetes/IGT [hazards ratio (HR): 3.54; 95% CI 1.18-10.6; P=0.024]. For CRP and waist circumference, the corresponding figures were HR: 6.81; 95% CI 2.50-18.6; P<0.001 and HR: 3.33; 95% CI 1.47-7.6; P=0.004, respectively.

CONCLUSION: Low levels of IGFBP-1 predicted the long-term development of type 2 diabetes or IGT in a middle-aged population. The association was independent of CRP and abdominal obesity.

Place, publisher, year, edition, pages
Cedex, France: Elsevier, 2009
Keyword
CRP, IGFBP-1, Prediction; Screening, Type 2 diabetes, Longitudinal study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17690 (URN)10.1016/j.diabet.2008.11.003 (DOI)000267655700006 ()19297224 (PubMedID)
Available from: 2009-04-14 Created: 2009-04-14 Last updated: 2014-01-13Bibliographically approved
4. A consultation-based method is equal to SCORE and an extensive laboratory-based method in predicting risk of future cardiovascular disease
Open this publication in new window or tab >>A consultation-based method is equal to SCORE and an extensive laboratory-based method in predicting risk of future cardiovascular disease
2009 (English)In: European Journal of Cardiovascular Prevention & Rehabilitation, ISSN 1741-8267, E-ISSN 1741-8275, Vol. 16, no 5, 536-540 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: As cardiovascular disease (CVD) is one of the most common causes of mortality worldwide, much interest has been focused on reliable methods to predict cardiovascular risk.

DESIGN: A cross-sectional, population-based screening study with 17-year follow-up in Southern Sweden.

METHODS: We compared a non-laboratory, consultation-based risk assessment method comprising age, sex, present smoking, prevalent diabetes or hypertension at baseline, blood pressure (systolic >/=140 or diastolic >/=90), waist/height ratio and family history of CVD to Systemic COronary Risk Evaluation (SCORE) and a third model including several laboratory analyses, respectively, in predicting CVD risk. The study included clinical baseline data on 689 participants aged 40-59 years without CVD. Blood samples were analyzed for blood glucose, serum lipids, insulin, insulin-like growth factor-I, insulin-like growth factor binding protein-1, C-reactive protein, asymmetric dimethyl arginine and symmetric dimethyl arginine. During 17 years, the incidence of total CVD (first event) and death was registered.

RESULTS: A non-laboratory-based risk assessment model, including variables easily obtained during one consultation visit to a general practitioner, predicted cardiovascular events as accurately [hazard ratio (HR): 2.72; 95% confidence interval (CI): 2.18-3.39, P<0.001] as the established SCORE algorithm (HR: 2.73; 95% CI: 2.10-3.55, P<0.001), which requires laboratory testing. Furthermore, adding a combination of sophisticated laboratory measurements covering lipids, inflammation and endothelial dysfunction, did not confer any additional value to the prediction of CVD risk (HR: 2.72; 95% CI: 2.19-3.37, P<0.001). The c-statistics for the consultation model (0.794; 95% CI: 0.762-0.823) was not significantly different from SCORE (0.767; 95% CI: 0.733-0.798, P=0.12) or the extended model (0.806; 95% CI: 0.774-0.835, P=0.55).

CONCLUSION: A risk algorithm based on non-laboratory data from a single primary care consultation predicted long-term cardiovascular risk as accurately as either SCORE or an elaborate laboratory-based method in a defined middle-aged population.

Place, publisher, year, edition, pages
London, UK: Sage Publications, 2009
Keyword
Algorithm, cardiovascular, mortality, risk, screening
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17691 (URN)10.1097/HJR.0b013e32832b1833 (DOI)000271456200003 ()19357517 (PubMedID)
Available from: 2009-04-14 Created: 2009-04-14 Last updated: 2014-01-13Bibliographically approved

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