Background:Digital interventions have shown promise in supporting healthy behaviors among university students; however, few interventions support simultaneous change across multiple health behaviors. Moreover, behavioral interventions are typically evaluated as a whole, making it challenging to disentangle the contribution of individual components to the overall effects.

Objective:This study estimated the effects of the components of a digital behavior intervention on alcohol, diet, physical activity, and smoking outcomes among university students in Sweden.

Methods:A double-blind randomized factorial trial with 6 two-level factors was conducted. University students in Sweden were proactively recruited through student health care centers and social media. Participants were eligible if they were aged 18 years or older and had at least one health behavior classified as unhealthy. The effects of 6 components were estimated: screening and feedback; goal-setting and planning; motivation; skills and know-how; mindfulness; and self-authored SMS text messages. Primary outcomes were weekly alcohol consumption and frequency of heavy episodic drinking, average daily fruit and vegetable consumption, weekly sugary drink consumption, weekly moderate-to-vigorous physical activity (MVPA), and 4-week point prevalence of smoking.

Results:A total of 1704 students were randomized. The effectiveness of individual and pairwise components was estimated using available data from 1118 (65.61%) participants at 2 months and 874 (51.29%) at 4 months, with sensitivity analyses conducted using imputed missing data. Most consistently, the evidence indicated that screening and feedback affected fruit and vegetable consumption (2-month mean difference 0.11, compatibility interval [CoI] –0.02 to 0.24; probability of effect [POE] 94.7% and 4-month mean difference 0.12, CoI –0.03 to 0.26; POE 94.4%), as did skills and know-how (2-month mean difference 0.19, CoI 0.06-0.33; POE 99.8% and 4-month mean difference 0.14, CoI 0.01-0.28; POE 96.9%). The combination of these 2 components was even more effective (2-month mean difference 0.30, CoI 0.11-0.48; POE 99.9% and 4-month mean difference 0.26, CoI 0.05-0.46; POE 99.4%). The motivation and mindfulness components, both individually and in combination, increased MVPA at 2 months (combined mean difference 78.0, CoI 28.3-128.2; POE 99.9%); however, this effect was not observed at 4 months. Combining screening and feedback with skills and know-how increased MVPA at 4 months (mean difference 60.1, CoI 3.6-116.5; POE 98.2%). Heavy episodic drinking was reduced at 2 months by screening and feedback (incidence rate ratio 0.87, CoI 0.74-1.02; POE 95.2%), and the effect was greater when combined with goal-setting and mindfulness. There was some evidence that the motivation component was harmful with respect to heavy episodic drinking and that self-authored SMS text messages were harmful with respect to sugary drink consumption.

Conclusions:We dismantled a complex digital multiple behavior intervention and examined it using a factorial design to provide novel insights into the effectiveness of the intervention’s different components. Both marginal and synergistic effects were observed across multiple behaviors, providing evidence regarding which components are most promising in complex interventions. These findings should be considered in light of the risk of bias introduced by attrition to follow-up, which was high in this effectiveness trial with low barriers to participation.

Trial Registration:International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN23310640; https://www.isrctn.com/ISRCTN23310640

Coffee is the most common drink in the world, second only to water. This makes caffeine, the ingredient of coffee known for its wakefulness-promoting effects, one of the most used psychoactive substances. The psychoactive property of caffeine is well-characterized, and entails its interaction with the adenosine receptors, involved in sleep regulation. While studies have shown a deleterious immediate effect of caffeine on sleep, less is known about the effects of chronic caffeine exposure. In the present cross-sectional study, we investigated this relationship across a large cohort of 30,154 individuals participating in the Swedish Cardiopulmonary Bioimage Study (SCAPIS), which allowed us to compare habitual coffee intake with sleep habits, subjective estimate of daytime sleepiness, and underlying genetic variants. According to our analyses, different degrees of coffee consumption, confirmed by statistical association with previously reported genetic variants, showed very low association with estimated patterns of sleep habits or perceived daytime sleepiness. These results indicate that coffee may be less impactful on sleep habits than previously thought, or that other mechanisms, such as the adaptive capabilities of the adenosine system in adult coffee users, may dampen its psychoactive potency.

Several of the requirements for obtaining a medical degree according to the Swedish Higher Education Ordinance illustrate the scientific basis of the profession, and systematic reviews as well as health technology assessments (HTA) constitute cornerstones in evidence-based medicine. In this study, medical students' experience of scientific education related to the profession was explored, and their knowledge achieved was sampled by five multiple-choice questions (MCQ). A total of 433 out of 641 students attending the final semester in six medical schools in Sweden participated (response rate: 68%). Most of them experienced that a majority of the scientifically related learning outcomes for the medical degree had been adequately examined. Regarding the steps of a systematic review, 60% stated that they had been trained to define a specific research question, 64% to find relevant literature according to such a specific research question, 72% to assess scientific articles according to a checklist, 40% to compile results from several studies, and 35% to assess the certainty of evidence according to GRADE. Only 6% stated that they had received education regarding HTA, a factor that was strongly associated with students' perception that they had obtained adequate skills regarding how patient work is based on scientific evidence (adjusted odds ratio [OR] 14.1; 95% CI 1.80-110). Such an association was also found for credit-awarded hands-on evidence-related learning activities during clinical courses (OR 2.72; 95% CI 1.02-7.24). The median student answered 3 of 5 MCQs correctly. The results of a case/control study, a forest plot, and the concept of cost-effectiveness were frequently interpreted erroneously. In conclusion, several aspects of the scientific basis for professional life as a medical doctor seem to be well covered in the medical degree program, whereas others deserve increased attention.

Totalt 433 termin 11-studenter vid 6 lärosäten svaradepå hur läkarprogrammet förberett dem för evidensbaserat patientarbete.

Drygt 7 av 10 uppgav att de fått träna på att granskavetenskapliga artiklar enligt mall, men färre att de tränat på andra moment i en systematisk översikt.b Medianstudenten hade 3 av 5 rätt på kunskapsfrågor relaterade till HTA, men en fall–kontrollstudie, ett skogsdiagram och begreppet kostnadseffektivitet tolkadesofta på fel sätt.

Undervisning i HTA samt poänggivande moment i tillämpad evidensbaserad medicin under kliniska terminer var förknippade med upplevelsen att läkarprogrammet gett tillräcklig färdighet i hur man baserar patientarbete på vetenskap.

Objective: To examine associations between body mass index (BMI) in early pregnancy and gestational weight gain (GWG) with cardiovascular health in middle age using the 'Life's Essential 8' (LE8) concept of the American Heart Association (AHA).Design: Population-based cohort study.Setting: Swedish CardioPulmonary bioImage Study (SCAPIS).Population: A total of 8871 women from SCAPIS were included.Methods: Information on cardiovascular health in middle age was collected from SCAPIS and linked to pregnancy weight data obtained from the Swedish Medical Birth Register, with an average follow-up time of 24.5 years. An LE8 score between 0 and 100 was determined, where a score under 60 points was defined as poor cardiovascular health. Binary logistic regression and restricted cubic splines were used.Main outcome measures: Cardiovascular health according to LE8 in middle age.Results: The odds of having poor cardiovascular health in middle age were significantly higher in women who had overweight (adjusted odds ratio, aOR 3.30, 95% CI 2.82-3.88) or obesity (aOR 7.63, 95% CI 5.86-9.94), compared with women classified as being of normal weight in pregnancy. Higher odds were also found for excessive GWG (aOR 1.31, 95% CI 1.09-1.57), compared with women who gained weight within the recommendations.Conclusions: A high BMI in early pregnancy and excessive GWG were associated with greater odds of poor cardiovascular health in middle age. Although further studies are needed, our results highlight pregnancy as an important period to support long-term cardiovascular health.

ObjectiveThe objective of this study was to examine the chronic effects of a 20-week exercise training program on device-assessed sleep and sleep-disordered breathing; and to determine whether participating in a session of the exercise program had effects on device-assessed sleep the subsequent night in children with overweight/obesity.MethodsA randomized clinical trial was conducted from November 2014 to June 2016. A total of 109 children (age 8-11 years) with overweight/obesity were randomized into an exercise training or control group. The exercise program included aerobic and resistance training 3 to 5 days/week. The control group participants continued their usual lifestyle. Device-assessed sleep outcomes were measured using wrist-worn actigraphy at baseline, in the middle of the exercise program (10th week), and at postintervention for seven consecutive days (24 h/day), and sleep-disordered breathing was measured via the Pediatric Sleep Questionnaire.ResultsThe exercise training program had a statistically significant effect on wake after sleep onset time (-10.8 min/day, -0.5 SDs, p = 0.040). No other chronic or acute effects (i.e., the subsequent night of attending a session of the exercise training program) were observed on the remaining sleep outcomes.ConclusionsA 20-week exercise training program reduced wake after sleep onset time in children with overweight/obesity. Future randomized trials that include a sample of children with poor sleep health at baseline are needed to better appreciate the role of exercise in sleep health.

BackgroundThere is evidence for a link between hyperactivity and obesity, especially among older children. Both conditions seem to be multifactorial in origin and hypotheses of common underlying issues, such as emotional dysregulation, have been suggested. However, studies of the co-occurrence of the two conditions in younger age groups have been inconclusive.ObjectivesWe aimed to study the longitudinal associations of psychological strengths and difficulties at 4 years of age with health behaviours, body composition, physical fitness, and cardiovascular disease (CVD) risk factors 5 years later.MethodsParents of 226 4-year-old children filled out the Strengths and Difficulties Questionnaire (SDQ). At 9 years of age, we assessed health behaviours, physical fitness, body composition, and CVD risk factors. Associations were examined with linear regression models that were adjusted for sex, age of the child at 9, and maternal education.ResultsIn the adjusted models, hyperactivity at 4 was associated with higher fat-free mass (beta = 0.18, p = 0.007) and lower levels of sedentary behaviour (beta -0.14, p = 0.043) at 9 years. Furthermore, greater emotional problems at 4 were associated with lower intake of fruit and vegetables (beta -0.14, p = 0.038) at 9 years. However, there were no statistically significant associations between psychological difficulties and fat-mass index.ConclusionsOur novel data provide no evidence of an association between hyperactivity in preschool age and obesity or obesity-related behaviours in school age. Future studies examining how psychological factors relate to obesity development should consider a developmental perspective.

Objective: To examine the associations between the AmericanHeart Association scores (“Life’s Essential 8” [LE8] and “Life’s Simple 7” [LS7])and 2 subclinical coronary atherosclerosis indicators: coronary computed tomographic angiography (CCTA)-stenosis and coronary artery calcium (CAC).

Patients and Methods:We includedapopulation-basedsample, aged 50 to 64 years, recruited between 2013 and 2018 from the Swedish Cardiopulmonary Bioimage Study (n¼24,819,50.3%women). CCTA-stenosis was graded as no stenosis, stenosis (1%-49%) or severe stenosis ( 50%), whereas CAC was graded as 0,1 to 99, 100 to 399, or 400 Agatston units. Multinomial logistic regression and receiver operating characteristic (ROC) curves were used to study the associations between cardiovascular health scores and subclinical coronary atherosclerosis.

Results: Odds ratios (ORs) for CCTA-stenosis and severe CCTA-stenosis between the lowest (<50 points) vs the highest ( 80points) LE8 group were 4.18 (95% CI,3.56 to 4.91) and 11.17 (95% CI, 8.36 to 14.93), respectively. For corresponding CAC results, ORs were 3.36 (95% CI, 2.84 to 3.98), 7.72 (95% CI, 6.03 to 9.89), and 14.94 (95%CI, 10.47 to 21.31) for CAC scores of 1 to 99, 100 to 399, and 400, respectively. Area under ROC curves for predicting anystenosis were 0.642 (95% CI, 0.635 to 0.649) and 0.631 (95% CI, 0.624 to 0.638, P<.001) for LE8 and LS7, respectively.

Conclusion: Our data indicate that LE8 showed a strong, graded, and inverse association with CCTA-stenosis and CAC score. The capacity to predict CCTA-stenosis was comparable between LE8 and LS7, although LE8 had slightly higher prediction capacity of any stenosis. This study provides novel evidence that the LE8 score may be a useful tool for monitoring cardiovascular health.

Purpose To monitor cardiovascular health, in 2022, the American Heart Association (AHA) updated the construct “Life’s Simple 7” (LS7) to “Life’s Essential 8” (LE8). This study aims to analyze the associations and capacity of discrimination of LE8 and LS7 in relation to self-rated health (SRH) and health-related quality of life (HRQoL). 

Methods This study from the Swedish CArdioPulmonary bioImage Study (SCAPIS) included 28 731 Swedish participants, aged 50–64 years. Three diferent scores were derived from the SF-12 questionnaire: 1-item question SRH (“In general, would you say your health is …?”), mental-HRQoL and physical-HRQoL. Logistic regression, restricted cubic splines, and ROC analysis were used to study the associations between the AHA scores in relation to SRH and HRQoL. 

Results Compared to those with a LE8 score of 80, participants with a LE8 score of 40 were 14.8 times more likely to report poor SRH (OR: 14.8, 95% CI: 13.0–17.0), after adjustments. Moreover, they were more likely to report a poor mental-HRQoL (OR: 4.9, 95% CI: 4.2–5.6) and a poor physical-HRQoL (OR: 8.0, 95% CI: 7.0–9.3). Area under curves for discriminating poor SRH were 0.696 (95% CI: 0.687–0.704), 0.666 (95% CI: 0.657–0.674), and 0.643 (95% CI: 0.634–0.651) for LE8, LS7 (0–14), and LS7 (0–7), respectively, all p values <0.001 in the DeLong’s tests.

Conclusion LE8 and LS7 had strong and inverse associations with SRH, mental-HRQoL, and physical-HRQoL, though LE8 had a somewhat higher capacity of discrimination than LS7. The novel LE8, a construct initially conceived to monitor cardiovascular health, also conveys SRH and HRQoL.

Objectives To examine the associations between physical fitness in male adolescents and coronary and carotid atherosclerosis in middle age.Methods This population-based cohort study linked physical fitness data from the Swedish Military Conscription Register during adolescence to atherosclerosis data from the Swedish CArdioPulmonary bioImage Study in middle age. Cardiorespiratory fitness was assessed using a maximal cycle-ergometer test, and knee extension muscular strength was evaluated through an isometric dynamometer. Coronary atherosclerosis was evaluated via Coronary Computed Tomography Angiography (CCTA) stenosis and Coronary Artery Calcium (CAC) scores, while carotid plaques were evaluated by ultrasound. The associations were analysed using multinomial logistic regression, adjusted (marginal) prevalences and restricted cubic splines.Results The analysis included 8986 male adolescents (mean age 18.3 years) with a mean follow-up of 38.2 years. Physical fitness showed a reversed J-shaped association with CCTA stenosis and CAC, but no consistent association was observed for carotid plaques. After adjustments, compared with adolescents in the lowest tertile of cardiorespiratory fitness and muscular strength, those in the highest tertile had 22% (OR 0.78; 95% CI 0.61 to 0.99) and 26% (OR 0.74; 95% CI 0.58 to 0.93) lower ORs for severe (&gt;= 50%) coronary stenosis, respectively. The highest physical fitness group (high cardiorespiratory fitness and muscular strength) had 33% (OR 0.67; 95% CI 0.52 to 0.87) lower OR for severe coronary stenosis compared with those with the lowest physical fitness.Conclusion This study supports that a combination of high cardiorespiratory fitness and high muscular strength in adolescence is associated with lower coronary atherosclerosis, particularly severe coronary stenosis, almost 40 years later.

Background The ageing process can be influenced by energy intake and different macronutrients within the diet. The soluble form of the a-Klotho gene (called S-Klotho) is widely considered as a powerful anti-ageing biomarker. Objective To analyze the association of energy, dietary energy density and macronutrient intake with S-Klotho plasma levels in middle-aged sedentary adults. Methods A total of 72 (52.8% women) middle-aged sedentary adults (53.7 +/- 5.2 years old) participated in the study. Energy and macronutrients intake (i.e. fat, carbohydrate and protein) were assessed using three non-consecutive 24-h recalls. S-Klotho plasma levels were measured in the Ethylenediaminetetraacetic acid (EDTA) plasma using a solid-phase sandwich enzyme-linked immunosorbent assay. Results No association was observed between energy, dietary energy density or macronutrient intake and S-Klotho plasma levels in men (all P &gt;= 0.1). We found an inverse association between energy, protein and carbohydrate intake with S-Klotho plasma levels in women (all P &lt;= 0.043), which disappeared after controlling for age, lean mass index and sedentary time. An inverse association was observed between dietary energy density and S-Klotho plasma levels in women after controlling for covariates (all P &lt;= 0.05). Conclusion In summary, the present study showed an inverse association of dietary energy density with S-Klotho plasma levels in middle-aged women. In addition, our data suggest that the associations between energy and macronutrient intake could be highly dependent on lean mass and sedentary time.