"Dare to feel full"-A group treatment method for sustainable weight reduction in overweight and obese adults: A randomized controlled trial with 5-years follow-up.

OBJECTIVES: To assess the long-term effects on weight reduction and health of a group-based behavioral weight intervention over six months focusing eating for fulfillment as compared to a control regime with brief intervention. METHOD: Overweight or obese adults (n = 176, 80% female, mean BMI 33.8 ± 4.7 kg/m2, mean age 55.2 ±10.1 years) were randomized to a group treatment or control receiving a brief intervention. Ninety-three participants (53% of original sample) completed the 5-year follow-up. Anthropometrics, blood pressure and biochemical measurements, self-rated lifestyle habits, quality of life and medication were obtained at baseline, at the end of the 6-month intervention, and once a year for five years following randomization. RESULTS: A per-protocol analysis, performed due to a high drop-out rate, found that weight reduction was small and similar in the two groups after five years. Reduction of waist/hip ratio, total-cholesterol and triglycerides were somewhat larger in the control group than in the treatment group. No changes regarding blood pressure, quality of life or medication use between the treatment and control groups were found. CONCLUSIONS: No effect on weight reduction of the group intervention was found as compared to brief intervention but both groups achieved small weight loss over time. Findings indicate that any intervention or merely regular follow-ups might be promotive for weight maintenance in middle age.

Being in a meaningful context. Nature and animal-assisted activities as perceived by adults with autism.

INTRODUCTION: Animal-assisted and nature-based interventions in psychosocial treatment for various groups of clients have been studied internationally. However, there is little knowledge about how young adults with autism experience participation in such types of interventions. This clinical study aimed to describe the feasibility of animal-assisted and nature-based activities on a farm as a complementary intervention for young adults with autism and social withdrawal. METHODS: The participants were aged 18-30 years, diagnosed with autism and social withdrawal, with no organised occupation during the previous year. Eleven of 13 participants completed a 12-week intervention in small groups. They took part in interviews before and after, which focused on their current life situation and expectations about, and experiences of the intervention. The feasibility was described in terms of participants' characteristics, attendance, and their experiences of participating in the activity. Data were analysed with descriptive statistics and qualitative content analysis. CONSUMER AND COMMUNITY INVOLVEMENT: The intervention was formed in collaboration with participating supervisors, ordinary clinical staff, and a young woman with a user perspective. FINDINGS: The level of feasibility was found to be high. The mean participation rate during the activity days was 75% and varied from 50 to 100%. The analysis of the participants' experiences from the activity generated three categories, "Being in a meaningful context", "Creating a comfort zone" and "Developing structure in everyday life", and each of these included sub-categories. CONCLUSION: The main categories revealed a dynamic process based in meaningfulness, comfort and structure in everyday life. The positive experiences of undemanding activities, emotional relationships and non-verbal communication with the horses were prominent and might facilitate the development of social interaction. However, the intervention's timeframe of 12 weeks was experienced as too short for long-lasting change.

Depression was associated with younger age, female sex, obesity, smoking, and physical inactivity, in 1027 patients with newly diagnosed type 2 diabetes: a Swedish multicentre cross-sectional study.

BACKGROUND: Depression is a risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). The aims were to explore the prevalence of depression, anxiety, antidepressant use, obesity, Hemoglobin A1c > 64 mmol/mol, life-style factors, pre-existing CVD, in patients with newly diagnosed T2D; to explore associations with depression; and to compare with Swedish general population data. METHODS: Multicentre, cross-sectional study. INCLUSION CRITERIA: adults with serologically verified newly diagnosed T2D. Included variables: age, sex, current depression and anxiety (Hospital Anxiety and Depression Scale), previous depression, antidepressant use, obesity (BMI ≥ 30 and ≥ 40 kg/m2), Hemoglobin A1c, pre-existing CVD. Logistic regression analyses were performed. RESULTS: In 1027 T2D patients, aged 18-94 years, depression was associated with age (per year) (inversely) (odds ratio (OR) 0.97), anxiety (OR 12.2), previous depression (OR 7.1), antidepressant use (OR 4.2), BMI ≥ 30 kg/m2 (OR 1.7), BMI ≥ 40 kg/m2 (OR 2.3), smoking (OR 1.9), physical inactivity (OR 1.8), and women (OR 1.6) (all p ≤ 0.013). Younger women (n = 113), ≤ 59 years, compared to younger men (n = 217) had higher prevalence of current depression (31% vs 12%), previous depression (43 vs 19%), anxiety (42% vs 25%), antidepressant use (37% vs 12%), BMI ≥ 30 kg/m2 (73% vs 60%) and BMI ≥ 40 kg/m2) (18% vs 9%), and smoking (26% vs 16%) (all p ≤ 0.029). Older women (n = 297), ≥ 60 years, compared to older men (n = 400) had higher prevalence of previous depression (45% vs 12%), anxiety (18% vs 10%), antidepressant use (20% vs 8%), BMI ≥ 30 kg/m2 (55% vs 47%), BMI ≥ 40 kg/m2 (7% vs 3%) (all p ≤ 0.048), but not of current depression (both 9%). Compared to the Swedish general population (depression (women 11.2%, men 12.3%) and antidepressant use (women 9.8%, men 5.3%)), the younger women had higher prevalence of current depression, and all patients had higher prevalence of antidepressant use. CONCLUSIONS: In patients with newly diagnosed T2D, the younger women had the highest prevalence of depression, anxiety, and obesity. The prevalence of depression in young women and antidepressant use in all patients were higher than in the Swedish general population. Three risk factors for CVD, obesity, smoking, and physical inactivity, were associated with depression.

Factors associated with increased physical activity among patients prescribed physical activity in Swedish routine health care including an offer of counselor support: a 1-year follow-up.

BACKGROUND: The study addresses knowledge gaps in research regarding influences of routine health care delivery of physical activity on prescription (PAP). The aim was to investigate if patient and health care characteristics are associated with increased physical activity 1 year after prescription among patients offered counselor support in addition to health care professionals' prescription. The study was conducted in primary and secondary care in a Swedish health care region. METHODS: All PAP recipients during 1 year were invited (N = 1503) to participate in this observational prospective study. Data were collected from medical records and questionnaires (baseline and follow-up). Descriptive statistics and multiple logistic regression analysis were used. The outcome variable was increased physical activity after 1 year. Study variables were patient and health care characteristics. RESULTS: Three hundred and fifty-five patients with complete follow-up data were included. The mean age was 62 years (SD = 14; range, 18-90) and 68% were females. Almost half (47%) had increased physical activity 1 year after PAP. Multiple logistic regression analysis showed that increased physical activity at follow-up was positively associated with lower baseline activity, counselor use, and positive perception of support. Counselor users with low baseline activity had higher odds ratio for increased physical activity at follow-up than non-users (OR = 7.2, 95% CI = 2.2-23.5 vs. OR = 3.2, 95% CI = 1.4-7.5). Positive perception of support was associated with increased physical activity among counselor users but not among non-users. CONCLUSIONS: An increase in physical activity after PAP was related to low baseline activity, positive perception of support, and use of counselor support after PAP. Qualified counseling support linked to PAP seems to be important for achieving increased physical activity among patients with lower baseline activity.

A study protocol of the photo-supported conversations about the well-being intervention (Be Well™) for people with stress related disorders.

BACKGROUND: Stress-related illnesses constitute a huge problem in society. The primary care services in Sweden form the first line of care whose role is to coordinate interventions for reducing symptoms, as well as health-promoting interventions. There is lack of knowledge concerning health-promoting interventions for these illnesses. The aim of this study is to evaluate whether photo-supported conversations about well-being (Be Well™) as an intervention, in addition to care as usual within the primary care services, improves health and well-being for patients with stress-related illnesses. The intervention will be compared to a control group, who receive care as usual. A further aim is to conduct a process evaluation. METHODS/DESIGN: This ongoing project has a quasi-experimental design, using quantitative and qualitative methods, and includes patients from primary care centres in two Swedish counties. Seventy patients, 20-67 years, with stress-related illnesses will be recruited. They constitute an intervention group, which receive the intervention together with care as usual, and a control group, which receive care as usual. The intervention, photo-supported conversations about well-being, involves 12 sessions. Care as usual entails medication, occupational therapy, physiotherapy and/or psychotherapy. Data collection is carried out at baseline, and outcomes are assessed directly after the intervention, as well as six months after completion of the intervention. The outcomes are evaluated based on factors related to health, well-being and everyday occupations. Furthermore, data concerning experiences of well-being and perceptions of the intervention will be collected in interviews. The therapists will also be interviewed about their experiences of performing the intervention. Data will be analysed with non-parametric statistics, and qualitative methodology. DISCUSSION: The project is based on the concept that focusing on well-being despite living with stress-related illness may positively impact health and well-being as well as activity-related aspects, and that photo-supported conversations about well-being can contribute a complement to other treatment and rehabilitation. A strength is the use of a wide range of methods: such as quantitative measures, photographs, and qualitative interviews with participants and therapists. The results will thus provide knowledge about potential effects of this health-promoting intervention. Trial registration Clinical Trials.gov: NCT04832295; retrospectively registered 2nd April 2021 https://clinicaltrials.gov/ct2/show/NCT04832295.

Physical Activity on Prescription in Routine Health Care: 1-Year Follow-Up of Patients with and without Counsellor Support.

The effectiveness of counsellor support in addition to physical activity on prescription (PAP) from health care professionals has rarely been evaluated. This observational follow-up study investigated differences in physical activity levels and health-related quality of life (HRQoL) one year after PAP regarding patients' use of counsellor support in addition to PAP in routine care. The study was conducted in a Swedish health care region in which all patients receiving PAP from health care professionals were offered counsellor support. Data were collected from medical records and questionnaires (baseline and follow-up). Of the 400 study participants, 37% used counsellor support. The group of counsellor users attained a higher level of physical activity one year after receiving PAP compared to the group of non-users (p < 0.001). The level of physical activity was measured by a validated index (score 3-19) calculated from weekly everyday activity and exercise training. Comparison of the change in scores between baseline and follow-up showed a significant difference between the two groups, (p < 0.001). The median difference in the PAP + C group was 2.0 (interquartile range, 7.0) and 0.0. among non-users (interquartile range, 4.0). Significant differences in HRQoL were due to positive improvements among counsellor users, with the main improvement in general health. The conclusion is that patients using counsellor support after receiving PAP from health care professionals had higher physical activity and better HRQoL one year after compared with patients who did not use this support.

Evaluation of a multimodal pain rehabilitation programme in primary care based on clinical register data: a feasibility study.

AIM: Investigate the feasibility of identifying a well-defined treatment group and a comparable reference group in clinical register data. BACKGROUND: There is insufficient knowledge on how to avert neck/back pain from turning chronic or to impair work ability. The Swedish Government implemented a national multimodal rehabilitation (MMR) programme in primary care intending to promote work ability, reduce sick leave and increase return to work. Since randomised control trial data for effect is lacking, it is important to evaluate existing observational data from clinical settings. METHODS: We identified all unique patients with musculoskeletal pain (MSP) diagnoses undergoing the MMR programme in primary care in the Skåne Health care Register (n = 2140) during 2010-2011. A reference cohort in primary care (n = 56 300) with similar MSP diagnoses, same ages and the same level of sick leave before baseline was identified for the same period. The reference cohort received ordinary care and treatment in primary care. The final study group consisted of 603 eligible MMR patients and 2874 eligible reference patients. Socio-economic and health-related baseline data including sick leave one year before up to two years after baseline were compared between groups. FINDINGS: There were significant socio-economic and health differences at baseline between the MMR and the reference patients, with the MMR group having lower income, higher morbidity and more sick leave days. Sick leave days per year decreased significantly in the MMR group (118-102 days, P < 0.001) and in the reference group (50-42 days, P < 0.001) from one year before baseline to two years after. CONCLUSIONS: It was not feasible to identify a comparable reference group based on clinical register data. Despite an ambitious attempt to limit selection bias, significant baseline differences in socio-economic and health were present. In absence of randomised trials, effects of MMR cannot be sufficiently evaluated in primary care.

Standard mortality rates and years of life lost for serologically defined adult-onset type 1 and type 2 diabetes - A fifteen year follow-up.

AIMS: The Diabetes Incidence in Kronoberg (DIK) study of adult-onset diabetes used serological classification. Standard Mortality Rates (SMR) and Years of Life Lost (YLL) 15 years after adult-onset (18-100 years) of diabetes were compared to the population of Kronoberg. METHODS: Of 1609/1660 (97%) patients, 112 (7%) had type 1 (T1D) (GADA+ and/or ICA+, and/or C-peptide < 0.25 nmol/l), and 1497 (93%) had type 2 diabetes (T2D) (antibody- and C-peptide ≥ 0.25 nmol/l). The National Swedish Mortality Register provided time of death. RESULTS: For T1D SMR did not differ from the Kronoberg population in any age group. In T2D SMR was 1.20 (1.12-1.29). After 15 years 26% (29/112) T1D and 52% (785/1497) T2D patients had died, p < 0.0001. In T2D SMR was 5.6 (30-39 years), 2 (40-59 years), 1.4 (60-69 years), and thereafter no difference. There were no significant sex differences in mortality, and no YLL to adult-onset T1D, but five YLL to T2D for onset at ages 20-60 years. CONCLUSIONS: For adult-onset T1D SMR did not differ from the general population, in contrast to previous findings in childhood-onset (< 30 years of age) T1D. The difference in mortality between persons with diabetes and the general population was due to higher mortality in T2D.

Informing patients on planned consultation time - a randomised controlled intervention study of consultation time in primary care.

Objective: To investigate whether patients' pre-consultation knowledge of the time frames for the consultation influences the actual consultation time and/or patient and physician related outcomes; satisfaction and enablement.Design: Randomised controlled blinded intervention study.Setting: Four strategically chosen Primary Health Care Centres (PHCC:s) in Kronoberg county in Sweden participated.Intervention: Pre-consultation information on planned consultation time. During one week in each PHCC consecutive patients were randomised to intervention group or control group, when booking an appointment with a physician.Subjects: Patients >18 years of age.Main outcome measures: Consultation time, patient satisfaction, patient enablement and physician satisfaction.Results: No significant difference in consultation time was found between the intervention group and control group. No differences were seen between intervention group and control group regarding any of the other measures. Stratified data showed significantly shorter consultation time for the intervention group in one of the PHCC:s and for employed physicians. Employed physicians also rated consultations as being easier and were more satisfied with their consultations compared to non-employed physicians.Conclusion: Information on the planned consultation time has a potential to decrease consultation time in certain settings. No negative side effects were found in this study. Key pointsPatients prepare before their consultation but to influence its contents and length is difficult.Informing patients on estimated consultation time can influence actual consultation time.Informing patients on planned consultation time has no adverse effects in this study.

Patients' experiences of physical activity on prescription with access to counsellors in routine care: a qualitative study in Sweden.

BACKGROUND: Physical activity on prescription (PAP) has been implemented in several countries, including Sweden, to support patients who might benefit from increased physical activity. This study explores the experiences of recipients of PAP in routine health care in Sweden that offers the recipients support from physical activity counsellors. The aim was to explore influences on engagement in physical activity by PAP recipients' from a long-term perspective. METHODS: We conducted individual semi-structured interviews using a topic guide with a purposively selected sample of 13 adult PAP recipients 1.5 to 2.5 years after PAP. Interviews were recorded, transcribed verbatim and analysed through inductive and deductive content analysis. The questions were informed by Capability-Opportunity-Motivation-Behaviour (COM-B), which was also used as a framework to analyse the data by means of categorizing the factors (influences on the behaviour). RESULTS: Ten factors (i.e. sub-categories) that influenced the participants' engagement in physical activity were identified. PAP recipients' capability to engage in physical activity was associated with adapting the PAP to the individual's physical capacity and taking into account the individual's previous experiences of physical activity. PAP recipients' opportunity to engage in physical activity was related to receiving a prescription, receiving professional counselling and follow-up from a physical activity counsellor, collaboration between prescriber and counsellor, having access to appropriate activities, having a balanced life situation and having support from someone who encouraged continued physical activity. PAP recipients' motivation to engage in physical activity was associated with the desire to improve his or her health condition and finding activities that encouraged continuation. CONCLUSIONS: PAP recipients' engagement in physical activity was influenced by their capability, opportunity and motivation to undertake this behaviour. Numerous extraneous factors influence capability and motivation. Physical activity counsellors were found to be important for sustained activity because they use an individual approach to counselling and flexible follow-up adapted to each individual's need of support.

Structured physiotherapy including a work place intervention for patients with neck and/or back pain in primary care: an economic evaluation.

A cluster-randomized controlled trial, WorkUp, was conducted for working-aged patients at risk of sick leave or on short-term sick leave due to acute/subacute neck and/or back pain in Sweden. The purpose of WorkUp was to facilitate participants to stay at work or in case of sick leave, return-to-work. The aim of this study was to study whether the WorkUp trial was cost-effective. Patients in the intervention and reference group received structured evidence-based physiotherapy, while patients in the intervention group also received a work place dialogue with the employer as an add-on. The participants, 352 in total, were recruited from 20 physiotherapeutic units in primary healthcare in southern Sweden. The economic evaluation was performed both from a healthcare and a societal perspective with a 12-month time frame with extensive univariate sensitivity analyses. Results were presented as incremental cost-effectiveness ratios (ICER) with outcomes measured as quality-adjusted life-years (QALY) and proportion working for at least 4 weeks in a row without reported sick leave at 12-month follow-up. From the healthcare perspective, the ICER was €23,606 (2013 price year) per QALY gain. From the societal perspective the intervention was dominating, i.e.. less costly and more effective than reference care. Bootstrap analysis showed that the probability of the intervention to be cost-effective at €50,000 willingness-to-pay per QALY was 85% from the societal perspective. Structured evidence-based physiotherapeutic care together with workplace dialogue is a cost-effective alternative from both a societal and a healthcare perspective for acute/subacute neck and/or back pain patients.Trial registration ClinicalTrials.gov: NCT02609750.

Physical Activity on Prescription with Counsellor Support: A 4-Year Registry-Based Study in Routine Health Care in Sweden.

Background: Public health gains from physical activity on prescription (PAP) depend on uptake in routine care. We performed an evaluation of the implementation, in a Swedish county council, of counsellors who give personalized support to PAP recipients aimed at facilitating PAP delivery. The aim was to compare characteristics between PAP recipients and the health care population as well as between PAP recipients who used and did not use counsellor support. We also investigated professional belonging and health care setting of health care professionals who prescribed PAP. Methods: All patients’ ≥18 years who received PAP during 2009–2012 in primary and secondary care in the County Council of Kronoberg were included (n = 4879). Data were retrieved from electronic medical records. Main outcome measures were patient and professional characteristics. Results: A third of the PAP recipients had diseases in ≥5 diagnostic groups and more than half had ≥11 office visits the year before receiving PAP. Counsellor support was used by one-third and PAP recipients who used counsellor support had more multiple diagnoses and office visits compared with non-users. Physicians issued 44% of prescriptions and primary care was the predominant setting. The amount of PAP did not change over time, but the proportion of physicians’ prescriptions decreased while the proportion of nurses’ prescriptions increased. Conclusions: PAP recipients had high morbidity and were frequent health care attenders, indicating that PAP was predominantly used for secondary or tertiary prevention. PAP rates did not increase as intended after the implementation of counsellor support.

Early workplace dialogue in physiotherapy practice improved work ability at 1-year follow-up-WorkUp, a randomised controlled trial in primary care.

Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work. Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for patients with pain in ordinary primary care. We conducted a prospective pairwise cluster randomised controlled trial (ClinicalTrials.gov ID: NCT02609750) in primary care involving 20 primary care rehabilitation units with 1-year follow-up. Adult patients with acute/subacute neck and back pain, worked ≥4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and considered at-risk of sick leave were included (n = 352). All patients received structured physiotherapy and the intervention was the addition of CDM, delivered by the treating physiotherapist. The main confirmatory outcome, work ability (defined as working at least 4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week. Work ability was reached by significantly more patients in the intervention group (108/127, 85%) compared with the reference group (127/171, 74%) (P = 0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01-3.38). We conclude that an early workplace dialogue in addition to structured physiotherapy improved work ability significantly.

"Blue flags", development of a short clinical questionnaire on work-related psychosocial risk factors - a validation study in primary care.

BACKGROUND: Working conditions substantially influence health, work ability and sick leave. Useful instruments to help clinicians pay attention to working conditions are lacking in primary care (PC). The aim of this study was to test the validity of a short "Blue flags" questionnaire, which focuses on work-related psychosocial risk factors and any potential need for contacts and/or actions at the workplace. METHODS: From the original"The General Nordic Questionnaire" (QPSNordic) the research group identified five content areas with a total of 51 items which were considered to be most relevant focusing on work-related psychosocial risk factors. Fourteen items were selected from the identified QPSNordic content areas and organised in a short questionnaire "Blue flags". These 14 items were validated towards the 51 QPSNordic items. Content validity was reviewed by a professional panel and a patient panel. Structural and concurrent validity were also tested within a randomised clinical trial. RESULTS: The two panels (n = 111) considered the 14 psychosocial items to be relevant. A four-factor model was extracted with an explained variance of 25.2%, 14.9%, 10.9% and 8.3% respectively. All 14 items showed satisfactory loadings on all factors. Concerning concurrent validity the overall correlation was very strong rs = 0.87 (p < 0.001).). Correlations were moderately strong for factor one, rs = 0.62 (p < 0.001) and factor two, rs = 0.74 (p < 0.001). Factor three and factor four were weaker, bur still fair and significant at rs = 0.53 (p < 0.001) and rs = 0.41 (p < 0.001) respectively. The internal consistency of the whole "Blue flags" was good with Cronbach's alpha of 0.76. CONCLUSIONS: The content, structural and concurrent validity were satisfactory in this first step of development of the "Blue flags" questionnaire. In summary, the overall validity is considered acceptable. Testing in clinical contexts and in other patient populations is recommended to ensure predictive validity and usefulness.

Referring to multimodal rehabilitation for patients with musculoskeletal disorders - a register study in primary health care.

BACKGROUND: In 2008, the Swedish government introduced a National Rehabilitation Program, in which the government financially reimburses the county councils for evidence-based multimodal rehabilitation (MMR) interventions. The target group is patients of working age with musculoskeletal disorders (MSD), expected to return to work or remain at work after rehabilitation. Much attention in the evaluations has been on patient outcomes and on processes. We lack knowledge about how factors related to health care providers and community can have an impact on how patients have access to MMR. The aim of this study was therefore to study the impact of health care provider and community related factors on referrals to MMR in patients with MSD applying for health care in primary health care. METHODS: This was a primary health care-based cohort study based on prospectively ascertained register data. All primary health care centres (PHCC) contracted in Region Skåne in 2010-2012, referring to MMR were included (n = 153). The health care provider factors studied were: community size, PHCC size, public or private PHCC, whether or not the PHCCs provided their own MMR, burden of illness and the community socioeconomic status among the registered population at the PHCCs. The results are presented with descriptive statistics and for the analysis, non-parametric and multiple linear regression analyses were applied. RESULTS: PHCCs located in larger communities sent more referrals/1000 registered population (p = 0.020). Private PHCCs sent more referrals/1000 registered population compared to public units (p = 0.035). Factors related to more MMR referrals/1000 registered population in the multiple regression analyses were PHCCs located in medium and large communities and with above average socioeconomic status among the registered population at the PHCCs, private PHCC and PHCCs providing their own MMR. The explanation degree for the final model was 24.5%. CONCLUSIONS: We found that referral rates to MMR were positively associated with PHCCs located in medium and large sized communities with higher socioeconomic status among the registered population, private PHCCs and PHCCs providing their own MMR. Patients with MSD are thus facing significant inequities and were thus not offered the same opportunities for referrals to rehabilitation regardless of which PHCC they visited.

Biomarkers of systemic inflammation in farmers with musculoskeletal disorders; a plasma proteomic study.

BACKGROUND: Farmers have an increased risk for musculoskeletal disorders (MSD) such as osteoarthritis of the hip, low back pain, and neck and upper limb complaints. The underlying mechanisms are not fully understood. Work-related exposures and inflammatory responses might be involved. Our objective was to identify plasma proteins that differentiated farmers with MSD from rural referents. METHODS: Plasma samples from 13 farmers with MSD and rural referents were included in the investigation. Gel based proteomics was used for protein analysis and proteins that differed significantly between the groups were identified by mass spectrometry. RESULTS: In total, 15 proteins differed significantly between the groups. The levels of leucine-rich alpha-2-glycoprotein, haptoglobin, complement factor B, serotransferrin, one isoform of kininogen, one isoform of alpha-1-antitrypsin, and two isoforms of hemopexin were higher in farmers with MSD than in referents. On the other hand, the levels of alpha-2-HS-glycoprotein, alpha-1B-glycoprotein, vitamin D- binding protein, apolipoprotein A1, antithrombin, one isoform of kininogen, and one isoform of alpha-1-antitrypsin were lower in farmers than in referents. Many of the identified proteins are known to be involved in inflammation. CONCLUSIONS: Farmers with MSD had altered plasma levels of protein biomarkers compared to the referents, indicating that farmers with MSD may be subject to a more systemic inflammation. It is possible that the identified differences of proteins may give clues to the biochemical changes occurring during the development and progression of MSD in farmers, and that one or several of these protein biomarkers might eventually be used to identify and prevent work-related MSD.

Levels of perfluoroalkyl substances and risk of coronary heart disease: Findings from a population-based longitudinal study.

BACKGROUND: Cross-sectional studies have shown an association between exposure to perfluoroalkyl substances (PFASs) and coronary heart disease (CHD). These findings need to be evaluated in longitudinal settings. OBJECTIVES: To investigate the risk of CHD in relation to PFAS levels in a longitudinal setting among Swedish rural residents. METHODS: In a population-based prospective cohort of male farmers and rural residents recruited in 1990-1991, all men who received a CHD diagnosis between 1992 and 2009 were identified from national registers (n=253). For each CHD case, one control, matched for age, was chosen randomly from the cohort. For all cases and controls, levels of eight PFASs at baseline were measured in stored blood samples. In addition, for a subsample, PFAS levels were also measured in serum samples collected at a follow-up in 2002-2003. RESULTS: There were no statistically significant associations between levels of seven of the eight PFASs at baseline and risk for developing CHD. There was a significant association between perfluoroheptanoic acid (PFHpA) and CHD (OR=2.72; 95% CI: 1.52, 4.84) for the 3rd quartile and (OR=2.45; 95% CI: 1.40, 4.29) for the 4th quartile compared to the lowest quartile. Changes in levels of PFCs between baseline and follow-up did not differ systematically between cases and controls. CONCLUSIONS: This longitudinal study does not lend support to the previously reported cross-sectional relationship between PFAS levels and CHD risk. We found a significant association with PFHpA, but this could be a chance finding, considering its chemical resemblance to other PFASs.

Type 2 diabetes among farmers and rural and urban referents: cumulative incidence over 20 years and risk factors in a prospective cohort study.

BACKGROUND: Few studies have examined the risk of type 2 diabetes in various occupational groups. Farmers in Sweden have a low risk of coronary heart disease, but less is known about diabetes. OBJECTIVE: To analyze the cumulative incidence and relative risk of type 2 diabetes among farmers and referents taking lifestyle factors and components of the metabolic syndrome into account. METHODS: In a longitudinal observational cohort study we followed 1,220 farmers, 1,130 rural non-farmer referents and 1,219 urban referents over 20 years. Outcomes were generated from national registers and from two surveys 12 years apart. Baseline data were assessed at the first survey conducted in 1990-91. RESULTS: Farmers had a significantly lower risk of all diabetes compared with urban and rural referents (p<0.05). A total of 91 farmers (8.4%) and 102 non-farming rural referents (11.5%) were identified with type 2 diabetes over the 20 year study period (OR=0.70; 95% CI 0.52-0.95). Fractional analyses of lifestyle factors and components of the metabolic syndrome showed that the low risk of type 2 diabetes among farmers was explained in terms of physical activity and meal quality. Farmers had significantly higher physical capacity (p<0.001) and scored higher in a meal quality index than rural referents (p<0.001). CONCLUSIONS: The prevalence of type 2 diabetes was significantly lower among farmers. The low relative risk was explained by high physical activity and better meal quality, indicating that farmers' lifestyles and their work environment are health-promoting.