Interprofessional follow-up for people at risk of type 2 diabetes in primary healthcare - a randomized controlled trial with embedded qualitative interviews.

OBJECTIVE: To examine the effects of an empowerment-based interprofessional lifestyle intervention program among people at risk of type 2 diabetes on knowledge, skills, and confidence in self-management, health, psychological well-being, and lifestyle characteristics, and to explore the participants' perceptions of participating in the intervention. DESIGN AND METHODS: In line with the Medical Research Council complex interventions research methods framework, we conducted a randomized controlled trial with embedded qualitative interviews in primary healthcare clinics in Norway between 2019-2021. Of the patients at risk (The Finnish Diabetes Risk Score Calculator (FINDRISC) ≥15 or Body Mass Index (BMI) ≥30) 142 accepted the invitation, and 14 participants from the intervention group participated in individual interviews after the 12-month follow-up. Our primary outcome was the Patient Activation Measure (PAM-13). Secondary outcomes were EQ-5D-5L, EQ-VAS, WHO-Overall health, WHO-Overall QOL, weight, height, waist circumference, and regularity of physical activity. We used thematic analysis to analyse the qualitative data. RESULTS: There was no clinically relevant differences of neither the primary nor the secondary endpoints between intervention and control group. As to the qualitative data, we identified two distinct features: 'Meaningful perspectives on lifestyle changes' and 'Lifestyle change is not a linear process due to challenges faced along the way' putting ownership of their choices in life into picture. CONCLUSION: The negative results of the RCT stand in contrast to the findings given by the participants voices, perceiving the intervention as a key eye opener placing their health challenges in perspective. How to interpret these seemingly conflicting findings of participants being seen, heard, and understood, helping them to take more conscious ownership of their choices in life, and at the same time demonstrating no improvements in symptoms or measures, is a dilemma that needs further exploration. We should be careful to implement interventions that do not demonstrate any effects on the quantitative outcomes.

How valid is a prescription-based multimorbidity index (Rx-risk) in predicting mortality in the Outcomes and Multimorbidity In Type 2 diabetes (OMIT) study? A nation-wide registry-based cohort study from Norway.

OBJECTIVE: The prescription-based Rx-risk index has previously been developed to measure multimorbidity. We aimed to adapt and evaluate the validity of the Rx-risk index in prediction of mortality among persons with type 2 diabetes. DESIGN: Registry-based study. SETTING: Adults with type 2 diabetes in Norway identified within the 'Outcomes and Multimorbidity In Type 2 diabetes' cohort, with linkage to prescriptions from the Norwegian Prescription Database and mortality from the Population Registry. PARTICIPANTS: We defined a calibration sample of 42 290 adults diagnosed with type 2 diabetes 1950-2013, and a temporal validation sample of 7085 adults diagnosed 2014-2016 to evaluate the index validity over time PRIMARY OUTCOME MEASURE: All-cause mortality METHODS: For the calibration sample, dispensed drug prescriptions in 2013 were used to define 44 morbidity categories. Weights were estimated using regression coefficients from a Cox regression model with 5 year mortality as the outcome and all morbidity categories, age and sex included as covariates. The Rx-risk index was computed as a weighted sum of morbidities. The validity of the index was evaluated using C-statistic and calibration plots. RESULTS: In the calibration sample, mean (SD) age at start of follow-up and duration of diabetes was 63.8 (12.4) and 10.1 (7.0) years, respectively. The overall C-statistic was 0.82 and varied from 0.74 to 0.85 when stratifying on age groups, sex, level of education and country of origin. In the validation sample, mean (SD) age and duration of diabetes was 59.7 (13.0) and 2.0 (0.8) years, respectively. Despite younger age, shorter duration of diabetes and later time period, the C-index was high both in the total sample (0.84) and separately for men (0.83) and women (0.84). CONCLUSIONS: The Rx-risk index showed good discrimination and calibration in predicting mortality and thus presents a valid tool to assess multimorbidity among persons with type 2 diabetes.

Placental weight, surface area, shape and thickness - Relations with maternal ethnicity and cardio-metabolic factors during pregnancy.

INTRODUCTION: A better understanding of the determinants of placental growth is needed. Our primary aim was to explore associations between maternal ethnic origin and cardio-metabolic factors during pregnancy, and placental weight, surface area, shape and thickness. METHODS: A multi-ethnic population-based cohort study of 474 pregnant women examined at mean 15 and 28 weeks' gestation. Placentas were inspected after birth by a placental pathologist. Outcome measures were trimmed placental weight and three uncorrelated placental components; surface area, shape (oval vs round) and thickness, created through a principal components analysis. Multivariate linear regression models were used to explore the associations with maternal factors. RESULTS: Compared with ethnic European women, mothers with South- and East Asian ethnicity had placentas with lower weight (-51 g (95% CI: 75, -27) and -55 g (-95, -14) respectively), primarily due to a smaller surface area. The association between South Asian ethnicity and placental surface area was still significant after adjusting for maternal characteristics and cardio-metabolic factors. Fat mass index in early pregnancy was associated with higher placental weight and thickness. Placental surface area was positively associated with mid-gestational increases in fat mass, fasting glucose and triglycerides and with the 2-h glucose value at the 28 week oral glucose tolerance test, and inversely with a mid-gestational increase in HDL-cholesterol. DISCUSSION: Mid-gestational changes in fat mass, glucose, triglycerides and cholesterol were associated with, but only partly explained ethnic differences in placental surface area, while maternal fat mass in early pregnancy was associated with placental thickness.

DNA methylation risk score for type 2 diabetes is associated with gestational diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) share many pathophysiological factors including genetics, but whether epigenetic marks are shared is unknown. We aimed to test whether a DNA methylation risk score (MRS) for T2DM was associated with GDM across ancestry and GDM criteria. METHODS: In two independent pregnancy cohorts, EPIPREG (n = 480) and EPIDG (n = 32), DNA methylation in peripheral blood leukocytes was measured at a gestational age of 28 ± 2. We constructed an MRS in EPIPREG and EPIDG based on CpG hits from a published epigenome-wide association study (EWAS) of T2DM. RESULTS: With mixed models logistic regression of EPIPREG and EPIDG, MRS for T2DM was associated with GDM: odd ratio (OR)[95% CI]: 1.3 [1.1-1.8], P = 0.002 for the unadjusted model, and 1.4 [1.1-1.7], P = 0.00014 for a model adjusted by age, pre-pregnant BMI, family history of diabetes and smoking status. Also, we found 6 CpGs through a meta-analysis (cg14020176, cg22650271, cg14870271, cg27243685, cg06378491, cg25130381) associated with GDM, and some of their methylation quantitative loci (mQTLs) were related to T2DM and GDM. CONCLUSION: For the first time, we show that DNA methylation marks for T2DM are also associated with GDM, suggesting shared epigenetic mechanisms between GDM and T2DM.

High prevalence of retinopathy in young-onset type 2 diabetes and possible sex differences: insights from Norwegian general practice.

INTRODUCTION: People with young-onset type 2 diabetes (YOD), defined as diabetes diagnosis before age 40, have a high lifetime risk of vascular complications. We aimed to estimate the prevalence of YOD among adults with type 2 diabetes (T2D) in Norwegian general practice and explore associations between age at diabetes diagnosis and retinopathy overall and in men and women. RESEARCH DESIGN AND METHODS: We collected cross-sectional data from general practice electronic medical records of 10 241 adults with T2D in 2014, and repeated measurements of hemoglobin A1c (HbA1c) from 2012 to 2014. Using multivariate logistic regression, we assessed associations between YOD and later-onset T2D, sex and retinopathy. RESULTS: Of all individuals with T2D, 10% were diagnosed before 40 years of age in both sexes. Compared with later-onset T2D, HbA1c increased faster in YOD, and at the time of diagnosis HbA1c was higher in men, particularly in YOD. Retinopathy was found in 25% with YOD, twice as frequently as in later onset. After adjustments for confounders (age, country of origin, education, body mass index), OR of retinopathy was increased in both men with YOD (OR 2.6 (95% CI 2.0 to 3.5)) and women with YOD (OR 2.2 (1.5 to 3.0)). After further adjustments for potential mediators (diabetes duration and HbA1c), the higher OR persisted in men with YOD (OR 1.8 (1.3 to 2.4)) but was attenuated and no longer significant for women with YOD. CONCLUSIONS: Retinopathy prevalence was more than twice as high in YOD as in later-onset T2D. The increased likelihood of retinopathy in YOD was partly mediated by higher HbA1c and longer T2D duration, but after accounting for these factors it remained higher in men with YOD.

Pelvic girdle pain in pregnancy and early postpartum - prevalence and risk factors in a multi-ethnic cohort.

BACKGROUND: Pelvic girdle pain (PGP) is common during and after pregnancy. It has been assumed that Scandinavian women report more PGP than women of other ethnicities. However, there are few population-based studies on ethnic differences and few with ethnicity as risk factor for PGP. The purposes of the present study were: To examine the prevalence of self-reported PGP through pregnancy and early postpartum in a multi-ethnic cohort. To investigate how ethnicity and patient characteristics were associated with risk of PGP during pregnancy and early postpartum. To investigate if clinical and personal factors obtained in gestation week (GW) 15 were associated with PGP in GW28 and postpartum week (PPW) 14. METHODS: This study analyzed questionnaire data from 823 women from the Stork - Groruddalen mult-iethnic cohort study in Norway. Chi-square tests were used to investigate ethnic differences in prevalence of self-reported PGP, and logistic regression analyses to identify factors associated with self-reported PGP. RESULTS: Women from South-Asia and Middle East reported 10-20% higher prevalence of self-reported PGP at all time points compared with Western women. Ethnicity was associated with PGP in GW15 and PPW14, adjusted for parity. Pain locations in pelvic area (PGP locations) in GW15, especially combined symphysis and posterior PGP, gave the highest risk (OR=7.4) for PGP in GW28 and in PPW14 (OR = 3.9). Being multiparous was a risk for PGP in PPW14 (OR=1.9). CONCLUSIONS: Women of South Asian and Middle Eastern background had higher risk of self-reported PGP than Western women. Ethnicity was associated with PGP in GW15 and PPW14, after adjustments for parity. PGP locations in GW15 was the most prominent risk factor for PGP in GW28 and PPW14, whilst ethnicity was not significant in multivariable analyses.

Cross-Cultural Contact and Norwegian Language Skills Among Ethnic Minority Women in Norway, and Relationship with Physical Activity in Pregnancy and Postpartum: The STORK-Groruddalen Cohort Study.

There are few studies of the migration context factors and physical activity (PA) level among minority ethnic women in Europe. We investigated the association between migration context factors and moderate to vigorous physical activity (MVPA) among minority ethnic women. Objectively recorded MVPA were obtained from 487 minority ethnic women included in the STORK-Groruddalen Cohort Study at three time points in pregnancy/postpartum. We investigated the associations between (a) contact with ethnic Norwegians and (b) Norwegian language skills and. No associations were observed in pregnancy. Postpartum, women who reported contact with ethnic Norwegians accumulated 17 MVPA min/day (95% CI: -.60, 34.54) more than women with no contact. In complete case analyses, this difference was significant (27 MVPA min/day (95% CI: 8.60, 44.54)). In early postpartum women with contact with ethnic Norwegians seems to be more physically active than women without contact. No associations were observed in pregnancy.

Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help-insights from Norwegian general practice.

Objective: We opted to study how support staff operational capacity and diabetes competences may impact the timeliness of basal insulin-initiation in general practice patients with type 2 diabetes (T2D).Design/Setting/Outcomes: This was an observational and retrospective study on Norwegian primary care patients with T2D included from the ROSA4-dataset. Exposures were (1) support staff size, (2) staff size relative to number of GPs, (3) clinic access to a diabetes nurse and (4) share of staff with diabetes course (1 and 2 both relate to staff operational capacity, whereas 3 and 4 are both indicatory of staff diabetes competences). Outcomes were 'timely basal insulin-initiation' (primary) and 'attainment of HbA1c<7%' after insulin start-up (secondary). Associations were analyzed using multiple linear regression, and directed acyclic graphs guided statistical adjustments.Subjects: Insulin naïve patients with 'timely' (N = 294), 'postponed' (N = 219) or 'no need of' (N = 3,781) basal insulin-initiation, respectively.Results: HbA1c [median (IQR)] increased to 8.8% (IQR, 8.0, 10.2) prior to basal insulin-initiation, which reduced HbA1c to 7.3 (6.8-8.1) % by which only 35% of the subjects reached HbA1c <7%. Adjusted risk of 'timely basal insulin-initiation' was more than twofold higher if access to a diabetes nurse (OR = 2.40, [95%CI, 1.68, 3.43]), but related only vaguely to staff size (OR = 1.01, [95%CI, 1.00, 1.03]). No other staff factors related significantly to neither the primary nor the secondary outcome.Conclusion: In Norwegian general practice, insulin initiation in people with T2D may be affected by therapeutic inertia but access to a diabetes nurse may help facilitating more timely insulin start-up.

In patients with type 2 diabetes (T2D) cared for by their general practice physician (GP), insulin therapy was susceptible to therapeutic inertia.In Norwegian general practice, chance of timely basal insulin-initiation was found more than two-fold higher if the GP had access to a diabetes nurse.In contrast, the timeliness of basal insulin-initiation in general practice patients with T2D seemed unaffected by share of support staff with diabetes course and by factors indicatory of support staff overall operational capacity.In Norwegian general practice, a diabetes nurse seems to offer unique clinical benefits to the care of insulin treated patients with T2D.

Employing fasting plasma glucose to safely limit the use of oral glucose tolerance tests in pregnancy: a pooled analysis of four Norwegian studies.

Background/objective: There is no international consensus about the optimal approach to screening and diagnosis of gestational diabetes mellitus (GDM). Fasting plasma glucose (FPG) has been proposed as an alternative universal screening test to simplify the diagnosis of GDM. We investigate the ability of the FPG to predict a 2-hour glucose value below the cut-off for GDM, thereby "ruling out" the necessity of a full OGTT and assess the proportion of GDM-related complications associated with the identified FPG level. Materials and methods: This study included secondary data from four Norwegian pregnancy cohorts (2002-2013), encompassing 2960 women universally screened with late mid-pregnancy 75g OGTT measuring FPG and 2-hour glucose. For a range of FPG thresholds, we calculated sensitivity to predict elevated 2-hour glucose, number of OGTTs needed and percentage of GDM cases missed, applying modified World Health Organization (WHO) 2013 criteria (2013WHO) and 2017 Norwegian criteria (2017Norwegian). We analyzed pregnancy outcomes for women above and below our selected threshold. Results: The prevalence of GDM was 16.6% (2013WHO) and 10.1% (2017Norwegian). A FPG threshold of 4.7 mmol/L had a sensitivity of 76% (2013WHO) and 80% (2017Norwegian) for detecting elevated 2-hour glucose, with few missed GDM cases (2.0% of those ruled out and 7.5% of all GDM cases for 2013WHO, and 1.1% of those ruled out and 7% of all GDM cases for 2017Norwegian). When excluding women with FPG <4.7mmol/l and those with GDM based on FPG, only 24% (2013WHO) and 29% (2017Norwegian) would require OGTT. Women with FPG <4.7mmol/l, including missed GDM cases, had low risk of large-for-gestational-age newborns, cesarean section and operative vaginal delivery. Conclusion: A FPG threshold of 4.7mmol/l as a first step when screening for GDM could potentially eliminate the need for OGTT in 70-77% of pregnancies. Women with FPG below this threshold appear to carry low risk of GDM-associated adverse pregnancy outcomes.

Cohort profile update: the Norwegian STORK Groruddalen (STORK G) pregnancy and birth cohort-the role of ethnicity and causal pathways for obesity, type 2 diabetes, cardiovascular disease and other health issues.

PURPOSE: The STORK Groruddalen cohort was set up in 2008 to explore ethnic differences in: (1) maternal health, primarily gestational diabetes (GDM) and related health issues during pregnancy and post partum, and effects of exposures on risk for type 2 diabetes, cardiovascular disease and other health issues, and (2) offspring's growth and body composition, overweight/obesity and effects of early life exposures. PARTICIPANTS: 823 women (74% of invited) were followed from gestational week (GW) 15. Data were collected from 618 fathers. In total, 59% of women and 53% of fathers had origin from non-Western countries. Maternal mean age was 29.9 years (SD 4.9), and body mass index (BMI) 25.3 kg/m2 (4.9). Data were obtained from 772 women (94%) at GW 28, and 662 women (80%) 14 weeks post partum. Eleven years post partum, 385 women (53% of eligible/47% of original cohort) attended, age was 42.0 years (4.8) and BMI 27.1 kg/m2 (5.1). We have data for 783 children at birth, and for 586 at last time point, mean age 8.6 (0.5) years, weight 30.7 (6.8) kg and length 133.9 (6.3) cm. FINDINGS TO DATE: We collected questionnaire data from parents, clinical measurements and blood samples from mothers, and data on children's growth (mid-pregnancy to 8 years). Our biobank includes maternal blood and urine samples, biopsy material from placentas and umbilical venous cord blood. We found several clinically important differences in maternal health, with higher risk in ethnic minority groups for GDM, insulin resistance, vitamin D and iron deficiency, depressive symptoms and physical inactivity. Contrasting patterns of fetal growth and risk of overweight/thinness at preschool age were observed across ethnic groups. Maternal GDM, obesity and high gestational weight gain were associated with children's BMI trajectories. FUTURE PLANS: We will examine the impact of maternal and fetal health and development during pregnancy on long-term outcomes for mothers and offspring. TRIAL REGISTRATION NUMBER: Project title STORK G-2: Women and Risk of Type 2 Diabetes NCT03870724 (ClinicalTrials.gov).

A Culturally Adapted Diet and Physical Activity Text Message Intervention to Prevent Type 2 Diabetes Mellitus for Women of Pakistani Origin Living in Scotland: Formative Study.

BACKGROUND: Individuals of South Asian origin are at an increased risk of developing type 2 diabetes mellitus (T2DM) compared with other ethnic minority groups. Therefore, there is a need to develop interventions to address, and reduce, this heightened risk. OBJECTIVE: We undertook formative work to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. METHODS: We used a stepwise approach that was informed by the Six Steps in Quality Intervention Development framework, which consisted of gathering evidence through literature review and focus groups (step 1), developing a program theory for the intervention (step 2), and finally developing the content of the text messages and an accompanying delivery plan (step 3). RESULTS: In step 1, we reviewed 12 articles and identified 3 key themes describing factors impacting on diet and physical activity in the context of T2DM prevention: knowledge on ways to prevent T2DM through diet and physical activity; cultural, social, and gender norms; and perceived level of control and sense of inevitability over developing T2DM. The key themes that emerged from the 3 focus groups with a total of 25 women were the need for interventions to provide "friendly encouragement," "companionship," and a "focus on the individual" and also for the text messages to "set achievable goals" and include "information on cooking healthy meals." We combined the findings of the focus groups and literature review to create 13 guiding principles for culturally adapting the text messages. In step 2, we developed a program theory, which specified the main determinants of change that our text messages should aim to enhance: knowledge and skills, sense of control, goal setting and planning behavior, peer support, and norms and beliefs guiding behavior. In step 3, we used both the intervention program theory and guiding principles to develop a set of 73 text messages aimed at supporting a healthy diet and 65 text messages supporting increasing physical activity. CONCLUSIONS: We present a theory-based approach to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. This study outlines an approach that may also be applicable to the development of interventions for other ethnic minority populations in diverse settings. There is now a need to build on this formative work and undertake a feasibility trial of a text message-based diet and physical activity intervention to prevent T2DM for women of Pakistani origin living in Scotland.

Adverse pregnancy outcomes among women in Norway with gestational diabetes using three diagnostic criteria.

INTRODUCTION: The aim of this study was to examine the risk of adverse perinatal outcomes in women diagnosed with GDM by the World Health Organization (WHO) 1999 criteria, and in those retrospectively identified by the Norwegian-2017 and WHO-2013 criteria but not by WHO-1999 criteria. We also examine the effect of maternal overweight/obesity and ethnicity. MATERIAL AND METHODS: We used pooled data from four Norwegian cohorts (2002-2013), encompassing 2970 mother-child pairs. Results from universally offered 75-g oral glucose tolerance tests measuring fasting plasma glucose (FPG) and 2-hour glucose (2HG) were used to assign women into three diagnostic groups: Diagnosed and treated by WHO-1999 (FPG≥7.0 or (2HG ≥7.8 mmol/L), identified by WHO-2013 (FPG ≥5.1 or 2HG ≥8.5 mmol/L), and identified by Norwegian-2017 criteria (FPG ≥5.3 or 2HG ≥9.0 mmol/L). Perinatal outcomes included large-for-gestational-age (LGA) infants, cesarean section, operative vaginal delivery, preterm birth and preeclampsia. RESULTS: Compared to the non-GDM group, women diagnosed with GDM by either of the three criteria had an increased risk of large-for-gestational-age infants (adjusted odds ratios (OR) 1.7-2.2). Those identified by the WHO-2013 and Norwegian-2017 criteria but not diagnosed and treated by WHO-1999 criteria had an additional increased risk of cesarean section (OR 1.36, 95% CI 1.02,1.83 and 1.44, 95% CI 1.03,2.02, respectively) and operative vaginal delivery (OR 1.35, 95% CI 1.1,1.7 and 1.5, 95% CI 1.1,2.0, respectively). The proportions of LGA neonates and cesarean section were higher for women with GDM in both normal-weight and overweight/obese women. Asians had a lower risk of delivering large-for-gestational-age infants than Europeans applying national birthweight references, but maternal glucose values were similarly positively associated with birthweight in all ethnic groups. CONCLUSIONS: Women who met the WHO-2013 and Norwegian-2017 criteria, but were not diagnosed by the WHO-1999 criteria and therefore not treated, had an increased risk of LGA, cesarean section and operative vaginal delivery compared to women without GDM.

The impact of recommending iron supplements to women with depleted iron stores in early pregnancy on use of supplements, and factors associated with changes in iron status from early pregnancy to postpartum in a multi-ethnic population-based cohort.

BACKGROUND: We aimed to evaluate the impact of recommending supplementation to pregnant women with serum ferritin (SF) < 20 µg/L in early pregnancy on use of supplements, and to explore which factors were associated with changes in iron status by different iron indicators to 14 weeks postpartum. METHODS: A multi-ethnic population-based cohort study of 573 pregnant women examined at mean gestational week (GW) 15 (enrolment), at mean GW 28 and at the postpartum visit (mean 14 weeks after delivery). Women with SF < 20 µg/L at enrolment were recommended 30-50 mg iron supplementation and supplement use was assessed at all visits. Change of SF, soluble transferrin receptor and total body iron from enrolment to postpartum were calculated by subtracting the concentrations at the postpartum visit from that at enrolment. Linear and logistic regression analyses were performed to assess associations between use of supplements in GW 28 and changes in iron status and postpartum iron deficiency/anaemia. Change of iron status was categorized into 'steady low', 'improvement', 'deterioration', and 'steady high' based on SF status at enrolment and postpartum. Multinomial logistic regression analyses were performed to identify factors associated with change of iron status. RESULTS: At enrolment, 44% had SF < 20 µg/L. Among these women (78% non-Western European origin), use of supplements increased from 25% (enrolment) to 65% (GW 28). Use of supplements in GW 28 was associated with improved iron levels by all three indicators (p < 0.05) and with haemoglobin concentration (p < 0.001) from enrolment to postpartum, and with lower odds of postpartum iron deficiency by SF and TBI (p < 0.05). Factors positively associated with 'steady low' were: use of supplements, postpartum haemorrhage, an unhealthy dietary pattern and South Asian ethnicity (p ≤ 0.01 for all); with 'deterioration': postpartum haemorrhage, an unhealthy dietary pattern, primiparity and no use of supplements (p < 0.01 for all), and with 'improvement': use of supplements, multiparity and South Asian ethnicity (p < 0.03 for all). CONCLUSIONS: Both supplement use and iron status improved from enrolment to the postpartum visit among women recommended supplementation. Dietary pattern, use of supplements, ethnicity, parity and postpartum haemorrhage were identified as factors associated with change in iron status.

Associations between social support and physical activity in postpartum: a Norwegian multi-ethnic cohort study.

BACKGROUND: Social support is associated with higher self-reported physical activity (PA) in postpartum women, but it is unknown if similar association occur when using objective PA data. The aim was to explore the associations between social support and objectively recorded moderate-to-vigorous physical activity (MVPA) postpartum, and if associations differed across ethnic groups. METHODS: We used data from 636 women who participated in the STORK Groruddalen cohort study (2008-2010). MVPA minutes/day in bouts of ≥ 10 minutes was recorded by SenseWear Armband™ Pro3 (SWA) over 7 days, 14 weeks postpartum. Social support for PA from family or friends was measured by a modified 12-item version of the Social Support for Exercise Scale. We used single items, family support mean score (6 items) and friends' support mean score (6-items) in four separate count models, and adjusted for SWA week, age, ethnicity, education, parity, body mass index and time since birth. We tested interactions between social support and ethnicity. Analyses were performed on complete cases and imputed data. RESULTS: Based on imputed data, we observed that women who reported low and high support from family accumulated 16.2 (IQR: 6.1-39.1) and 18.6 (IQR: 5.0-46.5) MVPA minutes/day, respectively. Women who reported low and high support from friends accumulated 18.7 (IQR: 5.9-43.6) and 16.8 (IQR: 5.0-45.8) MVPA minutes/day. We observed a 12% increase in MVPA minutes/day for each additional increase in mean family support score (IRR = 1.12, 95% CI: 1.02 to 1.25). Women reporting high level of support from family on 'discuss PA', 'co-participation' and 'take over chores' accumulated 33%, 37% and 25% more MVPA minutes/day than women reporting low level of support respectively ('discuss PA': IRR = 1.33, 95% CI: 1.03 to 1.72, 'co-participation': IRR = 1.37, 95% CI: 1.13 to 1.66 and 'take over chores': IRR = 1.25, 95% CI: 1.02 to 1.54). Associations were not modified by ethnicity. No statistically significant association between support from friends and MVPA was observed. Similar results were found in complete case analyses, with a few exceptions. CONCLUSION: Overall family support and specific forms of support from family were associated with MVPA across ethnic groups, while support from friends was not associated with MVPA postpartum.

Seasonal variation in gestational diabetes mellitus among women in Norway: a national population-based study.

OBJECTIVES: Previous research on seasonal variation in the incidence of gestational diabetes mellitus (GDM) has shown inconclusive results. Furthermore, little is known about whether a seasonal variation in GDM might be associated with the maternal country of birth. We examined whether there was seasonal variation in GDM incidence by the maternal country background. DESIGN: National population-based registry study. SETTING AND PARTICIPANTS: We used national population-based data from the Medical Birth Registry of Norway (MBRN), n=1 443 857 (1990-2016) and data from four merged community-based studies (4GDM) with universal screening for GDM, n=2 978 (2002-2013). OUTCOME MEASURES: The association between season of pregnancy onset with incidence of GDM was examined separately in both datasets using logistic regression analyses, stratified by the mother's country background using two broad geographical categories (MBRN: Norwegian and immigrant; 4GDM: European and African/Asian ethnicity). Winter season was used as reference category. RESULTS: The incidence of GDM in MBRN was highest when the pregnancy started during the winter (Norwegian-born: 1.21%; immigrants: 3.32%) and lowest when pregnancy started during the summer for both Norwegian and immigrant women (Norwegian-born: 1.03% (OR 0.85, 95% CI 0.81 to 0.98); immigrants: 2.99% (OR 0.90, 95% CI 0.84 to 0.96)). The 4GDM data showed that women with European ancestry had the highest incidence of GDM when pregnancy started during autumn (10.7%, OR 1.01, 95% CI 0.69 to 1.46) and winter (10.6%), while ethnic African and Asian women had the highest incidence when pregnancy onset was during the summer (15.3%, OR 1.17, 95% CI 0.54 to 2.53). CONCLUSIONS: Based on national population-based data, this study suggests that GDM incidence varies by season in both Norwegian-born and immigrant women. The 4GDM dataset did not show a clear seasonal variation in GDM incidence, possibly due to the relatively small sample. Causes for the seasonal variation in GDM should be explored further.

Cross-Ancestry DNA Methylation Marks of Insulin Resistance in Pregnancy: An Integrative Epigenome-Wide Association Study.

Although there are some epigenome-wide association studies (EWAS) of insulin resistance, for most of them authors did not replicate their findings, and most are focused on populations of European ancestry, limiting the generalizability. In the Epigenetics in Pregnancy (EPIPREG; n = 294 Europeans and 162 South Asians) study, we conducted an EWAS of insulin resistance in maternal peripheral blood leukocytes, with replication in the Born in Bradford (n = 879; n = 430 Europeans and 449 South Asians), Methyl Epigenome Network Association (MENA) (n = 320), and Botnia (n = 56) cohorts. In EPIPREG, we identified six CpG sites inversely associated with insulin resistance across ancestry, of which five were replicated in independent cohorts (cg02988288, cg19693031, and cg26974062 in TXNIP; cg06690548 in SLC7A11; and cg04861640 in ZSCAN26). From methylation quantitative trait loci analysis in EPIPREG, we identified gene variants related to all five replicated cross-ancestry CpG sites, which were associated with several cardiometabolic phenotypes. Mediation analyses suggested that the gene variants regulate insulin resistance through DNA methylation. To conclude, our cross-ancestry EWAS identified five CpG sites related to lower insulin resistance.

Lower education and immigrant background are associated with lower participation in a diabetes education program - Insights from adult patients in the Outcomes & Multi-morbidity In Type 2 diabetes cohort (OMIT).

OBJECTIVES: Diabetes educational programmes should be offered to patients with type 2 diabetes mellitus (T2DM). We assessed the proportion of diabetes educational program participation among adults with T2DM, and its associations with place of residence in Norway, education, and immigrant background. METHODS: We identified 28,128 diagnosed with T2DM (2008-2019) in the Outcomes & Multi-morbidity In Type 2 diabetes cohort. To examine associations between sociodemographic factors and participation in diabetes start courses (yes/no), we computed adjusted risk ratios (95% CI) using log-binomial regression. RESULTS: Overall, 18% participated on the diabetes start course, but partaking differed by Norwegian counties (range:12-34%). Individuals with an immigrant background were 29% less likely to participate (RR 0.71, CI 0.65-0.79). Similarly, those with a lower educational level were 23% less likely to participate (RR 0.77, CI 0.72-0.83) than those with the highest education. The association between education and start course participation was not significant in the subgroup of immigrant individuals (RR 0.88 CI 0.70-1.12). CONCLUSIONS: We found that diabetes start course participation was overall low, especially in individuals with low education and immigrant background. PRACTICE IMPLICATIONS: More efforts are needed to promote diabetes start courses in patients with T2DM.

Level of education is associated with coronary heart disease and chronic kidney disease in individuals with type 2 diabetes: a population-based study.

INTRODUCTION: To study the relationship between education level and vascular complications in individuals with type 2 diabetes in Norway. RESEARCH DESIGN AND METHODS: Multiregional population-based cross-sectional study of individuals with type 2 diabetes in primary care. Data were extracted from electronic medical records in the period 2012-2014. Information on education level was obtained from Statistics Norway. Using multivariable multilevel regression analyses on imputed data we analyzed the association between education level and vascular complications. We adjusted for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration. Results are presented as ORs and 95% CIs. RESULTS: Of 8192 individuals with type 2 diabetes included, 34.0% had completed compulsory education, 49.0% upper secondary education and 16.9% higher education. The prevalence of vascular complications in the three education groups was: coronary heart disease 25.9%, 23.0% and 16.9%; stroke 9.6%, 7.4% and 6.6%; chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m2) 23.9%, 16.8% and 12.6%; and retinopathy 13.9%, 11.5% and 11.7%, respectively. Higher education was associated with lower odds for coronary heart disease (OR 0.59; 95% CI 0.49 to 0.71) and chronic kidney disease (OR 0.75; 95% CI 0.60 to 0.93) compared with compulsory education when adjusting for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration. CONCLUSIONS: In a country with equal access to healthcare, high education level was associated with lower odds for coronary heart disease and chronic kidney disease in individuals with type 2 diabetes.

Prevalence of postpartum anaemia and iron deficiency by serum ferritin, soluble transferrin receptor and total body iron, and associations with ethnicity and clinical factors: a Norwegian population-based cohort study.

Worldwide, there are limited data on the prevalence of postpartum anaemia and iron status. The aims of the present study were to assess the prevalence of anaemia and iron deficiency (ID) by three iron indicators 14 weeks postpartum, their relations to haemoglobin (Hb) and associations with ethnicity and clinical factors in a multi-ethnic population. We conducted a population-based cohort study of 573 women followed from early pregnancy. The prevalence of postpartum anaemia (Hb <12·0 g/dl) was 25 %. ID prevalence varied from 39 % by serum ferritin (SF <15 µg/l), to 19 % by soluble transferrin receptor (sTfR >4·4 mg/l) and 22 % by total body iron (TBI < 0 mg/kg). The mean Hb concentration was 12·8 g/dl in women with no ID, 12·6 g/dl in those with ID by SF only and 11·6 g/dl in those with ID by SF, sTfR and TBI. ID by sTfR and TBI defined by the current threshold values probably identified a more severe iron-deficient population compared with ID assessed by SF. Compared with Western Europeans, the prevalence of anaemia was at least the double in ethnic minorities (26-40 % v. 14 %; P < 0·01-0·05), and the prevalence of ID by sTfR and TBI, but not of ID by SF < 15 µg/l, was significantly higher in some minority groups. After adjustment for covariates, only South Asians had lower Hb and higher sTfR concentration. Insufficient iron intake, gestational anaemia or ID, and postpartum haemorrhage were associated with lower postpartum Hb concentration and poorer iron status.

Cohort profile: Outcomes & Multi-morbidity In Type 2 diabetes (OMIT) - a national registry-based observational cohort with focus on care and treatment of key high-risk groups in Norway.

PURPOSE: The 'Outcomes & Multi-morbidity in Type 2 Diabetes' (OMIT) is an observational registry-based cohort of Norwegian patients with type 2 diabetes (T2D) established to study high-risk groups often omitted from randomised clinical trials. PARTICIPANTS: The OMIT cohort includes 57 572 patients with T2D identified via linkage of Norwegian Diabetes Register for Adults and the Rogaland-Oslo-Salten-Akershus-Hordaland study, both offering data on clinical patient characteristics and drug prescriptions. Subsequently these data are further linked to the Norwegian Prescription Database for dispensed medications, the Norwegian Population Register for data on death and migration, Statistics Norway for data on socioeconomic factors and ethnicity and the Norwegian Directorate of Health for data on the general practices and clinical procedures involved in the care of cohort patients. OMIT offers large samples for key high-risk patient groups: (1) young-onset diabetes (T2D at age <40 years) (n=6510), (2) elderly (age >75 years) (n=15 540), (3) non-Western ethnic minorities (n=9000) and (4) low socioeconomic status (n=20 500). FINDINGS TO DATE: On average, patient age and diabetes duration is 67.4±13.2 and 12.3±8.3 years, respectively, and mean HbA1c for the whole cohort through the study period is 7.6%±1.5% (59.4±16.3 mmol/mol), mean body mass index (BMI) and blood pressure is 30.2±5.9 kg/m2 and 135±16.1/78±9.8 mm Hg, respectively. Prevalence of retinopathy, coronary heart disease and stroke is 10.1%, 21% and 6.7%, respectively. FUTURE PLANS: The OMIT cohort features 5784 subjects with T2D in 2006, a number that has grown to 57 527 in 2019 and is expected to grow further via repeated linkages performed every third to fifth year. At the next wave of data collection, additional linkages to Norwegian Patient Registry and Norwegian Cause of Death Registry for data on registered diagnoses and causes of death, respectively, will be performed.