Prevention Svenska
Chanelle Kirksey
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Ett hlsofrmjande och frebyggande arbete p lokal niv behver vara lngsiktigt, bygga p kunskap samt ha en bredd i sin ansats fr att lyckas, drfr har Folkhlsomyndigheten versatt EUPC, framtagen av Europeiska narkotikabyrn EMCDDA. Syftet r att tillgngliggra en vetenskaplig och teoretisk grund om prevention fr yrkesverksamma som arbetar inom omrdet fr alkohol, narkotika, dopning, tobak och nikotinprodukter samt spel om pengar (ANDTS). Innehllet kan dock tillmpas och fungera som inspiration fr prevention inom andra omrden som exempelvis vld, antisocialt beteende och kriminalitet.
Folkhlsomyndigheten (Fohm) r en nationell kunskapsmyndighet som arbetar fr en bttre folkhlsa. Det gr myndigheten genom att utveckla och stdja samhllets arbete med att frmja hlsa, frebygga ohlsa och skydda mot hlsohot. Vr vision r en folkhlsa som strker samhllets utveckling.
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Background: Bicycling to work may be a viable approach for achieving physical activity that provides cardiovascular health benefits. In this study we investigated the relationship of bicycling to work with incidence of obesity, hypertension, hypertriglyceridemia, and impaired glucose tolerance across a decade of follow-up in middle-aged men and women.
Conclusions: These data suggest that commuting by bicycle to work is an important strategy for primordial prevention of clinical cardiovascular risk factors among middle-aged men and women.
The Swedish Institute of Public Health presented guidelines for suicide prevention at the population level. The Swedish National Board of Health and Welfare presented guidelines on prevention of suicide in the individual. NASP:s role was to act as an expert for the FHI and to write the background materials to support the work of SoS.
On 27 April 2005, the Swedish Parliament announced that a National programme for suicide prevention should be developed (bet. 2004/05: SoU11, rskr.2004/05: 218). On 21 July 2005, the then government commissioned the Swedish Institute of Public Health (FHI) and The Swedish National Board of health and Welfare (SoS) to develop proposals for policies and measures needed for a national program for suicide prevention, which were created in consultation with the NASP. This included proposals for population-oriented strategies and actions for state agencies, counties and municipalities.
FHI and SoS created a proposal for a National Program for Suicide Prevention, which included an overall vision and nine strategies. The strategies and respondents' views are reported in: Extract from the Government bill 2007/08: 110 A renewed public health policy (March 2008)
The Swedish Obese Subjects (SOS) study has demonstrated that large weight losses in obese patients are associated with an 80% reduction in the 8-year incidence of diabetes (6). The Finnish Diabetes Prevention Study (DPS) and the Diabetes Prevention Program (DPP) have also demonstrated that modest weight loss achieved by lifestyle changes (diet and exercise) can significantly reduce the risk of developing type 2 diabetes in obese patients with impaired glucose tolerance (IGT) (7,8). A retrospective analysis of obese patients with IGT receiving orlistat treatment has shown that this weight loss agent may also be effective in reducing the progression to type 2 diabetes (9).
The prospective XENDOS (XENical in the prevention of Diabetes in Obese Subjects) study was primarily conducted to determine the long-term effect of orlistat, a gastrointestinal lipase inhibitor, in combination with lifestyle changes in reducing progression to type 2 diabetes and body weight over 4 years in obese, nondiabetic patients who had either normal glucose tolerance (NGT) or IGT. Secondary aims were to determine the effect of orlistat treatment on weight-related metabolic abnormalities associated with increased risk for cardiovascular disease and the safety and tolerability of orlistat over 4 years.
XENDOS was a 4-year, double-blind, randomized, placebo-controlled prospective study carried out at 22 Swedish medical centers between 1997 and 2002. Details of the study design and the system for centralized patient recruitment and scheduling of patients and staff at the centers have been described previously (10). The study protocol was approved by all relevant ethics review committees in Sweden and was conducted in accordance with the Declaration of Helsinki. All study subjects gave written informed consent.
After screening, eligible patients were randomized according to sex and OGTT results to receive either placebo or orlistat in a one-to-one ratio, using a centralized randomization procedure and schedule. Blinding was ensured by use of matching placebo and orlistat capsules. The investigators received sealed envelopes for each patient that contained the identity of the study medication.
Patients were randomized to orlistat 120 mg or placebo t.i.d. with breakfast, lunch, and dinner. Compliance was determined by counting the number of capsules returned by the patients at clinic visits and comparing the estimated percentage used against that dispensed.
Body weight was recorded at every study visit (every 3 months). Waist circumference was assessed at baseline, months 3 and 6, and every 6 months thereafter. Waist circumference was measured halfway between the lower rib margin and the iliac crest in the recumbent position after a normal expiration.
Standard clinical laboratory parameters, as well as plasma levels of the fat-soluble vitamins (vitamin A [retinol], 1,25-hydroxyvitamin D, 25-hydroxyvitamin D, vitamin E [α-tocopherol], and vitamin K1), were assessed every 6 months. Fasting blood samples were obtained before taking study medication and were analyzed by a central laboratory (Nova Medical Medi-Lab, Copenhagen, Denmark). Energy intake was estimated with a validated self-administered food questionnaire (12).
The intent-to-treat (ITT) population, used for the primary end point of time to onset of type 2 diabetes, consisted of all randomized patients who received at least one dose of study drug and had at least one follow-up efficacy assessment. Based on the ITT population, cumulative incidence rates of type 2 diabetes were calculated using a Kaplan-Meier estimate-of-survival function with partitions at 6-month intervals (the interval at which OGTTs were conducted). Because OGTT measurements were taken less frequently than body weight measurements (the first OGTT after randomization was taken at week 24), fewer patients were included in the ITT analyses of diabetes than of weight loss. The safety population consisted of all patients who received at least one dose of orlistat with a safety follow-up.
Statistical significance of differences between treatment groups for the primary end point of time to onset of diabetes were determined by the log-rank test (SAS PROC LIFETEST; SAS/STAT version 8). If significant, hazard ratios were determined as an estimate of relative risk of developing diabetes. The hazard ratio was derived using SAS PROC PHREG (Proportional Hazards Regression Methods; SAS/STAT version 8) with stratification factors of baseline glucose tolerance (IGT or NGT) and sex. To determine the effect of age and BMI on the relative risk of developing type 2 diabetes, age and BMI subgroups were categorized at baseline as above or below the median.
Quantitative changes in primary and secondary efficacy parameters were analyzed at yearly time points using an ANCOVA model. This included change from baseline as the response variable and center, treatment, and center-by-treatment interaction as the independent variables. Baseline values were used as covariates. For lipid parameters, the response variable was percentage change. We also analyzed body weight changes categorically. Descriptive statistics for all secondary parameters involving changes over time used observed data. Descriptive statistics for change in body weight and categorical body weight changes used last observation carried forward (LOCF) data unless otherwise noted. Observed, LOCF, and baseline observation carried forward (BLCF) (13) methods were used for hypothesis testing of quantitative parameters.
Baseline data were compared between completers and noncompleters. There was no substantial difference at baseline in age, weight, BMI, or the male-to-female ratio between completers and noncompleters in either treatment group (data not shown).
Average compliance with study drug administration from first dose until treatment termination was 93.3% for orlistat patients and 92.8% for placebo patients. This difference was not statistically significant.
The cumulative incidence of type 2 diabetes diagnosed on the basis of a repeat positive test was significantly lower with orlistat plus lifestyle treatment (log-rank P = 0.028). The cumulative incidence rate of type 2 diabetes after 4 years was 2.9% with orlistat versus 4.2% for placebo, corresponding to a 41% risk reduction (hazard ratio 0.593).
In patients with NGT at baseline, the progression rate to type 2 diabetes with placebo was very low (2.7% over 4 years) and insufficient to detect a statistically significant difference compared with orlistat (2.6% over 4 years).
Independent of orlistat or placebo treatment, the relative risk of developing type 2 diabetes was greater in patients with IGT than in those with NGT, in men than in women, in older than in younger individuals, and in individuals with a higher BMI (Table 2). Weight loss was significantly greater with orlistat than placebo in both patients with IGT at baseline (5.7 kg with orlistat vs. 3.0 kg with placebo; P < 0.01) and patients with NGT (5.8 vs. 3.0 kg, respectively; P < 0.001).
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