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The concept of metabolically healthy individuals with obesity (MHO) has gained considerable interest. Nevertheless, the lack of a standardized definition for metabolic health complicates the comparison of the prevalence and health implications of MHO. To compare three definitions of metabolic health in terms of their prevalence, overlap, and frequency with which criteria are met within a general population. We used data from 20 581 women and men aged 40-99 years attending the seventh survey of the Tromsø Study (Tromsø7) in 2015-2016. Participants were classified as metabolically healthy (MH) by definitions A) resembling metabolic syndrome (MetS) requiring ≤1/4 MetS components; B) strict requiring fulfillment of 0/4 MetS components, and C) empirically derived definition requiring fulfillment of 0/3 components including diabetes, elevated blood pressure and waist-to-hip ratio. Prevalence of MH was assessed descriptively in categories of normal weight, overweight and obesity based on body mass index (BMI). We used Venn diagrams to present the overlap between the three definitions applied to identify MH individuals, and the frequency of fulfilled components in metabolically unhealthy (MU) individuals (not classified as MH). All analyses were stratified by sex. Prevalence of MH was higher in women and participants in lower BMI categories. Using definition A, 50% of women and 38% of men with obesity were classified as MH. Under definition B, 18% of women and 10% of men with obesity were considered MH. Definition C resulted in prevalences of 29% and 18%, in women and men with obesity, respectively. Blood pressure was the most common component in MU individuals, met by 76%-89% of MU women and 81%-93% of MU men, depending on the definition. The considerable variation in MH prevalence across different definitions underscores the need for a consensus definition, to further establish public prevention and clinical treatment strategies.

Background Previous studies of the reproducibility of self-reported age at menarche have been limited because of small study samples, short follow-up and the limited age span of the women included. Methods The present study assessed the reproducibility of age at menarche in 6731 women with a wide variation of age when giving the information about age at menarche. The women reported age at menarche in a self-administered questionnaire, both in 1986–1987 and 1994–1995. They were all residents of Tromsø, Norway, and aged 25–73 in 1994–1995. In order to investigate the agreement between self-reported age at menarche at the two points in time, Pearson’s correlation coefficient was applied to assess the linear correlation between the reported menarcheal age at the two occasions. Analyses were stratified for age. A Bland-Altman plot was produced and limits of agreement computed. Results We found a high correlation and a strong agreement between self-reported age at menarche in 1986–1987 and 1994–1995. The overall Pearson’s correlation coefficient was 0.84 and was not attenuated by increasing age of the women. The Bland-Altman plot showed a strong agreement in self-reported age at menarche. The mean difference between self-reported age at menarche was 0.01 years with limits of agreement −1.52 to 1.54. Conclusion We found high reproducibility of self-reported age at menarche. The mean menarcheal age in the two surveys was identical (13.2 years) with 95% of the women reporting the same age at menarche or with a difference of 1 year. Only 0.7% of the women reported age at menarche with a difference of more than 2 years in 1986–1987 and 1994–1995.

Individuals with schizophrenia or substance use disorder have a substantially increased mortality compared to the general population. Despite a high and probably increasing prevalence of comorbid substance use disorder in people with schizophrenia, the mortality in the comorbid group has been less studied and with contrasting results. We performed a nationwide open cohort study from 2009 to 2015, including all Norwegians aged 20-79 with schizophrenia and/or substance use disorder registered in any specialized health care setting in Norway, a total of 125,744 individuals. There were 12,318 deaths in the cohort, and total, sex-, age- and cause-specific standardized mortality ratios (SMRs) were calculated, comparing the number of deaths in patients with schizophrenia, schizophrenia only, substance use disorder only or a co-occurring diagnosis of schizophrenia and substance use disorder to the number expected if the patients had the age-, sex- and calendar-year specific death rates of the general population. The SMRs were 4.9 (95% CI 4.7-5.1) for all schizophrenia patients, 4.4 (95% CI 4.2-4.6) in patients with schizophrenia without substance use disorder, 6.6 (95% CI 6.5-6.8) in patients with substance use disorder only, and 7.4 (95% CI 7.0-8.2) in patients with both schizophrenia and substance use disorder. The SMRs were elevated in both genders, in all age groups and for all considered causes of death, and most so in the youngest. Approximately 27% of the excess mortality in all patients with schizophrenia was due to the raised mortality in the subgroup with comorbid SUD. The increased mortality in patients with schizophrenia and/or substance use disorder corresponded to more than 10,000 premature deaths, which constituted 84% of all deaths in the cohort. The persistent mortality gap highlights the importance of securing systematic screening and proper access to somatic health care, and a more effective prevention of premature death from external causes in this group.

Background Cancer patients with a pre-existing mental disorder or substance use disorder (SUD) have a poorer prognosis compared to other cancer patients, with suboptimal routes to diagnosis and treatment as possible contributing factors. Shorter intervals from suspicion of cancer to start of cancer treatment have been observed following the implementation of Cancer Patient Pathways (CPP) in the Nordic countries, which may have led to a better prognosis. We aimed to investigate whether incident cancer patients with and without pre-existing mental disorder or SUD were equally likely to be included in a CPP. We also investigated the associations between pre-existing mental disorder or SUD and low primary care utilization, and cancers diagnosed post-emergency or close to death in non-CPP enrolees. Methods This population-based registry study included incident cancer patients aged 21–79 between 2015 and 2018 ( n  = 65,328). Information on pre-existing mental disorders or SUD was gathered from national registries of primary and specialised health care, prescriptions, and disability diagnosis. Propensity score analyses using inverse probability weighting along with the McNemar test were performed to evaluate the risk of non-inclusion in any CPP for all cancers combined, lifestyle-related cancers combined, and the most common cancers individually. Results Cancer patients with pre-existing mental disorder or SUD had an 8% (RR = 1.08; 95% Confidence Interval (CI) 1.03–1.13) higher risk of non-enrolment in a CPP. Patients with prior hospitalisation for mental disorder or SUD, and patients with pre-existing psychosis or depression were at particular risk of non-inclusion in a CPP compared to controls, especially for cancers that often present with symptoms late in the course of the disease, such as lung cancer. In line with this, patients with pre-existing mental disorder or SUD who were not referred to a CPP faced a 34% (RR = 1.34; 95% CI 1.18–1.53%) increased risk of unrecognised cancer close to death. Conclusions Cancer patients with pre-existing mental disorder or SUD have an increased risk of non-inclusion in a CPP. If not included in a CPP, they have an increased risk of having unrecognised cancer close to death. By addressing barriers to CPP-inclusion, and enhancing the quality of diagnostic and treatment services, healthcare systems could achieve better cancer outcomes for vulnerable patient groups.

Background The aim of this study was to analyse whether there are patient related or geographic differences in the use of catheter ablation among atrial fibrillation patients in Norway. Methods National population-based data on individual level of all Norwegians aged 25 to 75 diagnosed with atrial fibrillation from 2008 to 2017 were used to study the proportion treated with catheter ablation. Survival analysis, by Cox regression with attained age as time scale, separately by gender, was applied to examine the associations between ablation probability and educational level, income level, place of residence, and follow-up time. Results Substantial socioeconomic and geographic variation was documented. Atrial fibrillation patients with high level of education and high income were more frequently treated with ablation, and the education effect increased with increasing age. Patients living in the referral area of St. Olavs Hospital Trust had around three times as high ablation rates as patients living in the referral area of Finnmark Hospital Trust. Conclusions Differences in health literacy, patient preference and demands are probably important causes of socioeconomic variation, and studies on how socioeconomic status influences the choice of treatment are warranted. Some of the geographic variation may reflect differences in ablation capacity. However, geographic variation related to differences in clinical practice and provider preferences implies a need for clearer guidelines, both at the specialist level and at the referring level.

BackgroundThe impact of body mass index (BMI; kg/m2) and waist circumference (WC) on mortality in elderly individuals is controversial and previous research has largely focused on obesity.MethodsWith special attention to the lower BMI categories, associations between BMI and both total and cause-specific mortality were explored in 7604 men and 9107 women aged ≥65 years who participated in the Tromsø Study (1994–1995) or the North-Trøndelag Health Study (1995–1997). A Cox proportional hazards model adjusted for age, marital status, education and smoking was used to estimate HRs for mortality in different BMI categories using the BMI range of 25–27.5 as a reference. The impact of each 2.5 kg/m2 difference in BMI on mortality in individuals with BMI<25.0 and BMI≥25.0 was also explored. Furthermore, the relations between WC and mortality were assessed.ResultsWe identified 7474 deaths during a mean follow-up of 9.3 years. The lowest mortality was found in the BMI range 25–29.9 and 25–32.4 in men and women, respectively. Mortality was increased in all BMI categories below 25 and was moderately increased in obese individuals. U-shaped relationships were also found between WC and total mortality. About 40% of the excess mortality in the lower BMI range in men was explained by mortality from respiratory diseases.ConclusionsBMI below 25 in elderly men and women was associated with increased mortality. A modest increase in mortality was found with increasing BMI among obese men and women. Overweight individuals (BMI 25–29.9) had the lowest mortality.

ObjectiveWe aimed to examine associations between educational level, serving as an indicator of socioeconomic position, and prevalence of WHO-established leading behavioural and biological risk factors for non-communicable diseases (NCDs), in middle-aged to older women and men.DesignPopulation-based cross-sectional study.SettingAll inhabitants of the municipality of Tromsø, Norway, aged ≥40 years, were invited to the seventh survey (2015–2016) of the Tromsø Study; an ongoing population-based cohort study.ParticipantsOf the 32 591 invited; 65% attended, and a total of 21 069 women (53%) and men aged 40–99 years were included in our study.Outcome measuresWe assessed associations between educational level and NCD behavioural and biological risk factors: daily smoking, physical inactivity (sedentary in leisure time), insufficient fruit/vegetable intake (<5 units/day), harmful alcohol use (>10 g/day in women, >20 g/day in men), hypertension, obesity, intermediate hyperglycaemia and hypercholesterolaemia. These were expressed as odds ratios (OR) per unit decrease in educational level, with 95% CIs, in women and men.ResultsIn women (results were not significantly different in men), we observed statistically significant associations between lower educational levels and higher odds of daily smoking (OR 1.69; 95% CI 1.60 to 1.78), physical inactivity (OR 1.38; 95% CI 1.31 to 1.46), insufficient fruit/vegetable intake (OR 1.54, 95% CI 1.43 to 1.66), hypertension (OR 1.25; 95% CI 1.20 to 1.30), obesity (OR 1.23; 95% CI 1.18 to 1.29), intermediate hyperglycaemia (OR 1.12; 95% CI 1.06 to 1.19), and hypercholesterolaemia (OR 1.07; 95% CI 1.03 to 1.12), and lower odds of harmful alcohol use (OR 0.75; 95% CI 0.72 to 0.78).ConclusionWe found statistically significant educational gradients in women and men for all WHO-established leading NCD risk factors within a Nordic middle-aged to older general population. The prevalence of all risk factors increased at lower educational levels, except for harmful alcohol use, which increased at higher educational levels.

Elderly people may be at particular risk of Zn deficiency due to an increased prevalence of malnutrition. The aim of the present study was to evaluate the Zn status in community-living elderly people at risk of malnutrition. Cross-sectional population-based survey. Individuals at risk of malnutrition were identified by the Malnutrition Universal Screening Tool. Zn status was assessed by measuring serum Zn. Logistic regression was performed to evaluate the association between the risk of malnutrition and Zn deficiency. Municipality of Tromsø, Norway. Random sample of 743 men and 778 women aged 65-87 years. Zn deficiency was found in 10.1% of the participants, including 13.1% of the men and 7.3% of the women. Among the men and women at risk of malnutrition, 31.0% and 12.7%, respectively, had Zn deficiency. In a model adjusted for age, gender, serum albumin and smoking status, Zn deficiency was positively associated with the risk of malnutrition (OR=2.2; 95% CI 1.3, 3.6). Overall, Zn deficiency was found in one out of ten community-living elderly people and was associated with the risk of malnutrition. Our results encourage the assessment of Zn status in elderly people at risk of malnutrition, with a special emphasis on elderly men.

Background The shape of the associations between intake of foods basic in a healthy Nordic diet and long-term health is not well known. Therefore, we have examined all-cause mortality in a large, prospective cohort of women in Norway in relation to intake of: Nordic fruits and vegetables, fatty fish, lean fish, wholegrain products, and low-fat dairy products. Methods A total of 83 669 women who completed a food frequency questionnaire between 1996 and 2004 were followed up for mortality until the end of 2018. Cox proportional hazards regression models were used to examine the associations between consumption of the Nordic food groups and all-cause mortality. The Nordic food groups were examined as categorical exposures, and all but wholegrain products also as continuous exposures in restricted cubic spline models. Results A total of 8 507 women died during the 20-year follow-up period. Nordic fruits and vegetables, fatty fish and low-fat dairy products were observed to be non-linearly associated with all-cause mortality, while higher intake of lean fish and wholegrain products reduced all-cause mortality. Intake levels and hazard ratios (HR) and 95% confidence intervals (CI) associated with lowest mortality were approximately 200 g/day of Nordic fruits and vegetables (HR 0.83 (95% CI: 0.77–0.91)), 10–20 g/day of fatty fish (10 g/day: HR 0.98 (95% CI: 0.94–1.02)) and 200 g/day of low-fat dairy products (HR 0.96 (95% CI: 0.81–1.01)) compared to no consumption. Consumption of fatty fish ≥ 60 g/day compared to no intake statistically significantly increased the mortality (60 g/day: HR 1.08 (95% CI: 1.01–1.16)), as did consumption of low-fat dairy products ≥ 800 g/day compared to no intake (800 g/day: HR 1.10 (95% CI: 1.02–1.20)). After stratification by smoking status, the observed association between Nordic fruits and vegetables and all-cause mortality was stronger in ever smokers. Conclusion The associations between intake of foods basic in healthy Nordic diets and all-cause mortality may be non-linear. Therefore, assumptions of linear associations between traditional Nordic food groups and health outcomes could lead to wrong conclusions in analyses of healthy Nordic diets.

The obesity epidemic is dynamic with varying secular trends and differences between countries and ethnic groups. The objective of this study was to describe the age- and sex-specific longitudinal changes in weight and waist circumference in a rural Norwegian population with a high proportion of the indigenous Sami population. Based on two population-based surveys, SAMINOR 1 (2003-2004) and SAMINOR 2 (2012-2014), we present longitudinal changes in weight and waist circumference according to age at baseline in the SAMINOR 1 Survey and sex during the 10-year period. The analyses included 1538 men and 1958 women aged 36 to 69 at baseline (birth year 1934 to 1967). Forty-one percent of the population were Sami. Both weight and waist circumference were measured. The mean weight increased 0.8 kg (95% confidence interval: 0.5, 1.1) in men and 0.3 kg (95% confidence interval: 0, 0.5) in women. In both men and women, younger individuals gained significantly more weight during the 10-year follow-up than older participants (p < 0.001). The mean weight showed a statistically significant increase in men aged 36-54 and women aged 36-49 at baseline and was statistically significantly reduced in men and women aged 60-69. The mean waist circumference increased by 6.3 cm (95% confidence interval: 6.0, 6.6) in men and 8.4 cm (95% confidence interval 8.1, 8.8) in women. The mean waist circumference increased statistically significantly from SAMINOR 1 to SAMINOR 2 in all age groups, and there was an inverse relationship between age at baseline and change in waist circumference (p < 0.001). Waist circumference increased more than can be explained by changes in weight and age during the 10-year period. The inverse relationships between age at baseline in SAMINOR 1 and the 10-year change in weight and waist circumference were found in both Sami and non-Sami participants. The findings underline the need for prevention of obesity, particularly in younger people, as it is difficult to achieve permanent weight loss.