Impact of weight maintenance and loss on diabetes risk and burden: a population-based study in 33,184 participants

$\textbf{Background}$ Weight loss in individuals at high risk of diabetes is an effective prevention method and a major component of the currently prevailing diabetes prevention strategies. The aim of the present study was to investigate the public health potential for diabetes prevention of weight maintenance or moderate weight loss on a population level in an observational cohort with repeated measurements of weight and diabetes status. $\textbf{Methods}$ Height, weight and diabetes status were objectively measured at baseline and 10 year follow-up in a population-based cohort of 33,184 participants aged 30–60 years between 1990 and 2013 in Västerbotten County, Sweden. The association between risk of incident diabetes and change in BMI or relative weight was modelled using multivariate logistic regression. Population attributable fractions (PAF) were used to assess population impact of shift in weight. $\textbf{Results}$ Mean (SD) BMI at baseline was 25.0 (3.6) kg/m$^2$. Increase in relative weight between baseline and follow-up was linearly associated with incident diabetes risk, odds ratio (OR) 1.05 (95% confidence interval (CI) 1.04–1.06) per 1% change in weight. Compared to weight maintenance (±1.0 kg/m$^2$), weight gain of >+1.0 kg/m$^2$ was associated with an increased risk of incident diabetes, OR 1.52 (95% CI 1.32, 1.74), representing a PAF of 21.9% (95% CI 15.8, 27.6%). For moderate weight loss (−1.0 to −2.0 kg/m$^2$) the OR was 0.72 (95% CI 0.52, 0.99). $\textbf{Conclusions}$ Weight maintenance in adulthood is strongly associated with reduced incident diabetes risk and there is considerable potential for diabetes prevention in promoting this as a whole population strategy.This work was supported by the Medical Research Council [MC_UU_12015/ 4], the Swedish Council for Working Life and Social Research [FAS 2006_1512] and the Swedish Research Council [2006-21576-36119-666]. The Västerbotten Intervention Programme is financed by Västerbotten County Council. Dr Feldman is supported by the Raymond and Beverly Sackler Foundation through Churchill College, Cambridge

Screening for type 2 diabetes: Do screen-detected cases fare better?

Aims/hypothesis We aimed to investigate whether diabetes cases detected through screening have better health outcomes than clinically detected cases in a population-based cohort of adults who were eligible to be screened for diabetes at 10 year intervals. Methods The Västerbotten Intervention Programme is a community- and individual-based public health programme in Västerbotten County, Sweden. Residents are invited to clinical examinations that include screening for diabetes by OGTTs at age 30, 40, 50 and 60 years (individuals eligible for screening, n = 142,037). Between 1992 and 2013, we identified 1024 screen-detected cases and 8642 clinically detected cases of diabetes using registry data. Clinically detected individuals were either prior screening participants (n = 4506) or people who did not participate in screening (non-participants, n = 4136). Study individuals with diabetes were followed from date of detection until end of follow-up, emigration, death or incident cardiovascular disease (CVD), renal disease or retinopathy event, and compared using Cox proportional hazard regression adjusted for calendar time, age at detection, year of detection, sex and socioeconomic status. Results The average age at diabetes diagnosis was 4.6 years lower for screen-detected individuals compared with clinically detected individuals. Overall, those who were clinically detected had worse health outcomes than those who were screen-detected (HR for all-cause mortality 2.07 [95% CI 1.63, 2.62]). Compared with screen-detected study individuals, all-cause mortality was higher for clinically detected individuals who were screening non-participants (HR 2.31 [95% CI 1.82, 2.94]) than for those clinically detected who were prior screening participants (HR 1.70 [95% CI 1.32, 2.18]). Estimates followed a similar pattern for CVD, renal disease and retinopathy. Conclusions/interpretation Individuals with screen-detected diabetes were diagnosed earlier and appeared to fare better than those who were clinically detected with regard to all-cause mortality, CVD, renal disease and retinopathy. How much of these associations can be explained by earlier treatment because of screening rather than healthy user bias, lead time bias and length time bias warrants further investigation.This work was supported by the Medical Research Council (MC_UU_12015/4), the Swedish Council for Working Life and Social Research (FAS 2006_1512) and the Swedish Research Council (2006-21576-36119-666). The VIP is financed by Västerbotten County Council. ALF is supported by the Raymond and Beverly Sackler Foundation through Churchill College, Cambridge

Leadership in rural medicine: The organization on thin ice?

OBJECTIVE: To explore the personal experiences of and conceptions regarding leading rural primary care in Northern Norway. DESIGN: Qualitative content analysis of focus-group interviews. SETTING: Lead primary care physicians in the three northernmost counties. SUBJECTS: Four groups with 22 out of 88 municipal lead physicians in the region. RESULTS: Three main categories were developed and bound together by an implicit theme. Demands and challenges included the wide leadership span of clinical services and public health, placed in a merged line/board position. Constraints of human resources and time and the ever changing organizational context added to the experience of strain. Personal qualifications indicates the lack of leadership motivation and training, which was partly compensated for by a leader role developed through clinical undergraduate training and then through the responsibilities and experiences of clinical work. In Exercising the leadership, the participants described a vision of a coaching and coordinating leadership and, in practice, a display of communication skills, decision-making ability, result focusing, and ad hoc solutions. Leadership was made easier by the features of the small, rural organization, such as overview, close contact with cooperating partners, and a supportive environment. There was incongruence between demands and described qualifications, and between desired and executed leadership, but nevertheless the organization was running. Leadership demonstrated a “working inadequacy”. CONCLUSION: Under resource constraints, leadership based on clinical skills favours management by exception which, in the long run, appears to make the leadership less effective. Leadership training which takes into account the prominent features of rural and decentralized primary care is strongly needed