To Örebro University

BACKGROUND: The prevalence of obesity is a global health challenge, as obesity is associated with various comorbidities, reduced quality of life, and increased mortality. Providing effective treatment to improve health and quality of life for people with obesity is a major health care concern. Internet-delivered treatment (IDT) is an alternative treatment that increases patient accessibility and reachability; however, pilot testing is required before such interventions are evaluated in full-scale studies or implemented.

OBJECTIVE: This study aims to investigate the feasibility and user-friendliness of an IDT program for obesity (IDT-O); to evaluate body weight, dietary habits, physical activity, psychosocial functioning, and experiences of treatment in those who completed the 6-month treatment; and to investigate the dropouts' experiences of the treatment.

METHODS: A prospective 1-year observational approach, evaluated through a multimethod research design, was adopted. Inclusion criteria were age 18 years and older, BMI of ≥30 kg/m2, or BMI of 28-29.9 kg/m2 with obesity-related comorbidity. Participants were offered a 6-month therapist-assisted IDT-O program providing evidence-based obesity treatment, behavioral and lifestyle support, and strategies to address weight stigma. BMI, participants' dietary habits, self-reported physical activity, psychosocial functioning, experiences of treatment effects, and treatment satisfaction were measured before treatment and after 6 and 12 months. Dropouts were followed up through qualitative interviews.

RESULTS: A total of 20 participants (17 females and 3 male; mean age 44.2, SD 16.4 years) started the IDT-O program, and 35% (7/20) completed all 12 modules. Ten (8 females) out of 13 dropouts were interviewed. Both quantitative and qualitative findings showed that participants were generally satisfied with the content and design of the intervention. Those who completed the IDT-O lost some weight (mean 2.0%, 95% CI -1.09 to 5.13), reported improved dietary habits (effect size [ES] 0.25, 95% CI -0.51 to 1.00), increased physical activity (ES 0.93, 95% CI -0.08 to 1.87), and improved psychosocial functioning (distress: ES 0.43, 95% CI 0.-0.37 to 1.19; avoidance: ES 0.67, 95% CI -0.18 to 1.48), 6 months after completing the treatment. The qualitative analysis of the interviews revealed "The programme was OK, but it does not suit everyone" as the main theme. The main themes were based on the 3 subthemes: "It wasn't for me," "There were good things," and "There are things to improve."

CONCLUSIONS: The findings indicate that the IDT-O holds potential as a treatment for people with obesity, although one limitation is that only 35% (7/20) of the participants completed the pilot program. Improvements in lifestyle habits and psychosocial functioning were observed in those who completed the IDT-O, but these findings are preliminary and need to be confirmed in a more comprehensive study. The issue of nonadherence underscores the importance of both thoroughly assessing patients before treatment and further development of IDT-O programs.

Highlights

•  Internet-delivered obesity treatment can help change lifestyle habits

•  Expectations for weight loss were not met

•  Life circumstances made it difficult to commit to treatment

•  Internet-delivered treatment is not for everyone.

BACKGROUND: The aim was to investigate trends in obesity prevalence by gender and educational level in the general population aged 30-69 years, based on large surveys conducted in Mid-Sweden in 2012, 2017 and 2022.

METHODS: The study included 22 082, 15 264 and 17 055 respondents, respectively. Obesity (body mass index ≥30 kg/m2) was based on self-reported weight and height. Trends in obesity prevalence, including comparisons across educational levels, were estimated by age-standardised proportions with corresponding 95% CIs. Differences between genders, educational levels and survey years were tested using multiple logistic regression.

RESULTS: The overall age-standardised prevalence of obesity increased from 17.6% in 2012 to 20.1% in 2017 and to 23.3% in 2022. There was no statistically significant difference in obesity prevalence between men and women. Large and persisting inequalities between educational levels were however observed. In 2022, the prevalence of obesity was about 30% among persons with low/middle education and 18% among persons with high education.

CONCLUSION: Efforts to tackle the obesity epidemic are urgently required in Sweden, taking into consideration the circumstances of groups with low and middle levels of education.

OBJECTIVE: The aim of this study was to investigate factors associated with reported need of weight loss support among adults with overweight or obesity in the general population.

DESIGN: A cross-sectional population study based on a survey questionnaire sent to a random population sample. Multivariate odds ratios for reported need of weight loss support were calculated for socio-economic, lifestyle and health indicators, in total and by gender and age group.

SETTING: Five counties in Sweden in 2022. PARTICIPANTS: The study includes 10 069 persons with overweight or obesity (BMI ≥ 25 kg/m2) aged 30-69 years. BMI was based on self-reported weight and height.

RESULTS: In total, about 20 % reported needing weight loss support. The factors most strongly associated with reported need of weight loss support were obesity and female gender. Lack of social support, economic difficulties, physical inactivity, poor self-rated health, musculoskeletal pain and depression were also associated with reported need of weight loss support, whereas diabetes and hypertension were not. Some differences in these associations were observed between age groups.

CONCLUSION: Reported need of weight loss support is more common among women than among men and associated with obesity, lack of social support, economic difficulties, physical inactivity, poor self-rated health, musculoskeletal pain and depression in both genders. These factors are important for planning preventive and weight-control measures among adults with overweight or obesity.

OBJECTIVE: The aim was to examine the psychometric properties of the Hospital Anxiety and Depression Scale (HADS) in cohorts of working age stroke survivors, before and after inpatient rehabilitation.

METHODS: Stroke patients aged 18-66 years registered in the national quality register WebRehab Sweden were included in the study at hospital admission (n = 256), discharge (n = 223), and 1-year follow-up (n = 313). Classical and modern (Rasch) methods were used for psychometric evaluation.

RESULTS: The two-factor HADS model measuring anxiety and depression showed better fit than a single factor measuring emotional distress. The instrument's psychometric stability before and after rehabilitation was satisfactory. The anxiety scale showed good psychometric properties, except for item 7, which is not anxiety-specific. Some concerns were observed for the depression items showing weaker discriminant validity, and item 8 performing poorly as a measure of depression. Cronbach's alpha and McDonald's omega coefficients showed satisfactory internal consistency reliability, whereas Rasch person reliability coefficients indicated weaker reliability, especially for the depression scale. Effect size of change between hospital admission and discharge showed a reduction in anxiety and depression symptoms.

CONCLUSIONS: HADS showed a stable two-factor structure over the rehabilitation period. Patients' perception of items was not affected by the recovery, allowing relevant comparison of HADS scores between different phases of the rehabilitation process. Measures of responsiveness suggest that HADS is sensitive to capturing improvements in emotional distress following rehabilitation interventions. Overall, despite minor psychometric weaknesses, HADS is a suitable instrument for assessing anxiety and depresssion symptoms in stroke patients aged 18-66 years.

BACKGROUND: Assessment of Rehabilitation Needs Checklist (ARNC), has been developed to assess rehabilitation need in cancer patients and is recommended by the Confederation of Regional Cancer Centres in Sweden, known as Hälsoskattningen. The aim of the study was to test the reliability and validity of the ARNC, mainly by comparing it with the Distress thermometer and EORTC QLQ-C30.

METHODOLOGY: A sample of 993 persons identified in the Swedish cancer register. The study participants were diagnosed with cancer in 2021 in the Mid Sweden region. The psychometric methods tested reliability and validity including factor analysis.

RESULTS: The response rate was 38%. The test-retest analysis showed that ICC was 0.80 or higher for 12 of the ARNC items. A strong or modarete correlation between ARNC and the other instruments was found in all functional scales and for most items. CFA of the 13-item two-factor model showed a RMSEA value of 0.04, CFI and TLI values of 0.97 and 0.96, and a SRMR value of 0.05, indicating a satisfactory model fit.

CONCLUSION: The evaluation of the ARNC suggests that it is an acceptable and reliable screening instrument for detecting symptoms and signs indicating a possible need of rehabilitation. The medium to strong correlations between ARNC items and the EORTC QLQ- C30 items and scales suggest that ARNC could be an alternative also for research purposes when a shorter and less comprehensive instrument is needed. The simple design could be an advantage as it lowers the burden on cancer patients.

AIM: To describe experiences of living with obesity before the start of a group-based lifestyle intervention.

BACKGROUND: Obesity is a chronic disease that affects a person's physical and psychological health. Increased knowledge of experiences of living with obesity is required.

DESIGN: A qualitative study with a descriptive design.

METHODS: Semi-structured individual interviews with 17 participants living with obesity (Body Mass Index 32-49) were conducted between October and November 2019. The interviews were analysed using qualitative content analysis. The COREQ checklist was followed.

RESULTS: The analysis resulted in one main theme: Struggling for a lighter tomorrow and three subthemes: Suffering, Resilience and Need for support in making changes. For the majority of the participants, living with obesity was a lifelong struggle involving suffering on different levels. Yet despite this, the participants had not given up and hoped for a better life. They showed a degree of resilience and motivation, and a perceived ability to achieve lifestyle changes. However, there was a pronounced need for support to help them achieve this.

CONCLUSION: Living with obesity is complex and carries a risk of medical complications as well as psychosocial suffering. Healthy lifestyle habits to achieve better health and to lose weight should be encouraged, taking patient resources into account. Patients also need help in handling weight stigmatisation, and both healthcare professionals and society must engage with this.

RELEVANCE TO CLINICAL PRACTICE: Obesity is a chronic disease, and patients need ongoing support. Therefore, care for patients with obesity in primary health care must be further developed. Patient resources and strengths have to be acknowledged and encouraged in the process of helping them adopt healthy lifestyle habits. The findings of this study can contribute to ending weight stigmatisation by increasing the knowledge of living with obesity.

OBJECTIVE: This study aimed to investigate the associations between general health expectations and patient satisfaction with treatment for the two common spine surgery procedures diskectomy for lumbar disk herniation (LDH) and decompression for lumbar spinal stenosis (LSS). DESIGN: Register study with prospectively collected preoperative and 1-year postoperative data.

SETTING: National outcome data from Swespine, the national Swedish spine register.

PARTICIPANTS: A total of 9929 patients, aged between 20 and 85 years, who were self-reported non-smokers, and were operated between 2007 and 2016 for one-level LSS without degenerative spondylolisthesis, or one-level LDH, were identified in the national Swedish spine register (Swespine). We used SF-36 items 11c and 11d to assess future health expectations and present health perceptions. Satisfaction with treatment was assessed using the Swespine satisfaction item.

INTERVENTIONS: One-level diskectomy for LDH or one-level decompression for LSS.

PRIMARY OUTCOME MEASURES: Satisfaction with treatment. RESULTS: For LSS, the year 1 satisfaction ratio among patients with negative future health expectations preoperatively was 60% (95% CI 58% to 63%), while it was 75% (95% CI 73% to 76%) for patients with positive future health expectations preoperatively. The corresponding numbers for LDH were 73% (95% CI 71% to 75%) and 84% (95% CI 83% to 85%), respectively.

CONCLUSIONS: Patients operated for the common lumbar spine diseases LSS or LDH, with negative future general health expectations, were significantly less satisfied with treatment than patients with positive expectations with regard to future general health. These findings are important for patients, and for the surgeons who counsel them, when surgery is a treatment option for LSS or LDH.

INTRODUCTION: Physical activity (PA) after metabolic and bariatric surgery (MBS) can influence weight loss, health status, and quality of life. Known mediators to participate in PA are enjoyment, self-efficacy, and social support. Little is known about PA behavior in MBS individuals. The aim of this study was to explore levels of PA and the PA mediators enjoyment, self-efficacy, and social support before and after MBS and to investigate changes over time.

METHODS: Adults scheduled to undergo MBS were recruited from a Swedish university hospital. Accelerometer-measured and self-reported PA, body weight, and PA mediators were collected at baseline and at 12 to 18 months post-surgery.

RESULTS: Among 90 individuals included, 50 completed the follow-up assessment and had valid accelerometer data. Sedentary time (minutes/day) was unchanged, but sedentary time as percentage of wear time decreased significantly from 67.2% to 64.5% (p<0.05). Time spent in light PA and total PA increased significantly from 259.3 to 288.7 min/day (p < 0.05) and from 270.5 to 303.5 min/day (p < 0.01), respectively. Step counts increased significantly from 6013 to 7460 steps/day (p < 0.01). There was a significant increase in self-reported PA, enjoyment, self-efficacy for exercise, and positive social support from family. The increase in PA mediators did not lead to a significant change in time spent in moderate to vigorous PA.

CONCLUSION: The increase in PA-mediators was not associated with an increase in moderate to vigorous PA, but the strengthened PA mediators suggest potential for an increase in moderate to vigorous PA in patients undergoing MBS.

BACKGROUND AND OBJECTIVE: Mapping algorithms can be used for estimating quality-adjusted life years (QALYs) when studies apply non-preference-based instruments. In this study, we estimate a regression-based algorithm for mapping between the World Health Organization Disability Assessment Schedule (WHODAS 2.0) and the preference-based instrument SF-6D to obtain preference estimates usable in health economic evaluations. This was done separately for the working and non-working populations, as WHODAS 2.0 discriminates between these groups when estimating scores.

METHODS: Using a dataset including 2258 participants from the general Swedish population, we estimated the statistical relationship between SF-6D and WHODAS 2.0. We applied three regression methods, i.e., ordinary least squares (OLS), generalized linear models (GLM), and Tobit, in mapping onto SF-6D from WHODAS 2.0 at the overall-score and domain levels. Root mean squared error (RMSE) and mean absolute error (MAE) were used for validation of the models; R2 was used to assess model fit.

RESULTS: The best-performing models for both the working and non-working populations were GLM models with RMSE ranging from 0.084 to 0.088, MAE ranging from 0.068 to 0.071, and R2 ranging from 0.503 to 0.608. When mapping from the WHODAS 2.0 overall score, the preferred model also included sex for both the working and non-working populations. When mapping from the WHODAS 2.0 domain level, the preferred model for the working population included the domains mobility, household activities, work/study activities, and sex. For the non-working population, the domain-level model included the domains mobility, household activities, participation, and education.

CONCLUSIONS: It is possible to apply the derived mapping algorithms for health economic evaluations in studies using WHODAS 2.0. As conceptual overlap is incomplete, we recommend using the domain-based algorithms over the overall score. Different algorithms must be applied depending on whether the population is working or non-working, due to the characteristics of WHODAS 2.0.