Anne Karen Jenum

• Tibelles, Hatuia Bø; Kirkebøen, Lars Johannessen; Jenum, Anne Karen; Straand, Jørund; Berg, Tore Julsrud & Buhl, Esben Selmer (2025). Young-onset type 2 diabetes and associations with high disability rate, low educational level and immigrant background: A study from Norwegian general practice. BMJ Open. 15(9). doi: 10.1136/bmjopen-2024-096521. Full text in Research Archive
• Shakeel, Nilam; Jenum, Anne Karen; Waage, Christin; Mdala, Ibrahimu; Werner, Erik Lønnmark & Natvig, Bård [Show all 7 contributors for this article] (2025). Symptom burden in middle-aged women, the role of immigrant status. BMC Public Health. 25. doi: 10.1186/s12889-025-25093-x. Full text in Research Archive Show summary

  Background Subjective health complaints (SHCs) are symptoms from various organs that do not have an obvious explanation. Immigrants in Western countries are often exposed to multiple stressors that may trigger SHCs. Increased symptom load may reflect subjective health and functioning in the present and in the future. We, therefore, aimed to identify symptom load and distribution of subjective health complaints among middle-aged women by immigrant status. Methods This is a cross-sectional study which uses 11-year follow-up data from the STORK Groruddalen Cohort Study of 823 healthy pregnant women enrolled in primary antenatal care in a multi-ethnic city district in Oslo from 2008 to 2010. 11 years later, 379 women (53% of the eligible) provided questionnaire data on subjective health complaints drawn from the Subjective Health Complaints Inventory (SHCI) and regarding demographics and health issues collected through interviews. Participants were divided into three immigrant status groups: born in Norway by Norwegian parents (reference), born in Norway with one or two foreign born parents, and born abroad. The primary outcomes were the total score and the scores for each of the five domains in the SHCI: musculoskeletal pain, pseudo-neurology and gastrointestinal problems, allergy and flu. In addition, we studied the distribution of the 29 health complaints from the SHCI. Results Musculoskeletal symptoms were most severe and prevalent in all three immigrant-status groups. Compared to women born in Norway with Norwegian parents (reference), women born abroad had significantly higher total scores (median: 11.0 (IQR: 14.82–21.45) vs. 7.6 (9.38–12.78) (p = 0.002)). For musculoskeletal pain, the crude median scores were 4.3 (0.92–4.36) for women born abroad and 2.1 (3.81–5.72) for women born in Norway with Norwegian parents (p < 0.001). The following health complaints, headache, migraine, dizziness, pain in feet on exertion, bloating, constipation, chest pain, breathing difficulties and asthma, were more prevalent in women born abroad than in the reference group, before and after adjusting for age and education. Conclusion SHCs were more frequent and severe among women born abroad compared to the reference group. This knowledge is essential to identify women at risk and target appropriate interventions. Trial registration The study (STORK G 2) was prospectively registered at ClinicalTrials.gov (registration number: NCT03870724), registration date: 08.03.2019.

• Toftemo, Ingun; Brænd, Anja Maria; Jenum, Anne Karen & Sletner, Line (2025). Overweight prevalence increases from 2 to 8 years of age among children with immigrant background in a Norwegian multiethnic population. Scandinavian Journal of Public Health. ISSN 1403-4948. 53(8), p. 889–897. doi: 10.1177/14034948251356059. Full text in Research Archive Show summary

  Aims: Little is known about ethnic disparities in childhood obesity in Europe. We explored the development of ethnic differences in overweight (including obesity) from age 2 to 8 years. Methods: We collected routine weight and height measures for 604 children from the Norwegian multiethnic, population-based STORK Groruddalen pregnancy and birth cohort (52.6% European, 26.8% south Asian, and 20.5% Middle East/north African ethnic background). Using chi-square tests for trend and binominal logistic regression analyses adjusted for sex and maternal factors, we explored the development of ethnic differences in overweight. For children with south Asian origin, we performed body mass index adjustments considering their relatively higher adiposity. Results: From age 2 to 8 years, prevalence of overweight was stable in European children (13.1% at 2 years, and 15.1% at 8 years). In children with immigrant background, prevalence increased; from 5.4% to 17.2% in children with south Asian origin, and from 16.2% to 35.8% in children with Middle East/north African background ( p for trend < 0.001 in both groups). At age 8 years, the latter group had almost a threefold higher risk of overweight (odds ratio (OR) 2.89; 95% confidence interval 1.54–5.42) compared with European-origin children, while ethnic south Asian children had a double risk (OR 2.07; 1.19–3.59) after adjustments for body composition. Conclusions: From 2 to 8 years of age, prevalence of childhood overweight increased in children with immigrant background but remained stable in ethnic Europeans. To reduce ethnic disparities in health, effective efforts to prevent obesity in children with immigrant background should start very early in life.

• Waage, Christin; Jenum, Anne Karen; Mdala, Ibrahimu; Lee-Ødegård, Sindre; Brænd, Anja Maria & Sletner, Line [Show all 8 contributors for this article] (2025). Diabetes and prediabetes among women universally screened for gestational diabetes: a multi-ethnic, population-based, prospective study with eleven years follow-up. BMC Public Health. 25(1). doi: 10.1186/s12889-025-22493-x. Full text in Research Archive Show summary

  Background Gestational diabetes (GDM) is a strong risk factor for later development of diabetes. However, data are scarce on the long-term risk for diabetes or prediabetes diagnosed by HbA1c, in non-selected, multi-ethnic populations universally screened for GDM using the WHO2013 criteria. We aimed to investigate the development of diabetes or prediabetes eleven years after the index pregnancy and identify risk factors in pregnancy or shortly after. Methods A population-based cohort study of 360 women with complete eleven years follow-up data for diabetes (HbA1c≥48 mmol/mol) or prediabetesADA (HbA1c 39–47 mmol/mol). Women were enrolled in gestational week 15 and universally screened with an oral glucose tolerance test in week 28. We performed least absolute shrinkage and selection operator (LASSO) regression to identify predictors of future diabetes or prediabetesADA and constructed a nomogram to predict individual risks. Results Diabetes or prediabetesADA combined, was found in 26.9%, and the prevalence was slightly higher in previous GDM compared with non-GDM women (35.6% versus 23.5%; p=0.019). The relative risk (RR) for developing diabetes or prediabetesADA was moderately elevated in GDM compared with non-GDM women (1.4 [1.0, 1.9], p=0.035). Seven women (1.9%) had diabetes and all of these except for one, had previous GDM. Hence, the crude prevalence was 5.8% among GDM women vs. 0.4% among non-GDM women. The RR for developing diabetes was substantially higher in GDM vs. non-GDM women (14.8 [2.6, 277.1], p=0.012). PrediabetesADA was found in 25% and the RR for prediabetesADA was not significantly increased for GDM compared to non-GDM women (1.3 [0.9, 1.8], p=0.143). Among Europeans, 17.0% had diabetes or prediabetesADA, compared to 43.0% among South Asians (p<0.001) and 34.4% among other ethnicities (p=0.002). The most significant predictors identified from the LASSO were HbA1c measured in early pregnancy, ethnicity, and a family history of diabetes. Conclusions The risk for developing diabetes was low, overall and among GDM women. Still GDM represented a strong risk for diabetes, but not for prediabetesADA. HbA1c early in pregnancy, non-European ethnicity, and a family history of diabetes were the strongest risk factors for developing diabetes or prediabetesADA.

• Strandberg, Ragnhild Bjarkøy; Nilsen, Roy Miodini; Pouwer, Francois; Igland, Jannicke; Røssberg, Jan Ivar & Jenum, Anne Karen [Show all 8 contributors for this article] (2025). Pharmacologically treated depression, anxiety, and insomnia in individuals with type 2 diabetes: The role of diabetes duration, age, and age at diabetes onset. A Norwegian population-based registry study from the OMIT cohort. Journal of Psychosomatic Research. ISSN 0022-3999. 190, p. 1–8. doi: 10.1016/j.jpsychores.2025.112057. Full text in Research Archive Show summary

  Objective To examine whether type 2 diabetes (T2D) duration (‘0–4’; ‘≥5–9’; ≥10–19′; ‘≥20 years') was associated with use of medication for depression, anxiety, or insomnia, and if possible associations were modified by age, age at T2D onset, sex, and education. Methods We used data from 55,083 adults with T2D in the national registry-based cohort study Outcomes & Multi-morbidity In T2D (2006–2019). Adjusted associations and effect modifications were estimated using binary logistic regressions with generalized estimation equations in the subgroups age (<60, ≥60 years), age at diabetes onset (<40, ≥40 years), sex (men, women), and education (primary, high school, university). Results At initial registration, 12 % used medication for depression, 10 % for anxiety, and 16 % for insomnia. These prevalence estimates increased with diabetes duration in most subgroups. Individuals with early onset T2D had higher prevalence of depression than those with late onset, which increased with diabetes duration (per category change diabetes duration 0.7 % (95 % CI 0.2, 1.2), P for trend = 0.003). For anxiety and insomnia, a stronger association was found in those with early T2D onset compared to late onset (per category change 1.3 % (95 % CI 0.9, 1.8) and 1.9 (95 % CI 1.3, 2.4), P for interaction = 0.001; 0.01). Conclusion The prevalence of pharmacologically treated depression, anxiety, and insomnia increased with diabetes duration; this finding may imply that assessment of mental health disorders at the initial phase and along the diabetes trajectory are needed. As the prevalences advanced most prominently in people with early onset T2D, future studies should determine underlying mechanisms to test age-appropriate preventive interventions.

• Bargas, Nicolas Fragoso; Mcbride, Nancy S.; Lee-Ødegård, Sindre; Lawlor, Deborah A.; Yousefi, Paul D. & Moen, Gunn-Helen [Show all 14 contributors for this article] (2025). Epigenome-wide association study of objectively measured physical activity in peripheral blood leukocytes. BMC Genomics. 26. doi: 10.1186/s12864-025-11262-0. Full text in Research Archive Show summary

  Background: Few studies have explored the association between DNA methylation and physical activity. The aim of this study was to evaluate the association of objectively measured hours of sedentary behavior (SB) and moderate physical activity (MPA) with DNA methylation. We further aimed to explore the association between SB or MPA related CpG sites and cardiometabolic traits, gene expression, and genetic variation. Results: For discovery, we performed cross sectional analyses in pregnant women from the Epigenetics in pregnancy (EPIPREG) sample with both DNA methylation (Illumina MethylationEPIC BeadChip) and objectively measured physical activity data (SenseWear™ Pro 3 armband) (European = 244, South Asian = 109). For EWAS of SB and MPA, two main models were designed: model (1) a linear mixed model adjusted for age, smoking, blood cell composition, including ancestry as random intercept, and model (2) which was additionally adjusted for the total number of steps per day. In model 1, we did not identify any CpG sites associated with neither SB nor MPA. In model 2, SB was positively associated (false discovery rate, FDR < 0.05) with two CpG sites within the VSX1 gene. Both CpG sites were positively associated with BMI and were associated with several genetic variants in cis. MPA was associated with 122 significant CpG sites at FDR < 0.05 (model 2). We further analyzed the ten most statistically significant MPA related CpG sites and found that they presented opposite associations with sedentary behavior and BMI. We were not able to replicate the SB and MPA-related CpG sites in the Avon Longitudinal Study of Parents and Children (ALSPAC). ALSPAC had available objectively measured physical activity data from Actigraph (without steps/day available) and leucocyte DNA methylation data collected during adolescence (n = 408, European). Conclusion: This study suggests associations of objectively measured SB and MPA with maternal DNA methylation in peripheral blood leukocytes, that needs to be confirmed in larger samples of similar study design.

• Opsahl, Julia Onsrud; Bargas, Nicolas Fragoso; Lee, Y.; Carlsen, E. Ø.; Kiryushchenko, Nadezhda & Qvigstad, E. [Show all 13 contributors for this article] (2024). Epigenome-wide association study of DNA methylation in maternal blood leukocytes with BMI in pregnancy and gestational weight gain. International Journal of Obesity. ISSN 0307-0565. 48(4), p. 584–593. doi: 10.1038/s41366-024-01458-x. Full text in Research Archive Show summary

  Objectives We aimed to discover CpG sites with differential DNA methylation in peripheral blood leukocytes associated with body mass index (BMI) in pregnancy and gestational weight gain (GWG) in women of European and South Asian ancestry. Furthermore, we aimed to investigate how the identified sites were associated with methylation quantitative trait loci, gene ontology, and cardiometabolic parameters. Methods In the Epigenetics in pregnancy (EPIPREG) sample we quantified maternal DNA methylation in peripheral blood leukocytes in gestational week 28 with Illumina’s MethylationEPIC BeadChip. In women with European (n = 303) and South Asian (n = 164) ancestry, we performed an epigenome-wide association study of BMI in gestational week 28 and GWG between gestational weeks 15 and 28 using a meta-analysis approach. Replication was performed in the Norwegian Mother, Father, and Child Cohort Study, the Study of Assisted Reproductive Technologies (MoBa-START) (n = 877, mainly European/Norwegian). Results We identified one CpG site significantly associated with GWG (p 5.8 × 10−8) and five CpG sites associated with BMI at gestational week 28 (p from 4.0 × 10–8 to 2.1 × 10–10). Of these, we were able to replicate three in MoBa-START; cg02786370, cg19758958 and cg10472537. Two sites are located in genes previously associated with blood pressure and BMI. DNA methylation at the three replicated CpG sites were associated with levels of blood pressure, lipids and glucose in EPIPREG (p from 1.2 × 10−8 to 0.04). Conclusions We identified five CpG sites associated with BMI at gestational week 28, and one with GWG. Three of the sites were replicated in an independent cohort. Several genetic variants were associated with DNA methylation at cg02786379 and cg16733643 suggesting a genetic component influencing differential methylation. The identified CpG sites were associated with cardiometabolic traits.

• Tibelles, Hatuia Bø; Jenum, Anne Karen; Kirkebøen, Lars Johannessen; Berg, Tore Julsrud; Claudi, Tor & Cooper, John [Show all 10 contributors for this article] (2024). High prevalence of retinopathy in young-onset type 2 diabetes and possible sex differences: insights from Norwegian general practice. BMJ Open Diabetes Research & Care. 12(1). doi: 10.1136/bmjdrc-2023-003624. Full text in Research Archive Show summary

  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.

• Graue, Marit; Igland, Jannicke; Oftedal, Bjørg Synnøve Frøysland; Haugstvedt, Anne; Riise, Hilde Kristin Refvik & Zoffmann, Vibeke [Show all 9 contributors for this article] (2024). Interprofessional follow-up for people at risk of type 2 diabetes in primary healthcare–a randomized controlled trial with embedded qualitative interviews. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 42(3), p. 450–462. doi: 10.1080/02813432.2024.2337071. Full text in Research Archive Show summary

  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.

• Igland, Jannicke; Forster, Rachel Bedenis; Jenum, Anne Karen; Strandberg, Ragnhild Bjarkøy; Berg, Tore Julsrud & Røssberg, Jan Ivar [Show all 8 contributors for this article] (2024). 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. BMJ Open. 14(3). doi: 10.1136/bmjopen-2023-077027. Full text in Research Archive Show summary

  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.

• Robinson, Hilde Stendal; Vøllestad, Nina Køpke; Bennetter, Karin Elisabeth; Waage, Christin Wiegels; Jenum, Anne Karen & Richardsen, Kåre Rønn (2024). Pelvic girdle pain in pregnancy and early postpartum – prevalence and risk factors in a multi-ethnic cohort. BMC Musculoskeletal Disorders. 25(1). doi: 10.1186/s12891-023-07135-w. Full text in Research Archive Show summary

  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 diferences 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 diferences 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 signifcant in multivariable analyses.

• Sletner, Line; Yajnik, Chittaranjan S.; Turowski, Gitta Erika; Michelsen, Trond Melbye; Sommer, Christine & Birkeland, Kåre Inge [Show all 8 contributors for this article] (2024). Placental weight, surface area, shape and thickness - Relations with maternal ethnicity and cardio-metabolic factors during pregnancy. Placenta. ISSN 0143-4004. 148, p. 69–76. doi: 10.1016/j.placenta.2024.02.002. Full text in Research Archive Show summary

  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.

• Snilsberg, Øyvind; Iversen, Tor; Jenum, Anne Karen & Zhang, Yuting (2024). Effects of a national checklist on recommended procedures among patients with type 2 diabetes. BMC Health Services Research. 24(1). doi: 10.1186/s12913-024-11940-x. Full text in Research Archive Show summary

  Background Type 2 diabetes (T2D) is a common, potentially disabling, and costly chronic condition that requires consistent management. In 2008, Norway introduced a national checklist outlining services to include in an annual T2D exam, along with a reimbursement code for general practitioners (GPs) to bill upon completing it. This study investigates whether GP adoption of the checklist improves adherence to recommended services for T2D patients. Methods To investigate the impact of GP checklist adoption, we use Norwegian registry data from 2006 to 2021 and apply two difference-in-differences (DID) methods that account for staggered adoption timing: the two-way fixed effects (TWFE) estimator and Callaway and Sant’Anna’s DID method for variation in exposure timing (CSDID) (Callaway B. et al., J Econom 225:200–30, 2021). Results We find that installing the electronic form has modest effects on the use of some recommended procedures. Conclusions Our study suggests that using the electronic form can have a positive effect on recommended services. However, the modest impact indicates that installing the form does not necessarily translate into its active regular use. Keywords Checklist, National quality program, Physician incentives, Diabetes management, Norwegian Diabetes Register for Adults

• Linares-Pineda, Teresa M.; Bargas, Nicolas Fragoso; Picón, María José; Molina-Vega, Maria; Jenum, Anne Karen & Sletner, Line [Show all 14 contributors for this article] (2024). DNA methylation risk score for type 2 diabetes is associated with gestational diabetes. Cardiovascular Diabetology. 23(1). doi: 10.1186/s12933-024-02151-z. Full text in Research Archive Show summary

  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.

• Nøkleby, Kjersti; Jenum, Anne Karen; Buhl, Esben Selmer; Claudi, Tor; Cooper, John & Flottorp, Signe Agnes [Show all 9 contributors for this article] (2024). Effects on HbA1c of referral of type 2 diabetes patients to secondary care. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. p. 1–11. doi: 10.1080/02813432.2024.2433107. Full text in Research Archive Show summary

  Aim: To study trajectories of HbA1c in type 2 diabetes (T2D) patients referred to diabetes outpatient clinics (DOCs), and to explore characteristics of referrals and patient pathways in patients treated in DOCs. Methods: We retrospectively followed T2D patients from the Norwegian population-based ROSA 4 study to identify persons with T2D who were referred to a DOC. We used latent class trajectory modelling to identify subgroups of patients with similar patterns of HbA1c one year before to one year after the first consultation at a DOC. We performed multinomial regression analyses to identify baseline characteristics associated with group membership. Results: Four hundred and two of 6716 T2D patients started treatment at a DOC, constituting a yearly starting rate of 1.5%. We identified three classes of HbA1c trajectories: (1) stable moderate hyperglycaemia (75%); (2) severe hyperglycaemia with a decline in HbA1c around referral (14%) and (3) severe hyperglycaemia with a decline in HbA1c after starting treatment at the DOC (11%). HbA1c trajectories were associated with diabetes duration RRR 0.92, CI (0.87, 0.97) in class 2 vs. 1 and 0.93 (0.88, 0.98) in class 3 vs. 1. Some differences were found between clinics in rejection rate, processes of care, and duration of follow-up. Conclusions: Norwegian GPs handle most T2D patients themselves. Those with T2D and severe hyperglycaemia had a considerable benefit from being referred to a DOC, though with two separate trajectories: One where HbA1c improved around the time of referral, and another that improved after starting in a DOC.

• Bennetter, Karin Elisabeth; Waage, Christin; Jenum, Anne Karen; Vøllestad, Nina Køpke; Robinson, Hilde Stendal & Richardsen, Kåre Rønn (2023). 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. Journal of Immigrant and Minority Health. ISSN 1557-1912. 26, p. 63–71. doi: 10.1007/s10903-023-01535-9. Full text in Research Archive
• Bennetter, Karin Elisabeth; Richardsen, Kåre Rønn; Vøllestad, Nina Køpke; Jenum, Anne Karen; Robinson, Hilde Stendal & Mdala, Ibrahimu [Show all 7 contributors for this article] (2023). Associations between social support and physical activity in postpartum: a Norwegian multi-ethnic cohort study. BMC Public Health. 23(1). doi: 10.1186/s12889-023-15507-z. Full text in Research Archive Show summary

  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. Keywords Physical activity, MVPA, Social support, Postpartum, Family, Friends, Ethnicity

• Krasuska, Marta; Davidson, Emma M.; Beune, Erik; Jenum, Anne Karen; Gill, Jason M.R. & Stronks, Karien [Show all 9 contributors for this article] (2023). 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. JMIR Formative Research. 7(1). doi: 10.2196/33810. Full text in Research Archive Show summary

  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.

• Rai, Anam Shakil; Sletner, Line; Jenum, Anne Karen; Øverby, Nina Cecilie; Stafne, Signe Nilssen & Qvigstad, Elisabeth [Show all 8 contributors for this article] (2023). Employing fasting plasma glucose to safely limit the use of oral glucose tolerance tests in pregnancy: a pooled analysis of four Norwegian studies. Frontiers in Endocrinology. 14. doi: 10.3389/fendo.2023.1278523. Full text in Research Archive Show summary

  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.

• Fragoso-Bargas, Nicolas; Page, Christian Magnus; Joubert, Bonnie R.; London, Stephanie J.; Lee-Ødegård, Sindre & Opsahl, Julia Onsrud [Show all 13 contributors for this article] (2023). Epigenome-wide association study of serum folate in maternal peripheral blood leukocytes. Epigenomics. ISSN 1750-1911. 15(1), p. 39–52. doi: 10.2217/epi-2022-0427. Full text in Research Archive Show summary

  Aim: To perform an epigenome-wide association study (EWAS) of serum folate in maternal blood. Methods: Cross-ancestry (Europeans = 302, South Asians = 161) and ancestry-specific EWAS in the EPIPREG cohort were performed, followed by methyl quantitative trait loci analysis and association with cardiometabolic phenotypes. Replication was attempted using maternal folate intake and blood methylation data from the MoBa study and verified if the findings were significant in a previous EWAS of maternal serum folate in cord blood. Results & conclusion: cg19888088 (cross-ancestry) in EBF3, cg01952260 (Europeans) and cg07077240 (South Asians) in HERC3 were associated with serum folate. cg19888088 and cg01952260 were associated with diastolic blood pressure. cg07077240 was associated with variants in CASC15. The findings were not replicated and were not significant in cord blood.

• Stalheim, Astrid Melteig; Iversen, Marjolein M.; Jenum, Anne Karen; Sletner, Line; Stafne, Signe Nilssen & Qvigstad, Elisabeth [Show all 10 contributors for this article] (2023). Seasonal variation in gestational diabetes mellitus among women in Norway: a national population-based study. BMJ Open. 13(3), p. 1–8. doi: 10.1136/bmjopen-2022-063725. Full text in Research Archive Show summary

  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.

• Rai, Anam Shakil; Sletner, Line; Jenum, Anne Karen; Øverby, Nina Cecilie; Stafne, Signe Nilssen & Qvigstad, Elisabeth [Show all 8 contributors for this article] (2023). Adverse pregnancy outcomes among women in Norway with gestational diabetes using three diagnostic criteria. PLOS ONE. 18(7). doi: 10.1371/journal.pone.0280750. Full text in Research Archive Show summary

  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.

• Næss-Andresen, Marthe-Lise; Jenum, Anne Karen; Berg, Jens Petter; Falk, Ragnhild Sørum & Sletner, Line (2023). 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. BMC Pregnancy and Childbirth. 23:350(1), p. 1–13. doi: 10.1186/s12884-023-05668-5. Full text in Research Archive Show summary

  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.

• Mdala, Ibrahimu; Nøkleby, Kjersti; Berg, Tore Julsrud; Cooper, John; Sandberg, Sverre & Løvaas, Karianne Fjeld [Show all 9 contributors for this article] (2023). Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help—insights from Norwegian general practice. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 42(1). doi: 10.1080/02813432.2023.2296118. Full text in Research Archive Show summary

  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.

• Næss-Andresen, Marthe-Lise; Jenum, Anne Karen; Berg, Jens Petter; Falk, Ragnhild Sørum & Sletner, Line (2022). 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. Journal of Nutritional Science (JNS). 11. doi: 10.1017/jns.2022.45. Full text in Research Archive Show summary

  Abstract 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 &lt;12·0 g/dl) was 25 %. ID prevalence varied from 39 % by serum ferritin (SF &lt;15 μg/l), to 19 % by soluble transferrin receptor (sTfR &gt;4·4 mg/l) and 22 % by total body iron (TBI &lt; 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 &lt; 0·01–0·05), and the prevalence of ID by sTfR and TBI, but not of ID by SF &lt; 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.

• Forster, Rachel Bedenis; Strandberg, Ragnhild Bjarkøy; Tibballs, Katrina Louise Bø; Nøkleby, Kjersti; Berg, Tore Julsrud & Iversen, Tor [Show all 15 contributors for this article] (2022). 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. BMJ Open. 12(5). doi: 10.1136/bmjopen-2021-054840. Full text in Research Archive Show summary

  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.

• Strandberg, Ragnhild Bjarkøy; Nilsen, Roy Miodini; Pouwer, Frans; Igland, Jannicke; Forster, Rachel Bedenis & Jenum, Anne Karen [Show all 8 contributors for this article] (2022). 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). Patient Education and Counseling. ISSN 0738-3991. 107, p. 1–7. doi: 10.1016/j.pec.2022.107577. Full text in Research Archive Show summary

  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.

• Lofterød, Trygve; Frydenberg, Hanne; Veierød, Marit Bragelien; Jenum, Anne Karen; Reitan, Jon Brinchmann & Wist, Erik [Show all 7 contributors for this article] (2022). The influence of metabolic factors and ethnicity on breast cancer risk, treatment and survival: The Oslo ethnic breast cancer study. Acta Oncologica. ISSN 0284-186X. 61(5), p. 649–657. doi: 10.1080/0284186X.2022.2053573. Full text in Research Archive Show summary

  Background Breast cancer risk remains higher in high-income compared with low-income countries. However, it is unclear to what degree metabolic factors influence breast cancer development in women 30 years after immigration from low- to a high-incidence country. Methods Using Cox regression models, we studied the association between pre-diagnostic metabolic factors and breast cancer development, and whether this association varied by ethnicity among 13,802 women participating in the population-based Oslo Ethnic Breast Cancer Study. Ethnic background was assessed and pre-diagnostic metabolic factors (body mass index, waist:hip ratio, serum lipids and blood pressure) were measured. A total of 557 women developed invasive breast cancer, and these women were followed for an additional 7.7 years. Results Among women with an unfavorable metabolic profile, women from south Asia, compared with western European women, had a 2.3 times higher breast cancer risk (HR 2.30, 95% CI 1.18–4.49). Compared with the western European women, the ethnic minority women were more likely to present with triple-negative breast cancer (TNBC) (OR 2.11, 95% CI 0.97–4.61), and less likely to complete all courses of planned taxane treatment (OR 0.26, 95% CI 0.08–0.82). Among TNBC women, above-median triglycerides:HDL-cholesterol (>0.73) levels, compared with below-median triglycerides:HDL-cholesterol (≤0.73) levels, was associated with 2.9 times higher overall mortality (HR 2.88, 95% CI 1.02–8.11). Conclusions Our results support the importance of metabolic factors when balancing breast cancer prevention and disease management among all women, and in particular among non-western women migrating from a breast cancer low-incidence to a high-incidence country.

• Pervjakova, Natalia; Moen, Gunn-Helen Øiseth; Borges, Maria-Carolina; Ferreira, Teresa; Cook, James P. & Allard, Catherine [Show all 73 contributors for this article] (2022). Multi-ancestry genome-wide association study of gestational diabetes mellitus highlights genetic links with type 2 diabetes. Human Molecular Genetics. ISSN 0964-6906. 31(19), p. 3377–3391. doi: 10.1093/hmg/ddac050. Full text in Research Archive Show summary

  Gestational diabetes mellitus (GDM) is associated with increased risk of pregnancy complications and adverse perinatal outcomes. GDM often reoccurs and is associated with increased risk of subsequent diagnosis of type 2 diabetes (T2D). To improve our understanding of the aetiological factors and molecular processes driving the occurrence of GDM, including the extent to which these overlap with T2D pathophysiology, the GENetics of Diabetes In Pregnancy Consortium assembled genome-wide association studies of diverse ancestry in a total of 5485 women with GDM and 347 856 without GDM. Through multi-ancestry meta-analysis, we identified five loci with genome-wide significant association (P < 5 × 10−8) with GDM, mapping to/near MTNR1B (P = 4.3 × 10−54), TCF7L2 (P = 4.0 × 10−16), CDKAL1 (P = 1.6 × 10−14), CDKN2A-CDKN2B (P = 4.1 × 10−9) and HKDC1 (P = 2.9 × 10−8). Multiple lines of evidence pointed to the shared pathophysiology of GDM and T2D: (i) four of the five GDM loci (not HKDC1) have been previously reported at genome-wide significance for T2D; (ii) significant enrichment for associations with GDM at previously reported T2D loci; (iii) strong genetic correlation between GDM and T2D and (iv) enrichment of GDM associations mapping to genomic annotations in diabetes-relevant tissues and transcription factor binding sites. Mendelian randomization analyses demonstrated significant causal association (5% false discovery rate) of higher body mass index on increased GDM risk. Our results provide support for the hypothesis that GDM and T2D are part of the same underlying pathology but that, as exemplified by the HKDC1 locus, there are genetic determinants of GDM that are specific to glucose regulation in pregnancy.

• Fragoso-Bargas, Nicolas; Elliott, Hannah R.; Lee-Ødegård, Sindre; Opsahl, Julia Onsrud; Sletner, Line & Jenum, Anne Karen [Show all 12 contributors for this article] (2022). Cross-Ancestry DNA Methylation Marks of Insulin Resistance in Pregnancy: An Integrative Epigenome-Wide Association Study. Diabetes. ISSN 0012-1797. 72(3), p. 415–426. doi: 10.2337/db22-0504. Full text in Research Archive
• Slåtsve, Kristina Barbara; Claudi, Tor; Lappegård, Knut Tore; Jenum, Anne Karen; Larsen, Marthe & Nøkleby, Kjersti [Show all 12 contributors for this article] (2022). Level of education is associated with coronary heart disease and chronic kidney disease in individuals with type 2 diabetes: a population-based study. BMJ Open Diabetes Research & Care. 10(5). doi: 10.1136/bmjdrc-2022-002867. Full text in Research Archive Show summary

  Introduction - To study the relationship between education level and vascular complications in individuals with type 2 diabetes in Norway.<p> <p>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.<p> <p>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.<p> <p>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.

• Beune, Erik; Muilwijk, Mirthe; Jelsma, Judith G. M.; Valkengoed, Irene van; Teitsma-Jansen, Annemarie M. & Kumar, Bernadette N. [Show all 14 contributors for this article] (2022). The acceptability and effect of a culturally-tailored dance intervention to promote physical activity in women of South Asian origin at risk of diabetes in the Netherlands—A mixed-methods feasibility study. PLOS ONE. 17(2). doi: 10.1371/journal.pone.0264191. Full text in Research Archive Show summary

  Objective Populations of South Asian (SA) origin are at high risk of type 2 diabetes (T2D) and related complications. Analysis of T2D prevention interventions for these populations show that limited attention has been given to facilitating increased physical activity (PA) in a culturally appropriate manner. The aim of this feasibility study was to identify whether culturally tailored dance is acceptable to women of SA origin, and whether it may have an effect on PA and PA-related social cognitive determinants. Methods A community-based culturally tailored dance intervention choreographed to Bollywood music was evaluated among 26 women of SA origin in the Netherlands for 10 weeks, 2 times per week. This feasibility study was conducted as a before-after, mixed-methods study, combining data from focus groups, individual interviews, questionnaires and accelerometers. Results The majority of participants were in the age of 50–59 years and at moderate-to-high T2D risk. There was high attendance (73%), low drop out (12%) and high satisfaction scores for various program components. Key reasons for participation were the cultural appropriateness, in particular the combination of historically and emotionally embedded Indian music and dance, and the non-competitive nature of the intervention. On average, in each of the 19 one-hour sessions, participants spent 30.8 minutes in objectively assessed light intensity PA, 14.1 minutes in moderate intensity PA and 0.3 minutes in vigorous PA, and took 2,100 steps during a session. At follow-up, total moderate-to-vigorous PA increased by 7.8 minutes per day (95%CI: 3.1, 12.5) and daily steps increased by 784 (95%CI: 173, 1394), with a concomitant reduction in light PA of 12 minutes per day (95%CI: -21.9, -2.2). Positive shifts in some PA-behavioral social cognitive determinants and no negative side-effects were observed. Conclusions Bollywood Dance appears to be a feasible, culturally acceptable and potentially effective approach to increase PA in SA women in the Netherlands. A pilot cluster RCT is needed to confirm these initial findings on effectiveness.

• Sommer, Christine; Vangberg, Kjersti G; Moen, Gunn-Helen Øiseth; Evans, David M.; Lee-Ødegård, Sindre & Høgestøl, Ingvild Kristine [Show all 11 contributors for this article] (2022). Insulin and Body Mass Index Decrease Serum Soluble Leptin Receptor Levels in Humans. Journal of Clinical Endocrinology and Metabolism (JCEM). ISSN 0021-972X. 108(5), p. 1110–1119. doi: 10.1210/clinem/dgac699. Full text in Research Archive Show summary

  Context Serum soluble leptin receptor (sOb-R) may protect against future type 2 diabetes or serve as a marker for protective features, but how sOb-R is regulated is largely unknown. Objective This work aimed to test how serum sOb-R is influenced by glucose, insulin, body fat, body mass index (BMI), food intake, and physical activity. Methods We performed an epidemiological triangulation combining cross-sectional, interventional, and Mendelian randomization study designs. In 5 independent clinical studies (n = 24-823), sOb-R was quantified in serum or plasma by commercial enzyme-linked immunosorbent assay kits using monoclonal antibodies. We performed mixed-model regression and 2-sample Mendelian randomization. Results In pooled, cross-sectional data, leveling by study, sOb-R was associated inversely with BMI (β [95% CI] −0.19 [−0.21 to −0.17]), body fat (−0.12 [−0.14 to −0.10), and fasting C-peptide (−2.04 [−2.46 to −1.62]). sOb-R decreased in response to acute hyperinsulinemia during euglycemic glucose clamp in 2 independent clinical studies (−0.5 [−0.7 to −0.4] and −0.5 [−0.6 to −0.3]), and immediately increased in response to intensive exercise (0.18 [0.04 to 0.31]) and food intake (0.20 [0.06 to 0.34]). In 2-sample Mendelian randomization, higher fasting insulin and higher BMI were causally linked to lower sOb-R levels (inverse variance weighted, −1.72 [−2.86 to −0.58], and −0.20 [−0.36 to −0.04], respectively). The relationship between hyperglycemia and sOb-R was inconsistent in cross-sectional studies and nonsignificant in intervention studies, and 2-sample Mendelian randomization suggested no causal effect of fasting glucose on sOb-R. Conclusion BMI and insulin both causally decreased serum sOb-R levels. Conversely, intensive exercise and food intake acutely increased sOb-R. Our results suggest that sOb-R is involved in short-term regulation of leptin signaling, either directly or indirectly, and that hyperinsulinemia may reduce leptin signaling.

• Waage, Christin; Mdala, Ibrahimu; Stigum, Hein; Jenum, Anne Karen; Birkeland, Kåre Inge & Shakeel, Nilam [Show all 9 contributors for this article] (2022). Lipid and lipoprotein concentrations during pregnancy and associations with ethnicity. BMC Pregnancy and Childbirth. 22(1). doi: 10.1186/s12884-022-04524-2. Full text in Research Archive Show summary

  Background To describe ethnic differences in concentrations of lipids and lipoproteins, and their changes, during pregnancy to postpartum. Methods This was a population-based cohort study conducted in primary antenatal care in Norway. The participants (n = 806) were healthy, pregnant women, 59% were ethnic minorities. Outcomes were triglycerides, total cholesterol, HDL- and LDL-cholesterol, analysed from fasting blood samples drawn at gestational age (weeks) 15, 28 and 14 weeks postpartum. We performed linear regression models and linear mixed models to explore the total effect of ethnicity on the outcomes, adjusting for gestational age /week postpartum, maternal age and education. The analyses are corrected for multiple testing using the Bonferroni correction. Results At gestational age 15, triglyceride concentrations were lower in women of African origin (1.03 mmol/mol (95% CI: 0.90, 1.16)) and higher in women of South Asian (primarily Pakistan and Sri Lanka) origin (1.42 mmol/mol (1.35, 1.49)) and East Asian (primarily Vietnam, Philippines and Thailand) origin (1.58 mmol/mol (1.43, 1.73)) compared with Western Europeans (1.26 mmol/mol (1.20, 1.32)). Women of Asian and African origin had a smaller increase in triglycerides, LDL- and total cholesterol from gestational age 15 to 28. At gestational age 28, LDL-cholesterol levels were lowest among East Asians (3.03 mmol/mol (2.72, 3.34)) compared with Western Europeans (3.62 mmol/mol (3.50, 3.74)). Triglycerides and HDL-cholesterol were lower postpartum than at gestational age 15 in all groups, but the concentration of LDL-cholesterol was higher, except in Africans. South and East Asian women had lower HDL-cholesterol and higher triglycerides postpartum, while African women had lower triglycerides than Western Europeans. Conclusion We found significant differences in the concentrations of lipids and lipoproteins and their changes during pregnancy and the early postpartum period related to ethnic origin.

• Slåtsve, Kristina Barbara; Claudi, Tor; Lappegård, Knut Tore; Jenum, Anne Karen; Larsen, Marthe & Nøkleby, Kjersti [Show all 9 contributors for this article] (2021). Factors associated with treatment in primary versus specialist care: A population-based study of people with type 2 and type 1 diabetes. Diabetic Medicine. ISSN 0742-3071. 38(7). doi: 10.1111/dme.14580. Full text in Research Archive Show summary

  Aims The objectives of this study are to identify the proportion and characteristics of people with type 1 and 2 diabetes treated in primary, specialist and shared care and to identify the proportion of persons with type 2 diabetes reaching HbA1c treatment targets and the clinical risk factors and general practitioner and practice characteristics associated with treatment in specialist care. Methods Population-based cross-sectional study including all adults ≥18 years diagnosed with diabetes in primary and specialist care in Salten, Norway. We used multivariable mixed-effects logistic regression models with level of care as outcome variable and population, general practitioner, and practice characteristics as exposure variables. Results Of 2704 people with type 2 diabetes, 13.5% were treated in shared care and 2.1% in specialist care only. Of 305 people with type 1 diabetes, 14.4% received treatment in primary care only. The HbA1c treatment target of 53 mmol/mol (7.0%) was reached by 67.3% of people with type 2 diabetes in primary care versus 30.4% in specialist care. HbA1c, use of insulin, coronary heart disease, retinopathy and urban practice location were positively associated with treatment in specialist care. General practitioners’ use of a structured form and a diabetes nurse were negatively associated with specialist care. Conclusions Of people with type 2 diabetes, 16% were treated in specialist care. They had higher HbA1c and more vascular complications, as expected from priority guidelines. The use of a structured diabetes form and diabetes nurses seem to support type 2 diabetes follow-up in primary care.

• Sletner, Line; Moen, Aina Elisabeth Fossum; Yajnik, Chittaranjan S; Kiryushchenko, Nadezhda; Sommer, Christine & Birkeland, Kåre Inge [Show all 8 contributors for this article] (2021). Maternal Glucose and LDL-Cholesterol Levels Are Related to Placental Leptin Gene Methylation, and, Together With Nutritional Factors, Largely Explain a Higher Methylation Level Among Ethnic South Asians. Frontiers in Endocrinology. 12. doi: 10.3389/fendo.2021.809916. Full text in Research Archive Show summary

  Background Leptin, mainly secreted by fat cells, plays a core role in the regulation of appetite and body weight, and has been proposed as a mediator of metabolic programming. During pregnancy leptin is also secreted by the placenta, as well as being a key regulatory cytokine for the development, homeostatic regulation and nutrient transport within the placenta. South Asians have a high burden of type 2 diabetes, partly attributed to a “thin-fat-phenotype”. Objective Our aim was to investigate how maternal ethnicity, adiposity and glucose- and lipid/cholesterol levels in pregnancy are related to placental leptin gene ( LEP ) DNA methylation. Methods We performed DNA methylation analyses of 13 placental LEP CpG sites in 40 ethnic Europeans and 40 ethnic South Asians participating in the STORK-Groruddalen cohort. Results South Asian ethnicity and gestational diabetes (GDM) were associated with higher placental LEP methylation. The largest ethnic difference was found for CpG11 [5.8% (95% CI: 2.4, 9.2), p&amp;lt;0.001], and the strongest associations with GDM was seen for CpG5 [5.2% (1.4, 9.0), p=0.008]. Higher maternal LDL-cholesterol was associated with lower placental LEP methylation, in particular for CpG11 [-3.6% (-5.5, -1.4) per one mmol/L increase in LDL, p&amp;lt;0.001]. After adjustments, including for nutritional factors involved in the one-carbon-metabolism cycle (vitamin D, B12 and folate levels), ethnic differences in placental LEP methylation were strongly attenuated, while associations with glucose and LDL-cholesterol persisted. Conclusions Maternal glucose and lipid metabolism is related to placental LEP methylation, whilst metabolic and nutritional factors largely explain a higher methylation level among ethnic South Asians.

• Rai, Anam Shakil; Sletner, Line; Jenum, Anne Karen; Øverby, Nina Cecilie; Stafne, Signe Nilssen & Lekva, Tove [Show all 8 contributors for this article] (2021). Identifying women with gestational diabetes based on maternal characteristics: an analysis of four Norwegian prospective studies. BMC Pregnancy and Childbirth. 21. doi: 10.1186/s12884-021-04086-9. Full text in Research Archive Show summary

  Background There is still no worldwide agreement on the best diagnostic thresholds to define gestational diabetes (GDM) or the optimal approach for identifying women with GDM. Should all pregnant women perform an oral glucose tolerance test (OGTT) or can easily available maternal characteristics, such as age, BMI and ethnicity, indicate which women to test? The aim of this study was to assess the prevalence of GDM by three diagnostic criteria and the predictive accuracy of commonly used risk factors. Methods We merged data from four Norwegian cohorts (2002–2013), encompassing 2981 women with complete results from a universally offered OGTT. Prevalences were estimated based on the following diagnostic criteria: 1999WHO (fasting plasma glucose (FPG) ≥7.0 or 2-h glucose ≥7.8 mmol/L), 2013WHO (FPG ≥5.1 or 2-h glucose ≥8.5 mmol/L), and 2017Norwegian (FPG ≥5.3 or 2-h glucose ≥9 mmol/L). Multiple logistic regression models examined associations between GDM and maternal factors. We applied the 2013WHO and 2017Norwegian criteria to evaluate the performance of different thresholds of age and BMI. Results The prevalence of GDM was 10.7, 16.9 and 10.3%, applying the 1999WHO, 2013WHO, and the 2017Norwegian criteria, respectively, but was higher for women with non-European background when compared to European women (14.5 vs 10.2%, 37.7 vs 13.8% and 27.0 vs 7.8%). While advancing age and elevated BMI increased the risk of GDM, no risk factors, isolated or in combination, could identify more than 80% of women with GDM by the latter two diagnostic criteria, unless at least 70–80% of women were offered an OGTT. Using the 2017Norwegian criteria, the combination “age≥25 years or BMI≥25 kg/m2” achieved the highest sensitivity (96.5%) with an OGTT required for 93% of European women. The predictive accuracy of risk factors for identifying GDM was even lower for non-European women. Conclusions The prevalence of GDM was similar using the 1999WHO and 2017Norwegian criteria, but substantially higher with the 2013WHO criteria, in particular for ethnic non-European women. Using clinical risk factors such as age and BMI is a poor pre-diagnostic screening method, as this approach failed to identify a substantial proportion of women with GDM unless at least 70–80% were tested.

• Nøkleby, Kjersti; Berg, Tore Julsrud; Mdala, Ibrahimu; Buhl, Esben Selmer; Claudi, Tor & Cooper, John [Show all 9 contributors for this article] (2021). High adherence to recommended diabetes follow-up procedures by general practitioners is associated with lower estimated cardiovascular risk. Diabetic Medicine. ISSN 0742-3071. 38(8), p. 1–11. doi: 10.1111/dme.14586. Full text in Research Archive Show summary

  Aims To explore whether the general practitioners’ (GPs’) performance of recommended processes of care was associated with estimated risk of cardiovascular disease (CVD) and poor glycaemic control in patients with type 2 diabetes. Methods A cross-sectional study from Norwegian general practice including 6015 people with type 2 diabetes <75 years old, without CVD and their 275 GPs. The GPs were split into quintiles based on each GP’s average performance of six recommended processes of care. The quintiles were the exposure variable in multilevel regression models with 10-year risk of cardiovascular events estimated by NORRISK 2 (total and modifiable fraction) and poor glycaemic control (HbA1c >69 mmol/mol (>8.5%)) as outcome variables. Results The mean total and modifiable estimated 10-year CVD risk was 12.3% and 3.3%, respectively. Compared with patients of GPs in the highest-performing quintile, patients treated by GPs in the lowest quintile had an adjusted total and modifiable CVD risk that was 1.88 (95% CI 1.17–2.60) and 1.78 (1.14–2.41) percent point higher. This represents a relative mean difference of 16.6% higher total and 74.8% higher modifiable risk among patients of GPs in the lowest compared with the highest quintile. For patients with GPs in the lowest-performing quintile, the adjusted odds of poor glycaemic control was 1.77 (1.27–2.46) times higher than that for patients with a GP in the highest quintile. Conclusions We found a pattern of lower CVD risk and better glycaemic control in patients of GPs performing more recommended diabetes processes of care.

• Davidson, Emma M.; Krasuska, Marta; Jenum, Anne Karen; Gill, Jason; Beune, Erik & Stronks, Karien [Show all 9 contributors for this article] (2021). Developing a realist informed framework for cultural adaptation of lifestyle interventions for the prevention of type 2 diabetes in South Asian populations in Europe. Diabetic Medicine. ISSN 0742-3071. 38:e145484(11), p. 1–12. doi: 10.1111/dme.14584. Full text in Research Archive Show summary

  Aims Selected lifestyle interventions proven effective for White-European populations have been culturally adapted for South Asian populations living in Europe, who are at higher risk of type 2 diabetes. However, a limited theoretical basis underpins how cultural adaptations are believed to augment intervention effectiveness. We undertook a realist review to synthesise existing literature on culturally adapted type 2 diabetes prevention interventions, to develop a framework that shows ‘how’ cultural adaptation works, for ‘whom’ and in ‘what contexts’. Methods We followed the stepped methodological approach of realist review. Our work concluded a European-wide project (EuroDHYAN), and core studies were identified from the preceding EuroDHYAN reviews. Data were extracted, coded into themes and synthesised to create ‘Context–Mechanism–Outcome’ configurations and to generate a refined explanatory framework. Results We identified eight core intervention papers. From this evidence, and supporting literature, we examined the ‘Team’ domain of cultural adaptation and identified a mechanism of shared cultural identity which we theorised as contributing to strong team-participant relationships. We also identified four key contexts which influenced intervention outcomes: ‘research setting’ and ‘heterogeneous populations’ (intrinsic to the intervention) and ‘broader environment’ and ‘socio-cultural stress’ (extrinsic barriers). Conclusions This work instigates research into the mechanisms of cultural adaptation which, if pursued, will allow a more nuanced understanding of how to apply adaptations, and for whom. In practice we recommend greater consideration of heterogeneous and intersecting population characteristics; how intervention design can safeguard sustainability; and how the four key contexts identified influence how, and whether, these interventions work.

• Fragoso-Bargas, Nicolas; Opsahl, Julia Onsrud; Kiryushchenko, Nadezhda; Böttcher, Yvonne; Lee-Ødegård, Sindre & Qvigstad, Elisabeth [Show all 15 contributors for this article] (2021). Cohort profile: Epigenetics in Pregnancy (EPIPREG) – Population-based sample of European and South Asian pregnant women with epigenome-wide DNA methylation (850k) in peripheral blood leukocytes. PLOS ONE. 16(8), p. 1–15. doi: 10.1371/journal.pone.0256158. Full text in Research Archive Show summary

  Pregnancy is a valuable model to study the association between DNA methylation and several cardiometabolic traits, due to its direct potential to influence mother’s and child’s health. Epigenetics in Pregnancy (EPIPREG) is a population-based sample with the aim to study associations between DNA-methylation in pregnancy and cardiometabolic traits in South Asian and European pregnant women and their offspring. This cohort profile paper aims to present our sample with genetic and epigenetic data and invite researchers with similar cohorts to collaborative projects, such as replication of ours or their results and meta-analysis. In EPIPREG we have quantified epigenome-wide DNA methylation in maternal peripheral blood leukocytes in gestational week 28±1 in Europeans (n = 312) and South Asians (n = 168) that participated in the population-based cohort STORK Groruddalen, in Norway. DNA methylation was measured with Infinium MethylationEPIC BeadChip (850k sites), with technical validation of four CpG sites using bisulphite pyrosequencing in a subset (n = 30). The sample is well characterized with few missing data on e.g. genotype, universal screening for gestational diabetes, objectively measured physical activity, bioelectrical impedance, anthropometrics, biochemical measurements, and a biobank with maternal serum and plasma, urine, placenta tissue. In the offspring, we have repeated ultrasounds during pregnancy, cord blood, and anthropometrics up to 4 years of age. We have quantified DNA methylation in peripheral blood leukocytes in nearly all eligible women from the STORK Groruddalen study, to minimize the risk of selection bias. Genetic principal components distinctly separated Europeans and South Asian women, which fully corresponded with the self-reported ethnicity. Technical validation of 4 CpG sites from the methylation bead chip showed good agreement with bisulfite pyrosequencing. We plan to study associations between DNA methylation and cardiometabolic traits and outcomes.

• Sletner, Line; Jenum, Anne Karen; Qvigstad, Elisabeth & Hammerstad, Sara Salehi (2021). Thyroid Function during Pregnancy in A Multiethnic Population in Norway. Journal of the Endocrine Society (JES). 5(7), p. 1–12. doi: 10.1210/jendso/bvab078. Full text in Research Archive Show summary

  Abstract Context Ethnic differences in thyroid function during pregnancy have been reported. However, it is unclear if this is equally valid across ethnic groups within multiethnic populations. Objective We aimed to assess ethnic differences in thyrotropin (TSH) and free thyroxine (FT4), and the prevalence of thyroid dysfunction and thyroid autoimmunity during pregnancy. Methods In a population-based cohort of 785 pregnant women in Oslo, Norway, TSH, FT4, and thyroid peroxidase antibodies (TPO Abs) were measured twice: at gestational week (GW) 15 and 28, and urine iodine concentration at GW 15. Associations were assessed using multivariate linear regression. Results We found ethnic differences in TSH levels at both time points, but not for fT4. South Asians had 0.42 mU/L (95% CI, 0.20-0.64) higher TSH than Europeans in GW 15. This difference persisted after adjusting for covariates (including TPO Ab positivity and iodine status), and increased further as pregnancy progressed. In contrast, East Asians had the lowest TSH. No new cases of overt hypothyroidism were detected in early pregnancy, but subclinical hypothyroidism was found in 6.6% among all, highest in South Asians (14.2%). Hyperthyroidism early in pregnancy was observed in 3.7% (almost all subclinical), highest in East Asians (11.9%). The prevalence of TPO Ab positivity was 4%, highest in South Asians (8%). Conclusion In a multiethnic population of presumably healthy women, we found ethnic variations in TSH but not FT4 levels throughout pregnancy. South Asians had higher TSH and more subclinical hypothyroidism, not explained by their higher prevalence of TPO Ab positivity. Larger studies are needed to define ethnic- and trimester-specific reference ranges in pregnancy.

• Rabanal, Kjersti Stormark; Igland, Jannicke; Tell, Grethe S.; Jenum, Anne Karen; Klemsdal, Tor Ole & Ariansen, Inger [Show all 8 contributors for this article] (2020). Validation of the cardiovascular risk model NORRISK 2 in South Asians and people with diabetes. Scandinavian Cardiovascular Journal. ISSN 1401-7431. 55(1), p. 56–62. doi: 10.1080/14017431.2020.1821909. Full text in Research Archive Show summary

  Objectives To evaluate the predictive ability of the previously published NORRISK 2 cardiovascular risk model in Norwegian-born and immigrants born in South Asia living in Norway, and to add information about diabetes and ethnicity in an updated model for South Asians and diabetics (NORRISK 2-SADia). Design. We included participants (30–74 years) born in Norway (n = 13,885) or South Asia (n = 1942) from health surveys conducted in Oslo 2000–2003. Cardiovascular disease (CVD) risk factor information including self-reported diabetes was linked with information on subsequent acute myocardial infarction (AMI) and acute cerebral stroke in hospital and mortality registry data throughout 2014 from the nationwide CVDNOR project. We developed an updated model using Cox regression with diabetes and South Asian ethnicity as additional predictors. We assessed model performance by Harrell’s C and calibration plots. Results. The NORRISK 2 model underestimated the risk in South Asians in all quintiles of predicted risk. The mean predicted 13-year risk by the NORRISK 2 model was 3.9% (95% CI 3.7–4.2) versus observed 7.3% (95% CI 5.9–9.1) in South Asian men and 1.1% (95% CI 1.0–1.2) versus 2.7% (95% CI 1.7–4.2) observed risk in South Asian women. The mean predictions from the NORRISK 2-SADia model were 7.2% (95% CI 6.7–7.6) in South Asian men and 2.7% (95% CI 2.4–3.0) in South Asian women. Conclusions. The NORRISK 2-SADia model improved predictions of CVD substantially in South Asians, whose risks were underestimated by the NORRISK 2 model. The NORRISK 2-SADia model may facilitate more intense preventive measures in this high-risk population.

• Snell, Kym I.E.; Allotey, John; Smuk, Melanie; Hooper, Richard; Chan, Claire & Ahmed, Asif [Show all 60 contributors for this article] (2020). External validation of prognostic models predicting pre-eclampsia: individual participant data meta-analysis. BMC Medicine. 18, p. 1–18. doi: 10.1186/s12916-020-01766-9. Full text in Research Archive Show summary

  Background Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk during pregnancy is required to plan management. Although there are many published prediction models for pre-eclampsia, few have been validated in external data. Our objective was to externally validate published prediction models for pre-eclampsia using individual participant data (IPD) from UK studies, to evaluate whether any of the models can accurately predict the condition when used within the UK healthcare setting. Methods IPD from 11 UK cohort studies (217,415 pregnant women) within the International Prediction of Pregnancy Complications (IPPIC) pre-eclampsia network contributed to external validation of published prediction models, identified by systematic review. Cohorts that measured all predictor variables in at least one of the identified models and reported pre-eclampsia as an outcome were included for validation. We reported the model predictive performance as discrimination (C-statistic), calibration (calibration plots, calibration slope, calibration-in-the-large), and net benefit. Performance measures were estimated separately in each available study and then, where possible, combined across studies in a random-effects meta-analysis. Results Of 131 published models, 67 provided the full model equation and 24 could be validated in 11 UK cohorts. Most of the models showed modest discrimination with summary C-statistics between 0.6 and 0.7. The calibration of the predicted compared to observed risk was generally poor for most models with observed calibration slopes less than 1, indicating that predictions were generally too extreme, although confidence intervals were wide. There was large between-study heterogeneity in each model’s calibration-in-the-large, suggesting poor calibration of the predicted overall risk across populations. In a subset of models, the net benefit of using the models to inform clinical decisions appeared small and limited to probability thresholds between 5 and 7%. Conclusions The evaluated models had modest predictive performance, with key limitations such as poor calibration (likely due to overfitting in the original development datasets), substantial heterogeneity, and small net benefit across settings. The evidence to support the use of these prediction models for pre-eclampsia in clinical decision-making is limited. Any models that we could not validate should be examined in terms of their predictive performance, net benefit, and heterogeneity across multiple UK settings before consideration for use in practice.

• Nøkleby, Kjersti; Berg, Tore Julsrud; Mdala, Ibrahimu; Tran, Anh Thi; Bakke, Åsne & Gjelsvik, Bjørn E. [Show all 12 contributors for this article] (2020). Variation between general practitioners in type 2 diabetes processes of care. Primary Care Diabetes. ISSN 1751-9918. 15(3), p. 1–7. doi: 10.1016/j.pcd.2020.11.018. Full text in Research Archive Show summary

  Aims To explore variation in general practitioners’ (GPs’) performance of six recommended procedures in type 2 diabetes patients <75 years without cardiovascular disease. Methods Cross-sectional study of quality of diabetes care in Norway based on electronic health records from 2014. GPs (clustered in practices) were divided in quintiles based on a composite measure of performance of six processes of care. We fitted a multilevel partial ordinal regression model to identify GP factors associated with being in quintiles with better performance. Results We identified 6015 type 2 diabetes patients from 275 GPs in 77 practices. The GPs performed on average 63.4% of the procedures; on average 46% in the poorest quintile to 81% in the best quintile with a larger range in individual GPs. After adjustments, use of a structured follow-up form was associated with GPs being in upper three quintiles (OR 12.4 (95% CI 2.37–65.1). Routines for reminders were associated with being in a better quintile (OR 2.6 (1.37–4.92). GPs’ age >60 years and heavier workload were associated with poorer performance. Conclusion We found large variations in GPs’ performance of processes of care. Factors reflecting structure and workload were strongly associated with performance.

• Martinez-Amezcua, Pablo; Haque, Waqas; Khera, Rohan; Kanaya, Alka M.; Sattar, Naveed & Lam, Carolyn S.P. [Show all 17 contributors for this article] (2020). The upcoming epidemic of heart failure in South Asia. Circulation: Heart Failure. ISSN 1941-3289. 13:e007218(10), p. 1–15. doi: 10.1161/CIRCHEARTFAILURE.120.007218. Full text in Research Archive
• Allotey, John; Snell, Kym I.E.; Smuk, Melanie; Hooper, Richard; Chan, Claire & Ahmed, Asif [Show all 62 contributors for this article] (2020). Validation and development of models using clinical, biochemical and ultrasound markers for predicting pre-eclampsia: an individual participant data meta-analysis. Health Technology Assessment. ISSN 1366-5278. 24(72), p. 1–290. doi: 10.3310/hta24720. Full text in Research Archive Show summary

  Background: Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management. Objectives: To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers. Design: This was an individual participant data meta-analysis of cohort studies. Setting: Source data from secondary and tertiary care. Predictors: We identified predictors from systematic reviews, and prioritised for importance in an international survey. Primary outcomes: Early-onset (delivery at < 34 weeks' gestation), late-onset (delivery at ≥ 34 weeks' gestation) and any-onset pre-eclampsia. Analysis: We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I 2 and τ2. A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals. Results: The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia. Limitations: Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data. Conclusion: For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings.

• Tran, Anh Thi; Berg, Tore Julsrud; Mdala, Ibrahimu; Gjelsvik, Bjørn E.; Cooper, John & Sandberg, Sverre [Show all 8 contributors for this article] (2020). Factors associated with potential over- and undertreatment of hyperglycaemia and annual measurement of HbA<inf>1c</inf> in type 2 diabetes in norwegian general practice. Diabetic Medicine. ISSN 0742-3071. doi: 10.1111/dme.14500. Full text in Research Archive Show summary

  Aims To identify individual and general practitioner (GP) characteristics associated with potential over- and undertreatment of hyperglycaemia in type 2 diabetes and with HbA1c not being measured. Methods A cross-sectional study that included 10233 individuals with type 2 diabetes attending 282 GPs. Individuals with an HbA1c measurement during the last 15 months were categorized as potentially overtreated if they were prescribed a sulphonylurea and/or insulin when the HbA1c was less than 53 mmol/mol (7%) when aged over 75 years or less than 48 mmol/mol (6.5%) when aged between 65 and 75 years. Potential undertreatment was defined as age less than 60 years and HbA1c > 64 mmol/mol (8.0%) or HbA1c > 69 mmol/mol (8.5%) and treated with lifestyle modification and/or monotherapy. We used multilevel binary and multinominal logistic regression models to examine associations. Results Overall, 4.1% were potentially overtreated, 7.8% were potentially undertreated and 11% did not have HbA1c measured. Characteristics associated with potential overtreatment were as follows: long diabetes duration, prescribed antihypertensive medication, cardiovascular disease and renal failure. Potential undertreatment was associated with male gender, non-western origin and low educational level. Characteristics associated with not having an HbA1c measurement performed were male gender, age < 50 years and cardiovascular diseases. GP specialist status and GPs’ use of a Noklus diabetes application reduced the risk of not having an HbA1c measurement performed. Conclusion Potential overtreatment in elderly individuals with type 2 diabetes was relatively low. Nevertheless, appropriate de-intensification or intensification of treatment and regular HbA1c measurement in identified subgroups is warranted.

• Kjøllesdal, Marte Karoline Råberg; Jenum, Anne Karen; Næss, Oyvind & Sletner, Line (2020). The association between birthweight and grandparental type 2 diabetes and cardiovascular disease in a multiethnic population. Journal of Developmental Origins of Health and Disease. ISSN 2040-1744. 11(4), p. 403–409. doi: 10.1017/S2040174419000758. Full text in Research Archive
• Toftemo, Ingun; Jenum, Anne Karen & Sletner, Line (2020). Body mass index trajectories up to preschool age in a multi-ethnic population; relations with maternal gestational diabetes, BMI and gestational weight gain. Acta Paediatrica. ISSN 0803-5253. doi: 10.1111/apa.15637. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Iversen, Marjolein M.; Jenum, Anne Karen; Sørbye, Linn Marie; Vik, Eline Skirnisdottir & Schytt, Erica [Show all 8 contributors for this article] (2020). Gestational diabetes mellitus by maternal country of birth and length of residence in immigrant women in Norway. Diabetic Medicine. ISSN 0742-3071. 38(6), p. 1–10. doi: 10.1111/dme.14493. Full text in Research Archive Show summary

  Aims: Immigrant women are at higher risk for gestational diabetes mellitus (GDM) than non-immigrant women. This study described the prevalence of GDM in immigrant women by maternal country of birth and examined the associations between immigrants’ length of residence in Norway and GDM. Methods: This Norwegian national population-based study included 192,892 pregnancies to immigrant and 1,116,954 pregnancies to non-immigrant women giving birth during the period 1990–2013. Associations were reported as odds ratios (ORs) with 95% confidence intervals (CIs) using logistic regression models, adjusted for year of delivery, maternal age, marital status, health region, parity, education and income. Results: The prevalence and adjusted OR [CI] for GDM were substantially higher in immigrant women from Bangladesh (7.4%, OR 8.38 [5.41, 12.97]), Sri Lanka (6.3%, OR 7.60 [6.71, 8.60]), Pakistan (4.3%, OR 5.47 [4.90, 6.11]), India (4.4%, OR 5.18 [4.30, 6.24]) and Morocco (4.3%, OR 4.35 [3.63, 5.20]) compared to non-immigrants (prevalence 0.8%). Overall, GDM prevalence increased from 1.3% (OR 1.25 [1.14, 1.36]) to 3.3% (OR 2.55 [2.39, 2.71]) after 9 years of residence in immigrants compared to non-immigrant women. This association was particularly strong for women from South Asia. Conclusions: Gestational diabetes mellitus prevalence varied substantially between countries of maternal birth and was particularly high in immigrants from Asian countries. GDM appeared to increase with longer length of residence in certain immigrant groups.

• Slåtsve, Kristina Barbara; Claudi, Tor; Lappegård, Knut Tore; Jenum, Anne Karen; Larsen, Marthe & Cooper, John [Show all 8 contributors for this article] (2020). The total prevalence of diagnosed diabetes and the quality of diabetes care for the adult population in Salten, Norway. Scandinavian Journal of Public Health. ISSN 1403-4948. p. 1–11. doi: 10.1177/1403494820951004. Full text in Research Archive Show summary

  Objective: To assess the total prevalence of types 1 and 2 diabetes and to describe and compare cardiovascular risk factors, vascular complications and the quality of diabetes care in adults with types 1 and 2 diabetes in Salten, Norway. Research design and methods: Cross-sectional study including all patients with diagnosed diabetes in primary and specialist care in Salten, 2014 (population 80,338). Differences in cardiovascular risk factors, prevalence of vascular complications and attained treatment targets between diabetes types were assessed using regression analyses. Results: We identified 3091 cases of diabetes, giving a total prevalence in all age groups of 3.8%, 3.4% and 0.45% for types 2 and 1 diabetes, respectively. In the age group 30–89 years the prevalence of type 2 diabetes was 5.3%. Among 3027 adults aged 18 years and older with diabetes, 2713 (89.6%) had type 2 and 304 (10.0%) type 1 diabetes. The treatment target for haemoglobin A1c (⩽7.0%/53 mmol/mol) was reached in 61.1% and 22.5% of types 2 and 1 diabetes patients, respectively. After adjusting for age, sex and diabetes duration we found differences between patients with types 2 and 1 diabetes in mean haemoglobin A1c (7.1% vs. 7.5%, P<0.001), blood pressure (136/78 mmHg vs. 131/74 mmHg, P<0.001) and prevalence of coronary heart disease (23.1% vs. 15.8%, P<0.001). Conclusions: The prevalence of diagnosed type 2 diabetes was slightly lower than anticipated. Glycaemic control was not satisfactory in the majority of patients with type 1 diabetes. Coronary heart disease was more prevalent in patients with type 2 diabetes.

• Tollånes, Mette Christophersen; Jenum, Anne Karen; Berg, Tore Julsrud; Løvaas, Karianne Fjeld; Cooper, John & Sandberg, Sverre (2020). Availability and analytical quality of hemoglobin A1c point-of-care testing in general practitioners’ offices are associated with better glycemic control in type 2 diabetes. Clinical Chemistry and Laboratory Medicine. ISSN 1434-6621. 58(8), p. 1349–1356. doi: 10.1515/cclm-2020-0026. Full text in Research Archive Show summary

  Background: It is not clear if point-of-care (POC) testing for hemoglobin A1c (HbA1c) is associated with glycemic control in type 2 diabetes. Methods: In this cross-sectional study, we linked general practitioner (GP) data on 22,778 Norwegian type 2 diabetes patients to data from the Norwegian Organization for Quality Improvement of Laboratory Examinations. We used general and generalized linear mixed models to investigate if GP offices’ availability (yes/no) and analytical quality of HbA1c POC testing (average yearly “trueness score”, 0–4), as well as frequency of participation in HbA1c external quality assurance (EQA) surveys, were associated with patients’ HbA1c levels during 2014–2017. Results: Twenty-eight out of 393 GP offices (7%) did not perform HbA1c POC testing. After adjusting for confounders, their patients had on average 0.15% higher HbA1c levels (95% confidence interval (0.04–0.27) (1.7 mmol/mol [0.5–2.9]). GP offices participating in one or two yearly HbA1c EQA surveys, rather than the maximum of four, had patients with on average 0.17% higher HbA1c levels (0.06, 0.28) (1.8 mmol/mol [0.6, 3.1]). For each unit increase in the GP offices’ HbA1c POC analytical trueness score, the patients’ HbA1c levels were lower by 0.04% HbA1c (−0.09, −0.001) (−0.5 mmol/mol [−1.0, −0.01]). Conclusions: Novel use of validated patient data in combination with laboratory EQA data showed that patients consulting GPs in offices that perform HbA1c POC testing, participate in HbA1c EQA surveys, and maintain good analytical quality have lower HbA1c levels. Accurate HbA1c POC results, available during consultations, may improve diabetes care.

• Jenum, Anne Karen; Brekke, Idunn; Mdala, Ibrahimu; Muilwijk, Mirthe; Ramachandran, Ambady & Kjøllesdal, Marte Karoline Råberg [Show all 19 contributors for this article] (2019). Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials. Diabetologia. ISSN 0012-186X. 62(8), p. 1337–1348. doi: 10.1007/s00125-019-4905-2. Full text in Research Archive
• Tran, Anh Thi; Berg, Tore Julsrud; Gjelsvik, Bjørn E.; Mdala, Ibrahimu; Thue, Geir & Cooper, John [Show all 11 contributors for this article] (2019). Ethnic and gender differences in the management of type 2 diabetes: a cross-sectional study from Norwegian general practice. BMC Health Services Research. 19:903, p. 1–11. doi: 10.1186/s12913-019-4557-4. Full text in Research Archive Show summary

  Background: Ethnic minority groups from Asia and Africa living in Western countries have a higher prevalence of type 2 diabetes (T2DM) than the general population. We aimed to assess ethnic differences in diabetes care by gender. Methods: Population-based, cross-sectional study identified 10,161 individuals with T2DM cared for by 282 General Practitioners (GP) in Norway. Ethnicity was based on country of birth. Multilevel regression models adjusted for individual and GP factors were applied to evaluate ethnic differences by gender. Results: Diabetes was diagnosed at a younger mean age in all other ethnic groups compared with Westerners (men: 45.9–51.6 years vs. 56.4 years, women: 44.9–53.8 years vs. 59.1 years). Among Westerners mean age at diagnosis was 2.7 years higher in women compared with men, while no gender difference in age at diagnosis was found in any minority group. Daily smoking was most common among Eastern European, South Asian and Middle East/North African men. In both genders, we found no ethnic differences in processes of care (GPs’ measurement of HbA1c, blood pressure, LDL-cholesterol, creatinine). The proportion who achieved the HbA1c treatment target was higher in Westerners (men: 62.3%; women: 66.1%), than in ethnic minorities (men 48.2%; women 53.5%). Compared with Western men, the odds ratio (OR) for achieving the target was 0.45 (95% CI 0.27 to 0.73) in Eastern European; 0.67 (0.51 to 0.87) in South Asian and 0.62 (0.43 to 0.88) in Middle Eastern/North African men. Compared with Western women, OR was 0.49 (0.28 to 0.87) in Eastern European and 0.64 (0.47 to 0.86) South Asian women. Compared with Westerners, the blood pressure target was more often achieved in South Asians and Middle Easterners/North Africans in both genders. Small ethnic differences in achieving the LDL-cholesterol treatment target by gender were found. Conclusion: Diabetes was diagnosed at a considerably earlier age in both minority men and minority women compared with Westerners. Several minority groups had worse glycaemic control compared with Westerners in both genders, which implies that it is necessary to improve glucose lowering treatment for the minority groups. Smoking cessation advice should particularly be offered to men in most minority groups.

• Caínzos-Achirica, Miguel; Fedeli, Ugo; Sattar, Naveed; Agyemang, Charles; Jenum, Anne Karen & McEvoy, John William [Show all 15 contributors for this article] (2019). Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe. Atherosclerosis. ISSN 0021-9150. 286, p. 105–113. doi: 10.1016/j.atherosclerosis.2019.05.014. Full text in Research Archive
• Kinnunen, Tarja I.; Richardsen, Kåre Rønn; Sletner, Line; Torgersen, Leila; Sommer, Christine & Waage, Christin Wiegels [Show all 8 contributors for this article] (2019). Ethnic differences in body mass index trajectories from 18 years to postpartum in a population-based cohort of pregnant women in Norway. BMJ Open. 9(2). doi: 10.1136/bmjopen-2018-022640. Full text in Research Archive Show summary

  Objectives: To explore ethnic differences in changes in body mass index (BMI) from the age of 18 years to 3 months postpartum. Design: A population-based cohort study. Setting: Child Health Clinics in Oslo, Norway. Participants: Participants were 811 pregnant women (mean age 30 years). Ethnicity was categorised into six groups. Primary outcome measures: The outcome variable was BMI (kg/m2) measured at the age of 18 and 25 years, at prepregnancy and at 3 months postpartum. Body weight at 18 years, 25 years and prepregnancy were self-reported in early pregnancy, while body height and weight at 3 months postpartum were measured. The main statistical method was generalised estimating equations, adjusted for age. The analyses were stratified by parity due to ethnicity×time×parity interaction (p<0.001). Results: Primiparous South Asian women had a 1.45 (95% CI 0.39 to 2.52) kg/m² higher and Middle Eastern women had 1.43 (0.16 to 2.70) kg/m2 higher mean BMI increase from 18 years to postpartum than Western European women. Among multiparous women, the mean BMI increased 1.99 (1.02 to 2.95) kg/m2 more in South Asian women, 1.48 (0.31 to 2.64) kg/m2 more in Middle Eastern women and 2.49 (0.55 to 4.42) kg/m2 more in African women than in Western European women from 18 years to prepregnancy. From 18 years to postpartum, the mean increase was 4.40 (2.38 to 6.42) kg/m2 higher in African women and 1.94 to 2.78 kg/m2 higher in the other groups than in Western European women. Conclusions: Multiparous women of ethnic minority origin seem substantially more prone to long-term weight gain than multiparous Western European women in Norway.

• Næss-Andresen, Marthe-Lise; Eggemoen, Åse Ruth; Berg, Jens Petter; Falk, Ragnhild Sørum & Jenum, Anne Karen (2019). Serum ferritin, soluble transferrin receptor, and total body iron for the detection of iron deficiency in early pregnancy: A multiethnic population-based study with low use of iron supplements. American Journal of Clinical Nutrition. ISSN 0002-9165. 109(3), p. 566–575. doi: 10.1093/ajcn/nqy366. Full text in Research Archive Show summary

  Which blood-based indicator best reflects the iron status in pregnant women is unclear. Better assessments of iron status in today's multiethnic populations are needed to optimize treatment and clinical recommendations.We aimed to determine the prevalence of anemia (hemoglobin &lt;11.0 g/dL in first and &lt;10.5 g/dL in second trimester) and iron deficiency (ID) by the iron indicators serum ferritin &lt;15 µg/L, serum soluble transferrin receptor (sTfR) &gt;4.4 mg/L, and calculated total body iron &lt;0 mg/kg, and their associations with ethnicity.This was a population-based cross-sectional study from primary antenatal care of 792 healthy women in early pregnancy in Oslo, Norway. We categorized the women into 6 ethnic groups: Western European, South Asian, Middle Eastern, Sub-Saharan African, East Asian, and Eastern European.Anemia was found in 5.9% of women (Western Europeans: 1.8%; non-Western: 0–14%, P &lt; 0.05). ID from ferritin was found in 33% (Western Europeans: 15%; non-Western: 27–55%, P &lt; 0.05). ID from sTfR was found in 6.5% (Western Europeans: 0.3%; non-Western: 0–20%, P &lt; 0.01). Calculated total body iron indicated ID in 11% (Western Europeans: 0.6%, non-Western: 7.0–28%, P &lt; 0.01). The prevalence of ID was significantly higher by all measures in South Asian, Sub-Saharan African, and Middle Eastern than in Western European women, and the ethnic differences persisted after adjusting for confounders. South Asians, Sub-Saharan Africans, and Middle Easterners had lower iron concentrations by all measures for all hemoglobin intervals. Anemia related to ID varied from 35% (sTfR) to 46% (total body iron) and 72% (ferritin) depending on the iron indicator used.Women at the highest risk of ID and anemia were of South Asian, Middle Eastern, and Sub-Saharan African origin. The prevalence of ID differed considerably depending on the iron indicator used.

• Gjelsvik, Bjørn E.; Tran, Anh Thi; Berg, Tore Julsrud; Bakke, Åsne; Mdala, Ibrahimu & Nøkleby, Kjersti [Show all 12 contributors for this article] (2019). Exploring the relationship between coronary heart disease and type 2 diabetes: a cross-sectional study of secondary prevention among diabetes patients. British Journal of General Practice Open. doi: 10.3399/bjgpopen18X101636. Full text in Research Archive Show summary

  Background: Coronary heart disease (CHD) and stroke are the major causes of death among people with diabetes. Aim: To describe the prevalence and onset of CHD and stroke among patients with type 2 diabetes mellitus (T2DM) in primary care in Norway, and explore the quality of secondary prevention. Design & setting: A cross-sectional study of data was undertaken from electronic medical records (EMRs) of 10 255 patients with T2DM in general practice. The study took place in five counties of Norway (Oslo, Akershus, Rogaland, Hordaland, and Nordland). Quality of care was assessed based on national guideline recommendations. Method: Summary statistics with adjustments and binary logistic regression models were used. Results: In total, 2260 patients (22.1%) had CHD and 759 (7.4%) had stroke. South Asians had significantly more CHD than ethnic Norwegians (29.5%, 95% confidence interval [CI] = 26.1 to 33.0 versus 21.5%, CI = 20.6 to 22.3) and other ethnic groups, and experienced onset of CHD or stroke at a mean of 7 years before Norwegians. In 47.9% of the patients, CHD was diagnosed before T2DM. Treatment target for low-density lipoprotein (LDL) cholesterol was reached for 30.0% and for systolic blood pressure (SBP) for 65.1% of the patients with CHD. Further, 20.9% of patients with CHD were present smokers, and only 5.0% of patients reached all four treatment targets (no smoking, HbA1c ≤7.0%, SBP <135 mmHg, LDL-cholesterol <1.8 mmol/l). Conclusion: The diagnosis of CHD preceded the diagnosis of T2DM in half of the patients. The prevalence of CHD was highest and onset earlier among ethnic South Asians. More intensive treatment of lipids, blood pressure, and smoking are needed in patients with T2DM and CHD.

• Bakke, Åsne; Dalen, Ingvild; Thue, Geir; Cooper, John; Skeie, Svein & Berg, Tore Julsrud [Show all 10 contributors for this article] (2019). Variation in the achievement of HbA1c, blood pressure and LDL cholesterol targets in type 2 diabetes in general practice and characteristics associated with risk factor control. Diabetic Medicine. ISSN 0742-3071. p. 1–11. doi: 10.1111/dme.14159. Full text in Research Archive Show summary

  Aims To identify population, general practitioner, and practice characteristics associated with the achievement of HbA1c, blood pressure and LDL cholesterol targets, and to describe variation in the achievement of risk factor control. Methods We conducted a cross‐sectional survey of 9342 people with type 2 diabetes, 281 general practitioners and 77 general practices in Norway. Missing values (7.4%) were imputed using multiple imputation by chained equations. We used three‐level logistic regression with the achievement of HbA1c, blood pressure and LDL cholesterol targets as dependent variables, and factors related to population, general practitioners, and practices as independent variables. Results Treatment targets were achieved for HbA1c in 64%, blood pressure in 50%, and LDL cholesterol in 52% of people with type 2 diabetes, and 17% met all three targets. There was substantial heterogeneity in target achievement among general practitioners and among practices; the estimated proportion of a GPs diabetes population at target was 55–73% (10–90 percentiles) for HbA1c, 36–63% for blood pressure, and 47–57% for LDL cholesterol targets. The models explained 11%, 5% and 14%, respectively, of the total variation in the achievement of HbA1c, blood pressure and LDL cholesterol targets. Use among general practitioners of a structured diabetes form was associated with 23% higher odds of achieving the HbA1c target (odds ratio 1.23, 95% confidence interval (CI) 1.02–1.47) and 17% higher odds of achieving the LDL cholesterol target (odds ratio 1.17, 95% CI 1.01–1.35). Conclusions Clinical diabetes management is difficult, and few people meet all three risk factor control targets. The proportion of people reaching target varied among general practitioners and practices. Several population, general practitioner and practice characteristics only explained a small part of the total variation. The use of a structured diabetes form is recommended.

• Abuelmagd, Walaa Metwally Ali Abdalaah; Osman, Bavi Botan; Håkonsen, Helle; Jenum, Anne Karen & Toverud, Else-Lydia (2019). Experiences of Kurdish immigrants with the management of type 2 diabetes: a qualitative study from Norway. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 37(3), p. 345–352. doi: 10.1080/02813432.2019.1639911. Full text in Research Archive Show summary

  Objective: To explore the experiences of immigrant Kurdish patients in Oslo, Norway, related to the management of type 2 diabetes mellitus (T2DM). Design: A qualitative study with focus group interviews. Setting: Participants were recruited at meeting places in Oslo through Kurdish networks. Subjects: Eighteen Kurdish immigrants (9 females and 9 males) living in Oslo, aged 40 to 64 years, diagnosed with T2DM participated in a total of five focus groups. Participants had to be proficient in the Norwegian language to be eligible. Main outcome measures: Immigrant Kurdish patients’ experiences with being diagnosed with T2DM, their disease management, and need for medical information. Results: Participants stressed that living with T2DM was emotionally challenging, mainly because they were afraid of possible complications of the disease. They claimed to adhere satisfactorily to their medicines and blood glucose measurements. The majority of participants shared that they had made changes to their diet, even though it was difficult. To the contrary, physical activity received only minimal attention. The participants’ main source of information was general practitioners and the majority of them were satisfied with the information that they had received about their disease and its management. Conclusion: Kurdish T2DM patients in the present study from Norway reported that they adhered to the medical treatment, even if they were stressed about living with the disease. However, they were more occupied with changing their diet than to be physically active. Therefore, healthcare personnel should try to be aware of lifestyle challenges among their patients.

• Brekke, Idunn; Richardsen, Kåre Rønn & Jenum, Anne Karen (2019). Sickness absence in pregnancy: associations with sedentary behavior. A population-based cohort study from Norway. BMC Public Health. 19(1). doi: 10.1186/s12889-018-6379-4. Full text in Research Archive Show summary

  Background Sickness absence in pregnancy accounts for a large part of sickness-related absenteeism among women. Exercise in pregnancy is associated with a lower level of sickness absence, however little is known about how sedentary behaviour is related to sickness absence in pregnancy. In the current study, we hypothesize a positive association between sedentary hours/day and the risk of long-term sickness absence. Methods Population-based cohort study of pregnant women attending three Child Health Clinics in Groruddalen, Oslo, 823 Women (74% of those eligible) were included between 2008 and 2010. Questionnaire data were collected at gestational weeks 10–20 (visit 1) and 28 (visit 2). Sedentary time and physical activity were objectively recorded at visit 1 with the multi-sensor SenseWear™ Pro3 Armband (SWA). Long-term sickness absence was self-reported at visit 2. We explored the association between sedentary time and long-term sickness absence in pregnancy using multiple logistic regression analysis. Results The odds of long-term sickness absence was significantly increased per one-hour increase in daily sedentary time (odds ratio 1.45 [95% confidence interval 1.13–1.84]), providing support for our hypothesis that sedentary time is positively associated with long-term sickness absence. Conclusions Pregnant women with a sedentary lifestyle have a higher risk of long-term sickness absence from work. Reducing sedentary time in pregnancy may improve health, and may, in turn reduce sickness absence in pregnancy.

• Arora, G. P.; Åkerlund, M.; Bruns, C; Moen, Gunn-Helen; Wasenius, N. S. & Sommer, Christine [Show all 17 contributors for this article] (2019). Phenotypic and genotypic differences between Indian and Scandinavian women with gestational diabetes mellitus. Journal of Internal Medicine. ISSN 0954-6820. doi: 10.1111/joim.12903. Full text in Research Archive
• Torbjørnsen, Astrid; Småstuen, Milada C; Jenum, Anne Karen; Årsand, Eirik & Ribu, Lis (2018). The Service User Technology Acceptability Questionnaire: Psychometric Evaluation of the Norwegian Version. JMIR Human Factors. 5(4). doi: 10.2196/10255. Full text in Research Archive Show summary

  <p><i>Background</i>: When developing a mobile health app, users’ perception of the technology should preferably be evaluated. However, few standardized and validated questionnaires measuring acceptability are available.</p> <p><i>Objective</i>: The aim of this study was to assess the validity of the Norwegian version of the Service User Technology Acceptability Questionnaire (SUTAQ).</p> <p><i>Methods</i>: Persons with type 2 diabetes randomized to the intervention groups of the RENEWING HEALTH study used a diabetes diary app. At the one-year follow-up, participants in the intervention groups (n=75) completed the self-reported instrument SUTAQ to measure the acceptability of the equipment. We conducted confirmatory factor analysis for evaluating the fit of the original five-factor structure of the SUTAQ.</p> <p><i>Results</i>: We confirmed only 2 of the original 5 factors of the SUTAQ, perceived benefit and care personnel concerns.</p> <p><i>Conclusions</i>: The original five-factor structure of the SUTAQ was not confirmed in the Norwegian study, indicating that more research is needed to tailor the questionnaire to better reflect the Norwegian setting. However, a small sample size prevented us from drawing firm conclusions about the translated questionnaire.</p>

• Toftemo, Ingun; Jenum, Anne Karen; Lagerløv, Per; Juliusson, Petur Benedikt; Falk, Ragnhild Sørum & Sletner, Line (2018). Contrasting patterns of overweight and thinness among preschool children of different ethnic groups in Norway, and relations with maternal and early life factors. BMC Public Health. 18:1056, p. 1–10. doi: 10.1186/s12889-018-5952-1. Full text in Research Archive Show summary

  Background: Childhood obesity is a worldwide health challenge and risk factor for adult life obesity, which predisposes to development of type 2 diabetes and cardiovascular diseases. However, also thinness in early life has been related to these diseases, especially if followed by fat gain. In European countries, susceptibility to cardio-metabolic diseases varies considerably between ethnic groups. We investigated ethnic differences in overweight and thinness in a multi-ethnic, population-based cohort of preschool children in Norway, and associations with maternal and early postnatal factors. Methods: Participants were children aged 4–5 years (n = 570) drawn from the population-based STORK Groruddalen cohort of healthy women and offspring followed from early pregnancy. Ethnic groups were: European (n = 298), South Asian (n = 154), and Middle East/North African (n = 118). Children’s growth data were provided from routine visits at local Child Health Clinics. Weight status was defined by the International Obesity Task Force. Using multinomial logistic regression analysis, we explored ethnic differences in overweight and thinness, and associations with maternal-, pre, − and postnatal factors. Results: Children of Middle East/North African origin had higher prevalence of overweight (22.0%) compared to European (12.8%) children, and in adjusted logistic regression analysis almost the double risk (OR 1.98; 95%CI: 1.08–3.63). Prevalence was lower in children of South Asian origin (5.2%). Children with South Asian background had higher prevalence of thinness (26.0%) compared to ethnic Europeans (10.4%), and the double risk (OR 2.20; 95%CI: 1.25–3.87) in adjusted models. Applying newly suggested BMI adjustments in South Asian children, taking into account their relatively increased adiposity, markedly increased the prevalence of overweight, and decreased the prevalence of thinness in this subgroup. Birthweight and maternal prepregnant overweight were strongly, positively associated with overweight, and inversely associated with thinness. Lower maternal age was associated with overweight only. Conclusions: In a multi-ethnic cohort we found strikingly different patterns of overweight and thinness among children of different ethnic groups at age 4–5 years, and a strong association between maternal BMI and their children’s weight status. More knowledge is needed on what characterizes and what promotes healthy growth patterns in multi-ethnic populations.

• Torbjørnsen, Astrid; Småstuen, Milada Cvancarova; Jenum, Anne Karen; Årsand, Eirik & Ribu, Lis (2018). Acceptability of an mHealth app intervention for persons with type 2 diabetes and its associations with initial self-management: Randomized controlled trial. Journal of Medical Internet Research (JMIR). ISSN 1439-4456. 6(5). doi: 10.2196/mhealth.8824. Full text in Research Archive Show summary

  <p><i>Background</i>: Mobile health interventions are increasingly used in health care. The level of acceptability may indicate whether and how such digital solutions will be used.</p> <p><i>Objective</i>: This study aimed to explore associations between the level of acceptability of a mobile diabetes app and initial ability of self-management for patients with type 2 diabetes.</p> <p><i>Methods</i>: Participants with type 2 diabetes were recruited from primary health care settings to a 3-armed randomized controlled trial in the Norwegian study in the RENEWING HEALTH project. At the 1-year follow-up, 75 out of 101 participants from the intervention groups completed an acceptability questionnaire (The Service User Technology Acceptability Questionnaire). In the randomized controlled trial, the 2 intervention groups (n=101 in total) received a mobile phone with a diabetes diary app, and one of the groups received additional health counseling given by telephone calls from a diabetes specialist nurse (n=50). At baseline, we collected clinical variables from medical records, whereas demographic data and self-management (The Health Education Impact Questionnaire) measures were self-reported. Log data from the use of the app by self-monitoring were registered continuously. Associations between initial ability to self-manage at baseline and acceptability of the diabetes diary app after 1 year were analyzed using linear regression.</p> <p><i>Results</i>: We found statistically significant associations between 5 of the 8 self-management domains and perceived benefit, one of the acceptability factors. However, when adjusting for age, gender, and frequency of use, only 1 domain, skill and technique acquisition, remained independently associated with perceived benefit. Frequency of use of the app was the factor that revealed the strongest association with the acceptability domain perceived benefit.</p> <p><i>Conclusions</i>: Our findings indicate that persons with diabetes may accept the app, despite its perceived benefit being associated with only one of the 8 domains of their initial level of self-management.</p> <p><i>Trial Registration</i>: ClinicalTrials.gov NCT01315756; https://clinicaltrials.gov/show/NCT01315756 (Archived by WebCite at http://www.webcitation.org/6z46qPhWl)</p>

• Shakeel, Nilam; Richardsen, Kåre Rønn; Martinsen, Egil Wilhelm; Eberhard-Gran, Malin; Slinning, Kari & Jenum, Anne Karen (2018). Physical activity in pregnancy and postpartum depressive symptoms in a multiethnic cohort. Journal of Affective Disorders. ISSN 0165-0327. 236, p. 93–100. doi: 10.1016/j.jad.2018.04.081. Full text in Research Archive Show summary

  Introduction: There is strong evidence that postpartum depression is associated with adverse health effects in the mother and infant. Few studies have explored associations between physical activity in pregnancy and postpartum depression. We aimed to investigate whether physical activity during pregnancy was inversely associated with postpartum depressive symptoms, PPDS in a multiethnic sample. Method: Population-based, prospective cohort of 643 pregnant women (58 % ethnic minorities) attending primary antenatal care from early pregnancy to postpartum in Oslo between 2008 and 2010. Data on demographics and health outcomes were collected during standardized interviews. PPDS was defined by a sum score ≥10 from the Edinburgh Postnatal Depression Scale (EPDS), 3 months after birth. Physical activity was recorded with Sense Wear™ Pro3 Armband (SWA) in gestational week 28 and defined as moderate-to- vigorous intensity physical activity (MVPA) accumulated in bouts ≥10 minutes. Results: Women who accumulated ≥150 MVPA minutes/week had significantly lower risk (OR=0.2, 95%CI: 0.06-0.90), for PPDS compared to those who did not accumulate any minutes/week of MVPA, adjusted for ethnic minority background, depressive symptoms in index pregnancy in the index pregnancy and self-reported pelvic girdle syndrome. The results for MVPA persisted in the sub-sample of ethnic minority women. Limitations: Numbers of cases with PPDS were limited. The SWA does not measure water activities. Due to missing data for SWA we used multiple imputations. Conclusion: Women meeting the physical activity recommendation (>150 MVPA min/week) during pregnancy have a lower risk of PPDS compared to women who are not active during pregnancy.

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• Iversen, Tor; Snilsberg, Øyvind; Jenum, Anne Karen & Zhang, Yuting (2025). Continuity and switching in primary care. Full text in Research Archive Show summary

  This paper investigates the dual impact of continuity and discontinuity in patient-GP relationships on quality related healthcare services, focusing on patients with Type 2 Diabetes (T2D) in Norway. It challenges the traditional dichotomy in the literature by exploring the apparent contradiction that both continuity and switching GPs can improve healthcare outcomes. The research utilizes a comprehensive dataset, encompassing all Norwegian T2D patients from 2018 to 2023, to examine the outcomes of recommended services by GPs. The study's primary contribution is its simultaneous analysis of both continuity and switching using consistent data and subjects. The medical literature finds that continuity is beneficial in primary care, enhancing diagnostic accuracy, treatment quality and patient satisfaction. The study affirms this, revealing significant benefits in healthcare service provision, particularly for eye exams after 4-5 years with the same GP, and other services after 15 years. The results manifest the positive correlation between longer patient-GP relationships and the probability of receiving recommended services. The analysis also reveals that switching GPs can yield advantages when a new GP offers a higher quality of care. For patients who after forced discontinuity, are switched to GPs with superior practice styles, the likelihood of receiving recommended services, such as annual checkups, increases significantly. This result supports the hypothesis of potential health gains from a GP switch, presenting a nuanced trade-off between continuity and improvement through switching. The paper breaks new ground by demonstrating these trade-offs analytically, showing that continuity and the quality of GP practice styles both significantly impact healthcare outcomes. It emphasizes that an additional year with the same GP enhances service likelihoods while switching to a higher-performing GP can surpass this continuity benefit. Robustness checks support the findings of positive effects of both continuity and switching. The study addresses a notable gap by integrating both continuity and switching dynamics into a unified framework, thus stimulating a more balanced view on GP-patient relationships in primary care.

• Iversen, Tor; Snilsberg, Øyvind; Jenum, Anne Karen & Zhang, Yuting (2025). Continuity and switching in primary care. Full text in Research Archive Show summary

  This paper investigates the dual impact of continuity and discontinuity in patient-GP relationships on quality related healthcare services, focusing on patients with Type 2 Diabetes (T2D) in Norway. It challenges the traditional dichotomy in the literature by exploring the apparent contradiction that both continuity and switching GPs can improve healthcare outcomes. The research utilizes a comprehensive dataset, encompassing all Norwegian T2D patients from 2018 to 2023, to examine the outcomes of recommended services by GPs. The study's primary contribution is its simultaneous analysis of both continuity and switching using consistent data and subjects. The medical literature finds that continuity is beneficial in primary care, enhancing diagnostic accuracy, treatment quality and patient satisfaction. The study affirms this, revealing significant benefits in healthcare service provision, particularly for eye exams after 4-5 years with the same GP, and other services after 15 years. The results manifest the positive correlation between longer patient-GP relationships and the probability of receiving recommended services. The analysis also reveals that switching GPs can yield advantages when a new GP offers a higher quality of care. For patients who after forced discontinuity, are switched to GPs with superior practice styles, the likelihood of receiving recommended services, such as annual checkups, increases significantly. This result supports the hypothesis of potential health gains from a GP switch, presenting a nuanced trade-off between continuity and improvement through switching. The paper breaks new ground by demonstrating these trade-offs analytically, showing that continuity and the quality of GP practice styles both significantly impact healthcare outcomes. It emphasizes that an additional year with the same GP enhances service likelihoods while switching to a higher-performing GP can surpass this continuity benefit. Robustness checks support the findings of positive effects of both continuity and switching. The study addresses a notable gap by integrating both continuity and switching dynamics into a unified framework, thus stimulating a more balanced view on GP-patient relationships in primary care.

• Snilsberg, Øyvind; Iversen, Tor; Jenum, Anne Karen & Zhang, Yuting (2025). Kontinuitet og diskontinuitet i fastlegeordningen. Full text in Research Archive Show summary

  Bakgrunn Flere norske undersøkelser viser at kontinuitet i forholdet mellom pasient og fastlege har stor betydning for oppfølging og helseutfall blant pasientene. Vi er ikke kjent med undersøkelser som både undersøker effekten av kontinuitet og diskontinuitet i form av bytte til ny fastlege Formål Vår hypotese er at kontinuitet er positivt for oppfølging og helseutfall. Samtidig kan også diskontinuitet være positivt hvis byttet av fastlege skjer til en fastlege som er bedre enn den forrige. I studien undersøker vi hvordan kontinuitet og diskontinuitet i pasient-fastlege-forholdet påvirker om fastlegen utfører anbefalte helsetjenester til pasienter med type 2-diabetes (T2D) i Norge. Metode Ved hjelp av norske landsomfattende registerdata på individnivå fra 2018 til 2023 analyserer vi hvordan kontinuitet påvirker hvorvidt en pasient med T2D mottar anbefalte tjenester som HbA1c-tester og årskontroll. Vi undersøker også hvordan bytte til en fastlege som i større grad leverer anbefalte tjenester, påvirker om pasienten selv mottar disse tjenestene. Diskontinuitet i våre data oppstår ved at fastlegen slutter som fastlege, for eksempel ved å pensjonere seg. Diskontinuiteten er dermed eksogen for pasienten. Resultat Vi finner at flere år med samme fastlege er assosiert med høyere sannsynlighet for å motta anbefalte tjenester, særlig etter mer enn ti år. Videre finner vi at bytte til en fastlege som oftere leverer anbefalte tjenester, medfører en betydelig økning i sannsynligheten for å motta disse tjenestene. Samlet sett antyder resultatene at både kontinuitet og fastlegens egenskaper er avgjørende for om en pasient med T2D får anbefalte tjenester. Konklusjon Mens politiske tiltak ofte vektlegger kontinuitet, tyder våre funn på at bytte også kan være fordelaktig når det innebærer en overgang til en bedre fastlege. Dette understreker viktigheten av å gjøre kvalitetsinformasjon på tvers av fastleger transparent

• Strandberg, Ragnhild Bjarkøy; Nilsen, Roy Miodini; Pouwer, Francois; Igland, Jannicke; Røssberg, Jan Ivar & Jenum, Anne Karen [Show all 8 contributors for this article] (2025). Associations of diabetes duration with depression, anxiety and insomnia in people with type 2 diabetes mellitus. Full text in Research Archive
• Bargas, Nicolas Fragoso; Mcbride, Nancy S.; Lee-Ødegård, Sindre; Lawlor, Deborah A.; Yousefi, Paul D. & Moen, Gunn-Helen [Show all 14 contributors for this article] (2025). Correction to: Epigenome-wide association study of objectively measured physical activity in peripheral blood leukocytes (BMC Genomics, (2025), 26, 1, (62), 10.1186/s12864-025-11262-0). BMC Genomics. 26(1). doi: 10.1186/s12864-025-11311-8. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Nilsen, Roy Miodini; Pouwer, Francois; Igland, Jannicke; Røssberg, Jan Ivar & Jenum, Anne Karen [Show all 8 contributors for this article] (2024). Associations of diabetes duration with anxiety, depression, and insomnia in people with type 2 diabetes. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Nilsen, Roy Miodini; Pouwer, Francois; Igland, Jannicke; Forster, Rachel Bedenis & Jenum, Anne Karen [Show all 8 contributors for this article] (2024). Associations of immigrant background and diabetes start course participation in individuals with type 2 diabetes in Norway – a study from the OMIT-cohort. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Iversen, Marjolein M.; Jenum, Anne Karen; Sørbye, Linn Marie; Vik, Eline Skirnisdottir & Aasheim, Vigdis [Show all 7 contributors for this article] (2024). Gestational diabetes mellitus by maternal country of birth in immigrant women. Full text in Research Archive
• Waage, Christin; Toftemo, Ingun; Brænd, Anja Maria; Sletner, Line; Sommer, Christine & Birkeland, Kåre Inge [Show all 10 contributors for this article] (2023). 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. BMJ Open. 13(10), p. 1–11. doi: 10.1136/bmjopen-2023-076251. Full text in Research Archive Show summary

  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/m 2 (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/m 2 (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.

• Buhl, Esben Selmer; Igland, Jannicke; Forster, Rachel Bedenis; Jenum, Anne Karen; Strandberg, Ragnhild Bjarkøy & Berg, Tore Julsrud [Show all 8 contributors for this article] (2023). Prediction of mortality and validation of the ATC-code based Rx-risk comorbidity index in the “Outcomes & Multi-Morbidity In Type 2 diabetes” (OMIT) cohort. Full text in Research Archive
• Tibballs, Katrina Louise Bø; Kirkebøen, Lars Johannessen; Jenum, Anne Karen; Straand, Jørund & Buhl, Esben Selmer (2023). EDUCATION LEVEL AND COUNTRY BACKGROUND IN YOUNG-ONSET TYPE 2 DIABETES. Full text in Research Archive Show summary

  EDUCATION LEVEL AND COUNTRY BACKGROUND IN YOUNG-ONSET TYPE 2 DIABETES Background Type 2 diabetes (T2D) is associated with socioeconomic status and country background, but knowledge about the influence of these factors in young-onset T2D (YOD) is sparce. We aimed to examine the risk of YOD according to education level and country background. Methods Cross-sectional data from 2014 on 10241 individuals with T2D from Norwegian general practices (ROSA 4 study) were linked to data from Statistics Norway on country background and education level. Using separate data for the population of Norway, ROSA 4 individuals were compared with individuals matched for age, sex and residential area. Poisson regression analyses of T2D risk by country background and education compared YOD (diagnosis before age 40) with later onset T2D. Results In ROSA 4, 10% had YOD. Of these, 39% had non-Western background (22% South Asians) vs. 20% in the matched population. Among South Asians 29% of T2D was diagnosed before age 40 vs 7% of those with Norwegian background. Compulsory education was the highest education level in 36% in ROSA 4 vs 26% in the matched population. In YOD, these shares were 41% and 21%. T2D risk was increased in non-Western background compared to Norwegian background, particularly in South Asians (Incidence rate ratio, IRR 4.2 (4.0-4.5)). The risk was doubled in YOD (IRR 8.9 (8.0-9.8)). T2D risk was increased in individuals with lower education levels and the effect was larger in YOD (see table). There was an interaction between education level and country background in their association with YOD risk, individuals with Norwegian background, but not to South Asians, with low education having increased risk. Conclusion Non-Western background is associated with increased risk of T2D onset at a younger age. South Asians have particularly high risk. Low education is a risk factor for young-onset T2D in Norwegians, but not in South Asian immigrants.

• Waage, Christin; Mdala, Ibrahimu; Brænd, Anja Maria; Jenum, Anne Karen & Birkeland, Kåre Inge (2023). Prediabetes and diabetes 11 years after pregnancy in ethnic minority groups with and without gestational diabetes. Full text in Research Archive
• Bargas, Nicolas Fragoso; Linares-Pineda, Teresa; Molina-Vega, María; Picón, María José; Jenum, Anne Karen & Sletner, Line [Show all 14 contributors for this article] (2023). Methylation risk score for gestational diabetes on DNA methylation patterns associated with type 2 diabetes. Full text in Research Archive
• Tibballs, Katrina Louise Bø; Kirkebøen, Lars Johannessen; Jenum, Anne Karen; Straand, Jørund & Buhl, Esben Selmer (2023). Country background, education level, employment and disability in young-onset type 2 diabetes. Full text in Research Archive Show summary

  Country background, education level, employment and disability in young-onset type 2 diabetes Background and Aims Young-onset type 2 diabetes (YOD – diagnosis before age 40) entails high disease burden and is mainly managed in general practice. Knowledge of how socioeconomic status and country background impact YOD risk is sparce. We aimed to study effects of education level and country background on YOD risk and effects of YOD on employment and disability. Materials and Methods Cross-sectional data on 10241 individuals with type 2 diabetes (T2D) from Norwegian general practices (ROSA 4 study, 2014), linked to data on country background, education level, disability benefits and employment, were compared with population data matched for age, sex and residential area. Using negative binomial regression and adjusting for age and sex, we analyzed YOD risk by country background and education level, and the effects of YOD on risk of disability and labour market absence. Results T2D risk was increased in non-Western compared to Norwegian background. South Asians exhibited the greatest risk increase, five-fold for T2D (adjusted incidence rate ratio, aIRR 4.7 (4.3-5.2)) and nine-fold for YOD (aIRR 8.9 (7.3-11.0)). T2D risk in low education was almost double that in high education, with YOD risk significantly higher than for later onset T2D (see table). There was significant interaction between low education and country background, with only Westerners exhibiting a substantially increased risk of YOD (aIRR 3.2 (2.4-4.4)). Disability risk was doubled in T2D (aIRR 2.2 (2.0-2.3) and three-fold higher in YOD (aIRR 3.1 (2.7-3.5) than in the population. Workforce participation was only reduced in T2D diagnosed before age 50. Conclusion Non-Western, particularly South Asian background and low education was associated with increased risk of YOD. Low education was an important YOD risk factor only for Westerners. Risk of disability and labour market absence was significantly higher in YOD than in later onset T2D and in the general population.

• Bennetter, Karin Elisabeth; Waage, Christin; Richardsen, Kåre Rønn; Jenum, Anne Karen; Vøllestad, Nina Køpke & Robinson, Hilde Stendal [Show all 7 contributors for this article] (2022). Associations between social support and physical activity among postpartum women: a cohort study. Full text in Research Archive
• Stalheim, Astrid M.; Iversen, Marjolein M.; Jenum, Anne Karen; Sletner, Line; Stafne, Signe Nilssen & Qvigstad, Elisabeth [Show all 10 contributors for this article] (2022). Seasonal variation in gestational diabetes mellitus. Full text in Research Archive
• Bennetter, Karin Elisabeth; Waage, Christin; Richardsen, Kåre Rønn; Jenum, Anne Karen & Robinson, Hilde Stendal (2022). Moderate-to-vigorous physical activity level 11 years postpartum in a multiethnic sample. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Nilsen, Roy Miodini; Pouwer, Francois; Igland, Jannicke; Forster, Rachel Bedenis & Jenum, Anne Karen [Show all 8 contributors for this article] (2022). Participation in diabetes educational programs in adults with type 2 diabetes in Norway: whom are we reaching? Full text in Research Archive
• Igland, Jannicke; Forster, Rachel Bedenis; Jenum, Anne Karen; Strandberg, Ragnhild Bjarkøy; Berg, Tore Julsrud & Røssberg, Jan Ivar [Show all 8 contributors for this article] (2022). The validity of the Rx-risk comorbidity index among adults in the Outcomes & Multimorbidity in Type 2 diabetes cohort (OMIT). Full text in Research Archive
• Waage, Christin; Richardsen, Kåre Rønn; Jenum, Anne Karen; Vøllestad, Nina Køpke & Robinson, Hilde Stendal (2022). Associations between social support and physical activity among postpartum women: a cohort study. European Journal of Public Health. ISSN 1101-1262. doi: 10.1093/eurpub/ckac131.440. Full text in Research Archive
• Robinson, Hilde Stendal; Waage, Christin Wiegels; Vøllestad, Nina Køpke; Jenum, Anne Karen; Mdala, Ibrahimu & Richardsen, Kåre Rønn (2022). Associations between social support and physical activity among postpartum women: a cohort study. Full text in Research Archive
• Toftemo, Ingun; Jenum, Anne Karen; Sletner, Line; Richardsen, Kåre Rønn & Brænd, Anja Maria (2022). Does exposure to gestational diabetes cause obesity in pre-pubertal children? Full text in Research Archive
• Mdala, Ibrahimu; Richardsen, Kåre Rønn; Vøllestad, Nina Køpke; Jenum, Anne Karen; Robinson, Hilde Stendal & Waage, Christin Wiegels (2022). Moderate-to-vigorous physical activity level 11 years postpartum in a multi-ethnic sample. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Iversen, Marjolein M.; Jenum, Anne Karen; Sørbye, Linn Marie; Vik, Eline Skirnisdottir & Schytt, Erica [Show all 8 contributors for this article] (2022). Gestational diabetes and maternal country of birth. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Nilsen, Roy Miodini; Pouwer, Frans; Igland, Jannicke; Forster, Rachel Bedenis & Jenum, Anne Karen [Show all 8 contributors for this article] (2022). Associations of immigrant background and diabetes start course participation in adults with type 2 diabetes in Norway - a study from the OMIT-cohort. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Jenum, Anne Karen & Iversen, Marjolein M. (2022). Tiltak for å forebygge svangerskapsdiabetes må være kulturelt tilpasset. https://sykepleien.no/fag. doi: 10.4220/Sykepleiens.2022.87985. Full text in Research Archive
• Fragoso-Bargas, Nicolas; Lee-Ødegård, Sindre; Moen, Gunn-Helen Øiseth; oppsahl, JO; Sletner, Line & Jenum, Anne Karen [Show all 13 contributors for this article] (2022). Epigenome-Wide Association Study of objectively measured moderate physical activity in pregnan. Full text in Research Archive Show summary

  Epigenome-Wide Association Study of objectively measured moderate physical activity in pregnancy Nicolas Fragoso-Bargas1,2, Sindre Lee-Ødegård2, Gunn-Helen Moen2,3,4,5, Julia O. Opsahl2, Line Sletner2,6, Anne Karen Jenum2, Paul Franks7, Rashmi B. Prasad8, Leif C. Groop8, Elisabeth Qvigstad1,2, Kåre I. Birkeland2, Kåre R. Richardsen9, Christine Sommer1 1Oslo University Hospital, Oslo, Norway, 2University of Oslo, Oslo, Norway, 3The University of Queensland Diamantina Institute, Brisbane, Australia, 4Norwegian University of Science and Technology, Trondheim, Norway, 5University of Bristol, UK, 6Akershus University Hospital, Oslo, Norway, 7Lund University Genetic and Molecular Epidemiology, Malmö, Sweden, 8Lund University Diabetes Centre, Malmö, Sweden,9Oslo Metropolitan University, Oslo, Norway. Physical activity (PA) is recommended during pregnancy to reduce the risk of excessive weight gain and gestational diabetes mellitus, and to improve general health. DNA methylation (DNAm) has been proposed as a potential molecular mechanism through which physical activity (PA) mediates the effects on the transcriptome. Here we performed an epigenome-wide association study (EWAS) of objectively measured moderate physical activity in pregnancy, which has not been performed previously. In EPIPREG (a sub-sample of the population-based STORK Groruddalen study) we quantified DNAm at gestational week 28 (±2 SD) with Illumina’s Infinium Methylation EPIC BeadChip. With SenseWear™ Pro3 Armband, we measured hours per day of moderate PA (3.0 to 6.0 metabolic equivalent for task (MET)) and steps/day. DNAm outliers that were 4 times the interquartile range below or above the 25TH and 75TH percentiles respectively were removed, before the beta values were transformed to M-values. Of the 472 that passed the EWAS quality control, 239 European (EUR) and 109 South Asian women (SA) had two valid days of recorded PA (19.2h per day), and were non-outliers (±4 SD) in their respective ethnic group. We used two approaches to test the association between M-values and moderate PA (hours/day): 1) A trans-ethnic approach using mixed linear models adjusted for blood cell proportions, age, smoking, number of steps, number of valid days (between 2 to 8), and ethnicity as a random intercept, and 2) through separate analyses in EUR and SA using linear modelling adjusted with the before mentioned covariates. We accepted a false discovery rate of 10%. In the trans-ethnic analysis, only cg08148261 located in the promoter area of LDHB was significantly associated with moderate PA. In Europeans, eight sites were significant: cg19031974 (BSN-AS2), cg19053287 (MCF2L) cg14930390 (MUTED), cg18517050 (CIAPIN1) and cg26191378 (TMUB1), located near promoter areas, cg27160968 (ESRRA) and cg15879426 (c17orf101) located in exon boundaries, and cg10421808 which is unannotated. In South Asians, only cg05999993 in the promoter area of AOAH was associated with moderate PA. Most of the sites showed decreased DNAm at increased moderate PA (hours/day), while in cg10421808, cg14930390 and cg15879426 the opposite was observed. In conclusion, we found several significant associations between DNAm and moderate PA. Several CpGs were located near gene promoter areas, which could imply altered transcription of the respective genes. These findings suggest that PA may exert changes in DNAm with important transcriptional implications during pregnancy.

• Fragoso-Bargas, Nicolas; Lee-Ødegård, Sindre; Moen, Gunn-Helen Øiseth; Oppsahl, JO; Sletner, Line & Jenum, Anne Karen [Show all 12 contributors for this article] (2022). Epigenome-Wide Association Study of objectively measured physical activity in pregnancy. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Iversen, Marjolein M.; Jenum, Anne Karen; Sørbye, Linn Marie; Vik, Eline Skirnisdottir & Aasheim, Vigdis [Show all 7 contributors for this article] (2021). Gestational diabetes mellitus by maternal country of birth and length of residence in immigrant women. Full text in Research Archive
• Strandberg, Ragnhild Bjarkøy; Iversen, Marjolein M.; Jenum, Anne Karen; Sørbye, Linn Marie; Vik, Eline Skirnisdottir & Aasheim, Vigdis [Show all 7 contributors for this article] (2021). Gestational diabetes mellitus by maternal country of birth and length of residence in immigrant women in Norway. Full text in Research Archive
• Stalheim, Astrid M.; Iversen, Marjolein M.; Jenum, Anne Karen; Sletner, Line; Nilsen, Roy Miodini & Aasheim, Vigdis [Show all 7 contributors for this article] (2021). Associations between seasonality and gestational diabetes mellitus. Full text in Research Archive
• Jenum, Anne Karen (2021). Diabetes and guidelines in practice. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. doi: 10.4045/tidsskr.21.0191. Full text in Research Archive
• Shakeel, Nilam; Eberhard-Gran, Malin; Martinsen, Egil Wilhelm; Slinning, Kari & Jenum, Anne Karen (2019). Depressive symptoms in pregnant and postpartum women. Full text in Research Archive
• Torbjørnsen, Astrid; Ribu, Lis; Jenum, Anne Karen & Småstuen, Milada Cvancarova (2020). Effect of an mHealth intervention for persons with type 2 diabetes and their acceptability of the device: Results from the Norwegian randomised controlled study in RENEWING HeALTH. Universitetet i Oslo. Full text in Research Archive Show summary

  Having type 2 diabetes constitutes a burden for the persons affected, and digital solutions can be useful supplements to clinical care enabling individualized approach and strengthening of self-management. The aims of the thesis were to investigate the effects and acceptability of use of a diabetes diary as a mobile app with or without health counselling compared to usual care by performing a three-armed randomized controlled trial assessing clinical health data, self-reported questionnaires and in-depth interviews. The use of the mobile app for one year did not show any statistically significant effect on long-term blood glucose (HbA1c), health related quality of life, self-management, depression or lifestyle measures, even with four months of health counselling from a diabetes specialist nurse. The acceptability of the app was measured with the Service User Technology Acceptability Questionnaire (SUTAQ). The questionnaire assesses apps used in health care, and was translated into Norwegian. Factor analysis only confirmed two of five predefined domains, perceived benefit and care personnel concerns. Self-management measured at baseline was not associated to acceptability of the app after one year. Qualitative findings indicated different patterns of use, such as routine storage of measures, and use of the measures to gain new insight in relations between blood glucose, physical activity and diet. Barriers, such as negative experiences with the technology, could lead to stress and in turn increased blood glucose. Contact with health care personnel was of importance to provide new insight, or to confirm self-management decisions made. In summary, there is a need for further studies with interdisciplinary collaboration focusing on the utility of mobile apps in daily life and integration of use of apps in health care.

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