Background: Cardiovascular disease (CVD) is the leading cause of death worldwide. Well-established risk factors for CVD include increasing age, male sex, sedentary lifestyle, obesity, smoking, diabetes, hypertension, dyslipidaemia and low socio-economic status. Traditional risk factors do, however, not fully explain cardiovascular risk in general. In this thesis we focused on two conventional risk factors (smoking, blood pressure), and two unconventional risk markers (adiponectin, an adipocyte derived protein; and sialic acid (SA), a marker of systemic inflammation) for prediction of CVD events. Aims: In Paper I we examined to what degree smoking habits modify the risk of CVD in relation to systolic blood pressure levels in middle-aged men. In Paper II we investigated the predictive role of adiponectin for risk of CVD as well as the cross-sectional associations between adiponectin and markers of glucose metabolism, also in men. In Paper III we examined if increasing pulse pressure (PP) and increasing levels of SA both increase the risk of CVD and whether their effects act in synergism. In Paper IV the association of SA with risk of incident diabetes mellitus and related complications, resulting in hospitalization, was studied. Subjects and Methods: Two large-scale, population-based, screening studies with long follow-up periods have been used. The Malmö Preventive Project (MPP) was used with 22,444 individuals in Paper I and a sub cohort of 3,885 individuals in Paper II. The Värmland Health Survey (VHS) was used in Papers III and IV with 37,843 and 87,035 individuals, respectively. Results: CVD risk increases with increasing systolic blood pressure levels and this risk is almost doubled in smokers. Total adiponectin level is not associated with increased risk of future CVD but it is inversely associated with markers of glucose metabolism. PP and SA both contribute to risk of future CVD. Adjustment for mean arterial pressure reduces the risk induced by PP. Elevated SA contributes to increased risk of incident diabetes and related complications leading to hospitalization.

Background: Inflammation is the natural reaction of the body to an antigen. In some conditions, this reaction continues even after the elimination of the antigen, entering a chronic stage; it targets normal cells of the body and causes extensive damage. Rheumatoid arthritis (RA) is such a condition. It associates with significant metabolic alterations that lead to changes in body composition and especially body fat (BF) increases. In the general population, increased body fat (i.e. obesity) associates with a number of health disorders such as systemic low grade inflammation and a significantly increased risk for cardiovascular disease (CVD). Both effects of obesity could have detrimental effects in RA. Increased inflammation could worsen disease activity while obesity could further increase the already high CVD risk in RA. However, obesity in RA has attracted minimal scientific attention. Aims: The present project aimed to: 1) assess whether the existing measures of adiposity are able to identify the changes in body composition of RA patients, 2) if necessary develop RA-specific measures of adiposity, 3) investigate the association of obesity with disease characteristics and CVD profile of the patients, 4) and identify factors that might affect body weight and composition in these patients. Methods: A total of 1167 volunteers were assessed. Of them 43 suffered from osteoarthritis and 82 were healthy controls. These, together with 516 RA patients were used in the first study. Their body mass index (BMI), BF, and disease characteristics were assessed. In the second, third, fourth and fifth studies a separate set of 400 RA patients was assessed. In addition to the above assessments, their cardiovascular profile and more detailed disease characteristics were obtained. For the final study, 126 RA patients were assessed for all the above and also data on their physical activity levels and their diet were collected. Results: Assessments of adiposity for the general population are not valid for RA patients. Thus, we proposed RA-specific measures of adiposity. These are able to better identify RA patients with increased BF. We were also able to find associations between obesity and disease activity. Both underweight and obese RA patients had more active disease compared to normal-weight patients. Obese patients had significantly worse CVD profile compared to normal-weight. The newly devised measures of adiposity were able to identify those at increased risk. However, not all obese individuals were unhealthy and not all normal-weight healthy. Among our patients we were able to identify subtypes of obesity with distinct phenotypic characteristics that warrant special attention. Finally, we were able to identify factors that influence body weight and composition. Cigarette smoking protected against obesity while its cessation associated with increased adiposity. Physical activity was also found to be protective against obesity while diet or inflammation of the disease failed to produce any significant results. Conclusions: Obesity is a significant threat to the health of RA patients. The measures of adiposity developed herein should be used to identify obese RA patients. Physical activity seems like the sole mode for effective weight management in this population. Health and exercise professionals should actively encourage their patients to exercise as much as they can. This study has created more questions than it answered; further research in the association of obesity and inflammation, as well as in ways to treat it, is essential.

published_or_final_version / Community Medicine / Master / Master of Public Health

published_or_final_version / Community Medicine / Master / Master of Public Health

published_or_final_version / Community Medicine / Master / Master of Public Health

published_or_final_version / Community Medicine / Master / Master of Public Health

published_or_final_version / abstract / Community Medicine / Master / Master of Public Health

published_or_final_version / Nursing Studies / Master / Master of Philosophy

published_or_final_version / Nursing Studies / Doctoral / Doctor of Philosophy

This dissertation consists of three chapters on questions in Environmental Economics, addressing policy and health issues in indoor and outdoor environments. In the first chapter, I explores price and quantity policy solutions to externalities that arise from private decisions made over time, focusing on resource extraction as a specific example. In the U.S., mining causes more pollution than any other single industry. I show how tax policy can optimally address a flow externality associated with resource extraction when the policymaker faces asymmetric information in the short run. Chapter 2 investigates whether ordinary exposure to a common indoor air pollutant—Nitrogen Dioxide (NO₂)—affects respiratory health. About 40 percent of occupied homes in the U.S. use gas stoves for cooking, which produce NO₂ as a byproduct of combustion (US Census, 2006), and peak concentrations in homes may reach above 900 ppb when a gas stove is used for cooking (Dennekamp et al., 2001). Permanent or fatal lung damage occurs at NO₂ concentrations greater than 1000 ppb (Samet and Utell, 1990). Previous studies find mixed evidence of negative effects from indoor NO₂ (Basu and Samet, 1999), but exposure may be endogenous in these analyses. I address this problem by developing a physical model of indoor NO₂ concentrations that depends on ventilation decisions and housing characteristics and estimate it using data from the third wave of the National Health and Nutrition Examination Survey. In every model I consider, I find no significant effects of gas stoves on respiratory outcomes. In the final chapter, I combine data on state and local tobacco control ordinances from Americans for Non-smokers Rights Tobacco US Tobacco Control Laws Database with a sample of 35 million births in the U.S. to examine the impact of smoking bans on birth weight and related outcomes. Using difference-in-difference techniques, I identify the effects of state bans net of local bans, as well as the effects of local bans net of state bans. The results suggest less restrictive bans do more to improve birth outcomes than “100% smokefree” bans do, particularly in urban settings. / text