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INTRODUCTION: Smoke-free workplaces are considered an important part of tobacco control strategies. The purpose of this study was to evaluate implementation fidelity and explore the significance of social and contextual factors for the implementation of a strict smoke-free workplace intervention in a large Danish medical company.METHODS: The UK Medical Research Council's guidance for process evaluation was used as a framework. Data were collected from approximately six months before the implementation until ten months after (2019-2020). A mixed method study design was used (a survey of 398 employees, a focus group of four employees and field visits on two days). Data were analyzed separately and later integrated through triangulation. We used the Fisher's exact test in the analysis of the questionnaire.RESULTS: We assessed the implementation fidelity through four key factors: reach, dose and delivery, mechanisms of change, and context for the intervention components. Despite compliance issues, the policy component had high implementation fidelity. However, the implementation fidelity of the smoking cessation support component was low. We identified three social mechanisms influencing the employees' responsiveness towards the policy: expectation, the social aspect of the smoking facilities, and management leadership. COVID-19 was identified as the main contextual factor affecting the implementation.CONCLUSIONS: Although not all elements of the intervention components were implemented as planned, the strict smoke-free workplace intervention is considered implemented. Further strategies can be initiated to raise implementation fidelity through better communication concerning the cessation support component, compliance, and enforcement of the policy.

No study has yet investigated the intake of different types of whole grain (WG) in relation to all-cause and cause-specific mortality in a healthy population. The aim of the present study was to investigate the intake of WG products and WG types in relation to all-cause and cause-specific mortality in a large Scandinavian HELGA cohort that, in 1992-8, included 120 010 cohort members aged 30-64 years from the Norwegian Women and Cancer Study, the Northern Sweden Health and Disease Study, and the Danish Diet Cancer and Health Study. Participants filled in a FFQ from which data on the intake of WG products were extracted. The estimation of daily intake of WG cereal types was based on country-specific products and recipes. Mortality rate ratios (MRR) and 95% CI were estimated using the Cox proportional hazards model. A total of 3658 women and 4181 men died during the follow-up (end of follow-up was 15 April 2008 in the Danish sub-cohort, 15 December 2009 in the Norwegian sub-cohort and 15 February 2009 in the Swedish sub-cohort). In the analyses of continuous WG variables, we found lower all-cause mortality with higher intake of total WG products (women: MRR 0.89 (95% CI 0.86, 0.91); men: MRR 0.89 (95% CI 0.86, 0.91) for a doubling of intake). In particular, intake of breakfast cereals and non-white bread was associated with lower mortality. We also found lower all-cause mortality with total intake of different WG types (women: MRR 0.88 (95% CI 0.86, 0.92); men: MRR 0.88 (95% CI 0.86, 0.91) for a doubling of intake). In particular, WG oat, rye and wheat were associated with lower mortality. The associations were found in both women and men and for different causes of deaths. In the analyses of quartiles of WG intake in relation to all-cause mortality, we found lower mortality in the highest quartile compared with the lowest for breakfast cereals, non-white bread, total WG products, oat, rye (only men), wheat and total WG types. The MRR for highest v. lowest quartile of

Individual lifestyle factors have been associated with lifestyle diseases and premature mortality by an accumulating body of evidence. The impact of a combination of lifestyle factors on mortality has been investigated in several studies, but few have applied a simple index taking national guidelines into account. The objective of the present prospective cohort study was to investigate the combined impact of adherence to five lifestyle factors (smoking, alcohol intake, physical activity, waist circumference and diet) on all-cause, cancer and cardiovascular mortality based on international and national health recommendations. A Cox proportional hazards model was used to estimate hazard ratios (HR) with 95 % CI. During a median follow-up of 14 years, 3941 men and 2827 women died. Among men, adherence to one additional health recommendation was associated with an adjusted HR of 0·73 (95 % CI 0·71, 0·75) for all-cause mortality, 0·74 (95 % CI 0·71, 0·78) for cancer mortality and 0·70 (95 % CI 0·65, 0·75) for cardiovascular mortality. Among women, the corresponding HR was 0·72 (95 % CI 0·70, 0·75) for all-cause mortality, 0·76 (95 % CI 0·73, 0·80) for cancer mortality and 0·63 (95 % CI 0·57, 0·70) for cardiovascular mortality. In the present study, adherence to merely one additional health recommendation had a protective effect on mortality risk, indicating a huge potential in enhancing healthy lifestyle behaviours of the population.

The phyto-oestrogen enterolactone has been hypothesised to protect against hormone-dependent cancers, probably through its anti-oestrogenic potential. We investigated whether a higher level of plasma enterolactone was associated with a lower incidence of endometrial cancer in a case-cohort study in the 'Diet, Cancer and Health' cohort. The cohort study included 29 875 women aged 50-64 years enrolled between 1993 and 1997. Information on diet and lifestyle was provided by self-administrated questionnaires and blood was drawn from each participant. Time-resolved fluoroimmunoassay was used for biochemical determination of plasma enterolactone. A total of 173 cases and 149 randomly selected cohort members were included. We estimated incidence rate ratio (IRR) and 95 % CI by a Cox proportional hazards model. A 20 nmol/l higher plasma concentration of enterolactone was associated with a non-significant lower risk of endometrial cancer (IRR 0·93, 95 % CI 0·84, 1·04). When excluding women with low enterolactone concentrations (quartile 1) due to potential recent antibiotic use, the association became slightly stronger, but remained non-significant (IRR 0·90, 95 % CI 0·79, 1·02). Menopausal status, hormone replacement therapy or BMI did not modify the association. In conclusion, we found some support for a possible inverse association between plasma enterolactone concentration and endometrial cancer incidence.

Objective: To identify the dietary, lifestyle and socio-economic factors associated with the intake of whole grains (WG) in Norway, Sweden and Denmark. Design: A cross-sectional study. Setting: Subsample of the Scandinavian cohort ‘HELGA’ consisting of three prospective cohorts: The Norwegian Women and Cancer Study; The Northern Sweden Health and Disease Study; and the Danish Diet, Cancer and Health Study. Subjects: A total of 8702 men and women aged 30–65 years. Dietary data are from one 24 h dietary recall and data on socio-economic status and lifestyle factors including anthropometric values are from the baseline collection of data. Results: Vegetables, fruits, dairy products, fish and shellfish, coffee, tea and margarine were directly associated with the intake of WG, whereas red meat, white bread, alcohol and cakes and biscuits were inversely associated. Smoking and BMI were consistently inversely associated with the intake of WG. Furthermore, length of education was directly associated with the intake of WG among women. Conclusions: The intake of WG was found to be directly associated with healthy diet, lifestyle and socio-economic factors and inversely associated with less healthy factors, suggesting that these factors are important for consideration as potential confounders when studying WG intake and disease associations.

Objective: To examine the dietary intake of total sugar, added sugar, non-added sugar and starch as well as dietary fibre and glycaemic index (GI) and their respective associations with insulin resistance. Design: Mixed linear models were used to study both cross-sectional and prospective associations between carbohydrate components and insulin resistance separately in girls and boys. Diet was assessed by a single 24 h recall interview and insulin resistance was calculated using the homoestasis model assessment (HOMA). Setting: The Danish part of the European Youth Heart Studies (EYHS) I and II. Subjects: Girls and boys at 8–10 and 14–16 years from EYHS I (n 651) and 8–10-year olds from baseline followed up 6 years later in EYHS II (n 233). Results: Among girls, a difference in dietary total sugar of 43 g/MJ was associated with a 1 SD difference of HOMA and a difference in dietary fibre of 28g/MJ was associated with a 1 SD difference of HOMA, independent of age, maturity and other confounders (both P50?03). No baseline associations were found among boys and no prospective associations were found in either sex. Conclusions: Dietary intake of total sugar may play an adverse role and fibre may play a beneficial role in concurrent insulin resistance among girls but not boys. Sex differences may be due to differences in maturity, physical activity, food patterns and selective reporting behaviours.

Udgivelsesdato: 2009-Feb-6, OBJECTIVE: To evaluate the association between wholegrain products intake and other dietary, lifestyle, anthropometric and socio-economic factors. DESIGN: Cross-sectional study, with data on diet, lifestyle and socio-economic factors obtained from questionnaires. Anthropometric measurements were collected by trained professionals. Multiple linear and principal components regression analyses were used in statistical analyses. SETTING: Part of the Diet, Cancer and Health study, a prospective cohort study to evaluate the aetiological role of diet on cancer risk, conducted in the greater Copenhagen and Aarhus area, Denmark. SUBJECTS: Men and women (n 54 720) aged 50-64 years. RESULTS: In multiple linear regression analyses focusing on individual dietary factors, intake of wholegrain products was associated with intake of all dietary factors studied (fish, red meat, poultry, processed meat, dairy products, fruits, vegetables, cakes and refined-grain products). The strongest positive associations were seen for intake of vegetables and processed meat, whereas the strongest negative associations were seen for intake of red meat and refined-grain products. Regression analyses on dietary patterns identified by principal components analysis yielded similar results. Also, wholegrain products intake was positively associated with cycling, taking dietary supplements and high school education, and negatively associated with intake of alcohol, BMI and smoking. CONCLUSIONS: Intake of wholegrain products is associated with other dietary factors, healthier lifestyle habits and higher socio-economic status. Therefore future studies need to account for the possible confounding by other dietary and lifestyle-related parameters when investigating relationships between wholegrain products intake and disease risk.