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  • 1. Abarca-Goméz, Leandra
    et al.
    Abdeen, Ziad A
    Abdul Hamid, Zargar
    Abu-Rmeileh, Niveen M
    Acosta-Cazares, Benjamin
    Acuin, Cecilia
    Adams, Robert J
    Aekplakorn, Wichai
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ezzati, Majid
    Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.2017In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 390, no 10113, p. 2627-2642Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Underweight, overweight, and obesity in childhood and adolescence are associated with adverse health consequences throughout the life-course. Our aim was to estimate worldwide trends in mean body-mass index (BMI) and a comprehensive set of BMI categories that cover underweight to obesity in children and adolescents, and to compare trends with those of adults.

    METHODS: We pooled 2416 population-based studies with measurements of height and weight on 128·9 million participants aged 5 years and older, including 31·5 million aged 5-19 years. We used a Bayesian hierarchical model to estimate trends from 1975 to 2016 in 200 countries for mean BMI and for prevalence of BMI in the following categories for children and adolescents aged 5-19 years: more than 2 SD below the median of the WHO growth reference for children and adolescents (referred to as moderate and severe underweight hereafter), 2 SD to more than 1 SD below the median (mild underweight), 1 SD below the median to 1 SD above the median (healthy weight), more than 1 SD to 2 SD above the median (overweight but not obese), and more than 2 SD above the median (obesity).

    FINDINGS: Regional change in age-standardised mean BMI in girls from 1975 to 2016 ranged from virtually no change (-0·01 kg/m2 per decade; 95% credible interval -0·42 to 0·39, posterior probability [PP] of the observed decrease being a true decrease=0·5098) in eastern Europe to an increase of 1·00 kg/m2 per decade (0·69-1·35, PP>0·9999) in central Latin America and an increase of 0·95 kg/m2 per decade (0·64-1·25, PP>0·9999) in Polynesia and Micronesia. The range for boys was from a non-significant increase of 0·09 kg/m2 per decade (-0·33 to 0·49, PP=0·6926) in eastern Europe to an increase of 0·77 kg/m2 per decade (0·50-1·06, PP>0·9999) in Polynesia and Micronesia. Trends in mean BMI have recently flattened in northwestern Europe and the high-income English-speaking and Asia-Pacific regions for both sexes, southwestern Europe for boys, and central and Andean Latin America for girls. By contrast, the rise in BMI has accelerated in east and south Asia for both sexes, and southeast Asia for boys. Global age-standardised prevalence of obesity increased from 0·7% (0·4-1·2) in 1975 to 5·6% (4·8-6·5) in 2016 in girls, and from 0·9% (0·5-1·3) in 1975 to 7·8% (6·7-9·1) in 2016 in boys; the prevalence of moderate and severe underweight decreased from 9·2% (6·0-12·9) in 1975 to 8·4% (6·8-10·1) in 2016 in girls and from 14·8% (10·4-19·5) in 1975 to 12·4% (10·3-14·5) in 2016 in boys. Prevalence of moderate and severe underweight was highest in India, at 22·7% (16·7-29·6) among girls and 30·7% (23·5-38·0) among boys. Prevalence of obesity was more than 30% in girls in Nauru, the Cook Islands, and Palau; and boys in the Cook Islands, Nauru, Palau, Niue, and American Samoa in 2016. Prevalence of obesity was about 20% or more in several countries in Polynesia and Micronesia, the Middle East and north Africa, the Caribbean, and the USA. In 2016, 75 (44-117) million girls and 117 (70-178) million boys worldwide were moderately or severely underweight. In the same year, 50 (24-89) million girls and 74 (39-125) million boys worldwide were obese.

    INTERPRETATION: The rising trends in children's and adolescents' BMI have plateaued in many high-income countries, albeit at high levels, but have accelerated in parts of Asia, with trends no longer correlated with those of adults.

    FUNDING: Wellcome Trust, AstraZeneca Young Health Programme.

  • 2. Arouca, Aline B
    et al.
    Santaliestra-Pasías, Alba M
    Moreno, Luis A
    Marcos, Ascensión
    Widhalm, Kurt
    Molnár, Dénes
    Manios, Yannis
    Gottrand, Frederic
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Umeå universitet.
    Michels, Nathalie
    Diet as a moderator in the association of sedentary behaviors with inflammatory biomarkers among adolescents in the HELENA study2018In: European Journal of Nutrition, ISSN 1436-6207, E-ISSN 1436-6215Article in journal (Refereed)
    Abstract [en]

    AIM: To assess if a healthy diet might attenuate the positive sedentary-inflammation relation, whereas an unhealthy diet may increase the effect of sedentary behaviors on inflammatory biomarkers.

    METHODS: In 618 adolescents (13-17 years) of the European HELENA study, data were available on body composition, a set of inflammation markers, and food intake assessed by a self-administered computerized 24 h dietary recall for 2 days. A 9-point Mediterranean diet score and an antioxidant-rich diet z-score were used as dietary indices and tested as moderators. A set of low-grade inflammatory characteristics was used as outcome: several cytokines in an inflammatory ratio (IL-6, IL-10, TNF-α, TGFβ-1), C-reactive protein, three cell-adhesion molecules (sVCAM-1, sICAM-1, sE-selectin), three cardiovascular risk markers (GGT, ALT, homocysteine) and three immune cell types (white blood cells, lymphocytes, CD3). Sedentary behaviors were self-reported and analyzed as total screen time. Multiple linear regression analyses tested moderation by diet in the sedentary behaviors-inflammation association adjusted for age, sex, country, adiposity (sum of six skinfolds), parental education, and socio-economic status.

    RESULTS: Both diet scores, Mediterranean and antioxidant-rich diet, were significant protective moderators in the effect of sedentary behaviors on alanine-transaminase enzyme (P = 0.014; P = 0.027), and on the pro/anti-inflammatory cytokine ratio (P = 0.001; P = 0.004), but not on other inflammatory parameters.

    CONCLUSION: A higher adherence to the Mediterranean diet or an antioxidant-rich diet may attenuate the onset of oxidative stress signs associated by sedentary behaviors, whereas a poor diet seems to increase inflammation.

  • 3. Bentham, James
    et al.
    Ezzati, Majid
    A century of trends in adult human height2016In: eLIFE, E-ISSN 2050-084X, ISSN 2050-084X, Vol. 5, p. 1-29, article id e13410Article in journal (Refereed)
    Abstract [en]

    Being taller is associated with enhanced longevity, and higher education and earnings. We reanalysed 1472 population-based studies, with measurement of height on more than 18.6 million participants to estimate mean height for people born between 1896 and 1996 in 200 countries. The largest gain in adult height over the past century has occurred in South Korean women and Iranian men, who became 20.2 cm (95% credible interval 17.5–22.7) and 16.5 cm (13.3– 19.7) taller, respectively. In contrast, there was little change in adult height in some sub-Saharan African countries and in South Asia over the century of analysis. The tallest people over these 100 years are men born in the Netherlands in the last quarter of 20th century, whose average heights surpassed 182.5 cm, and the shortest were women born in Guatemala in 1896 (140.3 cm; 135.8– 144.8). The height differential between the tallest and shortest populations was 19-20 cm a century ago, and has remained the same for women and increased for men a century later despite substantial changes in the ranking of countries.

  • 4.
    Elvhage, Gudrun
    et al.
    Stockholms Universitet.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Identifying children at risk in Swedish schools2016Conference paper (Refereed)
  • 5. Esteban-Cornejo, Irene
    et al.
    Henriksson, Pontus
    Cadenas-Sanchez, Cristina
    Vanhelst, Jérémy
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Gottrand, Frederic
    Kersting, Mathilde
    Moreno, Luis A
    Ruiz, Jonatan R
    Ortega, Francisco B
    Early life programming of attention capacity in adolescents: The HELENA study2018In: Maternal and Child Nutrition, ISSN 1740-8695, E-ISSN 1740-8709, Vol. 14, no 1, article id e12451Article in journal (Refereed)
    Abstract [en]

    The study aims to examine the individual and combined association of early life factors (birth weight, birth length, and any and exclusive breastfeeding) with attention capacity in adolescents. The study included 421 European adolescents (243 girls), aged 12.5-17.5 years, who participated in the Healthy Lifestyle in Europe by Nutrition in Adolescence Study. Body weight and length at birth of adolescents were collected from parental records. The duration of any and exclusive breastfeeding were self-reported. The d2 Test of Attention was administered to assess attention capacity. The main results showed that birth weight, birth length, breastfeeding, and exclusive breastfeeding were related to attention capacity in boys (β ranging from 0.144 to 0.196; all p < .05) after adjustment for age, centre, gestational age, maternal education, family affluence scale, and body mass index. Among boys, differences in attention capacity were found according to tertiles of birth weight and birth length (p < .05), as well as borderline significant differences across groups of any and exclusive breastfeeding (p = 0.055 and p = 0.108, respectively) after adjusting for potential confounders. In addition, boys with 3 early life risk factors (low birth weight, low birth length, and <3 months of breastfeeding) had significantly lower scores in attention capacity compared with boys with 0 risk factors (percentile score - 15.88; p = 0.009). In conclusion, early life factors, both separately and combined, may influence attention capacity in male European adolescents. Importantly, the combination of the 3 early life risk factors, low birth weight, low birth length, and <3 months of breastfeeding, even in normal ranges, may provide the highest reduction in attention capacity.

  • 6.
    Forsner, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap, Pediatrik.
    Att vara barn i sjukdom och sjukvård: barns berättelser om sina upplevelser av sjukdom och sjukvårdsrädsla2006Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The overarching aim of this thesis is to illuminate the experience of illness and the meaning of fear of medical care through children’s narratives.

    A purposive sample of 22 children and youths, aged from 2 to 18 years, narrated through play and conversation their experiences of illness and of their fear of contact with medical care. The data were analysed using thematic qualitative content analysis and the phenomenological hermeneutic method.

    In childhood, the experience of being ill seems to vary with the child’s age. At the ages of 7 to 10 years, the child’s way of thinking can colour the experience;imagination can produce both problems and opportunities. Children seem to combine imagination and reality, and contrasts in the experience coexist such as being scared/confident, sad/cosy and hurt/having fun. At the age of 11 to 18,being ill seemed to imply being lost, hurt and in need of comfort from themselves and others. Medical care can be frightening to children and what is fearful can differ with age. To a 2-year-old child, medical care seemed to be dangerous; to children aged 7 to 11 years, it seemed threatening, like a monster. To the 2-year-old child, there seemed to be a conflict between, on the one hand, living up to expectations by ‘being good’ and hiding their feelings or, on the other hand, communicating their fear.

    The narrations by children in the 7–11 year age group, point to the importance of empathy when caring for children, i.e., to be receptive of the child’s fear in order to help the child through and out of the fear. To be afraid for a two-yearold was to have one’s trust broken yet still be searching for a trustful relationship. However, if the child is received along with the fear, this opened up an opportunity for the child to develop courage and to gain control over the fear when under gentle care.

    The results of this research revealed the possibility of using play to create stories in a creative relationship with the child. To express one’s inner feeling is a gift of trust, a gift of hospitality. Thus when caring for children we can be the ones who are receiving that gift. We can accept the offer of being a guest in the child’s world.

  • 7.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Behandling av barn i samband med smärtsamma procedurer i hälso- och sjukvård– kunskapsdokument2014In: Information från Läkemedelsverket, ISSN 1101-7104, no 3, p. 9-22Article in journal (Other academic)
  • 8.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Guided Imagery2014In: Information från Läkemedelsverket, ISSN 1101-7104, no 3, p. 43-44Article in journal (Other academic)
  • 9. Forsner, Maria
    Guided imagery: Fantasin som hjälper barn i smärta2006In: Barn & psykosomatik: i teori och klinik / [ed] Alfvén, Gösta, Stockholm: Norstedts akademiska förlag , 2006Chapter in book (Other academic)
  • 10.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Omvårdnad vid procedurer2015In: Pediatrisk omvårdnad / [ed] Inger Hallström och Tor Lindberg, Stockholm: Liber , 2015, 2Chapter in book (Other academic)
  • 11.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Omvårdnad vid procedurer2009In: Pediatrisk omvårdnad / [ed] Inger Hallström, Tor Lindberg, Stockholm: Liber, 2009Chapter in book (Other academic)
  • 12.
    Forsner, Maria
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    Smärta hos barn2013In: Kvalitetsindikatorer inom omvårdnad / [ed] Ewa Idvall, Stockholm: Gothia Förlag AB, 2013, 6, p. 24-27Chapter in book (Other academic)
  • 13.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Berggren, Jenny
    Masaba, Jennipher
    Ekbladh, Annelie
    Children's and Youths' Clinic, Central Lasarettet, Växjö, Sweden.
    Lindholm Olinder, Anna
    Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, Stockholm, Sweden; Uppsala University, Department of Medical Sciences, Akademiska Sjukhuset, Uppsala, Sweden.
    Parents’ experiences of caring for a child younger than two years of age treated with continuous subcutaneous insulin infusion2014In: European Diabetes Nursing, ISSN 1551-7853, E-ISSN 1551-7861, Vol. 11, no 1, p. 7-12Article in journal (Refereed)
    Abstract [en]

    Diabetes during infancy is uncommon and continuous subcutaneous insulin infusion (CSII) is the recommended treatment with such young children. However, this form of treatment has not been investigated previously from the perspective of the parents.

    The aim of this study was to determine parents' experiences of caring for a child less than two years old who had diabetes mellitus and was being treated with CSII therapy.

    Three pairs of parents were interviewed twice to elucidate their views on the initial period and on daily living. Data were submitted to qualitative content analysis and resulted in seven categories and one theme, the latter being: ‘The diabetes disease was threatening our baby's life, but then the insulin pump came as a rescuing, though challenging, angel’. Parents initially felt life had been turned upside down, but later they felt in control nearly all the time.

    It was concluded that parents of infants with diabetes are in great need of support in order to manage the disease and CSII technology. The fear of losing control and the lack of relief lead to social isolation. Educating someone close to the family could be a valuable intervention.

  • 14.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Elvhage, Gudrun
    Stockholm Universitet.
    Narratives about concerns for child maltreatment.2016Conference paper (Refereed)
  • 15.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Eriksson, Katarina
    Svedberg, Marianne
    Furingsten, Lovisa
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    When children die: a survey in Sweden about hospital guidelines related to care after death2014Conference paper (Refereed)
  • 16.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Goodholm, Marie
    Andersson, Malin
    Karlsson, Pernilla
    Umeå Universitet.
    Lindh, Viveca
    Umeå Universitet.
    Nordyke, Katrina
    Umeå Universitet.
    Ivarsson, Anneli
    Umeå Universitet.
    Guided Imagery during venipuncture in twelve year old school children Guided Imagery during venipuncture, 12-year old children’s experiences from a CD screening: An intervention evaluated with FAS, VAS and written narratives2010Conference paper (Refereed)
  • 17.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Heimdal, Sara
    Jacobsson, Marlene
    Furingsten, Lovisa
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Lûtzén, Kim
    Karolinska Institutet.
    Health care professionals’ experiences of moral stress when children are dying2014Conference paper (Refereed)
  • 18.
    Forsner, Maria
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk vetenskap.
    Jansson, Lilian
    Kriström, Berit
    Söderberg, Anna
    Being afraid of medical care: a narrative mediated through the symbolic play of one 2 year-old boyManuscript (preprint) (Other (popular science, discussion, etc.))
  • 19. Forsner, Maria
    et al.
    Jansson, Lilian
    Soerlie, Venke
    Being ill as narrated by children aged 11-18 years2005In: Journal of Child Health Care, Vol. 9, no 4, p. 314-323Article in journal (Refereed)
    Abstract [en]

    Being ill from a child’s perspective has not been often investigated. The aim of this study was to illuminate the experience of being ill between the ages of 11-18 years. Four girls and one boy who were suffering short-term illness were interviewed and the data obtained subjected to qualitative content analysis. Illness disrupted their daily lives and made things unrecognizable. Being ill at the age of 11-18 seemed to imply being lost, hurt and in need of comfort from themselves and others. These narrations may indicate to health care professionals how they can improve their practice. This study suggests what is appreciated by children of this age when ill, namely being spoken to and informed about the illness and treatment. The children valued peace and quiet and wanted to listen to and adjust to their bodies.

  • 20.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Jansson, Lilian
    Söderberg, Anna
    Afraid of medical care: school-aged children’s narratives about medical fear2009In: Journal of Pediatric Nursing: Nursing Care of Children and Families, ISSN 0882-5963, E-ISSN 1532-8449, Vol. 24, no 6, p. 519-528Article in journal (Refereed)
    Abstract [en]

    Fear can be problematic for children who come into contact with medical care. This study aimed to illuminate the meaning of being afraid when in contact with medical care, as narrated by children 7–11 years old. Nine children participated in the study, which applied a phenomenological hermeneutic analysis methodology. The children experienced medical care as “being threatened by a monster,” but the possibility of breaking this spell of fear was also mediated. The findings indicate the important role of being emotionally hurt in a child's fear to create, together with the child, an alternate narrative of overcoming this fear.

  • 21.
    Forsner, Maria
    et al.
    Umeå universitet, Medicinsk fakultet, Klinisk vetenskap, Pediatrik.
    Jansson, Lilian
    Sørlie, Venke
    The experience of being ill as narrated by hospitalized children aged 7-10 years with short-term illness.2005In: Journal of Child Health Care, Vol. 9, no 2, p. 153-165Article in journal (Refereed)
    Abstract [en]

    Children's illness has been investigated through the eyes of parents and nurses but the child's own perspective has been largely ignored. The aim of this study is to illuminate the 7-10-year-olds' experiences of being ill. Three girls and four boys were interviewed and narrated their experience about short-term illness. The data obtained was subjected to a thematic qualitative content analysis. The analysis suggests that the children combined reality and imagination and contrasts seemed to coexist such as being scared/confident, sad/cosy and hurt/having fun. They felt caught and tried to escape. The experience of illness as narrated by children can lead to a richer understanding and influence the way we care for paediatric patients.

  • 22.
    Forsner, Maria
    et al.
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    Mörelius, Evalotte
    Linköpings universitet.
    Läkemedelshantering för barn2013In: Kvalitetsindikatorer inom omvårdnad / [ed] Idvall, Ewa, Stockholm: Gothia Förlag AB, 2013, 6, p. 62-64Chapter in book (Other academic)
  • 23.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Mörelius, Evalotte
    Linköpings universitet.
    Hanberger, Lena
    Linköpings universitet.
    Kvalitetsindikatorer inom omvårdnad i barnsjukvården: en pilottest2013Conference paper (Refereed)
  • 24.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Mörelius, Evalotte
    Linköpings universitet.
    Hanberger, Lena
    Linköpings Universitet.
    Ygge, Britt-Marie
    Karolinska Universitetet.
    Nursing quality indicators in paediatric hospital care2013Conference paper (Refereed)
  • 25.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Nilsson, S
    Finnström, B
    Mörelius, E
    Expectation prior to human papilloma virus vaccination: 11 to 12-year-old girls' written narratives2016In: Journal of Child Health Care, ISSN 1367-4935, E-ISSN 1741-2889, Vol. 20, no 3, p. 365-373Article in journal (Refereed)
    Abstract [en]

    Expectations prior to needle-related procedures can influence individuals’ decision making and compliance with immunization programmes. To protect from human papilloma virus (HPV) and cervical cancer, the immunization needs to be given before sexual debut raising interest for this study’s aim to investigate how 11 to 12-year-old girls narrate about their expectations prior to HPV vaccination. A total of 27 girls aged 11 to 12 years participated in this qualitative narrative study by writing short narratives describing their expectations. The requirement for inclusion was to have accepted HPV vaccination. Data were subjected to qualitative content analysis. Findings showed the following expectations: going to hurt, going to be scared and going to turn out fine. The expectations were based on the girls’ previous experiences, knowledge and self-image. The latent content revealed that the girls tried to transform uneasiness to confidence. The conclusion drawn from this study is that most girls of this age seem confident about their ability to cope with possible unpleasantness related to vaccinations. However, nurses need to find strategies to help those children who feel uneasy about needle-related procedures.

  • 26.
    Forsner, Maria
    et al.
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    Nilsson, Stefan
    Göteborgs universitet.
    Kommunikation om smärta2014In: Kommunikation med barn och unga i vården / [ed] Söderbäck, Maja, Stockholm: Liber, 2014Chapter in book (Other (popular science, discussion, etc.))
  • 27.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Nilsson, Stefan
    Göteborgs Universitet.
    Finnström, Berit
    Högskolan Väst.
    Mörelius, Evalotte
    Linköpings Universitet.
    Pain, anxiety and hope to manage, girl´s expectations prior to HPV vaccination2015Conference paper (Refereed)
  • 28.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Norström, Fredrik
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University.
    Nordyke, Katrina
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University.
    Ivarsson, Anneli
    Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University.
    Lindh, Viveca
    Department of Nursing, Umeå University.
    Relaxation and guided imagery used with 12-year-olds during venipuncture in a school-based screening study2014In: Journal of Child Health Care, ISSN 1367-4935, E-ISSN 1741-2889, Vol. 18, no 3, p. 241-252Article in journal (Refereed)
    Abstract [en]

    Needle-related procedures are reported to be problematic for children. In a school-based celiac disease screening, 12-year-olds’ experiences with relaxation and guided imagery (R-GI) during venipuncture were investigated. One group tried nurse-led R-GI (n = 60) and another group received standard care (SC; n = 49). A mixed method design was applied using short written narratives, facial affective scale (FAS), and visual analog scale (VAS) for pain intensity. Qualitative content analysis highlighted that diversity and contradictions when facing blood tests. FAS scores were significantly lower in the SC group before (p = 0.01), during (p = 0.01), and after (p = 0.01) venipuncture. VAS scores did not differ between the groups. The blood test was mostly experienced as unproblematic, and GI during venipuncture did not decrease pain or affect. However, the fact that a number of children scored high FAS indicates a need for effective methods to help children cope with needle-related school-based procedures.

  • 29.
    Forsner, Maria
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Siljebo, Petra
    Umeå Universitet.
    Björklund, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Medical fear in chronically ill children2010Conference paper (Refereed)
  • 30.
    Forsner, Maria
    et al.
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    Ygge, Britt-Marie
    Karolinska Institutet.
    Venösa infarter hos barn2013In: Kvalitetsindikatorer inom omvårdnad / [ed] Idvall, Ewa, Gothia Förlag AB, 2013, 6, p. 118-121Chapter in book (Other academic)
  • 31.
    From, Ingrid
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Portfolio in Nursing Education2014Conference paper (Refereed)
  • 32.
    Furingsten, Lovisa
    et al.
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    Sjögren, Reet
    Mälardalen university, Sweden.
    Forsner, Maria
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    Caring for dying children in an acute paediatric ward2013Conference paper (Other academic)
    Abstract [en]

    Introduction

    Swedish acute paediatric wards usually focuses on children with urgent and short-time illnesses and the care is not always suited for a dying child. Caring for dying children in this context therefor faces special challenges and needs to be further investigated through research from the health care professionals´ (HCP) perspective.

     

    Purpose

    The aim was to describe caring as presented in professional caregivers’ experiences of caring for dying children in paediatric ward.

     

    Material

    Four HCP in a paediatric ward, which had been caring for at least one dying child during the last five years, participated.

     

    Methods

    A phenomenological approach was chosen using qualitative in-depth interviews, starting with one opening question, continuing with follow-up questions according to responsive listening. Data were analysed following four steps suggested by Giorgi: reading to capture the global sense, constitution of parts into ‘meaning units’, transformation from implicit meaning to explicit constituents and gaining structure.

     

    Results

    The findings are represented in five constituents. Presence is a prerequisite for caring when a child is dying. Self-knowledge and support from others are suggested to help when the HCP is suffering and struggling with the injustice in dying. The essence of caring for dying children is like a musical attuned composition. The moments are vulnerable and could easily be disrupted and turn into disharmony.

     

    Conclusions

    The HCP needs self-knowledge to be true and sensitive in the perceived situation of injustice when caring for dying children and their families. Caring assumes presence; however, caring for dying children is found to mean suffering to HCP and raises the need for support from others.

  • 33.
    Furingsten, Lovisa
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Sjögren, Reet
    Mälardalen University and Linnaeus University.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ethical challenges when caring for dying children2015In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 22, no 2, p. 176-187Article in journal (Refereed)
    Abstract [en]

    Background: Caring for dying children presents special challenges, according to the children themselves, their relatives and healthcare professionals. 

    Objective: The aim of this study was to describe caring as represented in healthcare workers' experiences of caring for dying children. 

    Method: A phenomenological approach was chosen, in-depth interviews were carried out and data were analysed in four steps focusing on (a) open reading, (b) meaning units, (c) constituents and (d) essence. 

    Ethical considerations: Four nurses in a general acute paediatric care setting in Sweden participated after providing written informed consent. Voluntary participation and confidentiality were ensured, and the study was ethically approved. 

    Findings: The essence of caring for dying children was likened to a musically attuned composition, comprising five constituents: presence, self-knowledge, injustice in dying, own suffering and in need of others. Presence was found to be a prerequisite for caring when a child is dying. Self-knowledge and support from others can be of help when struggling with emotional pain and injustice. 

    Discussion: Caring for dying children has been found to be a delicate task for healthcare workers all over the world, and the ethical dimension is emphasized in international research. In this study, emotional pain and suffering accompanied caring, but an atmosphere in which it is possible to give and get support from colleagues and to have time to grieve and time to focus on the patient's needs may ease the burden, as can having time to process thoughts about life and death, and a possibility to grow in self-knowledge. 

    Conclusion: Caring in ethically demanding situations may be facilitated through presence, atmosphere, self-knowledge and time. The challenge does not demand highly technological solutions; these assets are readily available, no matter where on earth. However, there is a need to further investigate these prerequisites for caring, particularly when a child is dying.

  • 34. Mattsson, Janet
    et al.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Bolander Laksov, Klara
    Facilitation of learning in specialist nursing training in the PICU: the supervisors´ concerns in the learning situation2014In: Nurse Education in Practice, ISSN 1471-5953, E-ISSN 1873-5223, Vol. 4, no 12Article in journal (Refereed)
    Abstract [en]

    With the aim to unfold nurses’ concerns of the supervision of the student in the clinical caring situation of the vulnerable child, clinical nurses situated supervision of postgraduate nursing students in the Pediatric Intensive Care Unit (PICU) are explored. A qualitative approach, interpretive phenomenology, with participant observations and narrative interviews, was used. Two qualitative variations of patterns of meaning for the nurses’ clinical facilitation were disclosed in this study. Learning by doing theme supports the students learning by doing through performing skills and embracing routines. The reflecting theme supports thinking and awareness of the situation. As the supervisor often serves as a role model for the student this might have an immediate impact on how the student applies nursing care in the beginning of his or her career. If the clinical supervisor narrows the perspective and hinders room for learning the student will bring less knowledge from the clinical education than expected, which might result in reduced nursing quality.

  • 35. Mattsson, Janet
    et al.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Castrén, Maaret
    Arman, Maria
    Caring for children in pediatric intensive care: an observational study focusing on nurses' conserns2013In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 20, no 5, p. 528-538Article in journal (Refereed)
    Abstract [en]

    Children in the pediatric intensive care unit are indisputably in a vulnerable position, dependent on nurses to acknowledge their needs. It is assumed that children should be approached from a holistic perspective in the caring situation to meet their caring needs. The aim of the study was to unfold the meaning of nursing care through nurses’ concerns when caring for children in the pediatric intensive care unit. To investigate the qualitative aspects of practice embedded in the caring situation, the interpretive phenomenological approach was adopted for the study. The findings revealed three patterns: medically oriented nursing—here, the nurses attend to just the medical needs, and nursing care is at its minimum, leaving the children’s needs unmet; parent-oriented nursing care—here, the nursing care emphasizes the parents’ needs in the situation, and the children are viewed as a part of the parent and not as an individual child with specific caring needs; and smooth operating nursing care orientation—here, the nursing care is focused on the child as a whole human being, adding value to the nursing care. The conclusion drawn suggests that nursing care does not always respond to the needs of the child, jeopardizing the well-being of the child and leaving them at risk for experiencing pain and suffering. The concerns present in nursing care has been shown to be the divider of the meaning of nursing care and need to become elucidated in order to improve the cultural influence of what can be seen as good nursing care within the pediatric intensive care unit.

  • 36. Mattsson, Janet
    et al.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Castrén, Maaret
    Arman, Maria
    Clinical Judgment of Pain in the Non-Verbal Child at the PICU: A Phenomenographic Study2011In: Journal of Palliative Care & Medicine, ISSN 2165-7386Article in journal (Refereed)
  • 37. Mattsson, Janet
    et al.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Castrén, Maaret
    Bolander Laksov, Klara
    Arman, Maria
    A qualitative national study of nurses’ clinical knowledge development of pain in pediatric intensive care2012In: Journal of Nursing Education and Practice, ISSN 1925-4040, E-ISSN 1925-4059, Vol. 2, no 2Article in journal (Refereed)
    Abstract [en]

    Background: Vulnerable children undergoing intensive care might still experience pain when they should not, due tonurses and pediatricians insufficient knowledge about how critical illness affects childrens’ signs of pain. How signs ofpain are learned in clinical practice might be one of the remaining aspects in nurses insufficient pain alleviation. In theworkplace learning is directed by what the units shared meaning finds as significant and meaningful to learn. However,what it is viewed as meaningful to learn about pain from the nurses’ perspective might not be meaningful from the child’sperspective. When working together in the PICU, nurses rely on each other and interact in many ways, and theirunderstanding is related to situated knowledge and facilitated by a personal reference group of colleagues. Professionalconcern, depending on culture, traditions, habits, and workplace structures forms the clinical learning patterns in thePICU. However little is known about nurses’ clinical learning patterns or collegial facilitation within the PICU. Theseassumptions lead to the aim of the study: to elucidate patterns in clinical knowledge development and unfold the role offacilitator nurses in relation to pain management in the PICU.

    Method: The study had a qualitative interpretive design approach using semi-structured interviews, analyzed withqualitative content analysis to elucidate both manifest and latent content.

    Results: The findings elucidates that the workplace culture supports or hinders learning and collaboration. Knowledgedevelopment within practice is closely connected to the workplace culture and to nurses’ significant networks. Thefindings also clarify that nurses needs to feel safe in the workplace and on an individual level to build and rely onsignificant networks that facilitates their own personal knowledge development. There is an ongoing interaction betweenthe learning patterns and the facilitation the significant networks offer.

    Conclusions: Nurses need to embrace effective learning about children’s pain from day one. Lack of a facilitatingstructure for learning, lack of assessment within clinical practice, and the focus on the individual nurses’ learning areremaining considerable problems when it comes to alleviating the vulnerable child’s pain. To increase the possibility ofpain alleviation in the clinical setting, it is of importance to attend to the caring culture and build a safe collaborative culture that is patient centered. This requires an environment that allows for open discussion, where questioning andreflecting is a natural part of the culture within the group. These factors need highlighting and thorough examination fromthe organization. Nurses focus on learning, and interact in a learning community of practice that is furthered when theyexperience a safe environment and find that their questions are taken seriously. Approaches to promote a scholarship ofnursing care are needed to develop clinical learning and, consequently, raise the quality of pain care.

  • 38.
    Mattsson, Janet Yvonne
    et al.
    Karolinska Institutet, Sweden.
    Arman, Maria
    Karolinska Institutet, Sweden.
    Castren, Maaret
    Karolinska Institutet, Sweden.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Meaning of caring in pediatric intensive care unit from the perspective of parents: A qualitative study2014In: Journal of Child Health Care, ISSN 1367-4935, E-ISSN 1741-2889, Vol. 18, no 4, p. 336-345Article in journal (Refereed)
    Abstract [en]

    When children are critically ill, parents still strive to be present and participate in the care of their child. Pediatric intensive care differs from other realms of pediatric care as the nature of care is technically advanced and rather obstructing than encouraging parental involvement or closeness, either physically or emotionally, with the critically ill child. The aim of this study was to elucidate the meaning of caring in the pediatric intensive care unit from the perspective of parents. The design of this study followed Benner's interpretive phenomenological method. Eleven parents of seven children participated in observations and interviews. The following aspects of caring were illustrated in the themes arising from the findings: being a bridge to the child on the edge, building a sheltered atmosphere, meeting the child's needs, and adapting the environment for family life. The overall impression is that the phenomenon of caring is experienced exclusively when it is directed toward the exposed child. The conclusion drawn is that caring is present when providing expert physical care combined with fulfilling emotional needs and supporting continuing daily parental care for the child in an inviting environment.

  • 39. Mattsson, Janet Yvonne
    et al.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Arman, Maria
    Uncovering pain in critically ill non-verbal children: nurses' clinical experiences in the paediatric intensive care unit2011In: Journal of Child Health Care, ISSN 1367-4935, E-ISSN 1741-2889, Vol. 15, no 3, p. 187-198Article in journal (Refereed)
    Abstract [en]

    Critically ill paediatric patients are frequently exposed to pain that is required to be assessed and treated effectively. The most reliable resource for assessing pain is the child itself, but children in the paediatric intensive care unit (PICU) are commonly unable to communicate their needs, requiring professional caregivers to uncover and interpret pain. However, nurses and paediatricians do not have sufficient knowledge of how critical illness affects childrens' signs of pain. The aim of this study was to illuminate clinical experiences of pain in the PICU; describing nurses' perceptions of expressions of pain in non-verbal, critically ill 2-6 year old children. The participants were 17 experienced PICU nurses. Data were analysed according to the phenomenographic method and three qualitatively different main categories, gained from clinical experience, emerged: changes in the measurable parameters; perceived muscular tension; and, altered behaviour. Furthermore, contrasting the categories revealed two diverse perspectives to focus pain: measure-oriented and patient-oriented. Subtle expressions of pain were recognised when focus was patient-oriented. These findings support the necessity of actively looking for pain deriving from various perspectives and considering diverse caring needs when doing so. Acknowledging pain makes pain visible.

  • 40. Michels, Nathalie
    et al.
    Vynckier, Lisa
    Moreno, Luis A
    Beghin, Laurent
    de la O, Alex
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Gonzalez-Gross, Marcela
    Huybrechts, Inge
    Iguacel, Isabel
    De Henauw, Stefaan
    Mediation of psychosocial determinants in the relation between socio-economic status and adolescents' diet quality2017In: European Journal of Nutrition, ISSN 1436-6207, E-ISSN 1436-6215, Vol. 57, no 3, p. 951-963Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To examine the underlying reasons for the positive relation between socio-economic status (SES) and the diet quality of adolescents.

    METHODS: In 2081 adolescents (12.5-17.5 years) of the European HELENA study, a continuous variable on diet quality via 2-day 24-h recalls was available. SES was reflected by parental education, parental occupation and family affluence. Mediation by several psychosocial determinants was tested: self-efficacy, availability at school and home, social support, barriers, benefits, awareness and some self-reported influencers (parents, school, taste, health, friends, food readily available, easy preparation, hunger, price and habits). Multiple mediation analyses were adjusted for age, sex and country.

    RESULTS: The availability of soft drinks and fruit at home, social support, parental influence, barriers, price influence, taste influence, health influence and food being readily available were significant mediators. The multiple mediation indirect effect accounted for 23-64% of the total effect. Both occupation and education and both maternal and paternal factors could be explained by the mediation. The unavailability of soft drinks was the strongest mediator (17-44% of the total effect).

    CONCLUSION: Up to 64% of the positive relation between SES and the diet quality in adolescence could be explained by several healthy eating determinants. Focusing on these factors in low-SES populations can minimize social inequalities in diet and health by improving the diet of these specific adolescents.

  • 41. Nilsson, Stefan
    et al.
    Finnström, Berit
    Högskolan Väst.
    Mörelius, Evalotte
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Relaxation and Guided Imagery for children during vaccination: effects on stress, pain and unpleasantness.2015Conference paper (Refereed)
  • 42.
    Nilsson, Stefan
    et al.
    School of Health Sciences, University of Borås, Institute of Health and Care Sciences, University of Gothenburg.
    Finnström, Berit
    Department of Nursing, Health and Culture, University West.
    Mörelius, Evalotte
    Division of Activity, Health and Care, Department of Social and Welfare Studies, Linköping University.
    Forsner, Maria
    Dalarna University, School of Health and Social Studies, Caring Science/Nursing.
    The facial affective scale as a predictor for pain unpleasantness when children undergo immunizations.2014In: Nursing Research and Practice, ISSN 2090-1429, E-ISSN 2090-1437, Vol. 2014, no e628198Article in journal (Refereed)
    Abstract [en]

    Needle fear is a common problem in children undergoing immunization. To ensure that the individual child's needs are met during a painful procedure it would be beneficial to be able to predict whether there is a need for extra support. The self-reporting instrument facial affective scale (FAS) could have potential for this purpose. The aim of this study was to evaluate whether the FAS can predict pain unpleasantness in girls undergoing immunization. Girls, aged 11-12 years, reported their expected pain unpleasantness on the FAS at least two weeks before and then experienced pain unpleasantness immediately before each vaccination. The experienced pain unpleasantness during the vaccination was also reported immediately after each immunization. The level of anxiety was similarly assessed during each vaccination and supplemented with stress measures in relation to the procedure in order to assess and evaluate concurrent validity. The results show that the FAS is valid to predict pain unpleasantness in 11-12-year-old girls who undergo immunizations and that it has the potential to be a feasible instrument to identify children who are in need of extra support to cope with immunization. In conclusion, the FAS measurement can facilitate caring interventions.

  • 43. Nilsson, Stefan
    et al.
    Finnström, Berit
    Mörelius, Evalotte
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    The Facial Affective Scale (FAS) as a predictor for pain unpleasantness when children undergo immunizations2014In: Nursing Research and Practice, ISSN 2090-1429, E-ISSN 2090-1437, Vol. 2014, article id 628198Article in journal (Refereed)
    Abstract [en]

    Needle fear is a common problem in children undergoing immunization. To ensure that the individual child’s needs are met during a painful procedure it would be beneficial to be able to predict whether there is a need for extra support. The self-reporting instrument facial affective scale (FAS) could have potential for this purpose. The aim of this study was to evaluate whether the FAS can predict pain unpleasantness in girls undergoing immunization. Girls, aged 11-12 years, reported their expected pain unpleasantness on the FAS at least two weeks before and then experienced pain unpleasantness immediately before each vaccination. The experienced pain unpleasantness during the vaccination was also reported immediately after each immunization. The level of anxiety was similarly assessed during each vaccination and supplemented with stress measures in relation to the procedure in order to assess and evaluate concurrent validity. The results show that the FAS is valid to predict pain unpleasantness in 11-12-year-old girls who undergo immunizations and that it has the potential to be a feasible instrument to identify children who are in need of extra support to cope with immunization. In conclusion, the FAS measurement can facilitate caring interventions.

  • 44. Nilsson, Stefan
    et al.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Finnström, Berit
    Mörelius, Evalotte
    Relaxation and guided imagery do not reduce stress, pain and unpleasantness for 11- to 12-year-old girls during vaccinations2015In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 104, no 7, p. 724-729Article in journal (Refereed)
    Abstract [en]

    Aim: Relaxation and guided imagery is a distraction technique known to reduce discomfort during paediatric medical procedures. We examined whether its use decreased the stress experienced by 11- to 12-year-old girls receiving the human papilloma virus vaccination, as well as the intensity and unpleasantness of any pain.

    Methods: A randomised crossover trial was conducted with 37 girls. During the first vaccination, each girl was randomised to receive either relaxation and guided imagery or standard care. They then received the other form of care during the second vaccination. Salivary cortisol was measured before each vaccination, and 30 minutes after it was administered. The girls reported pain intensity and pain unpleasantness before and directly after each vaccination and stress after each vaccination.

    Results: On a group level, relaxation and guided imagery did not decrease cortisol levels, self-reported stress, pain intensity and pain unpleasantness. Salivary cortisol levels decreased significantly in both groups during the second vaccination.

    Conclusion: Relaxation and guided imagery did not prove beneficial during the vaccination of 11- to 12-year-old girls and is not recommended as a regular nursing intervention. However, further research is needed into effective techniques to help children who experience pain unpleasantness in connection with needle procedures.

  • 45. Nilsson, Stefan
    et al.
    Hanberger, Lena
    Olinder, Anna Lindholm
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Umeå universitet.
    The Faces Emotional Coping Scale as a self-reporting instrument for coping with needle-related procedures: An initial validation study with children treated for type 1 diabetes2017In: Journal of Child Health Care, ISSN 1367-4935, E-ISSN 1741-2889, Vol. 21, no 4, p. 392-403Article in journal (Refereed)
    Abstract [en]

    The aim of this study was to determine the concurrent and content validity, sensitivity and inter-rater reliability of the Faces Emotional Coping Scale (FECS) to evaluate the children's anticipation of the level of emotional coping in conjunction with a venepuncture. A total of 153 children with type 1 diabetes and 86 of their parents participated in the study. The age of the children, 76 of whom were boys, ranged from 7 to 18 years. The child and his or her parent reported the child's coping ability, and the child reported the pain intensity and unpleasantness of a venepuncture. The child also wrote a short narrative about his or her experience of the needle procedure. The FECS correlated negatively with the Coloured Analogue Scale and the Facial Affective Scale and positively with the FECS by proxy. The narratives of 90 children correlated negatively with the FECS. Younger children reported significantly lower scores than older children did regarding their ability to cope with a venepuncture. The children's scores on the FECS showed good agreement with the parents' scores. In this study, the FECS was deemed valid for measuring children's ability to cope with their emotions when undergoing needle-related procedures like venepuncture.

  • 46. Tranback, A.J.
    et al.
    Dickens, Stina
    Mattsson, Janet
    Karolinska Institutet.
    Karling, Mats
    Umeå Universitet.
    Ljungman, Gustav
    Uppsala Universitet.
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    My child suffers pain: a narrative exploration of how parents perceive and manage children’s pain at home2012Conference paper (Refereed)
  • 47. Wisnuwardani, Ratih Wirapuspita
    et al.
    De Henauw, Stefaan
    Androutsos, Odysseas
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Umeå universitet.
    Gottrand, Frédéric
    Huybrechts, Inge
    Knaze, Viktoria
    Kersting, Mathilde
    Le Donne, Cinzia
    Michels, Nathalie
    Estimated dietary intake of polyphenols in European adolescents: the HELENA study.2019In: European Journal of Nutrition, ISSN 1436-6207, E-ISSN 1436-6215, Vol. 58, no 6, p. 2345-2363Article in journal (Refereed)
    Abstract [en]

    PURPOSE: Knowledge about polyphenols intakes and their determinants among adolescents might be helpful for planning targeted prevention strategies at an early age.

    METHODS: In the European multicenter cross-sectional HELENA study of 2006-2007, 2428 subjects (47% boys) had data on dietary intake of polyphenols from 2 non-consecutive 24 h recalls via linking with the Phenol-Explorer database. Differences by sex, age, country, BMI, maternal education, paternal education, family affluence, smoking status, alcohol use, and physical activity were explored by linear regression.

    RESULTS: Median, lower and upper quartiles of polyphenol intakes were 326, 167 and 564 mg/day, respectively. Polyphenol intake was significantly higher in the oldest (16-17.49 years), girls, non-Mediterranean countries, lowest BMI, highest paternal education, and alcohol consumers. Main food contributors were fruit (23%, mainly apple and pear, i.e., 16.3%); chocolate products (19.2%); and fruit and vegetable juices (15.6%). Main polyphenol classes were flavonoids (75-76% of total) and phenolic acids (17-19% of total). The three most consumed polyphenols were proanthocyanidin polymers (> 10 mers), hesperidin, and proanthocyanidin 4-6 oligomers.

    CONCLUSION: The current study provided for the first time numbers on the total polyphenol intake and their main food sources in a heterogeneous group of European adolescents. Major differences with adult populations are the lower polyphenol consumption and the major food sources, such as chocolate and biscuits. The discussed determinants and polyphenol types already point to some important population groups that need to be targeted in future public health initiatives.

  • 48. Wisnuwardani, Ratih Wirapuspita
    et al.
    De Henauw, Stefaan
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Gottrand, Frédéric
    Huybrechts, Inge
    Knaze, Viktoria
    Kersting, Mathilde
    Donne, Cinzia Le
    Manios, Yannis
    Michels, Nathalie
    Polyphenol intake and metabolic syndrome risk in European adolescents: the HELENA study2019In: European Journal of Nutrition, ISSN 1436-6207, E-ISSN 1436-6215Article in journal (Refereed)
    Abstract [en]

    PURPOSE: The role of polyphenol intake during adolescence to prevent metabolic syndrome (MetS) is little explored. This study aimed to evaluate the association between intake of total polyphenols, polyphenol classes and the 10 most consumed individual polyphenols with MetS risk in European adolescents.

    METHODS: Of the cross-sectional HELENA study, 657 adolescents (54% girls; 14.8% overweight; 12.5-17.5 year) had a fasting blood sample and polyphenol intake data from two non-consecutive 24-h recalls matched with the Phenol-Explorer database. MetS was defined via the pediatric American Heart Association definition. Multilevel linear regressions examined the associations of polyphenol quartiles with MetS components, while logistic regression examined the associations with MetS risk.

    RESULTS: After adjusting for all potential confounders (socio-demographics and nine nutrients), total polyphenol intake, polyphenol classes and individual polyphenols were not associated with MetS risk. From all MetS components, only BMI z-score was modestly inversely associated with total polyphenol intake. Further sub analyses on polyphenol classes revealed that flavonoid intake was significantly associated with higher diastolic blood pressure and lower BMI, and phenolic acid intake was associated with higher low-density cholesterol. For individual polyphenols, the above BMI findings were often confirmed (not independent from dietary intake) and a few associations were found with insulin resistance.

    CONCLUSION: Higher intakes of total polyphenols and flavonoids were inversely associated with BMI. No consistent associations were found for other MetS components.

  • 49. Zhou, Bin
    et al.
    Bentham, James
    Di Cesare, Mariachiara
    Bixby, Honor
    Danaei, Goodarz Danaei
    Hajifathalian, Kaveh
    Taddei, Cristina
    Carrillo-Larco, Rodrigo M
    Forsner, Maria
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Ezzati, Majid
    Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants2018In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 47, no 3, p. 872-883Article in journal (Refereed)
    Abstract [en]

    Background: Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure.

    Methods: We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20–29 years to 70–79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probittransformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure.

    Results: In 2005–16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the highincome Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association.

    Conclusions: Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups.

  • 50. Zhou, Bin
    et al.
    Ezzati, Majid
    Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19.1 million participants2017In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 389, no 10064, p. 37-55Article in journal (Refereed)
    Abstract [en]

    Background

    Raised blood pressure is an important risk factor for cardiovascular diseases and chronic kidney disease. We estimated worldwide trends in mean systolic and mean diastolic blood pressure, and the prevalence of, and number of people with, raised blood pressure, defined as systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher.

    Methods

    For this analysis, we pooled national, subnational, or community population-based studies that had measured blood pressure in adults aged 18 years and older. We used a Bayesian hierarchical model to estimate trends from 1975 to 2015 in mean systolic and mean diastolic blood pressure, and the prevalence of raised blood pressure for 200 countries. We calculated the contributions of changes in prevalence versus population growth and ageing to the increase in the number of adults with raised blood pressure.

    Findings

    We pooled 1479 studies that had measured the blood pressures of 19·1 million adults. Global age-standardised mean systolic blood pressure in 2015 was 127·0 mm Hg (95% credible interval 125·7–128·3) in men and 122·3 mm Hg (121·0–123·6) in women; age-standardised mean diastolic blood pressure was 78·7 mm Hg (77·9–79·5) for men and 76·7 mm Hg (75·9–77·6) for women. Global age-standardised prevalence of raised blood pressure was 24·1% (21·4–27·1) in men and 20·1% (17·8–22·5) in women in 2015. Mean systolic and mean diastolic blood pressure decreased substantially from 1975 to 2015 in high-income western and Asia Pacific countries, moving these countries from having some of the highest worldwide blood pressure in 1975 to the lowest in 2015. Mean blood pressure also decreased in women in central and eastern Europe, Latin America and the Caribbean, and, more recently, central Asia, Middle East, and north Africa, but the estimated trends in these super-regions had larger uncertainty than in high-income super-regions. By contrast, mean blood pressure might have increased in east and southeast Asia, south Asia, Oceania, and sub-Saharan Africa. In 2015, central and eastern Europe, sub-Saharan Africa, and south Asia had the highest blood pressure levels. Prevalence of raised blood pressure decreased in high-income and some middle-income countries; it remained unchanged elsewhere. The number of adults with raised blood pressure increased from 594 million in 1975 to 1·13 billion in 2015, with the increase largely in low-income and middle-income countries. The global increase in the number of adults with raised blood pressure is a net effect of increase due to population growth and ageing, and decrease due to declining age-specific prevalence.

    Interpretation

    During the past four decades, the highest worldwide blood pressure levels have shifted from high-income countries to low-income countries in south Asia and sub-Saharan Africa due to opposite trends, while blood pressure has been persistently high in central and eastern Europe.

    Funding

    Wellcome Trust.

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