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BACKGROUND About two-thirds of Canadians are physically inactive . As a risk factor for several chronic diseases , physical inactivity can potentially be a substantial public health burden . We estimated the direct health care costs attributable to  physical inactivity  in Canada , the number of lives lost prematurely each year that are attributable to a sedentary lifestyle and the effect that a reduction of 10 % in inactivity levels ( a Canadian objective for 2003 ) could have on reducing direct health care costs . METHODS We calculated summary relative risk ( RR ) estimates from prospect i ve longitudinal studies of the effects of physical inactivity on coronary artery disease , stroke , colon cancer , breast cancer , type 2 diabetes mellitus and osteoporosis . We then computed the population -attributable fraction ( PAF ) for each illness from the summary RR and the prevalence of physical inactivity ( i.e. , 62 % ) and applied the PAF to the total direct health care expenditures for 1999 and to the number of deaths in 1995 associated with each disease to determine the health care costs and lives lost prematurely that were directly attributable to physical inactivity . RESULTS About $ 2.1 billion , or 2.5 % of the total direct health care costs in Canada , were attributable to physical inactivity in 1999 . A sensitivity analysis ( simultaneously varying each of the health care costs and PAF by + /- 20 % ) indicated that the costs could be as low as $ 1.4 billion and as high as $ 3.1 billion . About 21,000 lives were lost prematurely in 1995 because of inactivity . A 10 % reduction in the prevalence of physical inactivity has the potential to reduce direct health care expenditures by $ 150 million a year . INTERPRETATION Physical inactivity represents an important public health burden in Canada . Even modest reductions in inactivity levels could result in substantial cost savings Almost three decades ago the Finnish led the way for prevention of coronary heart disease by successfully implementing the community based North Karelia project.1 With the recent publication of their r and omised controlled clinical trial of prevention of type 2 diabetes , Tuomilehto et al have now shown that effective lifestyle changes can prevent another major chronic disease of our time . 2 3 Type 2 diabetes has long been linked with behavioural and environmental factors such as overweight , physical inactivity , and dietary habits.4 The findings from the Finnish trial confirm this link . Major lifestyle changes result ing from industrialisation are contributing to a rapid rise in diabetes worldwide , but especially in industrialising countries . An estimated 135 million people worldwide had diagnosed diabetes in 1995 , and this number is expected to rise to at least 300 million by 2025.4 Between 1995 and 2025 the number of people with diabetes will increase by 42 % ( from 51 to 72 million ) in industrialised countries and by 170 % ( from 84 to 228 million ) in industrialising countries . Diabetes exerts a huge Cardiovascular disease is the leading cause of death in persons with diabetes mellitus . This disorder affects approximately 16 million Americans , at least 15 million of whom have type 2 diabetes mellitus ( 1 ) . Among diabetic persons , coronary heart disease causes more than 50 % of all deaths and stroke causes an additional 15 % ( 2 ) . Diabetic women are at particularly high risk for cardiovascular disease , and diabetes eliminates the usual female advantage for death from coronary disease . While an inverse association between increased physical activity and lower risk for cardiovascular disease is well established in the general population ( 3 ) , sparse data are available among diabetic persons ( 4 , 5 ) . Intervention studies have shown that exercise increases insulin sensitivity and glucose tolerance and induces favorable changes in blood lipid levels among persons with type 2 diabetes mellitus ( 6 ) . Exercise as an adjunct to diet regimens yields greater and more sustained weight loss in obese patients with type 2 diabetes mellitus ( 7 ) . Even moderately intense exercise , such as walking , improves insulin sensitivity and reduces body weight ( 8) . Because walking is safe and easy , it may provide a promising way to reduce risk for cardiovascular events among diabetic persons . In this study , we examined in detail the relationship between levels of physical activity  and incidence of coronary heart disease and stroke among women with type 2 diabetes mellitus in the Nurses ' Health Study . In particular , we evaluated  walking  ( the most common form of physical activity among diabetic persons ) in relation to cardiovascular events . Methods Study Sample The Nurses ' Health Study cohort was established in 1976 . The original cohort consisted of 121 700 female registered nurses who were 30 to 55 years of age and resided in 11 large U.S. states . The nurses completed a mailed question naire about their medical history and lifestyle , and follow-up question naires administered every 2 years up date information on potential risk factors and identify newly diagnosed cases of coronary heart disease and other illness . Our study includes 5125 women who , on any question naire from 1976 to 1992 , reported having physician-diagnosed diabetes mellitus and being 30 years of age or older at disease onset ( a working definition for type 2 diabetes mellitus ) . Women who reported a history of coronary heart disease ( including myocardial infa rct ion , angina , or coronary revascularization ) , stroke , or cancer on or before the 1980 question naire ( when physical activity was first assessed ) were excluded at baseline . The follow-up rate for nonfatal events was 97 % of the total potential person-years . Confirmation of Diabetes Mellitus A supplementary question naire regarding symptoms , diagnostic tests , and hypoglycemic  therapy was mailed to women who indicated on any biennial question naire that they had received a diagnosis of diabetes . A case of diabetes was considered confirmed if at least one of the following was reported on the supplementary question naire : 1 ) classic symptoms plus a fasting plasma glucose level of at least 140 mg/dL ( 7.8 mmol/L ) or a r and om plasma glucose level of at least 200 mg/dL [ 11.1 mmol/L ] , 2 ) at least two elevated plasma glucose concentrations on different occasions ( a fasting level 140 mg/dL [ 7.8 mmol/L ] or a r and om level 200 mg/dL [ 11.1 mmol/L ] , a concentration 200 mg/dL after 2 hours or more on oral glucose tolerance testing , or both ] in the absence of symptoms , or 3 ) treatment  with hypoglycemic medication ( insulin or an oral hypoglycemic agent ) . The validity of this question naire has been verified in a sub sample of the study cohort ( 9 ) . Of a r and om sample of 84 women classified by the question naire as having type 2 diabetes mellitus , 71 gave permission for their medical records to be review ed ; records were available for 62 of 71 . An endocrinologist blinded to the information on the supplementary question naires review ed the records according to National Diabetes Data Group ( NDDG ) criteria ( 10 ) . The diagnosis of type 2 diabetes mellitus was confirmed in 61 of 62 women ( 98 % ) ( 9 ) . A secondary set of analyses included only women with definite type 2 diabetes mellitus according to the NDDG criteria . We used the NDDG diagnostic criteria because the analytic cohort preceded the American Diabetes Association guideline , which was published in 1997 ( 11 ) . Assessment of Physical Activity Women were first asked about physical activity on the 1980 question naire . They were asked to report the average number of hours they had spent each week during the past year on such moderate and vigorous recreational activities as vigorous sports , jogging , brisk walking or striding , bicycling , heavy gardening , and heavy housework . On the 1982 question naire , women were asked a slightly different question : For how many hours per week , on average , do you engage in activity strenuous enough to build up a sweat ? In 1986 , 1988 , and 1992 , women were asked to report the average time spent per week on the following activities : walking , jogging , running , bicycling , lap swimming , playing tennis or squash , and participating in calisthenics . They were also asked to report the average number of flights of stairs that they climbed each week . Women also reported their usual walking pace : easy ( < 2 miles per hour [ mph ] ) , average ( 2 to 2.9 mph ) , brisk ( 3 to 3.9 mph ) , or very brisk ( 4 mph ) . Because fewer than 2 % of women reported a very brisk pace , we combined the brisk and very brisk categories in analyses of walking pace and diabetes risk . For 1980 , 1982 , 1986 , 1988 , and 1992 , we created a measure of average hours per week spent in moderate or vigorous recreational activities ( all activities described above except for hours spent walking at an easy or average pace ) . For 1986 , 1988 , and 1992 , using a list of physical activities ( 12 ) , we calculated a weekly metabolic equivalent of task ( MET ) score for total physical activities , vigorous activities ( requiring 6 MET/h ) , nonvigorous activities ( requiring<6 MET/h ) , and walking . The validity of the question naire in assessing physical activity has been described elsewhere ( 13 ) . Correlation between activities reported in four 1-week diaries and those reported on the question naire was 0.62 . Ascertainment of End Points The primary end points for this study were incident coronary heart disease ( defined as nonfatal myocardial infa rct ion or fatal coronary heart disease ) and stroke that occurred after the 1980 question naire was returned but before 1 June 1994 . We requested permission to review the medical records of women who reported having a nonfatal myocardial infa rct ion or stroke on a follow-up question naire . Study physicians with no knowledge of the women 's self-reported risk factors review ed the records . Nonfatal myocardial infa rct ion was confirmed if it met the criteria of the World Health Organization of symptoms and the patient 's records showed diagnostic electrocardiographic changes or elevated cardiac enzyme levels ( 14 ) . Infa rct ions that required hospital admission and were confirmed by interview or letter but for which no medical records were available were design ated as probable ( 19 % ) . We included all confirmed and probable cases in the analyses because the results were the same after probable cases were excluded . Stroke was confirmed by medical records according to the criteria of the National Survey of Stroke ( 15 ) , which define it as a constellation of neurologic deficits , sudden or rapid in onset , lasting at least 24 hours . Events were further subclassified as hemorrhagic stroke ( subarachnoid or intraparenchymal ) , ischemic stroke ( thrombotic or embolic ) , or stroke of unknown cause . Deaths were reported by next of kin and the U.S. Postal Service or were ascertained through the National Death Index . After combining all sources , we estimated that follow-up for deaths was more than 98 % complete ( 16 ) . Fatal coronary heart disease was defined as fatal myocardial infa rct ion if confirmed by hospital records or autopsy or if coronary heart disease was listed as the cause of death on the death certificate , was the underlying and most plausible cause , and was supported by evidence of previous coronary heart disease . The cause of death on the death certificate was never in itself considered to provide sufficient confirmation of death from coronary heart disease . We also included sudden death within 1 hour of onset of symptoms in women with no plausible cause other than coronary disease ( 8 % of fatal cases ) . Fatal strokes were coded by using the same criteria as nonfatal cases , but autopsy evidence as well as the death certificate listing was accepted . Statistical Analysis The study base was defined as the pool of person-time that gives rise to incident cases of cardiovascular disease among patients with both prevalent and incident diabetes . We conducted two sets of analyses , one using 1980 as the baseline to evaluate long-term overall effects of moderate or vigorous activities and the other using 1986 as the baseline to examine specific effects of regular walking .  Person-time for each participant was calculated from the date of return of the 1980 or 1986 question naires to the date of confirmed cardiovascular disease , death from any cause , or 1 June 1994 , whichever came first . In the first set of analyses , relative risks were computed as the incidence rate in a specific category of average hours spent on moderate or vigorous activities per week divided by the incidence rate in the lowest category , with adjustment for 5-year categories of age . Tests of linear trend across increasing categories of average hours spent on moderate or vigorous activities were conducted by treating the categories as a single continuous variable and assigning the median score for the category as its value . To best represent long-term levels of physical activity for individual women and to reduce measurement error , we created measures of the cumulative average of physical Exercise has become a st and ard therapy for patients with type 2 diabetes ( 1 ) . Regular exercise improves conventional clinical risk factors , cardiorespiratory fitness , and components of the insulin resistance syndrome ( 2 - 6 ) . However , it is unclear whether physical activity improves the prognosis of patients with diabetes . No data are available on the association of physical activity or cardiorespiratory fitness with mortality in patients with diabetes . The overall benefit of exercise for these patients is unclear , and some experts are concerned that macrovascular and microvascular complications may be worsened by an exercise program ( 1 , 7 ) . Some consider exercise only as a supplement to diet therapy ( 8) . Studies have shown repeatedly that low cardiorespiratory fitness and physical inactivity are directly associated with cardiovascular disease and all-cause mortality ( 9 - 14 ) , and our preliminary study with a small number of end points suggested that this association might persist across plasma glucose levels ( 15 ) . In the current study , we evaluated the prospect i ve association of cardiorespiratory fitness and physical inactivity with mortality in men who have type 2 diabetes . Methods The material presented in this report was derived from the Aerobics Center Longitudinal Study ( ACLS ) , a prospect i ve observational study of patients examined at The Cooper Clinic in Dallas , Texas . The study was review ed and approved annually by the institutional review board at The Cooper Institute . Additional details of study methods and study group characteristics of this cohort have been published elsewhere ( 12 , 13 ) . Patients Participants were men with type 2 diabetes who completed a baseline medical evaluation at The Cooper Clinic in Dallas , Texas , during 1970 to 1993 . These men came to The Cooper Clinic for a medical examination and health counseling . Many were sent by their employers for these services , some were referred by their personal physicians , and others were self-referred . More than 92 % of the patients are white , and most are employed in executive or professional occupations ; more than 75 % are college graduates . Study participants come from middle and upper socioeconomic strata , but they are similar to other well-characterized study group-based cohorts in terms of blood pressure , cholesterol level , body weight , and cardiorespiratory fitness ( 6 , 16 , 17 ) . We excluded men taking insulin and those with a history of cancer at baseline . Clinical Examination The baseline evaluation was performed after participants gave informed written consent for the baseline medical examination and registration in the follow-up study . Examinations followed an overnight fast of at least 12 hours and included personal and family health histories , a question naire on demographic characteristics and health habits , a physical examination , a maximal exercise test on a treadmill , anthropometry , electrocardiography , blood chemistry analyses , and blood pressure measurement . Technicians who followed a st and ard manual of operations administered all procedures . Question naire Patients completed an extensive self-report of personal and family medical diseases and conditions . Each clinic physician examines only four or five patients per day and thus has time for thorough additional probing of items on the self-reported question naire . This complete review of the patient 's medical history and the subsequent physical examination are strengths of the ACLS and provide a more thorough evaluation of baseline health status than is possible in many epidemiologic studies . The question naire also featured items on health habits , including current smoking status and smoking history and whether the participant was currently dieting to lose weight or following any other special dietary plan . Physical activity pattern was ascertained by self-report on the question naire . An extensive list of leisure-time physical activities was presented , and participants indicated activities in which they had participated in the 3 months before the examination . In later study years , they gave additional details on the number of times per week and the duration of exercise sessions . Laboratory Evaluations Cardiorespiratory fitness was assessed by using a maximal exercise test that followed a modified version of Balke and Ware 's protocol ( 18 ) . Briefly , the test began with the participant walking on a horizontal treadmill at 88 m/min . After the first minute , the elevation increased to 2 % , and it further increased 1 % each minute up to 25 minutes . For the few patients who were still able to continue , the elevation was held constant after 25 minutes and the speed increased to 5.4 m/min until the participant reached volitional fatigue . Exercise test performance with this protocol correlates highly with measured maximal oxygen uptake ( r=0.92 ) ( 19 ) . Serum sample s were analyzed by using automated techniques in a laboratory that participates in and meets the quality control st and ards of the Centers for Disease Control and Prevention Lipid St and ardization Program . Blood pressure was measured by auscultatory methods with a mercury sphygmomanometer according to American Heart Association guidelines ( 20 ) . The lowest of three blood pressure measurements at the clinic examination was recorded as the baseline blood pressure . Height and weight were measured by using a st and ard beam-balance scale and stadiometer , and body mass index was calculated . Type 2 Diabetes Diabetes was defined according to criteria of the American Diabetes Association : fasting plasma glucose level of 7.0 mmol/L or greater ( 126 mg/dL ) ( 21 ) . Three hundred seventy patients who did not meet this criterion but who gave a history of physician-diagnosed diabetes were considered to have diabetes . Patients were classified as having known diabetes or unknown diabetes according to their diabetes status before the baseline Cooper Clinic examination . Definition of Exposure Variables The principal exposure variables used in our analyses were  cardiorespiratory fitness and self-reported physical activity .  These exposures were determined at the baseline examination . Cardiorespiratory Fitness  We categorized  total time from the maximal exercise test into frequency distributions for specific age groups ( 30 to 39 , 40 to 49 , 50 to 59 , and 60 years ) . The least fit 20 % of the participants in each age group were classified as low fit , the next 40 % of the distribution as moderately fit , and the highest 40 % as high fit . We have used these cut-points to define fitness in previous studies ( 12 , 13 ) , and they are based on our entire cohort rather than on diabetic patients only . We selected these cut-points before undertaking the current analysis . Cardiorespiratory fitness is expressed as maximal metabolic units ( METs ) attained during the exercise test . The METs are calculated as the working metabolic rate divided by the resting metabolic rate , and 1 MET is equivalent to an oxygen uptake of 3.5 mL1 kg 1 . Physical Activity Patients who reported walking , jogging , or participating in aerobic exercise programs in the 3 months before the examination were classified as active , regardless of the frequency and duration of exercise . Otherwise , patients were classified as inactive . In our cohort , more than 76 % of men who reported being active at baseline still reported being active at the second visit after more than 1 year . In comparison , only 34 % of men who reported being inactive at baseline reported being active at the second examination ( P<0.001 ) . Self-reported physical activity status in our cohort is correlated with maximal exercise test performance ( 6 , 22 ) . Baseline or Parental Cardiovascular Disease We defined baseline cardiovascular disease as a personal history of heart attack , stroke , or a revascularization procedure ; an abnormal resting or exercise electrocardiogram ; or the highest heart rate during exercise testing that was less than 85 % of the age-predicted maximal heart rate ( [ 220 age in years ] 0.85 ) . Men who reported a history of cardiovascular disease in either parent were classified as having parental cardiovascular disease . Conventional Cardiovascular Disease Risk Factors We assigned men to risk strata for conventional cardiovascular disease risk factors on the basis of recent recommendations ( 23 ) . We defined high blood pressure as systolic blood pressure of 140 mm Hg or more , diastolic blood pressure of 90 mm Hg or more , or a history of physician-diagnosed hypertension . We classified participants with a total cholesterol level of 6.2 mmol/L ( 240 mg/dL ) or more as having high cholesterol , those with self-reported current smoking as current smokers , those with a self-reported parental history of myocardial infa rct ion or stroke as having a history of parental cardiovascular disease , those with a body mass index less than 25.0 kg/m2 as normal weight , and those with a body mass index of 25.0 kg/m2 or more as overweight . Statistical Analysis Our primary outcome measure was all-cause mortality . We used the National Death Index to identify  decedents in the ACLS . The National Death Index has been shown to be an effective , accurate means of ascertaining deaths in the general population , with a sensitivity of about 96 % and a specificity of 100 % ( 24 ) . We obtained official death certificates from states in which there were ACLS decedents , and we had the certificates coded by a nosologist according to the International Classification of Diseases , Ninth Revision . Only the underlying cause of death was used in analyses for this report . Data were analyzed by using the SAS statistical package ( SAS Institute , Inc. , Cary , North Carolina ) . The analyses assumed that physical activity and fitness were essentially unchanged during the study period . We used survival curves to estimate survival function against time and log [ log ( survival time ) ] to check the proportional hazards model assumption . Log [ log ( survival function ) ] estimates were approximately parallel across exposure BACKGROUND Physical activity and body mass index ( calculated as weight in kilograms divided by height in meters squared ) independently alter the risk of coronary heart disease ( CHD ) ; however , their combined effect on CHD is not established . Our objective was to study the combined association of physical activity and body mass index on CHD . METHODS Prospect i ve cohort study of 38,987 women free of cardiovascular disease , cancer , and diabetes at baseline in the Women 's Health Study , with 10.9 mean years of follow-up .  Weight , height , and recreational activities were reported on entry . Body mass index was categorized as normal weight ( < 25 ) , overweight ( 25 to < 30 ) , and obese ( > or = 30 ) . Active was defined as 1000 kilocalories or more expended on recreational activities weekly . Six joint body weight-physical activity categories were defined . The main outcome measure was the occurrence of incident CHD during follow-up , defined as a cardiovascular event including nonfatal myocardial infa rct ion , coronary artery bypass graft , percutaneous transluminal coronary angioplasty , or CHD death . RESULTS A total of 948 cases of incident CHD occurred during follow-up . Higher body mass index and physical inactivity were individual predictors of CHD . In joint analyses , compared with active normal-weight individuals , the multivariate-adjusted hazard ratios ( 95 % confidence intervals ) were 1.54 ( 1.14 - 2.08 ) for overweight-active ; 1.87 ( 1.29 - 2.71 ) for obese-active ; 1.08 ( 0.84 - 1.39 ) for normal weight-inactive ; 1.88 ( 1.46 - 2.42 ) for overweight-inactive ; and 2.53 ( 1.94 - 3.30 ) for obese-inactive . Increasing levels of walking also result ed in significant reductions in CHD risk for overweight and obese individuals . CONCLUSIONS The risk of CHD associated with elevated body mass index is considerably reduced by increased physical activity levels . However , the risk is not completely eliminated , reinforcing the importance of being lean and physically active Background Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide . Most chronic diseases are associated with underlying preventable risk factors , such as elevated blood pressure , high blood glucose or glucose intolerance , high lipid levels , physical inactivity , excessive sedentary behaviours , and overweight/obesity . The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood . Sugar-sweetened beverages are known to be significant sources of additional caloric intake , and given recent attention to their contribution in the development of chronic diseases , a systematic review is warranted . We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are . Methods / Design Of interest are studies addressing sugar-sweetened beverage consumption , taking a broad perspective . Both direct consumption studies as well as those evaluating interventions that influence consumption ( e.g. school policy , educational ) will be relevant . Non-specific or multi-faceted behavioural , educational , or policy interventions may also be included subject to the level of evidence that exists for the other interventions /exposures . Comparisons of interest and endpoints of interest are pre-specified . We will include r and omized controlled trials , controlled clinical trials , interrupted time series studies , controlled before-after studies , prospect i ve and retrospective comparative cohort studies , case – control studies , and nested case – control design s. The MEDLINE ® , Embase , The Cochrane Library , CINAHL , ERIC , and PsycINFO ® data bases and grey literature sources will be search ed . The processes for selecting studies , abstract ing data , and resolving conflicts are described . We will assess risk of bias using design -specific tools . To determine sets of confounding variables that should be adjusted for , we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessment s. Meta- analysis will be conducted where appropriate ; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach will be used to determine the quality of evidence for outcomes . Systematic review registration PROSPERO CRD42014009641 OBJECTIVE To ascertain the relationship of physical inactivity and short-term all-cause mortality in a prospect i ve cohort of r and omly selected managed care organization members aged 40 years and older who have multiple chronic diseases . METHODS Clinical data bases were used to identify all health plan members aged 40 years and older with 2 or more chronic health conditions ( hypertension , coronary heart disease , diabetes mellitus , or dyslipemia ) in 1994 . A r and om sample of 2336 members was surveyed by mail and telephone interview regarding their health-related behaviors .  Survey data were linked to mortality data from the 1995 to 1997 Minnesota Death Index . Cox proportional hazards regression was used to ascertain the association between physical inactivity and subsequent all-cause mortality , adjusting for potential confounders . RESULTS Members who reported less than 30 minutes a week of physical activity at baseline had a subsequent mortality risk ratio of 2.82 ( P<.001 ) vs those with 30 or more minutes of physical activity a week . Increased mortality risk persisted ( mortality risk ratio , 2.15 ; P<.001 ) after adjustments for age , sex , current smoking , functional impairment , and comorbidity score . CONCLUSIONS In adults with chronic diseases , the physically inactive had higher observed mortality within a 42-month period . If physical inactivity reflects an independent mortality risk , efforts to maintain physical activity in such patients may yield significant clinical benefits within a short period . By contrast , if inactivity is primarily a proxy for other factors that elevate mortality risks , a simple physician inquiry regarding inactivity may help to identify patients at risk of death Background The burden of cardiovascular diseases ( CVDs ) remains unclear in many regions of the world . Objectives The GBD ( Global Burden of Disease ) 2015 study integrated data on disease incidence , prevalence , and mortality to produce consistent , up-to- date estimates for cardiovascular burden . Methods CVD mortality was estimated from vital registration and verbal autopsy data . CVD prevalence was estimated using modeling software and data from health surveys , prospect i ve cohorts , health system administrative data , and registries . Years lived with disability ( YLD ) were estimated by multiplying prevalence by disability weights . Years of life lost ( YLL ) were estimated by multiplying age-specific CVD deaths by a reference life expectancy . A sociodemographic index ( SDI ) was created for each location based on income per capita , educational attainment , and fertility . Results In 2015 , there were an estimated 422.7 million cases of CVD ( 95 % uncertainty interval : 415.53 to 427.87 million cases ) and 17.92 million CVD deaths ( 95 % uncertainty interval : 17.59 to 18.28 million CVD deaths ) . Declines in the age-st and ardized CVD death rate occurred between 1990 and 2015 in all high-income and some middle-income countries . Ischemic heart disease was the leading cause of CVD health lost globally , as well as in each world region , followed by stroke . As SDI increased beyond 0.25 , the highest CVD mortality shifted from women to men . CVD mortality decreased sharply for both sexes in countries with an SDI > 0.75 . Conclusions CVDs remain a major cause of health loss for all regions of the world . Sociodemographic change over the past 25 years has been associated with dramatic declines in CVD in regions with very high SDI , but only a gradual decrease or no change in most regions . Future up date s of the GBD study can be used to guide policymakers who are focused on reducing the overall burden of noncommunicable disease and achieving specific global health targets for CVD IMPORTANCE Leisure-time physical activity has been associated with lower risk of heart-disease and all-cause mortality , but its association with risk of cancer is not well understood . OBJECTIVE To determine the association of leisure-time physical activity with incidence of common types of cancer and whether associations vary by body size and /or smoking . DESIGN , SETTING , AND PARTICIPANTS We pooled data from 12 prospect i ve US and European cohorts with self-reported physical activity ( baseline , 1987 - 2004 ) . We used multivariable Cox regression to estimate hazard ratios ( HRs ) and 95 % confidence intervals for associations of leisure-time physical activity with incidence of 26 types of cancer . Leisure-time physical activity  levels were modeled as cohort-specific percentiles on a continuous basis and cohort-specific results were synthesized by r and om-effects meta- analysis . Hazard ratios for high vs low levels of activity are based on a comparison of risk at the 90th vs 10th percentiles of activity . The data analysis was performed from January 1 , 2014 , to June 1 , 2015 . EXPOSURES Leisure-time physical activity of a moderate to vigorous intensity . MAIN OUTCOMES AND MEASURES Incident cancer during follow-up . RESULTS A total of 1.44 million participants ( median [ range ] age , 59 [ 19 - 98 ] years ; 57 % female ) and 186 932 cancers were included . High vs low levels of leisure-time physical activity were associated with lower risks of 13 cancers : esophageal adenocarcinoma ( HR , 0.58 ; 95 % CI , 0.37 - 0.89 ) , liver ( HR , 0.73 ; 95 % CI , 0.55 - 0.98 ) , lung ( HR , 0.74 ; 95 % CI , 0.71 - 0.77 ) , kidney ( HR , 0.77 ; 95 % CI , 0.70 - 0.85 ) , gastric cardia ( HR , 0.78 ; 95 % CI , 0.64 - 0.95 ) , endometrial ( HR , 0.79 ; 95 % CI , 0.68 - 0.92 ) , myeloid leukemia ( HR , 0.80 ; 95 % CI , 0.70 - 0.92 ) , myeloma ( HR , 0.83 ; 95 % CI , 0.72 - 0.95 ) , colon ( HR , 0.84 ; 95 % CI , 0.77 - 0.91 ) , head and neck ( HR , 0.85 ; 95 % CI , 0.78 - 0.93 ) , rectal ( HR , 0.87 ; 95 % CI , 0.80 - 0.95 ) , bladder ( HR , 0.87 ; 95 % CI , 0.82 - 0.92 ) , and breast ( HR , 0.90 ; 95 % CI , 0.87 - 0.93 ) . Body mass index adjustment modestly attenuated associations for several cancers , but 10 of 13 inverse associations remained statistically significant after this adjustment .  Leisure-time physical activity  was associated with higher risks of malignant melanoma ( HR , 1.27 ; 95 % CI , 1.16 - 1.40 ) and prostate cancer ( HR , 1.05 ; 95 % CI , 1.03 - 1.08 ) . Associations were generally similar between overweight/obese and normal-weight individuals . Smoking status modified the association for lung cancer but not other smoking-related cancers . CONCLUSIONS AND RELEVANCE Leisure-time physical activity was associated with lower risks of many cancer types . Health care professionals counseling inactive adults should emphasize that most of these associations were evident regardless of body size or smoking history , supporting broad generalizability of findings Cardiovascular disease ( CVD ) , including stroke , heart attack and heart failure , is the leading cause of death and disability worldwide . Raised blood pressure ( BP ) is a major cause of CVD , responsible for 62 % of stroke and 49 % of coronary heart disease cases . There is much evidence for a causal relationship between salt intake and BP . The current salt intake in many countries around the world is between 9 g ⁄d and 12 g ⁄d ( ie , 3.6–4.8 g of sodium ) . R and omized trials have demonstrated that a modest reduction in salt intake lowers BP in individuals with raised BP and also in those with ‘ ‘ normal ’ ’ BP . Furthermore , there is a dose-response relationship . Within the range of 12 g ⁄d to 3 g ⁄d , the lower the salt intake , the lower the BP . Because raised BP throughout its range is a major cause of CVD , salt reduction would reduce cardiovascular risk . It was estimated that a reduction of 6 g ⁄d in salt intake would reduce stroke by 24 % and coronary heart disease by 18 % . This would prevent approximately 35,000 stroke and coronary heart disease deaths a year in the United Kingdom and approximately 2.5 million deaths worldwide . Both prospect i ve studies and outcome trials have demonstrated that a lower salt intake is related to a reduced risk of CVD .  Salt reduction is one of the most cost-effective interventions to reduce CVD in both developed and developing countries . For example , the UK salt reduction campaign , which result ed in a fall in salt intake by approximately 10 % ( ie , from 9.5 g ⁄d in 2003 to 8.6 g ⁄d by May 2008 ) , cost just £ 15 million and led to approximately 6000 fewer CVD deaths per year , saving the UK economy approximately £ 1.5 billion per annum according to the recent report by the UK government ’s health advisory agency , the National Institute for Health and Clinical Excellence . In most developed countries , approximately 80 % of salt consumed is added to foods at the stage of manufacturing , and the consumers have no say over how much salt is added . Therefore , to achieve a reduction in population salt intake , it is imperative that the food industry make a gradual and sustained reduction in the amount of salt that is added to all foods . This approach has been successful in the United Kingdom and is now being exp and ed worldwide . World Salt Awareness Week was introduced by the salt reduction action group World Action on Salt and Health ( WASH ) in 2008 . The event serves as a platform for international experts in the fields of hypertension and nephrology to raise the profile of the importance of salt reduction to both the public and health professionals worldwide OBJECTIVE We evaluated the hypothesis that higher levels of total daily physical activity can eliminate the increased mortality rate associated with overweight and obesity . DESIGN Population -based prospect i ve cohort study . SETTING Central Sweden . SUBJECTS A total of 37,633 men at baseline 45 - 79 years of age and free of known cancer and cardiovascular disease and diabetes completed a  self-administered life-style question naire , which included questions on body-mass index ( BMI ) and physical activity . During 9.7 years of follow-up , we identified a total of 4086 deaths . MAIN OUTCOME MEASURES Mortality rate ratios ( RRs ) . RESULTS Compared to men who were lean ( BMI < 25 kg m(-2 ) ) and active ( top tertile of total physical activity level ) the multivariable adjusted RRs ( 95 % confidence interval ) of death from all causes were 1.44 ( 1.11 - 1.86 ) for obese ( BMI > or = 30 kg m(-2 ) ) and active men , 1.54 ( 1.34 - 1.77 ) for lean ( BMI < 25 kg m(-2 ) ) but inactive ( bottom tertile ) men , and 1.81 ( 1.48 - 2.23 ) for obese-inactive men . After excluding the first 3 years of follow-up , current and former smokers , those who had lost weight from age 20 years to age at baseline , and heavy manual workers , the adjusted RRs of death from all causes were 1.65 ( 1.20 - 2.27 ) for overweight-to-obese and active men , 2.15 ( 1.59 - 2.91 ) for lean-inactive men , and 2.04 ( 1.52 - 2.74 ) for overweight-to-obese and inactive men compared to lean-active men . CONCLUSIONS We conclude that both overweight and physical inactivity are important predictors of mortality . Our findings do not support the hypothesis that a higher level of physical activity compensates the excess mortality associated with overweight and obesity Background Coronary artery disease ( CAD ) is accountable for more than 7 million deaths each year according to the World Health Organization ( WHO ) . In a European population 80 % of patients diagnosed with CAD are overweight and 31 % are obese . Physical inactivity and overweight are major risk factors in CAD , thus central strategies in secondary prevention are increased physical activity and weight loss . Methods / Design In a r and omized controlled trial 70 participants with stable CAD , age 45–75 , body mass index 28–40 kg/m2 and no diabetes are r and omized ( 1:1 ) to 12 weeks of  intensive exercise or weight loss both succeeded by a 40-week follow-up . The exercise protocol consist of supervised aerobic interval training ( AIT ) at 85 - 90 % of VO2peak 3 times weekly for 12 weeks followed by supervised AIT twice weekly for 40 weeks . In the weight loss arm dieticians instruct the participants in a low energy diet ( 800–1000 kcal/day ) for 12 weeks , followed by 40 weeks of weight maintenance combined with supervised AIT twice weekly . The primary endpoint of the study is change in coronary flow reserve after the first 12 weeks ’ intervention . Secondary endpoints include cardiovascular , metabolic , inflammatory and anthropometric measures . Discussion The study will compare the short and long-term effects of a protocol consisting of AIT alone or a rapid weight loss followed by AIT . Additionally , it will provide new insight in mechanisms behind the benefits of exercise and weight loss . We wish to contribute to the creation of effective secondary prevention and sustainable rehabilitation strategies in the large population of overweight and obese patients diagnosed with CAD.Trial registration Clinical Trials.gov : CONTEXT Recent guidelines for treatment of overweight and obesity include recommendations for risk stratification by disease conditions and cardiovascular disease ( CVD ) risk factors , but the role of physical inactivity is not prominent in these recommendations . OBJECTIVE To quantify the influence of low cardiorespiratory fitness , an objective marker of physical inactivity , on CVD and all-cause mortality in normal-weight , overweight , and obese men and compare low fitness with other mortality predictors . DESIGN Prospect i ve observational data from the Aerobics Center Longitudinal Study . SETTING Preventive medicine clinic in Dallas , Tex . PARTICIPANTS A total of 25714 adult men ( average age , 43.8 years [ SD , 10.1 years ] ) who received a medical examination during 1970 to 1993 , with mortality follow-up to December 31 , 1994 . MAIN OUTCOME MEASURES Cardiovascular disease and all-cause mortality based on mortality predictors ( baseline CVD , type 2 diabetes mellitus , high serum cholesterol level , hypertension , current cigarette smoking , and low cardiorespiratory fitness ) stratified by body mass index . RESULTS During the study period , there were 1025 deaths ( 439 due to CVD ) during 258781 man-years of follow-up . Overweight and obese men with baseline CVD or CVD risk factors were at higher risk for all-cause and CVD mortality compared with normal-weight men without these predictors . Using normal-weight men without CVD as the referent , the strongest predictor of CVD death in obese men was baseline CVD ( age- and examination year-adjusted relative risk [ RR ] , 14.0 ; 95 % confidence interval [ CI ] , 9.4 - 20.8 ) ; RRs for obese men with diabetes mellitus , high cholesterol , hypertension , smoking , and low fitness were similar and ranged from 4.4 ( 95 % CI , 2.7 - 7.1 ) for smoking to 5.0 ( 95 % CI , 3.6 - 7.0 ) for low fitness . Relative risks for all-cause mortality in obese men ranged from 2.3 ( 95 % CI , 1.7 - 2.9 ) for men with hypertension to 4.7 ( 95 % CI , 3.6 - 6.1 ) for those with CVD at baseline . Relative risk for all-cause mortality in obese men with low fitness was 3.1 ( 95 % CI , 2.5 - 3.8 ) and in obese men with diabetes mellitus 3.1 ( 95 % CI , 2.3 - 4.2 ) and as slightly higher than the RRs for obese men who smoked or had high cholesterol levels . Low fitness was an independent predictor of mortality in all body mass index groups after adjustment for other mortality predictors . Approximately 50 % ( n = 1674 ) of obese men had low fitness , which led to a population -attributable risk of 39 % for CVD mortality and 44 % for all-cause mortality . Baseline CVD had population attributable risks of 51 % and 27 % for CVD and all-cause mortality , respectively . CONCLUSIONS In this analysis , low cardiorespiratory fitness was a strong and independent predictor of CVD and all-cause mortality and of comparable importance with that of diabetes mellitus and other CVD risk factors The purpose of this analytical review was to estimate the direct and indirect economic costs of  physical inactivity and obesity in Canada in 2001 . The relative risks of diseases associated with physical inactivity and obesity were determined from a meta- analysis of existing prospect i ve studies and applied to the health care costs of these diseases in Canada . Estimates were derived for both the direct health care expenditures and the indirect costs , which included the value of economic output lost because of illness , injury-related work disability , or premature death . The economic burden of physical inactivity was $ 5.3 billion ( $ 1.6 billion in direct costs and $ 3.7 billion in indirect costs ) while the cost associated with obesity was $ 4.3 billion ( $ 1.6 billion of direct costs and $ 2.7 billion of indirect costs ) . The total economic costs of physical inactivity and obesity represented 2.6 % and 2.2 % , respectively , of the total health care costs in Canada . The results underscore the importance of public health efforts aim ed at combating the current epidemics of physical inactivity and obesity in Canada Background Effective interventions to prevent overweight and obesity in children are urgently needed especially in inner-city neighbourhoods where prevalence of overweight and inactivity among primary school children is high . A school based intervention was developed aim ing at the reduction of overweight and inactivity in these children by addressing both behavioural and environmental determinants . Methods / design The main components of the intervention ( Lekker Fit ! ) are the re-establishment of a professional physical education teacher ; three ( instead of two ) PE classes per week ; additional sport and play activities outside school hours ; fitness testing ; classroom education on healthy nutrition , active living and healthy lifestyle choices ; and the involvement of parents . The effectiveness of the intervention is evaluated through a cluster r and omized controlled trial in 20 primary schools among grade s 3 through 8 ( 6–12 year olds ) . Primary outcome measures are BMI , waist circumference and fitness . Secondary outcome measures are assessed in a subgroup of grade 6–8 pupils ( 9–12 year olds ) through classroom question naires and constitute of nutrition and physical activity behaviours and behavioural determinants . Multilevel regression analyses are used to study differences in outcomes between children in the intervention schools and in  control schools , taking clustering of children within schools into account . Discussion Hypotheses are that the intervention results in a lower prevalence of children being overweight and an improved mean fitness score , in comparison with a control group where the intervention is not implemented . The results of our study will contribute to the discussion on the role of physical education and physical activity in the school curriculum . Trial registration [ IS RCT N84383524 Abstract Objective . To investigate the feasibility and impact on BMI and physical fitness of an intervention for obese and inactive children , based on physical activity and carried out in primary health care . Design . A prospect i ve , longitudinal one-year follow-up study . Setting . The community of Kristians and , Norway ( 80 000 inhabitants ) . Intervention . A 40-week structured intervention based on physical training with some lifestyle advice for the obese child and one parent . Subjects . A total of 62 physically inactive children aged 6–14 years with iso- BMI ≥ 30 kg/m2 . Main outcome measures . Body mass index ( BMI ) , maximum oxygen uptake , and physical fitness in tests of running , jumping , throwing , and climbing assessed at baseline and after six and 12 months as well as number of dropouts and predicting factors . Results . A total of 49 out of 62 children completed the first six months and 37 children completed 12 months . Dropout rate was higher when parents reported being physically inactive at baseline or avoided physical participation in the intervention . The children 's maximum oxygen uptake increased significantly after 12 months from 27.0 to 32.0 ml/kg/min ( means ) , as did physical fitness ( endurance , speed , agility , coordination , balance , strength ) and BMI was significantly reduced . Conclusion / implication s. This one-year activity-based intervention for obese and inactive children performed in primary health care succeeded by increasing cardiovascular capacity and physical fitness combined with reduced BMI in those who completed . Dropout was substantial and depended on the attendance and compliance with physical activity by the parents Background — Sugar-sweetened beverages ( SSBs ) are consumed globally and contribute to adiposity . However , the worldwide impact of SSBs on burdens of adiposity-related cardiovascular diseases ( CVDs ) , cancers , and diabetes mellitus has not been assessed by nation , age , and sex . Methods and Results — We modeled global , regional , and national burdens of disease associated with SSB consumption by age/sex in 2010 . Data on SSB consumption levels were pooled from national dietary surveys worldwide . The effects of SSB intake on body mass index and diabetes mellitus , and of elevated body mass index on CVD , diabetes mellitus , and cancers were derived from large prospect i ve cohort pooling studies . Disease-specific mortality/morbidity data were obtained from Global Burden of Diseases , Injuries , and Risk Factors 2010 Study . We computed cause-specific population -attributable fractions for SSB consumption , which were multiplied by cause-specific mortality/morbidity to compute estimates of SSB-attributable death/disability . Analyses were done by country/age/sex ; uncertainties of all input data were propagated into final estimates . Worldwide , the model estimated 184 000 ( 95 % uncertainty interval , 161 000–208 000 ) deaths/y attributable to SSB consumption : 133 000 ( 126 000–139 000 ) from diabetes mellitus , 45 000 ( 26 000–61 000 ) from CVD , and 6450 ( 4300–8600 ) from cancers . Five percent of  SSB-related deaths occurred in low-income , 70.9 % in middle-income , and 24.1 % in high-income countries . Proportional mortality attributable to SSBs ranged from < 1 % in Japanese > 65 years if age to 30 % in Mexicans < 45 years of age . Among the 20 most populous countries , Mexico had largest absolute ( 405 deaths/million adults ) and proportional ( 12.1 % ) deaths from SSBs . A total of 8.5 ( 2.8 , 19.2 ) million disability-adjusted life years were related to SSB intake ( 4.5 % of diabetes mellitus – related disability-adjusted life years ) . Conclusions — SSBs are a single , modifiable component of diet that can impact preventable death/disability in adults in high- , middle- , and low-income countries , indicating an urgent need for strong global prevention programs CONTEXT Physical inactivity and body mass index ( BMI ) are established independent risk factors in the development of type 2 diabetes ; however , their comparative importance and joint relationship with diabetes are unclear . OBJECTIVE To examine the relative contributions and joint association of physical activity and BMI with diabetes . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study of 37 878 women free of cardiovascular disease , cancer , and diabetes with 6.9 years of mean follow-up .  Weight , height , and recreational activities were reported at study entry . Normal weight was defined as a BMI of less than 25 ; overweight , 25 to less than 30 ; and obese , 30 or higher . Active was defined as expending more than 1000 kcal on recreational activities per week . MAIN OUTCOME MEASURE Incident type 2 diabetes , defined as a new self-reported diagnosis of diabetes . RESULTS During the follow-up , 1361 cases of incident diabetes occurred . Individually , BMI and physical activity were significant predictors of incident diabetes . Compared with normal-weight individuals , the multivariate-adjusted hazard ratio ( HR ) was 3.22 ( 95 % confidence interval [ CI ] , 2.69 - 3.87 ) for overweight individuals and 9.09 ( 95 % CI , 7.62 - 10.8 ) for obese individuals . For overall activity ( kilocalories expended per week ) , compared with the least active first quartile , the multivariate-adjusted HRs were 0.91 ( 95 % CI , 0.79 - 1.06 ) for the second quartile , 0.86 ( 95 % CI , 0.74 - 1.01 ) for the third , and 0.82 ( 95 % CI , 0.70 - 0.97 ) for the fourth ( P for trend = .01 ) . In the combined analyses , overweight and obese participants , whether active or inactive , had significantly elevated risks , compared with normal-weight active individuals . The multivariate-adjusted HRs were 1.15 ( 95 % CI , 0.83 - 1.59 ) for normal-weight inactive , 3.68 ( 95 % CI , 2.63 - 5.15 ) for overweight active , 4.16 ( 95 % CI , 3.05 - 5.66 ) for overweight inactive , 11.5 ( 95 % CI , 8.34 - 15.9 ) for obese active , and 11.8 ( 95 % CI , 8.75 - 16.0 ) for obese inactive participants . CONCLUSIONS Although BMI and physical inactivity are independent predictors of incident diabetes , the magnitude of the association with BMI was greater than with physical activity in combined analyses . These findings underscore the critical importance of adiposity as a determinant of diabetes Background Worldwide in 2000 , 10 % of children aged five to 17 years were reported as being overweight with an additional 2‐3 % being obese . Overweight and obesity in childhood can adversely impact on both physical and psychological health . The rise in the prevalence of childhood obesity is a complex issue but widely recognised contributors include increased energy intake , decreased levels of physical activity and greater time spent in sedentary pursuits . A large number of environmental and cultural factors have also been identified as contributing to the problem . Evidence to support an optimal approach to treating childhood obesity is limited with many studies showing only modest results at best in the long‐term . However , the importance of family‐based treatment that combines diet , physical activity and behavioral components has been acknowledged in a recent Cochrane Systematic Review . It has also been suggested that interventions offered in the community setting may help overcome barriers to participation , by making programs more accessible and allowing the targeting of specific sub‐groups of the population . Objectives The objective of this review was to identify the effectiveness of parent‐centred interventions implemented in the community setting in modifying eating and physical activity behaviors or weight‐related outcomes of children . Inclusion criteria Types of participants This review considered studies that included free‐living children of pre‐school , primary and secondary school age and /or their parents/guardians aged > 18 years . Types of intervention(s)/phenomena of interest Intervention programs were required to have a parental component , to target eating and /or exercise behaviors for the prevention or treatment of obesity , and child weight status reported . Types of studies All intervention studies were included in the review including : r and omized controlled trials ( RCTs ) ; non‐r and omized controlled trials , longitudinal studies , cohort ( both retrospective and prospect i ve ) , case control and time series studies which had been conducted in a community setting . Types of outcomes This review considered studies that included overweight/obesity related outcomes , eating behavior outcomes , physical activity behaviour outcomes , and sedentary behavior outcomes and constructs . Search strategy A literature search of community‐based parent‐centred intervention studies to promote nutrition and physical activity for the prevention and treatment and of childhood overweight and obesity was performed in eight electronic data bases dating from 1975 to April 2009 . Method ological quality Studies were critically appraised for method ological quality using st and ardized tools . Data collection Data was extracted by one review er using a st and ardized data extraction form developed by the research ers and checked for accuracy and consistency by a second review er . Data synthesis Data in relation to setting , methodology , intervention components and effect on weight , dietary intake and physical activity was extracted , and described in a narrative synthesis . Where possible a meta‐ analysis was undertaken . Results Of the home‐based interventions , five of nine studies reported statistically significant changes in anthropometric outcomes post intervention . Of the 10 studies in the before and after school care setting , seven reported a significant decrease in a weight‐related outcome post intervention , with only one reporting an increase . Conclusions Results from the review support the after‐school setting as the most promising for community intervention setting for targeting parents as agents of change within child obesity prevention and treatment programs . Implication s for practice At this stage , interventions to support parents should target the after‐school environment as opposed to being conducted in the home , summer camps , leisure centers or churches . Targeting a decrease in energy intake and sweetened beverages in parallel with increasing number of daily steps and decreasing screen time use . Implication s for research Future studies of high quality are needed across the full range of community setting s. Given that currently most of the higher quality RCTs and the studies showing positive impacts of weight change are in the after‐school setting , further studies in this area using similar method ologies to those already published will facilitate future meta‐analyses in this area PURPOSE To investigate the association between pre- and postdiagnosis physical activity ( as well as change in prediagnosis to postdiagnosis physical activity ) and mortality among women with breast cancer . PATIENTS AND METHODS This was a prospect i ve observational study of 933 women enrolled onto the Health , Eating , Activity , and Lifestyle Study who were diagnosed with local or regional breast cancer between 1995 and 1998 and observed until death or September 2004 , whichever came first . The primary outcomes measured were total deaths and breast cancer deaths . The primary exposures were  physical activity in the year before and 2 years after diagnosis and the pre- to postdiagnosis change in physical activity . RESULTS Compared with inactive women , the multivariable hazard ratios ( HRs ) for total deaths for women expending at least 9 metabolic equivalent hours per week ( approximately 2 to 3 h/wk of brisk walking ) were 0.69 ( 95 % CI , 0.45 to 1.06 ; P = .045 ) for those active in the year before diagnosis and 0.33 ( 95 % CI , 0.15 to 0.73 ; P = .046 ) for those active 2 years after diagnosis . Compared with women who were inactive both before and after diagnosis , women who increased physical activity  after diagnosis had a 45 % lower risk of death ( HR = 0.55 ; 95 % CI , 0.22 to 1.38 ) , and women who decreased physical activity  after diagnosis had a four-fold greater risk of death ( HR = 3.95 ; 95 % CI , 1.45 to 10.50 ) . CONCLUSION Moderate-intensity physical activity after a diagnosis of breast cancer may improve prognosis Background Childhood obesity is not only associated with adult obesity but also with increased risk of adult onset of type 2 diabetes and subsequent coronary heart disease . The potential effects of school-based health intervention programmes on cardiovascular risk and surrogate markers are unclear , as only few studies have attempted to investigate a complete risk profile including a detailed laboratory analysis or micro- and macrovascular function . In this study a comprehensive school-based r and omized intervention programme will be investigated in 10 - 14-year old children addressing the influence of lifestyle intervention on inactivity , cardiometabolic risk factors and early signs of vascular disease . Methods / Design 15 secondary schools in Southern Germany are r and omly assigned to intervention or control schools . Children in the fifth grade ( 10 - 11 years ) will be observed over four years . The study combines a school-based with a home-based approach , aim ing at children , teachers and parents . The main components are weekly lifestyle-lessons for children , taught by regular classroom teachers to increase physical activity in- and outside of school , to improve eating patterns at school and at home , to reduce media consumption and to amplify well-being . In 4 - 6 annual meetings , teachers receive information about health-related topics with worksheets for children and supporting equipment , accounting for school-specific needs and strategies . Parents ' trainings are provided on a regular basis . All examinations are performed at the beginning and at the end of every school year . Anthropometry includes measurements of BMI , waist and upper arm circumferences , skinfold thickness as well as peripheral blood pressure . Blood sampling includes lipid parameters , insulin , glucose , hsCRP , adiponectin , and IL-6 as well as testosteron and estrogen to determine maturation status . Vascular function is non-invasively assessed by measuring arterial stiffness in large arteries using a sphygmograph and by analysing arteriolar and venular diameters in the retinal microcirculation using a non-mydriatric vessel analyser . A question naire is filled out to determine daily physical activity , motivational factors , dietary habits , quality of life ( KINDL-R ) and socio-economic data . Physical fitness is assessed by a six-item test battery . Discussion Our study aims to provide a feasible long-term intervention strategy to re-establish childhood health and to prevent obesity-related cardiovascular dysfunction in children . Trial Registration Northern Irel and has the highest incidence of coronary heart disease ( CHD ) in the world . The physical fitness , activity patterns , health knowledge , attitudes , and dietary habits of a r and om , stratified sample of 3211 Northern Irish children , comprising 1540 boys and 1671 girls , age range 11 - 18 years were examined . At all ages boys were significantly more active than girls . The most important finding was an appreciable decline in physical activity levels after the age of 14 years reaching extremely low levels in older girls . While 75 % of exercise taken was not related to school , physical education classes constituted the only exercise taken by one third of pupils . Girls had healthier nutritional habits and were more inclined to employ weight control measures than boys . There was a preponderance of children with a higher body mass index indicating a tendency to obesity in the child population . Over 20 % of school leavers of both sexes regularly smoked cigarettes and 20 % regularly drank alcohol . The postulated relationship between childhood inactivity , adult sedentary lifestyle , and increased risk of CHD raises serious cause for concern regarding the future cardiovascular health of many children Abstract Objective To assess the prospect i ve associations of baseline and long term trajectories of physical activity on mortality from all causes , cardiovascular disease , and cancer . Design Population based cohort study . Setting Adults from the general population in the UK . Participants 14 599 men and women ( aged 40 to 79 ) from the European Prospect i ve Investigation into Cancer and Nutrition-Norfolk cohort , assessed at baseline ( 1993 to 1997 ) up to 2004 for lifestyle and other risk factors ; then followed to 2016 for mortality ( median of 12.5 years of follow-up , after the last exposure assessment ) . Main exposure  Physical activity energy expenditure ( PAEE ) derived from question naires , calibrated against combined movement and heart rate monitoring . Main outcome measures Mortality from all causes , cardiovascular disease , and cancer . Multivariable proportional hazards regression models were adjusted for age , sex , sociodemographics , and changes in medical history , overall diet quality , body mass index , blood pressure , triglycerides , and cholesterol levels . Results During 171 277 person years of follow-up , 3148 deaths occurred . Long term increases in PAEE were inversely associated with mortality , independent of baseline PAEE . For each 1 kJ/kg/day per year increase in PAEE ( equivalent to a trajectory of being inactive at baseline and gradually , over five years , meeting the World Health Organization minimum physical activity guidelines of 150 minutes/week of moderate-intensity physical activity ) , hazard ratios were : 0.76 ( 95 % confidence interval 0.71 to 0.82 ) for all cause mortality , 0.71 ( 0.62 to 0.82 ) for cardiovascular disease mortality , and 0.89 ( 0.79 to 0.99 ) for cancer mortality , adjusted for baseline PAEE , and established risk factors . Similar results were observed when analyses were stratified by medical history of cardiovascular disease and cancer . Joint analyses with baseline and trajectories of physical activity show that , compared with consistently inactive individuals , those with increasing physical activity trajectories over time experienced lower risks of mortality from all causes , with hazard ratios of 0.76 ( 0.65 to 0.88 ) , 0.62 ( 0.53 to 0.72 ) , and 0.58 ( 0.43 to 0.78 ) at low , medium , and high baseline physical activity , respectively . At the population level , meeting and maintaining at least the minimum physical activity recommendations would potentially prevent 46 % of deaths associated with physical inactivity . Conclusions Middle aged and older adults , including those with cardiovascular disease and cancer , can gain substantial longevity benefits by becoming more physically active , irrespective of past physical activity levels and established risk factors . Considerable population health impacts can be attained with consistent engagement in physical activity during mid to late life Diabetes mellitus contributes substantially to the global burden of disease , with an estimated 100 million people affected worldwide , and its prevalence is increasing rapidly.1 Macrovascular complications are among the chief causes of major morbidity in people with diabetes , and most of their deaths are attributed to cardiovascular causes.2 3 In type 2 ( “ non-insulin dependent ” ) diabetes , blood triglyceride concentrations tend to be raised and high density lipoprotein ( HDL ) cholesterol concentrations reduced even with good metabolic control , whereas a similar pattern tends to emerge in type 1 ( “ insulin dependent ” ) diabetes mellitus only when glycaemic control is poor.4 5 Typically in both type 1 and type 2 diabetes , however , blood concentrations of total and low density lipoprotein ( LDL ) cholesterol are similar to those in the general population . This may have contributed to the belief that LDL cholesterol is of little relevance to the risk of cardiovascular disease in diabetes4 6 and , apart from those with pronounced dyslipidaemia or pre-existing coronary heart disease ( CHD ) , most people with diabetes do not receive cholesterol lowering treatment despite their increased risk . Prospect i ve epidemiological studies in the general population show that there is a positive association between CHD risk and blood total cholesterol concentration , which continues down at least to 3 mmol/l ( that is , well below the range commonly seen in western population s)7 without any evidence of a “ threshold ” below which lower cholesterol is not associated with lower risk . In these observational studies , the continuous association is roughly linear between CHD risk plotted on a doubling scale and the concentration of total or LDL cholesterol . This implies that the proportional reduction in CHD risk associated with a particular prolonged absolute difference in cholesterol is similar throughout the range studied . Hence , the absolute size of the reduction in CHD produced by lowering LDL cholesterol by BACKGROUND Physical inactivity is a risk behavior for cardiovascular and other diseases . Schools can promote public health objectives by increasing physical activity among youth . METHODS The Child and Adolescent Trial for Cardiovascular Health ( CATCH ) was a multicenter , r and omized trial to test the effectiveness of a cardiovascular health promotion program in 96 public schools in four states . A major component of CATCH was an innovative , health-related physical education ( P+ ) program . For 2.5 years , r and omly assigned schools received a st and ardized PE intervention , including curriculum , staff development , and follow-up . RESULTS Systematic analysis of 2,096 PE lessons indicated students engaged in more moderate-to-vigorous physical activity ( MVPA ) in intervention than in control schools ( P = 0.002 ) . MVPA during lessons in intervention schools increased from 37.4 % at baseline to 51.9 % , thereby meeting the established Year 2000 objective of 50 % . Intervention children reported 12 more min of daily vigorous physical activity ( P = 0.003 ) and ran 18.6 yards more than control children on a 9-min run test of fitness ( P = 0.21 ) . CONCLUSIONS The implementation of a st and ardized curriculum and staff development program increased children 's  MVPA in existing school PE classes in four geographic and ethnically diverse communities . CATCH PE provides a tested model for improving physical education in American schools Overweight and physical inactivity are risk factors for increased disease burden and health care expenditure . Well- design ed studies are still needed to determine the treatment efficacy of worksite interventions targeting such risk factors . This r and omized controlled trial was conducted at one of Australia 's casinos in 2002 - 2003 , to investigate the effects of a comprehensive exercise and lifestyle intervention on physical fitness . Only 6.4 % of the workforce expressed interest in being study participants . Seventy-three employees ( aged 32 + /- 8 years , 51 % overweight/obese , 73 % shift workers and 52 % women ) were recruited and r and omized to treatment or wait-list control groups for 24 weeks , 44 of whom completed the intervention . Components of the intervention include supervised moderate-to-high intensity exercise including combined aerobic ( at least 20 min duration 3 days/week ) and weight-training ( for an estimated 30 min completed 2 - 3 days/week ) , and dietary/health education ( delivered via group seminars , one-on-one counselling and literature through the provision of a worksite manual ) . ANCOVA , by intention-to-treat and of study completers , found significant between-group differences in the mean waist circumference and predicted maximal oxygen uptake ( VO2max ) , favouring the intervention , but effects were concentrated in one subject . For study completers , between-group differences in the mean waist circumference ( 82.3 + /- 9.2 versus 90.5 + /- 17.8 cm , p = 0.01 ) and predicted VO2max ( 47 versus 41 ml/kg/min , p < 0.001 ) remained significant without the outlier , favouring the intervention . Higher intervention compliance predicted greater improvements in physical fitness . No significant effects on body mass or body mass index were found . This worksite intervention significantly improved waist circumference and aerobic fitness in healthy but sedentary employees , most of whom were shift workers .  Worksite interventions have the potential to counter the increasing burden of overweight and obesity , particularly visceral adiposity , as well as physical inactivity ; however , substantial barriers to adoption/adherence need to be overcome for greater feasibility and impact on employee physical health Abstract Background Coronary heart disease ( CHD ) is the most prevalent type of cardiac disease among adults worldwide , including those in Singapore . Most of its risk factors , such as smoking , physical inactivity and high blood pressure , are preventable . mHealth has improved in the last decade , showing promising results in chronic disease prevention and health promotion worldwide . Our aim was to develop and examine the effect of a 4-week Smartphone-Based Coronary Heart Disease Prevention ( SBCHDP ) programme in improving awareness and knowledge of CHD , perceived stress as well as cardiac-related lifestyle behaviours in the working population of Singapore . Methods The smartphone app “ Care4Heart ” was developed as the main component of the programme . App content was review ed and vali date d by a panel of experts , including two cardiologists and two experienced cardiology-trained nurses . A pilot r and omised controlled trial was conducted . Eighty working people were recruited and r and omised to either the intervention group ( n = 40 ) or the control group ( n = 40 ) . The intervention group underwent a 4-week SBCHDP programme , whereas the control group were offered health promotion websites only . The participants ’ CHD knowledge , perceived stress and behavioural risk factors were measured at baseline and on the 4th week using the Heart Disease Fact Question naire-2 , Perceived Stress Scale , and Behavioural Risk Factor Surveillance System . Results After the SBCHDP programme , participants in the intervention group had a better awareness of CHD being the second leading cause of death in Singapore ( X2 = 6.486 , p = 0.039 ) , a better overall CHD knowledge level ( t = 3.171 , p = 0.002 ) , and better behaviour concerning blood cholesterol control ( X2 = 4.54 , p = 0.033 ) than participants in the control group . Conclusion This pilot study partially confirmed the positive effects of the SBCHDP programme in improving awareness and knowledge of CHD among the working population . Due to the small sample size and short follow-up period , this study was underpowered to detect significant differences between groups . A full-scale longitudinal study is required in the future to confirm the effectiveness of the SBCHDP programme Objective : To estimate the excess deaths associated with weight loss in combination with leisure time physical activity among overweight or obese people . Design : Prospect i ve cohort study .Subjects : In two consecutive examinations in 1976–1978 and 1981–1983 , 11 135 people participated in the Copenhagen City Heart Study . Of these , 3078 overweight or obese participants lost weight or remained weight stable from 1976–1978 to 1981–1983 , and were without pre-existing diagnosis of diabetes , stroke , ischaemic heart disease or cancer in 1981–1983 . They were followed up until 2007 in the Danish Civil Registration System , with a < 0.2 % loss to follow-up only . Measurements : The following measurements were taken : body mass index ( BMI ) and physical activity in 1976–1978 and 1981–1983 and hazard ratio ( HR ) of mortality during 53 976 person-years of follow-up . Results : Of the initially overweight or obese subjects who either lost weight or remained weight stable , 2060 died . Overall , weight loss was associated with excess mortality when compared with weight stability . Weight loss was associated with a higher mortality among those who became physically inactive , compared with those who remained active while losing weight ( men : HR 2.25 , 95 % confidence interval 1.31–3.84 ; women : 1.43 , 1.07–1.91 ) . However , losing weight while remaining physically active was still associated with excess mortality when compared with those who were weight stable and initially active ( men : 1.72 , 1.27–2.34 ; women : 1.57 , 1.06–2.31 ) . Among those who remained physically inactive , weight loss seemed associated with excess mortality when compared with weight loss among those who became active , although not statistically significant ( men : 2.00 , 0.94–4.29 ; women : 1.40 , 0.82–2.39 ) . Finally , weight loss among those who became physically active was not associated with excess mortality when compared with those who were weight stable and initially inactive ( men : 1.12 , 0.61–2.07 ; women : 1.19 , 0.58–2.43 ) . Conclusion : Weight loss among the overweight or obese seemed hazardous to survival . However , weight loss seemed less hazardous to survival among those who remained physically active or those who became active Background Over 75 % of the annual estimated 9.5 million deaths in India occur in the home , and the large majority of these do not have a certified cause . India and other developing countries urgently need reliable quantification of the causes of death . They also need better epidemiological evidence about the relevance of physical ( such as blood pressure and obesity ) , behavioral ( such as smoking , alcohol , HIV-1 risk taking , and immunization history ) , and biological ( such as blood lipids and gene polymorphisms ) measurements to the development of disease in individuals or disease rates in population s. We report here on the rationale , design , and implementation of the world 's largest prospect i ve study of the causes and correlates of mortality . Methods and Findings We will monitor nearly 14 million people in 2.4 million nationally representative Indian households ( 6.3 million people in 1.1 million households in the 1998–2003 sample frame and 7.6 million people in 1.3 million households in the 2004–2014 sample frame ) for vital status and , if dead , the causes of death through a well-vali date d verbal autopsy ( VA ) instrument . About 300,000 deaths from 1998–2003 and some 700,000 deaths from 2004–2014 are expected ; of these about 850,000 will be coded by two physicians to provide causes of death by gender , age , socioeconomic status , and geographical region . Pilot studies will evaluate the addition of physical and biological measurements , specifically  dried blood spots .  Preliminary results from over 35,000 deaths suggest that VA can ascertain the leading causes of death , reduce the misclassification of causes , and derive the probable underlying cause of death when it has not been reported . VA yields broad classification of the underlying causes in about 90 % of deaths before age 70 . In old age , however , the proportion of classifiable deaths is lower . By tracking underlying demographic denominators , the study permits quantification of absolute mortality rates . Household case-control , proportional mortality , and nested case-control methods permit quantification of risk factors . Conclusions This study will reliably document not only the underlying cause of child and adult deaths but also key risk factors ( behavioral , physical , environmental , and eventually , genetic ) . It offers a globally replicable model for reliably estimating cause-specific mortality using VA and strengthens India 's flagship mortality monitoring system . Despite the misclassification that is still expected , the new cause-of-death data will be substantially better than that available previously BACKGROUND The incidence of congestive heart failure ( CHF ) has been increasing steadily in the United States during the past 2 decades . We studied risk factors for CHF and their corresponding attributable risk in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study . PARTICIPANTS AND METHODS A total of 13 643 men and women without a history of CHF at baseline examination were included in this prospect i ve cohort study . Risk factors were measured using st and ard methods between 1971 and 1975 . Incidence of CHF was assessed using medical records and death certificates obtained between 1982 and 1984 and in 1986 , 1987 , and 1992 . RESULTS During average follow-up of 19 years , 1382 CHF cases were documented . Incidence of CHF was positively and significantly associated with male sex ( relative risk [ RR ] , 1.24 ; 95 % confidence interval [ CI ] , 1.10 - 1.39 ; P<.001 ; population attributable risk [ PAR ] , 8.9 % ) , less than a high school education ( RR , 1.22 ; 95 % CI , 1.04 - 1.42 ; P = .01 ; PAR , 8.9 % ) , low physical activity ( RR , 1.23 ; 95 % CI , 1.09 - 1.38 ; P<.001 ; PAR , 9.2 % ) , cigarette smoking ( RR , 1.59 ; 95 % CI , 1.39 - 1.83 ; P<.001 ; PAR , 17.1 % ) , overweight ( RR , 1.30 ; 95 % CI , 1.12 - 1.52 ; P = .001 ; PAR , 8.0 % ) , hypertension ( RR , 1.40 ; 95 % CI , 1.24 - 1.59 ; P<.001 ; PAR , 10.1 % ) , diabetes ( RR , 1.85 ; 95 % CI , 1.51 - 2.28 ; P<.001 ; PAR , 3.1 % ) , valvular heart disease ( RR , 1.46 ; 95 % CI , 1.17 - 1.82 ; P = .001 ; PAR , 2.2 % ) , and coronary heart disease ( RR , 8.11 ; 95 % CI , 6.95 - 9.46 ; P<.001 ; PAR , 61.6 % ) . CONCLUSIONS Male sex , less education , physical inactivity , cigarette smoking , overweight , diabetes , hypertension , valvular heart disease , and coronary heart disease are all independent risk factors for CHF . More than 60 % of the CHF that occurs in the US general population might be attributable to coronary heart disease Context Previous studies have examined the association between coffee consumption and a variety of specific diseases , such as type 2 diabetes , different types of cancer , and cardiovascular disease . However , the relationship between coffee consumption and all-cause mortality remains unclear . Contribution This study followed 2 large cohorts of men and women who provided data on coffee consumption , other behaviors , and health outcomes every 2 to 4 years over 2 decades . High coffee consumption was not related to increased mortality and may even be associated with lower total and cardiovascular mortality . Caution Misclassification of coffee consumption or confounding by other behavioral factors may account for these observations . The Editors Several epidemiologic studies have examined coffee consumption and risk for coronary heart disease and other chronic diseases , but data on coffee consumption in relation to all-cause and disease-specific mortality are sparse . Some studies found that those who drank coffee were the healthiest cohort members ( 15 ) , an inverse association that has been attributed to a possible confounding effect by morbidity . However , it has recently been suggested that the inverse association between coffee and all-cause mortality is attributable to the beneficial effect of coffee consumption on inflammation ( 6 ) . The Appendix Table lists the previous studies that have examined coffee consumption and the risk for mortality by different causes . Appendix Table . Cohort Studies Addressing the Association between  Coffee Consumption and All-Cause and Disease-Specific Mortality  In support of this hypothesis , we found in a previous study an inverse association between  coffee consumption and several markers of inflammation and endothelial dysfunction ( 7 ) . In addition , in the NHS ( Nurses ' Health Study ) and HPFS ( Health Professionals Follow-up Study ) , consumption of 6 or more cups of coffee per day was associated with a slightly lower risk for fatal coronary heart disease versus nonconsumers in both men and women ( 8) . Moreover , epidemiologic studies have consistently found an association between higher coffee consumption and lower risk for type 2 diabetes ( 9 ) . Finally , several studies have suggested that coffee might decrease the risk for some types of cancer , such as liver , colon , oral , pharyngeal , and esophageal ( 1012 ) . The objective of this study was to assess the association of  coffee consumption with all-cause , cardiovascular disease ( CVD ) , and cancer mortality . The long follow-up and the use of repeated dietary measurements allowed us to assess long-term coffee consumption . In addition , information about incident diseases during the follow-up and up date d measurements of main risk factors for CVD and cancer allowed us to control for potential confounders in detail . Methods Study Population The HPFS was established in 1986 and the NHS in 1976 . Information ( excluding diet ) on the cohort members has been up date d every 2 years . Further details have been published elsewhere ( 13 ) . We used 1980 as baseline for the NHS because this was the first year in which dietary information was collected in this cohort . After excluding participants with CVD or cancer at baseline or those with no information about coffee consumption at baseline ( 1183 persons in the HPFS and 879 in the NHS ) , we included 41736 men and 86214 women who were followed until 2004 . The Harvard School of Public Health and Brigham and Women 's Hospital Human Subjects Committee Review Board approved the study protocol . Assessment of  Coffee Consumption  Dietary question naires were sent to the HPFS participants in 1986 , 1990 , 1994 , and 1998 and to the NHS participants in 1980 , 1984 , 1986 , 1990 , 1994 , and 1998 . In each question naire , participants were asked how often on average during the previous year they had consumed coffee and tea . The participants could choose from 9 responses .  Decaffeinated coffee and different types of caffeinated soft drinks  were first assessed in 1986 in the HPFS and in 1984 in the NHS . We also inquired at baseline about whether the participant 's consumption for each beverage had greatly increased or decreased during the preceding 10 years . Using the U.S. Department of Agriculture food composition sources supplemented with other sources , we estimated that the caffeine content was 137 mg per cup of coffee , 47 mg per cup of tea , 46 mg per can or 12-ounce bottle of a soft drink , and 7 mg per 1-ounce serving of chocolate c and y. We assessed the total intake of caffeine by summing the caffeine content for a unit of each food during the previous year multiplied by a weight proportional to the frequency of its consumption . In our validation study , we obtained high correlations between consumption of coffee and other caffeinated beverages estimated from the food frequency question naire and consumption estimated from repeated 1-week diet records ( coffee , r= 0.78 ; tea , r= 0.93 ; and caffeinated soft drinks , r= 0.85 ) ( 14 ) . Ascertainment of Mortality Deaths were reported by the next of kin or the postal authorities or were ascertained through the National Death Index . We estimated that follow-up for deaths was more than 98 % complete ( 15 ) . For all deaths , we sought death certificates and , when appropriate , requested permission from the next of kin to review medical records . The underlying cause of death was assigned according to the International Classification of Diseases , Eighth Revision ( ICD-8 ) . The primary end point in this analysis was death from any cause . We also conducted analyses according to the main causes of deaths in the cohorts , which were CVD ( ICD-8 codes 390.0 through 458.9 and 795.0 to 795.9 ) and cancer ( ICD-8 codes 140.0 through 207.9 ) , and according to secondary causes of death , such as chronic liver disease and cirrhosis ( ICD-8 code 571.0 ) , chronic obstructive pulmonary disease ( ICD-8 codes 492.0 , 496.0 , and 519.0 ) , diabetes ( ICD-8 codes 250.0 , 250.1 , and 250.9 ) , neurodegenerative diseases ( ICD-8 codes 331.0 and 332.0 ) , and sudden death ( ICD-8 code 798.0 ) . Assessment of Medical History , Anthropometric Data , and Lifestyle Factors In the baseline question naires , we requested information about age ; weight and height ; smoking status ; parental history with respect to myocardial infa rct ion ; menopausal status and use of hormone therapy in women ; and history of hypertension , hypercholesterolemia , and type 2 diabetes mellitus . We up date d this information , with the exception of height and parental history , in the biennial follow-up question naires . We assessed perceived health in 2000 by asking the participants to describe their health as excellent , very good , good , fair , or poor . We calculated body mass index , and we also assessed physical activity biennially . In the HPFS , participants were queried about the average time spent per week during the preceding year in specific activities ( for example , walking outdoors , jogging , and bicycling ) ( 16 ) . The time spent in each activity in hours per week was multiplied by its typical energy expenditure , expressed in metabolic equivalent tasks and then summed over all activities to yield a metabolic equivalent task or hour score . In the NHS , physical activity was reported in hours per week of moderate ( for example , brisk walking ) and vigorous exercise ( for example , strenuous sports and jogging ) ( 17 ) . St and ard portion sizes for alcoholic drinks were specified as a can , bottle , or glass for beer ; 4-oz glass for wine ; and 1 drink or shot for liquor . Detailed information on the validity and reproducibility of the information from the question naires about self-reported weight , physical activity , and alcohol consumption has been reported elsewhere ( 1820 ) . Statistical Analysis We classified participants according to levels of coffee consumption . We calculated person-years of exposure from the date of return of the baseline question naire to the date of death or 1 June 2004 , whichever came first . To reduce within-participant variation and best represent long-term diet , we used the cumulative average of coffee consumption from all available dietary question naires up to the start of each 2-year follow-up interval ( 21 ) ; for example , in the HPFS , the average of the 1986 and 1990 intake was used for the follow-up between 1990 and 1994 ; and the average of the 1986 , 1990 , and 1994 intake was used for the follow-up between 1994 and 1998 . When a food frequency question naire had a missing value for coffee , we used the value from the previous question naire . We used sex-specific Cox proportional hazard models to investigate the association between coffee consumption and incidence of all-cause and disease-specific mortality . To control as finely as possible for confounding by age and calendar time , we stratified the analysis jointly by age in months at start of follow-up and calendar year of the current question naire cycle . We used hazard ratios to estimate relative risks in each category in comparison with participants in the lower category of coffee consumption . We adjusted multivariable models for smoking status , body mass index , physical activity , alcohol intake , use of hormone therapy for women , parental history of myocardial infa rct ion , and dietary factors ( total energy intake ; use of multivitamin and vitamin E supplements ; polyunsaturated , saturated , n-3 , and trans fat intake ; glycemic load ; and folic acid intake ) by using categorical variables . To test for linear trends across categories , we modeled coffee consumption as a continuous variable by using the median value of each level of coffee consumption . In addition , we calculated pooled relative risks for all-cause mortality in men and women combined across categories of coffee consumption by using a r and om-effects method . We also examined a possible nonlinear relation between coffee consumption and total and cardiovascular mortality nonparametrically with restricted cubic splines ( 22 ) . We conducted stratified analyses according to smoking status , alcohol Background High levels of physical inactivity are linked to several chronic diseases including coronary heart disease , type-2 diabetes , obesity , some cancers and poor mental health . Encouraging people to be more active has proven difficult . One way to incorporate physical activity into the daily routine is through the journey to and from work . Although behaviour change techniques ( BCTs ) are considered valuable in promoting behaviour change , there is very little in the published literature about the views and experiences of those encouraged to use them . Methods The Walk to Work study was a feasibility study incorporating an exploratory cluster r and omised controlled trial . The 10-week intervention involved training workplace-based Walk to Work promoters ( volunteers or nominated by participating employers ) to encourage colleagues to increase walking during their daily commute . The intervention used nine specific BCTs : Intention formation , barrier identification , specific goal setting , instruction , general encouragement , self-monitoring of behaviour social support , review of behavioural goals and relapse prevention . Digitally recorded interviews were undertaken with 22 employees , eight of whom were Walk to Work promoters to underst and their views and experiences of using these techniques . The Framework method of data management and constant comparison were used to analyse the data and identify key themes . Results For each individual BCT , there appeared to be people who found it useful in helping them to increase walking to work and others who did not . Following training , the Walk to Work promoters varied in the extent to which they were able to fulfil their role : additional support and encouragement during the 10-week intervention may be required for the promoters to maintain motivation . Wider context ual ( economic climate , unprecedented wet weather ) and organisational ( workload , car parking facilities ) issues were identified that influenced the delivery of , and response to , the intervention . Conclusions Walk to work interventions employing BCTs should include sufficient techniques to enable participants to choose a ‘ package ’ to suit their needs . Additional support at organisational level should also be encouraged , and consideration given to wider context ual factors that impinge on the delivery of , and response to , the intervention . Trial registration IS RCT N72882329 Background Declining levels of physical fitness in children are linked to an increased risk of developing poor physical and mental health .  Physical activity programs for children that involve regular high intensity physical activity , along with muscle and bone strengthening activities , have been identified by the World Health Organisation as a key strategy to reduce the escalating burden of ill health caused by non-communicable diseases . This paper reports the rationale and methods for a school-based intervention design ed to improve physical fitness and physical activity levels of Grade s 5 and 6 primary school children . Methods / Design Fit-4-Fun is an 8-week multi-component school-based health-related fitness education intervention and will be evaluated using a group r and omized controlled trial . Primary schools from the Hunter Region in NSW , Australia , will be invited to participate in the program in 2011 with a target sample size of 128 primary schools children ( age 10 - 13 ) . The Fit-4-Fun program is theoretically grounded and will be implemented applying the Health Promoting Schools framework . Students will participate in weekly curriculum-based health and physical education lessons , daily break-time physical activities during recess and lunch , and will complete an 8-week ( 3 × per week ) home activity program with their parents and /or family members . A battery of six health-related fitness assessment s , four days of pedometery-assessed physical activity and a question naire , will be administered at baseline , immediate post-intervention ( 2-months ) and at 6-months ( from baseline ) to determine intervention effects . Details of the method ological aspects of recruitment , inclusion criteria , r and omization , intervention program , assessment s , process evaluation and statistical analyses are described . Discussion The Fit-4-Fun program is an innovative school-based intervention targeting fitness improvements in primary school children . The program will involve a range of evidence -based behaviour change strategies to promote and support physical activity of adequate intensity , duration and type , needed to improve health-related fitness . Trial Registration NoAustralia and New Zeal and Clinical Trials Register ( ANZCTR ) : Background An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030 . For the year 2010 , it is estimated that 3.96 million excess deaths in the age group 20 - 79 years are attributable to diabetes around the world . Self-management is recognised as an integral part of diabetes care . This paper describes the protocol of a r and omised controlled trial of an automated interactive telephone system aim ing to improve the uptake and maintenance of essential diabetes self-management behaviours . Methods / Design A total of 340 individuals with type 2 diabetes will be r and omised , either to the routine care arm , or to the intervention arm in which participants receive the  Telephone-Linked Care ( TLC ) Diabetes program in addition to their routine care . The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months . They receive the study h and book and a glucose meter linked to a data uploading device . The TLC system consists of a computer with software design ed to provide monitoring , tailored feedback and education on key aspects of diabetes self-management , based on answers voiced or entered during the current or previous conversations . Data collection is conducted at baseline ( Time 1 ) , 6-month follow-up ( Time 2 ) , and 12-month follow-up ( Time 3 ) . The primary outcomes are glycaemic control ( HbA1c ) and quality of life ( Short Form-36 Health Survey version 2 ) . Secondary outcomes include anthropometric measures , blood pressure , blood lipid profile , psychosocial measures as well as measures of diet , physical activity , blood glucose monitoring , foot care and medication taking . Information on utilisation of healthcare services including hospital admissions , medication use and costs is collected . An economic evaluation is also planned . Discussion Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes . Furthermore , the study will provide insight into the potential for more widespread uptake of automated telehealth interventions , globally . Trial Registration UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT Introduction Large proportions of the population are not meeting recommended levels of physical activity and have increasingly sedentary lifestyles . Low levels of physical activity are predictive of poor health outcomes and time spent sedentary is related to a host of risk factors independently of physical activity levels . Building an evidence base of the best approaches to intervene in the lifestyles of inactive individuals is crucial in preventing long-term disease , disability and higher mortality rates . Methods and analysis Systematic search es will be conducted on all relevant data bases ( eg , PubMed , Scopus , CINAHL , PsycINFO ) . Studies will be included if they assess interventions aim ed at changing physical activity or sedentary behaviour levels in adults ( over 18 ) who are inactive and do not suffer from chronic conditions . Studies must also be r and omised controlled trials ( RCTs ) , have a primary outcome of physical activity or sedentary behaviour , and measure outcomes at least 6 months after intervention completion . Studies will be coded using the Behaviour Change Technique ( BCT ) taxonomy v1 and Template for Intervention Description and Replication ( TIDieR ) guidelines . 2 review ers will independently screen full-text articles and extract data on study characteristics , participants , BCTs , intervention features and outcome measures . Study quality will also be assessed independently by 2 review ers using the Cochrane risk of bias tool . A meta- analysis will be considered if there is sufficient homogeneity across outcomes . GRADE criteria will be used to assess quality of evidence . Dissemination This will be the first review to systematic ally appraise interventions aim ed at changing the physical activity or sedentary behaviour of inactive individuals using RCT design s with a 6-month follow-up post-intervention . This review will better inform intervention design ers targeting inactive population s and inform the design of a future complex intervention . Review registration number This protocol was registered with the International Prospect i ve Register of Systematic Review s ( PROSPERO ) on 17 October 2014 ( registration number : CRD42014014321 ) The aim of this study is to review recent data on dietary fiber ( DF ) and the glycemic index ( GI ) , with special focus on studies from the Nordic countries regarding cardiometabolic risk factors , type 2 diabetes , cardiovascular disease , cancer , and total mortality . In this study , recent guidelines and scientific background papers or up date s on older reports on DF and GI published between 2000 and 2011 from the US , EU , WHO , and the World Cancer Research Fund were review ed , as well as prospect i ve cohort and intervention studies carried out in the Nordic countries . All of the reports support the role for fiber-rich foods and DF as an important part of a healthy diet . All of the five identified Nordic papers found protective associations between high intake of DF and health outcomes ; lower risk of cardiovascular disease , type 2 diabetes , colorectal and breast cancer . None of the reports and few of the Nordic papers found clear evidence for the GI in prevention of risk factors or diseases in healthy population s , although association was found in sub-groups , e.g. overweight and obese individuals and suggestive for prevention of type 2 diabetes . It was concluded that DF is associated with decreased risk of different chronic diseases and metabolic conditions . There is not enough evidence that choosing foods with low GI will decrease the risk of chronic diseases in the population overall . However , there is suggestive evidence that ranking food based on their GI might be of use for overweight and obese individuals . Issues regarding methodology , validity and practicality of the GI remain to be clarified BACKGROUND Increased physical activity has been hypothesized to be a means of breast cancer prevention . We examined the associations between physical activity at two different times in life and breast cancer risk . METHODS We analyzed data from the Nurses ' Health Study II , a prospect i ve study of women aged 25 - 42 years in 1989 . On the baseline survey , women were asked , " While in high school and between the ages 18 and 22 years , how often did you participate in strenuous physical activity  at least twice a week ? " We averaged answers to these two questions to develop a measure of late adolescent activity . Women were also asked at baseline to report the number of hours per  week they currently spent in different nonoccupational activities . During 6 years of follow-up , we identified 372 cases of invasive breast cancer . Data were analyzed by use of multivariate pooled logistic regression to produce relative risk ( RR ) and confidence intervals ( CIs ) of being diagnosed with the disease . RESULTS Women who were more active in late adolescence were not at reduced risk of breast cancer compared with less active women . For those women who reported engaging in strenuous activity at least twice per week for 10 - 12 months per year in late adolescence , the RR of cancer , compared with those who never engaged in such activity , was 1.1 ( 95 % CI = 0.8 - 1.6 ) . Similarly , higher levels of recent nonoccupational physical activity were not associated with reduced risk of breast cancer ( RR for > or = 7 hours of activity/week relative to < 1 hour/week = 1.1 ; 95 % CI = 0.8 - 1.5 ) . CONCLUSION Our findings do not support a link between physical activity , in late adolescence or in the recent past , and breast cancer risk among young adult women OBJECTIVE Hyperinsulinemia may promote mammary carcinogenesis . Insulin resistance has been linked to an increased risk of breast cancer and is also characteristic of type 2 diabetes . We prospect ively evaluated the association between type 2 diabetes and invasive breast cancer incidence in the Nurses ' Health Study . RESEARCH DESIGN AND METHODS A total of 116,488 female nurses who were 30 - 55 years old and free of cancer in 1976 were followed through 1996 for the occurrence of type 2 diabetes and through 1998 for incident invasive breast cancer , verified by medical records and pathology reports . RESULTS During 2.3 million person-years of follow-up , we identified 6,220 women with type 2 diabetes and 5,189 incident cases of invasive breast cancer . Women with type 2 diabetes had a modestly elevated incidence of breast cancer ( hazard ratio [ HR ] = 1.17 ; 95 % CI 1.01 - 1.35 ) compared with women without diabetes , independent of age , obesity , family history of breast cancer , history of benign breast disease , reproductive factors , physical activity , and alcohol consumption . This association was apparent among postmenopausal women ( 1.16 ; 0.98 - 1.62 ) but not premenopausal women ( 0.83 ; 0.48 - 1.42 ) . The association was predominant among women with estrogen receptor-positive breast cancer ( 1.22 ; 1.01 - 1.47 ) . CONCLUSIONS Women with type 2 diabetes may have a slightly increased risk of breast cancer We investigated several aspects of the role of physical activity in colon and rectal cancer etiology that remain unclear in the European Prospect i ve Investigation into Nutrition and Cancer . This cohort of 413,044 men and women had 1,094 cases of colon and 599 cases of rectal cancer diagnosed during an average of 6.4 years of follow-up . We analyzed baseline data on occupational , household , and recreational activity to examine associations by type of activity , tumor subsite , body mass index ( BMI ) , and energy intake . The multivariate hazard ratio for colon cancer was 0.78 [ 95 % confidence interval ( 95 % CI ) , 0.59 - 1.03 ] among the most active participants when compared with the inactive , with evidence of a dose-response effect ( Ptrend = 0.04 ) . For right-sided colon tumors , the risk was 0.65 ( 95 % CI , 0.43 - 1.00 ) in the highest quartile of activity with evidence of a linear trend ( Ptrend = 0.004 ) . Active participants with a BMI under 25 had a risk of 0.63 ( 95 % CI , 0.39 - 1.01 ) for colon cancer compared with the inactive . Finally , an interaction between BMI and activity ( Pinteraction = 0.03 ) was observed for right-sided colon cancers ; among moderately active and active participants with a BMI under 25 , a risk of 0.38 ( 95 % CI , 0.21 - 0.68 ) was found as compared with inactive participants with BMI > 30 . No comparable decreased risks were observed for rectal cancer for any type of physical activity for any subgroup analyses or interactions considered . We found that physical activity  reduced colon cancer risk , specifically for right-sided tumors and for lean participants , but not rectal cancer . ( Cancer Epidemiol Biomarkers Prev 2006;15(12):2398–407 Background and purpose Previous studies have shown that physical inactivity and obesity are risk factors for the development of colorectal cancer . However , controversy exists regarding the influence of these factors on survival in colorectal cancer patients . We evaluated the impact of recreational physical activity and body mass index ( BMI )  before and after colorectal cancer diagnosis on disease-specific mortality and all-cause mortality . Patients and methods This prospect i ve cohort study included 1,339 women enrolled in the Women ’s Health Initiative study who were diagnosed with colorectal cancer subsequent to study enrollment .  BMI and recreational physical activity  were measured before cancer diagnosis at study entry ( pre-diagnostic ) and after diagnosis at study follow-up interviews ( post-diagnostic ) . We used Cox regression to estimate the association between pre- and post-diagnostic exposures and survival after colorectal cancer diagnosis . Results Among women diagnosed with colorectal cancer , 265 ( 13 % ) deaths occurred during a median study follow-up of 11.9 years , of which 171 ( 65 % ) were attributed to colorectal cancer . Compared with women reporting no pre-diagnostic recreational physical activity , those reporting activity levels of ≥18 MET-h/week had significantly lower colorectal cancer-specific mortality ( hazard ratio ( HR ) = 0.68 ; 95 % confidence interval ( CI ) : 0.41–1.13 ) and all-cause mortality ( HR = 0.63 ; 95 % CI : 0.42–0.96 ) . Similar inverse associations were seen for post-diagnostic recreational physical activity . Neither pre- nor post-diagnostic BMI were associated with mortality after colorectal cancer diagnosis . Conclusion Recreational physical activity before and after colorectal cancer diagnosis , but not BMI , is associated with more favorable survival Background The prevalence of childhood obesity increased worldwide in recent decades and is associated with risk factors for the development of chronic diseases in adulthood . Strategies for health promotion directed at an early age , with recommendation for healthy habits , can achieve good results . The objective of this study is to evaluate the effectiveness of an innovative , simple and cost effective educational program to improve eating habits , physical activity and the knowledge about healthy habits in children , as well as in their families , as compared to routine outpatient care . Methods / Design The study is design ed as a r and omized clinical trial . Sample size is estimated to include 37 children , aged between 7 and 11 years , and their guardians , r and omized for an intervention or a control group . The intervention will consist of 11-weekly group meetings of nutritional education and distribution of explanatory material , with orientation about healthy food and family habits and physical activity . Recreational , simple and low cost re sources , carefully design ed for the presentation of contents to the children and parents , will be used in all meetings . The control group will receive st and ard outpatient care based in individual clinical practice guidelines . The primary outcomes will be changes in dietary habits , knowledge and physical activity of children and adults . The secondary outcomes will be changes of body mass index , waist circumference , systolic and diastolic blood pressure and laboratory tests , in children and adults . Discussion The Happy Heart Study offers a playful and low-cost approach for the prevention and control of obesity and cardiovascular disease in children . Although this program is being planned for implementation in Brazil , the method can be adapted to many other countries . Registry of protocol Protocol registered on the site ensaiosclinicos.gov.br : RBR-8ttw64 Prolonged cigarette smoking causes even more deaths from other diseases than from lung cancer . In developed countries , the absolute age-sex-specific lung cancer rates can be used to indicate the approximate proportions due to tobacco of deaths not only from lung cancer itself but also , indirectly , from vascular disease and from various other categories of disease . Even in the absence of direct information on smoking histories , therefore , national mortality from tobacco can be estimated approximately just from the disease mortality statistics that are available from all major developed countries for about 1985 ( and for 1975 and so , by extrapolation , for 1995 ) . The relation between the absolute excess of lung cancer and the proportional excess of other diseases can only be approximate , and so as not to overestimate the effects of tobacco it has been taken to be only half that suggested by a recent large prospect i ve study of smoking and death among one million Americans . Application of such methods indicates that , in developed countries alone , annual deaths from smoking number about 0.9 million in 1965 , 1.3 million in 1975 , 1.7 million in 1985 , and 2.1 million in 1995 ( and hence about 21 million in the decade 1990 - 99 : 5 - 6 million European Community , 5 - 6 million USA , 5 million former USSR , 3 million Eastern and other Europe , and 2 million elsewhere , [ ie , Australia , Canada , Japan , and New Zeal and ] ) . More than half these deaths will be at 35 - 69 years of age : during the 1990s tobacco will in developed countries cause about 30 % of all deaths at 35 - 69 ( making it the largest single cause of premature death ) plus about 14 % of all at older ages . Those killed at older ages are on average already almost 80 years old , however , and might have died soon anyway , but those killed by tobacco at 35 - 69 lose an average of about 23 years of life . At present just under 20 % of all deaths in developed countries are attributed to tobacco , but this percentage is still rising , suggesting that on current smoking patterns just over 20 % of those now living in developed countries will eventually be killed by tobacco ( ie , about a quarter of a billion , out of a current total population of just under one and a quarter billion ) Background —Sudden cardiac death ( SCD ) is a leading cause of death in the United States , but the relative public health burden is unknown . We estimated the burden of premature death from SCD and compared it with other diseases . Methods and Results —Analyses were based on the following data sources ( using most recent sources that provided appropriately stratified data ): ( 1 ) leading causes of death among men and women from 2009 US death certificate reporting ; ( 2 ) individual cancer mortality rates from 2008 death certificate reporting from the Centers for Disease Control and Prevention ’s National Program of Cancer Registries ; ( 3 ) county , state , and national population data for 2009 from the US Census Bureau ; and ( 4 ) SCD rates from the Oregon Sudden Unexpected Death Study ( SUDS ) population -based surveillance study of SCD between 2002 and 2004 . Cases were identified from multiple sources in a prospect ively design ed surveillance program . Incidence , counts , and years of potential life lost for SCD and other major diseases were compared . The age-adjusted national incidence of SCD was 60 per 100 000 population ( 95 % confidence interval , 54–66 per 100 000 ) . The burden of premature death for men ( 2.04 million years of potential life lost ; 95 % uncertainty interval , 1.86–2.23 million ) and women ( 1.29 million years of potential life lost ; 95 % uncertainty interval , 1.13–1.45 million ) was greater for SCD than for all individual cancers and most other leading causes of death . Conclusions —The societal burden of SCD is high relative to other major causes of death . Accordingly , improved national surveillance with the goal of optimizing and monitoring SCD prevention and treatment should be a high priority Cardiovascular disease begins early in life but might be prevented or delayed by primary prevention programs design ed for children and adolescents .  Regular physical activity is an important part of primary prevention programs , and school physical education programs have potential for the promotion of regular physical activity . Cardiovascular disease is the major cause of death among Hispanics and African Americans in the United States . Low levels of fitness and increased body mass index are common in African American and Hispanic adolescents . Increased physical activity and the adoption of healthy eating habits would increase fitness and reduce body mass index among these adolescents . The purpose of the study was to undertake a small-scale controlled trial to determine if Dance for Health , an intervention program design ed to provide an enjoyable aerobic program for African American and Hispanic adolescents , has a significant effect on improving aerobic capacity , helping students maintain or decrease weight , and on improving attitudes toward physical activity and physical fitness . In the first year of the program ( 1990 - 91 ) , approximately 110 boys and girls ages 10 - 13 years participated in an aerobic dance pilot program three times per week for 12 weeks . Dance for Health was revised and continued in the 1992 - 93 school year with seventh grade students and an added culturally sensitive health curriculum . Forty-three students were r and omized to Dance for  Health and 38 to  usual physical activity . Those in the intervention class received a health education curriculum twice a week and a dance oriented physical education class three times a week . The usual physical activity consisted mostly of playground activities . Students in the intervention had a significantly greater lowering in body mass index and resting heart rate than students in regular physical activity The World Bank , the Gates Foundation and the World Health Organization promote national child deworming programmes in developing countries.1 They assert these programmes will improve nutritional status , health and school performance , and hence contribute to economic growth . Indeed , the World Health Organization states that deworming contributed to Japan ’s economic boom in the 1950s,2 and Nobel Laureates meeting in Copenhagen ranked deworming as the fourth most important intervention to solve the health problems of the whole world.3 Surprisingly , the evidence base for these cl aims from controlled studies is limited . Critically , according to the Cochrane review which two of us author , there is quite good evidence of no effect for the main biomedical outcomes in deworming , making the broader societal benefits on economic development barely credible ( Figure 1).4 Nevertheless , the advocates increasingly rely on a single large quasi-r and omized trial carried out in Kenya , published in 2004 in Econometrica,5 which reports school attendance . Figure 1 . Conceptual framework used to underpin the effects of deworming programmes on economic growth  in developing countries . Contemporary evidence questions this model , as there is now quite good contemporary evidence , summarized in the Cochrane review , that ... This study has been highly influential . The International Initiative for Impact Evaluation commissioned the London School of Hygiene and Tropical Medicine ( LSHTM ) to replicate the analysis , as the original analysis is ‘ based on econometric approaches and used a language and format that would be unfamiliar to many health care research ers’.6 The replication aim ed to provide detail of the methods and reporting in line with the CONSORT statement . The team are internationally recognized , independent and meticulous in their approach . They agreed a protocol , carefully checked and corrected the raw data , and then re-ran their prespecified analysis .6 Their first paper is a pure replication,7 exactly repeating the authors ’ original analysis . This paper clarifies some method ological details not provided in the original paper , but it also uncovers a series of important coding and analysis errors . Some of the corrected results are consistent with the original findings , but others are quite different . Most notably , the much quoted ‘ positive externalities’—where the benefits of treating children in one school ‘ spill over ’ to benefit children in adjacent schools — vanish in their corrected analysis . Their second paper uses approaches more familiar to epidemiologists , and allows a more thorough exploration of the data .8 There are substantial amounts of missing information , and some unexpected patterns that are difficult to explain . For example , there is a correlation between the number of observations in each school and the reported attendance , with more observations associated with lower attendance reported — except in some of the intervention groups , where more frequent observation is associated with better attendance . This raises the possibility that the process of observation influenced outcome reporting and this was different in control and intervention groups . The second paper confirms an association with higher attendance in the deworming schools when stratified by year , but found the combined estimate across years was much larger , and the authors caution the validity of the combined year estimate : this may be due to the stepped-wedge design where the combined year estimate includes a before and after comparison ; or it may be due to the problems with secular and group effects of the number of observations of school attendance varying . To further complicate matters , there was also a concurrent ‘ School Assistance Program ’ ( SAP ) evaluating five other interventions in 27/75 of the study schools , which was not part of the r and omized intervention . Attendance patterns differed on the basis of involvement in the SAP , which the authors suggest could well lead to bias.8 One of the critical points the LSHTM papers make is that the administration of the deworming drugs was part of a ‘ complex health education and drug treatment intervention’.8 The intervention schools also received regular public health lectures , wall charts and teacher training on worm prevention . Interestingly , the pure replication shows very similar impacts of the intervention on children in the intervention schools irrespective of whether they took the deworming medicine or not.7 For Miguel and colleagues , they term this as ‘ indirect within-school effects ’ of deworming , but equally the effects could be due to the non-specific effects of the health promotion interventions in the intervention schools . So where does this take us ? There is a small effect on school attendance for sure , but this should not be over-interpreted , as the LSHTM authors say , given the concerns raised regarding the risk of bias , and the independent effects on school attendance of the programme of health promotion . In addition , the study shows that allocation to the deworming group does not influence student progress , as the re- analysis shows clearly no evidence of a difference in examination performance between deworming and control groups.7,8 In the context of the global evidence base , there is only one other study that has examined school attendance with no obvious effect shown.4 Given all these uncertainties , we simply do n’t know if there is truly an effect on school attendance from the data , in taking all these factors into account formally in a GRADE analysis .4 But what weakens the case of deworming still further is that there is now quite good evidence of no effect for most of the main outcomes ( Figure 1 ) , including nutritional status , haemoglobin , cognition and school performance . This is important because without these effects it seems implausible that deworming itself would have an independent effect on school attendance or economic development . Obviously children infected with worms should be treated . Trials from over 20 years ago in an area of Kenya where all the children were heavily infected showed benefit . Another trial in India showed benefit , but subsequent trials in the same area failed to show an effect.4,9 So deworming may have helped in these exceptional , heavily infected , untreated population s from another decade , but this is scarcely a solid base for contemporary policy : public health nutrition has changed , worm burden has declined and this probably accounts for the lack of effect on biomedical outcomes in contemporary studies .10 We have been perplexed by the un question ing belief behind deworming in the advocates , and have found it is deep rooted in American history . The Rockefeller Sanitary Commission in 1909 sought to eradicate hookworm in the Southern USA population , where it was seen as a cause of ‘ some of the proverbial laziness of the poorer classes ’ and to improve worker productivity ; these were extended with the Rockefeller International Health Commission established in 1913.11 The beliefs and assumptions appear to continue , with ‘ Deworm the World ’ aim ing to deworm 220 million children in India during 2015.12 What have we learned from this ? Certainly that replication is a valuable process , not least for errors that have the potential to mislead , but also to provide a much better interpretation of the potential biases in studies . In terms of policies in deworming , it suggests donors and Nobel Prize winners need to be aware of their prior assumptions , and base decisions on the all the evidence from reliable studies within a systematic review , not just select a single study . They need to look at all relevant outcomes , not just one . They need to consider bias and confounding . Our view is that current promotion of community deworming is certainly a panacea : a single solution to multiple problems in low- and middle-income countries , and that the belief that deworming will impact substantially on economic development seems delusional when you look at the results of reliable controlled trials . This is a view , based on over 15 years of engagement with critically appraising the literature in this field.13 We recommend anyone responsible for public or philanthropic money going to large scale deworming to read these replication studies , the original publication , the authors ’ responses to the replication and the 2015 version of the Cochrane review that includes corrections from these replications plus data from five further studies , including the recently published DEVTA study of 2 million children.4,14 Then make up your own mind . Conflict of interest : PG and DTR are authors of a Cochrane review of community deworming programmes . PG is funded by the Department for International Development to provide reliable independent systematic review s for the benefit of developing countries ; PG receives salary support from Countdown , a DFID-supported research grant in programmatic implementation of neglected tropical disease programmes T 2 diabetes mellitus ( T2DM ) is a metabolic disease affecting the metabolism of carbohydrates , proteins and lipids due to initial insulin resistance at the cellular levels followed by progressive insulin deficiency . The consequence of that is gradual increment of serum blood glucose , which binds independent of the enzymes to the proteins in the blood , as well as the tissue proteins ; one of these measurable protein is the red blood cells hemoglobin , which enabled the clinician to assess diabetes control by the percentage of glycosylation of this protein every 3 months , which correlates well to the other tissue involvement and the disease control . Diabetes-related complications are related to the micro and macro vascular derangement due to glycosylated protein in these vessels tissues , leading to nephropathy , retinopathy , neuropathy , myocardial infa rct ion , stroke , and death found to be more frequent and seen at earlier age.1 Estimate of global T2DM indicates that diabetes now affects 246 million people worldwide , and is expected to affect approximately 380 million by 2025 , representing 7.1 % of the world adult population .2 The Kingdom of Saudi Arabia ( KSA ) has one of the highest prevalence of T2DM worldwide since the percentage of diabetes mellitus is estimated to be 23.7 % of the overall population .3 Structured exercise interventions have been shown to be at least as efficacious as the pharmaceutical agents for improving glycemic control.4 Most people with T2DM do not do enough physical activity to benefit their health , and in comparison with the general population , people with diabetes experience a higher frequency of relapse to sedentary behavior.5 Our primary objective is to investigate the effects of supervised aerobic exercise on glycemic control , the glycosylated hemoglobin ( HbA1c ) level , as well as the effect on medication doses adjustments , before and after the study in T2DM Saudi male patients . Our secondary objective was to assess its effect on their lipid profile . This study was performed as collaboration between the Department of Physical Education at the King Fahd University of Petroleum and Minerals ( KFUPM ) and King Fahd Hospital of the University ( KFHU ) , University of Dammam from July to October 2012 . Fifty male patients registered in the diabetes clinic records at KFHU , Al-Khobar , KSA were r and omly selected using the stratified r and om sampling and pooled in the study for inclusion and exclusion criteria filtering . Twenty-four patients diagnosed with T2DM , age range of 25 - 55 years ( 43.86±10.3 years ) were selected to be enrolled in the study . Their medication profiles were documented at the beginning and at the end of the program from their medical files . Diet and lifestyle of patients were not controlled by the study . We excluded patients known to have cardiovascular disease , hypertension , retinopathy , neuropathy , bronchial asthma , arthritis , and morbidly obese . We also excluded those who were involved in any physical exercise program or subjects living very far from KFUPM , the site of the physical exercise . After initial screening and baseline assessment s , all 24 subjects were r and omly allocated to 2 different groups namely ; intervention group ( n=12 ) and control group ( n=12 ) . The exercise group subjects signed a written informed consent after being informed regarding all possible risks associated with exercise training programme .  Comprehensive clinical examination , as well as laboratory testing and fitness assessment were performed for each subject before participation in the exercise training programme , as well as at the end of the programme . All subjects went through one week of familiarization before the start of the programme . After a few weeks , 2 subjects withdrew from the intervention group due to personal reasons . Only 10 subjects completed the 12 weeks of the exercise training programme  . The exercise training programme was given at the fitness centre of KFUPM . The entire duration of the 12-week exercise training programme was closely supervised by 2 qualified personnel . Attendance was verified every day through direct observation and documented records . Exercise data were recorded every day on a chart . The exercise session includes running or walking on treadmill , and cycling on bicycle ergometer . We provided 10 minutes of warming up period and 10 minutes of cooling down period in each exercise session . Each participant had to check his blood glucose levels before and after the exercise . Subjects performed exercise 3 times per week on alternate days with no more than a 2-day gap . The training was design ed to provide an alternate day as a replacement for missed training sessions during the week . Subjects started with training intensity of 40 - 50 % of maximum heart rate Brief Obesity in childhood is increasing worldwide . To combat overweight and obesity in childhood , the school-based Children 's Health InterventionaL Trial ( CHILT ) project combines health education and physical activity . This paper examines the effect of intervention on the body mass index ( BMI ) and motor abilities after 20.8 ± 1.0 months in 12 r and omly selected primary schools compared with 5 r and omly selected control schools .  The anthropometric data were assessed , BMI was calculated . Coordination was determined by lateral jumping and endurance performance by a 6-minute run . No difference in the prevalence of overweight and obesity was found between the intervention ( IS ) and control schools ( CS ) either at baseline or following intervention ( each p > 0.05 ) . The increase in the number of lateral jumps was significantly higher in the IS than in the CS ( p < 0.001 ) . For the 6-minute run the increase in distance run was significantly improved in IS ( p = 0.020 ) . All variables were controlled for gender and age . Overweight and obese children in both IS and CS produced significantly lower scores in coordination and endurance tasks than normal and underweight children during both examinations ( each p ≤ 0.001 ) , adjusted for gender and age . Preventive intervention in primary schools offers an effective means to improve motor skills in childhood and to break through the vicious circle of physical inactivity - motor deficits - frustration - increasing inactivity possibly combined with an excess energy intake and weight gain . To prevent overweight and obesity these measures have to be intensified . Key PointsSchool-based prevention improves motor abilities in primary school children . The incidence of obesity is not influenced by school-based intervention . To prevent obesity in early childhood the measures have to be intensified and parents should be included National Institutes of Health ( NIH ) consensus and state-of-the-science statements are prepared by independent panels of health professionals and public representatives on the basis of 1 ) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality ( AHRQ ) , 2 ) presentations by investigators working in areas relevant to the conference questions during a 2-day public session , 3 ) questions and statements from conference attendees during open discussion periods that are part of the public session , and 4 ) closed deliberations by the panel during the remainder of the second day and the morning of the third . This statement is an independent report of the panel and is not a policy statement of the NIH or the federal government . The statement reflects the panel 's assessment of medical knowledge available at the time the statement was written . Thus , it provides a snapshot in time of the state of knowledge on the conference topic . When reading the statement , keep in mind that new knowledge is inevitably accumulating through medical research . Tobacco use is the leading preventable cause of premature death in the United States . Each year , more than 440000 Americans die of tobacco-related disease , accounting for 1 in every 5 deaths . Cigarette smoking is responsible for more than 30 % of cancer deaths annually in the United States . Smoking also contributes substantially to deaths from heart disease , stroke , and chronic obstructive pulmonary disease . According to current estimates , 21 % of American adults ( 44.5 million individuals ) and 22 % of American high school students ( 3.75 million individuals ) smoke . Cigarettes are the predominant form of tobacco that Americans consume , but tobacco consumption also includes smokeless tobacco , cigars , and pipes . In addition to the toll in human lives , tobacco use is an enormous economic burden on society . From 1995 to 1999 , estimated annual smoking-attributable economic costs in the United States were $ 75.5 billion for direct medical care for adults and $ 81.9 billion for lost productivity . Tobacco use per capita has decreased from about 14 pounds per year in the 1950s to about 5 pounds per year in 2000 , suggesting that public health interventions have been effective . Yet it is unlikely that the United States will reach the Healthy People 2010 objectives of reducing smoking prevalence to 12 % or less in adults and 16 % or less in youth . Further progress in reducing tobacco use is an important challenge facing the public health , medical , and political communities . For these reasons , the National Cancer Institute and the NIH 's Office of Medical Applications of Research sponsored a State-of-the-Science Conference on Tobacco Use : Prevention , Cessation , and Control on 12 - 14 June 2006 in Bethesda , Maryl and . The key questions to be addressed at the State-of-the-Science Conference were : 1 ) What are the effective population - and community-based interventions to prevent tobacco  use in adolescents and young adults , including among diverse population s ? 2 ) What are the effective strategies for increasing consumer dem and for and use of proven , individually oriented cessation treatments , including among diverse population s ? 3 ) What are the effective strategies for increasing the implementation of proven , population -level , tobacco-use cessation strategies , particularly by health care systems and communities ? 4 ) What is the effect of smokeless tobacco product marketing and use on overall harm to the population from tobacco use ? 5 ) What is the effectiveness of prevention and of cessation interventions in population s with co-occurring morbidities and risk behaviors ? 6 ) What research is needed to make the most progress and greatest public health gains nationally and internationally ? At the conference , invited experts presented information pertinent to these questions , and a systematic literature review prepared under contract with AHRQ was summarized . The evidence report ( www.ahrq.gov/clinic/epcix.htm ) emphasized r and omized , controlled trials ; systematic review s ; and other experimental or observational studies with more than 100 participants . During the conference , attendees provided both oral and written statements in response to the key questions . The panel members weighed this evidence as they addressed the key conference questions . 1 . What Are the Effective  Population - and Community-Based Interventions  to Prevent Tobacco Use in Adolescents and Young Adults , Including among Diverse population s ? Never starting to use tobacco is a much better strategy than having to stop . Tobacco use usually begins primarily during adolescence . Almost 25 % of 12th grade rs have smoked in the previous 30 days , and almost all adult daily smokers tried cigarettes before age 18 years . Research reports suggest a flattening of the past decade 's downward trend in adolescent smoking .  Adolescents ( 13 to 18 years of age ) and young adults ( 18 to 24 years of age ) are susceptible to cultural influences , including family , friends , peers , media , community , and tobacco marketing influence . Gender , racial/ethnic background , socioeconomic status , geography , and sexual orientation all influence tobacco use and the effectiveness of strategies to prevent it , which means that many preventive strategies are needed . What We Know Previous review s have identified 3 effective general population approaches to preventing tobacco use in adolescents and young adults : 1 ) increased prices through taxes on tobacco products ; 2 ) laws and regulations that prevent young people from gaining access to tobacco products , reduce their exposure to tobacco smoke , and restrict tobacco industry advertising ; and 3 ) mass media campaigns . Previous review s show that school-based intervention programs aim ed at preventing tobacco use in adolescents are effective in the short term . Comprehensive statewide programs have also reduced overall tobacco use in young adults . What We Need to Learn Although previous evidence shows that clean indoor air and youth access policies reduce adolescent smoking rates , we need to know more about the effectiveness of these policies in specific population s. The evidence that culturally sensitive programs are more effective in reducing smoking among adolescents and young adults is not adequate to support a firm conclusion . We need to develop school-based strategies that lead to sustained reduction in starting tobacco use . 2 . What Are the Effective Strategies for Increasing Consumer Dem and for and Use of Proven , Individually Oriented Cessation Treatments , Including among Diverse Population s ? About 70 % of the 44.5 million adult smokers in the United States want to quit , but of those who try to quit in a given year , fewer than 5 % succeed . Effective treatments can double or triple quit rates , but too few smokers try these interventions and too few physicians offer them . What We Know Previous systematic review s identified effective strategies for increasing use of the following proven individually oriented cessation treatments . A mass media education campaign uses brief , recurring messages to inform and to motivate tobacco users to quit . It is effective in increasing tobacco use cessation when combined with other interventions . For example , media messages that direct viewers to call for further information or support increase use of telephone-based tobacco cessation information or support services . Proactive telephone smoking cessation support occurs when the health care provider initiates contact with the smoker . Advice to stop smoking is effective , especially when combined with other interventions , such as educational approaches or pharmacologic therapies . Increasing the unit price for tobacco products increases tobacco use cessation and reduces consumption regardless of the smoker 's ethnicity , gender , and socioeconomic status . Reducing out-of-pocket costs for effective cessation therapiesfor example , because health insurance pays for the serviceincreases their use . Making smokers aware of their health insurance 's coverage policy can increase use of smoking cessation treatments . Culturally tailored , gender-specific , and language -appropriate programs show promise . What We Need to Learn Generic interventions may be less effective than interventions tailored to specific population s , so we need to underst and how best to tailor interventions . To increase dem and for treatments , smokers must want them , expect them , and ask for them . We need to learn how to make treatments more attractive to tobacco users . We need to create a sustained dem and for effective treatments . 3 . What Are the Effective Strategies for Increasing the Implementation of Proven , Population -Level Tobacco Use Cessation Strategies , Particularly by Health Care Systems and Communities ? Despite strong evidence that a variety of pharmacologic and behavioral interventions increase tobacco cessation , only a small proportion of tobacco users ever try them . Strategies that target individual tobacco users may be effective but fail to reach most smokers . Community-level strategies target broad geographic population s ( for example , cities ) or smaller , more localized groups of people ( for example , military bases , colleges ) . Clinical setting s in which to implement community-level strategies range in scope from individual practice s to large integrated organizations . What We Know Community-based interventions aim to increase dem and for cessation interventions ( media campaigns , higher prices , smoke-free environments ) or facilitate access to cessation services ( community-level quit lines , offering cessation services in community setting s ) . Evidence suggests that media campaigns , telephone-counseling programs ( quit lines ) , and increases in tobacco prices and taxes are effective . Providing cessation services in non clinical community setting s shows some promise , but the literature lacks good evidence of community setting interventions in the United States . Abstract Obesity , physical inactivity , and sedentary behavior , concomitants of the modern environment , are potentially modifiable breast cancer risk factors . This study investigated the association of anthropometric measurements , physical activity and sedentary behavior  , with the risk of incident , invasive breast cancer using a prospect i ve cohort of women enrolled in the Canadian Study of Diet , Lifestyle and Health . Using a case-cohort design , an age-stratified subcohort of 3,320 women was created from 39,532 female participants who returned completed self-administered lifestyle and dietary question naires at baseline . A total of 1,097 incident breast cancer cases were identified from the entire cohort via linkage to the Canadian Cancer Registry . Cox regression models , modified to account for the case-cohort design , were used to estimate hazard ratios ( HR ) and 95 % confidence intervals ( CI ) for the association between anthropometric characteristics , physical activity , and the risk of breast cancer . Weight gain as an adult was positively associated with risk of post-menopausal breast cancer , with a 6 % increase in risk for every 5 kg gained since age 20 ( HR 1.06 ; 95 % CI 1.01–1.11 ) . Women who exercised more than 30.9 metabolic equivalent task ( MET ) hours per week had a 21 % decreased risk of breast cancer compared to women who exercised less than 3 MET hours per week ( HR 0.79 ; 95 % CI 0.62–1.00 ) , most evident in pre-menopausal women ( HR 0.62 ; 95 % CI 0.43–0.90 ) . As obesity reaches epidemic proportions and sedentary lifestyles have become more prevalent in modern population s , programs targeting adult weight gain and promoting physical activity may be beneficial with respect to reducing breast cancer morbidity BACKGROUND The purpose of this study was to analyse both cross-sectional associations and how longitudinal changes in lifestyle factors from one state in 1980 - 1981 to another in 1988 - 1989 influence self-reported health status . Another aim was to estimate the hazard ratios for all-cause mortality for the changes in lifestyle factors and self-reported hypertension during the same period of time . METHOD The cross-sectional and the longitudinal analyses are based on the same simple r and om sample of 3,843 adults , aged 25 - 74 , interviewed in 1980 - 1981 and 1988 - 1989 and is part of the Swedish Annual Level-of-Living Survey . About 85 % of the respondents in the first interview participated in a second interview in 1988 - 1989 . Cross-sectional odds ratios , based on a marginal model , were estimated using the generalized estimating equations . The transitional models were analysed using unconditional logistic regression . A proportional hazard model was applied to investigate the influence of lifestyle transitions on mortality . RESULTS Physical inactivity , being a current or former smoker and obesity ( women only ) were strong risk factors for poor health either as main effects and /or combined ( interactions ) . There was a strong interaction between physical activity and smoking , and for women , also between body mass index ( BMI ) and physical activity . Smoking , physically inactive and obese women had about a ten times higher risk of poor health status than non-smoking , physically active , and normal-weight women . The corresponding risk for men was about five times higher . Physically active , but smoking and obese individuals showed only moderately increased risks for poor health status . The transitional model showed that those who were physically inactive in 1980 - 1981 , but did exercise in 1988 - 1989 , improved their health after adjustments for sociodemographic and other lifestyle factors . Continuing to smoke or being physically inactive or having hypertension at both points in time were all associated with higher hazard ratios for all-cause mortality ( 1.6 , 1.9 and 1.8 , respectively ) than those who reported that they were in good status at both points in time . CONCLUSIONS We found that physical activity protects against poor health irrespective of an increased BMI and smoking . The major clinical implication s are the long-st and ing benefits of physical activity and not smoking Background Adolescents with overweight and poor physical fitness have an increased likelihood of developing cardiovascular diseases during adulthood . In Ecuador , a health promotion program improved the muscular strength and speed-agility , and reduced the decline of the moderate-to-vigorous physical activity of adolescents after 28 months . We performed a sub-group analysis to assess the differential effect of this intervention in overweight and low-fit adolescents . Methods We performed a cluster-r and omized pair matched trial in schools located in Cuenca – Ecuador . In total 20 schools ( clusters ) were pair matched , and 1440 adolescents of grade 8 and 9 ( mean age of 12.3 and 13.3 years respectively ) participated in the trial . For the purpose s of the subgroup analysis , the adolescents were classified into groups according to their weight status ( body mass index ) and aerobic capacity ( scores in the 20 m shuttle run and FITNESSGRAM st and ards ) at baseline . Primary outcomes included physical fitness ( vertical jump , speed shuttle run ) and physical activity ( proportion of students achieving over 60 min of moderate – to-vigorous physical activity/day ) . For these primary outcomes , we stratified analysis by weight ( underweight , normal BMI and overweight/obese ) and fitness ( fit and low fitness ) groups . Mixed linear regression models were used to assess the intervention effect . Results The prevalence of overweight/obesity , underweight and poor  physical  fitness  was 20.3 % , 5.8 % and 84.8 % respectively . A higher intervention effect was observed for speed shuttle run in overweight ( β = −1.85 s , P = 0.04 ) adolescents compared to underweight ( β = −1.66 s , P = 0.5 ) or normal weight ( β = −0.35 s , P = 0.6 ) peers . The intervention effect on vertical jump was higher in adolescents with poor physical fitness ( β = 3.71 cm , P = 0.005 ) compared to their fit peers ( β = 1.28 cm , P = 0.4 ) . The proportion of students achieving over 60 min of moderate-to-vigorous physical activity/day was not significantly different according to weight or fitness status . Conclusion Comprehensive school-based interventions that aim to improve diet and physical activity could improve speed and strength aspects of physical fitness in low-fit and overweight/obese adolescents . Trial registration Clinical trials.gov identifier NCT01004367 . Registered October 28 , 2009 Background This prospect i ve longitudinal study investigates whether suspected motor problems and low preference for active play in childhood are associated with  physical inactivity and low cardiorespiratory fitness in adolescence . Methodology /Principal Findings The study sample consisted of the Northern Finl and Birth Cohort 1986 ( NFBC 1986 ) composed of 5,767 children whose parents responded to a postal inquiry concerning their children 's motor skills at age 8 years and who themselves reported their physical activity at age 16 years .  Cardiorespiratory fitness  was measured with a  cycle ergometer test at age 16 years . Odds ratios ( OR ) and their 95 % confidence intervals ( 95 % CI ) for the level of physical activity and fitness were obtained from multinomial logistic regression and adjusted for socio-economic position and body mass index . Low preference for active play in childhood was associated with physical inactivity ( boys : OR 3.31 , 95 % CI 2.42–4.53 ; girls : OR 1.79 , 95 % CI 1.36–2.36 ) and low cardiorespiratory fitness ( boys : OR 1.87 , 95 % CI 1.27–2.74 ; girls : OR 1.52 , 95 % CI 1.09–2.11 ) in adolescence . Suspected gross ( OR 2.16 , 95 % CI 1.33–3.49 ) and fine ( OR 1.88 , 95 % CI 1.35–2.60 ) motor problems were associated with physical inactivity among boys . Children with suspected motor problems and low preference for active play  tended to have an even higher risk of physical inactivity in adolescence . Conclusions / Significance Low preference for active play in childhood was associated with physical inactivity and low cardiorespiratory fitness in adolescence . Furthermore , children with suspected motor problems and low preference for active play tended to have an even higher risk of physical inactivity in adolescence . Identification of children who do not prefer active play and who have motor problems may allow targeted interventions to support their motor learning and participation in active play and thereby promote their physical activity and fitness in later life Background Physical inactivity increases the risk of many chronic diseases including coronary heart disease , type 2 diabetes and some cancers . It is recommended that adults should undertake at least 150 minutes of moderate intensity physical activity throughout the week but many adults do not achieve this . An opportunity for working adults to accumulate the recommended activity levels is through the daily commute . Methods Employees will be recruited from workplaces in south-west Engl and and south Wales . In the intervention arm ,  workplace Walk-to-Work promoters  will be recruited and trained . Participating employees will receive Walk-to-Work material  s and support will be provided through four contacts from the promoters over 10 weeks . Workplaces in the control arm will continue with their usual practice . The intervention will be evaluated by a cluster r and omized controlled trial including economic and process evaluations . The primary outcome is daily minutes of moderate to vigorous physical activity ( MVPA ) . Secondary outcomes are : overall physical activity ; sedentary time ; modal shift away from private car use during the commute ; and physical activity/MVPA during the commute .  Accelerometers , GPS receivers and travel diaries will be used at baseline and one year follow-up . Question naires will be used at baseline , immediately post intervention , and one year follow-up . The process evaluation will examine the context , delivery and response to the intervention from the perspectives of employers , Walk-to-Work promoters and employees using question naires , descriptive statistics , fieldnotes and interviews . A cost-consequence study will include employer , employee and health service costs and outcomes . Time and consumables used in implementing the intervention will be measured . Journey time , household commuting costs and expenses will be recorded using travel diaries to estimate costs to employees . Presenteeism , absenteeism , employee wellbeing and health service use will be recorded . Discussion Compared with other forms of physical activity , walking is a popular , familiar and convenient , and the main option for increasing physical activity in sedentary population s. To our knowledge , this is the first full-scale r and omised controlled trial to objective ly measure ( using accelerometers and GPS receivers ) the effectiveness of a workplace intervention to promote walking during the commute to and from work . Trial registration IS RCT N15009100 ( 10 December 2014 ) We examined the independent and combined associations of physical activity and obesity with  incident type 2 diabetes in men and women . The InterAct case – cohort study consists of 12,403 incident type 2 diabetes cases and a r and omly selected subcohort of 16,154 individuals , drawn from a total cohort of 340,234 participants with 3.99 million person-years of follow-up .  Physical activity  was assessed by a four-category index . Obesity was measured by BMI and waist circumference ( WC ) . Associations between  physical activity , obesity and case-ascertained incident type 2 diabetes were analysed by Cox regression after adjusting for educational level , smoking status , alcohol consumption and energy intake . In combined analyses , individuals were stratified according to physical activity level , BMI and WC . A one-category difference in physical activity ( equivalent to approximately 460 and 365 kJ/day in men and women , respectively ) was independently associated with a 13 % ( HR 0.87 , 95 % CI 0.80 , 0.94 ) and 7 % ( HR 0.93 , 95 % CI 0.89 , 0.98 ) relative reduction in the risk of type 2 diabetes in men and women , respectively . Lower levels of physical activity  were associated with an increased risk of diabetes across all strata of BMI . Comparing inactive with active individuals , the HRs were 1.44 ( 95 % CI 1.11 , 1.87 ) and 1.38 ( 95 % CI 1.17 , 1.62 ) in abdominally lean and obese inactive men , respectively , and 1.57 ( 95 % CI 1.19 , 2.07 ) and 1.19 ( 95 % CI 1.01 , 1.39 ) in abdominally lean and obese inactive women , respectively .  Physical activity is associated with a reduction in the risk of developing type 2 diabetes across BMI categories in men and women , as well as in abdominally lean and obese men and women Context The best way to estimate deaths from smoking is to observe people over many decades , as done in a 50-year study of male British physicians . No such study exists for women . Content A 25-year study of residents of rural Norway included 24505 women . Of these women , 2333 women died at age 40 to 70 years ( 9.4 % of never smokers and 18.7 % of continuing smokers ) , mostly from cardiovascular disease and cancer . Continuing heavy smokers survived 1.4 fewer years than never smokers . Mortality rates in smokers and nonsmokers were lower in women than in men . Caution s Participants were white and lived in rural areas . Implication s Active smoking has a large effect on women 's longevity in middle age . The Editors An early report on smoking and longevity appeared more than 60 years ago ( 1 ) , and it suggested a clear survival advantage of nonsmokers over heavy smokers in midlife . More than a half century later , another report presented precise survival curves for men by smoking habits ( 2 ) . In the time between these reports , the historic dimension of the health consequences of smoking was increasingly realized ( 3 - 9 ) . The World Health Organization now recognizes tobacco use as the major preventable cause of adult death , and about 5 million deaths worldwide each year ( 8.8 % of all deaths annually ) are attributed to smoking ( 10 ) . More than half of smoking-attributable deaths worldwide ( 56 % ) occur in people younger than 70 years of age and account for 13 % of deaths in people 30 to 69 years of age ( 9 ) . On a global scale , the death toll from tobacco use is increasing ( 9 , 11 ) , and accurately quantifying and updating the number of premature deaths due to smoking is an important task . Estimated numbers of deaths caused by smoking on a national , international , or global level have been calculated by combining relative risks for smokers versus nonsmokers for different causes of death from the second large prospect i ve American Cancer Society Cancer Prevention Study ( CPS-II ) ( 12 , 13 ) with direct or indirect ( via lung cancer mortality rates ) estimates of smoking histories and national mortality statistics ( 6 , 9 , 14 - 17 ) . However , estimating the number of smoking-attributable deaths that occur in a population in a given year depends on the maturity of the smoking epidemic and will predict the lifetime mortality experience of smoking men and women only under certain conditions ( 18 ) . To predict individual risks precisely , follow-up studies of individuals through their lifetime are needed . Such studies are rare and have not always estimated direct long-term risk for death . Among studies of survival and smoking ( 1 , 19 , 20 ) , the British doctors ' study ( 2 , 21 ) has provided the longest follow-up ( 50 years ) and has allowed for direct and precise calculation of survival of men through middle age and beyond . Using data from nearly 50000 Norwegian adults who were born in the second quarter of the 20th century and were followed in the last quarter , we studied smoking , death in middle age ( 40 to 70 years of age ) , and causes of death in both women and men . Methods Study Sample Between 1974 and 1978 , all men and women 35 to 49 years of age who were residing in the 3 rural Norwegian counties of Oppl and , Sogn og Fjordane , and Finnmark were invited to a cardiovascular health screening examination . Excluding 783 men and 215 women who were temporarily absent from their residence , 91.4 % of the men and 94.2 % of the women gave a self-report of their past and current smoking habits and were screened for cardiovascular risk factors ( 22 , 23 ) . Thus , our report is based on mortality follow-up between 40 and 70 years of age ( middle age ) of 24505 women and 25034 men ( who were born between 1925 and 1941 ) . Approximately 92 % of the respondents attended a second survey and 65 % attended a third survey about 5 years and 10 years after the first examination , respectively . We grouped participants into never smokers ( no report of smoking at any examination ) ; former smokers ; or continuing smokers of 1 to 9 cigarettes , 10 to 19 cigarettes , or 20 or more cigarettes per day ( heavy smokers ) . As a supplementary analysis to facilitate comparison with the 40-year follow-up of the British doctors ' study ( 2 ) , we also studied men who reported smoking 25 or more cigarettes daily . We classified persons as continuing smokers on the basis of the information from the last of up to 3 examinations . On the basis of information given about time since smoking cessation and changes among the 3 examinations , we separated the former smokers into 3 groups on the basis of their age when they stopped smoking ( < 40 years , 40 to 49 years , or 50 to 59 years ) . Mortality Follow-up We performed mortality follow-up by record linkage using the Norwegian 11-digit birth number ( date of birth plus a 5-digit identifier ) , which is unique to each person residing in Norway , to obtain the date and underlying cause of death kept by Statistics Norway . Loss to follow-up was due only to emigration , and we censored 93 men and 99 women ( 0.4 % ) on their registered date of taking residence abroad . Our report is based on mortality follow-up through the year 2000 . We classified the 7013 deaths in middle age into 7 groups on the basis of the underlying cause of death coded at Statistics Norway by using the 8th , 9th , or 10th revisions of the International Classification of Diseases ( ICD ) and European shortlist categories ( 24 ) . The groups were deaths due to 1 ) lung cancer ( 151 deaths in women and 316 deaths in men ) ; 2 ) other types of smoking-related cancer , including cancer of the lip , oral cavity , pharynx , larynx , esophagus , stomach , liver , pancreas , cervix uteri , kidney , bladder , and acute myelogenous leukemia ( 262 deaths in women and 386 deaths in men ) ; 3 ) other types of cancer ( 796 deaths in women and 648 deaths in men ) ; 4 ) cardiovascular disease , including sudden death ( 624 deaths in women and 2252 deaths in men ) ; 5 ) other medical causes ( 358 deaths in women and 505 deaths in men ) ; 6 ) alcohol abuse and chronic liver disease ( 20 deaths in women and 115 deaths in men ) ; and 7 ) accidents and violence ( 122 deaths in women and 458 deaths in men ) . Types of smoking-related cancer were those reported to be associated with smoking in the 2004 U.S. Surgeon General report ( 25 ) . Statistical Analysis We estimated KaplanMeier survival curves from 40 to 70 years of age separately for men and women , and for the various smoking categories , using age as the time scale . We performed computations with the survfit function of S-PLUS , version 6.1 ( Insightful Corp. , Seattle , Washington ) . The limited number of individuals who were recruited before 40 years of age led to unstable survival estimates . For this reason , we calibrated all survival analyses to start at 100 % at age 40 years . We estimated mortality hazard ( rate ) ratios comparing the persons in various smoking categories with never smokers by using the Cox proportional hazards model with age as the time scale and calculated with and without adjustment for potential confounding . The confounders were the following variables , which were all registered at the first examination : marital status ( not married or married ) , duration of education ( 0 to 9 years , 10 years , 11 to 12 years , or 13 years ) , county of residence , and physical activity in leisure time ( sedentary , moderate , intermediate , or intensive ) . We also used the Cox model to estimate  womenmen mortality hazard ratios overall and with the different cause-of-death groups as outcomes . We performed these analyses for never smokers and for continuing smokers with additional adjustment for age when smokers began smoking and for number of cigarettes smoked per day . We performed tests for difference in regression coefficients between men and women and between smokers and nonsmokers ( interaction tests ) , with the variance estimated as the sum of each coefficient 's variance . We calculated adjusted survival first by predicting survival probabilities for each individual from the Cox model with confounders and then by averaging over all individuals in the sample ( 26 , 27 ) . We did this separately for women and men . We computed the average number of years of life lost between 40 and 70 years of age by summing person-time lost over the survival curves . To compute cause-specific mortality probabilities for the interval of 40 to 70 years of age , we analyzed the different cause-of-death groups in a competing risk framework . Again , we performed the computations separately for men and women and for the different smoking categories . Let Pxj be the probability of death of cause j between 40 and 70 years of age for a person in smoking group x. This probability can be estimated from the following formula : where Sx(t ) is the KaplanMeier estimate of all-cause survival in smoking group x and xj ( t ) is the NelsonAalen estimator of cumulative cause-specific hazard , which is computed by using cause j as the outcome and treating all other causes as censoring ( 28 ) . Note that the probabilities Pxj sum to Px , the all-cause probability of dying between 40 and 70 years of age for a person in smoking group x. The NelsonAalen estimator is used rather than the KaplanMeier , since cause-specific KaplanMeier estimates do not correctly account for deaths from other causes . We estimated the probability of dying between 40 and 70 years of age as a function of age when smoking began . We calculated these probabilities separately for men and women and for the 3 smoking categories ( 1 to 9 cigarettes per day , 10 to 19 cigarettes per day , and 20 cigarettes per day ) . We obtained the estimates by fitting a Cox model with a P-spline function ( pspline function of S-PLUS ) ( 29 ) to show the effect of age when smoking began . The P-spline allows for a flexible effect estimation , avoiding the need to assume a prespecified functional relationship between exposure and outcome , such as linear or polynomial ( 30 ) . We then estimated the predicted survival from 40 to 70 years of age by using the S-PLUS survfit Evidence is emerging that physical activity ( PA ) may improve overall survival after breast cancer diagnosis . However , the effect of PA on breast cancer recurrence and on cause-specific mortality is less investigated . We assessed the association of pre-diagnosis PA with recurrence , overall and cause-specific survival in a prospect i ve cohort study in Germany including 3,393 non-metastatic breast cancer patients aged 50 - 74 years .  Cox proportional hazards models were calculated adjusted for relevant prognostic factors . During a median follow-up of 5.6 years , 367 patients deceased .  Overall mortality was significantly inversely associated with pre-diagnosis recreational PA . However , this effect was mainly attributed to deaths due to causes other than breast cancer . Multiple fractional polynomial analyses yielded a nonlinear association with markedly increased non-breast cancer mortality for women who did not engage in any sports or cycling in the years before the breast cancer diagnosis with a hazard ratio ( HR , none vs. any ) of 1.71 , 95 % confidence interval ( 1.16 , 2.52 ) . There were no further risk reductions with increasing activity levels . The association with breast cancer-specific mortality showed a similar dose-response but was far less pronounced with HR ( none vs. any ) = 1.22 ( 0.91 , 1.64 ) . In contrast , regarding cancer recurrence the dose-response was linear . However , this association was restricted to estrogen/progesterone receptor-negative ( ER-/PR- ) cases ( p interaction = 0.033 ) with HR ( highest vs. no recreational PA ) = 0.53 ( 0.24 , 1.16 ) , p trend = 0.0045 . Thus , breast cancer patients with a physically inactive lifestyle pre-diagnosis may decease prematurely irrespective of their cancer prognosis . Higher levels of exercise may reduce the risk of recurrence of ER-/PR- breast tumors OBJECTIVE : To investigate the independent associations and the possible interaction of  body mass index ( BMI ) , leisure time physical activity ( LTPA ) and perceived physical fitness and functional capability with the risk of mortality . DESIGN : Prospect i ve 16 y follow-up study .SUBJECTS : A regionally representative cohort of 35–63 -y-old Finnish men ( n=1090 ) and women ( n=1122 ) . MEASUREMENTS : All-cause , cardiovascular disease ( CVD ) and coronary heart disease ( CHD ) mortality were derived from the national census data until the end of September 1996 while the initial levels of BMI , LTPA , physical fitness and function were determined from self-administered question naires . RESULTS : After adjustment for age , marital and employment status , perceived health status , smoking and alcohol consumption , the Cox proportional hazards model showed that BMI was not associated with the risk of death among the men or the women . Compared with the most active subjects the men and women with no weekly vigorous activity had relative risks of 1.61 ( 95 % confidence interval , CI , 0.98–2.64 ) and 4.68 ( 95 % CI , 1.41–15.57 ) , respectively , for CVD mortality , and for the men there was a relative risk of 1.66 ( 95 % CI , 0.92–2.99 ) for CHD mortality . When compared with the men who perceived their fitness as better than their age-mates , the men with the ‘ worse ’ assessment had a relative risk of 3.29 ( 95 % CI , 1.80–6.02 ) for all-cause mortality and 4.37 ( 95 % CI , 1.80–10.6 ) for CVD mortality . Men with at least some difficulty in walking a distance of 2 km had a relative risk of 1.62 ( 95 % CI , 1.05–2.50 ) for all-cause mortality when compared with those who had no functional difficulties . In addition , in the comparison with subjects with no functional difficulties , the men and women who had some difficulty climbing several flights of stairs had relative risks of 1.47 ( 95 % CI , 0.97–2.23 ) and 2.39 ( 95 % CI , 1.25–4.60 ) for all-cause mortality , respectively . For CVD mortality the relative risks were 1.85 ( 95 % CI , 1.04–3.30 ) and 3.38 ( 1.22–9.41 ) , respectively . CONCLUSIONS : Although BMI did not prove to be an independent risk factor for mortality from CVD , CHD or from all causes combined , perceived physical fitness and functional capability did . An increase in LTPA seems to have a similar beneficial effect on the mortality risk of obese and nonobese men and women , and the effect also seems to be similar for fit and unfit subjects Diabetes is an “ old disease ” . The first description of diabetes written on papyrus about 3500 years ago is found in the Ebers papyrus  , which was discovered in Egypt in 1873 by the German archeologist Georg Ebers . Humans , like most mammals , may develop diabetes , if sufficient environmental exposure to physical inactivity , unhealthy diet and obesity are present . Genetic effects are important for the individual risk of type 2 diabetes ( T2D ) but twin studies have shown that the genetic effects combined explain less than 50 % of the risk of T2D ( 1 ) . Today we know almost 100 susceptibility genes associated with T2D but the relative importance of each of these genes is low ( 2 ) , and together they explain only a small part of the disease risk . Thus , genetic screening can not be used for the prediction of T2D for individuals . On the other h and , healthy lifestyle can also prevent T2D in people who are genetically at high risk , e.g. those with positive family history ( 3 ) . Thus , the importance of lifestyle factors for the development and prevention of T2D is overwhelming . The strongest evidence in medicine is considered to come from r and omized controlled trials ( RCTs ) . They are also important in providing the link to causal inference that in most observational studies can not be derived . At the same time , observational studies are necessary for the identification of factors associated with an increased or decreased risk of a disease , and for generation of hypotheses on potential means for prevention based on modifiable risk factors . Observational studies have by now identified a large number of factors that are associated with the development of T2D or with the protection against it . Most of them are related to physical activity , diet and obesity . It has also been shown unequivocally that exposures ( poor nutrition , infections , smoking , etc . ) during fetal life and early infancy result ing in insufficient development ( often shown as low birth weight ) also predict T2D later in life ( 4 ) . Traditionally , T2D has been considered to be a disease of the elderly . However , with increasing obesity and sedentary lifestyle in children , there are increasing numbers of cases of T2D already occurring at a young age in many population s ( 5 ) . In the past two decades several innovative RCTs have repeatedly shown that interventions on modifiable risk factors can reduce the incidence of diabetes in high-risk groups . The evidence has been summarized in several systematic review s and meta-analyses ( 6,7 ) . There is compelling scientific evidence from RCTs that T2D can be prevented or its onset delayed . The key for prevention is a multimodal package of lifestyle changes that is a sum outcome of dietary and physical activity behaviours . The power of lifestyle was dramatically illustrated by the Finnish Diabetes Prevention Study ( DPS ) that explicitly showed that when the study participants with impaired glucose tolerance reached all five modest lifestyle intervention targets , none of them progressed to T2D ( 8) . Importantly , lifestyle intervention lasting for 3–6 years has been shown to have a carry-over effect on T2D incidence that lasts for several years ; up to 15 in the Finnish Diabetes Prevention Study ( 9 ) and 20 years in the China Da Qing Diabetes Prevention Study ( 10 ) . The observed sustained risk reduction seems to be a result of sustained lifestyle changes , but the legacy effect of improved glycaemia during the early intervention may also have contributed to the long-term effect . The follow-up data from the Chinese study indicate moreover that vascular risks are also reduced by lifestyle management . Several prognostic question naires exist for detecting people at risk of T2D ( 11 ) . One of the screening tools with an adequately high sensitivity and specificity is the Finnish Diabetes Risk Score ( FINDRISC ) developed in Finl and ( 12 ) . The FINDRISC has been successfully implemented in the Finnish primary health care system and used also in many other countries . The FINDRISC was also tested in the Omani population and as a result a slightly modified Omani Diabetes Risk Score was developed ( 13 ) which may be a suitable screening tool for the Arab population s in the Middle East . Lifestyle interventions aim ing at translating evidence from efficacy RCTs on T2D prevention into “ real world ” intervention programmes have also been carried out in various population s. Such data were recently combined in a meta- analysis considering the relationship between intervention effectiveness and adherence to guidelines ( 14 ) . The primary meta- analysis included 22 studies with outcome data for weight loss at 12 months . The pooled result of the direct pairwise meta- analysis shows that Purpose of review This review highlights recent work evaluating the relationship between exercise , physical activity and physical and mental health . Both cross-sectional and longitudinal studies , as well as r and omized clinical trials , are included . Special attention is given to physical conditions , including obesity , cancer , cardiovascular disease and sexual dysfunction . Furthermore , studies relating physical activity to depression and other mood states are review ed . The studies include diverse ethnic population s , including men and women , as well as several age groups ( e.g. adolescents , middle-aged and older adults ) . Recent findings Results of the studies continue to support a growing literature suggesting that exercise , physical activity and physical-activity interventions have beneficial effects across several physical and mental-health outcomes . Generally , participants engaging in regular physical activity display more desirable health outcomes across a variety of physical conditions . Similarly , participants in r and omized clinical trials of physical-activity interventions show better health outcomes , including better general and health-related quality of life , better functional capacity and better mood states . Summary The studies have several implication s for clinical practice and research . Most work suggests that exercise and physical activity are associated with better quality of life and health outcomes . Therefore , assessment and promotion of exercise and physical activity may be beneficial in achieving desired benefits across several population s. Several limitations were noted , particularly in research involving r and omized clinical trials . These trials tend to involve limited sample sizes with short follow-up periods , thus limiting the clinical implication s of the benefits associated with physical activity . Abbreviations CAD : coronary artery disease ; COPD : chronic obstructive pulmonary disease ; CRP : cardiac rehabilitation program ; CVD : cardiovascular disease ; GMCB : group-mediated cognitive – behavioural ; HRQOL : health-related quality of life Colorectal cancer ( CRC ) is a major health concern and a leading cause of cancer death in the Western world . The estimated lifetime risk of CRC is 5 % to 6 % , the incidence rate increases sharply after the age of 50 . Approximately 75 % of new cases occur in individuals at average risk [ 1 , 2 ] . Worldwide , it is estimated that there will be over one million new CRC cases in the year 2001 ( personal communication ) , and the annual ageadjusted incidence rate is 57 per 100 000 . Survival is directly related to the extent of disease at the time of diagnosis . Those diagnosed at an advanced stage have an estimated 5-year survival rate of 7 % , in contrast with a survival rate of 92 % for individuals detected at an early stage , since advanced CRC is largely refractory to conventional therapy and is one of the least curable malignancies [ 3 ] . Despite continuing advances in diagnosis and therapy , long-term survival has not improved significantly over the last four decades , and almost 50 % of CRC patients will eventually die of their disease [ 1 , 2 ] . This situation m and ates improvement in the early detection of this surgically curable disease and preventative interventions to reduce the incidence of the disease and its downstream morbidities and mortality . Indeed , given our underst and ing of the pathogenesis of CRC , current screening technologies , and effective preventative interventions , CRC should be highly preventable . Colorectal cancer has become an important issue for physicians and the general population in the last decade , ever since preventative medicine became a key issue in health care . Indeed , CRC is preventable in up to 90 % of cases [ 4 , 5 ] . CRC fulfils the criteria a disease must have for mass screening . Indeed , intestinal tumorigenesis is exceptionally suited for screening , since the adenoma – carcinoma sequence allows the detection and removal of pre-malignant lesions , and it is well established that patients who are maintained free of adenomas by endoscopic polypectomy are generally kept cancer free [ 4 , 6 , 7 ] . A study using Markov chain analysis has found that CRC decreases the life expectancy calculated for the entire US population by 292 days at age 50–54 years and by 70 days at age 70–74 years [ 8 ] . At the same time , an important controversial issue is the optimal screening approach for the averagerisk population at the age of 50 years . Endoscopic screening is undoubtedly the most effective screening method , but its potential disadvantages , such as invasiveness and cost , should be considered . The simplest and most evaluated screening method available for CRC is the fecal occult blood test ( FOBT ) . This periodic stool testing is considered a lowpriced , non-invasive test that requires no cathartic preparation . It can be performed on mailed specimens without a health center visit , and may reflect the full length of the colon . On the other h and , it is a less sensitive method , since many cancers and the large majority of pre-malignant adenomas do not bleed and are therefore missed . Furthermore , high falsepositive rates , due to dietary peroxidases and meat , or frequent and trivial sources of occult bleeding , lead to unnecessary colonoscopies that drive up programmatic costs . The first national screening program with FOBT was introduced in 1977 in Germany . The evaluation of this program was limited because of confidentiality problems . Case – control studies have yielded conflicting results regarding the effectiveness of FOBT as a screening modality [ 9 ] . The rationale for the use of FOBT screening programs is based on three major long-term r and omized trials . Overall , those trials using annual FOBT have reported a 15 % to 33 % reduction in CRC related death ( for review , see reference 10 ) . The Minnesota prospect i ve case – controlled study [ 11 ] is the study that is most cited . It included 46 000 subjects and showed a reduction in CRC mortality , after 13–18 years of follow-up , of 33 % for annual FOBT examination . Biennial testing result ed in only a minor non-significant mortality reduction ( 6 % ) after 13 years . It increased to a cumulative 21 % reduction after 18 years [ 11 , 12 ] . The benefit of FOBT alone in the Minnesota study was question ed , since 38 % of the participants underwent colonoscopy , which may have influenced the mortality reduction rate . The authors have attributed 6 % to 11 % of the mortality reduction to the chance detection of lesions ( especially small adenomas ) by colonoscopy . Background : Children who undergo treatment for childhood acute lymphoblastic leukemia ( ALL ) and lymphoma are at risk for several long-term health problems . Obesity , for which survivors of ALL and lymphoma are also at risk , may further exacerbate these problems . This pilot study evaluates changes in physical activity and body composition among children being treated for ALL and lymphoma and their parents . Procedures : Recently diagnosed adolescent ALL and lymphoma patients were recruited from 2 pediatric hematology and oncology clinics , and matched on age , race , and sex to healthy individuals in the community .  Changes in diet , physical activity , and body composition  were collected at baseline , 6 , and 12 months . Results : All children ( n=15 ) were , on average , 10.3 years of age at enrollment , and were fairly evenly distributed with regard to sex . Analyses revealed a significant difference between cases and controls with respect to the change in body mass index from baseline to 12 months ( P=0.01 ) . In addition , controls demonstrated a significantly greater increase in moderate-vigorous physical activity than the cases [ 229.8 metabolic equivalent of tasks ( METs ) vs. 23.5 METs ] ; indicating cases remained fairly inactive over the course of treatment . Conclusions : Our data corroborate previous findings that following treatment for ALL and lymphoma , childhood cancer survivors tend to be less active and at greater risk for obesity than their healthy peers . The present study , which assessed cases prospect ively over a 12-month period during the early phases of treatment , extends prior reports by demonstrating that these outcomes are evident at an early stage in treatment OBJECTIVE Physical activity has been associated with lower diabetes risk , but several prospect i ve studies among women found that activity only slightly attenuated the diabetes risk associated with high body mass index ( BMI ) . We investigated the independent and joint associations between vigorous activity and BMI on  diabetes risk in men . METHODS This was a prospect i ve cohort design within the Physicians ' Health Study , using Cox proportional hazards models to calculate hazard ratios ( HRs ) and 95 % confidence intervals ( CIs ) of incident diabetes in 20,757 men without diabetes at baseline . Models were based on self-reported BMI and exercise frequency  at baseline , first separately and then with a 6-category joint variable combining World Health Organization BMI category ( normal/overweight/obese ) with activity status ( active/inactive ) using weekly vigorous activity as the threshold . RESULTS After a median follow-up of 23.1 years , there were 1836 cases of incident diabetes . Compared with active participants with normal BMI s , active but overweight and obese men had multivariable-adjusted HRs of 2.39 ( 95 % CI , 2.11 - 2.71 ) and 6.22 ( 95 % CI , 5.12 - 7.56 ) . Inactive men with normal , overweight , or obese BMI s had multivariable-adjusted HRs of 1.41 ( 95 % CI , 1.19 - 1.67 ) , 3.14 ( 95 % CI , 2.73 - 3.62 ) , and 6.57 ( 95 % CI , 5.25 - 8.21 ) . CONCLUSION Active men with normal and overweight BMI s had lower diabetes hazards than their inactive counterparts , but no difference by weekly activity was seen in obese men . Elevated BMI is a key driver of diabetes risk , with relatively modest attenuation by activity Background Given the increase in overweight and obesity prevalence in adolescents in the last decade , effective prevention strategies for these conditions in adolescents are urgently needed . The PRALIMAP ( Promotion de l'ALImentation et de l'Activité Physique ) trial aims to evaluate the effectiveness for these conditions of 3 health promotion strategies -- educational , screening and environmental -- applied singly or in combination in high schools over a 2-year intervention period . Methods PRALIMAP is a stratified 2 × 2 × 2 factorial cluster r and omised controlled trial including 24 state high schools in Lorraine , northeastern France , in 2 waves : 8 schools in 2006 ( wave 1 ) and 16 in 2007 ( wave 2 ) . Students entering the selected high schools in the 4 academic years from 2006 to 2009 are eligible for data collection . Interventional strategies are organized over 2 academic years . The follow-up consists of 3 visits : at the entry of grade 10 ( T0 ) , grade 11 ( T1 ) and grade 12 ( T2 ) . At T0 , 5,458 ( 85.7 % ) adolescents participated . The educational strategy consists of nutritional lessons , working groups and a final party . The screening strategy consists in detecting overweight/obesity and eating disorders in adolescents and proposing , if necessary , an adapted care management program of 7 group educational sessions . The environmental strategy consists in improving dietary and physical activity offerings in high schools and facilities , especially catering . The main outcomes are body size evolution over time , nutritional behaviour and knowledge , health and quality of life . An evaluation process documents how each intervention strategy is implemented in the schools and estimates the dose of the intervention , allowing for a per protocol analysis after the main intention-to-treat analysis . Discussion PRALIMAP aims at improving the prevention and management of overweight and obesity in adolescents by translating current evidence into public health practice . Particular attention is paid to clustering , multiple factorials and long-term duration to address common pitfalls in health promotion trials . The results should inform how best to implement , in a school environment , effective nutrition prevention programs targeting adolescents who are at a point their lives when they develop responsibilities and empowerment for health attitude behaviours . Trial registration This trial is registered at Clinical Trials.gov under NCT00814554 Background — Whether physical activity reduces the impact of obesity on the risk of acute coronary events is much debated . However , little is known about the role of other potentially modifiable lifestyle factors in combination with obesity . Methods and Results — We followed up 54 783 women and men from the prospect i ve Danish Diet , Cancer and Health study who were 50 to 64 years at baseline ( 1993 to 1997 ) and free of coronary artery disease and cancer . During a median of 7.7 years , 1127 incident cases of acute coronary syndrome ( ACS ) occurred . After multivariable adjustments , each unit of body mass index was associated with a 5 % and 7 % higher risk of ACS among women and men , respectively ( both P<0.0001 for trend ) . Overweight ( body mass index , 25 to 29.9 kg/m2 ) and obesity ( body mass index ≥30 kg/m2 ) were associated with a higher risk of ACS among the physically active and inactive , in nonsmokers and smokers , and among those who adhered more or less to a heart-healthy dietary pattern . Obese individuals who were active 1 to 3.5 h/wk had a lower risk than sedentary , obese individuals . In addition , obese nonsmokers had a lower risk than obese smokers . Adherence to a healthy diet  was associated with a lower risk of ACS ; however , the relative risk was not different among obese individuals with the most healthy diet versus obese individuals with a less healthy diet . Conclusions — Obesity confers an elevated risk of ACS in both healthy and less healthy subgroups of lifestyle behaviors . Adherence to healthy lifestyle behaviors was associated with a lower risk even among obese individuals Background Ageing is associated with a decrease in physical activity . This decrease particularly occurs during specific transitional life stages . Especially during adolescence and young adulthood a steep decrease in physical activity is observed . Inactive people are often not aware of their inactivity . Providing feedback on the actual physical activity level by an activity monitor can increase awareness and may in combination with an individually tailored physical activity advice stimulate a physically active lifestyle . Methods In a r and omized controlled trial the effectiveness of providing an activity monitor in combination with a personal physical activity advice through the Internet will be examined . Outcome measures are level of physical activity , determinants of physical activity , quality of life , empowerment , aerobic fitness and body composition .  Participants are relatively inactive adolescents and young adults who are measured at baseline , after 3 months intervention and 5 months after the end of the intervention . In addition , facilitating and hindering factors for implementation of the intervention will be investigated . Discussion The use of a personal activity monitor in combination with web-based assisted individually tailored health promotion offers a good opportunity to work interactively with large groups of adolescents and young adults and provide them with advice based on their actual activity level . It has great potential to motivate people to change their behaviour and to our knowledge has not been evaluated before The purpose of this review is to summarize literature that describes the impact of exercise on health and physical function among children during and after treatment for cancer . Relevant studies were identified by entering the following search terms into Pubmed : aerobic training ; resistance training ; stretching ; pediatric ; children ; AND cancer . Reference lists in retrieved manuscripts were also review ed to identify additional trials . We include fifteen intervention trials published between 1993 and 2011 that included children younger than age 21 years with cancer diagnoses . Nine included children with an acute lymphoblastic leukemia ( ALL ) diagnosis , and six children with mixed cancer diagnoses . Generally , interventions tested were either in-hospital supervised exercise training or home based programs design ed to promote physical activity . Early evidence from small studies indicates that the effects of exercise include increased cardiopulmonary fitness , improved muscle strength and flexibility , reduced fatigue and improved physical function . Generalizations to the entire childhood cancer and childhood cancer survivor population s are difficult as most of the work has been done in children during treatment for and among survivors of ALL . Additional r and omized studies are needed to confirm these benefits in larger population s of children with ALL , and in population s with cancer diagnoses other than ALL The current review aim ed to systematic ally identify dietary , physical activity and sedentary behaviours in preschool children ( 4 - 6 years of age ) that are prospect ively related to overweight or obesity later in childhood . Prospect i ve studies published between January 1990 and June 2010 were selected from search es in PubMed , EMBASE , PsycINFO , CINAHL and Cochrane Library . Studies examining the prospect i ve association between at least one relevant behaviour measured during preschool period ( children aged 4 - 6 years at baseline ) in relation to at least one anthropometric measurement at follow-up ( age < 18 years ) were included . Harvest plots were used to summarize the results and draw conclusions from the evidence . Of the 8,718 retrieved papers , 23 papers reporting on 15 different study sample s were included in this review . Strong evidence was found for an inverse association between total physical activity and overweight . Moderate evidence was observed for a positive association between television viewing and overweight . Because of the heterogeneity in the assessed dietary behaviours , insufficient evidence was found for an association between  dietary intake or specific dietary behaviours and overweight . These results suggest that interventions aim ing to prevent overweight among preschool children should focus on promotion of total physical activity and limitation of screen time and that further research is needed to establish whether and which dietary behaviours are important for obesity prevention in this age group . However , despite the lack of evidence for dietary behaviours from the present review , future interventions may already target specific dietary behaviours that are highly prevalent and for which there a clear rationale as well as preliminary evidence that these behaviours are associated with overweight CONTEXT Despite decades of use and considerable research , the role of estrogen alone in preventing chronic diseases in postmenopausal women remains uncertain . OBJECTIVE To assess the effects on major disease incidence rates of the most commonly used postmenopausal hormone therapy in the United States . DESIGN , SETTING , AND PARTICIPANTS A r and omized , double-blind , placebo-controlled disease prevention trial ( the estrogen-alone component of the Women 's Health Initiative [ WHI ] ) conducted in 40 US clinical centers beginning in 1993 . Enrolled were 10 739 postmenopausal women , aged 50 - 79 years , with prior hysterectomy , including 23 % of minority race/ethnicity . INTERVENTION Women were r and omly assigned to receive either 0.625 mg/d of conjugated equine estrogen ( CEE ) or placebo . MAIN OUTCOME MEASURES The primary outcome was coronary heart disease ( CHD ) incidence ( nonfatal myocardial infa rct ion or CHD death ) . Invasive breast cancer incidence was the primary safety outcome . A global index of risks and benefits , including these primary outcomes plus stroke , pulmonary embolism ( PE ) , colorectal cancer , hip fracture , and deaths from other causes , was used for summarizing overall effects . RESULTS In February 2004 , after review ing data through November 30 , 2003 , the National Institutes of Health ( NIH ) decided to end the intervention phase of the trial early . Estimated hazard ratios ( HRs ) ( 95 % confidence intervals [ CIs ] ) for CEE vs placebo for the major clinical outcomes available through February 29 , 2004 ( average follow-up 6.8 years ) , were : CHD , 0.91 ( 0.75 - 1.12 ) with 376 cases ; breast cancer , 0.77 ( 0.59 - 1.01 ) with 218 cases ; stroke , 1.39 ( 1.10 - 1.77 ) with 276 cases ; PE , 1.34 ( 0.87 - 2.06 ) with 85 cases ; colorectal cancer , 1.08 ( 0.75 - 1.55 ) with 119 cases ; and hip fracture , 0.61 ( 0.41 - 0.91 ) with 102 cases . Corresponding results for composite outcomes were : total cardiovascular disease , 1.12 ( 1.01 - 1.24 ) ; total cancer , 0.93 ( 0.81 - 1.07 ) ; total fractures , 0.70 ( 0.63 - 0.79 ) ; total mortality , 1.04 ( 0.88 - 1.22 ) , and the global index , 1.01 ( 0.91 - 1.12 ) . For the outcomes significantly affected by CEE , there was an absolute excess risk of 12 additional strokes per 10 000 person-years and an absolute risk reduction of 6 fewer hip fractures per 10 000 person-years . The estimated excess risk for all monitored events in the global index was a nonsignificant 2 events per 10 000 person-years . CONCLUSIONS The use of CEE increases the risk of stroke , decreases the risk of hip fracture , and does not affect CHD incidence in postmenopausal women with prior hysterectomy over an average of 6.8 years . A possible reduction in breast cancer risk requires further investigation . The burden of incident disease events was equivalent in the CEE and placebo groups , indicating no overall benefit . Thus , CEE should not be recommended for chronic disease prevention in postmenopausal women Reports of studies relating physical activity to stroke and cancer sub-types indicate inconsistent findings . Some are hampered by low statistical power , owing to a low number of events , and a failure to adjust for potential confounding variables . The purpose of this study was to relate physical activity to 12 mortality endpoints in a prospect i ve cohort study of 11,663 men aged 40–64 years who responded to an enquiry about travel activity during a baseline medical examination conducted between 1967 and 1969 . During 25 years of follow-up there were 4672  deaths .  Travel activity  was inversely related to mortality attributable to all-causes , coronary heart disease , respiratory disease and lung cancer , whereas the association with stroke was positive . There was evidence for attenuation of some of these associations on adjustment for potentially confounding variables . Our simplistic measure of physical activity may , in part , explain the weak associations seen Purpose Although many studies have linked obesity with increased risk of thyroid cancer  , few have investigated the role of obesity-related lifestyle characteristics and medical conditions in the etiology of this disease . We examined the associations of  self-reported physical activity and diabetes history with  thyroid cancer risk in a large pooled analysis of prospect i ve cohort studies . Methods Data from five prospect i ve studies in the U.S. ( n = 362,342 men , 312,149 women ) were coded using st and ardized exposure , covariate , and outcome definitions . Hazard ratios ( HR ) and 95 % confidence intervals ( CI ) for thyroid cancer were estimated using age as the time metric and adjusting for sex , education , race , marital status , cigarette smoking , body mass index , alcohol intake , and cohort . Effect modification by other risk factors ( e.g. , age , sex , and body mass index ) and differences by cancer subtype ( e.g. , papillary , follicular ) were also examined . Results Over follow-up ( median = 10.5 years ) , 308 men and 510 women were diagnosed with a first primary thyroid cancer . Overall , subjects reporting the greatest amount of physical activity had an increased risk of the disease ( HR = 1.18 , 95 % CI:1.00–1.39 ) ; however , this association was restricted to participants who were overweight/obese ( ≥25 kg/m2 ; HR = 1.34 , 95 % CI:1.09–1.64 ) as opposed to normal-weight ( < 25 kg/m2 ; HR = 0.92 , 95 % CI:0.69–1.22 ; P-interaction = 0.03 ) . We found no overall association between self-reported history of diabetes and thyroid cancer risk ( HR = 1.08 , 95 % CI:0.83–1.40 ) . Conclusion Neither physical inactivity nor diabetes history was associated with increased risk of thyroid cancer . While it may have been a chance finding , the possible increased risk associated with greater physical activity warrants further investigation Background Overweight and obesity have a dramatic negative impact on children 's health not only during the childhood but also throughout the adult life . Preventing the development of obesity in children is therefore a world-wide health priority . There is an obvious urge for sustainable and evidence d-based interventions that are suitable for families with young children , especially for families with overweight or obese parents . We have developed a prevention program , Early STOPP , combating multiple obesity-promoting behaviors such unbalanced diet , physical inactivity and disturbed sleeping patterns . We also aim to evaluate the effectiveness of the early childhood obesity prevention in a well-characterized population of overweight or obese parents . This protocol outlines methods for the recruitment phase of the study . Design and methods This r and omized controlled trial ( RCT ) targets overweight and /or obese parents with infants , recruited from the Child Health Care Centers ( CHCC ) within the Stockholm area . The intervention starts when infants are one year of age and continues until they are six and is regularly delivered by a trained coach ( dietitian , physiotherapist or a nurse ) . The key aspects of Early STOPP family intervention are based on Swedish recommendations for CHCC , which include advices on healthy food choices and eating patterns , increasing physical activity/reducing sedentary behavior  and regulating  sleeping patterns . Discussion The Early STOPP trial design addresses weaknesses of previous research by recruiting from a well-characterized population , defining a feasible , theory-based intervention and assessing multiple measurements to vali date and interpret the program effectiveness . The early years hold promise as a time in which obesity prevention may be most effective . To our knowledge , this longitudinal RCT is the first attempt to demonstrate whether an early , long-term , targeted health promotion program focusing on  healthy eating , physical activity/reduced sedentary behaviors and normalizing sleeping patterns could be effective . If proven so , Early STOPP may protect children from the development of overweight and obesity . Trial registration The protocol for this study is registered with the clinical trials registry clinical trials.gov , ID : ES-2010 Abstract Background : Obesity is the most common chronic pediatric disease in westernized societies , with minorities and children from low socioeconomic status being mostly affected . Arab-Israelis are the largest minority population in Israel . Objective : The aim of this study is to examine the prevalence of obesity and to prospect ively study the effects of a health promotion , school-based intervention on nutrition and physical activity knowledge and preferences , anthropometric measures , and fitness in Arab-Israeli kindergarten children . Participants : One hundred fifty-four children completed a school year with combined dietary-behavioral-physical activity intervention and were compared with 188 controls ( age 4.2–6.5 years ) . Results : The prevalence of overweight and obesity among Arab-Israeli kindergarten children was 28.9 % . Compared with control , the intervention led to a significantly greater ( control vs. intervention , respectively , p<0.05 ) increase in nutrition knowledge ( 51.2±1.5%–48.9±1.6 % vs. 48.9±1.6%–85.9±1.4 % ) and preferences ( 47.4±1.5%–47.7±1.6 % vs. 45.2±1.8%–87.1±1.4 % ) , increase in physical activity knowledge ( 47.2±1.3%–47.0±1.7 % vs. 49.2±1.7%–90.8±1.3 % ) and preferences ( 52.3±1.3%–54.2±1.8 % vs. 56.2±1.4%–92.8±1.0 % ) , and improvement in fitness ( –10.2±1.6 vs. 11.6±1.4 shuttle run laps ) . The intervention was associated with favorable changes in height gain ( 5.0±0.1 vs. 6.2±0.1 cm ) , body mass index ( BMI –0.41±0.06 vs. –0.71±0.06 kg/m2 ) and BMI percentile ( –10.0±1.3 % vs. –16.2±1.2 % ) in the control and intervention groups , respectively . Conclusions : A kindergarten dietary-physical activity intervention applied by the kindergarten teachers led to a decrease in BMI , BMI percentile , improved nutrition and physical activity knowledge and preferences , and improved fitness . Such programs may play important role in health promotion , prevention , and treatment of childhood obesity in minority communities from early age Background This study aim ed to estimate the cost-effectiveness of a universal strategy to promote physical activity in primary care . Methods Data were analysed for a cohort of participants from the general practice research data base . Empirical estimates informed a Markov model that included five long-term conditions ( diabetes , coronary heart disease , stroke , colorectal cancer and depression ) . Simulations compared an intervention promoting physical activity in healthy adults with st and ard care . The intervention effect on physical activity was from a meta- analysis of r and omised trials . The annual cost of intervention , in the base case , was one family practice consultation per participant year . The primary outcome was net health benefit in quality adjusted life years ( QALYs ) . Results A cohort of 262,704 healthy participants entered the model . Intervention was associated with an increase in life years lived free from physical disease . With 5 years intervention the increase was 52 ( 95 % interval −11 to 115 ) per 1,000 participants entering the model ( probability increased 91.9 % ) ; with 10 years intervention the increase was 102 ( 42–164 ) per 1,000 ( probability 99.7 % ) . Net health benefits at a threshold of £ 30,000 per QALY were 3.2 ( −11.1 to 16.9 ) QALYs per 1,000 participants with 5 years intervention ( probability cost-effective 64.7 % ) and 5.0 ( −9.5 to 19.3 ) with 10 years intervention ( probability cost-effective 72.4 % ) . Conclusions A universal strategy to promote physical activity in primary care has the potential to increase life years lived free from physical disease . There is only weak evidence that a universal intervention strategy might prove cost-effective Background : Physical inactivity and obesity increase the risk of  colorectal cancer  but little is known about whether they influence prognosis after diagnosis . Methods : Incident cases of colorectal cancer were identified among participants of the Melbourne Collaborative Cohort Study , a prospect i ve cohort study of 41 528 Australians recruited from 1990 to 1994 . Participants diagnosed with their first colorectal cancer between recruitment and 1 August 2002 were eligible . At the time of study entry , body measurements were taken and participants were interviewed about their physical activity . Information on tumour site and stage , treatments given , recurrences , and deaths were obtained from systematic review of the medical records . Results : A total of 526 cases of colorectal cancer were identified . Median follow up among survivors was 5.5 years , and 208 deaths had occurred , including 181 from colorectal cancer . After adjusting for age , sex , and tumour stage , exercisers had an improved disease specific survival ( hazard ratio 0.73 ( 95 % confidence interval ( CI ) 0.54–1.00 ) ) . The benefit of exercise was largely confined to stage II – III tumours ( hazard ratio 0.49 ( 95 % CI 0.30–0.79 ) ) . Increasing per cent body fat result ed in an increase in disease specific deaths ( hazard ratio 1.33 per 10 kg ( 95 % CI 1.04–1.71 ) ) . Similarly , increasing waist circumference reduced disease specific survival ( hazard ratio 1.20 per 10 cm ( 95 % CI 1.05–1.37 ) ) . Conclusions : Increased central adiposity and a lack of regular physical activity prior to the diagnosis of colorectal cancer is associated with poorer overall and disease specific survival Malaria remains one of the world ’s most significant health and development problems . More than 2.4 billion of the world ’s population residing in 100 countries or territories are at risk of malaria . This results in an estimated 300−500 million clinical cases each year , 90 % of which occur in Africa south of the Sahara Desert . 1 In these high-burden areas of Africa , Plasmodium falciparum , the most dangerous species of human malaria , causes the great majority of infections . In addition , Anopheles gambiae , the most efficient vector of malaria , predominates throughout large areas of the Africa continent . This combination of a highly dangerous pathogen carried from person to person by a highly competent , resilient vector results in at least one million deaths among young African children each year . Malaria also challenges national authorities with a substantial impediment to economic development , costing the region between $ 3 billion and 12 billion and inhibiting economic growth by as much as 1.3 % each year . 2 The strong relationship between malaria and poverty is perhaps best summarized by the observation that where malaria prospers most , human societies prosper least . 3 During the decade of the 1990s , results from a series of r and omized , controlled trials in four areas of stable transmission in Africa showed that impressive gains in the health of young children  could be achieved by interfering with humanvector contact though use of insecticide-treated net ( ITN ) material s. 4–7 These trials demonstrated that wide-scale use of ITNs in areas of stable malaria could reduce overall child mortality by approximately one-fifth , saving an average of six lives per 1,000 children with an age range of 1−59 months protected each year . 8 In addition , ITN use could halve the number of episodes of clinical malaria and , in the trial conducted in coastal Kenya , a substantial impact of ITN  use on cases of severe malaria arriving at the hospital was also seen . Objective To examine the relation between body mass index ( kg/m2 ) and  cancer incidence and mortality . Design Prospect i ve cohort study . Participants 1.2 million UK women recruited into the Million Women Study , aged 50 - 64 during 1996 - 2001 , and followed up , on average , for 5.4 years for cancer incidence and 7.0 years for cancer mortality . Main outcome measures Relative risks of incidence and mortality for all cancers , and for 17 specific types of cancer , according to body mass index , adjusted for age , geographical region , socioeconomic status , age at first birth , parity , smoking status , alcohol intake , physical activity , years since menopause , and use of hormone replacement therapy . Results 45 037 incident cancers and 17 203 deaths from cancer occurred over the follow-up period . Increasing body mass index was associated with an increased incidence of endometrial cancer ( trend in relative risk per 10 units=2.89 , 95 % confidence interval 2.62 to 3.18 ) , adenocarcinoma of the oesophagus ( 2.38 , 1.59 to 3.56 ) , kidney cancer ( 1.53 , 1.27 to 1.84 ) , leukaemia ( 1.50 , 1.23 to 1.83 ) , multiple myeloma ( 1.31 , 1.04 to 1.65 ) , pancreatic cancer ( 1.24 , 1.03 to 1.48 ) , non-Hodgkin 's lymphoma ( 1.17 , 1.03 to 1.34 ) , ovarian cancer ( 1.14 , 1.03 to 1.27 ) , all cancers combined ( 1.12 , 1.09 to 1.14 ) , breast cancer in postmenopausal women ( 1.40 , 1.31 to 1.49 ) and colorectal cancer in premenopausal women ( 1.61 , 1.05 to 2.48 ) . In general , the relation between body mass index and mortality was similar to that for incidence . For colorectal cancer , malignant melanoma , breast cancer , and endometrial cancer , the effect of body mass index on risk differed significantly according to menopausal status . Conclusions Increasing body mass index is associated with a significant increase in the risk of cancer for 10 out of 17 specific types examined . Among postmenopausal women in the UK , 5 % of all cancers ( about 6000 annually ) are attributable to being overweight or obese . For endometrial cancer and adenocarcinoma of the oesophagus , body mass index represents a major modifiable risk factor ; about half of all cases in postmenopausal women are attributable to overweight or obesity OBJECTIVE To estimate the global prevalence and incidence of herpes simplex virus type 2 ( HSV-2 ) infection in 2003 . METHODS A systematic review was undertaken of published seroprevalence surveys describing the prevalence or incidence of HSV-2 by age and gender . For each of 12 regions , pooled prevalence values by age and gender were generated in a r and om-effect model . HSV-2 incidence was then estimated from these pooled values using a constant-incidence model . Values of the HSV-2 seroprevalence from the model fits were applied to the total population to estimate the numbers of people infected . FINDINGS The total number of people aged 15 - 49 years who were living with HSV-2 infection worldwide in 2003 is estimated to be 536 million , while the total number of people who were newly infected with HSV-2 in 2003 is estimated to be 23.6 million . While the estimates are limited by poor availability of data , general trends are evident . For example , more women than men were infected , and the number infected increased with age . Although prevalence varied substantially by region , predicted prevalence was mostly higher in developing regions than developed regions . CONCLUSION The prevalence of HSV-2 is relatively easy to measure since infection is lifelong and has a specific serological test . The burden of disease is less easy to quantify . Despite the often sparse data on which these estimates are based , it is clear that HSV-2 infection is widespread . The dramatic differences in prevalence between regions are worthy of further exploration Objective : To investigate the relationships between the time spent in specific intensities of activity and inactivity ,  cardiorespiratory fitness and body composition in children . Methods : A cross-sectional study was conducted in a r and om sample of schools . Height , weight and waist circumference were measured in 224 children aged 7–10 years . Cardiorespiratory fitness was estimated by the 20 m multistage running test , and physical activity was measured over 4 days by the RT3 ( a triaxial accelerometer ) . Time each day spent in moderate and vigorous intensities of activity was calculated . Results : Twelve schools agreed to participate in the study .  Body composition and fitness data were obtained for 224 children and activity data for 152 children . Boys were found to take part in about twice as much vigorous and hard activity as girls ( mean ( 95 % confidence interval ) 64.3 ( 53.2 to 75.4 ) min in boys compared with 37 ( 33.1 to 40.9 ) min in girls ; p<0.001 ) . In boys there was significant difference between those defined as normal , overweight and obese in the time spent in vigorous activity ( p<0.05 ) , but no such difference was found in girls . A significant negative correlation between waist circumference and time spent in vigorous activity ( r = –0.31 , p<0.05 ) was found in boys but not in girls . Time spent sedentary was positively correlated with waist circumference in boys ( r = 0.33 , p<0.01 ) but not in girls . In both boys and girls there were significant negative correlations between fitness and both body mass index ( r = –0.274 , p<0.001 ) and waist circumference ( boys : r = –0.503 , p<0.01 ; girls : r = –0.286 , p<0.01 ) . Conclusion : In boys , body composition was inversely related to fitness and to vigorous activity and was positively related to inactivity . In girls , body composition was related to fitness but not to specific components of physical activity Context Heavy alcohol consumption may increase risk for hypertension , but does it increase risk for cardiovascular disease ? Contributions In this 16-year prospect i ve study , 11711 male health professionals with hypertension reported their average alcohol consumption every 4 years . Compared with men who abstained from alcohol , men who consumed 10 to 14 g/d ( about 1 drink per day ) , 15 to 29 g/d , 30 to 49 g/d , and more than 49 g/d of alcohol had decreased risk for myocardial infa rct ion . Alcohol intake seemed unrelated to total death or death due to cardiovascular disease . Caution s Alcohol intake and hypertension were self-reported . Few outcomes limited ability to determine precise relationships between alcohol and stroke . The Editors Hypertension is a major public health burden in the United States . In 1999 , 65 million adults had the condition , an approximately 30 % increase from 1991 ( 1 ) . Hypertension is associated with a doubled risk for cardiovascular disease ( CVD ) and may account for 30 % of events associated with CVD ( 2 ) . Moderate alcohol consumption is inversely associated with CVD and total death ( 3 , 4 ) . However , intake of more than 30 grams of alcohol ( that is , more than 2 drinks ) per day is associated with an increased risk for hypertension ( 5 , 6 ) . Guidelines for alcohol consumption among patients with hypertension range from a limit of 2 to 3 drinks per day to complete abstention from alcohol ( 79 ) . These contradictory recommendations may reflect the paucity of information on the relation between alcohol consumption and risk for CVD among patients with hypertension . To our knowledge , only 3 studies have addressed the relationship of alcohol intake and death due to CVD among patients with hypertension ( 1012 ) . Although the studies reported lower numbers of death due to CVD with moderate alcohol consumption , none assessed specific incidence of MI . Of importance , the studies were limited to alcohol consumption assessed after diagnosis of hypertension and were unable to account for changes of alcohol consumption after the diagnosis . To address these issues , we investigated whether  alcohol consumption is inversely associated with CVD and death among 11711 men with hypertension participating in the Health Professionals Follow-Up Study ( HPFS ) , a prospect i ve cohort of male health professionals in the United States . Methods The HPFS enrolled 51529 male dentists , veterinarians , optometrists , pharmacists , osteopathic physicians , and podiatrists from the United States who were 40 to 75 years of age and who returned a mailed question naire about diet and medical history in  1986 . Follow-up question naires were sent biennially to up date information on exposures and newly diagnosed illnesses . Hypertensive status was determined from the biennial question naires . In 1986 , participants were asked if they had ever been diagnosed with hypertension and , if so , when . On subsequent question naires , participants reported whether they had been diagnosed with hypertension in the past 2 years and , if so , the year of diagnosis . For this analysis , we included 9016 men with hypertension whose condition was diagnosed during follow-up ( that is , men with incident hypertension ) and 2695 men with hypertension at baseline whose condition was diagnosed between 1975 and 1986 and who reported not changing their alcohol consumption during that time ( that is , men with prevalent hypertension ) . From the full cohort of 51529 men , we excluded 4397 who reported a baseline history of cardiovascular disease , stroke , or cancer ( other than nonmelanoma skin cancer ) ; 81 with hypertension diagnosed after a CVD event ; 1653 who had missing or implausible nutritional information at baseline ( including missing alcohol consumption,70 missing food items , or estimated daily energy intake 800 or 4200 kcal [ only 438 of these participants were actually hypertensive ] ) ; 271 with missing information for smoking , physical activity , or body mass index ( BMI ) ; and 95 whose initial question naire had other technical problems . We also excluded 6548 men at baseline because we could not determine their drinking history , because hypertension was diagnosed before 1975 , or because they reported substantially changing their alcohol consumption within 10 years before enrollment . Of the remaining men , we identified 11711 patients with hypertension at baseline or during follow-up who were eligible for analysis . Although our sample size was set by the size of the original HPFS cohort assembled in 1986 , a sample size calculation showed that 1700 participants in the abstaining and moderate-drinking categories would detect a relative risk of 0.6 , as observed by Malinski and colleagues ( 10 ) , with 80 % power and accepting a false-positive rate of 0.05 . We assessed alcohol consumption by using a 131-item semiquantitative food-frequency question naire with separate items for beer , white wine , red wine , and liquor . We specified st and ard portions as a glass , bottle , or can of beer ; a 4-ounce glass of wine ; and a shot of liquor . For each beverage , participants were asked how often on average over the past year they consumed that amount . We calculated ethanol intake by multiplying the frequency of consumption of each beverage by the alcohol content of the specified portion size ( 12.8 g for beer , 11.0 g for wine , and 14.0 g for liquor ) and summing across beverages ( 13 ) . This process was repeated for the years 1990 , 1994 , and 1998 , with an added item about light beer in 1994 . In 1986 , men also reported the number of days per week that they typically drank any form of alcohol . We examined associations between alcohol consumption estimated by using the food-frequency question naire with consumption estimated by using 2 one-week dietary records collected approximately 6 months apart from 136 participants residing in eastern Massachusetts ( 14 , 15 ) . The Spearman correlation coefficient between these 2 measures was 0.86 . Estimated mean alcohol intake was 12.8 grams per day using dietary records and 12.5 grams per day using the food-frequency question naire , with no evidence of systematic bias . The correlation coefficient for drinking frequency between our question naire and diet records was 0.79 . Outcomes and Measurements Our primary end points were incident nonfatal MI and fatal coronary heart disease or stroke . Myocardial infa rct ion and stroke were first identified by self-reports on biennial question naires and then confirmed by medical records with World Health Organization or National Survey of Stroke criteria ( 16 ) . Fatal MI and stroke were confirmed by medical records or autopsy reports . All end points were confirmed by a physician blinded to exposure status . Approximately 80 % of participants had MI that was considered definite ; the remaining patients had MI that was considered probable and were excluded as end points in sensitivity analyses . Further details of the confirmation of end points are published elsewhere ( 17 , 18 ) . Other end points were total death ; death due to CVD ; and death augmented by alcohol intake , including cirrhosis , alcohol-related types of cancer , accidents and other external causes , cancer of the colon and rectum , pneumonia , and hemorrhagic stroke according to Thun and colleagues ( 19 ) . Covariate information was derived from biennial question naires . Nutritional information was derived from food-frequency question naires . Participants self-reported cardiovascular risk factors ( self-report of physician-diagnosed diabetes and hypercholesterolemia , cigarette smoking , physical activity , and weight ) every 2 years . Aspirin use included use of aspirin and aspirin-containing products at least twice weekly . Regular use of lipid-lowering therapy and several categories of antihypertensive medication ( for example , diuretics , -blockers , calcium-channel blockers , and -blockers ) was also recorded biennially . Nutritional variables , anthropomorphic  measures ,  aspirin use , and self-reported CVD risk factors have been vali date d ( 2025 ) . We calculated person-years of follow-up from the date of return of the 1986 question naire ( for men with hypertension at baseline ) or date of diagnosis of hypertension ( for incident cases of hypertension ) to the date of the first CVD event , the date of death , or 31 January 2002 . We used Cox proportional hazards models with time-varying covariates to estimate hazard ratios for categories of alcohol intake relative to abstainers ( 26 ) . We simultaneously controlled for age ; smoking ( never , former , 1 to 14 cigarettes per day , 15 to 24 cigarettes per day , and 25 cigarettes per day ) ; BMI ( in quintiles ) ; diabetes ; hypercholesterolemia ; parental history of MI ; aspirin use ; lipid-lowering therapy ; 5 categories of leisure-time physical activity ; quintiles of energy intake ; and quintiles of energy-adjusted intake of saturated fat , trans fatty acids , folate , vitamin E , magnesium , sodium , potassium , -3 fatty acids , and dietary fiber . Alcohol consumption and dietary variables  were up date d every 4 years ; other potential confounders were up date d every 2 years . We stopped updating participants alcohol use if they developed cancer ( other than nonmelanoma skin cancer ) for all analyses . In secondary analyses for coronary heart disease outcomes , we censored participants when they developed cancer . To examine possible confounding by sociodemographic status , we adjusted for marital and employment status ( full-time , part-time , or retired ) , profession , and ethnicity in the multivariate model . We conducted tests of linear trend across categories of increasing alcohol consumption by treating the midpoints of consumption in categories as a continuous variable . The possibility of a nonlinear relation between alcohol consumption and risk for MI was examined with restricted cubic splines ( 27 ) and tested with the likelihood ratio test , comparing models with only the linear term to models with linear and cubic spline terms . None of the nonlinear models provided a statistically significantly better model-fit than Background Physical inactivity and sedentary lifestyles are known to predispose to overweight and obesity . These lifestyles are also known to track from childhood into adulthood with consequent cardiovascular and metabolic problems . This study aim ed to describe the frequency of physical activity  and the relationship between physical activity and body mass index of urban Nigerian school children and adolescents . Methods Children from seven schools in Abeokuta , southwest Nigeria were selected using a multi-staged r and om sampling technique . Results Of 570 children , 411 ( 72.1 % ) were involved in moderate to vigorous physical activities . Involvement in physical activity was higher in older children ( P<0.001 ) , males ( P<0.001 ) , and children of mothers with a higher educational level ( P=0.03 ) . Eleven ( 1.9 % ) children were overweight or obese whereas 163 ( 28.6 % ) were underweight . There were more children with underweight than overweight among the subject population with a high level of physical activity ( 35.6 % vs. 4.4 % , P=0.499 ) . Conclusions A large proportion of the children in urban Nigeria participate in physical activity . The prevalence of overweight and obesity is low but undernutrition is a major nutritional problem among these children DIABETES MELLITUS EXACTS AN ENORMOUS TOLL IN the United States by decreasing quality of life and causing death and disability , all at a huge economic cost . Yet simple diagnostic criteria and effective treatment choices that prevent or delay the onset of costly diabetes complications are readily available to health care professionals . It is time for health care professionals and patients with diabetes to take action together to reduce premature morbidity and mortality from diabetes-caused disease . The National Diabetes Education Program is the first joint diabetes initiative of the National Institutes of Health and the Centers for Disease Control and Prevention and involves public and private partnerships to promote early diagnosis and improve the treatment and outcomes for patients with type 1 and type 2 diabetes mellitus . It is estimated that in the United States , type 2 diabetes can be present for up to 9 to 12 years before initial clinical diagnosis . Microvasculardiseaseprogressesduringthis time , causing 15 % to 20 % of patients to have retinopathy and 5 % to 10%tohaveproteinuriaat the timeofdiagnosis . Patients with type 2 diabetes have high rates of hypertension , dyslipidemia , and obesity , major reasons for their 2to 4-fold higher rates ofcardiovasculardisease . Type2diabetes isoccurring increasingly in younger people . Although every patient can be expected to benefit from any increment in improved glycemic control , blood glucose control is more effective in preventing the initial development of microvascular complications than inpreventing theprogressionofcomplicationsonce theyhave become established . This finding underscores the need for aggressive treatment as soon as type 2 diabetes is diagnosed . Diabetes accounts for almost $ 100 billion in direct medical costs and indirect expenditures attributable to diabetes each year . Further , while patients with diabetes represented 4.5 % of the US population in 1992 , they accounted for 15 % of total US health care expenditures and 27 % of Medicare expenditures . There is a marked correlation between glycemic control of diabetes as measured by glycosylated hemoglobin ( HbA1c ) testing and the cost of medical care . Medical care charges increase significantly for every 1 % increase in HbA1c level above 7 % . In 1994 , excess expenditures for patients with diabetes in a managed care setting totaled $ 282.7 million or $ 3494 per person—2.4 times the cost for control subjects . Nearly 38 % of the total excess was spent treating the long-term complications of diabetes , predominantly coronary heart disease and end-stage renal disease . Because of its high and increasing prevalence , type 2 diabetes contributes a significant portion of these costs . There is substantial evidence that the human and economic burden of diabetes can be reduced significantly by early , aggressive therapeutic intervention . The Diabetes Control and Complications Trial and the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) demonstrated that intensive blood glucose control for patients with type 1 and type 2 diabetes significantly reduced the risk for retinopathy , nephropathy , and neuropathy . Lowering blood pressure in a subset of UKPDS patients to a mean of 144/82 mm Hg reduced the risk of strokes , diabetes-related deaths , heart failure , microvascular complications , and vision Background Physical inactivity is recognised as a public health concern within children and interventions to increase physical activity are needed . The purpose of this research was to evaluate the effect of a school-based healthy lifestyles intervention on physical activity , fruit and vegetable consumption , body composition , knowledge , and psychological variables . Method A non-r and omised controlled study involving 8 primary schools ( 4 intervention , 4 control ) . Participants were 589 children aged 7–11 years . The intervention lasted 10 months and comprised a CD-rom learning and teaching re source for teachers ; an interactive website for pupils , teachers and parents ; two highlight physical activity events ( 1 mile school runs/walks ) ; a local media campaign ; and a summer activity wall planner and record . Primary outcome measures were objective ly measured physical activity ( pedometers and accelerometers ) and fruit and vegetable consumption . Secondary outcomes included body mass index , waist circumference , estimated percent body fat , knowledge , psychological variables . Multi-level modelling was employed for the data analysis . Results Relative to children in control schools , those in intervention schools significantly increased their total time in moderate-to-vigorous physical activity ( MVPA ) ( by 9 minutes/day vs a decrease of 10 minutes/day ) , their time in MVPA bouts lasting at least one minute ( 10 minutes/day increase vs no change ) and increased daily steps ( 3059 steps per day increase vs 1527 steps per day increase ) . A similar pattern of results was seen in a subset of the least active participants at baseline . Older participants in intervention schools showed a significant slowing in the rate of increase in estimated percent body fat , BMI , and waist circumference . There were no differences between groups in fruit and vegetable intake . Extrinsic motivation decreased more in the intervention group . Conclusion The intervention produced positive changes in physical activity levels and body composition . It appeared to have little or no effect on consumption of fruit and vegetables . Schools are a suitable setting for the promotion of healthy lifestyles although more work , particularly focussed on dietary change , is needed in a variety of schools and social setting Abstract The purpose of the present study was to assess different aspects of physical activity and fitness in order to develop a basis for sport programmes for overweight and obese children . Eighty-eight prepubertal children ( 49 boys , 39 girls , 4.8–11.4 years old , 61 % obese , 14 % overweight and 25 % normal weight ) were examined . Body composition was assessed by combined use of anthropometrics and bioelectrical impedance analysis . Resting energy expenditure ( REE ) and total energy expenditure ( TEE ) were measured by indirect calorimetry ( IC ) and individually calibrated 24-h heart rate ( HR ) monitoring , respectively . Activity-related energy expenditure ( AEE ) and physical activity level ( PAL )  were calculated from TEE and REE .  Fitness [ assessed by O2-pulse , respiratory exchange ratio ( RER ) at submaximal work intensities ] was determined by ergometry . The maximal isometric muscle strength of the legs ( m. quadriceps , Fa max , m. ischiocruralis , Fb max ) was measured by computer tensiometry .  Children were grouped according to their nutritional state , AEE , O2-pulse and muscle strength . When compared with normal weight children , obese and overweight children had increased fat mass ( FM ) , fat-free mass ( FFM ) , waist-to-hip ratio and REE , but no group differences were observed for TEE , AEE , and PAL . Obese and overweight children spent more hours per day watching TV  . After correction for body weight and FFM , no group differences in REE were observed , but normal weight children had a higher O2-pulse than overweight and obese children . By contrast , RER was increased in the latter group . The fittest group had the lowest body weight , BMI , FM and FFM . Children with a low O2-pulse spent more hours per day watching TV . Grouping children according to their degree of muscle strength , younger children ( 4–7.5 years ) did not show group differences in nutritional state , energy expenditure , physical activity and fitness . However , in the group of 7.6- to 11-year-old children , those with the greatest muscle strength and FFM had reduced BMI , skin folds , FM and FFM . FM correlated inversely with O2-pulse , but was not associated with TEE , AEE , PAL or muscle strength . By contrast TV consumption was positively associated with FM . To summarize , overweight and obese children were less fit and watched more TV than their normal weight counterparts . FM did not correspond to TEE , AEE or PAL . Muscle strength was not associated with FM in young children , but was inversely associated with FM in older children . Our cross-sectional data are consistent with the idea that increased fitness and reduced physical inactivity may prevent children from being overweight Objective : To estimate the current burden of mortality attributable to excess weight in the European Union ( EU ) . Methods : Prevalence of overweight ( body mass index , BMI 25–29.9 kg/m2 ) and obesity ( BMI ≥30 kg/m2 ) were based on self-reported data from a survey with sample s representative of the 15 EU Member States in 1997 . Primary source of relative risk ( RR ) of death by BMI was the first American Cancer Prevention Study ( CPS I ) . Additional calculations were performed to account for effect of smoking ( using CPS I data for non- or never-smokers ) , for pre-existing illness ( using the second CPS , CPS II , data for healthy never-smokers ) and using RRs derived from European rather than US data ( using data from a meta- analysis of prospect i ve studies ) . Mortality attributable to excess weight was calculated by combining the prevalences of overweight and obesity , the RRs , and the number of deaths in the EU countries . Results : Annual deaths attributable to overweight and obesity totalled approximately 279 000 when RRs for all subjects were used . When RRs for nonsmokers only were applied to the entire population , about 304 000 deaths were attributable to excess weight . In analyses using RRs which controlled for both smoking and history of disease , the number of deaths attributable to excess weight was estimated at about 337 000 based on European data and at about 401 000 based on US data . In the EU , therefore , a minimum of 279 000 deaths were attributable to excess weight ( 7.7 % of all deaths , varying from 5.8 % for France through 8.7 % for the UK ) . More attributable deaths occurred among the obese ( 175 000 ) than among the overweight ( 104 000 ) . Around 70 % were cardiovascular disease deaths ( 195 000 ) and 20 % cancer deaths ( 53 000 ) . Conclusion : Mortality attributable to excess weight is a major public health problem in the EU . At least one in 13 annual deaths in the EU are likely to be related to excess weight . Sponsorship : This study has been partially funded by Madrid Regional Authority ( Comunidad de Madrid ) grant no. 08.4/0011/2000 Background Physical inactivity is an independent risk factor for diabetes and heart disease . There is evidence that increasing physical activity can reduce the risk of developing these chronic diseases , but less evidence about effective ways to increase adherence to physical activity . Interventions are therefore needed that produce sustained increases in adherence to physical activity , are cost-effective and improve clinical endpoints . Methods The Women 's Lifestyle Study is a two year r and omized controlled trial involving a nurse-led intervention to increase physical activity in 40–74 year old physically inactive women recruited from primary care . Baseline measures were assessed in a face-to-face interview with a primary care nurse . The intervention involved delivery of a ' Lifestyle script ' by a primary care nurse followed by telephone counselling for nine months and a face-to-face nurse visit at six months . Outcome measurements are assessed at 12 and 24 months . The primary outcome is physical activity measured using a vali date d physical activity question naire . Secondary outcomes include blood pressure , weight , waist circumference , physical fitness ( step test ) , serum HbA1c , fasting glucose , lipids , insulin , and quality of life ( SF36 ) . Costs were measured prospect ively to allow a subsequent cost-effectiveness evaluation if the trial is positive . Discussion Due to report in 2008 , the Women 's Lifestyle Study tests the effectiveness of an enhanced low-cost , evidence -based intervention in increasing physical activity , and improving cardiovascular and diabetes risk indicators over two years . If successful in demonstrating improvements in health outcomes , this r and omized controlled trial will be the first to demonstrate long-term cardiovascular and diabetes risk health benefit , in addition to improvements in physical activity , from a sustainable physical activity intervention based in primary care . Trial Registration Australian Clinical Trials Registry ( ACTR ) , ACTRN012605000490673 Introduction Challenges exist in identifying , recruiting and motivating sedentary patients with cancer to initiate physical activity towards recommended levels . We hypothesise that the onset period of adjuvant chemotherapy can be ‘ the open window of opportunity ’ to identify and motivate sedentary patients with breast and colon cancers , at risk for developing coronary heart disease , to initiate and sustain lifestyle changes . Aims To investigate the feasibility of oncologists/nurses screening for physical inactivity , in order to identify and recruit an at-risk population of sedentary patients with breast or colon cancer at the onset of adjuvant chemotherapy . Furthermore , the study will examine the adherence to one of two multimodal exercise interventions lasting 12 weeks ; ( 1 ) hospital-based , high intensity , group exercise intervention ( 2 ) home-based , low intensity , individual , pedometer intervention . Both arms will be compared with a control group . Methods and analyses All newly referred patients will be screened for sedentary behaviour , using national recommendations . Testing at baseline , 6 , 12 and 39 weeks will include ; ( 1 ) physiological testing ( VO2-peak , one repetition maximum muscle strength and lung function ( 2 ) fasting full body dual-energy X-ray absorptiometry scan ( 3 ) fasting blood glucose , insulin , lipids and cholesterols , ( 4 ) psychometric question naires ( general well-being , quality of life , anxiety and depression , motivational readiness ) . The r and omised controlled trial feasibility design is selected in order to examine barriers for recruitment , programme adherence , safety aspects and potential efficacy to the interventions during adjuvant chemotherapy . Ethics and dissemination The Scientific Committee of the Capital Region ( case No. H-1 - 2011 - 131 ) and the Danish Data Protection Agency ( j. No. 2011 - 41 - 6349 ) approved the study . Data will be entered and locked into a data base hosted by the Copenhagen Trial Unit , Rigshosptialet . Data will be available for analyses to project members and the trial statistician after the 45 included patients have completed the 12-week test . Results will be published in peer- review ed scientific journals . Trial registration Current Controlled Trials IS RCT N24901641 UNLABELLED Decreased fitness and increased fatness are relevant factors for decreased cardiovascular and bone health in children . One way to increase physical activity and hence fitness and to reduce the risk for overweight might be sports club participation ( SCP ) . PURPOSE To investigate the association of SCP with fatness and fitness in children in general and in those with increased risk for overweight and /or low fitness . METHODS A cross-sectional study was conducted in a r and om sample of 502 first- and fifth- grade primary school children . Fitness components were determined by 10 motor tests and body fatness by the sum of four skinfolds . SCP was defined as participation of at least once a week . RESULTS Two thirds of all children were participating in a sports club . Girls ' and boys ' participation rate as well as those of overweight children and of children with overweight parents were comparable to their respective normal weight peers . In contrast , children from migrant families ( odds ratio = 0.31 ; 95 % confidence interval = 0.20 - 0.48 ) and from inactive parents ( odds ratio = 0.16 ; 95 % confidence interval = 0.05 - 0.45 ) participated significantly less ( all P < 0.001 ) . SCP was associated with endurance ( 0.53 > beta > 0.37 , all P < 0.05 ) and partly with speed , strength , and coordination ( 0.41 > beta > 0.18 , all P < 0.05 ) . In overweight children and in children from overweight parents and migrant families , this association was not found . There was no association between SCP and fatness in any of the groups . CONCLUSIONS SCP rates were high and were associated with higher levels of most fitness components in children . Participation rates were lower for children of migrant families and children from inactive parents . In addition , the association between SCP and fitness components was not found in overweight children and in children from overweight parents and migrant families BACKGROUND Childhood obesity has become a growing public health issue in Taiwan . Obese children have risk factors for type 2 diabetes and cardiovascular disease . In this prospect i ve study , we investigated the effect of a twelve-week heart health education and physical activity program on body weight and risk factors for type 2 diabetes and cardiovascular disease . METHODS Subjects were 120 obese fifth grade rs ( 65 boys and 55 girls , aged 10 - 13 years ( mean 10.6 yrs ) , body mass index ( BMI ) at the 95th percentile or more ) and were r and omly assigned to an intervention group ( n=60 ) or control group ( n=60 ) . The intervention group received a twelve-week heart health education and physical activity program , while the control group did not . In both groups , a series of examinations were done at baseline and post-test , including height , weight , BMI , body fat , blood pressure ( BP ) , physical fitness ( 800-meter running test ) , heart health knowledge , and serum biochemistry . Differences for baseline and post-test data were compared between both groups . RESULTS Mean changes in the intervention group versus control group were significant for weight ( P = 0.024 ) , BMI ( P = 0.047 ) , percentage body fat ( P = 0.008 ) , physical fitness ( 800-meter running test ) ( P = 0.025 ) , heart health knowledge ( P = 0.006 ) , total cholesterol ( P = 0.027 ) , triglycerides ( P = 0.018 ) , high-density lipoprotein cholesterol ( HDL-C ) ( P = 0.009 ) , low-density lipoprotein cholesterol ( LDL-C ) ( P = 0.041 ) , sugar ( P = 0.035 ) , insulin ( P = 0.007 ) , and insulin resistance ( HOMA-IR ) ( P = 0.028 ) . At post-test , weight , BMI , body fat , total cholesterol , triglycerides , LDL-C , sugar , insulin and HOMA-IR had decreased , but HDL-C had increased in the intervention group . CONCLUSIONS A classroom-based weight-control intervention provides educational programs to promote cardiovascular health in children . This intervention is simple , practical , and beneficial for elementary school children BACKGROUND High sodium intake increases blood pressure , a risk factor for cardiovascular disease , but the effects of sodium intake on global cardiovascular mortality are uncertain . METHODS We collected data from surveys on sodium intake as determined by urinary excretion and diet in persons from 66 countries ( accounting for 74.1 % of adults throughout the world ) , and we used these data to quantify the global consumption of sodium according to age , sex , and country . The effects of sodium on blood pressure , according to age , race , and the presence or absence of hypertension , were calculated from data in a new meta- analysis of 107 r and omized interventions , and the effects of blood pressure on cardiovascular mortality , according to age , were calculated from a meta- analysis of cohorts . Cause-specific mortality was derived from the Global Burden of Disease Study 2010 . Using comparative risk assessment , we estimated the cardiovascular effects of current sodium intake , as compared with a reference intake of 2.0 g of sodium per day , according to age , sex , and country . RESULTS In 2010 , the estimated mean level of global sodium consumption was 3.95 g per day , and regional mean levels ranged from 2.18 to 5.51 g per day . Globally , 1.65 million annual deaths from cardiovascular causes ( 95 % uncertainty interval [ confidence interval ] , 1.10 million to 2.22 million ) were attributed to sodium intake above the reference level ; 61.9 % of these deaths occurred in men and 38.1 % occurred in women . These deaths accounted for nearly 1 of every 10 deaths from cardiovascular causes ( 9.5 % ) . Four of every 5 deaths ( 84.3 % ) occurred in low- and middle-income countries , and 2 of every 5 deaths ( 40.4 % ) were premature ( before 70 years of age ) . The rate of death from cardiovascular causes associated with sodium intake above the reference level was highest in the country of Georgia and lowest in Kenya . CONCLUSIONS In this modeling study , 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day . ( Funded by the Bill and Melinda Gates Foundation . ) Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied Background Physical inactivity and overweight are two known risk factors for postmenopausal breast cancer . Former exercise intervention studies showed that physical activity influences sex hormone levels , known to be related to postmenopausal breast cancer , mainly when concordant loss of body weight was achieved . The question remains whether there is an additional beneficial effect of physical activity when weight loss is reached . The aim of this study is to investigate the effect attributable to exercise on postmenopausal breast cancer risk biomarkers , when equivalent weight loss is achieved compared with diet-induced weight loss . Design The SHAPE-2 study is a three-armed , multicentre trial . 243 sedentary , postmenopausal women who are overweight or obese ( BMI 25–35 kg/m2 ) are enrolled . After a 4 - 6 week run-in period , wherein a baseline diet is prescribed , women are r and omly allocated to ( 1 ) a diet group , ( 2 ) an exercise group or ( 3 ) a control group . The aim of both intervention groups is to lose an amount of 5–6 kg body weight in 10–14 weeks . The diet group follows an energy restricted diet and maintains the habitual physical activity level . The exercise group participates in a 16-week endurance and strength training programme of 4 hours per week . Furthermore , they are prescribed a moderate caloric restriction . The control group is asked to maintain body weight and continue the run-in baseline diet . Measurements include blood sampling , question naires , anthropometrics ( weight , height , waist and hip circumference ) , maximal cycle exercise test ( VO2peak ) , DEXA-scan ( body composition ) and abdominal MRI ( subcutaneous and visceral fat ) . Primary outcomes are serum levels of oestradiol , oestrone , testosterone and sex hormone binding globulin ( SHBG ) . Discussion This study will give insight in the potential attributable effect of physical activity on breast cancer risk biomarkers and whether this effect is mediated by changes in body composition , in postmenopausal women . Eventually this may lead to the design of specific lifestyle guidelines for prevention of breast cancer . Trial registration The SHAPE-2 study is registered in the register of clinical trials.gov , Identifier : NCT01511276 Background Childhood obesity and physical inactivity are increasing dramatically worldwide . Children of low socioeconomic status and /or children of migrant background are especially at risk . In general , the overall effectiveness of school-based programs on health-related outcomes has been disappointing . A special gap exists for younger children and in high risk groups . Methods / Design This paper describes the rationale , design , curriculum , and evaluation of a multicenter preschool r and omized intervention study conducted in areas with a high migrant population in two out of 26 Swiss cantons . Twenty preschool classes in the German ( canton St. Gallen ) and another 20 in the French ( canton Vaud ) part of Switzerl and were separately selected and r and omized to an intervention and a control arm by the use of opaque envelopes . The multidisciplinary lifestyle intervention aim ed to increase physical activity and sleep duration , to reinforce healthy nutrition and eating behaviour , and to reduce media use . According to the ecological model , it included children , their parents and the teachers . The regular teachers performed the majority of the intervention and were supported by a local health promoter . The intervention included physical activity lessons , adaptation of the built infrastructure ; promotion of regional extracurricular physical activity ; playful lessons about nutrition , media use and sleep , funny homework cards and information material s for teachers and parents . It lasted one school year . Baseline and post-intervention evaluations were performed in both arms . Primary outcome measures included BMI and aerobic fitness ( 20 m shuttle run test ) . Secondary outcomes included total ( skinfolds , bioelectrical impedance ) and central ( waist circumference ) body fat , motor abilities ( obstacle course , static and dynamic balance ) , physical activity and sleep duration ( accelerometry and question naires ) , nutritional behaviour and food intake , media use , quality of life and signs of hyperactivity ( question naires ) , attention and spatial working memory ability ( two vali date d tests ) . Research ers were blinded to group allocation . Discussion The purpose of this paper is to outline the design of a school-based multicenter cluster r and omized , controlled trial aim ing to reduce body mass index and to increase aerobic fitness in preschool children in culturally different parts of Switzerl and with a high migrant population .Trial Registration Trial Registration : clinical trials.gov Abstract Objective : To determine the risk factors for non-insulin dependent diabetes in a cohort representative of middle aged British men . Design : Prospect i ve study . Subjects and setting : 7735 men aged 40 - 59 , drawn from one group practice in each of 24 towns in Britain . Known and probable cases of diabetes at screening ( n=158 ) were excluded . Main outcome measures : Non-insulin dependent diabetes ( doctor diagnosed ) over a mean follow up period of 12.8 years . Results : There were 194 new cases of non-insulin dependent diabetes . Body mass index was the dominant risk factor for diabetes , with an age adjusted relative risk ( upper fifth to lower fifth ) of 11.6 ; 95 % confidence interval 5.4 to 16.8 . Men engaged in moderate levels of physical activity had a substantially reduced risk of diabetes , relative to the physically inactive men , after adjustment for age and body mass index ( 0.4 ; 0.2 to 0.7 ) , an association which persisted in full multivariate analysis . A non-linear relation between alcohol intake and diabetes was observed , with the lowest risk among moderate drinkers ( 16 - 42 units/week ) relative to the baseline group of occasional drinkers ( 0.6 ; 0.4 to 1.0 ) . Additional significant predictors of diabetes in multivariate analysis included serum triglyceride concentration , high density lipoprotein cholesterol concentration ( inverse association ) , heart rate , uric acid concentration , and prevalent coronary heart disease . Conclusion : These findings emphasise the interrelations between risk factors for non-insulin dependent diabetes and coronary heart disease and the potential value of an integrated approach to the prevention of these conditions based on the prevention of obesity and the promotion of physical activity . Key messages Key messages This study shows a strong , grade d association between body mass index and risk of diabetes in middle aged men , with no evidence of a threshold effect The risk of diabetes is reduced by more than 50 % among men who take moderately vigorous exercise Cardiovascular disease risk factors that are linked with insulin resistance , such as hypertriglyceridaemia and hyperuricaemia , predict non-insulin dependent diabetes These findings support an integrated approach to the prevention of non-insulin dependent diabetes and cardiovascular disease based on the prevention of obesity and the promotion of physical Background : Although obesity is an established risk factor for coronary heart disease and stroke mortality , its role as a risk factor for other causes of death has not been extensively investigated , particularly in an industrial population . Methods : This prospect i ve mortality study included 20 years of follow up of middle-aged industrial workers ( n = 7139 ) at Shell Oil Company 's manufacturing and research facilities . Baseline health risk factor data as of December 31 , 1983 , and mortality data as of December 31 , 2003 , were extracted from the company 's Health Surveillance System . Relative risks ( RRs ) for selected causes of death by body mass index ( BMI ) category were calculated using the Cox proportional hazards model adjusted for age , sex , and smoking status as well as other potential risk factors , ie , cholesterol , hypertension , and fasting blood glucose . Results : Compared with employees with BMI between 18.5 and 24.9 kg/m2 , those with BMI of 30 kg/m2 or greater had a statistically increased RR ( adjusted for age , sex , and smoking status ) for all causes ( RR , 1.25 ; 95 % confidence interval [ CI ] = 1.03–1.51 ) , coronary heart diseases ( RR , 2.29 ; 95 % CI = 1.50–3.50 ) , cardiovascular diseases ( RR , 2.22 ; 95 % CI = 1.51–3.27 ) , diabetes ( RR , 16.97 ; 95 % CI = 2.11–136.44 ) , and accidental deaths ( RR , 2.64 ; 95 % CI = 1.23–5.66 ) . After adjusting for additional covariates , coronary heart diseases and cardiovascular diseases remained statistically significant . Conclusions : Obesity was associated with increased death rates for all causes , cardiovascular diseases , diabetes , and all accidents . Overweight individuals had a statistically lower cancer rate . Death rates for lung cancer and respiratory disease were lower among overweight/obese employees but did not reach statistical significance . Reductions of employee obesity can be an effective means of reducing these causes of death Westernization or industrialization leads to an increase in rates of colon cancer , which is the second leading cause of malignant death in the United States [ 1 ] . Although the precise causes of colon cancer remain unclear , a diet high in red meat or animal fat and low in fruits and vegetables appears to increase the risk for this malignancy [ 2 , 3 ] . It is perhaps less well recognized that an inverse association between physical activity and risk for colon cancer has been seen in studies of occupational activity only [ 4 - 12 ] and of both job-related and recreational activity [ 13 - 23 ] . In addition , many studies have found an association between body mass and elevated risk for colon cancer in men ; this association is weaker in women [ 24 - 33 ] . The fact that the association is stronger in men suggests that the abdominal distribution of adiposity typical in men may be an important component of enhanced risk . More limited evidence suggests that height , which may be a proxy for a person 's net energy intake during childhood and adolescence , is related to a higher risk for colon cancer [ 33 - 35 ] . We examine the association between physical activity , obesity , and attained height in relation to risk for colon cancers and their precursory adenomas in a large cohort of male health professionals in the United States . Waist and hip circumferences were available for a subcohort of the study population . We address the hypotheses that physical inactivity , obesity , and height increase the risk for colon cancer and adenoma independently of each other and of diet , and that the abdominal pattern of obesity is an additional independent risk factor . Methods Study Population The Health Professionals Follow-up Study [ 36 ] was started in 1986 ; in that year , 51 529 male dentists , optometrists , osteopaths , podiatrists , pharmacists , and veterinarians in the United States between 40 and 75 years of age responded to a mailed question naire . They reported on their leisure-time physical activity ( described below ) ; current body weight ; weight at age 21 years ; height ; history of cancer and other medical conditions ; parental history of various diseases , including colorectal cancer ; and use of aspirin and other nonsteroidal anti-inflammatory medications . They also reported dietary and alcohol intake using a vali date d [ 37 , 38 ] , semi-quantitative food-frequency question naire . We mailed an optional question naire in 1987 to assess  waist and hip circumferences . In 1988 , 1990 , and 1992 , we up date d exposure information and ascertained newly diagnosed medical conditions and history of colonoscopy or sigmoidoscopy , including the indications for endoscopy : bleeding in stool , positive results from tests for occult fecal blood , abdominal pain , diarrhea or constipation , family history of colorectal cancer , routine screening without symptoms , or follow-up [ 39 ] . Most of the deaths in the cohort were reported by family members or by the postal system in response to the follow-up question naires . We also used the National Death Index to identify deaths among nonrespondents [ 40 ] . Assessment of Physical Activity The 1986 question naire included a section about mainly recreational or leisure-time physical activity . The reliability and validity of question naires design ed to assess physical activity have been investigated [ 41 - 43 ] . A question naire such as the one used in our cohort was evaluated in a cohort of U.S. nurses and was found to provide useful information [ 44 ] , and similar results were found during a similar validation study done within the Health Professionals cohort ( Chasan-Taber S. Personal communication ) . Participants reported the average time per week spent doing each of eight moderate and vigorous activities , choosing from among 10 possible responses that ranged from 0 minutes to 11 or more hours per week . The specific activities listed were walking or hiking outdoors ( including walking during golf ) ; jogging ( slower than 10 minutes/mile ) ; running ( 10 minutes/mile or faster ) ; bicycling ( including that done on a stationary machine ) ; lap swimming ; tennis , squash , or racquetball ; and calisthenics or rowing . In addition , each respondent reported the number of flights of stairs he climbed daily and his usual walking pace . The reported time spent at each activity per week was multiplied by its typical energy expenditure requirements expressed in metabolic equivalents ( METs ) [ 45 ] to yield a MET-hour score . One MET , which is the energy expended by sitting quietly , is equivalent to 3.5 mL of oxygen uptake per kilogram of body weight per minute for a 70-kg adult . For example , 1 hour per week of running contributed 10.2 MET-hours , 1 hour of tennis contributed 6 MET-hours , and 1 hour of walking at a moderate pace contributed 3.2 MET-hours . Body weight was excluded from the derivation of energy expenditure from physical activity to avoid confounding the expenditure variable by body weight . If more than one published intensity level was available for a given activity , the moderate or general MET value was chosen . An average MET value was assigned to the categories that listed more than one activity , such as rowing or calisthenics , and squash or racquetball . Assessment of Anthropometric Variables  Each man reported his current weight and height and his weight at age 21 years on the 1986 question naire . In 1987 , we mailed an optional question naire once to obtain additional exposure information , including body circumference measurements . We instructed each participant to measure ( to the nearest quarter inch ) his waist at the umbilicus and his hips at the largest circumference between the waist and thighs while st and ing and without measuring over bulky clothing [ 46 ] . We provided a tape measure and an illustration to help st and ardize the measurements . Sixty-five percent of the cohort responded . We used the Quetelet index ( kilograms/height in meters2 ) as a measure of total adiposity , waist-to-hip ratio to measure relative distribution of fat , and waist circumference to estimate total abdominal fat . Although the waist-to-hip ratio has been used more widely , waist circumference provides an estimate of absolute abdominal adiposity , the component most closely related to important metabolic abnormalities , including hyperinsulinemia , hypertension , and high triglyceride levels . To remove extraneous variation in the waist circumference because of height ( taller men tend to have larger waist circumferences due to their larger body size rather than to obesity ) , we adjusted waist for height using residual analysis [ 47 ] . We first regressed waist on height using multiple linear regression and then added the residual to the average waist size ( 37.4 inches ) for a man of average height ( 70 inches ) to convert this measure back to the initial scale . This conversion created for each man a st and ardized waist circumference unconfounded by height . We evaluated the precision of self-reported anthropometric measures among 123 cohort members who were part of a dietary validation study [ 46 ] . Trained technicians paid the sub study participants two visits , approximately 6 months apart , to measure current weight and waist and hip circumferences . The Pearson correlation between self-report and the average of the technicians ' two measurements was 0.97 for weight , 0.95 for waist circumference , 0.88 for hip circumference , and 0.69 for waist-to-hip ratio . The men 's self- measurements of their waist circumferences were 0.36 inches greater , their self- measurements of hip circumferences were 0.78 inches smaller , and their self- measurements of weight were 2.3 pounds less than the technician 's measurements . Identification of Patients with Colorectal Cancers In 1988 , 1990 , and 1992 , we asked each participant whether cancer had been diagnosed during the previous 2 years . The response rate to the follow-up question naires was 94 % through 31 January 1992 . When a participant ( or a decedent 's next-of-kin ) reported a diagnosis of cancer of the colon or rectum , we sought permission to obtain hospital records and pathology reports . A study physician , blinded to exposure information , review ed all medical records received and extracted data about histologic type , anatomic location , and stage of the cancer . Proximal colon cancers were defined as those from the cecum to and including the splenic flexure , and distal colon cancers were defined as those in the descending and sigmoid colon . We confirmed 249 new cases of colorectal adenocarcinoma ( excluding carcinoma in situ ) , 90 % by medical records and the remainder with corroborating information about diagnosis and treatment from the cohort member . Two hundred three cancers were in the colon and 46 were in the rectum . Identification of Patients with Colorectal Adenomas and Controls Because more than 90 % of the adenomas were diagnosed during endoscopic procedures for screening or for unrelated gastrointestinal conditions , we restricted the adenoma analysis to men who had had a colonoscopy or sigmoidoscopy .  This was done to reduce the potential for detection bias . Most procedures were sigmoidoscopies ; thus , we analyzed only adenomas of the distal colorectum . Although we did not examine proximal colon adenomas , this should not have biased inferences for the distal colorectum . However , different causes for proximal adenomas may exist . A total of 12 879 men who did not meet any of the exclusion criteria ( see Data Analysis ) reported having had an endoscopy between 1986 and 1992 . In 1993 , we sent a mailing to a r and om sample of 200 controls ( men who reported negative results from an endoscopy ) to confirm that they did not have adenomas . After one mailing , 140 ( 70 % ) controls granted us permission to review the medical records of their endoscopic procedure ; none had an unreported , histologically confirmed adenoma . We were able to recontact 96 % of the men who reported a diagnosis of polyp , and we received medical records in response to more than 96 % of the requests sent to medical record departments , BACKGROUND We studied the relations between physical activity and changes in physical activity , all-cause mortality , and incidence of major coronary-heart-disease events in older men . METHODS In 1978 - 80 ( Q1 ) , 7735 men aged 40 - 59 were selected from general practice s in 24 British towns , and enrolled in a prospect i ve study of cardiovascular disease , which included physical activity data . In 1992 ( Q92 ) , 12 - 14 years later , 5934 of the men ( 91 % of available survivors , mean age 63 years ) gave further information on physical activity and were then followed up for a further 4 years . The main endpoints were all-cause mortality during 4 years of follow-up from Q92 , and major fatal and non-fatal coronary-heart-disease events during 3 years of follow-up from Q92 . FINDINGS Among 4311 men with no history of coronary heart disease , stroke , or " other heart trouble " by Q92 and who did not report " poor health " , there were 219 deaths . In the inactive/occasionally active , light , moderate , and moderately vigorous/vigorous activity groups there were 101 ( 18.5/1000 person-years ) 48 ( 11.4 ) , 23 ( 7.3 ) , and 47 ( 9.1 ) deaths , respectively ( adjusted risk ratios 1.00 , 0.61 [ 95 % CI 0.48 - 0.86 ] , 0.50 [ 0.31 - 0.79 ] , 0.65 [ 0.45 - 0.94 ] ) . Men who were sedentary at Q1 and who began at least light activity by Q92 had significantly lower all-cause mortality than those who remained sedentary , even after adjustment for potential confounders ( risk ratio=0.55 [ 0.36 - 0.84 ] ) . Physical activity improved both cardiovascular mortality ( 0.66 [ 0.35 - 1.23 ] ) and non-cardiovascular mortality ( 0.48 [ 0.27 - 0.85 ] ) . The relation between  physical activity  at Q92 , changes in physical activity , and mortality were similar for men with pre-existing cardiovascular disease . INTERPRETATION Maintaining or taking up light or moderate physical activity reduces mortality and heart attacks in older men with and without diagnosed cardiovascular disease . Our results support public-health recommendations for older sedentary people to increase physical activity , and for active middle-aged people to continue their activity into old age Research on mindfulness-based interventions ( MBIs ) for treating symptoms of a wide range of medical conditions has proliferated in recent decades . Mindfulness is the cultivation of nonjudgmental awareness in the present moment . It is both a practice and a way of being in the world . Mindfulness is purpose fully cultivated in a range of structured interventions , the most popular of which is mindfulness-based stress reduction ( MBSR ) , followed by mindfulness-based cognitive therapy ( MBCT ) . This paper begins with a discussion of the phenomenological experience of coping with a chronic and potentially life-threatening illness , followed by a theoretical discussion of the application of mindfulness in these situations . The literature evaluating MBIs within medical conditions is then comprehensively review ed , applying a levels of evidence rating framework within each major condition . The bulk of the research looked at diagnoses of cancer , pain conditions ( chronic pain , low back pain , fibromyalgia , and rheumatoid arthritis ) , cardiovascular disease , diabetes , human immunodeficiency virus (HIV)/acquired immune deficiency syndrome ( AIDS ) , and irritable bowel syndrome . Most outcomes assessed are psychological in nature and show substantial benefit , although some physical and disease-related parameters have also been evaluated . The field would benefit from more adequately powered r and omized controlled trials utilizing active comparison groups and assessing the moderating role of patient characteristics and program “ dose ” in determining outcomes Background Smoking , poor diet , and physical inactivity account for as much as 60 % of cancer risk . Latinos experience profound disparities in health behaviors , as well as the cancers associated with them . Currently , there is a dearth of controlled trials addressing these health behaviors among Latinos . Further , to the best of our knowledge , no studies address all three behaviors simultaneously , are culturally sensitive , and are guided by formative work with the target population . Latinos represent 14 % of the U.S. population and are the fastest growing minority group in the country . Efforts to intervene on these important lifestyle factors among Latinos may accelerate the elimination of cancer-related health disparities . Methods / design The proposed study will evaluate the efficacy of an evidence -based and theoretically-driven Motivation And Problem Solving ( MAPS ) intervention , adapted and culturally-tailored for reducing cancer risk related to smoking , poor diet , and physical inactivity among high-risk Mexican-origin smokers who are overweight/obese ( n = 400 ) . Participants will be r and omly assigned to one of two groups : Health Education ( HE ) or MAPS ( HE + up to 18 MAPS counseling calls over 18 months ) . Primary outcomes are smoking status , servings of fruits and vegetables , and both self-reported and objective ly measured physical activity . Outcome assessment s will occur at baseline , 6 months , 12 months , and 18 months . Discussion The current study will contribute to a very limited evidence base on multiple risk factor intervention studies on Mexican-origin individuals and has the potential to inform both future research and practice related to reducing cancer risk disparities . An effective program targeting multiple cancer risk behaviors modeled after chronic care programs has the potential to make a large public health impact because of the dearth of evidence -based interventions for Latinos and the extended period of support that is provided in such a program . Trial registration National Institutes of Health Clinical Trials Registry # Objectives To describe the risk factors associated with injuries result ing from physical education ( PE ) , leisure time physical activity ( leisure time PA ) and sports in 9–12-year-old children . Design Prospect i ve cohort study . Setting Primary schools . Participants Nine hundred and ninety-five children aged 9–12 years . Main outcome measures Injuries occurring during either PE class  , leisure time PA or sports , and caused the child to at least stop the current activity were recorded prospect ively . Individual weekly exposure was estimated from baseline and follow-up question naires . Potential risk factors were gender , age , socioeconomic status , ethnicity , habitual level of PA , body mass index and a motor fitness . A multivariate Cox proportional hazard regression model was developed , accounting for clustering within schools . Results Gender , age and level of PA were independent significant risk factors for injury . Different modalities of PA had different injury risk factors . Most importantly , the low levels of habitual PA  significantly increased injury risk . Conclusions The children at highest injury risk are the target audience of the contemporary PA promotion efforts . PA promotion should also focus on injury prevention Background Childhood obesity is the result of a long lasting imbalance between energy intake and energy expenditure . A major contributing factor is physical inactivity which is closely linked to bone health , cardiovascular disease risk , fitness and psychological factors . The school seems to provide an excellent setting to enhance levels of  physical activity ( PA ) .  However , there is insufficient data from previous school-based intervention trials on how to enhance overall PA . It is also unknown whether an intervention aim ed at increasing PA is effective in improving the children 's health . The purpose of this paper is to outline the design of a school-based r and omized , controlled trial ( RCT ) aim ing to increase overall PA and to improve fitness and health in 6- to 13-year-old children . Methods / Design 15 schools were r and omized to the intervention ( n = 9 ) or the control ( n = 6 ) group , stratified by geographic region ( urban vs. rural ) and by age ( 1st and 5th grade ) . Participation was given for all children in the intervention group since in this group the intervention was part of the normal school curriculum . The intervention during one academic year consisted of : 1 . two additional physical education classes per week given by trained physical education teachers adding up to a total of five PA classes per week , 2 . short PA breaks ( 2–5 min each ) during academic lessons , 3 . PA home work , and 4 . adaptation of recreational areas around the school . All children underwent  anthropometric measurements , blood pressure assessment , fitness testing , measurement of PA  and they filled out question naires . At least 70 % of all children agreed to blood sampling and measurements of body composition and bone mineral measurements by dual energy x-ray absorptiometry . The primary endpoints of the study after one year were an increase in total PA by accelerometry , an increase in aerobic fitness measured by the 20 m shuttle run , a decrease in percent body fat derived from skinfold measurements and an increase in quality of life as assessed by the child health question naire in the intervention group compared to the control group . Secondary outcomes were overall fitness , differences in body composition including body fat distribution , cardiovascular risk factors , psychosocial health , bone mineral content and density of femur , lumbar spine and total body and food intake . Discussion Our preliminary data suggest that the children were representative of Swiss children with respect to sex , socio-demographic status , and body mass index . Short-term results can be expected by the beginning of 2007 . We hypothesized that our intervention will lead to an increase in PA , fitness and overall health . Based on our data , we aim to provide important information regarding the influence of such an intervention on these outcome measures in school-aged children and to provide nationwide guidelines to improve PA in children Background Most women with breast cancer experience a progressive weight gain during and after treatment . Obesity is associated with an increased risk of recurrence , contralateral breast cancer , and death . Physical activity after cancer diagnosis has been reported to have positive effects on body composition and quality of life . We present the protocol of the InForma study , a trial testing the efficacy of an intervention on weight loss ( ≥5 % of the baseline body weight ) in a group of overweight or obese breast cancer survivors . Methods / design This is a four-arm r and omized controlled trial . Patients will receive a 6-month intervention and be followed for a further 18 months . Intervention is design ed to improve adherence to a healthy diet and /or to increase physical activity , taking advantage of a wrist-based activity monitor .  Participants will be recruited among overweight or obese breast cancer patients treated at the European Institute of Oncology , after completion of eventual adjuvant chemotherapy and /or radiotherapy . It is envisaged that 260 patients will be r and omized into four arms : Dietary Intervention ; Physical Activity Intervention ; Physical Activity and Dietary Intervention ; and Less Intensive Intervention . Women will be offered individualized counseling consisting of face-to face discussion and phone calls in addition to group meetings . A motivational interviewing approach will be used to encourage health behavior change . All participants will be given a pedometer device to monitor their physical activity . Participants ’ dietary intake will be repeatedly assessed using a vali date d food frequency question naire . Participants ’ quality of life and anxiety will be assessed with the Functional Assessment of Cancer Therapy-Breast and the State-Trait Anxiety Inventory question naires . Blood sample s will be collected at baseline and follow-up visits to assess lipid and hormone profiles . Body composition will be repeatedly assessed using bioelectrical impedance vector analysis for identifying changes of fat and fat-free mass . Women allocated to the less intensive intervention arm will be considered as the control group . Discussion While there is a rising concern about the role of obesity in cancer recurrence and survival , this trial with its multi-arm design , motivational approach and use of a pedometer device will provide important insights regarding the most effective approach in promoting weight control in breast cancer survivors . Trial registration IS RCT N53325751 ( registration date : 16 October 2015 ) ; Clinical Trials.gov NCT02622711 ( registration date : 2 December 2015 ) BACKGROUND Rates of physical inactivity and poor nutrition , which are 2 of the most important modifiable risk factors for cardiovascular disease in women , are substantial . Even so , studies of interventions design ed to improve lifestyle behaviors in women have been limited and often confined to particular geographical areas . OBJECTIVE To evaluate the effect of Choose to Move on increasing women 's physical activity , improving their knowledge of heart disease and stroke , and improving their nutrition . PARTICIPANTS AND METHODS A prospect i ve , nonr and omized , 12-week educational intervention design ed by the American Heart Association for women across the United States . Participants received a welcome kit and manual with weekly information about how to manage cardiovascular disease risk factors and how to build a support system for lifestyle change . Women ( N = 23 171 ) aged 25 years or older were recruited by direct mail , the media , health care providers , and other means . Follow-up evaluations were returned from 6389 women at 2 weeks , 5338 at 4 weeks , 4209 at 8 weeks , 3916 at 10 weeks , and 3775 at 12 weeks . Participants self-reported their physical activity , diet , and knowledge about heart disease , stroke , and related symptoms . RESULTS Ninety percent of the participants were white and 56 % were aged between 35 and 54 years . Among the participants who completed the week 12 follow-up evaluation , the percentage who reported being active ( at least moderate exercise > or = 5 times per week or > 2(1/2 ) hours per week for the past 1 to 6 months ) increased from 32 % at baseline to 67 % at the program 's end ( P = .001 ) . Participants currently limiting excess calories or fat increased from 72 % to 91 % at week 10 follow-up evaluation ( P = .001 ) . The proportion correctly identifying heart disease as the leading cause of death increased from 84 % to 91 % at week 10 follow-up evaluation ( P<.001 ) . CONCLUSIONS Women who completed the Choose to Move program evaluation reported that they significantly increased their levels of physical activity , reduced their consumption of high-fat foods , and increased their knowledge and awareness of cardiovascular disease risk and its symptoms . This program provides an important model for public health , voluntary , and other health organizations of population -based , targeted low-cost self-help programs that support the Healthy People 2010 objectives for physical activity , nutrition , and cardiovascular health People with diabetes are more likely to be hospitalized and to have longer duration s of hospital stay than those without diabetes . A recent survey estimated that 22 % of all hospital inpatient days were incurred by people with diabetes and that hospital inpatient care accounted for half of the 174 billion USD total U.S. medical expenditures for this disease ( 1 ) . These findings are due , in part , to the continued expansion of the worldwide epidemic of type 2 diabetes . In the U.S. alone , there are ∼1.6 million new cases of diabetes each year , with an over all prevalence of 23.6 million people ( 7.8 % of the population , with one-fourth of the cases remaining undiagnosed ) . An additional 57 million American adults are at high risk for type 2 diabetes ( 2 ) . Although the costs of illness-related stress hyperglycemia are not known , they are likely to be considerable in light of the poor prognosis of such patients ( 3–6 ) . There is substantial observational evidence linking hyperglycemia in hospitalized patients ( with or without diabetes ) to poor outcomes . Cohort studies as well as a few early r and omized controlled trials ( RCTs ) have suggested that intensive treatment of hyperglycemia improved hospital outcomes ( 5–8 ) . In 2004 , this evidence led the American College of Endocrinology ( ACE ) and the American Association of Clinical Endocrinologists ( AACE ) , in collaboration with the American Diabetes Association ( ADA ) and other medical organizations , to develop recommendations for treatment of inpatient hyperglycemia  ( 9 ) . In 2005 , the ADA added recommendations for treatment  of hyperglycemia in the hospitalto itsannual St and ards of Medical Care ( 10 ) . Recommendations from the ACE and the ADA generally endorsed tight glycemic control in critical care units . For patients in general medical and surgical units , where RCT evidence regarding treatment targets was lacking , glycemic goals similar to those advised for out patients were advocated ( 9 , Background : Evidence accumulates that physical inactivity is one of the few modifiable risk factors for breast cancer . The mechanism through which physical inactivity affects breast cancer risk is not clear . The study aim was to investigate the association between physical activity and breast density because mammographic density is strongly associated with breast cancer risk . Methods : We did a cross-sectional study in 620 women , of ages 49 to 68 years and participants of the Dutch Prospect -European Prospect i ve Investigation into Cancer and Nutrition cohort . A self-administered question naire was used to obtain information on duration and intensity of physical activity ( recreational , household , and occupational ) during the year preceding study recruitment . A total activity index ( inactive , moderately inactive , moderately active , and active ) was estimated by combining all activity types . Percent and absolute breast density were determined on screening mammograms using a computer-aided method . Multivariate linear regression was used to examine the association between physical activity and breast density . Results : Mean percent density was 35.3 % [ 95 % confidence interval ( 95 % CI ) , 31.8 - 38.8 ] for the inactive category compared with 36.1 % ( 95 % CI , 33.0 - 39.2 ) for the active category . Mean absolute density values for the inactive and active category were 45.8 cm2 ( 95 % CI , 40.9 - 50.7 ) and 42.6 cm2 ( 95 % CI , 38.3 - 47.0 ) , respectively . Subgroup analysis for postmenopausal women showed similar results , as did separate analyses for recreational and household activity . Conclusions : The result does not support a relation between current physical activity and mammographic density in postmenopausal women . ( Cancer Epidemiol Biomarkers Prev 2006;15(3):456–60 BACKGROUND AND METHODS Experiments in animals and two epidemiologic studies in humans suggest that aspirin and other nonsteroidal antiinflammatory drugs ( NSAIDs ) may be protective against colon cancer . We tested this hypothesis in a prospect i ve mortality study of 662,424 adults who provided information in 1982 on the frequency and duration of their aspirin use .  Death rates from colon cancer were measured through 1988 . The possible influence of other risk factors for colon cancer was examined in multivariate analyses for 598 case patients and 3058 matched control subjects drawn from the cohort . RESULTS Death rates from colon cancer decreased with more frequent aspirin use in both men and women . The relative risk among persons who used aspirin 16 or more times per month for at least one year was 0.60 in men ( 95 percent confidence interval , 0.40 to 0.89 ) and 0.58 in women ( 95 percent confidence interval , 0.37 to 0.90 ) . The risk estimates were unaffected when we excluded persons who reported at entry into the study that they had cancer , heart disease , stroke , or another condition that might influence both their aspirin use and their mortality . Adjustment for dietary factors , obesity , physical activity , and family history did not alter the findings significantly . No association was found between the use of acetaminophen and the risk of colon cancer . CONCLUSIONS Regular aspirin use at low doses may reduce the risk of fatal colon cancer . Whether this is due to a direct effect of aspirin , perhaps mediated by the inhibition of prostagl and in synthesis , or to other factors indirectly associated with aspirin use is unclear OBJECTIVE To prospect ively examine the effects of a r and omized school-based intervention on nutrition and physical activity knowledge and preferences , anthropometric measures , and fitness in low socioeconomic kindergarten children . STUDY DESIGN A total of 376 children completed a school-year combined dietary-behavioral-physical activity intervention  and were compared with 349 control subjects ( age 3.8 to 6.8 years ) . RESULTS The prevalence of overweight and obesity among the kindergarten children was 27.7 % . Even though the intervention was not associated with between group differences in body mass index changes , it was associated with significantly ( P < .05 ) greater increase in nutrition knowledge and preferences , physical activity knowledge and preferences , and improvement in fitness . There was a greater ( P < .05 ) decrease in the number of overweight children in the intervention group ( -31.9 % ) compared with the controls ( -17.5 % ) . CONCLUSIONS A kindergarten dietary-physical activity intervention applied by the kindergarten teachers , had no effect on body mass index changes between the groups , but improved nutrition and physical activity knowledge and preferences , improved fitness , and decreased the percent of overweight children . This intervention may play an important role in health promotion , prevention and treatment of childhood obesity Differences in disease prevalence , clinical manifestations , and health outcomes exist between men and women . Sources for this variation range from biological differentiation at the cellular level to behavioral differences influenced by societal gender norms . Typically , biologically based differences between men and women are called sex differences , whereas gender differences describe health differences related , at least in part , to societal constructs of gender ( 13 ) . For example , biological events unique to women , such as pregnancy and menopause , are probably associated with sex differences in occurrence of certain conditions or in response to some medical therapies ( 48 ) . Gender differences probably exist in health-related perceptions and behaviors for women and men with medical conditions that are prevalent for both sexes ( for example , heart disease and chronic pain ) ( 9 –16 ) . Although sex and gender differences are theoretically distinct , they remain difficult to disentangle when differences between men and women in health outcomes and treatment effectiveness are being examined . For this reason , and for brevity , we hereafter refer to sex and gender differences collectively as sex effects . In the past 2 decades , recognition of the importance of sex effects for health outcomes and treatment heterogeneity has been growing . Beginning in 1993 , the National Institutes of Health has issued policies requiring the inclusion of women and minorities in all clinical research and trial design s with valid analysis of sex effects or differences between racial and ethnic groups ( 17 , 18 ) . Since then , the inclusion of women in clinical trials has increased ( 19 , 20 ) , and sex effects have been identified for medications , such as nicotine replacement therapy , analgesics , and aspirin ( 13 , 14 , 21 ) . Recently , sex effects in adverse reactions led to sex-specific dosage recommendations for a widely used sedative ( 7 ) . Despite this progress , representation of women in clinical studies remains inadequate for many conditions ( 22 ) . Further , published clinical trials infrequently report sex effects or discuss the appropriateness of sex-specific analyses ( 19 , 20 , 23 ) . To advance the clinical evidence base and improve health outcomes for women , clinical research must include adequate numbers of women , appropriately conduct sex-specific analyses , and consistently report sex effects . Systematic review s ( SRs ) are a key source of information for clinicians , research ers , and guideline panels . By synthesizing the overall body of evidence for key clinical and research questions , SRs could potentially make a unique contribution to the evaluation of sex effects . To our knowledge , however , the reporting of sex effects by SRs has not been previously examined . Here , we use evidence mapping to systematic ally evaluate the reporting of sex effects by SRs examining a diverse set of interventions for chronic conditions common to women ( that is , depression , diabetes , and chronic pain ) . Evidence mapping is an emerging approach that describes key characteristics of studies for a broad area of medicine ( 2426 ) . Our evidence map addresses the volume and characteristics of eligible SRs , including the representation of women in primary studies , whether and how review s reported sex effects , and findings about sex effects . Methods This work was part of a larger report for the Veterans Health Administration ( VHA ) Evidence -based Synthesis Program ( ESP ) . The complete technical report is available online ( www.hsrd . research .va.gov/publications/esp ) and includes additional information on our methods . We focused on SRs to determine the reporting of sex effects , provide high-level information about the volume of current clinical evidence , and summarize information about actual sex effects . Prioritization of Conditions for Inclusion We used forced-ranking prioritization ( 27 ) with our VHA stakeholders to determine our conditions of interest . These stakeholders included representatives from the Health Services Research & Development Center for the Study of Healthcare Innovation , Implementation and Policy ; Health Services Research & Development Women 's Health Research Network ; Women 's Health Research in the Office of Research & Development ; Women 's Health Services ; and Mental Health Services . We initially selected 34 conditions ( Appendix Table 1 ) based on disease prevalence in women , disease burden in women , availability and breadth of effective treatments for men or women , and women veterans ' priorities for gender-specific care . Stakeholders ranked this initial set of conditions , discussed the rankings , and reranked conditions that initially received intermediate priority rankings . After 2 rounds of iterative prioritization , the following conditions were selected : depressive disorders , type 2 diabetes mellitus , and chronic pain ( that is , chronic low back pain , fibromyalgia , and chronic knee pain due to osteoarthritis ) . Appendix Table 1 . Conditions Presented to Stakeholders for Prioritization * Data Sources and Search es In collaboration with an expert reference librarian , we search ed PubMed and Cochrane Data base of Systematic Review s to identify eligible SRs published after 1 October 2009 through 31 October 2014 for depression , 13 February 2015 for diabetes , and 27 February 2015 for chronic pain . Search strategies used Medical Subject Headings and free-text terms for the conditions of interest , eligible interventions , and SRs ( Appendix Table 2 ) . We restricted the search to the past 6 years because SRs are typically out date d within 5 years of publication ( 28 ) , and our goal was to describe the current state of the clinical literature . In addition to electronic search ing , we screened published review s of review s for eligible articles . Appendix Table 2 . Search Strategies Study Selection and Quality Assessment Eligible SRs evaluated interventions in several broad categories ( that is , medications , behavioral interventions , supervised exercise , and quality improvement or organizational interventions ) . We also included condition-specific interventions , such as bariatric surgery for diabetes . Review s that evaluated mixed conditions or multiple interventions must have reported results separately for at least 1 eligible condition or intervention . We included review s of interventions in any setting , with any type of active or inactive comparator , and with any duration of follow-up . Detailed inclusion and exclusion criteria are provided in Appendix Table 3 . Appendix Table 3 . Detailed Inclusion and Exclusion Criteria for Review Eligibility Two investigators screened citations for eligibility , and citations that were considered to be relevant by either person were retained for full-text review . Full-text articles were review ed by 2 investigators , and disagreements were resolved through discussion or adjudicated by a third person . Formal assessment of review quality was beyond the scope of this project . However , we noted whether review s originated from organizations known for high- quality review s ( that is , Cochrane Collaboration , Agency for Healthcare Research and Quality Evidence -based Practice Centers , and VHA ESP ) . For review s reporting sex effects , we also assessed industry funding and whether statistical power was considered . Data Abstract ion Data were abstract ed by 1 investigator and review ed by a second person . Disagreements were resolved by discussion or by a third review er . Abstract ed data included the analysis method ( that is , qualitative synthesis , meta- analysis , network meta- analysis , or individual-patient data [ IPD ] meta- analysis ) ; clinical conditions ; interventions ; main outcomes ; number and design of primary studies ( for example , r and omized , controlled trials [ RCTs ] or observational cohorts ) ; proportion of women in the included primary studies ; and if sex effects were part of the study aims , analysis plan , or results . For review s reporting sex effects , we also recorded the number of primary studies used for sex-specific analyses , effect estimates , and the method used ( for example , metaregression , subgroup analysis , or IPD meta- analysis ) . All eligible review s on depressive disorders and chronic pain conditions were fully abstract ed . All diabetes review s of nonpharmacologic interventions were also fully abstract ed . For eligible diabetes medication review s ( n= 120 ) , we applied an additional prioritization procedure before full abstract ion . We prioritized review s that examined multiple classes of medications or evaluated a single class of medications when 6 or fewer eligible review s were identified . For SRs evaluating a single class ( > 6 eligible review s were identified ) , we used additional prioritization criteria ( for example , the most recent review published in a high-impact journal or work done by an organization known for high- quality review s ) . The remaining unselected but eligible review s ( n= 58 ) had a keyword text search for sex effects and were fully abstract ed only when this search yielded positive results ( n= 13 ) . Data Synthesis and Analysis of SRs We grouped eligible review s by intervention category and described the overall volume of clinical literature for interventions addressing each condition of interest . We also determined the number of review s reporting sex effects and summarized these results . Time trends for the proportion of these review s were examined for depression and diabetes . Examination of Primary RCTs for Selected Interventions We anticipated that some interventions for each condition would have few or no eligible SRs that addressed sex effects . Thus , for a subset of interventions for each condition , we evaluated primary RCTs to determine the feasibility of conducting a future review to evaluate sex effects . Specifically , we examined  quality improvement interventions and psychotherapy for depression ; diet , physical activity , and culturally tailored psychoeducation for diabetes ; behavioral interventions for chronic low back pain ; and exercise interventions PURPOSE Physical activity ( PA ) has been suggested to help increase the survival of individuals with cancer . The objective of this review was to systematic ally evaluate and summarize the available evidence investigating the effect of PA on the survival of individuals with cancer . METHODS Electronic data bases ( CINAHL , EMBASE , and MEDLINE ) were systematic ally search ed for r and omized controlled trials and cohort studies . Selected studies were assessed by two independent investigators for method ological quality , using the PEDro scale . RESULTS Ten prospect i ve cohort studies met the inclusion criteria . Quality - assessment scores averaged 5/10 on the PEDro scale , with two articles obtaining a score of 6/10 . The majority of studies found that individuals participating in higher levels of physical activity had a reduced risk of cancer-related mortality . This trend was observed specifically for breast , colon , and colorectal cancers . On average , it appears that engaging in higher levels of metabolic equivalent hours per week may help to improve survival rates among individuals diagnosed with cancer . CONCLUSION Patients diagnosed with cancer demonstrated a trend toward increased survival with greater levels of PA . However , because only prospect i ve cohort studies were included in the study , the conclusions drawn should be regarded with caution Background There are numerous published controlled trials assessing the safety and the benefits of physical activity ( PA ) for child and adult cancer survivors . However , trials exclusively comprised of adolescent cancer survivors aged 13 - 19 years , who may experience different health and quality of life ( QOL ) effects as a function of their developmental status , are lacking . Rather , some trials have included both adolescent and child cancer survivors together . Objective The aim of this systematic review was to synthesize the findings from r and omized controlled trails ( RCTs ) and controlled clinical trials ( CCTs ) investigating the effects of PA on health and QOL outcomes in sample s comprised of > 50 % adolescent cancer survivors to summarize the current state of evidence , identify knowledge gaps , and highlight areas in need of additional research within this population . Methods Using a search strategy developed for this review , 10 electronic data bases were search ed for RCTs and CCTs that reported on the effects of PA on at least 1 health and /or QOL outcome in sample s comprised of > 50 % adolescent cancer survivors . Results From the 2249 articles identified , 2 CCTs met the predetermined eligibility criteria and were included in this review . Combined , 28 adolescents ( of 41 participants ) who were receiving active treatment participated in the 2 studies review ed . A total of 4 health and QOL outcomes ( ie , bone mass , fatigue , grip strength , QOL ) were assessed pre- and post-PA intervention . Conclusions On the basis of the 2 studies review ed , PA appears to be safe and feasible .  PA also shows promise to mitigate reductions in bone mass and might be a viable strategy to improve fatigue , grip strength , and QOL . High- quality controlled trials with larger sample s exclusively comprised of adolescent cancer survivors that assess a wide range of outcomes are needed to determine the effects of PA on health and QOL outcomes in this population Objective To estimate the prevalence of wounds managed by the UK 's National Health Service ( NHS ) in 2012/2013 and the annual levels of healthcare re source use attributable to their management and corresponding costs . Methods This was a retrospective cohort analysis of the records of patients in The Health Improvement Network ( THIN ) Data base . Records of 1000 adult patients who had a wound in 2012/2013 ( cases ) were r and omly selected and matched with 1000 patients with no history of a wound ( controls ) .  Patients ’ characteristics , wound-related health outcomes and all healthcare re source use were quantified and the total NHS cost of patient management was estimated at 2013/2014 prices . Results Patients ’ mean age was 69.0 years and 45 % were male . 76 % of patients presented with a new wound in the study year and 61 % of wounds healed during the study year . Nutritional deficiency ( OR 0.53 ; p<0.001 ) and diabetes ( OR 0.65 ; p<0.001 ) were independent risk factors for non-healing . There were an estimated 2.2 million wounds managed by the NHS in 2012/2013 . Annual levels of re source use attributable to managing these wounds and associated comorbidities included 18.6 million practice nurse visits , 10.9 million community nurse visits , 7.7 million GP visits and 3.4 million hospital outpatient visits . The annual NHS cost of managing these wounds and associated comorbidities was £ 5.3 billion . This was reduced to between £ 5.1 and £ 4.5 billion after adjusting for comorbidities . Conclusions Real world evidence highlights wound management is predominantly a nurse-led discipline . Approximately 30 % of wounds lacked a differential diagnosis , indicative of practical difficulties experienced by non-specialist clinicians . Wounds impose a substantial health economic burden on the UK 's NHS , comparable to that of managing obesity ( £ 5.0 billion ) . Clinical and economic benefits could accrue from improved systems of care and an increased awareness of the impact that wounds impose on patients and the NHS Background The evidence that higher levels of physical activity and /or lower levels of physical inactivity are associated with beneficial health-related outcomes stems mainly from observational studies . Findings from these studies often differ from r and omised controlled trials and systematic review s currently demonstrate mixed results , due partly to heterogeneity in physical activity interventions , method ologies used and population s studied . As a result , translation into clinical practice has been difficult . It is therefore essential that an overview is carried out to compare and contrast systematic review s , and to identify those physical activity interventions that are the most effective in preventing and /or treating major chronic disease . This protocol has been registered on PROSPERO 2013 : CRD42013003523 . Methods We will carry out an overview of Cochrane systematic review s. We will search the Cochrane Data base of Systematic Review s for systematic review s of r and omised controlled trials that have a primary focus on disease-related outcomes . We will restrict review s to those in selected major chronic diseases . Two authors will independently screen search outputs , select studies , extract data and assess the quality of included review s using the assessment of multiple systematic review s tool ; all discrepancies will be resolved by discussing and reaching a consensus , or by arbitration with a third author . The data extraction form will summarise key information from each review , including details of the population ( s ) ( for example , disease condition ) , the context ( for example , prevention , treatment or management ) , the participants , the intervention(s ) , the comparison(s ) and the outcomes . The primary outcomes of interest are the prevention of chronic disease and /or improved outcomes , in the treatment or management of chronic disease . These outcomes will be summarised and presented for individual chronic diseases ( for example , any change in blood pressure in hypertension or glucose control in diabetes ) . Secondary outcomes of interest are to describe the structure and delivery of physical activity interventions  across chronic disease conditions and adverse events associated with physical activity . Discussion We anticipate that our results could inform research ers , guideline groups and policymakers of the most efficacious physical activity interventions in preventing and /or managing major chronic disease The assessment of physical activity at a single time to evaluate its association with cancer may be limited , since such a measure may not adequately reflect activity over the long term . To overcome this limitation , we studied 17,148 Harvard alumni aged 30 - 79 years who were followed prospect ively for the occurrence of colon cancer ( n = 225 ) and rectal cancer ( n = 44 ) from 1965 through 1988 .  Physical activity , based on self-reported stair climbing , walking , and sports play , was assessed in either 1962 or 1966 ( 1962/1966 ) and again in 1977 . The increased activity evaluated using either assessment ( 1962/1966 or 1977 ) taken alone was not associated with risk of colon cancer . However , alumni who were highly active ( energy expenditure of greater than 2500 kilocalories/wk ) at both assessment s had half the risk of developing colon cancer relative to those who were inactive ( less than 1000 kilocalories/wk ) at both assessment s ( age-adjusted rate ratio = 0.50 ; 90 % confidence interval = 0.27 - 0.93 ) , whereas those who were moderately active ( 1000 - 2500 kilocalories/wk ) at both assessment s had an age-adjusted rate ratio of 0.52 ( 90 % confidence interval = 0.28 - 0.94 ) . We conclude that either consistently higher levels of activity are necessary to protect against colon cancer or combining two assessment s increased the precision of physical activity measurement . We found no evidence that increased physical activity protected against rectal cancer Acute respiratory tract infection ( ARTI ) , which includes acute uncomplicated bronchitis , pharyngitis , rhinosinusitis , and the common cold , is the most common reason for acute outpatient physician office visits and antibiotic prescription in adults .  Antibiotics are prescribed at more than 100 million adult ambulatory care visits annually , and 41 % of these prescriptions are for respiratory conditions ( 1 ) . Inappropriate antibiotic use for ARTI is an important contributor to antibiotic resistance , an urgent public health threat ( 2 ) . In the United States , at least 2 million antibiotic-resistant illnesses and 23000 deaths occur each year , at a cost to the U.S. economy of at least $ 30 billion ( 2 ) . Increased community use of antibiotics is highly correlated with emerging antibiotic-resistant infections . In places with greater prescribing of broad-spectrum antibiotics , specifically extended-spectrum cephalosporins and macrolides , rates of multidrug-resistant pneumococcal disease are higher ( 3 ) . Antibiotics are also responsible for the largest number of medication-related adverse events , implicated in 1 of every 5 visits to emergency departments for adverse drug reactions ( 4 ) . Adverse events range in severity from mild ( for example , diarrhea and rash ) to life-threatening ( for example , StevensJohnson syndrome , anaphylaxis , or sudden cardiac death ) . Although data on adverse events after inappropriate antibiotic use are not available , an estimated 5 % to 25 % of patients who use antibiotics have adverse events , and about 1 in 1000 has a serious adverse event ( 2 ) . Clostridium difficile diarrhea , which can be life-threatening and is usually a result of antibiotic treatment , causes nearly 500000 infections and 29300 deaths in the United States each year , leading to an estimated $ 1 billion in extra medical costs ( 5 ) . In 2009 , direct antibiotic prescription costs totaled $ 10.7 billion ; 62 % of these costs ( $ 6.5 billion ) were attributed to antibiotic prescribing in the community setting , followed by $ 3.6 billion in hospitals and $ 527 million in nursing homes and long-term care facilities ( 6 ) . An estimated 50 % of antibiotic prescriptions may be unnecessary or inappropriate in the outpatient setting ( 7 ) ( Unpublished data . Centers for Disease Control and Prevention ) , which equates to more than $ 3 billion in excess costs . Over the past decade , antibiotic prescriptions have decreased by 18 % among persons aged 5 years or older in the United States ; however , prescriptions for  broad-spectrum antibiotics ( fluoroquinolones and macrolides ) have increased by at least 4-fold ( 8) . Reducing inappropriate antibiotic prescribing in the ambulatory setting is a public health priority . This article by the American College of Physicians ( ACP ) and the Centers for Disease Control and Prevention presents available evidence on the appropriate prescribing of antibiotics for adult patients with ARTI . The high-value care advice is intended to amplify rather than replace messages from recent clinical guidelines on appropriate antibiotic prescribing ( 919 ) and serves as an up date of the 2001 Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults ( 9 ) and a complement to the pediatric principles published in 2013 ( 20 ) . The target audience for this article is all clinicians providing care to adults seeking ambulatory care for ARTI . Methods We conducted a narrative review of evidence about appropriate antibiotic use for treatment of patients with ARTI syndromes , including acute uncomplicated bronchitis , pharyngitis , rhinosinusitis , and the common cold . We included current clinical guidelines from leading professional societies , such as the Infectious Diseases Society of America ( IDSA ) . Clinical guideline recommendations were augmented with evidence -based meta-analyses , systematic review s , and r and omized clinical trials . To identify these evidence -based articles , we conducted literature search es in the Cochrane Library , PubMed , MEDLINE , and EMBASE through September 2015 . We included only English- language articles and used the following Medical Subject Headings terms : acute bronchitis , respiratory tract infection , pharyngitis , rhinosinusitis , and the common cold . The focus of the article was limited to healthy adults without chronic lung disease ( such as cystic fibrosis , bronchiectasis , and chronic obstructive pulmonary disease ) or immunocompromising conditions ( congenital or acquired immunodeficiencies , HIV infection , chronic renal failure , nephrotic syndrome , leukemia , lymphoma , Hodgkin disease , generalized cancer , multiple myeloma , iatrogenic immunosuppression , or a history of solid organ transplantation ) . We present our findings for 4 ARTI syndromes and present a framework for antibiotic prescribing strategies for each ( Table ) . Table . Antibiotic Prescribing Strategies for Adult Patients With Acute Respiratory Tract Infection This article was review ed and approved by the Centers for Disease Control and Prevention and by the ACP High Value Care Task Force , whose members are physicians trained in internal medicine and its subspecialties and which includes experts in evidence synthesis . The Task Force developed the high-value care advice statements , which are summarized in the Figure , based on the narrative review of the literature . At each conference call , all members of the High Value Care Task Force declared all financial and nonfinancial interests . Figure . Summary of the American College of Physicians and Centers for Disease and Control and Prevention advice for high-value care on appropriate antibiotic use for acute respiratory tract infection in adults . Acute Uncomplicated Bronchitis Acute uncomplicated bronchitis is defined as a self-limited inflammation of the large airways ( bronchi ) with a cough lasting up to 6 weeks . The cough may or may not be productive ( 24 ) and is often accompanied by mild constitutional symptoms . Acute bronchitis is among the most common adult outpatient diagnoses , with about 100 million ( 10 % ) ambulatory care visits in the United States per year ( 8) , more than 70 % of which result in a prescription for antibiotics ( 25 , 26 ) . Acute bronchitis leads to more inappropriate antibiotic prescribing than any other ARTI syndrome in adults ( 8) . Determining the Likelihood of a Bacterial Infection More than 90 % of otherwise healthy patients presenting to their outpatient providers with an acute cough have a syndrome caused by a virus ( Table ) ( 10 , 21 , 22 ) . Nonviral pathogens , such as Mycoplasma pneumoniae and Chlamydophila pneumoniae , are occasionally identified in patients with acute bronchitis ( 10 ) , and Bordetella pertussis may be considered in situations where transmission in the community has been reported . However , determining whether a patient has a viral or nonviral cause can be difficult . The presence of purulent sputum or a change in its color ( for example , green or yellow ) does not signify bacterial infection ; purulence is due to the presence of inflammatory cells or sloughed mucosal epithelial cells . Acute bronchitis must be distinguished from pneumonia . For healthy immunocompetent adults younger than 70 years , pneumonia is unlikely in the absence of all of the following clinical criteria : tachycardia ( heart rate > 100 beats/min ) , tachypnea ( respiratory rate > 24 breaths/min ) , fever ( oral temperature > 38C ) , and abnormal findings on a chest examination ( rales , egophony , or tactile fremitus ) ( 10 , 27 ) . Appropriate Management Strategies The most recent clinical guidelines for management of acute uncomplicated bronchitis recommended against routine antibiotic treatment in the absence of pneumonia ( 11 ) . A systematic review of 15 r and omized , controlled trials found limited evidence to support the use of antibiotics for acute bronchitis and a trend toward increased adverse events in patients treated with antibiotics ( 28 ) . A r and omized , placebo-controlled trial ( not included in the Cochrane review ) comparing ibuprofen , amoxicillinclavulanic acid , and placebo showed no significant differences in the number of days to cough resolution ( 24 ) . Although macrolides ( azithromycin ) are frequently prescribed for patients with a cough , one study showed that patients with acute bronchitis treated with a macrolide  had significantly more adverse events than those receiving placebo ( 29 ) . Patients may benefit from symptomatic relief with cough suppressants ( dextromethorphan or codeine ) , expectorants ( guaifenesin ) , first-generation antihistamines ( diphenhydramine ) , decongestants ( phenylephrine ) , and -agonists ( albuterol ) , although data to support specific therapies are limited . -Agonists have not been shown to benefit patients without asthma or chronic obstructive lung disease ( 30 ) , and symptomatic therapy has not been shown to shorten the duration of illness ( 30 , 31 ) . Over-the-counter symptomatic relief has a low incidence of minor adverse effects , including nausea , vomiting , headache , and drowsiness ( 32 ) . Providers and patients must weigh the benefits and potential for adverse effects when considering symptomatic therapy . High-Value Care Advice 1 Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected . Pharyngitis Pharyngitis is usually a benign , self-limited illness characterized by a sore throat that is worse with swallowing , with or without associated constitutional symptoms . It is a common outpatient condition , with about 12 million visits representing 1 % to 2 % of all ambulatory care visits in the United States annually ( 33 ) . Although antibiotics are usually unnecessary , they are prescribed at most visits for pharyngitis ( 34 ) . Determining the Likelihood of a Bacterial Infection Most pharyngitis cases have a viral origin ; common causes include rhinovirus , coronavirus , adenovirus , herpes simplex virus , parainfluenza , enterovirus , EpsteinBarr virus , cytomegalovirus , and influenza ( 35 ) . Patients with a sore throat and associated symptoms  , Objective With increases in cancer survival , promotion of healthy lifestyle behaviors among survivors is receiving considerable attention . This study compared health behaviors among a large sample of Australian adult cancer survivors with an age- and sex-matched cohort of people with no cancer history . Methods Using the Australian National Health Survey , 968 cancer survivors were identified , and r and omly matched by age and sex to 5,808 respondents without a history of cancer . Six health behaviors were compared  ( smoking , physical activity , servings of vegetables , servings of fruit , alcohol use , skin checks )  , along with  overweight and obesity , using polytomous logistic regression analyses controlling for selected chronic conditions . Models were applied across both groups and by tumor site . Results Compared to the non-cancer comparison group , cancer survivors were significantly more likely to be current ( OR = 1.35 ) smokers , particularly those under 40 years ( OR = 1.69 ) , and more likely to have regular skin checks ( OR = 1.76 ) . Although not significant , there was consistent evidence that cancer survivors were slightly more likely to be overweight or obese ( p = 0.065 ) and have higher levels of alcohol consumption ( p = 0.088 ) . There was no evidence of differences between survivors and controls for levels of physical inactivity , vegetable consumption or fruit consumption .  Women with a history of gynecological cancers were much more likely to be current smokers ( OR = 2.37 ) , while other differences by sex and cancer site were consistent with overall patterns . Cancer survivors were also significantly more likely to report having a range of co-morbid chronic medical conditions . Conclusion Given their increased risk of second cancers and co-morbid chronic conditions , the lack of difference in behavioral risk factors confirms the need for a focus on improving the health behaviors of cancer survivors . Collaborative chronic disease management models may be particularly appropriate in this regard BACKGROUND Overweight and obesity as well as weight dissatisfaction have been increasing in prevalence worldwide . Body weight dissatisfaction and fear of fatness are potential contributors to disordered eating . The present study aim ed to investigate the prevalence of self-reported overweight and weight dissatisfaction along with associations with socio-demographic characteristics , body image , health complaints , risk behaviours , physical activity and television viewing in adolescents in Palestine . METHODS The 2003/04 Palestinian Health Behaviour in School-aged Children ( HBSC ) is a cross-sectional survey of 17,817 adolescents from 405 r and omly selected schools . Students from a representative sample of grade s 6 , 8 , 10 and 12 ( aged 12 - 18 years ) self-completed a modified version of the international World Health Organization collaborative Health Behaviour in School-aged Children ( HBSC-2002 ) question naire . RESULTS Although 16.5 % of the adolescents were overweight , almost twice that number ( 32.1 % ) were dissatisfied with their weight ( i.e. dieting or perceiving a need to diet ) . Of those adolescents , two-thirds were not actually overweight ( 56.4 % boys ; 73.5 % girls ) . One-fifth of the total number of adolescents ( 16.0 % boys ; 24.0 % girls ) were not overweight but were dissatisfied with their weight . Boys reporting overweight or weight dissatisfaction were more likely to have mothers with higher education or to be from more affluent families . Among both genders , but especially among girls , weight dissatisfaction was positively associated with most of the outcome variables ( body image , health complaints , risk behaviours , and television viewing ) regardless of weight status , whereas weight status was associated with only a few of the outcome variables . CONCLUSIONS Weight dissatisfaction , independent of weight status , is associated with body image , health complaints , risk behaviours and television viewing , and represents a potential health risk factor for adolescents . Preventive interventions should focus not only on weight status , but also on body weight dissatisfaction Context Some studies suggest that people with high levels of physical activity are less likely to develop dementia . Content All 1740 participants in this cohort study were 65 years of age or older and were cognitively intact at baseline . Over 6.2 years , the rate of dementia was 13.0 per 1000 person-years in those who exercised 3 or more times per week and 19.7 per 1000 person-years in those who exercised less than 3 times per week . Limitations The only measure of exercise intensity was self-reported frequency . The cohort was largely white and well-educated . Implication s This study adds to the evidence that regular exercise is associated with a lower risk for dementia . However , the existing evidence does not prove that regular exercise is associated with a lower dementia risk . The Editors Alzheimer disease and other dementing illnesses are major sources of morbidity and mortality ( 1 - 3 ) that affect millions of persons in the increasingly aging society of the United States . Research design ed to discover strategies to delay onset and progression of these potentially devastating illnesses is ongoing worldwide . Effective prevention strategies would result in substantial benefits through improved quality of life , prolonged independent life expectancy , and reduced economic cost and social burdens .  Regular physical exercise is an important element in overall health promotion ( 4 ) and might also be an effective strategy to delay onset of dementia ( 5 ) . A biological basis for how physical exercise might preserve brain function includes improved cerebral blood flow and oxygen delivery ( 6 ) and inducing fibroblast growth factor in the hippocampus ( 7 ) . More recent evidence suggests that reduced loss of hippocampal brain tissue in the aging brain is related to level of physical fitness ( 8) . Evidence from some longitudinal studies and r and omized trials suggests that physical exercise enhances cognitive function in older adults ( 9 - 15 ) , whereas other studies have failed to observe the benefits of physical exercise in preserving cognitive function ( 16 - 19 ) . Many people regard Alzheimer disease as one of the most dreaded consequences of aging . If regular physical exercise were shown to be effective in reducing the risk or delaying the onset of dementing illnesses , it would be another compelling reason to promote physical exercise . Few population -based longitudinal studies have examined the role of physical exercise on the risk for dementia in elderly persons . One recent longitudinal study showed that physical exercise was associated with decreased risk for decline in cognitive function ( odds ratio [ OR ] , 0.58 ) , Alzheimer disease ( OR , 0.50 ) , and any dementia ( OR , 0.63 ) ( 11 ) , whereas another longitudinal study showed no association between physical exercise and dementia ( 16 ) . More recent studies showed that walking was associated with a reduced risk for dementia and Alzheimer disease in a cohort of Japanese-American men ( 20 ) and that engaging in more diverse physical activities was associated with a reduced risk for dementia in the Cardiovascular Health Study ( 21 ) . The purpose of this study was 2-fold : 1 ) to determine whether regular exercise is associated with a reduced risk for incidence of dementia ( in particular , Alzheimer disease ) in a cohort followed biennially over 6 years and 2 ) to examine whether the association of physical exercise with incident dementia is modulated by other potential risk factors , such as depression , cardiovascular and cerebrovascular disease , diabetes , apolipoprotein E 4 allele , cognitive function , physical function , self-rated health , and lifestyle characteristics . Methods Study Sample The Adult Changes in Thought ( ACT ) study is a population -based , longitudinal study of aging and dementia . The ACT study was design ed to determine the incidence of Alzheimer disease , other types of dementia , and cognitive impairment as well as to determine risk factors for these conditions . The details of the ACT study have been described elsewhere ( 22 , 23 ) . Briefly , a r and om sample of 6782 individuals was drawn from Seattle-area members of Group Health Cooperative ( GHC ) , a consumer-governed health maintenance organization . The participants were 65 years of age and older when the study began in 1994 to 1996 . Those who had an existing diagnosis of dementia , were current residents of a nursing home , or were participating in other studies were ineligible ( n= 1360 ) . Of 5422 eligible persons , 2581 participated and 2841 declined participation . Age , sex , and ethnicity of the remaining 2581 participants did not differ significantly from those who were excluded . Nonresponse has been described elsewhere ( 22 ) . Declining to participate was more common among the oldest age group ( > 85 years ) , women , and African-American and minority groups ( 22 ) . Additional details regarding the incident rates of dementia and Alzheimer disease from the ACT study have been published elsewhere and are consistent with rates reported in U.S. and European cohort studies ( 22 ) . The institutional review boards of the University of Washington and Group Health Cooperative approved the ACT study . Participants received the  Cognitive Ability Screening Instrument ( CASI ) ( 24 ) as initial screening for cognitive function and were interviewed with structured question naires to obtain data , including demographic characteristics , medical history , memory and general functioning , and potential epidemiologic risk factors . Persons scoring 86 or higher on the CASI were entered directly into the ACT cohort as being cognitively intact . ( The CASI scores range from 0 to 100 ; a score of 86 corresponds to a Mini-Mental State Examination score of 25 to 26 . ) Persons with a score lower than 86 had additional medical record review and st and ardized clinical and neuropsychological evaluation for dementia . Persons who did not meet established criteria for dementia ( 25 ) were included in the ACT cohort . The current study sample was selected from the 2581 ACT participants to examine the temporal relationship of physical exercise preceding development of dementia . By design , we selected the 1895 persons whose CASI scores were above the 25th percentileCASI scores 91 to 100 . We excluded 686 persons whose CASI scores were in the lowest quartileCASI scores 62 to 90because the lowest quartile group might include persons who had mild cognitive impairment or impending dementia ( 26 ) . We did not collect information about the history of exercise before the participants entered the study . Therefore , in the group with low CASI scores , we could not be certain whether a reported low level of physical exercise preceded the development of dementia or was a consequence of the development of cognitive impairment or dementia . Of 1895 participants selected , 155 withdrew after the baseline visit and did not have a follow-up examination and were thus excluded from the analyses , leaving the analytic sample of 1740 persons . Incident Dementia We conducted biennial examinations to identify cases of incident dementia , when participants were rescreened with the CASI . Those who scored 86 or higher on the CASI remained in the ACT cohort . Scores on the CASI that were less than 86 at follow-up prompted a full st and ardized clinical examination . The results of rescreening by the CASI and by the clinical and neuropsychological examinations were review ed at a consensus diagnosis conference that included at least the examining physician , a neuropsychologist , another study physician , and the study nurse . Persons who did not meet the criteria for dementia were considered as not having dementia and were followed in the ACT cohort ( 22 , 23 ) . Persons who met the Diagnostic and Statistical Manual of Mental Disorders , fourth edition ( DSM-IV ) , criteria ( 25 ) for dementia were considered to have incident dementia . Dementia type was determined by the National Institute of Neurological and Communicative Diseases and Stroke-Alzheimer 's Disease and Related Disorders Association ( NINCDS-ADRDA ) criteria ( 27 ) for Alzheimer disease and by the DSM-IV criteria ( 25 ) for other types of dementia . Level of physical activity was not considered at the consensus conference . Physical Exercise Physical exercise was assessed at baseline by asking participants the number of days per week they did each of the following activities for at least 15 minutes at a time during the past year : walking , hiking , bicycling , aerobics or calisthenics , swimming , water aerobics , weight training or stretching , or other exercise . The frequency of exercise was calculated by the times per week that participants engaged in any of these forms of exercise . In this study , persons who exercised at least 3 times a week , above the lowest quartile , were classified as exercising regularly . Baseline Variables as Potential Confounders Numerous factors may influence the relationship between exercise and risk for dementia , including physical functioning , cognitive function , depression , health conditions , and lifestyle characteristics . Physical function was assessed by a performance-based physical function ( PPF ) test ( 23 ) , which consisted of 4 performance tests : 10-foot timed walk , time to st and from a seated position in a chair to a st and ing position 5 times , balance test , and grip strength in the dominant h and . Each test was scored from 0 to 4 points . The final PPF score was the sum of the scores for the 4 performance tests and ranged from 0 to 16 ; higher scores indicated better physical function . Details of the PPF test have been reported elsewhere ( 23 ) . Cognitive function was assessed by using the CASI , which provides quantitative assessment of attention , concentration , orientation , short-term memory , long-term memory , language ability , visual construction , list-generating fluency , abstract ion , and judgment ( 24 ) . At baseline , depression was measured by using the 11-item Center for Epidemiologic Studies Depression ( CES-D ) scale ( 28 ) . The CES-D scores ranged from 0 to 33 , with higher scores Regular physical activity has both short- and long-term health benefits in adults . No study has investigated childhood determinants of adult physical activity patterns , however . In a nonconcurrent prospect i ve study , the physical activity levels of 453 young men , 23 to 25 years of age , were compared with their physical fitness test scores as children ( 10 to 11 years of age and 15 to 18 years of age ) . The physically active adults had significantly better childhood physical fitness test scores than did the inactive adults . In 224 children , 2 years of fitness test results were available . The risk of physical inactivity in young adulthood was linearly related to the number of low scores on the 548.6-m ( 600-yd ) run and sit-ups tests as children ( P less than .001 ) . In stepwise multivariate discriminant analysis , the childhood 548.6-m run score was the best discriminator between currently physically active and inactive adults . Reported parental encouragement of exercise , level of education , participation in organized sports after high school , and reported spousal encouragement of exercise  also contributed significantly to the discriminant function . These results demonstrate that physical fitness testing in boys facilitates the identification of those at increased risk of becoming physically inactive young adults BACKGROUND Participation in regular moderate or vigorous physical activity substantially reduces risk for all-cause and cardiovascular-disease mortality and confers other health benefits . Efforts to decrease the population prevalence of inactivity will have a greater impact if they are tailored to the needs and preferences of the community . METHODS In the Pilot Survey of the Fitness of Australians , a question naire was administered to a r and omly selected sample of 2,298 adults and included questions on the preferred sources of assistance or support to become  physically active  , preferred activities , and barriers to regular participation . The responses of those who were identified as insufficiently physically active ( n = 1,232 ; 53.6 % ) were examined for men and women separately and for those aged 18 to 39 , 40 to 59 , and 60 to 78 years . RESULTS The most-preferred activity was walking ( 38 and 68 % of the youngest and oldest age groups , respectively ) . The most frequently cited barriers to more-regular participation in the youngest age group were insufficient time , lack of motivation and child care responsibilities . Among those aged 60 to 78 years , injury or poor health were the most frequently cited barriers to activity . The most-preferred source of advice or assistance changed with age : more than 50 % of the oldest age group wanted advice from a health professional ( compared with 22 % of the youngest group ) and the opportunity to exercise with a group was the most preferred source of support for the youngest age group . CONCLUSIONS The physical activity-related attributes of men and women and of younger and older age groups described in this study may be used to provide more relevant and appealing options for those who might otherwise be missed by " one-size-fits-all " physical activity promotion strategies Importance More research is required to clarify the association between physical activity and health in  “ weekend warriors ” who perform all their exercise in 1 or 2 sessions per week . Objective To investigate associations between the weekend warrior and other physical activity patterns and the risks for all-cause , cardiovascular disease ( CVD ) , and cancer mortality . Design , Setting , and Participants This pooled analysis of household-based surveillance studies included 11 cohorts of respondents to the Health Survey for Engl and and Scottish Health Survey with prospect i ve linkage to mortality records . Respondents 40 years or older were included in the analysis . Data were collected from 1994 to 2012 and analyzed in 2016 . Exposures Self-reported leisure time physical activity , with activity patterns defined as inactive ( reporting no moderate- or vigorous-intensity activities ) , insufficiently active ( reporting < 150 min/wk in moderate-intensity and < 75 min/wk in vigorous-intensity activities ) , weekend warrior ( reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from 1 or 2 sessions ) , and regularly active ( reporting ≥150 min/wk in moderate-intensity or ≥75 min/wk in vigorous-intensity activities from ≥3 sessions ) . The insufficiently active participants were also characterized by physical activity frequency . Main Outcomes and Measures All-cause , CVD , and cancer mortality ascertained from death certificates . Results Among the 63 591 adult respondents ( 45.9 % male ; 44.1 % female ; mean [ SD ] age , 58.6 [ 11.9 ] years ) , 8802 deaths from all causes , 2780 deaths from CVD , and 2526 from  cancer  occurred during 561 159 person-years of follow-up . Compared with the inactive participants , the hazard ratio ( HR ) for all-cause mortality was 0.66 ( 95 % CI , 0.62 - 0.72 ) in insufficiently active participants who reported 1 to 2 sessions per week , 0.70 ( 95 % CI , 0.60 - 0.82 ) in weekend warrior participants , and 0.65 ( 95 % CI , 0.58 - 0.73 ) in regularly active participants . Compared with the inactive participants , the HR for CVD mortality was 0.60 ( 95 % CI , 0.52 - 0.69 ) in insufficiently active participants who reported 1 or 2 sessions per week , 0.60 ( 95 % CI , 0.45 - 0.82 ) in weekend warrior participants , and 0.59 ( 95 % CI , 0.48 - 0.73 ) in regularly active participants . Compared with the inactive participants , the HR for cancer mortality was 0.83 ( 95 % CI , 0.73 - 0.94 ) in insufficiently active participants who reported 1 or 2 sessions per week , 0.82 ( 95 % CI , 0.63 - 1.06 ) in weekend warrior participants , and 0.79 ( 95 % CI , 0.66 - 0.94 ) in regularly active participants . Conclusions and Relevance Weekend warrior and other leisure time physical activity patterns characterized by 1 or 2 sessions per week may be sufficient to reduce all-cause , CVD , and cancer mortality risks regardless of adherence to prevailing physical activity guidelines Objective To establish in children whether inactivity is the cause of fatness or fatness the cause of inactivity . Design A non-intervention prospect i ve cohort study examining children annually from 7 to 10 years . Baseline versus change to follow-up associations were used to examine the direction of causality . Setting Plymouth , Engl and . Participants 202 children ( 53 % boys , 25 % overweight/obese ) recruited from 40 Plymouth primary schools as part of the EarlyBird study . Main outcome measures  Physical activity ( PA ) was measured using Actigraph accelerometers . The children wore the accelerometers for 7 consecutive days at each annual time point . Two components of PA were analysed : the total volume of PA and the time spent at moderate and vigorous intensities . Body fat per cent ( BF% ) was measured annually by dual energy x ray absorptiometry . Results BF% was predictive of changes in PA  over the following 3 years , but PA levels were not predictive of subsequent changes in BF% over the same follow-up period . Accordingly , a 10 % higher BF% at age 7 years predicted a relative decrease in daily moderate and vigorous intensities of 4 min from age 7 to 10 years ( r=−0.17 , p=0.02 ) , yet more PA at 7 years did not predict a relative decrease in BF% between 7 and 10 years ( r=−0.01 , p=0.8 ) . Conclusions Physical inactivity appears to be the result of fatness rather than its cause . This reverse causality may explain why attempts to tackle childhood obesity by promoting PA have been largely unsuccessful OBJECTIVE To assess physical activity levels among Saudi adults , and to examine the relationships of physical activity with body mass index ( BMI ) , waist circumference ( WC ) and obesity prevalence . METHODS Data taken from the Coronary Artery Disease in Saudis Study which is a National Epidemiological Health Survey carried out between 1995 and 2000 . Participants included 17395 Saudi males and females aged 30 - 70 years , selected r and omly using a multistage stratified cluster sampling technique .  Leisure-type and sport-related physical activities including walking were assessed using an interviewed-administered question naire . The activities were classified into five intensity categories and assigned metabolic equivalents ( MET ) according to the compendium of physical activity . Based on the intensity , duration and frequency of physical activity , subjects were classified into active or inactive category . RESULTS Inactivity prevalence ( 96.1 % ) was very high . There were significantly ( p<0.001 ) ) more inactive females ( 98.1 % ) than males ( 93.9 % ) . Inactivity prevalence increases with increasing age category , especially in males , and decreases with increasing education levels . Inactivity was the highest in the central region ( 97.3 % ; 95 % CI = 96.8 - 97.8 % ) and the lowest in the southern region of Saudi Arabia ( 94.0 % ; 95 % CI = 93.2 - 94.8 % ) . Further , active individuals exhibited lower values of BMI and WC . CONCLUSION These findings reveal the sedentary nature of Saudi population . The overwhelming majority of men and women did not reach the recommended physical activity levels necessary for promoting health and preventing diseases . The high prevalence of inactivity among Saudis represents a major public health concern Childhood obesity incidence has increased substantially and it has been argued that decreasing physical activity levels , coinciding with an increase in sedentary behaviours , are responsible . Australian guidelines were published in 2004 , recommending that children participate in a minimum of 60 min of physical activity daily and spend no more than 2h a day using electronic media for entertainment . We aim ed to compare compliance with these guidelines amongst children of differing weight status . The Childhood Injury Prevention Study ( CHIPS ) collected data from a r and omly selected sample of Brisbane primary and preschool children aged 5 - 12 years . The following data were available for 518 participants : age , gender , measured height and weight and estimated time per week from a parent-completed 7 days diary in physical activity out of school and sedentary leisure activities including television viewing and computer use . Using age st and ardised body mass index estimates , approximately 20 % of the cohort were overweight . Non-compliance with guidelines was 14.7 % for out of school physical activity participation , and 30.9 % for excess electronic media entertainment use . There was a 63 % increase in the odds of overweight status amongst children who were non-compliant with the electronic entertainment recommendations than those who were compliant ( adjusted odds ratio=1.63 ; 95 % CI=1.05 - 2.54 ) . Female gender and school level socioeconomic category were also independently associated with overweight status . Non-compliance with the minimal physical activity guideline increased the odds of being overweight by 28 % , however this difference was not statistically significant . One in seven children from the Greater Brisbane area are at risk for being insufficiently active whilst a third overuse electronic media . Given that overuse of electronic entertainment was positively associated with childhood obesity , these children should be the target of public health campaigns to promote alternative leisure time activities OBJECTIVE the objective of the study was to compare the differences in psychological well-being and quality of life during pregnancy and post partum of obese physically active women and obese physically inactive women enroled in a weight gain restriction programme . We also wanted to explore whether physical activity influences weight change or health status during pregnancy . DESIGN a prospect i ve intervention study . SETTING antenatal care clinic . PARTICIPANTS a total of 74 obese pregnant women in a physically active group and 79 obese women in a physically inactive group . MEASUREMENTS the women kept diaries of their physical activity during pregnancy and answered the Beck Anxiety Inventory  , the Edinburgh Postnatal Depression Scale and Medical Study Short-Form Health Survey in gestational weeks 15 and 35 and 11 weeks post partum .  Physical activity  was measured in metabolic equivalents . FINDINGS the physically active women experienced fewer depressive symptoms and estimated an improved quality of life during their pregnancies as measured by physical functioning , bodily pain , social functioning , role limitations due to emotional problems and general mental health as compared with the physically inactive women . There were no differences between the groups in gestational weight gain or weight change from early pregnancy to post partum or in prevalence of complications . KEY CONCLUSIONS physical activity among obese pregnant women provides better psychological well-being and improved quality of life , but does not prevent weight change . IMPLICATION S FOR PRACTICE staff at Antenatal Care Clinics that face obese pregnant women , should encourage and emphasise the benefits of being physically active throughout pregnancy The global epidemic of obesity and physical inactivity may have detrimental implication s for young people ’s  cognitive function and academic achievement . This prospect i ve study investigated whether childhood motor function predicts later academic achievement via physical activity , fitness , and obesity . The study sample included 8,061 children from the Northern Finl and Birth Cohort 1986 , which contains data about parent-reported motor function at age 8 y and self-reported physical activity , predicted cardiorespiratory fitness ( cycle ergometer test ) , obesity ( body weight and height ) , and academic achievement ( grade s ) at age 16 y.  Structural equation models with unst and ardized ( B ) and st and ardized ( β ) coefficients were used to test whether , and to what extent , physical activity , cardiorespiratory fitness , and obesity at age 16 mediated the association between childhood motor function and adolescents ’ academic achievement . Physical activity was associated with a higher grade -point average , and obesity was associated with a lower grade -point average in adolescence . Furthermore , compromised motor function in childhood had a negative indirect effect on adolescents ’ academic achievement via physical inactivity ( B = –0.023 , 95 % confidence interval = –0.031 , –0.015 ) and obesity ( B = –0.025 , 95 % confidence interval = –0.039 , –0.011 ) , but not via cardiorespiratory fitness . These results suggest that physical activity and obesity may mediate the association between childhood motor function and adolescents ’ academic achievement . Compromised motor function in childhood may represent an important factor driving the effects of obesity and physical inactivity on academic underachievement Regular physical activity is associated with a reduced risk of all-cause mortality , and mortality due to cardiovascular disease and cancer . Among adolescents , physical activity is associated with benefits in the prevention and control of emotional distress , and improvement of self-esteem . Countries in transitional epidemiological scenarios , such as Chile , need to develop effective strategies to improve physical activity as a way to face the epidemic of chronic diseases . The objective of this study was to evaluate the effects of a school-based physical activity program on physical fitness and mental health status of adolescents living in a low socioeconomic status area in Santiago , Chile . A quasi-experimental design was used to evaluate the effects of the program over one academic year . The study included 198 students aged 15 years old . Two ninth grade classes were r and omly selected as the  intervention group , with two classes of the same grade as controls . A social planning approach was used to develop the intervention . The program was design ed and implemented based on student preferences , teachers ' expertise and local re sources . Changes in physiological and mental health status were assessed . After the intervention , maximum oxygen capacity achieved a significant increase of 8.5 % in the intervention versus 1.8 % in the control group ( p < 0.0001 ) . Speed and jump performance scores improved significantly more in the intervention versus the control group ( p > 0.01 ) . Anxiety score decreased 13.7 % in the intervention group versus 2.8 % in the control group ( p < 0.01 ) , and self-esteem score increased 2.3 % in the intervention group and decreased 0.1 % in the control group after the end of the program ( p < 0.0001 ) . No significant change was observed in the depressive score . Student participation and compliance with the program was > 80 % . To conclude , a school-based program to improve physical activity in adolescents of low socioeconomic status , obtained a high level of participation and achieved significant benefits in terms of physical fitness and mental health status Whether to take hormone therapy is one of the most difficult medical decisions that healthy postmenopausal women face . The apparent coronary benefits ( 1 ) of hormone use are an important part of that decision . Although the data appear consistent in suggesting long-term coronary benefits , the Heart and Estrogen/progestin Replacement Study ( 2 ) showed an increased risk for coronary events during the first year of therapy in women with existing heart disease ; we also found such an elevated risk in an examination of secondary prevention in the Nurses ' Health Study ( 3 ) . More recently , a report from the Women 's Health Initiative , an ongoing r and omized clinical trial of hormone therapy for primary prevention of cardiovascular disease , suggested similar findings in healthy women ( National Institutes of Health . Press release ) . However , additional data on short-term effects of hormone use in women without previous cardiovascular disease are sparse . Many further questions also remain . Among them is the cardiovascular effect of daily doses lower than the st and ard 0.625 mg of oral conjugated estrogen . Recent studies suggest that lower doses of hormone therapy provide bone benefits ( 4 ) and , compared with higher doses , might decrease the risk for thromboembolism ( 5 ) and reduce endometrial hyperplasia ( 4 ) . However , few data are currently available on the relation between low-dose estrogen and primary prevention of heart disease and stroke . In an earlier report , we examined the relation between postmenopausal hormone therapy and primary prevention of cardiovascular disease based on 16 years of follow-up from the Nurses ' Health Study ( 6 ) . In the current analysis , we have almost 50 % more follow-up time among women taking daily doses less than 0.625 mg and more than 800 additional cases of cardiovascular disease , allowing more precise assessment of specific associations . Thus , we now report on the relation among  low-dose estrogen , short-term hormone use , and cardiovascular events in 70 533 postmenopausal women with no previous cardiovascular disease who were followed for up to 20 years . We also provide additional information on the effects of estrogen combined with progestin . Methods The Nurses ' Health Study Cohort The Nurses ' Health Study began in 1976 when 121 700 female nurses 30 to 55 years of age completed a mailed question naire about their postmenopausal hormone use and medical history , including cardiovascular disease and its risk factors . We up date information with biennial follow-up question naires . Dietary and physical activity question naires were added in 1980 . Cohort follow-up is greater than 90 % . Ascertainment of Hormone Use In 1976 , women were asked about use and duration of hormone therapy after menopause . Beginning in 1978 , we collected information on type of hormones taken , and starting in 1980 , we asked about the dose of oral conjugated estrogen . All information is up date d biennially . Identification of Cardiovascular Disease We identified first occurrences of nonfatal myocardial infa rct ion , fatal coronary disease , and fatal and nonfatal stroke between the return of the 1976 question naire and 1 June 1996 . Nurses who reported a nonfatal infa rct ion or stroke were asked for permission to review their medical records . Nonfatal myocardial infa rct ions were confirmed by hospital records if they met World Health Organization criteria ( 7 ) ( symptoms plus either elevated levels of cardiac enzymes or diagnostic electrocardiograms ) . Infa rct ions that required hospitalization and were corroborated by interview or letter but for which medical records were unobtainable were included as probable . Infa rct ions of indeterminate age discovered on routine examination were excluded . Nonfatal strokes were confirmed by review of medical records if they were characterized by a typical neurologic deficit , were rapid in onset , lasted at least 24 hours , and met the criteria of the National Survey of Stroke ( 8) . We classified strokes as ischemic ( thrombotic or embolic occlusion of a cerebral artery ) , subarachnoid hemorrhage , or intraparenchymal hemorrhage . We excluded subdural hematomas and strokes caused by infection or neoplasia . Strokes that required hospitalization and were corroborated by letter or interview but for which medical records were unavailable were included as probable . Most deaths were reported by the participants ' families . We search ed the National Death Index to identify deaths among nonrespondents to each 2-year question naire ; mortality follow-up was more than 98 % complete ( 9 ) . For all deaths possibly attributable to cardiovascular causes , we requested permission from relatives ( subject to state regulations ) to review the medical records . Deaths were considered to be due to coronary disease if medical records or autopsy findings confirmed a fatal myocardial infa rct ion . We also included coronary disease listed on the death certificate as the underlying cause without another , more plausible cause , if the nurse was known ( from hospital records , family , or other sources ) to have had coronary disease before death . In no case was the cause listed on the death certificate used as the sole criterion for coronary death . Sudden death within 1 hour of the onset of symptoms in participants with no other plausible cause of death besides coronary disease was also included . Fatal strokes were documented by autopsy or hospital records or if stroke was listed as the underlying cause on the death certificate . The category of major coronary heart disease combines nonfatal myocardial infa rct ion and coronary death ; similarly , total stroke includes nonfatal and fatal cases . The category of combined cardiovascular disease includes major coronary heart disease and stroke . Confirmed and probable cases in each category were analyzed together ( 80 % of major coronary events and 73 % of strokes were confirmed ) . In this and previous analyses ( 6 ) , results for probable cases were similar to those for confirmed cases . The investigators conducted all interviews and record review s without knowledge of participants ' hormone use status . Population for Analysis Women who reported stroke , myocardial infa rct ion , angina , coronary revascularization , or cancer ( except nonmelanoma skin cancer ) on the 1976 question naire were excluded because their disease may have caused them to alter their hormone use . Similarly , women who reported such diagnoses on a subsequent question naire were excluded from further analysis . Thus , at the start of each 2-year interval , the base population included no women reporting these diagnoses . Our own studies ( 6 , 10 ) and other studies ( 11 ) have suggested that hormone therapy may differentially affect incident and fatal strokes ; thus , we separately examined deaths due to stroke . In these analyses , we excluded women with cancer and cardiovascular disease at baseline but did not up date the exclusions because the women who develop cardiovascular disease during follow-up are those most likely to die of stroke . We classified women as postmenopausal from the time of natural menopause or hysterectomy with bilateral oophorectomy .  Women who underwent hysterectomy without bilateral oophorectomy  were considered postmenopausal when they reached the age at which natural menopause had occurred in 90 % of the cohort ( 54 years for smokers and 56 years for nonsmokers ) . In this cohort , the women 's reports of age at menopause ( 12 ) and type of menopause ( 13 ) were highly accurate . In 1976 , 21 947 postmenopausal women entered the analysis , and 48 586 women were added during follow-up as they became postmenopausal , for a total of 70 533 participants ; 808 825 person-years of follow-up were accrued from 1976 to 1996 . Statistical Analysis For each participant , person-months were allocated to hormone categories according to the 1976 data and were up date d every 2 years ( for estrogen dose , follow-up began in 1980 ) . For analyses of type of hormone therapy , we assigned the regimen reported on the 1978 question naire to women who reported hormone use in 1976 . Analyses of type of hormone therapy were limited to users of oral conjugated estrogen with or without oral medroxyprogesterone acetate  , since these were the most common hormone regimens . If no data were available on hormones in a given time period , women were assigned to a missing category for that time period . To maintain the prospect i ve nature of the study , hormone use ( including duration ) during each 2-year period was established from women 's reports at the start of the period ; thus , we probably underestimate duration of use by an average of 1 year . Follow-up for a participant ended at the first diagnosis of cardiovascular disease , death , or 1 June 1996 , whichever came first . The primary analysis is based on incidence rates for which person-months of follow-up were used as the denominator . We used relative risk as the measure of association , defined as the incidence of cardiovascular events among women in various categories of hormone use divided by the incidence among women who never used hormones . We computed age-specific rates by using 5-year categories ( 14 ) and age-adjusted relative risks by using MantelHaenszel rate ratios ( 15 ) with 95 % CIs ( 16 ) . We used pooled logistic regression  across the ten 2-year time periods to adjust simultaneously for potential confounding factors ( 17 ) . In this approach , independent blocks of person-time are pooled for regression analysis , and time-varying covariates are readily accommo date d by assigning successive blocks of person-time to the covariate values at the start of each follow-up cycle . The dependence of the incidence rates on time is modeled nonparametrically with indicator variables . Simulation studies have established the asymptotic equivalence of pooled logistic regression to Cox regression with time-dependent covariates ( 18 ) . The necessary conditions for this equivalence include relatively short time intervals and small probability of the outcome during each interval , both BACKGROUND Diet , physical activity , obesity , aspirin use , and family history may all modify the risk of colon cancer , but few epidemiologic studies are large enough to examine these factors simultaneously . PURPOSE We prospect ively assessed the relationship of diet and other factors to risk of fatal colon cancer . METHODS Using data from Cancer Prevention Study II -- an ongoing prospect i ve mortality study --we studied 764,343 adults who , in 1982 , completed a question naire on diet and other risk factors and did not report cancer or other major illness . We assessed mortality through August 1988 and identified 1150 deaths from colon cancer ( 611 men and 539 women ) .  Multivariate analyses were used to compare these case patients with 5746 matched control subjects drawn from the cohort . RESULTS Risk of fatal colon cancer decreased with more frequent consumption of vegetables and high-fiber grains ( P for trend = .031 in men and .0012 in women ) . The relative risk ( RR ) for the highest versus lowest quintile of vegetable intake was 0.76 in men ( 95 % confidence interval [ CI ] = 0.57 - 1.02 ) and 0.62 in women ( 95 % CI = 0.45 - 0.86 ) . Dietary consumption of vegetables and grains and regular use of aspirin were the only factors having an independent and statistically significant association with fatal colon cancer . Participants who consumed the least vegetables and grains and no aspirin had a higher risk compared with those who consumed the most vegetables and used aspirin 16 or more times per month . For men in the former category , the RR was 2.4 ( 95 % CI = 1.1 - 5.3 ) ; for women , it was 2.9 ( 95 % CI = 1.3 - 6.7 ) . Weaker associations were seen for physical inactivity , obesity , total dietary fat , and family history . No associations were seen with consumption of red meat or total or saturated fat in either sex , but this finding must be interpreted cautiously . CONCLUSIONS These findings support recommendations that increased consumption of vegetables and grains may reduce the risk of fatal colon cancer . Regular use of low doses of aspirin may prove to be an important supplemental measure Background Obesity is characterized by chronic mild inflammation and may influence the risk and progression of cancer . Purpose The current study is an exploratory analysis of the effect of a weight loss intervention that emphasized increased physical activity on inflammatory cytokines ( tumor necrosis factor-α [ TNF-α ] , interleukin-6 [ IL-6 ] , interleukin-8 [ IL-8 ] , and vascular endothelial growth factor [ VEGF ] ) at the end of the 16-week intervention period in overweight breast cancer survivors . Methods Study participants averaged 56 years of age ( N = 68 ) . Intervention participants ( n = 44 vs. 24 controls ) participated in a cognitive behavioral therapy-based weight management program as part of an exploratory r and omized trial . The intervention incorporated strategies to promote increased physical activity and diet modification . Baseline and 16-week data included height , weight , body composition , physical activity level , and biomarkers IL-6 , IL-8 , TNF-α , and VEGF . Results Weight loss was significantly greater in the intervention group than controls ( −5.7 [ 3.5 ] vs. 0.2 [ 4.1 ] kg , P < 0.001 ) . Paired t tests noted favorable changes in physical activity level ( P < 0.001 intervention , P = 0.70 control ) , marginally lower IL-6 levels ( P = 0.06 intervention , P = 0.25 control ) at 16 weeks for participants in the intervention group , and lower TNF-α levels for participants in the intervention ( P < 0.05 ) and control groups ( P < 0.001 ) . Increased physical activity was associated with favorable changes in IL-6 for participants in the intervention group ( R2 = 0.18 ; P < 0.03 ) . Conclusion Favorable changes in cytokine levels were observed in association with weight loss in this exploratory study with overweight breast cancer survivors Background Diarrheal disease remains a leading cause of illness and death , particularly in low-income countries . Its burden , microbiological causes and risk factors were examined in children aged 0–59 months living in Manhiça , rural southern Mozambique . Methods Trends of diarrhea-related burden of disease were estimated during the period 2001–2012 . A prospect i ve , age-stratified and matched ( by age , gender and geographical origin ) , case-control study was conducted during 2007–2011 . Clinical , epidemiology , anthropometric measurement and fecal sample s obtained from recruited children were used to estimate moderate-to-severe diarrhea ( MSD ) weighted attributable fractions . Results Over the last decade the incidence of acute diarrhea has dropped by about 80 % . Incidence of MSD per 100 child years at risk for the period 2007–2011 was 9.85 , 7.73 and 2.10 for children aged 0–11 , 12–23 and 24–59 months respectively . By adjusted population attributable fractions , most cases of MSD were due to rotavirus , Cryptosporidium , ETEC ST ( ST only or ST/LT ) , Shigella and Adenovirus 40/41 . Washing h and s and having facilities to dispose child ’s stools were associated with a reduced risk of MSD , while giving stored water to the child was associated with an increased risk of MSD . Conclusions Despite the predominantly decreasing trends observed throughout the last decade , diarrheal diseases remain today a major cause of morbidity among children aged 0–59 months living in this rural Mozambican area . Rotavirus , cryptosporidium , Shigella , ETEC ST and Adenovirus 40/41 were the most important aetiologies of MSD . Thus , well-known preventive strategies such as washing h and s , improving the treatment of stored water , having facilities to dispose children stools , and accelerating the introduction of the rotavirus vaccine should be promoted on a wider scale to reduce the current burden of diarrheal diseases Background Cardiovascular disease remains the leading killer of women in most developed areas of the world . Rates of physical inactivity and poor nutrition , which are two of the most important modifiable risk factors for cardiovascular disease in women , are substantial . This study sought to examine the effectiveness of a community-based lifestyle-modification program on increasing women 's physical activity in a r and omized trial guided by community-based participatory research ( CBPR ) methods . Methods A total of 335 healthy , 25–64 years old women who had been selected by a multiple-stage stratified cluster r and om sampling method in Bushehr Port/I.R. Iran , were r and omized into control and intervention groups . The intervention group completed an 8-week lifestyle modification program for increasing their physical activity , based on a revised form of Choose to Move program ; an American Heart Association Physical Activity Program for Women . Audio-taped activity instructions with music and practical usage of the educational package were given to the intervention group in weekly home-visits by 53 volunteers from local non-governmental and community-based organizations . Results Among the participants , the percentage who reported being active ( at lease 30 minutes of moderate intensity physical activity for at least 5 days a week , or at least 20 minutes of vigorous physical activity for at least three days a week ) increased from 3 % and 2.7 % at baseline to 13.4 % and 3 % ( p < 0.0001 ) at the ending of the program in the intervention and control groups , respectively . The participants in the intervention group reported more minutes of physical activity per week ( mean = 139.81 , SE = 23.35 ) than women in the control group ( mean = 40.14 , SE = 12.65 ) at week 8 ( p < 0.0001 ) . The intervention group subjects exhibited a significantly greater decrease in systolic blood pressure ( -10.0 mmHg ) than the control group women ( + 2.0 . mmHg ) . The mean ranks for posttest healthy heart knowledge in the intervention and control groups were 198.91 and 135.77 , respectively ( P < 0.0001 ) . Conclusion An intervention based on CBPR methods can be effective for the short-term adoption of physical activity behavior among women . The development of participatory process to support the adequate delivery of lifestyle-modification programs is feasible and an effective healthcare delivery strategy for cardiovascular community health promotion . Trial Registration BACKGROUND The influence of excess body weight on the risk of death from  cancer  has not been fully characterized . METHODS In a prospect ively studied population of more than 900,000 U.S. adults ( 404,576 men and 495,477 women ) who were free of cancer at enrollment in 1982 , there were 57,145 deaths from cancer during 16 years of follow-up . We examined the relation in men and women between the body-mass index in 1982 and the risk of death from all cancers and from cancers at individual sites , while controlling for other risk factors in multivariate proportional-hazards models . We calculated the proportion of all deaths from cancer that was attributable to overweight and obesity in the U.S. population on the basis of risk estimates from the current study and national estimates of the prevalence of overweight and obesity in the U.S. adult population . RESULTS The heaviest members of this cohort ( those with a body-mass index [ the weight in kilograms divided by the square of the height in meters ] of at least 40 ) had death rates from all cancers combined that were 52 percent higher ( for men ) and 62 percent higher ( for women ) than the rates in men and women of normal weight . For men , the relative risk of death was 1.52 ( 95 percent confidence interval , 1.13 to 2.05 ) ; for women , the relative risk was 1.62 ( 95 percent confidence interval , 1.40 to 1.87 ) . In both men and women , body-mass index was also significantly associated with higher rates of death due to cancer of the esophagus , colon and rectum , liver , gallbladder , pancreas , and kidney ; the same was true for death due to non-Hodgkin 's lymphoma and multiple myeloma . Significant trends of increasing risk with higher body-mass-index values were observed for death from cancers of the stomach and prostate in men and for death from cancers of the breast , uterus , cervix , and ovary in women . On the basis of associations observed in this study , we estimate that current patterns of overweight and obesity in the United States could account for 14 percent of all deaths from cancer in men and 20 percent of those in women . CONCLUSIONS Increased body weight was associated with increased death rates for all cancers combined and for cancers at multiple specific sites Review question / objective What are the effects of weight management interventions that include a diet component on weight‐related outcomes in pregnant and postpartum women ? The primary objective of this systematic review is to evaluate the effectiveness of weight management interventions which include a diet component and are aim ed at limiting gestational weight gain and postpartum weight retention in women . The second objective of this systematic review is to investigate included intervention components with respect to effect on weight‐related outcomes . This may include , but is not limited to : length of intervention , use of face‐to‐face counselling , group or individual consultations , use of other interventions components including exercise , use of goals and use of support tools like food diaries , coaching , including email or text message support . Background Around half of all women of reproductive age are either overweight or obese,1,2,3 with women aged 25‐34 years having a greater risk of substantial weight gain compared with men of all ages.1,4 Excessive gestational weight gain ( GWG ) and postpartum weight retention ( PPWR ) may play a significant role in long term obesity . Having one child doubles the five‐ and 10‐year obesity incidence for women , with many women who gain excessive weight during pregnancy remaining obese permanently.5 Excessive GWG and /or PPWR can also significantly contribute to short‐ and long‐term adverse health outcomes for mother , baby and future pregnancies.6,7 Maternal obesity increases the risk of pregnancy related complications such as pre‐eclampsia , gestational diabetes mellitus , stillbirth and the rate of caesarean section.8 Childhood obesity is a further long term complication of maternal obesity for offspring , which may persist in to adulthood.9 Excess GWG is also a risk factor for PPWR both in the short and long‐term.10,11 Nehring et al. conducted a meta‐ analysis with over 65,000 women showing that , compared to women who gained weight within recommendations during pregnancy , women with GWG above Institute of Medicine weight gain recommendations , 12 retained an additional 3.1 kg and 4.7 kg after three and greater than or equal to 15 years postpartum , respectively.13 The health risk associated with PPWR is highlighted in a study of 151,025 Swedish women followed between 1992 and 2001.The study identified the risk of adverse pregnancy outcomes for those who gained three or more units of Body Mass Index ( kg/m2 ) between consecutive pregnancies ( an average of two years ) was much higher compared with women whose BMI changed from ‐1.0 and 0.9 units.14 Long‐term chronic disease risk may also be affected by PPWR as weight retention at the end of the first year post‐partum has been found to be a predictor of maternal overweight 15 years later.15With around 14‐20 % of women retaining 5 kg or more 12 months postpartum,16,5 the risk of developing conditions like diabetes , metabolic syndrome and cardiovascular disease may be increased.17 It becomes evident that interventions which aim to support attainment of healthy weight both in the antenatal and postpartum periods are key health priorities for women during this life stage . Lifestyle factors of overweight , having poor diet quality , and not undertaking enough moderate‐to‐vigorous physical activity are amongst the top five predictors of mortality in women.18 Additionally it is noted that , for many women , pregnancy and the postpartum period are associated with a reduction in physical activity.19 It is known that a combination of poor dietary choices , an increase in sedentary time and reduction in physical activity are all contributors to the development of overweight and obesity . With this in mind , current research has focused on lifestyle interventions to limit GWG and PPWR . Thangaratinam et al. review ed 44 r and omized controlled trials ( 7278 women ) where interventions including diet , physical activity or both were evaluated for their influence on maternal weight during  pregnancy.20 Results indicate that all were significantly effective in reducing GWG compared with the control group . More specifically , dietary interventions were the most effective in reducing weight gain , with a mean weight loss of ‐3.84 kg compared with ‐0.72 kg and ‐1.06 kg for physical activity and the mixed ( diet plus physical activity ) approach , respectively.20 This finding is supported by Hill and colleagues ' recent systematic review of theory based interventions to limit GWG.21 Included studies in this review reported an underpinning theory base and were classified as adopting a dietary , physical activity or mixed approach . Hill et al. concluded that studies which included a diet intervention were significantly more effective at limiting GWG.21 In 2011 Tanentsapf et al. review ed the effect of dietary interventions alone for reducing GWG in normal weight , overweight and obese pregnant women.22 This review analysed 13 r and omized controlled trials and quasi‐r and omized controlled trials with a dietary intervention to prevent excessive GWG in women . The review concluded that dietary interventions during pregnancy were effective in reducing GWG with an effect of ‐1.92 kg ( n=1434 ) compared with the control group.22 Tanentsapf et al. identified that trials differed in the conduct of the interventions with various diet and non‐diet related components utilised . Dietary approaches were highly variable with some trials focusing only on calorie restriction and others included additional target macronutrient distribution for intake . Some trials further provided feedback based on maternal weight gain guidelines .12 Interventions also varied in delivery method with a variety of modes used , including face‐to‐face , individual or group consultations and /or written correspondence . The frequency of communication , despite the type or mix , also changed from trial to trial with additional methods via telephone , posted material s , feedback or food diaries utilised . The inclusion of physical activity in addition to diet intervention was also common . Whilst the recent review by Tanentsapf et al.22 identified that dietary interventions are effective in reducing GWG , the review did not investigate the impact that different intervention components , delivery methods or dietary counselling approaches had on gestational weight management . It remains unclear as to which intervention components optimize GWG in women . The impact of lifestyle interventions has also been investigated in the postpartum period . The recent systematic review from van der Pligt et al. reported seven of 11 studies review ed were successful in limiting PPWR.23 As with studies aim ed at limiting GWG , interventions included in van der Pligt et al. 's review differed greatly in their conduct . Six of these seven studies included both dietary and physical activity components for the intervention , with the final successful study including a diet only intervention . Five of the successful studies recruited overweight or obese women only . Intervention time varied considerably in successful studies with some running for as little at ten days , and others up to six months . Bertz et al. demonstrated that their 12‐week behavior modification intervention which targeted diet alone or diet and exercise , including two individual sessions with a dietitian and physical therapist , provision of scales for weight self‐monitoring and bi‐weekly text messages was successful in achieving significant weight loss following the intervention , and sustained at one year.24 The diet intervention and the diet and exercise intervention  yielded significant weight loss compared to the control . Following 12 weeks a reduction of ‐8.3 + /‐ 4.2 kg for diet intervention and ‐6.9 + /‐ 3.0 kg for diet and exercise was observed . Additionally after one year , the diet intervention showed ‐10.2 + /‐ 5.7 kg reduction and ‐7.3 + /‐ 6.3 kg for the diet and exercise intervention (p<0.001).24 Colleran et al. also found significant weight change results by implementing a 16‐week intervention which consisted of weekly individual sessions with a dietitian regarding calorie restriction , two additional home visits regarding exercise , weekly food diary completion and email support.25 The intervention group had greater weight loss compared to the control group ( ‐5.8 kg + /‐ 3.5 kg vs ‐1.6 kg + /‐ 5.4 kg ) . It can be seen that various methods have been utilized in investigating the impact of diet and physical activity interventions on PPWR . The review by van der Pligt et al.23 highlights the impact successful lifestyle interventions can have on postpartum weight change . However , this review did not investigate the different intervention strategies utilized . It remains unclear as to the optimal setting , delivery method , diet strategy , contact frequency or intervention length to limit PPWR . Previous systematic review s for both GWG and PPWR have focused on the effectiveness of lifestyle interventions as a whole for weight management in pregnant and postpartum women.20,23 And despite Tanentsapf et al. 's focus on dietary interventions for GWG,22 much is still unknown about the effectiveness of differing diet interventions over the antenatal and postpartum period . Specifically , the impact of differing diet intervention strategies on maternal weight gain is not known . Firstly , this systematic review will focus on whether  weight management interventions which include a dietary component  are effective in pregnant and postpartum women . In addition to this , this review will investigate the different intervention strategies utilized and their effectiveness in maternal weight management . A search of systematic review protocol data bases has shown that there is no current review underway for this topic Background : Recent reports suggest that obesity , or conditions associated with obesity , might be risk factors for  non-Hodgkin lymphoma ( NHL ) , a cancer with dramatically increasing incidence in western countries over the last several decades . Physical inactivity increases the risk of obesity and of type 2 diabetes , but there are few data on the association of physical activity with risk of NHL . Methods : We evaluated these factors in a population -based case – control study conducted in Detroit , Iowa , Los Angeles , and Seattle from 1998 to 2000 . Incident HIV-negative NHL cases aged 20–74 years were rapidly reported in each area ( n = 1321 ) . Controls were identified through r and om digit dialing and Medicare files , and were frequency matched to cases on sex , age , race , and study site ( n = 1057 ) . Risk factor data were collected by in-person interviews and self-administered question naires . Unconditional logistic regression was used to estimate the odds ratio ( OR ) and 95 % confidence intervals ( CI ) , adjusted for age , sex , race and study center . Results : High body mass index ( OR = 1.73 for 35 + versus < 25 kg/m2 ; 95 % CI 1.15–2.59 ) and history of gallstones ( OR = 1.95 , 95 % CI 1.11–3.40 ) were positively associated with diffuse NHL , but were not associated with follicular or all NHL combined . Height was positively associated with risk of all NHL combined ( OR = 1.38 for > 70 versus < 65 inches ; 95 % CI 0.98–1.94 ) , and positive associations were apparent for both diffuse and follicular NHL .  Non-occupational physical activity  was inversely associated with risk of all NHL combined ( ORs with increasing level : 1 , 0.75 , 0.71 , 0.55 , 0.68 ; p-trend = 0.04 ) and for diffuse and follicular NHL . We observed no association of total energy intake , type 2 diabetes , or hypertension with risk of NHL . In a multivariable model to predict risk of diffuse NHL , BMI ( OR = 2.15 for 35 + versus < 25 kg/m2 ; 95 % CI 1.09–4.25 ) and height ( OR = 1.63 for 71 + versus < 65 inches ; 95 % CI 0.75–3.57 ) were positively associated with risk while physical activity  was weakly and inversely associated risk ( ORs with increasing level : 1 , 0.76 , 0.72 , 0.78 , 0.82 ; p-trend = 0.9 ) . Conclusion : BMI and history of gallstones were positively associated with risk of diffuse NHL , supporting a role for obesity in this NHL subtype . Height was positively associated with NHL risk across subtypes , and suggests a role for early life nutrition in NHL risk . Non-occupational physical activity was only weakly and inversely associated with NHL risk after adjustment for obesity , height and alcohol use Background Grade d health benefits of physical activity have been demonstrated for the reduction of coronary heart disease , some cancers , and type-2 diabetes , and for injury reduction and improvements in mental health .  Older adults are particularly at risk of physical inactivity , and would greatly benefit from successful targeted physical activity interventions . Methods / Design The Healthy Steps study is a 12-month r and omized controlled trial comparing the efficacy of a pedometer-based Green Prescription with the conventional time-based Green Prescription in increasing and maintaining physical activity levels in low-active adults over 65 years of age . The Green Prescription interventions involve a primary care physical activity prescription with 3 follow-up telephone counselling sessions delivered by trained physical activity counsellors over 3 months . Those in the pedometer group received a pedometer and counselling based around increasing steps that can be monitored on the pedometer , while those in the st and ard Green Prescription group received counselling using time-based goals . Baseline , 3 month ( end of intervention ) , and 12 month measures were assessed in face-to-face home visits with outcomes measures being physical activity ( Auckl and Heart Study Physical Activity Question naire ) , quality of life ( SF-36 and EQ-5D ) , depressive symptoms ( Geriatric Depression Scale ) , blood pressure , weight status , functional status ( gait speed , chair st and s , and t and em balance test ) and falls and adverse events ( self-report ) . Utilisation of health services was assessed for the economic evaluation carried out alongside this trial . As well , a process evaluation of the interventions and an examination of barriers and motives for physical activity in the sample were conducted . The perceptions of primary care physicians in relation to delivering physical activity counselling were also assessed . Discussion The findings from the Healthy Steps trial are due in late 2009 . If successful in improving physical activity in older adults , the pedometer-based Green Prescription could assist in reducing utilisation of health services and improve cardiovascular health and reduction of risk for a range of non-communicable lifestyles diseases . Trial registration Australian and New Zeal and Clinical Trials Registry For decades , exercise has been considered a cornerstone of diabetes management , along with diet and medication . However , high- quality evidence on the importance of exercise and fitness in diabetes was lacking until recent years . The present document summarizes the most clinical ly relevant recent advances related to people with type 2 diabetes and the recommendations that follow from these . Our recently published technical review on physical activity/exercise and type 2 diabetes ( 1 ) includes greater detail on individual studies , on prevention of diabetes , and on the physiology of exercise . The present statement focuses on type 2 diabetes . Issues primarily germane to type 1 diabetes will be covered in a subsequent technical review and ADA Statement . The levels of evidence used are defined by the ADA in ref . 2 . Two r and omized trials each found that lifestyle interventions including ∼150 min/week of physical activity and  diet-induced weight loss of 5–7 % reduced the risk of progression from impaired glucose tolerance ( IGT ) to type 2 diabetes by 58 % ( 3,4 ) . A cluster-r and omized trial found that diet alone , exercise alone , and combined diet and exercise were equally effective in reducting the progression from IGT to diabetes ( 5 ) . Therefore , there is firm and consistent evidence that programs of increased physical activity  and modest weight loss reduce the incidence of type 2 diabetes in individuals with IGT . Boule et al. ( 6 ) undertook a systematic review and meta- analysis on the effects of structured exercise interventions in clinical trials of ≥8 weeks duration on HbA1c ( A1C ) and body mass in people with type 2 diabetes . Postintervention A1C was significantly lower in exercise than control groups ( 7.65 vs. 8.31 % , weighted mean difference −0.66 % ; P < 0.001 ) . In contrast , postintervention body weight did not differ between the exercise and control groups . Meta-regression confirmed that the beneficial effect of exercise on A1C Background There is growing evidence suggesting that prolonged sitting has negative effects on people ’s weight , chronic diseases and mortality . Interventions to reduce sedentary time can be an effective strategy to increase daily energy expenditure . The purpose of this study is to evaluate the effectiveness of a six-month primary care intervention to reduce daily of sitting time in overweight and mild obese sedentary patients . Method / Design The study is a r and omized controlled trial ( RCT ) . Professionals from thirteen primary health care centers ( PHC ) will r and omly invite to participate mild obese or overweight patients of both gender , aged between 25 and 65 years old , who spend 6 hours at least daily sitting . A total of 232 subjects will be r and omly allocated to an intervention ( IG ) and control group ( CG ) ( 116 individuals each group ) . In addition , 50 subjects with fibromyalgia will be included . Primary outcome is : ( 1 ) sitting time using the activPAL device and the Marshall question naire . The following parameters will be also assessed : ( 2 ) sitting time in work place ( Occupational Sitting and Physical Activity Question naire ) , ( 3 ) health-related quality of life ( EQ-5D ) , ( 4 ) evolution of stage of change ( Prochaska and DiClemente 's Stages of Change Model ) , ( 5 ) physical inactivity ( catalan version of Brief Physical Activity Assessment Tool ) , ( 6 ) number of steps walked ( pedometer and activPAL )  , ( 7 ) control based on analysis ( triglycerides , total cholesterol , HDL , LDL , glycemia and , glycated haemoglobin in diabetic patients ) and ( 8) blood pressure and anthropometric variables . All parameters will be assessed pre and post intervention and there will be a follow up three , six and twelve months after the intervention . A descriptive analysis of all variables and a multivariate analysis to assess differences among groups will be undertaken . Multivariate analysis will be carried out to assess time changes of dependent variables . All the analysis will be done under the intention to treat principle . Discussion If the SEDESTACTIV intervention shows its effectiveness in reducing sitting time , health professionals would have a low-cost intervention tool for sedentary overweight and obese patients management . Trial registration A service of the U.S. National Institutes of Health . Developed by the National Library of Medicine . Clinical Trials.gov Overweight and obesity have significant implication s during pregnancy and childbirth . The objective of this review was to provide a comprehensive overview of the effect of physical activity on pregnancy outcomes , the change of  physical activity during pregnancy , and women ’s perception of being physically active during pregnancy , with a particular focus on women who are overweight or obese . Many studies have investigated the beneficial effect of exercise during pregnancy , including reduced risk of gestational diabetes , preeclampsia , and operative birth , in addition to improved cardiovascular function , overall fitness , psychological well-being , and mood stability . Benefits for the infant include reduced risks of prematurity and improved fetal growth , although there is more limited information about longer-term health benefits for both women and infants . The existing literature examining physical activity patterns during pregnancy has generally focused on women of all body mass index categories , consistently indicating a reduction in activity over the course of pregnancy . However , the available literature evaluating physical activity during pregnancy among women who are overweight or obese is more limited and contradictory . A number of studies identified barriers preventing women from being active during pregnancy , including pregnancy symptoms , lack of time , access to child care , and concerns about their safety and that of their unborn baby . Conversely , significant enablers included positive psychological feelings , family influence , and receiving advice from health professionals . Very few studies have provided insights about perceptions of being active during pregnancy in the overweight and obese population . There is a need for a detailed description of physical activity patterns during pregnancy in women who are overweight or obese , and more r and omized trials evaluating exercise interventions for women who are overweight or obese , with a focus on clinical outcomes D iabetes is one of the most costly and burdensome chronic diseases of our time and is a condition that is increasing in epidemic proportions in the U.S. and throughout the world ( 1 ) . The complications result ing from the disease are a significant cause of morbidity and mortality and are associated with the damage or failure of various organs such as the eyes , kidneys , and nerves . Individuals with type 2 diabetes are also at a significantly higher risk for coronary heart disease , peripheral vascular disease , and stroke , and they have a greater likelihood of having hypertension , dyslipidemia , and obesity ( 2–6 ) . There is also growing evidence that at glucose levels above normal but below the diabetes threshold diagnostic now referred to as pre-diabetes , there is a substantially increased risk of cardiovascular disease ( CVD ) and death ( 5,7–10 ) . In these individuals , CVD risk factors are also more prevalent ( 5–7,9,11–14 ) , which further increases the risk but is not sufficient to totally explain it . In contrast to the clear benefit of glucose lowering to prevent or retard the progression of microvascular complications associated with diabetes ( 15– 18,21 ) , it is less clear whether the high rate of CVD in people with impaired glucose homeostasis , i.e. , those with impaired fasting glucose ( IFG ) , impaired glucose tolerance ( IGT ) , or diabetes , is caused by elevated blood glucose levels or will respond to treatments that lower blood glucose . Epidemiological studies have shown a clear relationship ( 19,20 ) , whereas intervention trials in people with diabetes suggest , but have not demonstrated , a clear benefit of glycemic control ( 15,16,21,22 ) . Additionally , there are no studies that have investigated a benefit of glucose lowering on macrovascular disease in subjects with only pre-diabetes ( IFG or IGT ) but not diabetes . Although the treatment of diabetes has become increasingly sophisticated , with over a dozen pharmacological agents available to lower blood glucose , a multitude of ancillary supplies and equipment available , and a clear recognition by health care professionals and patients that diabetes is a serious disease , the normalization of blood glucose for any appreciable period of time is seldom achieved ( 23 ) . In addition , in well-controlled socalled “ intensively ” treated patients , serious complications still occur ( 15–18,21 ) , and the economic and personal burden of diabetes remains . Furthermore , microvascular disease is already present in many individuals with undiagnosed or newly diagnosed type 2 diabetes ( 11,24– 28 ) . Given these facts , it is not surprising that studies have been initiated in the last decade to determine the feasibility and benefit of various strategies to prevent or delay the onset of  type 2 diabetes .  Two early reports ( 29,30 ) suggested that changes in lifestyle can prevent diabetes , but weaknesses in study design limited their general relevance . Recently , however , four well- design ed r and omized controlled trials have been reported ( 31–35 ) . In the Finnish study ( 31 ) , 522 middleaged ( mean age 55 years ) obese ( mean BMI 31 kg/m ) subjects with IGT were r and omized to receive either brief diet and exercise counseling ( control group ) or intensive individualized instruction on weight reduction , food intake , and guidance on increasing physical activity ( intervention group ) . After an average follow-up of 3.2 years , there was a 58 % relative reduction in the incidence of diabetes in the intervention group compared with the control subjects . A strong correlation was also seen between the ability to stop the progression to diabetes and the degree to which subjects were able to achieve one or more of the following : lose weight ( goal of 5.0 % weight reduction ) , reduce fat intake ( goal of 30 % of calories ) , reduce saturated fat intake ( goal of 10 % of calories ) , increase fiber intake ( goal of 15 g/1,000 kcal ) , and exercise ( goal of 150 min/week ) . No untoward effects of the lifestyle interventions were observed . In the Diabetes Prevention Program ( DPP ) ( 32–34 ) , the 3,234 enrolled subjects were slightly younger ( mean age 51 years ) and more obese ( mean BMI 34 kg/m ) but had nearly identical glucose intolerance compared with subjects in the Finnish study . About 45 % of the participants were from minority groups ( e.g , AfricanAmerican , Hispanic ) , and 20 % were 60 years of age . Subjects were r and omized to one of three intervention groups , which included the intensive nutrition and exercise counseling ( “ lifestyle ” ) group or either of two masked medication treatment groups : the biguanide metformin group or the placebo group . The latter interventions were combined with st and ard diet and exercise recommendations . After an average follow-up of 2.8 years ( range 1.8–4.6 years ) , a 58 % relative reduction in the progression to diabetes was observed in the lifestyle group ( absolute incidence 4.8 % ) , and a 31 % relative reduction in the progression of diabetes was observed in the metformin group ( absolute incidence 7.8 % ) compared with control subjects ( absolute incidence 11.0 % ) . ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● Background The purpose of this study was to describe the associations between different levels of long-term physical activity in leisure time and subsequent causes of deaths . Design The Copenhagen City Heart Study is a prospect i ve cardiovascular population study of 19 329 men and women aged 20–93 in 1976 .  Physical activity in leisure time was estimated at the examinations in 1976–78 and 1981–83 . This analysis consists of 2136 healthy men and 2758 women aged 20–79 years , with unchanged physical activity at the two examinations , and with all covariates included in the multivariate analyses : smoking , total-cholesterol , high-density lipoprotein-cholesterol , systolic blood pressure , diabetes mellitus , alcohol consumption , body mass index , education , income , and forced expiratory volume in 10.78 ( % predicted ) . Results Adjusted relative risks ( 95 % confidence interval ) for coronary heart disease were , for moderate physical activity 0.71 ( 0.51 , 0.99 ) and for high 0.56 ( 0.38 , 0.82 ) . For cancer , moderate activity 0.77 ( 0.61 , 0.97 ) and high activity 0.73 ( 0.56 , 0.95 ) and for all-cause mortality , moderate 0.78 ( 0.68 , 0.89 ) and high 0.75 ( 0.64 , 0.87 ) for both sexes combined . Using Kaplan — Meier plots we calculated gained years of expected lifetime from age 50 . Men with high physical activity  survived 6.8 years longer , and men with moderate physical activity 4.9 years longer than sedentary men . For women the figures were 6.4 and 5.5 years , respectively . Conclusion Long-term  moderate or high physical activity  was in both sexes associated with significantly lower mortality from coronary heart disease , cancer and all-causes . The same tendency was found for stroke and respiratory diseases , but the associations did not reach statistical significance . Eur J Cardiovasc Prev Rehabil 13:173–179 © 2006 The European Society of Background  Overweight and obesity in children in Mexico was among the countries with the highest prevalence 's in the world . Mexico currently has few innovative and comprehensive experiences to help curb the growth of this serious public health problem . Therefore , the aim of this study is to assess the effectiveness of a nutrition and physical activity strategy , called " Nutrition on the Go " ( " nutrición en movimiento " ) in maintaining the BMI values of school children in the State of Mexico . Methods A two-stage cluster trial was carried out . Sixty schools were selected in the State of Mexico , of which 30 were r and omly assigned to the intervention group ( IG ) and 30 to the control group ( CG ) . A total of 1020 fifth grade school children participated . The intervention strategy aim ed to decrease the energy content of school breakfasts and include fruits and vegetables , as well as increase physical activity and the consumption of water during the time spent at school . The strategy was implemented over a 6-month period . Results The estimated probability ( EP ) of obesity between baseline and the final stage for the IG decreased 1 % ( Initial EP = 11.8 % , 95%CI 9.0 , 15.2 , final EP = 10.8 , 95%CI 8.4 , 13 . ) For the CG , the probability increased 0.9 % ( baseline EP = 10.6 % ; 95%CI 8.1 , 13.7 ; final EP = 11.5 , 95%CI 9.0 , 14.6 ) . The interaction between the intervention and the stage is the average odd time corrected treatment effect , which is statistically significant ( p = 0.01 ) ( OR = 0.68 , 95%CI 0.52 , 091).This represents the interaction between intervention and stage , which is highly significant ( p = 0.01 ) ( OR = 0.68 ; 95%CI 0.52 , 091 ) . In addition , girls had a protective effect on obesity ( OR = 0.56 ; 95%CI 0.39 , 0.80 ) . Conclusions The intervention strategy is effective in maintaining the BMI of school children Background Childhood cancer and its treatment have considerable impact on a child 's physical and mental wellbeing . Especially long-term administration of chemotherapy and /or radiotherapy impairs physical fitness both during and after therapy , when children often present with muscle weakness and /or low cardiorespiratory fitness . Physical exercise can improve these two elements of physical fitness , but the positive effects of physical exercise might be further increased when a child 's wellbeing is simultaneously enhanced by psychosocial training . Feeling better may increase the willingness and motivation to engage in sports activities . Therefore , this multi-centre study evaluates the short and long-term changes in physical fitness of a child with a childhood malignancy , using a combined physical exercise and psychosocial intervention program , implemented during or shortly after treatment . Also examined is whether positive effects on physical fitness reduce inactivity-related adverse health problems , improve quality of life , and are cost-effective . Methods This multi-centre r and omized controlled trial compares a combined physical and psychosocial intervention program for children with cancer , with care as usual ( controls ) . Children with cancer ( aged 8 - 18 years ) treated with chemotherapy and /or radiotherapy , and who are no longer than 1 year post-treatment , are eligible for participation . A total of 100 children are being recruited from the paediatric oncology/haematology departments of three Dutch university medical centres . Patients are stratified according to pubertal stage ( girls : age ≤10 or > 10 years ; boys : ≤11 or > 11 years ) , type of malignancy ( haematological or solid tumour ) , and moment of inclusion into the study ( during or after treatment ) , and are r and omly assigned to the intervention or control group . Discussion Childhood cancer patients undergoing long-term cancer therapy may benefit from a combined physical exercise and psychosocial intervention program since it may maintain or enhance their physical fitness and increase their quality of life . However , the feasibility , patient need , and effectiveness of such a program should be established before the program can be implemented as part of st and ard care . Trial registration numberNTR1531 ( The Netherl and s National Trial Register Background Limited research has examined the association between physical activity , health-related fitness , and disease outcomes in breast cancer survivors . Here , we present the rationale and design of the Alberta Moving Beyond Breast Cancer ( AMBER ) Study , a prospect i ve cohort study design ed specifically to examine the role of physical activity and health-related fitness in breast cancer survivorship from the time of diagnosis and for the balance of life . The AMBER Study will examine the role of physical activity and health-related fitness in facilitating treatment completion , alleviating treatment side effects , hastening recovery after treatments , improving long term quality of life , and reducing the risks of disease recurrence , other chronic diseases , and premature death . Methods / Design The AMBER Study will enroll 1500 newly diagnosed , incident , stage I-IIIc breast cancer survivors in Alberta , Canada over a 5 year period . Assessment s will be made at baseline ( within 90 days of surgery ) , 1 year , and 3 years consisting of objective and self-reported measurements of physical activity , health-related fitness , blood collection , lymphedema , patient-reported outcomes , and determinants of physical activity . A final assessment at 5 years will measure patient-reported data only . The cohort members will be followed for an additional 5 years for disease outcomes . Discussion The AMBER cohort will answer key questions related to physical activity and health-related fitness in breast cancer survivors including : ( 1 ) the independent and interactive associations of physical activity and health-related fitness with disease outcomes ( e.g. , recurrence , breast cancer-specific mortality , overall survival ) , treatment completion rates , symptoms and side effects ( e.g. , pain , lymphedema , fatigue , neuropathy ) , quality of life , and psychosocial functioning ( e.g. , anxiety , depression , self-esteem , happiness ) , ( 2 ) the determinants of physical activity and health-related fitness including demographic , medical , social cognitive , and environmental variables , ( 3 ) the mediators of any observed associations between physical activity , health-related fitness , and health outcomes including biological , functional , and psychosocial , and ( 4 ) the moderators of any observed associations including demographic , medical , and biological/disease factors . Taken together , these data will provide a comprehensive inquiry into the outcomes , determinants , mechanisms , and moderators of physical activity and health-related fitness in breast cancer survivors Childhood obesity is a complex and multifaceted health problem linked to elevated risk for chronic diseases , such as diabetes , cancer , hypertension , and cardiovascular disease.1,2 Although research has increased dramatically in the past 2 decades , questions regarding factors driving overweight and obesity remain , particularly among youth of color who experience disproportionate rates of obesity and comorbid health conditions.3 Adolescence is a critical period in the developmental trajectory,4 in part because overweight and obese adolescents are more likely to remain overweight and /or obese in adulthood.3 Overweight and obesity have been associated with adverse symptoms and intra- and interpersonal psychological , social , and emotional issues that continue into adulthood , including depression and anxiety , social withdrawal , feeling worthless , lower self-esteem , and behavioral problems.5–7 Poor mental health may lead to increases in weight due to fluctuations in appetite , obesogenic behaviors ( eg , overeating ) to cope with negative mood , sedentary behavior , and increased isolation.8 Chronic stress or experiences of discrimination may also influence physiology and behaviors that affect weight gain.9 On the other h and , increased body mass index ( BMI ) could result in adverse emotional outcomes over time due to weight-based stigma , bullying , or poor self-esteem.5,6 The few longitudinal studies that have examined the association between emotional health and physical health outcomes have primarily taken a narrow focus of mental health symptoms ( e.g. , only examining depression)10 or behavioral concerns ( e.g. , conduct).11 Physical outcomes , including BMI , were often collected by self-report12 and /or retrospectively.13 Furthermore , they have been limited to predominantly White sample s of older adolescents or adults.12,13 Persistent racial and ethnic disparities in overweight and obesity further complicate research as well as clinical prevention and intervention efforts . Black and Latino youth experience disproportionate levels of overweight and obesity beginning as early as preschool and are more likely to remain obese as adults compared with Whites.14 Blacks and Latinos also are at disproportionate risk for multiple negative health conditions associated with overweight and obesity , such as diabetes.14,15 Reasons for such disparities remain poorly understood and understudied . Although emotional health has been associated with weight in both adults and youth,16 prior research has been limited to cross-sectional studies .17 Longitudinal , prospect i ve design s are critical to explicate the association between emotional health and BMI among Black and Latino youth . The primary objective of this study is to examine whether negative emotional symptoms prospect ively predict increases in BMI z-scores ( BMI -z ) across 2 years among a sample of predominantly Black and Latino , urban youth . We hypothesize that more negative emotional symptoms measured at baseline ( grade s 5 and 6 ) would predict increases in BMI -z scores 2 years later . Results can inform programs and interventions aim ed at reducing obesity in youth of color BACKGROUND Accurate estimates of childhood cancer incidence are important for policy makers to inform priority setting and planning decisions . However , many countries do not have cancer registries that quantify the incidence of childhood cancer . Moreover , even when registries do exist , they might substantially underestimate the true incidence , since children with cancer might not be diagnosed . We therefore aim ed to provide estimates of total childhood cancer incidence accounting for underdiagnosis . METHODS We developed a microsimulation model to simulate childhood cancer incidence for 200 countries and territories worldwide , taking into account trends in population growth and urbanicity , geographical variation in cancer incidence , and health system barriers to access and referral that contribute to underdiagnosis . To ensure model results were consistent with epidemiological data , we calibrated the model to publicly available cancer registry  data using a Bayesian approach in which the observed data are fixed and the model parameters ( cancer incidence and probabilities of health system access and referral ) are r and om variables . We estimated the total incidence of childhood cancer ( diagnosed and undiagnosed ) in each country in 2015 and projected the number of cases from 2015 to 2030 . FINDINGS Our model estimated that there were 397 000 ( 95 % uncertainty interval [ UI ] 377 000 - 426 000 ) incident cases of childhood cancer worldwide in 2015 , of which only 224 000 ( 95 % UI 216 000 - 237 000 ) were diagnosed . This finding suggests that 43 % ( 172 000 of 397 000 ) of childhood cancer cases were undiagnosed globally , with substantial variation by region , ranging from 3 % in western Europe ( 120 of 4300 ) and North America ( 300 of 10 900 ) to 57 % ( 43 000 of 76 000 ) in western Africa . In south Asia ( including southeastern Asia and south- central Asia ) , the overall proportion of undiagnosed cases was estimated to be 49 % ( 67 000 of 137 000 ) . Taking into account population projections , we estimated that there will be 6·7 million ( 95 % UI 6·3 - 7·2 ) cases of childhood cancer worldwide from 2015 to 2030 . At current levels of health system performance , we estimated that 2·9 million ( 95 % UI 2·7 - 3·3 ) cases of childhood cancer will be missed between 2015 and 2030 . INTERPRETATION Childhood cancer is substantially underdiagnosed , especially in south Asia and sub-Saharan Africa ( including western , eastern , and southern Africa ) . In addition to improving treatment for childhood cancer , health systems must be strengthened to accurately diagnose and effectively care for all children with cancer . As countries exp and universal health coverage , these estimates of total incidence will hopefully help guide efforts to appropriately increase health system capacity to ensure access to effective childhood cancer care . FUNDING Boston Children 's Hospital , Dana-Farber Cancer Institute , Harvard T H Chan School of Public Health , Harvard Medical School , National Cancer Institute , SickKids , St Jude Children 's Research Hospital , and Union for International Cancer Control CONTEXT Despite decades of accumulated observational evidence , the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain . OBJECTIVE To assess the major health benefits and risks of the most commonly used combined hormone preparation in the United States . DESIGN Estrogen plus progestin component of the Women 's Health Initiative , a r and omized controlled primary prevention trial ( planned duration , 8.5 years ) in which 16608 postmenopausal women aged 50 - 79 years with an intact uterus at baseline were recruited by 40 US clinical centers in 1993 - 1998 . INTERVENTIONS Participants received conjugated equine estrogens , 0.625 mg/d , plus medroxyprogesterone acetate , 2.5 mg/d , in 1 tablet ( n = 8506 ) or placebo ( n = 8102 ) . MAIN OUTCOMES MEASURES The primary outcome was coronary heart disease ( CHD ) ( nonfatal myocardial infa rct ion and CHD death ) , with invasive breast cancer as the primary adverse outcome . A global index summarizing the balance of risks and benefits included the 2 primary outcomes plus stroke , pulmonary embolism ( PE ) , endometrial cancer , colorectal cancer , hip fracture , and death due to other causes . RESULTS On May 31 , 2002 , after a mean of 5.2 years of follow-up , the data and safety monitoring board recommended stopping the trial of estrogen plus progestin vs placebo because the test statistic for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits . This report includes data on the major clinical outcomes through April 30 , 2002 . Estimated hazard ratios ( HRs ) ( nominal 95 % confidence intervals [ CIs ] ) were as follows : CHD , 1.29 ( 1.02 - 1.63 ) with 286 cases ; breast cancer , 1.26 ( 1.00 - 1.59 ) with 290 cases ; stroke , 1.41 ( 1.07 - 1.85 ) with 212 cases ; PE , 2.13 ( 1.39 - 3.25 ) with 101 cases ; colorectal cancer , 0.63 ( 0.43 - 0.92 ) with 112 cases ; endometrial cancer , 0.83 ( 0.47 - 1.47 ) with 47 cases ; hip fracture , 0.66 ( 0.45 - 0.98 ) with 106 cases ; and death due to other causes , 0.92 ( 0.74 - 1.14 ) with 331 cases . Corresponding HRs ( nominal 95 % CIs ) for composite outcomes were 1.22 ( 1.09 - 1.36 ) for total cardiovascular disease ( arterial and venous disease ) , 1.03 ( 0.90 - 1.17 ) for total cancer , 0.76 ( 0.69 - 0.85 ) for combined fractures , 0.98 ( 0.82 - 1.18 ) for total mortality , and 1.15 ( 1.03 - 1.28 ) for the global index . Absolute excess risks per 10 000 person-years attributable to estrogen plus progestin were 7 more CHD events , 8 more strokes , 8 more PEs , and 8 more invasive breast cancers , while absolute risk reductions per 10 000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures . The absolute excess risk of events included in the global index was 19 per 10 000 person-years . CONCLUSIONS Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal US women .  All-cause mortality was not affected during the trial . The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases , and the results indicate that this regimen should not be initiated or continued for primary prevention of CHD PURPOSE To examine the long-term association of leisure time physical activity ( LTPA ) and risk of death from coronary heart disease ( CHD ) and all-causes . METHODS Data are from a prospect i ve study of 12,138 middle-aged men at high risk for CHD participating in the MRFIT . Men were classified into deciles based on average min/d of LTPA reported at baseline , which were compared with cumulative CHD and all-cause mortality endpoints at the 16-year follow-up . RESULTS Men in the least-active decile of LTPA who averaged 4.9 min/d of LTPA ( range 0 to .9 min/d ) had excess age-adjusted mortality rates of 29 % and 22 % for CHD and all-causes , respectively , as compared to those in combined deciles 2 to 4 , who averaged 22.7 min/d of predominantly light and moderate LTPA ( range 10 - 36 min/d ) . No further decrement in mortality rates was noted in those in the higher declines of LTPA . These associations remained significant ( P < 0.05 ) after proportional hazards adjustments for additional possible confounding variables . CONCLUSION These data suggest that a relatively small amount ( 10 to 36 min/d ) of daily moderate intensity LTPA can significantly reduce premature mortality , particularly from CHD , in middle-aged and older men at high risk for CHD AIM The aim of the present study was to examine the impact of obesity and physical activity on the health and wellbeing of patients with breast cancer shortly after the adjuvant treatments . PATIENTS AND METHODS A total of 537 women aged 35 to 68 years with newly-diagnosed breast cancer were enrolled into the exercise intervention study .  The physical activity , physical performance ( 2-km walking test ) , cardiovascular risk factors , quality of life ( EORTC-QoL-C30 ) , co-morbidities and body-mass index ( BMI ) were measured after the adjuvant treatments . RESULTS Overall , 191 ( 39 % ) patients were overweight ( BMI = 25 - 30 ) and 85 ( 17 % ) obese ( BMI ≥ 30 ) . Physical activity and performance ( p<0.001 and p<0.001 ) , QoL ( p<0.001 ) and high density lipoprotein (HDL)-cholesterol decreased ( p<0.001 ) whereas age ( p=0.009 ) , co-morbidities ( p<0.001 ) , hypertension ( p=0.011 ) , metabolic syndrome ( p<0.001 ) , low density lipoprotein (LDL)-cholesterol ( p=0.0043 ) , triglycerides ( p<0.001 ) , glucose ( p<0.001 ) and insulin ( p<0.001 ) increased linearly with BMI . Higher waist circumference ( p=0.0011 ) , triglyceride ( p=0.020 ) , insulin ( p=0.0098 ) , rate of metabolic syndrome ( p=0.028 ) , and lower HDL-cholesterol ( p=0.012 ) and QoL ( p<0.001 ) were associated with low physical activity . Physical activity and BMI were the most important determinants of physical performance ( p<0.001 and p<0.001 , respectively ) . CONCLUSION Obesity and a sedentary lifestyle are related to poor physical performance , increased risk of cardiovascular diseases and impaired QoL , leading to a vicious circle , which impairs patients ' physical health and This paper is based on a portion of a long-term prospect i ve study conducted by the American Cancer Society over the period 1959–1972 . It describes the mortality experience according to variations in weight among 750,000 men and women drawn from the general population . The lowest mortality was found among those close to average weight and those 10–20 % below average weight . Mortality among men and women 30–40 % heavier than average was nearly 50 % higher than among those of average weight ; among those more than 40 % heavier than average it was nearly 90 % higher than among those of average weight . Coronary heart disease was the major factor in the higher mortality of overweights , being 55 % higher among those 30–40 % heavier than average , and about 100 % higher among those more than 40 % overweight . Cancer mortality was elevated only among those 40 % or more overweight ; cancer of the colon and rectum was the principal site of excess cancer mortality among men , while cancer of the gall bladder and biliary passages , breast , cervix , endometrium , uterus and ovary were the major sites of excess mortality among women . Mortality from diabetes was particularly high among overweights , especially women . The mortality findings of this study match closely those of the Build and Blood Pressure Study 1959 based on the experience of 412 million insured persons BACKGROUND / OBJECTIVES Aside from the health consequences , observational studies indicate that being overweight may also negatively affect cognitive function . However , existing evidence has to a large extent not controlled for the possible confounding effect of having different lifestyles . Therefore , the objective was to examine the independent associations between weight status and lifestyle indicators with cognitive performance in 8 - 11year old Danish children . SUBJECTS/ METHODS The analyses included 828 children ( measured in 2011 - 2012 ) each having one to three measurement occasions separated by approximately 100days .  Dietary intake , physical activity , sedentary time , and sleep duration were measured using dietary records and accelerometers . The Children 's Sleep Habits Question naire was used to access sleep problems and the And ersen test was carried out to estimate cardio-respiratory fitness ( CRF ) . Weight status ( underweight , normal weight , and overweight/obese ) was defined according to body mass index and cognitive performance was assessed using the d2-test of attention , a reading test , and a math test . A linear mixed model including a number of fixed and r and om effects was used to test associations between lifestyle indicators as well as BMI category and cognitive performance . RESULTS After adjustment for demographics , socioeconomics , and multiple lifestyle indicators , normal weight children had higher cognitive test scores than overweight/obese and underweight children of up to 89 % and 48 % of expected learning within one school year ( P<0.05 ) . Daily breakfast consumption , fewer sleep problems , higher CRF , less total physical activity , more sedentary time , and less light physical activity were associated with higher cognitive performance independently of each other in at least one of the three cognitive tests ( P<0.05 ) . CONCLUSIONS Normal weight children had higher cognitive performance compared to overweight/obese as well as underweight children , independent of multiple lifestyle indicators PURPOSE Prolonged sitting has emerged as a risk factor for early mortality , but the extent of benefit realized by replacing sitting time with exercise or activities of everyday living ( i.e. , nonexercise activities ) is not known . METHODS We prospect ively followed 154,614 older adults ( 59 - 82 yr ) in the National Institutes of Health-AARP Diet and Health Study who reported no major chronic diseases at baseline and reported detailed information about sitting time , exercise , and nonexercise activities .  Proportional hazard models were used to estimate adjusted hazard ratios and 95 % confidence intervals ( HR ( 95 % confidence interval ) ) for mortality . An isotemporal modeling approach was used to estimate associations for replacing sitting time with specific types of physical activity , with separate models fit for less active and more active participants to account for nonlinear associations . RESULTS During 6.8 yr ( SD , 1.0 ) of follow-up , 12,201 deaths occurred . Greater sitting time ( ≥12 vs < 5 h·d(-1 ) ) was associated with increased risk for all-cause and cardiovascular mortality . In less active adults ( < 2 h·d(-1 ) total activity ) , replacing 1 h·d(-1 ) of sitting with an equal amount of activity was associated with lower all-cause mortality for both exercise ( HR , 0.58 ( 0.54 - 0.63 ) ) and nonexercise activities ( HR , 0.70 ( 0.66 - 0.74 ) ) , including household chores , lawn and garden work , and daily walking . Among more active participants ( 2 + h·d(-1 ) total activity ) , replacement of sitting time with purpose ful exercise was associated with lower mortality ( HR , 0.91 ( 0.88 - 0.94 ) ) but not with nonexercise activity ( HR , 1.00 ( 0.98 - 1.02 ) ) . Similar results were noted for cardiovascular mortality . CONCLUSIONS Physical activity intervention strategies for older adults often focus on aerobic exercise , but our findings suggest that reducing sitting time and engaging in a variety of activities is also important , particularly for inactive adults Background The aim of the School site , Play Spot , Active transport , Club fitness and Environment ( SPACE ) Study was to develop , document , and assess a comprehensive intervention in local school districts that promote everyday physical activity ( PA ) among 11 - 15-year-old adolescents . The study is based on a social ecological framework , and is design ed to implement organizational and structural changes in the physical environment . Methods / design The SPACE Study used a cluster r and omized controlled study design . Twenty-one eligible schools in the Region of Southern Denmark were matched and r and omized in seven pairs according to eight matching variables summarized in an audit tool ( crow-fly distance from residence to school for 5 - 6th grade rs ; area household income ; area education level ; area ethnicity distribution ; school district urbanity ; condition and characteristics of school outdoor areas ; school health policy ; and active transport in the local area ) . Baseline measurements with accelerometers , question naires , diaries , and physical fitness tests  were obtained in Spring 2010 in 5 - 6th grade in 7 intervention and 7 control schools , with follow-up measurements to be taken in Spring 2012 in 7 - 8th grade . The primary outcome measure is objective average daily physical activity and will be supported by analyses of time spent in moderate to vigorous activity and time spent sedentary . Other secondary outcome measures will be obtained , such as , overweight , physical fitness , active commuting to/from school and physical activity in recess periods . Discussion A total of 1348 adolescents in 5 - 6th grade in the Region of Southern Denmark participated at baseline ( n = 14 schools ) . The response rate was high in all type of measurements ( 72.6 - 97.4 % ) . There were no significant differences between intervention and control groups at baseline according to selected background variables and outcome measures : gender ( p = .54 ) , age ( p = .17 ) , BMI ( p = .59 ) , waist circumference ( p = .17 ) , physical fitness ( p = .93 ) , and physical activity ( accelerometer ) ( p = .09).The r and omization and matched pair design produced equivalent groups according to central outcome measures and background variables . The SPACE for physical activity Study will provide new insights on the effectiveness of multicomponent interventions to improve adolescents ' physical activity level . Trial registration Current Controlled Trials IS RCT Several population studies from different countries have shown a J-shaped relation between intake of alcohol and mortality from all causes ( 1 - 6 ) . Studies comparing different countries have found a strong inverse relation between incidence rates of coronary heart disease and wine consumption but a weak or nonexistent relation for consumption of beer or spirits ( 7 - 9 ) . The findings that different types of alcoholic beverages have different effects on mortality are indirectly supported by several clinical and experimental studies ( 10 - 12 ) . In contrast , prospect i ve studies have shown that beer ( 13 ) , spirits ( 14 ) , and wine ( 15 ) may have protective effects . However , most of these investigations were based on population s with one predominant type of alcohol consumption ; this precluded valid comparison of the effects of the three different types of alcohol . We sought to analyze the effect of intake of different types of alcohol on mortality from all causes , coronary heart disease , and cancer in several large Danish cohort studies . Methods The Copenhagen Centre for Prospect i ve Population Studies is based on three study sample s : that of the Copenhagen City Heart Study ; that of the Copenhagen County Centre of Preventive Medicine ( the former Glostrup Population Studies ) , which includes six cohorts ; and that of the Copenhagen Male Study ( 16 - 18 ) . The study sample s of the Copenhagen City Heart Study , initiated in 1976 , and the Copenhagen County Centre of Preventive Medicine , initiated in 1964 , were r and omly selected within age strata from the population s residing in defined areas in greater Copenhagen . For the Copenhagen Male Study , initiated in 1971 , employees of 14 large companies in Copenhagen were invited to participate . The mean participation rate in all studies was 80 % ( range , 69 % to 88 % ) . The combined study sample comprises 13 064 men and 11 459 women for whom information on alcohol intake and lifestyle-related variables , described below , was complete . Alcohol Intake Participants of the Copenhagen City Heart Study and the studies in the Copenhagen County Centre of Preventive Medicine were asked about their current average weekly intake of beer , wine , and spirits .  In the Copenhagen Male Study , participants were asked about their average daily intake of beer , wine , and spirits on weekdays ( Monday through Thursday ) and weekends ( Friday through Sunday ) ; these reports were combined to estimate weekly alcohol consumption . Persons in our study who did not drink alcohol because they were receiving disulfiram or other medication were excluded from the analysis . One bottle of beer contains 11.6 g of alcohol , and 12 g is an approximate average for one serving of wine or spirits . We grouped participants into five categories on the basis of total intake of alcohol : less than 1 drink/wk ( nondrinkers ) , 1 to 7 drinks/wk , 8 to 21 drinks/wk , 22 to 35 drinks/wk , and more than 35 drinks/wk . Intake of beer , wine , and spirits was categorized similarly ; however , because of the frequency of end point data , more than 21 drinks/wk is the highest intake category for the individual types of beverages . Smoking Status Participants reported whether they were never-smokers , former smokers , or current smokers . Current smokers reported grams of tobacco smoked per day in the form of cigarettes ( 1 g/d ) , small cigars ( 3 g/d ) , cigars ( 5 g/d ) , and pipe tobacco ( 50 g/package ) . Five groups were defined : never-smokers , former smokers , smokers of 1 to 14 g of tobacco daily , smokers of 15 to 24 g of tobacco daily , and smokers of more than 24 g of tobacco daily . Education Participants reported the number of years that they attended school . Three groups were defined : fewer than 8 years , 8 to 11 years , and 12 or more years of school education . Physical Activity Participants reported whether they were physically active during leisure time . Four groups were defined : sedentary ( < 2 h/wk ) , light activity ( 2 to 4 h/wk ) , moderate activity ( > 4 h/wk , noncompetitive ) and heavy activity ( > 4 h/wk , competitive ) . Body Mass Index Body weight and height were measured while the participant was wearing light clothes and no shoes . Body mass index was calculated as weight in kg divided by height in meters squared . Five categories of body mass index were defined : less than 20.0 kg/m2 , 20.0 to 24.9 kg/m2 , 25.0 to 29.9 kg/m2 , 30.0 to 34.9 kg/m2 , and 35.0 kg/m2 or more . Changes in Lifestyle-Related Variables When participants were re-examined during follow-up , the newly obtained values for alcohol intake , smoking status , physical activity , and body mass index were used to replace the old values in the statistical analyses . Observation time and vital status were included in the modeling accordingly . Follow-up Participants were followed from date of entry into the study to date of death , loss to follow-up , emigration , or end of follow-up , whichever came first . The vital status of population s was followed by using each participant 's unique identification number in the national Central Person Register until 9 January 1995 . Fewer than 1 % of the participants were lost to follow-up . Causes of death were obtained from the National Board of Health and were defined by using codes from International Classifications of Diseases , Eighth Revision ( codes 410.0 to 414.0 for coronary heart disease and codes 140.0 to 209.0 for cancer ) . According to a previous study , the reported diagnoses for these grouped codes have proven to be sufficiently valid ( 20 ) . Statistical Analysis We performed Poisson regression ( 21 ) by using SAS/STAT software ( 22 ) to estimate the effect of alcohol intake on the risk for death . These models generate estimates of relative risk that are adjusted for confounders . Each model included the following potential confounders as categorical variables : age , cohort study , sex , education , body mass index , physical activity , and smoking status . Owing to collinearity , it was impossible to include both the amount by type of beverage ( beer , wine , or spirits ) consumed and total alcohol intake in the same regression . We therefore estimated the influence of alcohol according to number of drinks consumed per week [ 0 , 1 to 7 , 8 to 21 , 22 to 35,>35 ] in three regressions : 1 ) total alcohol consumption in drinks per week , without considering beverage type ; 2 ) alcohol consumption  in drinks of each beverage per week , without considering the total intake ; and 3 ) percentage of total alcohol intake consumed as wine ( 0 % , 1 % to 30%,>30 % ) . Effects that were insignificant according to the likelihood ratio test ( 5 % level ) were removed by backward elimination . A term indicating interaction between total alcohol intake and percentage alcohol consumed as beer  , wine , or spirits was included in the analyses to assess whether the effects of beer , wine , and spirits differed at different levels of total alcohol intake ; no such effects were identified , as judged from the fit of the model . Likewise , no interaction was found between sex and intake of different types of beverage in terms of mortality . Results A total of 4275 women and 1635 men drank less than 1 drink per week ; 64 women and 1032 men drank 35 or more drinks per week .  Of 13 613 participants who drank alcohol , 12 846 ( 69 % ) included wine in their intake ( Table 1 ) . During 257 859 person-years of follow-up , 4833 participants died ; of these , 1075 died of coronary heart disease and 1552 died of cancer . Table 1 . Baseline Characteristics of the Study Participants Baseline Characteristics Compared with participants who drank alcohol but no wine , those for whom wine made up more than 30 % of their total alcohol intake were more likely to be women and have a higher educational level but were less likely to be smokers ( Table 1 ) . Participants for whom wine made up more than 30 % of their alcohol intake were similar to those who drank no alcohol in terms of smoking habits , body mass index , and physical activity . Across categories of total alcohol intake , mean alcohol intake within the different categories of wine drinking was similar ; for example , among participants who drank 8 to 21 drinks/wk , those who drank no wine , those who drank 1 % to 30 % wine , and those who drank more than 30 % wine had a mean alcohol intake of 13.3 , 13.7 , and 12.8 drinks/wk , respectively . However , among light drinkers ( 1 to 7 drinks/wk ) , those who drank 1 % to 30 % of their alcohol as wine had a slightly higher mean intake than did those who avoided wine and those who drank more than 30 % of their alcohol intake as wine . Thus , assessment of the effects of wine intake may not be subject to residual confounding by total alcohol intake when controlled for as specified . Total Alcohol Intake and Mortality We found J-shaped relations between total alcohol intake and all-cause mortality in the three sub studies . Pooled analyses also revealed J-shaped relations ( Table 2 ) . When nondrinkers were used as the reference group ( relative risk , 1.00 ) , intake of 1 to 7 drinks per week carried a relative risk of 0.82 ( 95 % CI , 0.76 to 0.88 ) and intake of more than 35 drinks per week carried a relative risk of 1.10 ( CI , 0.95 to 1.26 ) . Alcohol intake was negatively related to death from coronary heart disease and positively related to death from cancer ( Table 2 ) . Table 2 . Relative Risk for Death with Regard to Total Alcohol Intake and Intake of Beer , Wine , and Spirits Intake of Beer , Wine , and Spirits and Mortality Light to moderate intake of beer or spirits had a small effect on death from all causes ( Table 2 ) . This finding contrasted with the effect of wine intake on mortality : Participants who drank 8 to 21 glasses of wine per week had a relative risk for death from all causes of 0.76 ( CI , 0.67 to 0.86 ) . Intake of fewer than 22 drinks of beer , wine , and spirits per week all carried lower risk for death from coronary heart disease ; the reduction in risk was of the same magnitude for beer and wine drinking but was smaller and not statistically significant for spirits drinking . Furthermore , light to moderate drinkers of wine Background : Physical inactivity leads to higher morbidity and mortality from chronic non-communicable diseases ( NCDs ) such as stroke and heart disease . In high income countries , studies have measured the population level of physical activity , but comparable data are lacking from most low and middle-income countries . Objective : To assess the level of physical inactivity  and its associated factors in selected rural sites in five Asian countries . Methods : The multi-site cross-sectional study was conducted in nine rural Health and Demographic Surveillance System ( HDSS ) sites within the INDEPTH Network in Bangladesh , India , Indonesia , Thail and , and Vietnam . Using the methodology from the WHO STEPwise approach to Surveillance ( STEPS ) , about 2,000 men and women aged 25–64 years were selected r and omly from each HDSS sampling frame .  Physical activity at work and during leisure time , and on travel to and from places , was measured using the Global Physical Activity Question naire version 2 ( GPAQ2 ) . The total activity was calculated as the sum of the time spent in each domain of activities in metabolic equivalent-minutes per week , and was used to determine the level of physical activity . Multivariable logistic regression was used to assess demographic factors associated with a low level of physical activity . Results : The prevalence of physical inactivity ranged from 13 % in Chililab HDSS in Vietnam to 58 % in Filabavi HDSS in Vietnam . The majority of men  were physically active , except in the two sites in Vietnam . Most of the respondents walked or cycled for at least 10 minutes to get from place to place , with some exceptions in the HDSSs in Indonesia and Thail and . The majority of respondents , both men and women , were inactive during their leisure time . Women , older age , and high level of education were significantly associated with physical inactivity . Conclusion : This study showed that over 1/4 men and 1/3 women in Asian HDSSs within the INDEPTH Network are physically inactive . The wide fluctuations between the two HDSS in Vietnam offer an opportunity to explore further urbanisation and environmental impacts on physical activity . Considering the importance of physical activity in improving health and preventing chronic NCDs , efforts need to be made to promote physical activity particularly among women , older people , and high education groups in these setting BACKGROUND While previous studies suggest that overweight , middle-aged men may face increased risk of colon cancer , it is unclear whether their weights as young adults influence this risk . It is also unknown whether their level of physical activity affects their risk of developing colon cancer . PURPOSE To determine the relationship between being overweight in middle-age or young adulthood and colon cancer risk , we prospect ively studied alumni of Harvard University . We also investigated whether being overweight influences risk differently for men with different levels of physical activity . METHODS In 1962 or 1966 ( 1962/1966 ) , alumni completed question naires on weight , height , other sociodemographic characteristics , and medical history . We obtained information on weight and height at college entry from university archives . Alumni ( n = 17,595 ) were followed from 1962/1966 to 1988 for colon cancer occurrence , ascertained from follow-up question naires in 1977 and 1988 and death certificates . RESULTS Between 1962/1966 and 1988 , 302 cases of colon cancer were diagnosed . Colon cancer risk increased with higher levels of Quetelet 's index ( weight [kg]/height [m]2 ) in 1962/1966 . Relative risk per unit increase , adjusted for age , physical activity , and parental history of cancer , was 1.08 ( 95 % confidence interval [ CI ] , 1.04 - 1.13 ) . Quetelet 's index at college entry did not predict risk as well ( adjusted relative risk per unit increase , 1.05 ; 95 % CI , 1.00 - 1.10 ) . The heaviest fifth of alumni during both college time and in 1962/1966 had almost two and one-half times the risk of the lightest fifth of alumni ( adjusted relative risk , 2.40 ; 95 % CI , 1.40 - 4.13 ) . When alumni were classified according to activity level in 1962/1966 , higher levels of Quetelet 's index were significantly associated with colon cancer risk only among those who were less active . CONCLUSIONS Overweight during middle-age or young adulthood is associated with higher colon cancer risk ; in overweight , physically active men , however , the risk of colon cancer may not be increased The aim of the present study was to investigate the impact of a multidimensional exercise intervention focusing on physical capacity ; one-repetition maximum ( 1RM ) and maximum oxygen uptake ( VO2Max ) , activity level , general well-being and quality of life in cancer patients undergoing chemotherapy .  The intervention comprised resistance and fitness training , massage , relaxation and body-awareness training .  Eighty-two cancer patients , with or without evidence of residual disease , were included : 66 patients with 13 different types of solid tumours and 16 patients with 6 types of haematological malignancies . The patients trained in mixed groups for 9 h weekly for 6 weeks . Physical capacity , physical activity level and psychosocial well-being as measured by the Medical Outcomes Study 36-item Short-Form Health Survey and the European Organization for Research and Treatment of Cancer Quality of Life Question naire C30 were assessed pre- and post-intervention . Highly significant increases were achieved in muscular strength ( p<0.001 ) , physical fitness ( p<0.001 ) and physical activity levels ( p<0.001 ) . The patients reported significant reduction in treatment-related symptoms , i.e. , fatigue ( p=0.006 ) and pain ( p=0.03 ) . Highly significant improvements were observed in physical functioning ( p<0.001 ) and role functioning ( p<0.001 ) . Even patients with advanced disease were able to improve their results after 6 weeks . It is concluded that a multidimensional exercise intervention , including resistance training , may be beneficial for cancer patients undergoing chemotherapy . This study indicates significant clinical meaningful improvements . The exact role of the intervention has to be defined in a r and omized controlled design . A clinical ly controlled trial including 250 patients is currently being carried out Background Excessive weight gain among youth is an ongoing public health concern . Despite evidence linking both policies and the built environment to adolescent and adult overweight , the association between health policies or the built environment and overweight are often overlooked in research with children . The purpose of this study was to examine if school-based physical activity policies and the built environment surrounding a school are associated with  weight status among children . Methods Objective ly measured height and weight data were available for 2,331 grade 1 to 4 students ( aged 6 to 9 years ) attending 30 elementary schools in Ontario , Canada . Student-level data were collected using parent reports and the PLAY-On question naire administered to students by study nurses . School-level policy data were collected from school administrators using the Physical Activity Module of the Healthy School Planner tool , and built environment data were provided by the Enhanced Points of Interest data re source . Multi-level logistic regression models were used to examine the school- and student-level characteristics associated with the odds of a student being overweight or obese . Results There was significant between-school r and om variation in the odds of a student being overweight [ σ2μ0 = 0.274(0.106 ) , p < 0.001 ] , but not for being obese [ σ2μ0 = 0.115(0.089 ) ] . If a student attended a school that provided student access to a variety of facilities on and off school grounds during school hours or supported active transportation to and from school , he/she was less likely to overweight than a similar student attending a school without these policies . Characteristics of the built environment were not associated with overweight or obesity among this large cross-sectional sample of children . Conclusions This new evidence suggests that it may be wise to target obesity prevention efforts to schools that do not provide student access to recreation facilities during school hours or schools that do not support active transportation for students . Future research should evaluate if school-based overweight and obesity prevention programming might be improved if interventions selectively targeted the school characteristics that are putting students at the greatest risk CONTEXT Diabetes mellitus and elevated postload plasma glucose levels have been associated with an increased risk of pancreatic cancer in previous studies . By virtue of their influence on insulin resistance , obesity and physical inactivity may increase risk of pancreatic cancer . OBJECTIVE To examine obesity , height , and physical activity in relation to pancreatic cancer risk . DESIGN AND SETTING Two US cohort studies conducted by mailed question naire , the Health Professionals Follow-up Study ( initiated in 1986 ) and the Nurses ' Health Study ( initiated in 1976 ) , with 10 to 20 years of follow-up . PARTICIPANTS A total of 46 648 men aged 40 to 75 years and 117 041 women aged 30 to 55 years who were free of prior cancer at baseline and had complete data on height and weight . MAIN OUTCOME MEASURES Relative risk of pancreatic cancer , analyzed by self-reported body mass index ( BMI ) , height , and level of physical activity . RESULTS During follow-up , we documented 350 incident pancreatic cancer cases . Individuals with a BMI of at least 30 kg/m(2 ) had an elevated risk of pancreatic cancer compared with those with a BMI of less than 23 kg/m(2 ) ( multivariable relative risk [ RR ] , 1.72 ; 95 % confidence interval [ CI ] , 1.19 - 2.48 ) . Height was associated with an increased pancreatic cancer risk ( multivariable RR , 1.81 ; 95 % CI , 1.31 - 2.52 for the highest vs lowest categories ) . An inverse relation was observed for moderate activity ( multivariable RR , 0.45 ; 95 % CI , 0.29 - 0.70 for the highest vs lowest categories ; P for trend < .001 ) . Total physical activity was not associated with risk among individuals with a BMI of less than 25 kg/m(2 ) but was inversely associated with risk among individuals with a BMI of at least 25 kg/m(2 ) ( pooled multivariable RR , 0.59 ; 95 % CI , 0.37 - 0.94 for the top vs bottom tertiles of total physical activity ; P for trend = .04 ) . CONCLUSION In 2 prospect i ve cohort studies , obesity significantly increased the risk of pancreatic cancer . Physical activity appears to decrease the risk of pancreatic cancer , especially among those who are overweight Background Obesity is the most common chronic pediatric disease in westernized , especially low socioeconomic societies . We previously demonstrated the beneficial effects of a r and omized prospect i ve school-based health education program for low socioeconomic status Arab-Israeli kindergarten children . Methods To examine whether the effects of our program on nutrition and physical activity knowledge and preferences , anthropometric measures , and fitness persisted one year after the end of intervention . We were able to perform the one year follow-up in 203 kindergarten children ( 59 % of our 342 original cohort ; 85 control , 118 intervention ) . Results At one year following the intervention BMI and BMI percentiles approached baseline level in both the intervention ( 16.4±0.2 kg/m2 and 61.5±2.4 % , respectively ) and control group participants ( 16.5±0.2 kg/m2 and 58.5±3.3 % , respectively ) . Yet , a year after the end of the intervention , the decrease in BMI % ile from baseline was significantly greater in the intervention group ( -7.8±1.5 vs. -1.9±1.9 , p<0.012 ) . Nutritional and physical activity knowledge and preferences , and physical fitness remained significantly elevated in the intervention compared to the control group participants . Conclusions The beneficial effects of a kindergarten dietary-physical activity intervention applied by the kindergarten teachers , on nutrition and physical activity knowledge and preferences , fitness , and BMI percentile were evident one year after the end of intervention . This promising program may play a role in health promotion , prevention and treatment of childhood obesity Cardiovascular disease remains the leading cause of death in women . Both obesity and diabetes mellitus are important independent risk factors for the development of cardiovascular disease . Obesity is the leading risk factor for type 2 diabetes . The Centers for Disease Control and Prevention report that 32 % of white and 53 % of black women are obese . Women with a body mass index ( BMI ) of 30 kg/m2 have a 28 times greater risk of developing diabetes than do women of normal weight . The risk of diabetes is 93 times greater if the BMI is 35 kg/m2.1 The presence of diabetes can increase a woman 's risk of heart disease 2-fold . In addition , the presence of diabetes overshadows the protective effects of the premenopausal state . In 2007 , 11.5 million of all women over the age of 20 ( 10.2 % ) had diabetes , and rates were slightly higher in ethnic minority groups : 10.4 % in Hispanic women and 11.8 % in non-Hispanic black women.2 The national prevalence rates of diabetes have increased in parallel with the rates of obesity ( Fig. 1 ) . Fig. 1 Age-adjusted percentage of U.S. adults who were obese or who had a diagnosis of diabetes mellitus . Screening Screening for obesity and diabetes is the 1st step to treatment and often reveals individuals who are at risk for but do not yet have overt disease . The United States Preventive Services Task Force ( USPSTF ) recommends that all adults be screened for obesity . Obesity signifies excess adipose tissue . The most widely used method for screening is determination of the BMI . The BMI is weight in kilograms divided by height in meters squared ( BMI = kg/m2 ) ( Table I ) . Most electronic medical records automatically calculate BMI if height and weight are entered . There are also many smart-phone applications and online calculators that can calculate BMI ( for example , http://www.nhlbisupport.com/ bmi ) . Other screening tools include  waist circumference and the waist-to-hip ratio . In women , a waist circumference > 35 in ( 88 cm ) or a waist-to-hip ratio > 0.7 indicates excess visceral fat and increased risk for disease . TABLE I. Body Mass Index ( BMI ) Classification Recommendations for screening for diabetes vary by guideline author . The USPSTF recommends screening asymptomatic patients who have  blood pressures > 135/80 mmHg  . The American Diabetes Association ( ADA ) recommends that individuals who are ≥18 years of age and have a BMI ≥25 kg/m2 and 1 additional risk factor for diabetes should be screened annually ( Table II).3 Individuals over the age of 45 without risk factors should be screened every 3 years . In January 2010 , the ADA released new recommendations for the use of hemoglobin A1C as a screening tool . An A1C greater than 6.5 % indicates diabetes . In addition , the results of screening tests for diabetes can identify individuals with “ prediabetes ” who have a markedly increased risk of developing overt disease.3 TABLE II . American Diabetes Association Recommendations on Screening for Type 2 Diabetes3 Non-Pharmaceutical Treatment Lifestyle-treatment options for diabetes mellitus and excess weight are similar , and 2 recent studies 4,5 have demonstrated the critical components for treating pre-diabetes and diabetes through weight loss , using caloric restriction and physical activity . The 1st study was the Diabetes Prevention Program.4 The purpose of the study was to identify individuals who were at risk for developing diabetes because of elevated fasting plasma glucose or impaired glucose tolerance levels that were not yet in the diagnostic range , in order to determine if metformin or an intensive lifestyle intervention could delay or prevent the onset of diabetes . More than 3,000 individuals with prediabetes were r and omized to receive placebo , metformin , or a 16-session lifestyle-modification program . The intensive lifestyle program set a goal of 7 % weight loss and 150 min/wk of moderate physical activity . Fifty percent of the lifestyle-intervention group lost 7 % of their body weight . The 3-year incidence of diabetes in the metformin group was 31 % lower than that in the placebo group . The incidence was 58 % lower in the lifestyle group than in the placebo group.4 The clinical implication s of this study are that we should 1 ) identify individuals with pre-diabetes and 2 ) recommend lifestyle modifications that result in a 7 % weight loss and include 150 min/wk of moderate physical activity . The 2nd study that examined lifestyle treatment of diabetes and obesity is the Look AHEAD Trial . The purpose of the study was to determine the effect of intentional weight loss on cardiovascular risk factors in individuals with diabetes . Approximately 5,100 individuals with type 2 diabetes and an elevated BMI were r and omized . Study conditions specified a 36-session intensive lifestyle intervention with the option of using partial meal replacements for caloric restriction or 4 sessions of st and ard diabetes support and education ( DSE ) . At 1 year , 55 % of the intensive-lifestyle-intervention group achieved 7 % weight loss . Hemoglobin A1C , systolic and diastolic blood pressure , and lipids improved significantly more in the intensive-lifestyle group than in the DSE group.5 The clinical implication of this study is that intentional weight loss of at least 7 % can improve the cardiovascular risk profile of patients with type 2 diabetes . Conclusions Excess weight affects two thirds of the U.S. adult population and increases risk for cardiovascular disease and diabetes . All patients should be screened for obesity and most should be screened for pre-diabetes and diabetes . The best treatment for diabetes is prevention . Prevention of diabetes can be accomplished through a 7 % weight loss through intensive lifestyle interventions that include caloric reduction and approximately 30 min of daily moderate physical activity . Practitioners will have access to these evidence -based programs soon . The Centers for Disease Control and Prevention are promoting community-based diabetes prevention programs throughout the country BACKGROUND Rural children are at a particular high risk for obesity . Given the importance of exercise in obesity and chronic disease prevention , this study evaluated the level and relationship between physical activity and fitness in a sample of rural third grade rs . The second purpose of the study was to determine potential differences in physical activity and fitness level by weight status in this sample . METHODS Twelve schools participating in a multidisciplinary research project were r and omly selected for the study . Body mass index-for-age percentile , the modified Self-administered Physical Activity Checklist  , and the FITNESSGRAM battery tests were utilized to determine children 's weight status , physical activity , and fitness level , respectively . RESULTS Thirty-eight percent of the 237 participating children ( 9.2 ± 0.4 years ) were overweight or obese . Nearly 15 % were extremely obese . Children spent 91.8 ± 83.8 and 32.2 ± 47.7 minutes in moderate- and vigorous-intensity activities . Obese children spent less time in moderate-intensity activity ( p < .01 ) and combined moderate- and vigorous-intensity activity more than other children ( p < .05 ) . Forty-three percent of all children failed to meet the fitness st and ard for muscular strength and 36 % failed to meet it for flexibility . CONCLUSIONS Rural children in this sample had higher rates of obesity compared to the national average ; they had poor fitness and 30 % failed to meet the minimum physical activity recommendations on the previous day . Future interventions should focus on increasing physical activity , especially of moderate-intensity , and improving physical fitness in order to reduce obesity and decrease the risk of future chronic diseases in this high-risk population Physical inactivity and lack of nutritious diets increase children ’s risk of obesity , especially children from low-income and ethnic minority groups . To address this risk , the school-based TAKE 10 ! program was implemented to increase the physical activity and improve the nutrition of K-6th grade students in one public urban school serving a predominantly low-income , Hispanic population . In this study the research ers ( a ) evaluated the program outcomes using the physical activity and nutrition question naires provided with the TAKE 10 ! curriculum material , teacher surveys , observations , and interview data ; ( b ) evaluated the question naires provided with the TAKE 10 ! curriculum material and provided suggestions for modification ; and ( c ) described the experience of a positive partnership among school , university , and community agencies implementing the TAKE 10 ! curriculum . Based on the findings , recommendations are offered for successful physical activity and nutrition health promotion programs for these children BACKGROUND Although many primary care patients are inactive , being able to classify even small amounts and intensities of activity and factors associated with these activity levels could be helpful for physicians who are trying to motivate their patients to become more physically active . METHODS Sociodemographics , physical activity , fitness , other cardiovascular risk factors , and psychosocial measures were measured at baseline in the 874 patients in the Activity Counseling Trial . Patients were categorized into three groups : ( 1 ) no moderate-to-vigorous physical activity ( MVPA ) , ( 2 ) some moderate but no vigorous activity , and ( 3 ) some vigorous activity . Multiple logistic regression was used to determine factors cross-sectionally associated with activity intensity . RESULTS One or more cardiovascular risk factors in addition to physical inactivity were present in 84 % of participants . Maximal oxygen uptake averaged 25.2 ml/kg/min ; 85 % had poor to fair aerobic fitness . Physical activity averaged 32.7 kcal/kg/day , with 13.5 min of MVPA/day ; 26 % engaged in some vigorous activity , 11 % engaged in no MVPA . In unadjusted analyses , gender , age , race , education , income , employment , smoking , alcohol use , and exercise self-efficacy were associated with activity intensity ( P = 0.05 - 0.001 ) . A greater percentage engaged in moderate than in vigorous activity in all subgroups . In multiple logistic regression analyses , odds ratios ( 95 % confidence intervals ) for engaging in vigorous activity were 0 . 39 ( 0.28 , 0.56 ) for women , 0.38 ( 0.19 , 0.75 ) for 65 + compared with 35- to 44-year-olds , and 1.14 ( 1.06 , 1.22 ) for 10-unit increases in performance self-efficacy score . CONCLUSIONS Most primary care patients who are physically inactive have additional cardiovascular risk factors , particularly overweight and obesity . All subgroups pursue moderate-intensity activity more often than vigorous activity . Women , older persons , and those with lower exercise self-efficacy are less likely to engage in vigorous activity Background : Ethnic minorities or those with low socioeconomic status ( SES ) are at increased risk of cardiovascular disease , type 2 diabetes , and all-cause mortality , compared to higher SES Whites . National surveys also indicate that low-income , ethnic minority women have the highest rates of inactivity in the United States . Purpose : This study ( the Increasing Motivation for Physical ACTivity or IMPACT study ) promoted adoption and maintenance of physical activity ( PA ) in sedentary , low-income women participating in federally funded job training programs . Methods : The study consisted of 2 months of weekly 1-hr classes , then r and om assignment to 10 months of either home-based telephone counseling for PA plus information and feedback via mailed newsletters ( Phone + Mail Counseling condition ) or just the mailed newsletters ( Mail Support condition ) . The IMPACT intervention included behavior change strategies for PA as well as discussion s related to motivational readiness for PA change . Participants completed surveys and physiological assessment s at baseline after the classes ended ( i.e. , at 10 weeks ) and at 6 and 12 months postbaseline . Seventy-three percent of r and omized participants ( n = 72 ) were Latina , with a mean age of 32 ± 10 years . More than half the women had not completed high school , and 73 % had an annual income less than $ 20,000 . Results : After 10 months of a homebased intervention , women in the phone + mail counseling condition had significantly greater increases in estimated total energy expenditure compared to women in the mail support condition ( p < .05 ) . Conclusions : Regular PA counseling delivered via the telephone and through the mail appears effective for encouraging regular PA among low-income women transitioning from welfare or job training to the workforce Type 2 diabetes is a common disease in industrialized countries . It is a major cause of cardiovascular disease and all-cause mortality ( 1 - 6 ) , and its prevalence has increased continuously over the past few decades ( 1 ) . The American Diabetes Association currently defines impaired fasting glucose as a fasting plasma glucose level from 6.1 to 6.9 mmol/L ( 110 to 125 mg/dL ) and type 2 diabetes as a fasting plasma glucose level of 7.0 mmol/L ( 126 mg/dL ) or more ( 1 ) . Data from several prospect i ve studies show an inverse association between physical activity and diabetes ( 7 - 13 ) . However , these studies are limited by the use of self-reporting of physical activity and presence of type 2 diabetes ( 7 - 12 ) . Self-reporting of physical activity tends to be imprecise , and type 2 diabetes is undiagnosed in about 50 % of the prevalent cases ( 14 ) . This leads to misclassification on both exposure and outcome measures ( 15 ) . These limitations may result in underestimation of the true association between sedentary habits and risk for type 2 diabetes . Impaired fasting glucose is a strong predictor of type 2 diabetes , cardiovascular disease , and other diabetic complications ( 6 , 16 - 18 ) . The underlying cause of impaired fasting glucose is unknown , and no prospect i ve study of the association between physical activity and impaired fasting glucose has been published . We examined the relation of cardiorespiratory fitness , objective ly determined by a maximal exercise test on a treadmill , to the incidence of impaired fasting glucose and type 2 diabetes . Cases of impaired fasting glucose and diabetes at baseline and follow-up were determined by using the American Diabetes Association 's current guidelines ( 1 ) . Methods Patients In our population -based prospect i ve study , we included 8633 men 30 to 79 years of age at baseline ( mean , 43.5 years ) who completed at least two medical evaluations at the Cooper Clinic in Dallas , Texas , from 1970 to 1995 . Patients come to the Cooper Clinic for preventive medical examinations and health promotion counseling . Many are sent by their employers for these services , some are referred by their personal physicians , and others are self-referred . More than 97 % of the patients are white , and most are employed in executive or professional occupations . More than 75 % are college graduates . Although study participants came from middle and upper socioeconomic strata , they were similar to other well-characterized population -based cohorts in terms of blood pressure , cholesterol level , body weight , and cardiorespiratory fitness ( 19 ) . The study was review ed and approved annually by the institutional review board at the Cooper Institute for Aerobics Research . Additional details of the study methods and population characteristics of the cohort have been published elsewhere ( 20 , 21 ) . Because clinical or sub clinical heart disease and other conditions associated with type 2 diabetes may alter the level of physical activity and thus cardiorespiratory fitness , we excluded men with an abnormal resting or exercise electrocardiogram or a history of heart attack , stroke , or cancer at the baseline clinical examination ( n=2350 ) . The baseline evaluation was performed after participants gave written informed consent for the initial medical examination and registration in the follow-up study . Examinations were done after patients had fasted for at least 12 hours and included personal and family health histories , a question naire on demographic characteristics and health habits  , a  physical examination  , an  exercise test , anthropometric measurement , electrocardiography , blood chemistry analyses , and blood pressure measurement . Technicians who followed a st and ard manual of operations administered all procedures . Impaired fasting glucose and type 2 diabetes were diagnosed according to American Diabetes Association criteria that define impaired fasting glucose as a fasting plasma glucose level of 6.1 to 6.9 mmol/L ( 110 mg/dL to 125 mg/dL ) and diabetes as a fasting plasma glucose level of 7.0 mmol/L ( 126 mg/dL ) or more ( 1 ) . Patients who did not meet these criteria but who reported a history of diabetes or current therapy with oral antidiabetic agents or insulin were also considered to have diabetes . We excluded patients who had diabetes at baseline according to any of these criteria ( n=377 ) .  Cardiorespiratory fitness was assessed with a maximal exercise test that followed a modified Balke protocol ( 22 ) . Details of treadmill speed and elevation have been described elsewhere ( 20 , 21 ) . Briefly , the test began with the patient walking on a horizontal treadmill at 88 m/min . After the first minute , the elevation increased to 2 % ; the elevation then increased 1 % each minute up to 25 minutes . For the few patients who were still able to continue , the elevation was held constant after 25 minutes and the speed was increased by 5.4 m/min until the patient reached volitional fatigue . Use of this protocol for the exercise test correlates highly ( r=0.92 ) with measured maximal oxygen uptake ( 23 ) . All patients in our study achieved at least 85 % of their age-predicted maximal heart rate ; average maximal heart rates ( SD ) in each age group were 186 11 beats/min for patients 30 to 39 years of age , 179 12 beats/min for those 40 to 49 years of age , 172 13 beats/min for those 50 to 59 years of age , and 162 17 beats/min for those 60 years of age or older .  Average maximal heart rates in each age group exceeded the age-predicted rate ( 220 beats/min age in years ) , which indicates that the exercise test can be considered maximal performance . We defined level of fitness by  total time on the treadmill  at the baseline examination , as in our previous studies ( 20 , 21 ) . Treadmill times were placed in frequency distributions for specific age groups ( 30 to 39 , 40 to 49 , 50 to 59 , or 60 or more years of age ) . The least fit 20 % of the participants in each age group were classified as low fitness , the next 40 % as moderate fitness , and the remaining 40 % as high fitness . The respective cut-points for  total treadmill time  in the low- , moderate- , and high-fitness groups were 945 seconds or less , 946 to 1259 seconds , and 1260 seconds or more for patients 30 to 39 years of age ; 849 seconds or less , 850 to 1020 seconds , and 1021 seconds or more for patients 40 to 49 years of age ; 750 seconds or less , 751 to 1035 seconds , and 1036 seconds or more for patients 50 to 59 years of age ; and 644 seconds or less , 645 to 953 seconds , and 954 seconds or more for patients 60 years of age or older . These cut-points at the 20th and 60th percentiles to define fitness levels were used in previous studies ( 20 , 21 ) and were selected before analysis for our investigation . However , we calculated these cut-points with patients in the current study , from which unhealthy persons were excluded . Therefore , they differ somewhat from the cut-points derived from the entire cohort of the Aerobics Center Longitudinal Study ( 21 ) . For some analyses , such as the models that included change in fitness from baseline to follow-up , cardiorespiratory fitness was expressed as maximal metabolic units ( metabolic equivalents [ METs ] , calculated as the working metabolic rate/resting metabolic rate ; 1 MET is equivalent to an oxygen uptake of 3.5 mL1 kg1 ) achieved on the exercise test . In other analyses , time on the treadmill was used as a continuous variable . Serum sample s were analyzed by using automated techniques in a laboratory that participates in the Centers for Disease Control and Prevention Lipid St and ardization Program . Blood pressure was measured by using auscultatory methods with a mercury sphygmomanometer . We defined high blood pressure as systolic blood pressure of at least 140 mm Hg , diastolic blood pressure of at least 90 mm Hg , or a history of hypertension . Height and weight were measured with a st and ard physician 's scale and stadiometer , and body mass index was calculated as weight in kg/height in m2 . Waist circumference was measured with a st and ard anthropometric tape . Statistical Analysis We used SAS statistical software for data analyses ( 24 ) . The incidence of impaired fasting glucose was calculated for men with normal fasting glucose at baseline , and the incidence of diabetes was based on data from all 8633 patients . For analyses with impaired fasting glucose as the outcome , we excluded 1122 men who had impaired fasting glucose at baseline and an additional 69 men who had normal fasting plasma glucose at baseline but developed diabetes during follow-up . Rates of impaired fasting glucose or diabetes were calculated by dividing the number of incident cases during the study period by the number of person-years over the same period . We defined the study period as the interval between the baseline examination and the last follow-up visit . We used logistic regression to estimate the association between dependent variables and independent variables after adjustment for possible confounding factors . We used general linear models to study the cross-sectional association of fitness level and parental history of diabetes ( 24 , 25 ) . To account for the possible cohort effect of baseline year , we examined the relation between incident cases and baseline year and found no association . We used tests for ordinal linear trend to evaluate the possible relation of higher treadmill time with risk for impaired fasting glucose or diabetes after dividing the sample into the three fitness groups . All P values are two-sided , and those less than 0.05 were considered statistically significant . Role of the Funding Source The funding agencies did not participate in the collection , analysis , or interpretation of data presented in this report or in the decision to su bmi t the manuscript for publication . Results During an average follow-up of 6.1 4.8 years ( range , 1 to 24.8 years ) that included 52 588 person-years , 593 men developed impaired fasting glucose and 149 developed diabetes . Of the men with incident diabetes , 139 ( 93 % ) were not aware of Background The prevalence of childhood obesity among adolescents has been rapidly rising in Mainl and China in recent decades , especially in urban and rich areas . There is an urgent need to develop effective interventions to prevent childhood obesity . Limited data regarding adolescent overweight prevention in China are available . Thus , we developed a school-based intervention with the aim of reducing excess body weight in children . This report described the study design . Methods / design We design ed a cluster r and omized controlled trial in 8 r and omly selected urban primary schools between May 2010 and December 2013 . Each school was r and omly assigned to either the intervention or control group ( four schools in each group ) . Participants were the 4th grade rs in each participating school . The multi-component program was implemented within the intervention group , while students in the control group followed their usual health and physical education curriculum with no additional intervention program . The intervention consisted of four components : a ) classroom curriculum , ( including physical education and healthy diet education ) , b ) school environment support , c ) family involvement , and d ) fun programs/events . The primary study outcome was body composition , and secondary outcomes were behaviour and behavioural determinants . Discussion The intervention was design ed with due consideration of Chinese cultural and familial tradition , social convention , and current primary education and exam system in Mainl and China . We did our best to gain good support from educational authorities , school administrators , teachers and parents , and to integrate intervention components into schools ’ regular academic programs . The results of and lesson learned from this study will help guide future school-based childhood obesity prevention programs in Mainl and China . Trial registration Registration number : A prospect i ve cohort study of London civil servants was used to examine the relation of physical activity to various causes of death .  6,702 men aged 40 - 64 y who participated in a baseline examination between 1969 and 1970 were followed up for 25 y during which time there were 2859 deaths . The association of two measures of physical activity ( leisure time activity and usual walking pace ) with cause-specific mortality was examined . Walking pace demonstrated inverse relations with mortality from all-causes , coronary heart disease ( CHD ) , other cardiovascular disease ( CVD ) , all cancers , respiratory disease , colorectal cancer and haematopoietic cancer following adjustment for risk factors which included age , employment grade , smoking , body mass index , and forced expiratory volume ( P [trend]<0.05 for all ) . In analyses restricted to men without disease at entry , walking pace retained inverse associations with all-cause , CHD , other cardiovascular disease , and haematopoietic cancer mortality ( P [trend]<0.05 for all ) .  Leisure time activity  was also inversely associated with mortality from all-causes , CHD , other CVD , and all-cancers following adjustment for risk factors ( P [trend]<0.05 for all ) . Eliminating deaths in the first 5 and 10 y of follow-up did not greatly alter these associations . It is concluded that physical activity may confer protection against death due to some cancers , in addition to reducing cardiovascular disease risk BACKGROUND Childhood obesity has been inconsistently associated with decreased levels of physical activity and fitness . Moreover , little is known about this relationship among Filipino preteens . METHODS This cross sectional study reports the association between childhood obesity , measures of physical activity , and fitness .  Children aged 11 to 12 from r and omly selected schools from San Juan , Metromanila were included . Outcome measures were body mass index , Filipino modified Physical Activity Question naire for Older children ( F_PAQ-C ) ,  st and ing broad jump , 50 m sprint  and  20 m multistage shuttle run .  RESULTS 380 children participated in the study . Obese children had significantly lower median scores in the F_PAQ-C compared with overweight children . Overweight children had lower scores in the st and ing broad jump , 50 m sprints and predicted VO2max as compared with children with normal BMI . There were modest associations between the 50 m sprint , predicted VO2max , and F_PAQ-C. CONCLUSION Our study has showed that physical activity and fitness scores were strongly correlated with childhood obesity . If childhood physical fitness is a predictor of physical fitness in adulthood which is a risk factor in cardiovascular diseases , there is a strong possibility that the prevalence of cardiovascular disease in the Philippines will increase dramatically in the future Background The aim of these review s is to inform the design and content of interventions to reduce obesity in young children . The behaviors that are associated with obesity/overweight have been studied extensively ; however , the factors associated with these behaviors in young children ( 0 to 6 years ) have not been systematic ally review ed . Over the past few years the focus of obesity prevention has shifted to preschool children because of the high prevalence of obesity at school entry and recognition that habits formed in early life could track into adulthood . In order to develop effective interventions and change behavior , it is important to underst and the factors that are associated with those behaviors . For example , we need to underst and whether it would be more important to target the family , childcare setting s or the wider environment and identify the most effective way of changing these energy balance related behaviors . Methods / Design Quantitative ( intervention and observational ) and qualitative literature on determinants/correlates of fruit and vegetable intake , sugar sweetened beverage and other unhealthy diet intake , and physical activity and sedentary behaviors in young children will be systematic ally identified , mapped and review ed . A common search strategy ( no language or period restrictions ) will be used to identify papers from eight electronic data bases and this will be supplemented by h and - search ing . Next , studies in developed countries that examine the factors associated with these behaviors in children aged 0 to 6 years ( at baseline ) will be screened and mapped descriptively followed by in-depth data extraction , quality assessment and synthesis . Data from quantitative studies will be summarized using either forest plots or harvest plots and narrative synthesis , and qualitative studies using thematic analysis . Qualitative evidence will be integrated with the quantitative evidence , using a parallel synthesis approach , to provide a deeper underst and ing of effective strategies to influence these energy balance related behaviors . Discussion In addition to updating and mapping current research , these review s will be the first to comprehensively synthesize and integrate both the quantitative and qualitative evidence pertaining to determinants/correlates/barriers/facilitators of obesity related behaviors in this young age group ( 0 to 6 years ) with the aim of informing future interventions . Systematic review registration International Prospect i ve Register for Systematic Review s ( PROSPERO ) Registration number : BACKGROUND Obesity is now the most common chronic pediatric disease . Early health education programs could serve to prevent and treat childhood obesity and its numerous complications . AIM To examine the effects of a r and omized prospect i ve school-based intervention on anthropometric measures , body composition , leisure time habits and fitness in preschool children . CHILDREN Fifty-four preschool children completed a 14-week combined dietary-behavioral-physical activity intervention and were compared to 47 age matched controls ( age 5 - 6 yr ) . RESULTS Daily physical activity was significantly greater in the intervention group compared to the controls ( 6,927 + /- 364 vs 5,489 + /- 284 steps/ day , respectively ; p < 0.003 ) . Favorable changes were observed in weight ( 0.35 + /- 0.08 vs 0.9 + /- 0.1 kg , p < 0.0005 ) , BMI percentile ( -3.8 + /- 1.3 vs 2.9 + /- 1.5 kg/m2 , p < 0.001 ) , fat percent ( by skinfolds , -0.65 + /- 0.3 vs 1.64 + /- 0.3 % , p < 0.028 ) and fitness ( endurance time -3.55 + /- 1.85 vs 3.16 + /- 2.05 % , p < 0.017 ) in the intervention versus control groups . CONCLUSIONS A preschool , dietary/physical activity intervention may play a role in health promotion , prevention and treatment of childhood obesity BACKGROUND Physical inactivity is a major modifiable lifestyle risk factor associated with cardiovascular disease . Tai Chi is a safe and popular form of physical activity among older adults , yet direct comparisons are lacking between Tai Chi and brisk walking in their ability to reduce cardiovascular disease risk factors and improve psychosocial well-being . METHODS 246 adults ( mean age = 64.4 ± 9.8 years , age range = 30 - 91 years , 45.5 % men ) with hypertension and at least two but not more than three modifiable cardiovascular disease risk factors ( diabetes , dyslipidaemia , overweight , physical inactivity and smoking ) were r and omly assigned to either Tai Chi ( n = 82 ) , brisk walking ( n = 82 ) or control ( n = 82 ) groups . The Tai Chi and brisk walking groups engaged in moderate-intensity physical activity 150 min/week for 3 months ; daily home-based practice was encouraged for another 6 months . The primary outcome was blood pressure . Secondary outcomes were fasting blood sugar , glycated haemoglobin , total cholesterol , triglycerides , high- and low-density lipoprotein , body mass index , waist circumference , aerobic endurance , perceived stress , quality of life and exercise self-efficacy . Data were collected at baseline , post-intervention at 3 months and follow-up assessment s at 6 and 9 months . Generalised estimating equation models were used to compare the changes in outcomes over time between groups . RESULTS At baseline , the participants had an average blood pressure = 141/81 and average body mass index = 26 ; 58 % were diabetics , 61 % presented with dyslipidemia and 11 % were smokers . No significant difference was noted between groups . Tai Chi  significantly lowered blood pressure ( systolic -13.33 mmHg ; diastolic -6.45 mmHg ) , fasting blood sugar ( -0.72 mmol/L ) , glycated haemoglobin ( -0.39 % ) and perceived stress ( -3.22 score ) and improved perceived mental health ( + 4.05 score ) and exercise self-efficacy ( + 12.79 score ) at 9 months , compared to the control group . In the Tai Chi group , significantly greater reductions in blood pressure ( systolic -12.46 mmHg ; diastolic -3.20 mmHg ) , fasting blood sugar ( -1.27 mmol/L ) , glycated haemoglobin ( -0.56 % ) , lower perceived stress ( -2.32 score ) , and improved perceived mental health ( + 3.54 score ) and exercise self-efficacy ( + 12.83 score ) were observed , compared to the brisk walking group . No significant changes in the other cardiovascular disease risk indicators were observed over time between groups . CONCLUSION Nurses play a key role in promoting exercise to reduce cardiovascular disease risk and foster a healthy lifestyle among adults . Tai Chi is better than brisk walking in reducing several cardiovascular disease risk factors and improving psychosocial well-being , and can be recommended as a viable exercise for building a healthy life free of cardiovascular disease BACKGROUND A high body-mass index ( BMI , the weight in kilograms divided by the square of the height in meters ) is associated with increased mortality from cardiovascular disease and certain cancers , but the precise relationship between BMI and all-cause mortality remains uncertain . METHODS We used Cox regression to estimate hazard ratios and 95 % confidence intervals for an association between BMI and all-cause mortality , adjusting for age , study , physical activity , alcohol consumption , education , and marital status in pooled data from 19 prospect i ve studies encompassing 1.46 million white adults , 19 to 84 years of age ( median , 58 ) . RESULTS The median baseline BMI was 26.2 . During a median follow-up period of 10 years ( range , 5 to 28 ) , 160,087  deaths were identified . Among healthy participants who never smoked , there was a J-shaped relationship between BMI and all-cause mortality . With a BMI of 22.5 to 24.9 as the reference category , hazard ratios among women were 1.47 ( 95 percent confidence interval [ CI ] , 1.33 to 1.62 ) for a BMI of 15.0 to 18.4 ; 1.14 ( 95 % CI , 1.07 to 1.22 ) for a BMI of 18.5 to 19.9 ; 1.00 ( 95 % CI , 0.96 to 1.04 ) for a BMI of 20.0 to 22.4 ; 1.13 ( 95 % CI , 1.09 to 1.17 ) for a BMI of 25.0 to 29.9 ; 1.44 ( 95 % CI , 1.38 to 1.50 ) for a BMI of 30.0 to 34.9 ; 1.88 ( 95 % CI , 1.77 to 2.00 ) for a BMI of 35.0 to 39.9 ; and 2.51 ( 95 % CI , 2.30 to 2.73 ) for a BMI of 40.0 to 49.9 . In general , the hazard ratios for the men were similar . Hazard ratios for a BMI below 20.0 were attenuated with longer-term follow-up . CONCLUSIONS In white adults , overweight and obesity ( and possibly underweight ) are associated with increased all-cause mortality . All-cause mortality is generally lowest with a BMI of 20.0 to 24.9 BACKGROUND Previous estimates have highlighted a large global burden of stillbirths , with an absence of reliable data from regions where most stillbirths occur . The Every Newborn Action Plan ( ENAP ) targets national stillbirth rates ( SBRs ) of 12 or fewer stillbirths per 1000 births by 2030 . We estimate SBRs and numbers for 195 countries , including trends from 2000 to 2015 . METHODS We collated  SBR data meeting prespecified inclusion criteria from national routine or registration systems , nationally representative surveys , and other data sources identified through a systematic review , web-based search es , and consultation with stillbirth experts . We modelled SBR ( ≥28 weeks ' gestation ) for 195 countries with restricted maximum likelihood estimation with country-level r and om effects . Uncertainty ranges were obtained through a bootstrap approach . FINDINGS Data from 157 countries ( 2207 data points ) met the inclusion criteria , a 90 % increase from 2009 estimates . The estimated average global SBR in 2015 was 18·4 per 1000 births , down from 24·7 in 2000 ( 25·5 % reduction ) . In 2015 , an estimated 2·6 million ( uncertainty range 2·4 - 3·0 million ) babies were stillborn , giving a 19 % decline in numbers since 2000 with the slowest progress in sub-Saharan Africa . 98 % of all stillbirths occur in low-income and middle-income countries ; 77 % in south Asia and sub-Saharan Africa . INTERPRETATION Progress in reducing the large worldwide stillbirth burden remains slow and insufficient to meet national targets such as for ENAP . Stillbirths are increasingly being counted at a local level , but countries and the global community must further improve the quality and comparability of data , and ensure that this is more clearly linked to accountability processes including the Sustainable Development Goals . FUNDING Save the Children 's Saving Newborn Lives programme to The London School of Hygiene & Tropical Medicine Objective To evaluate the impact of combinations of lifestyle factors on  mortality in middle aged women . Design Prospect i ve cohort study . Setting Nurses ’ health study , United States . Participants 77 782 women aged 34 to 59 years and free from cardiovascular disease and cancer in 1980 . Main outcome measure Relative risk of mortality during 24 years of follow-up in relation to five lifestyle factors ( cigarette smoking , being overweight , taking little moderate to vigorous physical activity , no light to moderate alcohol intake , and low diet quality score ) . Results 8882 deaths were documented , including 1790 from cardiovascular disease and 4527 from cancer . Each lifestyle factor independently and significantly predicted mortality . Relative risks for five compared with zero lifestyle risk factors were 3.26 ( 95 % confidence interval 2.45 to 4.34 ) for cancer mortality , 8.17 ( 4.96 to 13.47 ) for cardiovascular mortality , and 4.31 ( 3.51 to 5.31 ) for all cause mortality . A total of 28 % ( 25 % to 31 % ) of deaths during follow-up could be attributed to smoking and 55 % ( 47 % to 62 % ) to the combination of smoking , being overweight , lack of physical activity , and a low diet quality . Additionally considering alcohol intake did not substantially change this estimate . Conclusions These results indicate that adherence to lifestyle guidelines is associated with markedly lower  mortality in middle aged women . Both efforts to eradicate cigarette smoking and those to stimulate regular physical activity and a healthy diet should be intensified Background  Physical activity levels among breast cancer survivors are typically low , and knowledge of the correlates of increased physical activity among cancer survivors is limited . The purpose of this study was to examine factors that are associated with physical activity or inactivity among breast cancer survivors . Methods Data from 3088 women participating in the Women ’s Healthy Eating and Living ( WHEL ) Study , collected prior to r and omization , were the focus of the current analyses . Self-reports of physical activity levels , quality of life , depression , and dietary intakes  were collected . Pearson correlation analyses were employed to examine the associations among these variables , and multiple regression analyses were performed to examine the relationship between selected health behaviors and physical activity levels , after controlling for demographic , breast cancer-related , and psychosocial variables . Results Demographic and psychosocial variables were related to physical activity levels ( P < 0.001 for all ) . Cancer treatment type and cancer stage were correlated with survivors ’ physical activity levels ( P < 0.01 ) , but the associations were no longer significant after controlling for demographic variables . Physical activity levels were strongly associated with other health behaviors , especially dietary intakes ( P < 0.001 ) , even after controlling for demographic , cancer-related , and psychosocial factors . Conclusion Low physical activity  levels in breast cancer survivors are associated with specific behavioral and other factors , which can be considered as indicators of women at higher risk . Findings of significant differences in  physical activity levels based on demographic characteristics suggest the importance of promoting physical activity particularly among breast cancer survivors of ethnic minority or lower education levels Background In Lebanon , childhood obesity doubled during the past decade . Preventive measures should start early in life and Schools are considered an important environment to promote energy balance health behaviours . School-based programmes promoting healthy lifestyles are lacking . The purpose of this study was to evaluate the feasibility and effectiveness of a multicomponent school-based intervention to promote healthy eating and physical activity ( and prevent obesity ) with school children aged 9–11 years in Lebanon . Methods The intervention was developed based on the constructs of the Social Cognitive Theory and adapted to the culture of Lebanese and Arab population s. It consisted of three components : class curriculum , family involvement and food service .  Eight schools were purposively selected from two communities of different socioeconomic status ( SES ) in Beirut and , within each school type , were matched on SES , religious sect profile , and then r and omly assigned to either the intervention or control group . Anthropometric measurements and question naires on determinants of behavioural change , eating and physical activity habits were completed by the students in both groups at baseline and post intervention . Focus group interviews were conducted in intervention schools at the end of the study . Challenges encountered during the programme implementation were also identified , since Lebanon is considered a country with political unrest and no similar research projects were conducted in the area . Results Students in the intervention group reported purchasing and consuming less chips and sweetened drinks post-intervention compared with controls ( 86 % & 88 % less respectively p < 0.001 ) . Knowledge and self-efficacy scores increased for the intervention ( + 2.8 & + 1.7 points respectively p < 0.001 ) but not for the control group . There was no difference in physical activity and screen time habits and no changes in BMI between groups at post intervention . Interview data from focus groups showed that the programme was generally well accepted . Limitations for better outcomes include the length of the programme and the school environment . Conclusion “ Health-E-PALS ” intervention is a promising innovative , theory-based , culturally sensitive intervention to promote healthy eating habits and physical activity in Lebanese school children with a potential to be scaled up , replicated and sustained Background The worldwide increase in the rates of childhood overweight and physical inactivity requires successful prevention and intervention programs for children . The aim of the Active Living project is to increase physical activity and decrease sedentary behavior of Dutch primary school children by developing and implementing tailored , multicomponent interventions at and around schools . Methods / design In this project , school-centered interventions have been developed at 10 schools in the south of the Netherl and s , using a combined top-down and bottom-up approach in which a research unit and a practice unit continuously interact . The interventions consist of a combination of physical and social interventions tailored to local needs of intervention schools . The process and short- and long-term effectiveness of the interventions will be evaluated using a quasi-experimental study design in which 10 intervention schools are matched with 10 control schools . Baseline and follow-up measurements ( after 12 and 24 months ) have been conducted in grade s 6 and 7 and included accelerometry , GPS , and question naires . Primary outcome of the Active Living study is the change in physical activity levels , i.e. sedentary behavior ( SB ) , light physical activity ( LPA ) , moderate-to-vigorous physical activity ( MVPA ) , and counts-per-minute ( CPM ) . Multilevel regression analyses will be used to assess the effectiveness of isolated and combined physical and social interventions on children ’s PA levels . Discussion The current intervention study is unique in its combined approach of physical and social environmental PA interventions both at school(yard)s as well as in the local neighborhood around the schools . The strength of the study lies in the quasi-experimental design including objective measurement techniques , i.e. accelerometry and GPS , combined with more subjective techniques , i.e. question naires , implementation logbooks , and neighborhood observations . Trial registration Current Controlled Trials IS RCT N25497687 ( registration date 21/10/2015 ) , METC 12 - 4 - 077 , Project number BACKGROUND : Earlier observational studies of the relation between physical activity and obesity are inconsistent and ambiguous , showing a clear cross-sectional inverse relation , and a prospect i ve association only when physical activity at the time of follow-up is included . OBJECTIVE : To examine the long-term effect of leisure time physical activity ( LTPA ) on subsequent development of obesity and the effect of body weight on later physical inactivity in a population -based longitudinal setting taking into account the effects of historical changes on future changes as well as pertinent confounders . DESIGN : The study included 3653 women and 2626 men aged 20–78 y selected at r and om within sex – age strata from the general population of Copenhagen . At two surveys , 5 y apart ,  LTPA , body mass index ( BMI ) ( weight/height2 , kg/m2 ) , several possible confounders and modifying factors were assessed . Obesity ( defined as BMI ≥30 kg/m2 ) and LTPA was assessed at the 3rd survey 10 y later . Odds ratios ( with 95 % confidence limits ) for developing obesity between the last two surveys were estimated by logistic regression analysis , taking into account baseline and preceding changes in BMI and LTPA . A similar analysis of odds ratios for physical inactivity as outcome at the 3rd survey was conducted . RESULTS : Compared to physical inactivity , the odds ratios of development of obesity among women with medium and high level of activity were 0.81 ( 0.53 , 1.25 ) and 1.16 ( 0.73 , 1.84 ) , respectively , and among men , the odds ratios were 1.28 ( 0.71 , 2.33 ) and 1.65 ( 0.91 , 2.99 ) , respectively . Compared to median BMI , the odds ratio of later physical inactivity among women with high BMI was 1.91 ( 1.39 , 2.61 ) , and among men the odds ratio was 1.50 ( 1.01 , 2.22 ) . The associations were not confounded or modified by age , pre-existing diseases , smoking , alcohol intake , educational level , occupational physical activity or by familial predisposition to obesity . CONCLUSION : This study did not support that physical inactivity as reported in the freely living adult population in the long term is associated with the development of obesity , but the study indicates that obesity may lead to physical inactivity BACKGROUND The rising prevalence of obesity in children and adolescents is implicated in the metabolic abnormalities that track into adulthood . The associated increased incidence of insulin resistance , metabolic syndrome and type 2 diabetes being identified in younger cohorts has given rise to a critical global health issue . Muscular strength is a vital component of metabolic fitness that provides protection from insulin resistance in adults , and we have recently shown this to be true in children as well . Targeting muscular strength deficiencies at an early age may be an effective preventative strategy for metabolic syndrome and type 2 diabetes . PURPOSE There is limited evidence -based best practice for progressive resistance training ( PRT ) , adiposity and metabolic fitness in children and adolescents . The purpose of this paper is to describe the methodology we utilized for implementing a PRT program to avoid publication bias , enable replication of the study and share a novel program that we have found safe and suitable for use with youth . METHODS We conducted the first r and omized controlled trial ( RCT ) prescribing high-intensity PRT to children and adolescents ( 10 - 15 years ) as a community-based primary prevention program to address adiposity and metabolic health . Participants were instructed to complete 2 sets of 8 repetitions of 11 exercises targeting all the major muscle groups twice a week at an RPE of 15 - 18 for 8 weeks . RESULTS Primary outcome was waist circumference ; secondary outcomes included insulin resistance , lipid levels , muscle strength , cardiorespiratory fitness , body composition , self-efficacy , self-concept , habitual physical activity , nutritional and sedentary behavior patterns . CONCLUSION The supervised PRT program that we used with children and adolescents has been described in detail . The efficacy of this modality of exercise for metabolic fitness and other health outcomes is now under investigation CONTEXT Obesity is a major health problem in the United States , but the number of obesity-attributable deaths has not been rigorously estimated . OBJECTIVE To estimate the number of deaths , annually , attributable to obesity among US adults . DESIGN Data from 5 prospect i ve cohort studies ( the Alameda Community Health Study , the Framingham Heart Study , the Tecumseh Community Health Study , the American Cancer Society Cancer Prevention Study I , and the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study ) and 1 published study ( the Nurses ' Health Study ) in conjunction with 1991 national statistics on body mass index distributions , population size , and overall deaths . SUBJECTS Adults , 18 years or older in 1991 , classified by body mass index ( kg/m2 ) as overweight ( 25 - 30 ) , obese ( 30 - 35 ) , and severely obese ( > 35 ) . MAIN OUTCOME MEASURE Relative hazard ratio ( HR ) of death for obese or overweight persons . RESULTS The estimated number of annual deaths attributable to obesity varied with the cohort used to calculate the HRs , but findings were consistent overall . More than 80 % of the estimated obesity-attributable deaths occurred among individuals with a body mass index of more than 30 kg/m2 . When HRs were estimated for all eligible subjects from all 6 studies , the mean estimate of deaths attributable to obesity in the United States was 280184 ( range , 236111 - 341153 ) . Hazard ratios also were calculated from data for nonsmokers or never-smokers only . When these HRs were applied to the entire population ( assuming the HR applied to all individuals ) , the mean estimate for obesity-attributable death was 324 940 ( range , 262541 - 383410 ) . CONCLUSIONS The estimated number of annual deaths attributable to obesity among US adults is approximately 280000 based on HRs from all subjects and 325000 based on HRs from only nonsmokers and never-smokers PURPOSE / OBJECTIVES To describe and predict adherence to a physical activity protocol for patients with breast cancer receiving chemotherapy .  DESIGN Longitudinal , observational study . SETTING Cancer center in the upper Midwestern region of the United States . SAMPLE 36 patients with breast cancer aged 40 - 55 years who were receiving adjuvant treatment . METHODS A longitudinal study was conducted within a r and omized clinical trial comparing the effects of physical activity versus bisphosphonates on bone mineral density . Participants r and omized to physical activity were advised to walk 10,000 steps per day and received initial physical therapy consultation and ongoing motivational interviewing . Multilevel modeling was used to identify variables that predict adherence . MAIN RESEARCH VARIABLES Adherence to the 10,000-step protocol was estimated with total steps and mean steps per day . FINDINGS Thirty-six women were enrolled in the physical activity group ; 29 provided step data . The mean total steps per participant for the first six weeks was 280,571 ( SD = 111,992 ) , which is 67 % of the prescribed steps . Excluding days when no steps were recorded , the mean steps per day for the initial six-week period was 7,363 ( SD = 2,421 ) , a 74 % adherence rate . A significant linear increase occurred in steps per day after chemotherapy in a treatment cycle ( p < 0.0001 ) . Baseline inactivity predicted adherence . CONCLUSIONS Adherence to the walking program was compromised during chemotherapy but improved after chemotherapy completion . IMPLICATION S FOR NURSING Knowing that chemotherapy predicts adherence to a walking protocol is useful for selecting the type , timing , and intensity of physical activity interventions Background Exercise is a modifiable factor that is inversely related to risk for breast cancer .  To determine if physical activity has a preventative effect on development of premalignant breast lesions , we examined the association between exercise and the incidence of proliferative benign breast disease . Methods In 1997 , the Nurses ’ Health Study II cohort reported levels of physical activity during adolescence and adulthood using a vali date d recall instrument . We followed 40,318 participants free from benign breast disease ( BBD ) or cancer prospect ively for four years and confirmed 232 proliferative benign breast lesions by central ized pathology review . Cox proportional hazards models estimated the age-adjusted and multivariable-adjusted relative risks for physical activity and proliferative benign breast disease . Results We observed a significant inverse association for walking and incidence of BBD , risk was reduced by 9 % per hour of walking ( 95 % CI 0 % to 17 % ) , ( p trend = 0.05 ) . Despite a small number of cases , risk of columnar cell lesions also suggested an inverse association with strenuous activity ( RR for 4 or more hours of strenuous activity per week = 0.62 ; 0.31–1.22 compared to < 1 h per week ) . Conclusions This study suggests that exercise may be inversely associated with the risk of developing proliferative benign breast disease , one of the earliest steps in the development of breast cancer Abstract Background Data on the prevalence of overweight and obesity in Eastern Mediterranean countries remain scarce , particularly for children and adolescents . The objective of this study is to estimate the prevalence of obesity and examine associated factors and covariates amongst school adolescents in Syria . Methods A cross-sectional survey of a representative sample of 776 adolescents ( 386 males and 390 females ) , aged 15 - 18 years , was conducted in six r and omly chosen secondary schools in Damascus , the capital city of Syria .  Anthropometric measurements and dietary assessment data  were collected using st and ard methods and techniques . Overweight and obesity were defined according to World Health Organization 2007 child growth st and ards . Results The prevalence rates of overweight and obesity were estimated at 18.9 and 8.6 % , respectively . Carbohydrate and saturated fatty acid intakes were significantly higher amongst overweight and obese ( 250.66 and 32.82 g/day , respectively ) as compared with normal weight adolescents ( 218.12 and 26.10 g/day , respectively ) . Regression analysis showed that the likelihood of obesity was significantly greater amongst adolescent boys than girls ( OR = 2.30 , P < 0.05 ) and amongst subjects reporting family history of obesity ( OR = 2.98 , P < 0.05 ) . The odds of obesity increased consistently with increasing educational attainment of both parents and was higher ( OR = 1.63 ) amongst adolescents reporting lower crowding index than their counterparts . Conclusion Our findings of a positive association between obesity and socio-economic status measured by parental education and crowding index call for intervention strategies for the promotion of healthy dietary practice s not only amongst school adolescents but also parents , targeting families as the unit of intervention . Further studies are needed to examine nutritional habits and food choices amongst families of different socio-economic strata Context Inflammatory markers , such as C-reactive protein ( CRP ) , independently predict future coronary artery disease in patients without known disease at baseline . However , an elevated CRP level also predicts all-cause mortality ; therefore , it may not be specific for cardiovascular disease . Contribution This prospect i ve casecontrol study showed that CRP level predicted the development of acute cardiovascular events but not cancer among 28 345 women followed for a mean of 58 months . Clinical Implication s parental history of coronary heart disease . In women , CRP level appears specifically predictive of car-diovascular disease but not cancer . This study adds further evidence that CRP levels may be useful in the clinical prediction of cardiovascular risk , at least in population s. The Editors Recent evidence suggests that atherosclerosis is in part a chronic low- grade inflammatory condition ( 1 ) , and prospect i ve epidemiologic studies have demonstrated that plasma markers of inflammation , such as C-reactive protein ( CRP ) , are strong independent predictors of future coronary events in apparently healthy persons ( 2 - 6 ) . However , as an acute-phase reactant , CRP increases dramatically in various pathologic conditions . Moreover , CRP has been shown to predict all-cause mortality ( 7 , 8) , an observation that raises the possibility that CRP may not be specific for vascular disease . To evaluate this hypothesis , we directly compared the predictive value of CRP for incident cancer and cardiovascular disease , the two most important determinants of all-cause mortality in the western world . Methods We performed a prospect i ve , nested casecontrol analysis within the Women 's Health Study , an ongoing r and omized , double-blind , placebo-controlled trial of aspirin and vitamin E for primary prevention of heart disease and cancer , which involves 39 876 U.S. women 45 years of age and older . Of these study participants , 28 345 ( 71 % ) provided baseline blood sample s  , which were stored at 70 C until the time of laboratory analysis . In the Women 's Health Study , all participants are followed prospect ively for incident health events , including cancer and cardiovascular events . The methods used for cohort follow-up , end-point ascertainment , and adjudication for both cancer and cardiovascular events are described in detail elsewhere ( 5 , 9 ) . For this study , we defined case- patients as apparently healthy women who provided an adequate baseline plasma sample and who subsequently developed cancer ( n = 513 ) or an acute cardiovascular event ( myocardial infa rct ion , stroke , or cardiovascular death ) ( n = 130 ) over a mean follow-up period of 58 months . For each woman who had confirmed cancer or cardiovascular event during follow-up , one control of the same age ( 1 year ) and smoking habit ( former smoker , current smoker , or nonsmoker ) was selected from among participants who provided baseline plasma sample s and remained free of reported disease during the same follow-up period . Using these criteria , we evaluated 643 case- patients and an equal number of controls in two separate matched pairs , one for cancer ( n = 513 ) and another for cardiovascular events ( n = 130 ) . The Institutional Review Board of the Brigham and Women 's Hospital approved this study . For each case-patient and control , plasma stored since the baseline examination was thawed and assayed for CRP levels by using a high-sensitivity assay ( Dade Behring , Newark , Delaware ) ( 10 ) . Blood specimens were analyzed in blinded pairs with the position of the patient 's specimen varied at r and om to reduce the possibility of systematic bias and to decrease interassay variability . The day-to-day precision values , at CRP concentrations of 0.15 mg/L and 0.49 mg/L , were 4.9 % and 6.4 % , respectively . Because CRP values are skewed rightward , median plasma concentrations were computed , and the significance of any difference in the distributions between the case- patients and controls was assessed by performing the Wilcoxon rank-sum test . We then used conditional logistic regression models to determine the risk for developing cancer or cardiovascular end points after dividing the study sample into quartiles on the basis of the distribution of the control group . Adjusted estimates of risk were obtained by use of similar models that accounted for the matching variables and that controlled for r and omized treatment assignment ( for vitamin E , aspirin , or both ) , body mass index , diabetes mellitus , history of hyperlipidemia , history of hypertension , and parental history of coronary heart disease . All analyses were performed by using SAS software , release 8.2 ( SAS Institute , Inc. , Cary , North Carolina ) . All P values were two tailed , and CIs were computed at the 95 % level . The funding sources played no role in the design , conduct , or reporting of the study . Results Table 1 shows the baseline characteristics of the study participants . We noted no significant differences at baseline between women who subsequently developed cancer and those who did not . As expected , women who subsequently developed cardiovascular events had an increased baseline prevalence of hyperlipidemia , hypertension , diabetes , and obesity compared with controls who did not develop vascular events during follow-up . Table 1 . Baseline Clinical Characteristics of the Study Participants Overall , median levels of CRP  at baseline among women who subsequently developed cancer ( 2.6 mg/L [ interquartile range , 1.1 to 5.9 mg/L ] ) were not significantly different from those of the control group ( 2.5 mg/L [ interquartile range , 0.9 to 5.5 mg/L ] ) ( P > 0.2 ) . Furthermore , we observed no evidence of an association between baseline CRP level and the development of cancer in site-specific analyses evaluating carcinoma of the breast ( n = 223 ) , ovary or uterus ( n = 75 ) , colon ( n = 44 ) , lung ( n = 32 ) , hematopoietic system ( n = 31 ) , thyroid ( n = 14 ) , bladder ( n = 9 ) , brain ( n = 8) , or pancreas ( n = 8) ; melanoma ( n = 31 ) ; or other types of cancer ( n = 38 ) . In contrast , and consistent with previous work in this cohort for the end point of any vascular event ( 5 ) , median CRP levels at baseline among women who subsequently developed cardiovascular disease ( 5.1 mg/L [ interquartile range , 2.6 to 8.5 mg/L ] ) were significantly higher than those of the control group ( P < 0.001 ) . Table 2 presents relative risks for developing either cancer or cardiovascular disease according to increasing quartiles of CRP levels obtained at study entry . As Table 2 shows , there was little evidence that baseline levels of CRP predicted incident cancer in either crude or adjusted analyses . We found similar results after additional correction for alcohol use and age at menarche ( data not shown ) . In contrast , increasing quartiles of baseline CRP level were a strong marker of risk for incident cardiovascular disease in crude and adjusted analyses . For example , the adjusted relative risks from the lowest to the highest quartiles of baseline CRP levels were 1.0 , 2.9 , 3.4 , and 5.6 , respectively ( P for trend < 0.001 ) . Table 2 . Relative Risk for Future Cancer and Cardiovascular Events , according to Baseline Plasma C-Reactive Protein Level Discussion In this prospect i ve study of apparently healthy middle-aged and older women , baseline plasma CRP concentrations were not significantly related to the incidence of future cancer but were a strong independent predictor of future myocardial infa rct ion , stroke , and cardiovascular death . We believe these data have importance for general medical practice for several reasons . First , our data corroborate the findings in several previous reports ( 2 - 6 ) that baseline levels of CRP predict future vascular events among apparently healthy men and women ( 2 - 6 ) and that CRP level adds to the predictive value of total and high-density lipoprotein cholesterol levels ( 5 , 11 ) . As a result of these earlier findings , outpatient screening for CRP has recently become available . However , if CRP is clinical ly nonspecific , as two recent studies evaluating all-cause mortality suggest ( 7 , 8) , then screening for this inflammatory marker might have reduced diagnostic utility . Thus , our finding that CRP appears to be specific for incident vascular disease but not for incident cancer has substantial clinical importance and suggests that data linking CRP level to overall death rates may have been due to the large contribution that vascular disorders make to all-cause mortality , particularly in the western world . Second , the relative risks for future myocardial infa rct ion or stroke observed among women in the top versus bottom quartile of baseline CRP in this analysis are somewhat greater than those previously reported from this cohort for the end point of any vascular eventan end point that included not only myocardial infa rct ion , stroke , and cardiovascular disease mortality , but also coronary revascularization ( 5 ) . Thus , these data also suggest that CRP level may be a stronger marker for events involving atherosclerotic plaque rupture and acute thrombosis than for events primarily involving progression of lesional stenosis . These epidemiologic data are thus consistent with the hypothesis that inflammation is an important determinant of plaque vulnerability ( 12 ) . Finally , we believe that our observation that CRP levels do not strongly predict future cancers is itself of pathophysiologic interest ; this is of particular interest because levels of CRP and other inflammatory biomarkers are known to increase after development of certain malignancies ( 13 , 14 ) . As such , our data also suggest that the systemic inflammatory component of cancer previously reported in cross-sectional studies may be a late development in the genesis of that disease but is not likely to prove useful in determining risk among healthy persons . Several limitations of our study deserve attention . Plasma CRP levels increase acutely in a wide variety of pathologic conditions , including febrile illness , various inflammatory states , and trauma ( 15 ) . In The prevalence of type 2 diabetes mellitus is rapidly increasing in the United States ( 1 , 2 ) and worldwide ( 3 ) . Ecologic studies ( 4 ) , migration studies ( 4 , 5 ) , and analyses of secular trends ( 4 , 6 ) suggest that adoption of a western diet may be associated with increased incidence of type 2 diabetes . However , these studies could not separate the effects of diet from those of other risk factors , such as obesity and physical activity . Studies of the relation between diet and incidence of type 2 diabetes on an individual level have predominantly focused on intake of macronutrients and fiber ( 7 ) . However , these dietary factors alone probably explain only part of the effect of diet on glucose metabolism . Other nutrients , additives , contaminants , and unknown compounds and the physical properties of foods and interactions between nutrients ( for example , with respect to bioavailability ) may play a role in the deterioration of glucose metabolism . Hence , the examination of effects of food consumption may be an important complementary approach . Recently , the analysis of patterns of food consumption by using factor analysis has emerged as a useful tool for elucidating relationships between diet and health ( 8 - 11 ) . The overall dietary pattern may affect health more than individual foods and nutrients do . Furthermore , dietary patterns reflect the way foods are consumed in reality , which may provide insight into possibilities for dietary changes and may facilitate the translation of findings to public health recommendations . Recent dietary intervention studies have indicated that interventions focused on dietary patterns can decrease blood pressure ( 12 ) and reduce cardiovascular complications ( 13 ) . Data on dietary patterns and risk for type 2 diabetes are sparse . Although two cross-sectional studies of dietary patterns and diabetes have been conducted ( 11 , 14 ) , these studies incompletely controlled for confounding by other lifestyle factors . Therefore , we prospect ively examined the association between major dietary patterns and risk for type 2 diabetes in a large prospect i ve study of U.S. professional men with extensive , repeatedly obtained information on diet and other lifestyle factors . Methods Participants The Health Professionals Follow-up Study started in 1986 , when 51 529 male health professionals ( dentists , veterinarians , pharmacists , optometrists , osteopathic physicians , and podiatrists ) completed a detailed mailed question naire on medical history , diet , and other potential risk factors for major diseases .  The participants lived in all 50 U.S. states , were predominantly white , and were 40 to 75 years of age in 1986 . We excluded from the current analysis 1595 men who did not satisfy the a priori criteria of reporting daily energy intake of 3.3 to 17.6 MJ ( 800 to 4200 kcal/24 h ) and leaving fewer than 70 responses blank of the 131 food items on the diet question naire ( < 5 % had > 11 blanks ) . We also excluded men who reported having diabetes , cardiovascular disease ( myocardial infa rct ion , angina pectoris , coronary artery surgery , or stroke ) , or cancer ( except nonmelanoma skin cancer ) at baseline because having these diagnoses may affect diet or reporting of diet . After exclusions , the study sample comprised 42 504 men , who were followed for incidence of type 2 diabetes and other diseases for 12 years ( 1986 to 1998 ) . Every 2 years , the participants received question naires by mail that asked for up date d information on exposures and newly diagnosed diseases . The follow-up rate for potential person-years was about 97 % for nonfatal events . We identified deaths by reports from family members , coworkers , or postal authorities or through systematic search es of the National Death Index . Assessment of Dietary Patterns To assess dietary intake , we used a 131-item semiquantitative food-frequency question naire in 1986 , 1990 , and 1994 . The question naire specified for each food a commonly used unit or portion size , and the participants were asked to indicate how often , on average , they had consumed a given amount of the specified food during the past year . Each such item provided nine possible responses , ranging from never or less than once a month to 6 or more times per day . To reduce within-respondent variation and to best represent long-term dietary habits , we averaged the dietary intakes from all available dietary question naires up to the start of each follow-up interval ( the average of the 1986 and 1990 dietary intakes was related to incidence of type 2 diabetes between 1990 and 1994 ) ( 15 ) . To identify dietary patterns , we applied factor analysis to data from the food-frequency question naire . First , we grouped the food items on the question naire into 37 predefined food groups . We combined food items that were similar in nutrient profile and culinary use ( for example , spinach , iceberg or head lettuce , and romaine or leaf lettuce were combined into green leafy vegetables ) . We classified a food item individually if its composition differed substantially from that of other foods ( for example , eggs or pizza ) or if we suspected that it represents a particular dietary habit ( for example , wine or French fries ) . Second , we applied the principal components program for factor analysis of SAS software ( 16 ) with varimax rotation to the 37 food groups . Factor analysis aggregates correlated variables . The obtained factors are linear combinations of the included variables , explaining as much of the variation in the original variables as possible . Our analysis retained two factors based on the eigenvalue of the factors , the Scree test , and the interpretability of the derived factors , and we labeled these diets as the prudent pattern and the western pattern ( 9 ) . Third , for each participant , we calculated a  prudent pattern score and a  western pattern score  by summing the st and ardized intake of foods , weighted by the factor loadings of the foods ( 17 ) . We used these scores to rank participants according to the degree to which they conformed to each dietary pattern . We divided dietary pattern scores into quintiles ; thus , on this basis of his scores , each participant was grouped in a prudent-pattern quintile and a western-pattern quintile . To test the validity and reproducibility of the assessment of the dietary pattern scores by the food-frequency question naire , we examined a subgroup of 127 participants ( 9 ) . The Pearson correlation coefficient ( corrected for week-to-week variation in the diet records ) for a comparison between the responses to the food-frequency question naire and the diet records was 0.52 for the prudent dietary pattern and 0.74 for the western dietary pattern . Assessment of Nondietary Exposures The 1986 question naire and each biennial follow-up question naire assessed weight , smoking status , and physical activity .  Participants provided information on age , diagnosis of hypertension and hypercholesterolemia , and height in 1986 and on family history of diabetes in 1987 . The criterion for family history of type 2 diabetes was having at least one first-degree relative with a diagnosis of diabetes after 30 years of age . For each participant , we determined a physical activity level , measured in weekly metabolic equivalent hours , on the basis of reported time spent on various activities , which we weighted according to intensity level ( 18 ) . The validity of self-reported weight ( 19 ) and physical activity ( 18 ) in this cohort has been reported previously . Ascertainment of Type 2 Diabetes Mellitus We mailed a supplementary question naire on symptoms , diagnostic tests , and medication use to participants who indicated on any biennial follow-up question naire that he had received a diagnosis of diabetes mellitus . Confirmation of diabetes required at least one of the following : 1 ) an elevated plasma glucose level ( fasting plasma glucose level 7.8 mmol/L [ 140 mg/dL ] ; r and om plasma glucose level 11.1 mmol/L [ 200 mg/dL ] ; or  plasma glucose level after 2 hours or more during an oral glucose tolerance test 11.1 mmol/L [ 200 mg/dL ] ) plus at least one classic symptom [ excessive thirst , polyuria , weight loss , or hunger ] ; 2 ) at least two elevated plasma glucose levels measured on different occasions ; or 3 ) treatment with insulin or oral hypoglycemic medication . We excluded men who reported having type 1 diabetes on the supplementary question naire . These criteria for diabetes are consistent with those from the World Health Organization in 1985 ( 20 ) . We did not use the current diabetes classification of the American Diabetes Association ( 21 ) because among the men in our study , most cases of diabetes were diagnosed before these criteria were published . The validity of our assessment of type 2 diabetes was verified with medical records in a sub sample of 71 participants . A physician blinded to the information on the supplementary question naire review ed the records according to the diagnostic criteria . Of the 71 participants classified as having type 2 diabetes , 12 had incomplete medical recordsfor example , absent laboratory data ( n = 2 ) or only one set of laboratory data ( n = 9 ) . We confirmed the classification of type 2 diabetes in 57 ( 97 % ) of the other 59 other men in the sub sample . One participant denied having diabetes , and another participant lacked evidence of diabetes in his su bmi tted records . Statistical Analysis We used pooled logistic regression analyses with 2-year intervals to estimate the adjusted relative risk for each quintile compared with the lowest quintile of intake . With short time intervals and low rates of events , this approach gives results very similar to those of Cox proportional-hazards analyses ( 22 ) . Participants who died or received a diagnosis of diabetes during a 2-year cycle were censored at the end of that 2-year period and were not entered in any subsequent 2-year cycle . We used the cumulative average of available dietary assessment s up to the start of each 2-year follow-up interval ( 15 ) . We stopped updating a participant 's dietary OBJECTIVE : To examine the association of physical activity and body mass index ( BMI ) , and their combined effect , with the risk of total , cardiovascular disease ( CVD ) and cancer mortality .  DESIGN : Prospect i ve follow-up study .SUBJECTS : In all , 22 528 men and 24 684 women aged 25–64 y at baseline having 7394 deaths during a mean follow-up of 17.7 y . MEASUREMENT : A self-administered question naire data on smoking , socioeconomic factors , physical activity and medical history , together with measured height , weight , blood pressure and serum cholesterol using st and ardized protocol . RESULT : Physically active subjects had significantly lower age-adjusted mortality from cardiovascular , cancer and all causes compared with sedentary ones . Further adjustment for smoking , systolic blood pressure , cholesterol , BMI , diabetes and education affected the results only slightly . Obese subjects ( BMI ≥30 kg/m2 ) had significantly higher cardiovascular and total mortality than the normal weight ( 18.5≤ BMI < 25 kg/m2 ) subjects . Part of increased mortality among obese subjects was mediated through obesity-related cardiovascular risk factors . BMI had an inverse association with cancer mortality among men and almost significant direct association among women . Total mortality was also increased among the lean ( BMI < 18.5 kg/m2 ) subjects . However , less than 0.3 % of deaths were attributed to low body weight , whereas in men 5.5 % and in women 17.7 % of deaths were attributed to obesity . CONCLUSION : Regular physical activity and normal weight are both important indicators for a decreased risk of mortality from all causes , CVD and cancer . Physical activity had a strong independent effect on mortality , whereas the effect of BMI was partly mediated through other obesity-related risk factors Observational studies demonstrate an association between physical activity and improved outcomes in breast and colon cancer survivors . To test these observations with a large , r and omized clinical trial , an intervention that significantly impacts physical activity in these patients is needed . The Active After Cancer Trial ( AACT ) was a multicenter pilot study evaluating the feasibility of a telephone-based exercise intervention in a cooperative group setting . Sedentary ( engaging in < 60 min of recreational activity/week ) breast and colorectal cancer survivors were r and omized to a telephone-based exercise intervention or usual care control group . The intervention was delivered through the University of California at San Diego ; participants received ten phone calls over the course of the 16-week intervention . All participants underwent assessment of physical activity , fitness , physical functioning , fatigue and exercise self-efficacy at baseline and after the 16-week intervention . One hundred and twenty-one patients were enrolled through ten Cancer and Leukemia Group B ( CALGB ) institutions ; 100 patients had breast cancer and 21 had colorectal cancer . Participants r and omized to the exercise group increased physical activity by more than 100 versus 22 % in controls ( 54.5 vs. 14.6 min , P = 0.13 ) , and experienced significant increases in fitness ( increased 6-min walk test distance by 186.9 vs. 81.9 feet , P = 0.006 ) and physical functioning ( 7.1 vs. 2.6 , P = 0.04 ) as compared to the control group . Breast and colorectal cancer survivors enrolled in a multicenter , telephone-based physical activity intervention  increased physical activity and experienced significant improvements in fitness and physical functioning . Lifestyle intervention research is feasible in a cooperative group setting BACKGROUND The benefits of childhood physical activity include fitness , weight control , and exercise habits that may carry over into adulthood . School physical education is the primary program responsible for training the nation 's youth to be physically active and national objectives call for students to be engaged in moderate-to-vigorous physical activity at least 50 % of class time . The purpose of this study was to determine through systematic observation in a regional sample of elementary and middle schools the amount of moderate-to-vigorous physical activity students obtain during physical education classes . METHODS Twenty elementary schools and 7 middle schools were r and omly sample d from the 355 elementary schools and 117 middle schools in the 20 school districts in Harris County , Texas . In addition , 9 elementary and 6 middle schools that were identified as having excellent physical education programs were sample d purposively to provide a comparison . Seven systematic observations of student 's physical activity were conducted during physical education in each school . RESULTS The average moderate-to-vigorous physical activity in the r and omly selected elementary schools was 8.6 % , significantly less ( P < 0.05 ) than for the r and omly selected middle schools ( 16.1 % ) or for the comparison elementary schools ( 20.6 % ) and middle schools ( 24.0 % ) . CONCLUSIONS The average amount of  physical activity  observed in this regional sample of schools was less than the estimated national average of 27 % and far less than the national recommendation calling for a minimum of 50 % BACKGROUND Health-compromising behaviors among survivors of childhood cancer may increase their risks of cancer recurrence and the onset of chronic disease in adulthood . Regardless of whether such behaviors occur singly or in combination with one another , multiple behavioral risk factors must be identified and addressed early to promote better health outcomes within this special population . Adolescent survivors may be especially vulnerable , as reported rates of smoking and other risky behaviors are at or near levels of their healthy peers . The psychological literature suggests stress may play a role in risk behavior initiation and maintenance , including multiple behavioral risks , and that adolescent survivors are stress-prone . This report focuses on the prevalence and co-occurrence of three behavioral risk factors ( cigarette use , insufficient physical activity , and non-adherence to sun protection recommendations ) and describes stress-health behavior relationships in this special population . PROCEDURE All patients in this study ( n = 75 ) were adolescent survivors of childhood cancer and completed a baseline assessment of their  health behaviors and stress  as part of a r and omized controlled trial of health promotion . RESULTS Twenty-eight percent of the patients reported one of three risk factors , 12 % reported two of three risk factors , and 7 % reported all three risk factors . Non-adherence to sun protection was the single most common risk factor ; physical inactivity and non-adherent sun protection were the most common co-occurring risk factors . Greater age and stress were significantly associated with the presence of more behavioral risk factors . CONCLUSIONS The evidence suggests interventions to reduce multiple health-compromising behaviors in these patients are warranted , and that efforts to address these patients ' personal and family stress levels are important as well Background Despite the health risks , physical inactivity is common . Identifying the correlates of physical activity to inform the design of interventions to reduce the disease burden associated with physical inactivity is a public health imperative . Rural adults have a unique set of characteristics influencing their activity behaviour , and are typically understudied , especially in Engl and . The aim of this study was to identify the personal , social , and environmental correlates of physical activity in adults living in rural villages . Methods The study used baseline data from 2415 adults ( response rate : 37.7 % ) participating in the first time period of a stepped-wedge cluster r and omised trial , conducted in 128 rural villages from south-west Engl and . Data collected included demographic characteristics , social factors , perception of the local environment , village level factors ( percentage male , mean age , population density , Index of Multiple Deprivation , and sport market segmentation ) , and physical activity behaviour . R and om effects ( “ multilevel ” ) logistic regression models were fitted to the binary outcome whether individuals met physical activity guidelines , and r and om effects linear regression models were fitted to the continuous outcome MET-minutes per week leisure time physical activity , using the personal , social , environmental , and village-level factors as predictors . Results The following factors both increased the odds of meeting the recommended activity guidelines and were associated with more leisure-time physical activity : being male ( p = 0.002 ) , in good health ( p < 0.001 ) , greater commitment to being more active ( p = 0.002 ) , favourable activity social norms ( p = 0.004 ) , greater physical activity habit ( p < 0.001 ) , and recent use of recreational facilities ( p = 0.01 ) . In addition , there was evidence ( p < 0.05 ) that younger age , lower body mass index , having a physical occupation , dog ownership , inconvenience of public transport , and using recreational facilities outside the local village were associated with greater reported leisure-time physical activity . None of the village-level factors were associated with physical activity . Conclusions This study adds to the current literature on the correlates of physical activity behaviour by focusing on a population exposed to unique environmental conditions . It highlights potentially important correlates of physical activity that could be the focus of interventions targeting rural population s , and demonstrates the need to examine rural adults separately from their urban counterparts The purpose of the study was to investigate the effects of a school-based prevention program on physical activity , fitness , and obesity . We performed a prospect i ve study in eight Bavarian primary schools ( n = 724 children , 8.4 ± 0.7 years ) r and omized one to one to either an  intervention school ( IS , n = 427 ) or a  control school ( CS , n = 297 ) . Children in IS attended 10 health-related lessons at school over a period of 1 year . Parents and teachers attended two and three educational health-related lessons , respectively , and also received 10 newsletters on health issues . Daily physical activity ( ≥ 60 min/day ) , physical fitness ( six-item test battery ) , and anthropometric data were obtained at baseline and after 1 year . Physical activity and physical fitness increased in IS , but it failed to reach significant intervention effects . Nevertheless , a reduction in waist circumference was observed for all children [ mean change 1.7 cm ; 95 % confidence interval ( CI ) 1.2 - 2.3 ; P < 0.001 ) . This effect was more pronounced in overweight children ( > 90th percentile , n = 99 , mean change 3.2 cm ; 95 % CI 1.5 - 4.8 ; P < 0.001 ) . This easily administered preventative program involving children , parents , and teachers revealed that a generalized approach increasing physical activity will even be favorable in a subgroup of obese children OBJECTIVE We sought to evaluate factors that are associated with physical activity changes among adults within a 5-year period . METHODS From May 2001 to December 2002 we r and omly enrolled 1514 men and 1528 women without any evidence of cardiovascular or any other chronic disease . The sampling was stratified by the age-gender distribution of the greater area of Athens .  Weekly energy expenditure assessed by considering frequency , duration , and intensity of sports-related physical activity .  During 2006 , the 5-year follow-up was performed in 1955 participants , which included , among others , current physical activity status . RESULTS A total of 587 ( 61 % ) men and 673 ( 68 % ) women were classified as physically inactive at baseline , whereas 661 ( 69 % ) men and 728 ( 73 % ) women were classified as physically inactive at follow-up ; thus , a 13 % increase in physical inactivity rate was observed in men and a 7 % in women during the follow-up period ( p < 0.01 ) . Multivariate analysis revealed that male gender , being a nonsmoker , healthy eating , better self-reported quality -of-life , and lower prevalence of hypercholesterolemia and incidence of cardiovascular disease were the characteristics of people that remained physically active ; advanced age , anxiety and depression , overweight , and low quality -of-life were the baseline predictors of physical inactivity among initially active participants , which also had a greater incidence of cardiovascular disease . CONCLUSIONS Gender , aging , psychological disorders , body mass , smoking , dietary habits , perceived health status , and quality -of-life were the most important discriminating factors of physical activity changes & NA ; The aim of this longitudinal study was to assess changes with age regarding prevalence of pain and perceived health in a student population , as well as change over time at grade level . Pain included frequency of headache , abdominal , and musculoskeletal pain and perceived health included problems sleeping and /or if they often felt tired , lonely , and sad . If gender , age ( grade level ) , stress , physically activity were related to pain and health complaints were tested with multivariate logistic regression analysis . The students ( n = 1908 ) came from r and omly selected schools throughout Sweden and attended grade s 3 , 6 and 9 ( ages 9 , 12 and 15 at the onset of the year ) in 2001 . Three years later , 67 % ( n = 1276 ) of the same students answered a question naire that was constructed for the purpose of the studies . The responses given by the same students showed that girls ’ complaints of pain and perceived health increased with age and boys decreased . Over half ( 56 % ) of the girls and two‐thirds ( 67 % ) of the boys reported no frequent complaints either year . At grade level most variables were rated the same as three years earlier by the same age group . Stress was significantly related to pain and health complaints for girls and the risk of complaints , as calculated with odds ratio , was most evident for students who were characterized as being physically inactive in 2001 and remained inactive three years later . Jointly , significant predictors , such as stress , being physically inactive , gender and grade level , explained 8–20 % of the frequent complaints BACKGROUND Findings from the Look AHEAD trial showed no significant reductions in the primary outcome of cardiovascular disease incidence in adults with type 2 diabetes r and omly assigned to an intensive lifestyle intervention for weight loss compared with those r and omly assigned to diabetes support and education ( control ) . We examined whether the incidence of cardiovascular disease in Look AHEAD varied by changes in weight or fitness . METHODS Look AHEAD was a r and omised clinical trial done at 16 clinical sites in the USA , recruiting patients from Aug 22 , 2001 , to April 30 , 2004 . In the trial , 5145 overweight or obese adults aged 45 - 76 years with type 2 diabetes were assigned ( 1:1 ) to an intensive lifestyle intervention or diabetes support and education . In this observational , post-hoc analysis , we examined the association of magnitude of weight loss and fitness change over the first year with incidence of cardiovascular disease . The primary outcome of the trial and of this analysis was a composite of death from cardiovascular causes , non-fatal acute myocardial infa rct ion , non-fatal stroke , or admission to hospital for angina . The secondary outcome included the same indices plus coronary artery bypass grafting , carotid endartectomy , percutaneous coronary intervention , hospitalisation for congestive heart failure , peripheral vascular disease , or total mortality . We adjusted analyses for baseline differences in weight or fitness , demographic characteristics , and risk factors for cardiovascular disease . The Look AHEAD trial is registered with Clinical Trials.gov , number NCT00017953 . FINDINGS For the analyses related to weight change , we excluded 311 ineligible participants , leaving a population of 4834 ; for the analyses related to fitness change , we excluded 739 participants , leaving a population of 4406 . In analyses of the full cohort ( ie , combining both study groups ) , over a median 10·2 years of follow-up ( IQR 9·5 - 10·7 ) , individuals who lost at least 10 % of their bodyweight in the first year of the study had a 21 % lower risk of the primary outcome ( adjusted hazard ratio [ HR ] 0·79 , 95 % CI 0·64 - 0·98 ; p=0·034 ) and a 24 % reduced risk of the secondary outcome ( adjusted HR 0·76 , 95 % CI 0·63 - 0·91 ; p=0·003 ) compared with individuals with stable weight or weight gain . Achieving an increase of at least 2 metabolic equivalents in fitness change was associated with a significant reduction in the secondary outcome ( adjusted HR 0·77 , 95 % CI 0·61 - 0·96 ; p=0·023 ) but not the primary outcome ( adjusted HR 0·78 , 0·60 - 1·03 ; p=0·079 ) . In analyses treating the control group as the reference group , participants in the intensive lifestyle intervention group who lost at least 10 % of their bodyweight had a 20 % lower risk of the primary outcome ( adjusted HR 0·80 , 95 % CI 0·65 - 0·99 ; p=0·039 ) , and a 21 % lower risk of the secondary outcome ( adjusted HR 0·79 , 95 % CI 0·66 - 0·95 ; p=0·011 ) ; however , change in fitness was not significantly associated with a change in the primary outcome . INTERPRETATION The results of this post-hoc analysis of Look AHEAD suggest an association between the magnitude of weight loss and incidence of cardiovascular disease in people with type 2 diabetes . These findings suggest a need to continue to refine approaches to identify individuals who are most likely to benefit from lifestyle interventions and to develop strategies to improve the magnitude of sustained weight loss with lifestyle interventions . FUNDING US National Institute of Diabetes and Digestive and Kidney Diseases PURPOSE Information about factors related to overweight development in early stages of life is needed for design ing useful strategies to prevent overweight and related diseases . Longitudinal studies can contribute to this goal . The present study aim ed to identify factors in childhood that determine the development of overweight/obesity in adolescence . METHODS A prospect i ve study in 598 normal-weight Estonian and Swedish children age 9.5 ± 0.4 yr from the European Youth Heart Study , who were followed during 6 yr , was conducted . Weight and height were measured at baseline and follow-up , and weight status was ascertained according to the international criteria for body mass index . Cardiorespiratory fitness  ( expressed as  VO(2max ) ( mL·kg(-1)·min(-1 ) ) ) was assessed by a maximal bike test . Parents reported their weight , height , and educational level . RESULTS Being male ( vs female ) and Estonian ( vs Swedish ) was related to higher risk for incident overweight/obesity . Change in fitness was a stronger predictor of incident overweight/obesity than childhood fitness , parental overweight , or parental education . The risk of developing overweight/obesity was reduced 10 % every 1 mL·kg(-1)·min(-1 ) of VO(2max ) increase ( odds ratio = 0.90 and 95 % confidence interval = 0.84 - 0.95 ) after adjustment for a set of confounders including baseline body mass index and without differences by gender . CONCLUSIONS Our results suggest that improvements in fitness from childhood to adolescence are associated with a lower risk of becoming overweight/obese in adolescence . The current findings highlight the importance of promoting fitness through physical exercise from early stages in life , as a promising strategy to fight against overweight and obesity . Gender and country differences observed in this study require social and political attention Predictors of colorectal cancer have been extensively studied with some evidence suggesting that risk factors vary by subsite . Using data from 2 prospect i ve cohort studies , we examined established risk factors to determine whether they were differentially associated with colon and rectal cancer . Our study population included 87,733 women from the Nurses ' Health Study ( NHS ) and 46,632 men from the Health Professionals Follow Up Study ( HPFS ) .  Exposure information was collected via biennial question naires ( dietary variables were collected every 4 years ) . During the follow-up period ( NHS : 1980 to May 31 , 2000 ; HPFS : 1986 to January 31 , 2000 ) , we identified 1,139 cases of colon cancer and 339 cases of rectal cancer . We used pooled logistic regression to estimate multivariate relative risks for the 2 outcomes separately and then used polytomous logistic regression to compare these estimates . In the combined cohort , age , gender , family history of colon or rectal cancer , height , body mass index , physical activity , folate , intake of beef , pork or lamb as a main dish , intake of processed meat and alcohol were significantly associated with colon cancer risk . However , only age and sex were associated with rectal cancer . In a stepwise polytomous logistic regression procedure , family history and physical activity were associated with statistically significant different relative risks of colon and rectal cancer . Our findings support previous suggestions that family history and physical activity are not strong contributors to the etiology of rectal cancer . Future investigations of colon or rectal cancer should take into consideration risk factor differences by subsite Background : Childhood obesity has been becoming a worldwide public health problem . We conducted a community-based physical activity ( PA ) intervention program aim ing at childhood obesity prevention in general student population in Nanjing of China , the host city of the 2nd World Summer Youth Olympic Games ( YOG-Obesity study ) . Methods : This was a cluster r and omized controlled intervention study . Participants were the 4th ( mean age±s.e . : 9.0±0.01 ) and 7th ( mean age±s.e . : 12.0±0.01 ) grade students ( mean age±s.e . : 10.5±0.02 ) from 48 schools and r and omly allocated ( 1:1 ) to intervention or control groups at school level . Routine health education was provided to all schools , whereas the intervention schools additionally received an 1-year tailored multi-component PA intervention program , including classroom curricula , school environment support , family involvement and fun programs/events . The primary outcome measures were changes in body mass index , obesity occurrence and PA . Results : Overall , 9858 ( 97.7 % ) of the 10091 enrolled students completed the follow-up survey . Compared with the baseline , PA level increased by 33.13 min per week ( s.e . 10.86 ) in the intervention group but decreased by 1.76 min per week ( s.e . 11.53 ) in the control group ( P=0.028 ) . After adjustment for potential confounders , compared with the control group , the intervention group were more likely to have increased time of PA ( adj . Odds ratio=1.15 , 95 % confidence interval=1.06–1.25 ) , but had a smaller increase in mean body mass index ( BMI ) ( 0.22 ( s.e . 0.02 ) vs 0.46 ( 0.02 ) , P=0.01 ) and BMI z-score ( 0.07 ( 0.01 ) vs 0.16 ( 0.01 ) , P=0.01 ) , and were less likely to be obese ( adj . Odds ratio=0.7 , 95 % confidence interval=0.6 , 0.9 ) at study end . The intervention group had fewer new events of obesity/overweight but a larger proportion of formerly overweight/obese students having normal weight by study end . Conclusions : This large community-based PA intervention was feasible and effective in promoting PA and preventing obesity among the general student population in a large city in China . Experiences from this study are the lessons for China to control the childhood obesity epidemic We set out to examine the long-term effect of work-related and leisure time physical activity on risk of death from  coronary heart disease ( CHD ) and other causes . Data were obtained from a large prospect i ve population study of 7142 participant men aged 47 to 55 years at baseline in 1970 - 1973 and without symptomatic CHD . Data on physical activity at work and at leisure were assessed by way of a question naire . After 20 years follow-up men with physically dem and ing work had a slightly higher mortality from all causes , but not from CHD . The association with all-cause mortality disappeared after controlling for smoking , occupational class , and alcohol abuse . Men who were physically active during leisure time had a lower risk of death from CHD , cancer , and all causes . After controlling for smoking , diastolic blood pressure , serum cholesterol , body mass index , diabetes alcohol abuse , and low occupational class , the most active men had a relative risk ( RR ) of dying from CHD of 0.72 ( 0.56 - 0.92 95 % CI ) and of all causes of 0.70 ( 0.61 - 0.80 95 % CI ) . The adjusted relative risk for cancer death was of borderline significance . Noncardiovascular deaths other than cancer showed a strong relationship with low physical activity in the present study that remained after controlling for smoking , alcohol abuse , and other factors ( adjusted RR 0.55 ( 0.42 - 0.73 95 % CI ) ) . The protective effect of CHD and on mortality was present after excluding the first 8 years of follow-up , and at all levels of other risk factors , such as smoking , diastolic blood pressure , serum cholesterol , and body mass index . In conclusion , this long-term study demonstrates the protective effect of  leisure time physical activity on CHD death , cancer death , and on death from all causes . The effect on coronary death and on death from all causes was independent of other risk factors OBJECTIVE To assess the patterns and determinants of physical activity  among Saudi adult males living in Riyadh . METHODS Self-administered question naires were filled out by 1333 r and omly selected Saudi males 19 years and older , during the Fall of 1996 . RESULTS Over 53 % of Saudi males were totally physically inactive , and another 27.5 % were irregularly active . Only 19 % of the entire sample were active on a regular basis . A curvilinear relationship was found between age and inactivity , with the middle age group the least active .  Physical activity  was lower among those who were married , work in the private sectors , working 2 shifts , less educated , or who had only one day off during the week . Time constraint seems to be the major contributing factor to inactivity , while maintaining health and losing weight were the most important reason for being physically active among Saudi males . CONCLUSION The proportion of Saudi males who are at risk for inactivity is very high . Indeed , it is exceedingly higher than those who are at risk for hypertension , hypercholesterolemia , obesity , or cigarette smoking . Public policies are needed to encourage active living and discourage sedentary habits . Health care providers have an important role in promoting physical activity among the population BACKGROUND Several disorders have been attributed to  measles-mumps-rubella ( MMR ) vaccination  during the past decade . The aim of this prospect i ve follow-up study was to identify serious adverse events causally related to MMR vaccination . METHODS When the MMR vaccination program was launched in Finl and in 1982 , a countrywide surveillance system was set up to detect serious adverse events associated with MMR . To obtain detailed case histories vaccinees ' clinical charts were review ed . Serum sample s were analyzed to trace concurrent infections . SETTING All hospitals and health centers in Finl and from 1982 through 1996 . RESULTS Immunization of 1.8 million individuals and consumption of almost 3 million vaccine doses by the end of 1996 gave rise to 173 potentially serious reactions cl aim ed to have been caused by MMR vaccination . In all , 77 neurologic , 73 allergic and 22 miscellaneous reactions and 1 death  were reported , febrile seizure being the most common event . However , 45 % of these events proved to be probably caused or contributed by some other factor , giving an incidence of serious adverse events with possible or indeterminate causal relation with MMR vaccination of 5.3 per 100,000 vaccinees or 3.2 per 100,000 vaccine doses . CONCLUSIONS Causality between immunization and a subsequent untoward event can not be estimated solely on the basis of a temporal relation . Comprehensive analysis of the reported adverse reactions established that serious events causally related to MMR vaccine are rare and greatly outweighed by the risks of natural MMR diseases Background Colorectal cancer ( CRC ) is the third most commonly diagnosed cancer and the second highest cause of cancer death in the UK . Most cases occur in people over 50 years and CRC often co-exists with other lifestyle related disorders including obesity , type 2 diabetes mellitus ( T2DM ) and cardiovascular disease ( CVD ) . These diseases share risk factors related to the metabolic syndrome including large body size , abnormal lipids and markers of insulin resistance indicating common aetiological pathways . Methods / Design This 3 year study will be a two-arm , multicentre , r and omised controlled trial comparing the BeWEL lifestyle ( diet , physical activity and behaviour change ) programme against usual care . The pre-trial development will take 6 months and participants will be recruited over a 12 month period and undertake the intervention and follow up for 12 months ( total 24 months recruitment and intervention implementation ) with a further 6 months for data collection , analysis and interpretation . Four hundred and fifty two participants who have had a colorectal adenoma detected and removed ( through the national colorectal screening programme ) will provide 80 % power to detect a weight loss of 7 % over 12 months . Primary outcomes are changes in body weight and waist circumference . Secondary outcomes will include cardiovascular risk factors , psycho-social measures and intervention costs . Discussion The results from this study will enhance the evidence base for lifestyle change in patients at higher risk of chronic disease including obesity related cancers . International St and ard R and omised Controlled Trials No : IS RCT BACKGROUND An inverse association between moderate alcohol consumption and  coronary heart disease ( CHD ) has been observed in several epidemiological studies . To assess whether a similar association exists among diabetics , we examined the relation between light to moderate alcohol consumption and CHD in men with and without diabetes mellitus in a prospect i ve cohort study . METHODS AND RESULTS A total of 87 938 US physicians ( 2790 with diagnosed diabetes mellitus ) who were invited to participate in the Physicians ' Health Study and were free of myocardial infa rct ion , stroke , cancer , or liver disease at baseline were followed for an average of 5.5 years for death with CHD as the underlying cause . During 480 876 person-years of follow-up , 850 deaths caused by CHD were documented : 717 deaths among nondiabetic men and 133 deaths among diabetic men . Among men without diabetes at baseline , the relative risk estimates for those reporting rarely/never , monthly , weekly , and daily alcohol consumption were 1.00 ( referent ) , 1.02 , 0 . 82 , and 0.61 ( 95 % CI 0.49 to 0.78 ; P for trend < 0.0001 ) after adjustment for age , aspirin use , smoking , physical activity , body mass index , and history of angina , hypertension , and high cholesterol . Among men with diabetes at baseline , the relative risk estimates were 1.00 ( referent ) , 1.11 , 0.67 , and 0.42 ( 95 % CI 0.23 to 0.77 ; P for trend=0.0019 ) . CONCLUSIONS These results suggest that light to moderate alcohol consumption is associated with similar risk reductions in CHD among diabetic and nondiabetic men Background Childhood obesity is an increasing health problem globally . Overweight and obesity may be established as early as 2–5 years of age , highlighting the need for evidence -based effective prevention and treatment programs early in life . In adults , mobile phone based interventions for weight management ( mHealth ) have demonstrated positive effects on body mass , however , their use in child population s has yet to be examined . The aim of this paper is to report the study design and methodology of the MINSTOP ( Mobile-based Intervention Intended to Stop Obesity in Preschoolers ) trial . Methods / Design A two-arm , parallel design r and omized controlled trial in 300 healthy Swedish 4-year-olds is conducted . After baseline measures , parents are allocated to either an intervention- or control group . The 6- month mHealth intervention consists of a web-based application ( the MINSTOP app ) to help  parents promote healthy eating and physical activity in children .  MINISTOP is based on the Social Cognitive Theory and involves the delivery of a comprehensive , personalized program of information and text messages based on existing guidelines for a healthy diet and active lifestyle in pre-school children . Parents also register physical activity and intakes of c and y , soft drinks , vegetables as well as fruits of their child and receive feedback through the application . Primary outcomes include body fatness and energy intake , while secondary outcomes are time spent in sedentary , moderate , and vigorous physical activity , physical fitness and intakes of fruits and vegetables , snacks , soft drinks and c and y. Food and energy intake ( Tool for Energy balance in Children , TECH ) , body fatness ( pediatric option for BodPod ) , physical activity ( Actigraph wGT3x-BT ) and physical fitness ( the PREFIT battery of five fitness tests ) are measured at baseline , after the intervention ( six months after baseline ) and at follow-up ( 12 months after baseline ) . Discussion This novel study will evaluate the effectiveness of a mHealth program for mitigating gain in body fatness among 4-year-old children . If the intervention proves effective it has great potential to be implemented in child-health care to counteract childhood overweight and obesity . Trial registration Clinical Trials.gov NCT02021786 ; 20 Dec 2013 In several studies , many nutrients in fruits and vegetables , such as dietary fiber , potassium , and antioxidants , have been associated with reduced risk for cardiovascular disease ( 1 - 5 ) . However , as review ed elsewhere ( 6 ) , most prospect i ve studies that have specifically examined intake of fruits and vegetables in relation to risk for cardiovascular disease have been small , and their results have been inconsistent . Dietary assessment s were often crude and available only at baseline , and few studies have examined the effects of specific types of vegetables or fruits . In a recent report ( 7 ) , we evaluated the association between fruit and vegetable intake and risk for ischemic stroke . We found that persons in the highest quintile of fruit and vegetable intake had a relative risk of 0.69 ( 95 % CI , 0.52 to 0.92 ) compared with the lowest quintile of intake ; moreover , a 1-serving/d increase in fruit or vegetable intake was associated with a 6 % lower risk for ischemic stroke , after controlling for st and ard cardiovascular risk factors . In the current study , we sought to evaluate the association between intake of overall and specific fruits and vegetables and incidence of coronary heart disease . Methods Study Sample The sample s for this analysis consisted of participants in the Nurses ' Health Study ( 8) and Health Professionals ' Follow-Up Study ( 1 ) . The two studies have similar design s ; in both , participants complete mailed question naires about medical history , health behaviors , and occurrence of cardiovascular and other outcomes every 2 years . The Nurses ' Health Study began in 1976 , when 121 700 female registered nurses 30 to 55 years of age were recruited ; diet was first assessed in 1980 . Health Professionals ' Follow-up Study participants were recruited in 1986 and comprise 51 529 male health professionals , including dentists , veterinarians , pharmacists , optometrists , osteopaths , and podiatrists , 40 to 75 years of age . Sample for Analysis We excluded participants with incomplete dietary assessment s or with previously diagnosed cancer , diabetes or cardiovascular disease that was reported before the first dietary assessment . We followed 84 251 eligible women during 14 years of follow-up and 42 148 eligible men during 8 years follow-up for incidence of coronary heart disease . The rate of follow-up for nonfatal events was 97 % of the total potential person-years of follow-up in both cohorts . Assessment of Coronary Heart Disease End Points Our primary end point was nonfatal myocardial infa rct ion or fatal coronary disease occurring after return of the 1980 question naire but before 1 June 1994 in women and after return of the 1986 question naire but before 1 January 1994 in men . We sought to review medical records for all such reports . Records were review ed by physicians who were blinded to the participants ' risk factor status . Myocardial infa rct ion was confirmed by using World Health Organization criteria : symptoms plus either diagnostic electrocardiographic changes or elevated levels of cardiac enzymes ( 9 ) . Infa rct ions that required hospital admission and for which confirmatory information was obtained by interview or letter , but for which no medical records were available , were design ated as probable . We included all confirmed and probable cases in our analyses because results were the same after probable cases were excluded . Deaths were identified by using state vital records and the National Death Index or were reported by next of kin and the U.S. postal system . Follow-up for deaths was more than 98 % complete [ 10 ] . Death certificates along with medical records were used to ascertain cause of death . Fatal coronary disease was categorized as definite if 1 ) it was confirmed by hospital record or autopsy or 2 ) coronary disease was listed as the cause of death on the certificate , this was the underlying and most plausible cause , and evidence of previous coronary disease was available . We did not rely on the statement of the cause of death on the death certificate alone as providing sufficient confirmation of death due to coronary heart disease . If no medical records were available , we categorized persons in whom coronary heart disease was the underlying cause on the death certificate as presumed coronary heart disease . Analyses limited to confirmed cases yielded results very similar to those obtained when all cases were included , although with less precision . Persons who experienced sudden death within 1 hour of onset of symptoms and had no plausible cause other than coronary disease were categorized as coronary heart disease cases . Fatal cases of coronary heart disease constituted 30 % of all cases of coronary heart disease among women and 33 % among men . Dietary Assessment Diet was assessed in the Nurses ' Health Study in 1980 , 1984 , 1986 , and 1990 . A 61-item semi-quantitative food-frequency question naire that included 6 fruit items , 11 vegetable items , and 3 potato items was used in 1980 . In 1984 , the question naire was exp and ed to 126 items that covered 15 fruit items and 28 vegetable items plus potatoes ; similar question naires were repeated in 1986 and 1990 . In the Health Professionals ' Follow-up Study , diet was assessed in 1986 and 1990 by using food-frequency question naires very similar to those in the 1984 Nurses ' Health Study question naire . We excluded women who left 10 or more of the 61 items blank or who had implausible scores for total food intake ( < 500 or > 3500 kcal/d ) . Men who left 70 or more of the 131 dietary questions blank or who reported daily caloric intake outside the plausible range of 800 to 4200 calories were also excluded . For each food item , a st and ard serving size was specified . Natural portion sizesfor example , one banana or a small glass of tomato juicewere used whenever possible ; otherwise a weight or volume of that item commonly consumed by the U.S. population at one meal was used . On dietary question naires , participants reported their average intake of the specified portion size ( serving ) for each food over the past year . For each food item on the question naire , nine responses were possible , ranging from never or less than once per month to six or more times per day . Detailed descriptions of the reproducibility and validity of the food frequency question naire for men and women have been published elsewhere ( 11 - 13 ) . Frequencies and portions for the individual food items were converted to average daily intake of each fruit and vegetable item for each participant . The average daily intakes of individual food items were combined to compute total fruit and vegetable intake and intakes of composite fruit and vegetable groups . Definitions of the composite groups ( all fruits , all vegetables , citrus fruit , citrus fruit juice , cruciferous vegetables , green leafy vegetables , vitamin Crich fruits and vegetables , legumes , and potatoes ) were modified for our previous study ( 7 ) by using a report by Steinmetz and colleagues ( 14 ) . Vitamin Crich fruits and vegetables were defined as those containing more than 30 mg of vitamin C per serving . We did not include potatoes , tofu and soybeans , dried beans , and lentils as vegetables ; in addition , condiments such as chili sauce and garlic that had very small portion sizes were not counted in total vegetables . When aggregating items to compute the composite items , we assumed that individual foods for which values were missing implied no intake ( 15 ) . Statistical Analysis We found 1063 incident cases of coronary heart disease among men and 1127 among women .  Person-time for each participant was calculated from the date of return of the 1980 question naire in the Nurses ' Health Study or the 1986 question naire in the Health Professionals ' Follow-up Study to the first coronary heart disease event , death , or the cutoff date ( 1 June 1994 for women and 31 January 1994 for men ) , whichever occurred first . We excluded participants who reported cardiovascular disease or cancer or diabetes before completion of the baseline dietary question naires . Each participant contributed only one end point , and the cohort at risk for each 2-year follow-up period included only those who remained free of reported coronary heart disease at the beginning of each follow-up period . The study hypotheses were defined before data were collected . The analyses were performed separately in each cohort because of differences in sex and the question naires administered to the two cohorts . This approach was selected to achieve better control of confounding . We used pooled logistic regression with 2-year follow-up increments ( 16 ) to estimate relative risks ( incidence rate ratios ) and 95 % CIs within each cohort . Analyses were adjusted for age ( 5-year categories ) , smoking ( never , former , or current [ 1 to 14 cigarettes/d , 15 to 24 cigarettes/d , or 25 cigarettes/d ] ) , alcohol consumption ( five categories in women and seven categories in men ) , family history of myocardial infa rct ion ( before 65 years of age in women and before 60 years of age in men ) , body mass index ( quintiles ) ; use of multivitamin supplements , use of vitamin E , use of aspirin , physical activity ( two categories in women and quintiles in men ) , reported hypertension and hypercholesterolemia , total daily caloric intake ( 17 ) , and time period ( each 2-year follow-up period ) . Among women , we also controlled for postmenopausal hormone use . We up date d information on diet and risk factors for coronary heart disease over time to better represent long-term patterns ( 8 , 18 ) . In the Nurses ' Health Study , we used data from the 1980 , 1984 , 1986 , and 1990 question naires  , and in the Health Professionals ' Follow-up Study , we used data from the 1986 and 1990 question naires . For each 2-year follow-up period in which events were reported , we computed intake for each composite item as a cumulative average of intake from all available food-frequency question naires up to the start of the follow-up period . For participants who experienced angina , coronary artery bypass graft surgery or Objective We wanted to determine whether obesity , abdominal fat distribution , and physical inactivity act similarly and independently as risk factors for noninsulin- dependent diabetes mellitus ( NIDDM ) and impaired glucose tolerance ( IGT ) in Hindu and Muslim Asian Indians , African-origin Creoles , and Chinese Mauritians . Research Design and Methods We examined a population -based r and om cluster sample of 5080 adult subjects from the Indian Ocean isl and of Mauritius .  Glucose tolerance was assessed with a 75-g oral glucose tolerance test and World Health Organization criteria . Results Univariate data and multiple logistic regression models indicated that age , family history of diabetes , body mass index ( BMI ) , waisthip ratio ( WHR ) , and physical inactivity conveyed similar risk for NIDDM ( and IGT ) in each ethnic group . After adjusting for all other factors , Hindu ethnicity conferred additional risk for NIDDM ( but not IGT ) in men , but in women there were no clear ethnic differences . Although BMI and WHR were independently significant risk factors , WHR conveyed relatively stronger risk for NIDDM than BMI in women , whereas the converse was true in men . For ethnic groups combined , the independent odds ratios for IGT associated with moderate and low physical activity scores ( relative to high ) were 1.56 and 1.71 ( P < 0.05 ) , respectively , in men and 1.32 and 1.69 ( P < 0.05 ) in women . In subjects with asymptomatic NIDDM diagnosed during the survey , the independent odds ratios were 1.96 and 2.00 ( P < 0.05 ) in men and 1.73 and 2.70 ( P < 0.05 ) in women . Conclusions These data indicate that BMI , abdominally distributed fat , and physical inactivity are important independent risk factors for both IGT and NIDDM in diverse ethnic groups . Attributable risk fractions for Mauritius suggest that population wide modification of levels of these risk factors could potentially result in substantially lower occurrence of NIDDM ( and IGT ) . Such interventions should be attempted in high-risk population Context Seven- and 10-year results of the Canadian National Breast Screening Study ( CNBSS ) showed no reduction in breast cancer mortality from five annual mammographies and breast examinations for 40- to 49-year-old women . Some authors have argued that longer follow-up would reveal important benefits . Contribution After 11 to 16 years , the cumulative rate ratios for mammography versus usual care were 0.97 ( 95 % CI , 0.74 to 1.27 ) for breast cancer mortality without adjustment for non study mammography and 1.06 ( CI , 0.80 to 1.40 ) with adjustment . Clinical Implication s The CNBSS suggests that screening 40- to 49-year-old women is unlikely to reduce breast cancer by 20 % or more . Controversy will persist because other studies suggest that screening causes small reductions in breast cancer mortality . The Editors The Canadian National Breast Screening Study -1 ( CNBSS-1 ) , an individually r and omized trial in women 40 to 49 years of age at study entry , evaluated the efficacy of annual mammography , breast physical examination , and instruction on breast self-examination in reducing breast cancer mortality  ( 1 ) . The 7-year ( 2 ) and preliminary 10-year ( 3 ) mortality results were previously reported . At 7 years , 38 women in the mammography group and 28 women in the usual care group had died of breast cancer , for a rate ratio of 1.36 ( 95 % CI , 0.84 to 2.21 ) ( 2 ) . At 10 years , there were 82 breast cancer deaths in the mammography group and 72 in the usual care group ( rate ratio , 1.14 [ CI , 0.83 to 1.56 ] ) ( 3 ) . This article reports CNBSS-1 results after an average 13-year follow-up from study entry . Methods Patient Selection and Recruitment Participants were recruited through media publicity , personal invitation letters using population lists ( municipal registers and provincial health insurance registers ) , group mailings , and physicians ( 4 ) . Eligibility criteria were age 40 to 49 years , no previous diagnosis of breast cancer , not being pregnant , no mammography in the previous 12 months , and signed informed consent . The Human Experimentation Committee of the University of Toronto ( Toronto , Ontario , Canada ) and Human Experimentation Committees at 15 CNBSS collaborating centers approved the study . A total of 50 430 women age 40 to 49 years were enrolled from January 1980 through March 1985 . R and omization Before r and omization , all participants received an initial breast physical examination and instruction on breast self-examination . They were then immediately r and omly assigned to receive mammography and , thereafter , either annual screening with mammography and breast physical examination ( 25 214 women in the mammography group were available for analysis ) or usual care in the context of the Canadian health care system ( 25 216 women in the usual care group were available for analysis ) . Center coordinators r and omly assigned participants using prepared allocation lists , independent of breast physical examination findings . This sequence ensured that the conduct and interpretation of the breast physical examination would be unbiased by knowledge of whether mammography would follow . Intervention Screening Schedule In the mammography group , 62 % of women received five annual screenings . The remainder , recruited later , received four . Each screening examination comprised mammography , breast physical examination , and instruction and evaluation on breast self-examination . Women in the mammography group completed question naires at each rescreening visit . Women in the usual care group were not recalled for rescreening but were mailed annual question naires . We expected that these participants would continue their normal pattern of medical care as delivered through Canada 's universal health care coverage , including access to mammography for diagnosis . Study Procedures Two-view mammography was done on dedicated mammography units ( 5 ) , and second readers review ed mammograms deemed abnormal . Systematic audit procedures were used ( 6 ) . Nurses provided breast physical examination in 12 centers and physicians in 3 centers in Qubec ( 7 ) . These providers taught and evaluated breast self-examination while conducting their own examination ( 8) . If findings on breast physical examination or mammography were abnormal , participants were referred to a CNBSS review clinic . The study surgeon discussed mammography findings with the study radiologist , examined the participant , and decided whether further diagnostic procedures should be recommended to the woman 's physician . The woman 's physician determined whether and how to implement the study surgeon 's recommendations . Data Collection Protocol During the screening period , the center coordinators collected surgery and pathology reports for breast-related diagnostic and therapeutic procedures . The CNBSS pathologists review ed all slides . If the community and CNBSS pathologist disagreed , a panel of three to five CNBSS pathologists blindedly and independently review ed the slides . Extensive quality control procedures were used during data collection . After the screening centers closed in 1988 , the central CNBSS central office annually followed all women known to have breast cancer until 30 June 1996 , the cut-off for this analysis . Passive follow-up of all participants through linkage with the National Cancer Registry identified new diagnoses of breast cancer in study participants through 31 December 1993 . The central office collected pathology reports for postscreening cases of breast cancer . The community diagnosis was accepted for study purpose s. Family members responding to the annual mailed question naire identified deaths that occurred before completion of a participant 's screening schedule . Thereafter , women not known to have cancer were followed only through registry linkage ; their mammography experience was not traced . However , for women known to have breast cancer , attending physicians received annual requests for up date d clinical information , including death .  Attending physicians , who received annual requests for information on women with breast cancer , reported deaths until 30 June 1996 . Linkage with the Canadian Mortality Data base at Statistics Canada ( including deaths in Canadians who resided in the United States at the time of death ) identified causes of death in the entire cohort until 31 December 1993 . The procedures used to verify deaths from breast cancer were described previously ( 2 ) . Investigative procedures were initiated for women dying with breast cancer ; those whose death certificates mentioned breast cancer ; and those whose cause of death was described as unknown , unknown primary , lung cancer , colon cancer , or liver cancer . The review ers were blinded to study group allocation . All other causes of death were accepted as certified . For the most recent record linkage , more stringent confidentiality requirements exercised by many hospitals hindered verification . Thus , of the breast cancer deaths reported in this paper , a panel review ed 67 % in the mammography group and 77 % in the usual care group . The remaining deaths are as reported on death certificates . Study Outcomes Death due to or probably due to breast cancer was the major study outcome . A previous report of the CNBBS-1 noted axillary node status , as assessed by community pathologists , through 7 years of follow-up ( 2 ) . Subsequently ( 1993 to 1997 ) , to achieve consistent reporting of tumor size , all available material for screening-detected cancer and cancer detected between screenings was re-collected from originating institutions and review ed by one of the CNBSS pathologists or a colleague . Slides were obtained for review for nearly 80 % of requested cases . For the current analysis , pathologists measured the size of small tumors as observed on the slide or the size of the invasive component for mixed invasive and in situ tumors . Statistical Analysis Sample Size The CNBSS-1 was planned to evaluate whether breast cancer mortality would decrease by 40 % in the  mammography group compared with the usual care group after 5 years of follow-up , with a required sample size of 50 000 women ( = 0.05 ; power , 80 % ) ( 1 ) . At 5 years , however , too few women had died of breast cancer for the study to achieve the planned power . Thus , for the first report on breast cancer mortality , we extended follow-up to 7 years ( 2 ) . CNBSS Data base The data base includes records for 50 430 women , including demographic and risk factor variables and results of screening examinations , diagnostic and therapeutic procedures , pathology results , and causes of death . CNBSS Terminology The terms screen 1 , screen 2 , through screen 5 denote events associated with screening examinations in the mammography group . The initial breast physical examination received by the usual care group is called screen 1 . Screening-detected cancers are those diagnosed after a recommendation made by the study surgeon at the CNBSS review clinic . Interval cancers are cases of cancer that occurred less than 12 months after a screening examination at which no recommendation for diagnostic procedures was made . Incident cancers are cases of cancer that occurred more than 12 months after the previous CNBSS screening examination . Statistical Tests The statistical significance of differences in proportions was determined by using the chi-square test ( two-sided = 0.05 ) . For all observed-to-expected ratios , 95 % CIs were computed . Death rates were computed by using person-years based on stratification by quinquennium of age ; we assumed that all women not known to be dead are alive . Age was defined as age at entry . Because all eligible participants were included in the analysis and follow-up , this is an intention-to-treat analysis . Cox proportional-hazards regression was done to examine variables with the most significant independent influence on survival ( 9 ) , using the PHREG program in SAS software , version 6.12 ( SAS Institute , Inc. , Cary , North Carolina ) . Because the variable allocation to screening was our primary interest , it was There is limited evidence demonstrating the benefits of physical activity with regard to mortality risk or the harms associated with sedentary behavior in black adults , so we examined the relationships between these health behaviors and cause-specific mortality in a prospect i ve study that had a large proportion of black adults . Participants ( 40 - 79 years of age ) enrolled in the Southern Community Cohort Study between 2002 and 2009 ( n = 63,308 ) were prospect ively followed over 6.4 years , and 3,613 and 1,394 deaths occurred in blacks and whites , respectively . Black adults who reported the highest overall physical activity level ( ≥32.3 metabolic equivalent-hours/day vs. < 9.7 metabolic equivalent-hours/day ) had lower risks of death from all causes ( hazard ratio ( HR ) = 0.76 . 95 % confidence interval ( CI ) : 0.69 , 0.85 ) , cardiovascular disease ( HR = 0.81 , 95 % CI : 0.67 , 0.98 ) , and cancer ( HR = 0.76 , 95 % CI : 0.62 , 0.94 ) . In whites , a higher physical activity level was associated with a lower risk of death from all causes ( HR = 0.76 , 95 % CI : 0.64 , 0.90 ) and cardiovascular disease ( HR = 0.69 , 95 % CI : 0.49 , 0.99 ) but not cancer ( HR = 0.95 , 95 % CI : 0.67 , 1.34 ) . Spending more time being sedentary ( > 12 hours/day vs. < 5.76 hours/day ) was associated with a 20%-25 % increased risk of all-cause mortality in blacks and whites . Blacks who reported the most time spent being sedentary ( ≥10.5 hours/day ) and lowest level of physical activity ( < 12.6 metabolic equivalent-hours/day ) had a greater risk of death ( HR = 1.47 , 95 % CI : 1.25 , 1.71 ) . Our study provides evidence that suggests that health promotion efforts to increase physical activity level and decrease  sedentary time could help reduce mortality risk in black adults New analysis of a l and mark paper on the health and economic benefits of eliminating worm infections in children has found little evidence that it does any good . Deworming programmes have been heavily promoted by the World Bank , the World Health Organization , and international charities as a key to improving health , school performance , and , by inference , economic development in poor and middle income countries . India has recently launched the world ’s largest deworming programme , with the aim of treating 240 million children once or twice a year with albendazole , a drug that can eliminate worm infections.1 The policy relies on a limited evidence base , with a single r and omised trial carried out in 75 Kenyan schools regularly cited by its proponents . In this 2004 study Edward Miguel of the University of California at Berkeley and Michael Kramer of Harvard University found that the treated children had a lower prevalence of worm infestation , improved nutritional status , and higher school attendance.2 Importantly , they also found that these benefits extended to untreated children in the treated schools and to Background Modifiable behavioural risk factors — including exercise , obesity and smoking — have been causally associated with  colorectal cancer mortality . However , results have been inconsistent and undiagnosed cancers may affect baseline risk factors , distorting the temporal relationship that is observed between them . Objective To determine whether risk factors for colorectal cancers available in the Whitehall I study were predictive of colonic or rectal cancer mortality . Methods Prospect i ve cohort study over 40 years on Whitehall I men aged 40–69 on entry between 1967 and 1970 . Associations between baseline risk factors and cause-specific mortality were tested with Cox proportional hazards models . Events within the first 10 years of follow-up were excluded to minimise ‘ reverse causality . ’ Results 329 colon and 121 rectal cancer deaths occurred among 17 949 men followed up for a total of 472 523 person-years . Age and smoking were associated with increased mortality from colorectal cancers . Compared with never-smokers , current smoking was associated with age-adjusted HRs for colon and rectal cancers of 1.45 ( 95 % CI 1.03 to 2.03 ) and 1.97 ( 95 % CI 1.02 to 3.80 ) , respectively . A significant effect of current smoking on rectal cancer mortality was only apparent after events in the first 10 years of follow-up were excluded . No convincing evidence was found that body mass index , diabetes mellitus , blood pressure or physical activity were associated with colorectal cancer mortality . Conclusion Smoking significantly increases mortality from colorectal cancer  and its decreasing prevalence in the UK may partly explain falling mortality from the disease . Changes in health behaviours in response to early cancer symptoms may result in differential misclassification or ‘ reverse causality ’ unless early events are excluded . Although many individual cohort studies have not shown significant relationships between behavioural risk factors and colorectal cancer mortality , their contribution to meta-analyses remains important Background Despite documented health benefits for mother and baby , physical activity (PA)-level tends to decline in pregnancy . Overweight/obese and physically inactive women are two selected groups at increased risk of pregnancy complications . Thus , efficient strategies to maintain or increase PA-level in pregnancy and the postpartum period , especially among these women , are warranted . This secondary analysis examined the effect of a prenatal lifestyle-intervention on PA-level in late pregnancy and the first year postpartum , with sub analysis on initially physically active versus inactive and normal-weight versus overweight/obese women . Method The Norwegian Fit for Delivery ( NFFD ) r and omized controlled trial included healthy primiparous women with singleton pregnancies and body mass index ( BMI ) ≥19 kg/m2 assigned to an intervention group , n = 303 ( twice weekly group-exercises and dietary counseling ) or a control group , n = 303 ( st and ard prenatal care ) . The International Physical Activity Question naire short-form was used to assess PA-levels at inclusion ( mean gestational week ( GW ) 16 ) , GW 36 , and six and 12 months postpartum . Results At GW 36 , a positive intervention-effect with a significant between-group difference in total PA-level compared to time of inclusion was found for the total group ( 530 MET-min/week , p = 0.001 ) and the subgroups of normal-weight ( 533 MET-min/week , p = 0.003 ) and initially active women ( 717 MET-min/week , p<0.001 ) . Intervention-effect was dependent on exercise-adherence among overweight/obese and inactive women . Compared to time of inclusion , the intervention groups maintained total PA-level at GW 36 , while total PA-level decreased in the control groups . The PA-levels increased postpartum , but with no significant differences between the r and omization groups . Conclusion The NFFD prenatal combined lifestyle intervention had a significant effect on TPA-level in late pregnancy among women entering pregnancy normal-weight or physically active , thereby preventing the downward trend typically seen during pregnancy . Intervention-effect among overweight/obese and physically inactive women was , however , dependent on exercise-adherence . Long-term intervention-effect was not observed in the postpartum period PURPOSE To evaluate the impact of a unique school-based program of exercise , health education , and behavior modification on health knowledge , health behaviors , coronary risk factors , and cardiovascular fitness in minority adolescents . METHODS A total of 346 students from an inner-city public high school participated in health promotion intervention or regular physical education volleyball classes . Subjects were African-American ( 47 % ) , Asian-American ( 9 % ) , Hispanic ( 21 % ) , white ( 3 % ) , and other ( 19 % ) . The health promotion curriculum consisted of 11 weeks of daily circuit training exercise and health lecture- discussion s. RESULTS The groups were similar in age , height , weight , ethnicity , and socioeconomic status . Following intervention both boys ( P < .001 ) and girls ( P < .006 ) significantly improved health knowledge test scores . Significant benefits for girls included improved dietary habits ( P < .05 ) , reduced cholesterol ( P < .004 ) , and higher estimated V(O2)max ( P < .0001 ) . There were no other significant changes in boys . CONCLUSIONS The results suggest that a school-based health promotion program of exercise and health lecture- discussion is beneficial for multiethnic , inner-city adolescents , especially females Summary of the Recommendations The U.S. Preventive Services Task Force ( USPSTF ) concludes that the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes , impaired glucose tolerance , or impaired fasting glucose . This is a grade I recommendation . ( See Appendix Table 1 for a description of the USPSTF classification of recommendations . ) The USPSTF found good evidence that available screening tests can accurately detect type 2 diabetes during an early , asymptomatic phase . ( See Appendix Table 2 for a description of the USPSTF classification of levels of evidence . ) The USPSTF also found good evidence that intensive glycemic control in patients with clinical ly detected ( not screening detected ) diabetes can reduce the progression of microvascular disease . However , the benefits of tight glycemic control on microvascular clinical outcomes take years to become apparent . It has not been demonstrated that beginning diabetes control early as a result of screening provides an incremental benefit compared with initiating treatment after clinical diagnosis . Existing studies have not shown that tight glycemic control significantly reduces macrovascular complications , including myocardial infa rct ion and stroke . The USPSTF found poor evidence to assess possible harms of screening . As a result , the USPSTF could not determine the balance of benefits and harms of routine screening for type 2 diabetes . The USPSTF recommends screening for type 2 diabetes in adults with hypertension or hyperlipidemia . This is a grade B recommendation . The USPSTF found good evidence that , in adults who have hypertension and clinical ly detected diabetes , lowering blood pressure below conventional target blood pressure values reduces the incidence of cardiovascular events and cardiovascular mortality ; this evidence is considered fair when extrapolated to cases of diabetes detected by screening . Among patients with hyperlipidemia , there is good evidence that detecting diabetes substantially improves estimates of individual risk for coronary heart disease , which is an integral part of decisions about lipid-lowering therapy . Clinical Considerations In the absence of evidence of direct benefits of routine screening for type 2 diabetes , the decision to screen individual patients is a matter of clinical judgment . Patients at increased risk for cardiovascular disease may benefit most from screening for type 2 diabetes , since management of cardiovascular risk factors leads to reductions in major cardiovascular events . Clinicians should assist patients in making that choice . In addition , clinicians should be alert to symptoms suggestive of diabetes ( for example , polydipsia and polyuria ) and test anyone with these symptoms . Screening for diabetes in patients with hypertension or hyperlipidemia should be part of an integrated approach to reduce cardiovascular risk . Lower targets for blood pressure ( that is , diastolic blood pressure 80 mm Hg ) are beneficial for patients with diabetes and high blood pressure . The third report of the Adult Treatment Panel III of the National Cholesterol Education Program recommends lower targets for low-density lipoprotein cholesterol for patients with diabetes . Attention to other risk factors , such as physical inactivity , diet , and overweight , is also important , both to decrease risk for heart disease and to improve glucose control . Three tests have been used to screen for diabetes : fasting plasma glucose ( FPG ) , 2-hour postload plasma glucose , and hemoglobin A1c .  The American Diabetes Association ( ADA ) has recommended the FPG test for screening ( values 6.99 mmol/L [ 126 mg/dL ] indicate diabetes ) because it is easier and faster to perform , more convenient and acceptable to patients , and less expensive than other screening tests . The FPG test is more reproducible than the 2-hour plasma glucose test , has less intraindividual variation , and has similar predictive value for development of microvascular complications of diabetes . Compared with the FPG test , the 2-hour plasma glucose test may lead to more individuals being diagnosed as diabetic . Hemoglobin A1c is more closely related to FPG than to 2-hour plasma glucose , but at the usual cut-points it is less sensitive in detecting lower levels of hyperglycemia . The r and om  capillary blood glucose test has been shown to have reasonable sensitivity ( 75 % at a cut-point of 6.66 mmol/L [ 120 mg/dL ] ) in detecting persons who have an FPG level greater than or equal to 6.99 mmol/L ( 126 mg/dL ) or a 2-hour plasma glucose level greater than or equal to 11.1 mmol/L ( 200 mg/dL ) , if results are interpreted according to age and time since last meal ; however , the r and om blood glucose test is less well st and ardized for screening for diabetes . The ADA recommends confirmation of a diagnosis of diabetes with a repeated FPG test on a separate day , especially for patients with borderline FPG results and patients with normal FPG levels for whom suspicion of diabetes is high . The optimal screening interval is not known . The ADA , on the basis of expert opinion , recommends an interval of every 3 years but shorter intervals in high-risk persons . Regardless of whether the clinician and patient decide to screen for diabetes , patients should be encouraged to exercise , eat a healthy diet , and maintain a healthy weight , choices that may prevent or forestall the development of type 2 diabetes . More aggressive interventions to establish and maintain these behaviors should be considered for patients at increased risk for diabetes , such as those who are overweight , have a family history of diabetes , or have a racial or ethnic background associated with an increased risk ( for example , Native American persons ) .  Intensive programs of lifestyle modification ( diet , exercise , and behavior ) should also be considered for patients who have impaired fasting glucose or impaired glucose tolerance , since several large trials have demonstrated that these programs can significantly reduce the incidence of diabetes in these patients . Evidence and recommendations regarding counseling about diet , physical activity , and obesity are provided in the USPSTF evidence summaries Counseling to Promote a Healthy Diet , Counseling to Promote Physical Activity , and Screening and Treatment for Obesity in Adults , available on the Agency for Healthcare Research and Quality Web site at www.preventiveservices.ahrq.gov . The brief review of the evidence that is normally included in USPSTF recommendation statements is available in the complete recommendation and rationale statement on the USPSTF Web site ( www.preventiveservices.ahrq.gov ) . Recommendations of Others The ADA acknowledged that data from prospect i ve studies were insufficient to determine the benefits of diabetes screening and thus concluded that the decision to test for diabetes should be based on clinical judgment and patient preference ( 1 ) . On the basis of expert consensus , the ADA recommends clinicians consider screening for diabetes with the FPG test beginning at age 45 years and at a younger age for individuals with such risk factors as family history , overweight , and hypertension , among others . The American College of Obstetricians and Gynecologists endorses the ADA recommendations ( 2 ) . The American Heart Association recommends measuring fasting blood glucose in persons 20 years of age and older according to risk for diabetes , as part of overall risk assessment for cardiovascular disease ( 3 ) . The Canadian Task Force on Preventive Health Care is currently updating its recommendations on diabetes screening Context Can adults make sustained changes in unhealthy lifestyle behaviors ? Content In this multicenter trial , 810 adult volunteers with prehypertension or stage 1 hypertension were r and omly assigned to a multicomponent behavioral intervention group , a group combining the behavioral intervention plus the Dietary Approaches to Stop Hypertension ( DASH ) diet , or an advice only group . At 18 months , participants in both behavioral intervention groups had less hypertension , more weight loss , and better reduction in sodium and fat intake than those receiving advice only . The participants in the DASH diet group also increased their intake of fruits , vegetables , and fiber . Implication s Motivated adults can sustain several lifestyle changes over 18 months , which might reduce their risk for cardiovascular disease . The Editors The public health burden of chronic diseases related to suboptimal diet and physical inactivity is enormous . It has been estimated that these lifestyle factors contribute to approximately 20 % of deaths in the United States ( 1 ) . Incidence of atherosclerotic cardiovascular disease , overweight and obesity , elevated blood pressure and lipid levels , diabetes , osteoporosis , and cancer is increased by unhealthy lifestyles ( 2 - 8 ) . Multiple lifestyle factors , such as physical inactivity ; excessive intake of calories , sodium , saturated fat , and cholesterol ; and inadequate intake of fruits , vegetables , and low-fat dairy products , are etiologically related to the development of these diseases ( 4 , 5 , 8 - 10 ) . To reduce the burden of chronic disease , increased physical activity and changes in diet are needed , yet few intervention studies have attempted to achieve many lifestyle changes simultaneously . The PREMIER r and omized trial tested the effects of 2 multicomponent behavioral interventions on blood pressure ( 11 ) . Both interventions promoted increased physical activity , weight loss , and reduced sodium intake , each of which is recommended by the 2005 Dietary Guidelines Scientific Advisory Committee ( 12 ) . One intervention also added the Dietary Approaches to Stop Hypertension ( DASH ) diet ( 13 ) . This diet , which is high in fruits , vegetables , and low-fat dairy products and low in saturated fat , total fat , and cholesterol , meets each of the major nutrient recommendations that were established by the Institute of Medicine ( 14 - 18 ) . We report the effects of the PREMIER interventions on lifestyle changes and blood pressure status at 18 months . The main results of PREMIER , namely change in blood pressure at 6 months , were reported previously ( 11 ) . Methods The PREMIER study design and rationale ( 19 ) and intervention methods ( 11 ) have been described previously . The institutional review boards at each clinical center ; an external protocol review committee appointed by the National Heart , Lung , and Blood Institute ( NHLBI ) ; and the NHLBI review ed and approved the protocol ( available at www.kpchr.org/public/premier/intervention/default.asp ) . The NHLBI also appointed a data and safety monitoring board to monitor the trial . Each participant provided written informed consent . The trial was conducted from January 2000 through November 2002 . Study Participants Participants were generally healthy adults , age 25 years or older , who had prehypertension or stage 1 hypertension and met the Joint National Committee VI ( JNC VI ) criteria for a 6-month trial of nonpharmacologic therapy ( 2 ) . Targeted recruitment methods were used to ensure adequate representation of clinical ly important subgroups , in particular , African-American persons . Specific methods varied from site to site but included direct mailings , radio and newspaper advertisements , and networking within the local African-American communities . Eligibility criteria included not taking antihypertensive medication and having a systolic blood pressure of 120 to 159 mm Hg and a diastolic blood pressure of 80 to 95 mm Hg , based on the average of 3 screening visits . Persons with prehypertension ( systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg ) were included because of the excess risk for cardiovascular disease in those with blood pressure within this range ( 20 ) . Major exclusion criteria were a body mass index less than 18.5 kg/mg2 or greater than 45.0 kg/m2 , use of antihypertensive drugs or other drugs that affect blood pressure , JNC VI risk category C ( target organ damage or diabetes ) , use of prescription weight loss medications , previous cardiovascular event , congestive heart failure , angina , cancer , and consumption of more than 21 alcoholic drinks per week . Trial Conduct Eligible participants were r and omly assigned , with equal probability , to 1 of 3 groups : an advice only comparison group ( advice only ) ; an intervention group that targeted established , guideline -recommended lifestyle recommendations ( established ) ( 2 ) ; or an intervention group targeting the established recommendations and adding the DASH dietary pattern ( established plus DASH ) ( 13 ) . Computer-generated treatment assignments were stratified by clinic and hypertension status and were assigned in blocks of varying sizes to provide balance over time . The actual assignments were administered by using a password-protected , Web-based application developed by the coordinating center and accessible only by authorized individuals . All clinic measurement staff were blinded to treatment assignment , and all intervention staff were blinded to clinic measurements . Hypertension was defined by using the JNC VI criteria for hypertension treatment : an average systolic blood pressure of 140 mm Hg , a diastolic blood pressure greater than 90 mm Hg , or use of antihypertensive medication . Normal blood pressure was defined as systolic blood pressure less than 120 mm Hg , diastolic blood pressure less than 80 mm Hg , and no use of antihypertensive medication ( 21 ) ( Figure ) . Intervention was provided by master 's degreelevel counselors ( dietitians and health educators trained in behavioral methods ) . The counselors were central ly trained before the start of the study , attended annual 3-day training sessions , and participated in monthly conference calls . Figure . Flow diagram of enrollment , measurements , and visit completion . Advice Only  Group Participants in the advice group  received advice to follow the National High Blood Pressure Education Program lifestyle recommendations for blood pressure control ( 2 ) . Lifestyle recommendations included reducing weight ( if overweight ) , following a reduced-sodium diet , engaging in regular moderate-intensity physical activity , and eating a heart-healthy diet , including the DASH diet . This advice was provided in two 30-minute individual sessions , 1 immediately after r and om assignment and 1 after the 6-month data collection visit . A PREMIER counselor review ed the guidelines with the participant and provided printed educational material s and information about community re sources . This intervention did not include advice to keep a food or exercise diary . Behavioral Interventions in the Established and Established plus DASH Groups Participant goals for the established and established plus DASH groups included weight loss of at least 6.8 kg ( 15 lb ) for those with a body mass index of 25 kg/m2 or greater , at least 180 minutes per week of moderate-intensity physical activity , no more than 100 mmol per day of dietary sodium , and alcohol consumption of no more than 30 mL ( 1 oz ) per day ( 2 drinks ) for men and 15 mL ( 0.5 ) oz per day ( 1 drink ) for women . Participants assigned to the established plus DASH group ( but not those in the established group ) also received counseling on the DASH diet , with goals for increased consumption of fruits and vegetables ( 9 to 12 servings/d ) and low-fat dairy products ( 2 to 3 servings/d ) and reduced consumption of saturated fat ( 7 % of energy ) and total fat ( 25 % of energy ) . The intervention format , contact pattern , and behavior change strategies for the established and established plus DASH groups were identical . During the first 6 months , participants in both behavioral intervention groups attended 14 group sessions and 4 individual sessions ; during months 7 to 18 , they attended monthly group sessions supplemented with 3 individual counseling sessions . Throughout the trial , participants in the established and established plus DASH groups ( but not those in the advice group ) kept food diaries , monitored dietary calorie and sodium intakes , and recorded minutes of physical activity . Self-monitoring was used to provide individualized feedback , reinforcement , problem solving , and support . Social support for initial behavior changes and maintenance of change was provided during the group sessions . More detailed descriptions of the behavorial intervention methods are available ( 22 ) . Measurements Blood pressure was assessed twice at each measurement , and systolic and diastolic blood pressures were calculated by using the mean of all available measurements ( 4 sets before r and om assignment , 3 sets at 6 and 18 months , and 1 set at 3 and 12 months ) . For 4 participants who were started on antihypertensive drug therapy between the 12- and 18-month visits , we obtained an official set of blood pressure measurements before initiation of therapy and used these as our 18-month blood pressure values for analysis . A similar procedure was used to obtain the 6-month blood pressure value for the 1 participant who began taking antihypertensive drugs between the 3- and 6-month visits . Two 24-hour dietary recalls , 1 obtained on a weekday and the other obtained on a weekend , were collected at baseline and at 6 and 18 months by telephone interview ( 23 ) . Intakes of nutrients and food groups were calculated by using the Nutrition Data System for Research , version NDS-R 1998 ( University of Minnesota , Minneapolis , Minnesota ) . Urinary excretion of sodium ( reflecting salt intake ) and potassium ( reflecting fruit and vegetable intake ) was obtained from 24-hour urinary collection s at baseline Summary Background Although childhood overweight and obesity prevalence has increased substantially worldwide in the past three decades , scarce evidence exists for effective preventive strategies . We aim ed to establish whether a school-based intervention for children aged 9–10 years would prevent excessive weight gain after 24 months . Methods This pragmatic cluster r and omised controlled trial of the Healthy Lifestyles Programme ( HeLP ) , a school-based obesity prevention intervention , was done in 32 schools in southwest Engl and . All state-run primary and junior schools in Devon and Plymouth ( UK ) with enough pupils for at least one year-5 class were eligible . Schools were assigned ( 1:1 ) using a computer-generated sequence to either intervention or control , stratified by the number of year-5 classes ( one vs more than one ) and the proportion of children eligible for free school meals ( < 19 % [ the national average ] vs ≥19 % ) . HeLP was delivered to year-5 children ( ages 9–10 years ) over 1 year , and included dynamic and interactive activities such as physical activity workshops , education sessions delivered by teachers with short homework tasks , drama sessions , and setting goals to modify behaviour ( with parental support and one-to-one discussion s with HeLP coordinators ) . The primary outcome was change in body-mass index ( BMI ) st and ard deviation score ( SDS ) between baseline and 24 months , analysed in children with BMI data available for both timepoints . This study is registered with the International St and ard R and omised Controlled Trial register , number IS RCT N15811706 , and the trial status is complete . Findings Between March 21 , 2012 , and Sept 30 , 2013 , 32 eligible schools with 1324 children were recruited , of which 16 schools ( 676 children ) were r and omly assigned to the HeLP intervention  and 16 schools ( 648 children ) to control . All schools that began the trial completed the intervention , and 1244 children ( 628 in intervention group and 616 in control group )  had BMI data at both baseline and 24 months for the primary outcome analysis . Mean BMI SDS was 0·32 ( SD 1·16 ) at baseline and 0·35 ( 1·25 ) at 24 months in the intervention group , and 0·18 ( 1·14 ) at baseline and 0·22 ( 1·22 ) at 24 months in the control group . With adjustment for school-level clustering , baseline BMI scores , sex , cohort , and number of year-5 classes and socioeconomic status of each school , the mean difference in BMI SDS score ( intervention – control ) at 24 months was −0·02 ( 95 % CI −0·09 to 0·05 ) , p=0·57 . One parent reported an adverse event related to their child 's eating and activity behaviours , but agreed for the child to continue trial participation after discussion with the chief investigator . Interpretation Despite a theoretically informed and extensively piloted intervention that achieved high levels of engagement , follow-up , and fidelity of delivery , we found no effect of the intervention on preventing overweight or obesity . Although schools are an ideal setting in which to deliver population -based interventions , school-based interventions might not be sufficiently intense to affect both the school and the family environment , and hence the weight status of children . Future research should focus on more upstream determinants of obesity and use whole-systems approaches . Funding UK National Institute for Health Research , Public Health Research Programme Design Non-r and omised non-blinded school-based intervention study . Setting Two schools in the cities of Pune and Nasik , India . Participants The intervention group comprised children attending a Pune school from 7–10 years until 12–15 years of age . Two control groups comprised children of the same age attending a similar school in Nasik , and children in the Pune intervention school but aged 12–15 years at the start of the study . Intervention A 5-year multi-intervention programme , covering three domains : physical activity , diet and general health , and including increased extracurricular and intracurricular physical activity sessions ; daily yoga-based breathing exercises ; making physical activity a ‘ scoring ’ subject ; nutrition education ; healthier school meals ; removal of fast-food hawkers from the school environs ; and health and nutrition education for teachers , pupils and families . Main outcome measures Body mass index ( BMI ) , waist circumference , physical fitness according to simple tests of strength , flexibility and endurance ; diet ; and lifestyle indicators ( time watching TV , study ing and actively playing ) . Results After 5 years the intervention children were fitter than controls in running , long jump , sit-up and push-up tests ( p<0.05 for all ) . They reported spending less time sedentary ( watching TV and study ing ) , more time actively playing and eating fruit more often ( p<0.05 ) . The intervention did not reduce BMI or the prevalence of overweight/obesity , but waist circumference was lower than in the Pune controls ( p=0.004 ) . Conclusions It was possible to achieve multiple health-promoting changes in an academically competitive Indian school . These changes result ed in improved physical fitness , but had no impact on the children 's BMI or on the prevalence of overweight/obesity Background : Promoting physical activity is an important public health strategy for long-term reductions in incidence or severity of clinical disease . Benefits to health-related quality of life ( HRQL ) and subjective well-being may be as important and take less time to accrue . Purpose : We examined the HRQL benefits of a social-cognitive-theory-based intervention of the Activity Counseling Trial ( ACT ) , both directly in terms of changes in physical fitness and indirectly from increased self-efficacy associated with the intervention . Methods : In ACT , 395 female and 479 male inactive patients ages 35 to 75 years were r and omized to one of : physician advice , advice plus behavioral counseling during primary care visits , or advice plus behavioral counseling that also included telephone contact and behavioral classes .  Participants were assessed at baseline , 6 months , and 24 months . HRQL was assessed as perceived quality of life , perceived stress , depression , and general health . Satisfaction with function and appearance , self-efficacy , and social support were also assessed . Results : At 24 months women who received counseling or assistance had significant reductions in daily stress and improvements in satisfaction with body function compared to those receiving advice only . Men had reductions in daily stress across all treatment arms . These results mirrored V02max changes observed per group . Change in barriers self-efficacy was significantly associated with reductions in daily stress at 24 months . Conclusions : Patient benefit from ACT intervention was mediated by enhanced cardiorespiratory fitness and by barriers self-efficacy OBJECTIVE To determine the changes in percentage of body fat , cardiovascular fitness , and insulin levels during the 3-month summer break in overweight children enrolled in a school-based fitness program . STUDY DESIGN Overweight middle-school children were r and omized to a lifestyle-focused physical education class ( treatment ) or st and ard physical education class ( control ) for 1 school year ( 9 months ; previously reported ) . This analysis reports changes during the 3-month summer break in children who participated in the fitness intervention group and who remained at this school the following year and repeated a fitness class . At the beginning and end of the school year , children underwent evaluation of ( 1 ) fasting levels of insulin and glucose , ( 2 ) body composition by means of dual x-ray absorptiometry , and ( 3 ) maximum oxygen consumption as determined by treadmill use . SETTING Rural middle school and an academic children 's hospital . PARTICIPANTS Overweight middle-school children . INTERVENTION School-based fitness curriculum , followed by summer break , and an additional year of school-based fitness intervention . MAIN OUTCOME MEASURES Cardiovascular fitness test results ( maximum oxygen consumption ) , body composition , and fasting insulin levels . RESULTS Improvements seen during the 9-month school-year intervention in cardiovascular fitness , fasting insulin levels , and body composition were lost during the 3-month summer break . During this summer break , mean + /- SD fitness level decreased ( maximum oxygen consumption , -3.2 + /- 1.9 mL/kg per minute ; P = .007 ) , fasting insulin level increased ( + 44 + /- 69 pmol/L [ + 6.1 + /- 9.7 mIU/mL ] ; P = .056 ) , and percentage of body fat increased ( + 1.3 % + /- 1.3 % ; P = .02 ) to levels that were similar to those seen before the school intervention . CONCLUSION In obese middle-school children , school-based fitness interventions are an important vehicle for health promotion , but without sustained intervention , these benefits may be lost during the extended summer break Objectives To explore the extent to which muscular strength in adolescence is associated with all cause and cause specific premature mortality ( < 55 years ) . Design Prospect i ve cohort study . Setting Sweden . Participants 1 142 599 Swedish male adolescents aged 16 - 19 years were followed over a period of 24 years . Main outcome measures Baseline examinations included  knee extension , h and grip , and elbow flexion strength tests  , as well as measures of  diastolic and systolic blood pressure and body mass index . Cox regression was used to estimate hazard ratios for mortality according to muscular strength categories ( tenths ) . Results During a median follow-up period of 24 years , 26 145 participants died . Suicide was a more frequent cause of death in young adulthood ( 22.3 % ) than was cardiovascular diseases ( 7.8 % ) or cancer ( 14.9 % ) . High muscular strength in adolescence , as assessed by knee extension and h and grip tests , was associated with a 20 - 35 % lower risk of premature mortality due to any cause or cardiovascular disease , independently of body mass index or blood pressure ; no association was observed with mortality due to cancer . Stronger adolescents had a 20 - 30 % lower risk of death from suicide and were 15 - 65 % less likely to have any psychiatric diagnosis ( such as schizophrenia and mood disorders ) . Adolescents in the lowest tenth of muscular strength showed by far the highest risk of mortality for different causes . All cause mortality rates ( per 100 000 person years ) ranged between 122.3 and 86.9 for the weakest and strongest adolescents ; corresponding figures were 9.5 and 5.6 for mortality due to cardiovascular diseases and 24.6 and 16.9 for mortality due to suicide . Conclusions Low muscular strength in adolescents is an emerging risk factor for major causes of death in young adulthood , such as suicide and cardiovascular diseases . The effect size observed for all cause mortality was equivalent to that for well established risk factors such as elevated body mass index or blood pressure Background The negative impact of overweight ( including obesity ) and related treatment on children 's and adolescents '  health-related quality of life ( HRQoL ) has been shown in few specific sample s thus far . We examined HRQoL and emotional well-being in overweight children from an outpatient treatment sample as well as changes of these parameters during treatment . Methods In a cross-sectional design , self-reported HRQoL of 125 overweight ( including obese ) children who contacted a treatment facility , but had not yet receive treatment , were compared to 172 children from r and omly selected schools using independent two- sample t-tests . Additionally , in a longitudinal design , the overweight children were retested by administering the same question naire at the end of the intervention ( after one year ) . It included measures such as the  body mass index ( BMI ) , the general health item ( GHI ) , the KINDLR , and the Child Dynamic Health Assessment Scale ( ChildDynHA ) . Comparisons were based on dependent t-tests and the Wilcoxon signed-rank test . Results Overweight children showed statistically significant impairment in the GHI ( Cohen 's d = 0.59 ) and emotional well-being ( ChildDynha ) ( d = 0.33 ) compared to the school children . With respect to HRQoL , the friends dimension of the KINDLR was significantly impaired in the overweight group ( d = 0.33 ) . However , no impairment was found for the total HRQoL score or other KINDLR subdimensions . Regarding the longitudinal part of our study , most of the children improved their BMI , but the majority ( 87.5 % ) remained overweight . Nevertheless , the participants ' perceived health , emotional well-being , and generic as well as disease-specific HRQoL improved during intervention . Conclusion The findings emphasize the importance of patient-reported outcomes such as HRQoL. Even though overweight and obesity might accompany most of the children throughout their lifetime , the impairment associated with this chronic condition can be considerably reduced . Opportunities of health promotion in overweight/obese children and adolescents are discussed Background : Breast Cancer ( BC ) is the leading cause of deaths in Indian women . Emerging reports reveal alarming evidence of increasing incidence and mortality of BC among young Indian women in addition to the late presentation and poor prognosis . Despite the significant incidence , there is a lack of reliable data re sources and comprehensive epidemiologic studies relating to BC . The objective of this protocol is to conduct a full-scale systematic review and meta-analyses on the incidence , prevalence , and mortality of BC in 29 states and seven union territories of India . Methods : Data sources used will be Cochrane Review , MEDLINE , PubMed , Scopus , Science Direct , Web of Science , and international and national cancer registries such as World Health Organization , International Agency for Research on Cancer ( IARC ) , and National Centre for Disease Information and Research (NCDIR)-National Cancer Registry Program initiated by Indian Council of Medical Research . Relevant data will be extracted using a predefined data collection form . A defined search strategy will be implemented along with selection criteria to obtain full-text articles of relevant studies . This study protocol was prepared according to the Preferred Reporting Items for Systematic Review s and Meta- Analysis for Protocol s 2015 guidelines . Odds ratios ( ORs ) will be used to measure effect size . The r and om or fixed-effects meta-analyses model will be employed to aggregate the pooled estimates ( ORs ) with 95 % confidence intervals ( CIs ) separately . A forest plot will be produced to assess ORs and 95 % CIs . Publication bias will be assessed using funnel plot , and Egger regression will be applied to test the symmetry of the funnel plot . Ethics and dissemination : This proposed study will be based on published studies and the data from cancer registries . Therefore , human research ethics approval is not required . The results of this study will be published in a peer- review ed journal . PROSPERO registration no : CRD42018084003 The prevalence of type 2 diabetes continues to increase in minority and underserved patients , who are also more likely to have poorer control of diabetes and related risk factors for complications . Although the Look AHEAD trial has demonstrated improved risk factor control among overweight or obese diabetes patients who received an intensive lifestyle intervention  , translating such findings into accessible programs is a major public health challenge . The purpose of this paper is to report the design and baseline characteristics of the Lifestyle Interventions for the Treatment of Diabetes study ( LIFT Diabetes ) . The overall goal is to test the impact of a community-based lifestyle weight loss ( LWL ) intervention adapted from Look AHEAD on cardiovascular disease risk at 12-months and 24-months among minority and lower income diabetes patients . Secondary outcomes include body weight , physical activity , medication use , cost , re source utilization , and safety . The primary hypothesis being tested is that the  LWL  will result in 10 % relative reduction in CVD risk compared to the DSM . We have r and omized 260 overweight or obese adults with diabetes one of two 12-month interventions : a LWL condition delivered by community health workers or a diabetes self-management ( DSM ) education condition . The baseline demographic characteristics indicate that our sample is predominantly female , obese , low income , and ethnic minority . Translating evidence -based , lifestyle strategies , and targeting minority and underserved patients , will yield , if successful , a model for addressing the burden of diabetes and may favorably impact health disparities BACKGROUND A growing body of evidence suggests that physical activity during pregnancy can reduce risk of pregnancy complications . However , factors influencing activity in pregnant Hispanic women , who have high rates of sedentary activity as compared to non-Hispanic whites , are not well characterized . PURPOSE To assess patterns and correlates of physical activity among 1355 participants in Proyecto Buena Salud , a prospect i ve cohort of pregnant Hispanic women in Massachusetts from 2006 to 2011 . METHODS Analyses were conducted in 2012 . Pre- , early- , mid- , and late-pregnancy physical activity were assessed using the Pregnancy Physical Activity Question naire . Women reported the frequency and duration of household/caregiving , occupational , sports/exercise , and transportation activities  and were classified according to compliance with American College of Obstetricians and Gynecologists guidelines for physical activity . RESULTS Household/caregiving activity was the primary mode of pregnancy activity ranging from 56 % to 60 % of total activity while sports/exercise contributed the least ( < 10 % ) . Compared to nulliparous women , women with two or more children were 85 % less likely to become inactive at any time during pregnancy ( OR=0.15 , 95 % CI=0.04 , 0.56 , p-trend < 0.01 ) . Women with one or more children increased their total physical activity on average 9.73±2.04 MET-hours/week and 12.04±2.39 MET-hours/week , respectively , with the onset of pregnancy ( p<0.01 ) . Those with the highest levels of total physical activity prior to pregnancy were 87 % less likely to become inactive with the onset of pregnancy than those who were inactive prior to pregnancy ( OR=0.13 , 95 % CI= 0.05 , 0.29 ) . CONCLUSIONS Findings can inform culturally appropriate interventions design ed to reduce pregnancy complications through the promotion of physical activity during pregnancy Folate is essential for regenerating methionine , the methyl donor for DNA methylation , and for producing the purines and pyrimidines required for DNA synthesis . Inadequate availability of folate may contribute to aberrations in DNA methylation and may lead to abnormalities in DNA synthesis or repair , either of which may influence colon carcinogenesis . Epidemiologic evidence , including that from two prospect i ve studies done in men [ 1 , 2 ] , suggests that inadequate intake of folate may increase risk for colon cancer [ 3 ] . Prospect i ve data on women are limited , but one casecontrol study found a lower risk for colon cancer among women who used supplements that contained folic acid [ 4 ] . Whether intake from dietary sources higher than that considered adequate to avoid deficiency confers additional benefits is unknown . In addition , the temporal relation between folate status and incidence of colon cancer is unclear . In this report , we examine the temporal and dosage relations between intake of folate  , both from supplements and from foods , and risk for colon cancer in women in the Nurses ' Health Study . We pay particular attention to the problem of possible confounding by multivitamin use . Methods Study Sample The Nurses ' Health Study began in 1976 when 121 700 U.S. female registered nurses 30 to 55 years of age completed a mailed question naire on risk factors for cancer and coronary heart disease [ 5 ] . Every 2 years , we up date information and ask women to report newly diagnosed cases of cancer . In 1980 , we used a semiquantitative food-frequency question naire to establish a dietary cohort . For this analysis , we excluded women with implausibly high or low scores for total energy intake ; those who left 10 or more items blank on the food-frequency question naire ; and those who reported previous cancer ( other than nonmelanoma skin cancer ) , ulcerative colitis , or a familial polyposis syndrome . We also excluded women who provided incomplete information on  aspirin  and  multivitamin  use in 1980 . After exclusions , 88 756 women formed the analytic cohort . Dietary Assessment The 1980 semiquantitative food-frequency question naire [ 6 , 7 ] included items on 61 foods and beverages plus vitamin and mineral supplements . Similar but exp and ed question naires were administered in 1984 , 1986 , and 1990 . Current multivitamin use was assessed in each biennial question naire from 1980 to 1992 . We also asked about the br and s and types of breakfast cereal and multivitamins typically used , and we asked women who were current multivitamin users in 1980 to state how many years they had been taking multivitamin supplements . For each food listed , a commonly used unit or portion size was specified . Each woman was asked how often over the past year , on average , she had consumed that amount of each food ; she could choose from nine possible responses . We computed nutrient intakes by multiplying the consumption frequency of each unit of every food by the nutrient content of the specified portions by using composition values from U.S. Department of Agriculture sources [ 8 ] supplemented with other data , including data on specific br and s and types of multivitamins and breakfast cereal . In addition to giving information on diet , participants provided information on age , weight , height , smoking history , physical activity , aspirin use , colonoscopy or sigmoidoscopy , and parental history of colorectal cancer . Identification of Cases of Colon Cancer When a woman ( or next of kin for decedents ) reported a diagnosis of colon or rectal cancer , we asked for permission to obtain hospital records and pathology reports . The responses to the follow-up question naires accounted for 96 % of potential person-years through the end of the follow-up period ( June 1994 ) . Most deaths were reported by family members or the postal system in response to the follow-up question naires or were identified through the National Death Index [ 9 ] . A study physician who was blinded to exposure information review ed medical records and extracted pertinent data . We confirmed a total of 655 new cases of colorectal adenocarcinoma ( excluding carcinoma in situ ) . Of these , 442 were in the colon ( 218 in the proximal colon [ cecum to splenic flexure ] and 224 in the distal colon ) , 143 were in the rectum , and 70 were at undetermined sites . Data Analysis We analyzed total , supplementary , and dietary intake of folate  in relation to risk for colon cancer . Because risk factors for rectal cancers may differ , we did not consider them in the major analyses but report results for them separately . We conducted additional analyses for total colon cancer , including cases of colorectal cancer for which subsite information was unavailable ( these cases may have included some cases of rectal cancer ) , colorectal cancer , proximal colon cancer , and distal colon cancer . We first examined total and dietary intake of folate  in 1980 in relation to risk for colon cancer in the period from 1980 to 1994 . Then , to examine the potential time lag between folate intake and risk for colon cancer , we computed the time elapsed since the start of use of multivitamin supplements containing folic acid and up date d this variable every 2 years on the basis of the br and and type of multivitamins used and the frequency of multivitamin use reported biennially from 1980 to 1992 . For example , if a woman began using multivitamin supplements in 1976 , she was considered a user of 4 years in 1980 and a user of 6 years in 1982 . Before 1973 , 100 g of folic acid was the maximum dose allowed in supplements according to U.S. Food and Drug Administration ( FDA ) regulations , and many supplement formulations at that time did not contain folic acid . Thus , we considered 1973 ( when doses of 400 g were first allowed [ 10 ] ) to be the earliest possible starting point . Although our analysis of duration of use did not require that users report multivitamin consumption on each question naire , multivitamin use tended to be consistent . For example , 70 % of women who had 15 or more years of use reported multivitamin use on most question naires , and 75 % of women using multivitamins  in 1980 also took multivitamins in 1992 . Our basic model included variables suspected to be related to risk for colon cancer , including cigarette smoking before age 30 years ; family history of colorectal cancer ; physical activity level ; body mass index ( kg/m2 ) ; aspirin use ; and intakes of red meat ( beef , pork , or lamb as a main dish ) , alcohol , and fiber . Intakes of folate ,  methionine  , and other nutrients were adjusted for total energy intake by using residual analysis [ 11 ] . We used all variables as assessed in 1980 with the exception of age , which was up date d biennially . In additional models , we considered intake of total and saturated fat ; intake of calcium ; intake of vitamins A , C , D , and E ; postmenopausal estrogen use ; and history of endoscopic screening . Women were followed from the month in 1980 in which they responded , and they accumulated person-time until the month of diagnosis , the month of death from other causes , or June 1994 . We used the Mantel-Haenszel summary estimator to adjust for age ( across 5-year categories ) . For multivariate analyses , we used pooled logistic regression , which accounts for varying time to the outcome event [ 12 ] and is asymptotically equivalent to a Cox regression model with time-dependent covariates , given short time intervals and a low probability of outcome [ 13 ] . A participant contributed up to seven observations based on seven 2-year periods from 1980 to 1994 ; if a woman received a diagnosis of colon cancer or died of any cause , the subsequent 2-year periods were censored . Each 2-year set of observations contributed by each participant was pooled in the logistic regression analysis . We tested for trends , controlling for multiple covariates by modeling the specific exposure as a continuous variable in a logistic model that included the covariates . All reported P values are two-sided . Results We examined , by level of folate intake in 1980 , the distribution of various factors possibly related to colon cancer ( Table 1 ) . The first three categories of folate intake reflected primarily dietary sources , whereas 86.3 % of women with intake exceeding 400 g/d used multivitamin supplements . The group with the second-highest intake , of which 9.1 % took supplements , had the highest frequency of aspirin use , the lowest average body mass index , the lowest frequency of cigarette use in young adulthood , and the highest intake of dietary fiber .  Alcohol use decreased with increasing folate intake . In multivariate models , we adjusted for these factors in addition to strong predictors of colon cancer ( physical activity , red meat , and methionine ) in this population . Table 1 . Age-St and ardized Characteristics according to  Folate Intake in 1980 in Participants in the Nurses ' Health Study * In 1986 , we assessed erythrocyte folate level in a sub sample of 188 women . When we used the 1980 question naire to categorize folate intake , the mean erythrocyte folate level was 302 ng/mL for folate intake of 200 g/d or less ( n = 37 ) , 348 ng/mL for intake of 201 to 300 g/d ( n = 67 ) ; 346 ng/mL for intake of 301 to 400 g/d ( n = 41 ) ; and 387 ng/mL for intake of more than 400 g/d ( n = 43 ) . The lowest erythrocyte levels in these four intake categories were 168 , 197 , 209 , and 217 ng/mL , respectively ; all were within the normal range ( normal range > 150 ng/mL ) . The first three categories primarily represented dietary sources of folate ; intake of more than 400 g usually reflected supplement use . Among multivitamin users , the daily supplementary dose of folic acid was 100 g or more for 97 % of users , 200 g or more for 87 % of users , and 400 g or more for 69 % of users . Higher total intake of folate  in 1980 was related to a lower risk for colon cancer ( Table 2 ) . The age-adjusted and multivariate analyses ( including age ; aspirin use ; physical activity ; body mass index ; pack-years of smoking before age 30 years ; family history of Context Physician education and community-based interventions to educate people with hypertension may improve hypertension care in re source -poor setting s. Contribution Among 1341 patients living in 12 communities in Pakistan that were r and omly assigned to general practitioner education , home health visits by trained lay workers , both , or neither , patients in communities assigned to both interventions had the greatest improvements in systolic blood pressure ( 10.8 mm Hg ) after 2 years . Improvements were similar in all other groups ( about 5 mm Hg ) . Caution Twenty-two percent of patients were lost to follow-up . Implication Home visits by trained lay workers plus physician education deserves further study as a way to improve hypertension control in re source -poor setting s. The Editors Cardiovascular disease has , in just a few decades , become the leading cause of death in adults worldwide , accounting for 1 in 5 deaths . Hypertension confers the highest attributable risk for death and disease associated with cardiovascular disease ( 1 , 2 ) . Despite the demonstrated benefits of effective drug treatment ( 3 , 4 ) and the existence of many clinical practice guidelines ( 5 ) , hypertension prevention , treatment , and control rates remain suboptimal worldwide ( 6 ) . The situation is particularly acute in developing countries , such as Pakistan , India , and China , where hypertension has reached epidemic proportionsaffecting more than 20 % of the adult population (7)yet control rates are less than 6 % ( 8) . Poor health literacy and unhealthy lifestyles , compounded by lack of awareness of hypertension ( 7 ) , are part of the cause . In addition , the health systems in these countries are often dysfunctional : More than 80 % of the expenditure for chronic disease care is out-of-pocket ; private care general practitioners ( GPs ) , who primarily treat acute conditions , are the front-line service providers ; and national programs for preventing and controlling hypertension are inadequate . Serious deficiencies in management of hypertension also have been identified in the knowledge and practice of health care providers . ( 9 ) However , evidence for public health interventions to improve hypertension control rates through patient or physician education in Indo-Asian countries is lacking . We conducted the COBRA-1 ( Control of Blood Pressure and Risk Attenuation-1 ) trial in Karachi , Pakistan , to test the effectiveness of 2 community-based strategies : family-based home health education ( HHE ) , delivered by trained community health workers , to improve population -level health literacy and behaviors , and hypertension management training for GPs . We tested the effect of these interventions , alone and in combination , on blood pressure in adults with hypertension . We hypothesized that HHE would be more effective than no education , that the specially trained GPs would provide more effective care than that usually received in Karachi , and that the combined interventions would provide additional benefit . Methods Study Design and Setting We performed a cluster r and omized , controlled trial with a 22 factorial design to determine the effect of  family-based HHE and special training for GPs  on blood pressure in adults 40 years or older with hypertension . We used a cluster approach because our objective was to assess the effectiveness of both HHE and GP training as health system interventions at a population level , and an individual approach would be prone to contamination of interventions and biased outcomes ( 10 ) . The Aga Khan University Ethics Review Committee granted ethical approval . The sampling frame is described elsewhere ( 11 ) . In brief , we used a multistage r and om sampling technique to select 12 of 4200 low- to middle-income , geographic census-based clusters ( mean household monthly income , $ 70 ; about 250 households in each cluster ) in Karachi , the most populous city in Pakistan ( about 16 million inhabitants ) . We ensured at least a 10-km distance between clusters to minimize the risk for contamination by the intervention . Participants Persons 40 years or older who resided in the 12 clusters and had known hypertension or consistently elevated blood pressure on 2 separate visits ( mean of 2 of past 3 measurements of systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg ) were eligible for inclusion . We excluded pregnant women , persons who could not give informed consent , and bed-bound persons . R and omization and Intervention We used computer-generated codes to r and omly assign 3 clusters each to the following groups : HHE alone , GP alone , HHE and GP combined , and no intervention . Home Health Education We trained 6 community health workers ( 1 for each cluster ) over 6 weeks in methods for using behavior-changing communication strategies to convey st and ardized health education messages to all households in clusters assigned to receive HHE . The education status of the workers we employed was consistent with the requirements of the government-sponsored Lady Health Workers Programme of Pakistan ( 8 or preferably 10 years of schooling ) ( 12 ) . Salary scales and assigned workload were similarly consistent . The health messages included information on the deleterious effects of hypertension and nonpharmacologic interventions for preventing and controlling hypertension and cardiovascular disease , as well as advice on the importance of engaging in moderate physical activity ; maintaining normal body weight ; reducing salt intake ; consuming a diet rich in fruit , vegetables , and low-fat dairy products ; reducing intake of saturated and total fat ( including suggestions on sample recipes for culturally acceptable and economically feasible food products ) ; and smoking cessation ( Appendix 1 ) . The importance of achieving blood pressure targets and adhering to medication and physician follow-up was emphasized . The first HHE session , lasting 90 minutes , was held at a time when all members of the household could be present . Follow-up reinforcement visits of 30 minutes were made every 3 months . Appendix 1 . Training Manual for Community Health Workers General Practitioner Education We invited all GPs in the 6 study areas assigned to this intervention to receive training , with the aim of training at least two thirds of the GPs in each area . We considered this proportion to be feasible both for future uptake of the strategy and for assessing the effectiveness of training . Training was a 1-day session that focused on st and ard treatment algorithms for the stepped-care management of hypertension , which were based on the seventh report of the Joint National Committee ( 3 ) and the Fourth Working Party of the British Hypertension Society guidelines ( 4 ) and modified for the Indo-Asian population ( Appendix 2 ) . The course included components on nonpharmacologic ( diet , exercise , weight loss , and smoking cessation ) and pharmacologic interventions , prescription of low-cost and appropriate generic drugs , preferential use of single-dose drug regimens , scheduled follow-up visits guided by blood pressure , the stepped-care approach for titrating drugs to achieve target blood pressure , and satisfactory consultation sessions for patients , with explanations of treatment and use of appropriate communication strategies . For managing persons with known hypertension , GPs were advised to review medication and blood pressure ; simplify regimens ; and aim to return to a regimen that was in line , as reasonably as possible , with that recommended for those with newly diagnosed hypertension . The recommended target blood pressure was < 140/90 mm Hg for all patients . Although this diverges from recent guidelines for special subgroups ( such as diabetic persons or those with end-organ damage ) , we reasoned that we needed to keep the intervention , guidelines , and targets simple for both patients and practitioners in a setting where blood pressure control rates are less than 3 % ( 7 ) . The training sessions for GPs used a case-based curriculum and were interactive . We provided a certificate of training at the end of the course . Appendix 2 . Training Manual for General Practitioner All study participants were advised to consult a local GP . If participants in the clusters r and omly assigned to a trained GP group did not already have a preferred GP , we gave them a list of trained GPs in their cluster from which to choose . However , it remained the participant 's choice whether they attended a physician on the list . We did not provide for medications or fee-for-health care services . Participants were blinded to intervention status ( training of GP ) . Neither the patients nor the GPs received reimbursement for participation . Screening and Recruitment All households in each cluster were visited , and we obtained informed consent for screening from all adults 40 years and older , whose blood pressure was then measured 3 times with a calibrated automated device ( Omron HEM-737 IntelliSense ; Omron Healthcare , Vernon Hills , Illinois ) in the sitting position after 5 minutes of rest . Those with known hypertension were invited to participate . Those with elevated blood pressure who were not receiving antihypertensive medication were visited again for remeasurement of blood pressure 1 to 4 weeks after the initial visit . If mean blood pressure remained elevated , these persons were also invited to participate . A routine physical examination was performed , and the following information was collected : smoking status , food frequency , and physical activity by question naire , the latter by using the international physical activity question naire ; blood pressure , measured as described above ; anthropometric characteristics ( height , weight , and waist and hip circumferences ) ; and fasting blood glucose level ( Synchron Cx-7/Delta , Beckman Coulter , Fullerton , California ) and lipid profile ( Hitachi-912 , Roche , Basel , Switzerl and ) ( 11 ) . Follow-up Procedures Trained outcomes assessors ( who were not part of and had no relationship with the community health worker team ) evaluated BACKGROUND Given the increasing prevalence of obesity among youth over the past decade , prevention has become an international public health priority . PURPOSE To evaluate the 2-year effectiveness of three strategies aim ed at preventing overweight and obesity among adolescents in a high school setting . DESIGN PRomotion de l'ALIMentation et de l'Activité Physique ( PRALIMAP ) is a school-based RCT . Each study high school was assigned to receive or not , over a 2-year period ( Grade s 10 and 11 ) , each of three prevention strategies according to a 2 × 2 × 2 factorial school r and omization . Data were collected in 2006 - 2009 and analyzed in 2009 - 2011 . SETTING / PARTICIPANTS A total of 3538 adolescents ( aged 15.6±0.7 years at baseline ) in 24 public high schools in Lorraine ( northeastern France ) completed the PRALIMAP trial . INTERVENTIONS The prevention strategies were education ( development of nutritional knowledge and skills ) ; environment ( creation of a favorable environment by improving availability of " healthy " dietary items and physical activity ) ; and screening and care ( detection of overweight/obesity and , if necessary , adapted care management ) . MAIN OUTCOMES MEASURES The main outcome of interest was BMI ; BMI z-score and prevalence of overweight/obesity were considered as secondary outcomes . RESULTS Adolescents who completed the PRALIMAP trial were younger , less often suspected of having eating  disorders and depression , and came from a higher socioeconomic class than those who did not . The 2-year change of outcomes was more favorable in the 12 screening and care high schools compared to the no-screening ones : a 0.11 lower increase in BMI ( p=0.0303 ) ; a 0.04 greater decrease in BMI z-score ( p=0.0173 ) ; and a 1.71 % greater decrease in overweight/obesity prevalence ( p=0.0386 ) . Education and environment strategies were not more effective than no strategy intervention . CONCLUSIONS Although the screening and care strategy is an effective way to prevent , at 2 years , overweight and obesity among adolescents in a high school setting , its effects over and above no strategy intervention were small . TRIAL REGISTRATION This study is registered at www . clinical trials.govNCT00814554 OBJECTIVES : The objective of this study was to evaluate a 12-session home/community-based health promotion/obesity prevention program ( Challenge ! ) on changes in BMI status , body composition , physical activity , and diet . METHODS : A total of 235 black adolescents ( aged 11–16 years ; 38 % overweight/obese ) were recruited from low-income urban communities . Baseline measures included weight , height , body composition , physical activity ( PA ) , and diet . PA was measured by 7-day play-equivalent physical activity ( ≥1800 activity counts per minute ) . Participants were r and omly assigned to health promotion/obesity prevention that is anchored in social cognitive theory and motivational interviewing and was delivered by college-aged black mentors or to control . Postintervention ( 11 months ) and delayed follow-up ( 24 months ) evaluations were conducted . Longitudinal analyses used multilevel models with r and om intercepts and generalized estimating equations , controlling for baseline age/gender . Stratified analyses examined baseline BMI category . RESULTS : Retention was 76 % over 2 years ; overweight/obese status declined 5 % among intervention adolescents and increased 11 % among control adolescents . Among overweight/obese youth , the intervention reduced total percentage of body fat and fat mass and increased fat-free mass at delayed follow-up and increased play-equivalent physical activity at postintervention but not at delayed follow-up . Intervention adolescents declined significantly more in snack/dessert consumption than control adolescents at both follow-up evaluations . CONCLUSIONS : At postintervention , there were intervention effects on diet and PA but not BMI category or body composition . At delayed follow-up , dietary changes were sustained and the intervention prevented an increase in BMI category . Body composition was improved for overweight/obese youth . Changes in body composition follow changes in diet and PA and may not be detected immediately after intervention BACKGROUND The aim of this cross-sectional study was to record the prevalence of underweight , overweight and obesity in primary school children living in Istanbul and to examine the relationship between increased body weight and certain cardiovascular disease ( CVD ) risk factors . METHODS A total of 510 r and omly selected children aged 12 and 13 years of age ( 257 boys , 253 girls ) were examined . Information regarding  anthropometrical indices , energy and macronutrient intake , physical activity , physical fitness and lipid profile were collected . Classification of children in overweight and obese subgroups was based on the cut-off points proposed by Cole et al. RESULTS The prevalence of underweight , overweight and obesity was found to be 15.3 % , 10.6 % and 1.6 % , respectively . Both overweight boys and girls were found to have lower physical fitness compared to their normal-weight counterparts , but no difference was observed for energy and macronutrient intake . Overweight boys were found to have higher total cholesterol ( P < 0.001 ) , low-density lipoprotein cholesterol ( P < 0.01 ) , triglycerides ( P < 0.01 ) and total cholesterol/high-density lipoprotein cholesterol ( HDL-C ) ratio ( P < 0.05 ) compared to their normal-weight counterparts , while overweight girls were found to have lower HDL-C ( P < 0.05 ) compared to their normal-weight peers . CONCLUSIONS Underweight and overweight coexisted in the current population . Increased body weight was accompanied by unfavorable lipid profiles and lower fitness levels . Consequently , there is an emergent need for early identification and underst and ing of behavioral and physiological variables related to obesity and CVD , so that appropriate interventions can be targeted to children who are at risk for adult onset of these diseases Extensive research supports the harmful effects of high dietary sodium.[1 - 11 ] In several animal species , including chimpanzees , diets with added sodium result in increased blood pressure ( BP ) , and , in all setting s , sodium-induced hypertension is harmful.[12 ] Further , in several animal models , increased dietary sodium directly causes inflammation and vascular , cardiac , and renal target organ damage independent of BP.[1 , 13 ] Increased dietary sodium is a procarcinogen for gastric cancer in animal studies and a probable procarcinogen in humans , as shown in epidemiological studies that have found close associations between sodium intake and gastric cancer.[14 , 15 ] Reducing dietary sodium  decreases BP  in adults and children,[1 ] with a linear relationship down to the lowest levels of sodium intake tested in r and omized controlled trials ( about 1200 mg/d of sodium ) . Increased dietary sodium is also associated with increased vascular events in healthy population s and was estimated to cause more than 3 million sodium-related deaths in 2010 ( http://viz.healthmetrics and evaluation.org/gbd-compare/ ) . Reducing dietary sodium  is projected to be one of the most effective ( and cost-effective ) interventions to improve health.[16 ] Major health and scientific organizations around the world have recommended that dietary sodium levels be reduced HEART FAILURE ( HF ) IS A MAJOR PUBLIC HEALTH PROBlem , with a prevalence of more than 5 million cases and an incidence of 660 000 new cases per year in the United States alone . Among patients older than 65 years , HF has become the most common discharge diagnosis and the primary cause of readmission within 60 days of discharge , result ing in estimated costs of $ 34.8 billion per year . Nearly half of all patients with HF have a preserved ejection fraction ( HFPEF ) . Patients with HFPEF have a high all-cause mortality after hospitalization for HF : 2.9 % , in-hospital mortality ; 9.5 % , 60to 90-day mortality ; 22 % to 29 % , 1-year mortality ; and 65 % , 5-year mortality . These data underscore the urgent need to find ways to improve outcomes for these patients . Unlike patients with HF and reduced ejection fraction , few large r and omized controlled trials have been specifically design ed for patients with HFPEF . These trials have shown minimal benefit , result ing in persons concluding that there is little evidence on which treatments to use for patients with HFPEF . Underlying the belief that there are few evidence -based therapies for patients with HFPEF is the implication that adverse outcomes in these patients are driven by worsening HF , which may not necessarily be accurate . Although recent large observational studies have shown high rates of morbidity and mortality in patients with HFPEF , these studies have not documented causes of rehospitalization or death . However , data from prior observational studies and clinical trials suggest that these outcomes are driven by important comorbidities that are common in patients with HFPEF . Patients diagnosed with HFPEF are typically elderly ( mean age , 74 - 76 years ) , more often women ( 62%-66 % ) , and frequently have multiple comorbidities , including hypertension ( 55%-77 % ) , coronary artery disease ( CAD ) ( 36%-53 % ) , atrial fibrillation ( 32%-41 % ) , diabetes mellitus  ( 32%-45 % ) ,  chronic kidney disease ( 23%-26 % ) , cerebrovascular disease ( 15 % ) , as well as obesity and anemia . In the Acute Decompensated Heart Failure National Registry ( ADHERE ) study , 91 % of patients with HFPEF had a diagnosis of hypertension , CAD , or diabetes . Secular trends demonstrate that the prevalence of comorbidities in patients with HFPEF is continuing to increase . CAD may be especially important in patients with HFPEF . Although CAD appears to be less common in patients with HFPEF than in patients with HF and reduced ejection fraction , the prevalence and severity of angiographically documented CAD in patients with HFPEF has not been well studied . In the Coronary Artery Surgery Study ( CASS ) , in which CAD was documented by coronary angiography , the presence and extent of CAD was a major determinant of prognosis in patients with HFPEF . Similarly , in the Duke Cardiovascular Data bank of patients with angiographically documented CAD , the presence of severe multivessel coronary disease has been associated with increased mortality in patients with HFPEF . Unlike recent large outcome studies of patients with HFPEF that have primarily examined all-cause rehospitalization and all-cause mortality , prior studies have ascertained the specific causes of adverse events , which help inform the cause of morbidity and mortality in patients with HFPEF . Two large r and omized clinical trials of patients with HFPEF and mortality data have been completed to date : the C and esartan in Heart Failure — Preserved ( CHARMPreserved ) and the Ancillary Digitalis Investigation Group ( Ancillary DIG ) trial , which showed that an angiotensinreceptor blocker and digoxin , respectively , did not improve survival . Although susceptible to selection bias , the CHARM-Preserved trial and Ancillary DIG trial provide important insight into the causes of morbidity and mortality in patients with HFPEF . In each trial , during Self-reported rates of participation in sport vary by country . In the UK , about 40 % of men and women aged 16 years or older participate in at least one sport every week . Although few data exist to assess trends for participation in sport , there is little evidence of change in the past decade among adults . Large cohort studies suggest that such participation in sport is associated with a 20 - 40 % reduction in all-cause mortality compared with non-participation . R and omised trials and crossover clinical studies suggest that playing sport is associated with specific health benefits . Some sports have relatively high injury risk although neuromuscular training programmes can prevent various lower extremity injuries . Clinicians can influence a large number of patients through brief interventions that promote physical activity , and encouragement toward participation in sport for some physically inactive patients qualifies as evidence -based therapy . Exercise might also be considered as a fifth vital sign and should be recorded in patients ' electronic medical records and routine histories INTRODUCTION Shift work ( an occupation requiring work between 2200 and 0500H ) comprises approximately 20 % of the workforce in Europe and North America [ 1 ] . This is likely to increase , with many shift workers ( SWs ) in emergency services , retail , hospitality , healthcare , transportation and manufacturing [ 2 ] . SWs are at increased risk for negative health outcomes , including cancer and other chronic diseases [ 3 , 4 ] . Biological changes from poor lifestyle habits related to shift work ( e.g. low physical activity ( PA ) , poor nutrition , obesity ) are thought to contribute to this risk ; these factors are also amenable to lifestyle intervention [ 5 ] . PA in particular , reduces cancer risk [ 6 ] , and has many positive physical and psychological benefits [ 7 ] . It is a simple , cost-effective strategy that may be implemented by individual workers or within workplaces to mitigate risk . Unfortunately , SWs are unlikely to engage in regular PA [ 8 ] . In Canada , only 15.9 % of SWsmeet the PA guidelines and have lower levels of aerobic fitness than those of day workers [ 9 ] . Few behavioural interventions improving health outcomes in SWs have been published [ 10 ] . In a targeted PA intervention , nurses r and omised to 4 months of supervised PA  improved aerobic fitness , muscular strength , fatigue and musculoskeletal symptoms . However , authors reported low adherence and large loss to follow-up , perhaps due to the supervised scheduled sessions [ 11 , 12 ] . Sustained behaviour change is a challenge and requires targeted efforts to encourage individuals to reach an adequate dose of PA to change health outcomes [ 13 ] . Due to irregular schedules and time constraints , SWs may be less likely to adhere to a traditional supervised PA intervention with face-to-face behavioural support [ 12 ] . Women SWs cite work schedule interference and lack of time as PA barriers and report scheduling flexibility as the most important in PA [ 14 ] . This highlights the need for a creative and innovative programming to promote PA in SWs . Distance-based interventions , in which individuals exercise independent of study staff or participants , may include telephone counselling and website or smart phone app-based technology . These interventions are highly flexible and may help overcome barriers related to timing and scheduling that are important for SWs . In a review of telephone-based PA interventions , 14 of 17 found evidence for behaviour change [ 15 ] . These may be a way to implement scalable , individuallytailored interventions in SWs . The primary objective of this study was to test the feasibility of a distance-based PA intervention in women SWs . Feasibility studies are important for establishing effective processes and underst and ing re sources required before attempting a r and omised controlled trial ( RCT ) , in order to put forward interventions that are most likely to be efficacious [ 16 ] . As this work was funded by a grant to examine the role of lifestyle in reducing breast cancer risk in SWs , only women were included . A secondary objective was to conduct a preliminary evaluation of intervention efficacy , to estimate effect size for future studies Context Many think we need more information about the safety of respiratory medications for chronic obstructive pulmonary disease ( COPD ) . Contribution This large casecontrol study examined associations between medications and risk for death in veterans with newly diagnosed COPD .  Inhaled corticosteroids were associated with decreased risk for death .  Theophylline and ipratropium were associated with increased risk for respiratory and cardiovascular death , respectively . Caution Potential confounders , such as smoking status and disease severity , were not known . Associations may not reflect causal relationships . Implication Additional research about the safety of ipratropium , one of the most commonly prescribed medications for COPD , is needed . The Editors Chronic obstructive pulmonary disease ( COPD ) is associated with substantial burden in terms of prevalence of disease ( 1 ) , death and disability risk ( 2 , 3 ) , and health care costs ( 4 ) . Despite recent interest in examining long-term outcomes associated with medications in patients with COPD ( 5 , 6 ) , some issues are not easily addressed by using r and omized clinical trials . From a pharmacovigilance perspective , relatively rare adverse eventssuch as death associated with medication usemay not be detected in the short term . The patients who receive a medication may not be similar to those participating in clinical trials ( 7 , 8) and may be more vulnerable to such events . Thus , evidence of longer-term benefits and harms associated with medicationsparticularly in patients with COPD , who tend to be elderly and have multiple comorbid conditions (9)can be informed by research that relies on observational data . Potential safety concerns with medications used to manage COPD may be substantial . A recent meta- analysis ( 10 ) showed a nearly 2.5-fold increase in respiratory deaths among patients receiving long-acting -agonists  compared with those receiving placebo . In the Lung Health Study ( 11 ) , the group r and omly assigned to ipratropium bromide had more than twice as many cardiovascular deaths as those receiving placebo . In addition , the U.S. Food and Drug Administration recently issued a notice regarding the potential for an increased risk for stroke associated with tiotropium use in patients with COPD ( 12 ) . The extent to which these safety concerns exist and can be generalized to patients with COPD outside the context of clinical trials is unclear . Therefore , we sought to examine the association between medication use and risk for death , including respiratory and cardiovascular deaths , in a large population of patients with recently diagnosed COPD . Methods We conducted this nested casecontrol study in patients with recently diagnosed COPD by using national Veterans Affairs inpatient , outpatient , pharmacy , and mortality data bases , supplemented with data from the Centers for Medicare & Medicaid Services . Our sample comprised U.S. veterans who used the U.S. Veterans Health Administration health care system . The Hines Veterans Affairs Hospital , Hines , Illinois , institutional review board approved our research . Cohort Patients were eligible for inclusion if they received a diagnosis of COPD ( International Classification of Diseases , 9th Revision [ ICD-9 ] , codes 491.x , 492.x , or 496 ) between 1 October 1999 and 30 September 2003 at 2 or more outpatient visits within 12 months or were admitted to the hospital with a primary diagnosis of COPD . Patients had to be 45 years of age or older when they received their first eligible diagnosis , have used Veterans Health Administration health care services for at least 1 year before their first COPD diagnosis , and have received respiratory medications . We excluded patients with a diagnosis of asthma . We followed patients from the date of their second eligible outpatient visit or their inpatient visit until death or 30 September 2004 . Case Patients We identified all deaths that occurred during follow-up by using the Veterans Affairs Vital Status data base , a combination of Veterans Affairs , Medicare , and Social Security Administration mortality data that captures approximately 98 % of veteran deaths ( 13 ) . Of these , 40 % was r and omly sample d and we attempted to determine cause of death . This sample was estimated to provide more than 80 % power to detect odds ratios of 0.85 or lower or 1.15 or higher for each medication class . We ascertained cause of death by using National Death Index Plus data from the National Center for Health Statistics . We defined 4 groups of case patients on the basis of cause of death : respiratory , cardiovascular , respiratory or cardiovascular , and all-cause mortality . We defined respiratory as death due to a respiratory system disease ( ICD-10 codes J00 to J99 ) and cardiovascular as death due to ischemic heart disease ( ICD-10 codes I20 to I25 ) , cardiomyopathy , cardiac arrest , or arrhythmias ( ICD-10 codes I42 to I51 ) . The index date for case patients was their death date . Control Participants Selecting more than 5 control participants per case patient can yield limited gains in efficiency ; however , because we were assessing several medications simultaneously , we selected up to 10 control participants per case patient ( 14 ) . We r and omly selected control participants for each case patient from eligible patients who were alive at the time of the case event ( 15 , 16 ) . We matched control participants to case patients individually on the basis of sex , age category ( 45 to 54 years , 55 to 64 years , 65 to 74 years , 75 to 84 years , and 85 years of age ) , region of the country , and year of diagnosis . We assigned control participants the same index date as their matched case patients . Exposure We defined exposure to respiratory medications as having received medications in the 180 days preceding each patient 's index date . We identified medication exposure to inhaled corticosteroids , ipratropium , long-acting -agonists , theophylline , and short-acting -agonists . We defined primary exposure as any exposure in the 180-day period before the index date . We created mutually exclusive medication regimens on the basis of medication exposure . Exposure to short-acting -agonists was not considered as part of the regimen but was included as a covariate in the analysis . Covariates We identified covariates by using data from the year before diagnosis date until the index date . We used pharmacy data to identify medication use , including exposure to systemic steroids , antihypertensives , lipid-lowering medications , antiarrhythmics , and diabetes medications . We used inpatient and outpatient diagnoses to identify comorbid conditions . We measured health care utilization as the annual number of hospitalizations and outpatient physician visits . We identified COPD exacerbations during follow-up and whether they were inpatient or outpatient by using a previously described algorithm ( 17 ) . Statistical Analysis We performed separate analyses for respiratory-specific , cardiovascular-specific , and all-cause mortality . We used conditional logistic regression to estimate adjusted odds ratios ( ORs ) and 95 % CIs . We included the variables that we considered clinical ly important in each of the regression models . Specifically , we included measures of COPD -related severity in all of the models and included markers of cardiovascular disease in the models for cardiovascular and all-cause mortality . We included any remaining variables that changed OR estimates for respiratory medications by more than 10 % in the final models ( 18 ) . We assessed model fit by using the Bayesian information criterion and the Wald test of likelihood ratios and through examination of outlier effects with leverage and fit diagnostics ( 19 ) . Adjusted odds ratios represented risk for events in patients receiving medication compared with those who had not received inhaled corticosteroids , ipratropium , long-acting -agonists , or theophylline in the previous 6 months . We performed all analyses with Stata/MP 10.0 for Windows ( StataCorp , College Station , Texas ) . We conducted several sensitivity analyses to evaluate the robustness of our results . First , we restricted the comparison group to patients who were actively treated with a short-acting -agonist in the 180 days preceding the index date . Second , because veterans may use health care services outside the Veterans Health Administration system , we restricted the analysis to patients 65 years of age or older . We used Medicare health care utilization data on these patients to capture health care utilization outside of the Veterans Health Administration system . Third , we examined dose response by classifying those in the highest quartile of average daily dose into a high-dose group and the rest of those exposed into a low-dose group . Fourth , to observe the effects of ipratropium independent of short-acting -agonist exposure , we excluded patients who received a combination of ipratropium and short-acting -agonists in a single inhaler . Fifth , to address the imbalance in prevalence of chronic heart failure between case patients and control participants , we created analytic cohorts by matching on presence of chronic heart failure and repeated our analyses . Finally , we used the array approach to estimate the effect that unmeasured confounding could have had on point estimates of the association between medications and mortality ( 20 ) . We varied the level of risk associated with the unmeasured confounder and the prevalence in the medication groups relative to the no-treatment groups to determine what level of differential exposure would change the conclusions from the primary analysis . We focused on current smoking rates and COPD severity because we considered these to be 2 of the most important and influential unmeasured confounders . We compared rates of smoking status and COPD severity across treatment groups by using data from a recently published study ( 21 ) . Role of the Funding Source This research was funded by the U.S. Department of Veterans Affairs Health Services To estimate the global burden of nontyphoidal Salmonella gastroenteritis , we synthesized existing data from laboratory-based surveillance and special studies , with a hierarchical preference to ( 1 ) prospect i ve population -based studies , ( 2 ) " multiplier studies , " ( 3 ) disease notifications , ( 4 ) returning traveler data , and ( 5 ) extrapolation . We applied incidence estimates to population projections for the 21 Global Burden of Disease regions to calculate regional numbers of cases , which were summed to provide a global number of cases . Uncertainty calculations were performed using Monte Carlo simulation . We estimated that 93.8 million cases ( 5th to 95th percentile , 61.8 - 131.6 million ) of gastroenteritis due to Salmonella species occur globally each year , with 155,000 deaths ( 5th to 95th percentile , 39,000 - 303,000 deaths ) . Of these , we estimated 80.3 million cases were foodborne . Salmonella infection represents a considerable burden in both developing and developed countries . Efforts to reduce transmission of salmonellae by food and other routes must be implemented on a global scale BACKGROUND Moderate-to-vigorous-intensity physical activity is recommended to maintain and improve health , but the mortality benefits of light activity and risk for sedentary time remain uncertain . OBJECTIVES Using accelerometer-based measures , we 1 ) described the mortality dose-response for sedentary time and light- and moderate-to-vigorous-intensity activity using restricted cubic splines , and 2 ) estimated the mortality benefits associated with replacing sedentary time with physical activity , accounting for total activity . DESIGN US adults ( n = 4840 ) from NHANES ( 2003 - 2006 ) wore an accelerometer for ≤7 d and were followed prospect ively for mortality . Proportional hazards models were used to estimate adjusted HRs and 95 % CIs for mortality associations with time spent sedentary and in light- and moderate-to-vigorous-intensity physical activity . Splines were used to graphically present behavior-mortality relation . Isotemporal models estimated replacement associations for sedentary time , and separate models were fit for low- ( < 5.8 h total activity/d ) and high-active participants to account for nonlinear associations . RESULTS Over a mean of 6.6 y , 700 deaths occurred . Compared with less-sedentary adults ( 6 sedentary h/d ) , those who spent 10 sedentary h/d had 29 % greater risk ( HR : 1.29 ; 95 % CI : 1.1 , 1.5 ) . Compared with those who did less light activity ( 3 h/d ) , those who did 5 h of light activity/d had 23 % lower risk ( HR : 0.77 ; 95 % CI : 0.6 , 1.0 ) . There was no association with mortality for sedentary time or light or moderate-to-vigorous activity in highly active adults . In less-active adults , replacing 1 h of sedentary time with either light- or moderate-to-vigorous-intensity activity was associated with 18 % and 42 % lower mortality , respectively . CONCLUSIONS Health promotion efforts for physical activity have mostly focused on moderate-to-vigorous activity . However , our findings derived from accelerometer-based measurements suggest that increasing light-intensity activity and reducing sedentary time are also important , particularly for inactive adults INTRODUCTION The prevalence of type 2 diabetes in Thail and is 9.8 percent which is double the number forecast by World Health Organization . There is inadequate information to statistically represent all Thai diabetic patients for their causes of death . OBJECTIVE To determine the clinical characteristics that predicted death and causes of death in Thai diabetic patients . MATERIAL AND METHOD This prospect i ve cohort was a 3-year follow-up study of the Thai Diabetes Registry project done between April , 2003 , and February , 2006 , which registered 9,419 diabetic patients attending 11 diabetic clinics in tertiary medical centers in Bangkok and major provinces of Thail and . The dead or alive status ( 99.5 % ) was determined . The causes of death were defined by review ing the medical records . RESULTS Of the 9,370 diabetic patients registered , 425 patients  died , 1.84 percent per year . There was an increased risk of death associated with age , type of healthcare plan , lower education , insulin use , smoking , history of coronary artery disease and cerebrovascular disease , serum creatinine and high HbA1c . Lipid-lowering medication and metformin decreased the risk of death . Cardiovascular disease , infection and cancer were the prevalent causes of death . CONCLUSION The present study showed risk factors that influenced death and causes of death in Thai diabetics Purpose Physical activity has been known to improve survival and quality of life of patients with breast cancer . To find factors associated with physical activity , we analyzed the data set of the multicenter controlled trial of exercise intervention . Methods Three hundred fifty-six participants were assigned to two groups : “ Smart After-Care ” ( smartphone application and pedometer were provided ) or exercise education only .  Physical activity was measured by International Physical Activity Question naire – Short Form ( IPAQ-SF ) at baseline and after 12 weeks . The association between physical activity and other clinical characteristics was analyzed . Results At baseline , physical activity amount was 2315.5 ± 3513.2 MET min/week : 33.0 % inactive , 49.6 % minimally active , and 17.4 % health-enhancing physical activity ( HEPA ) active . Factors associated with HEPA include cancer stage and grip strength . A significantly lower proportion was HEPA active among those with advanced stage than among those with stage 0 . After intervention , physical activity was increased to 3466.2 ± 4712.5 MET min/week : 15.3 % inactive , 50.4 % minimally active , and 34.2 % HEPA active . Physical activity was increased in 63.4 % of the participants . Factors associated with physical activity increase include cancer stage , diarrhea , and type of exercise intervention . Participants with advanced stage have a 3.3 times higher chance of increasing physical activity . Participants who received “ Smart After-Care ” have a 64 % higher chance of increasing physical activity . Conclusion Before the intervention , participants with advanced stage are less likely to be HEPA active .  Exercise intervention was more beneficial for those with advanced stage or physical symptoms . “ Smart After-Care ” was more effective than education only in increasing physical activity Background : Population -based studies directed at promoting physical activity in youth have shown limited success in obesity prevention . Objective : To assess whether an intervention integrating environmental changes to induce sustained changes in physical activity , prevents overweight in adolescents . Design : Four-year r and omized trial started in 2002 in eight middle schools of Eastern France . The intervention , r and omized at school level , was design ed to promote physical activity by changing attitudes through debates and attractive activities , and by providing social support and environmental changes encouraging physical activity . Subjects : Nine hundred and fifty four 12-year-old six- grade rs . Measurements : Body mass index ( BMI ) , body composition , physical activity by question naire , plasma lipids and glucose , insulin resistance . Results : Intervention students had a lower increase in BMI ( P=0.01 ) and age- and gender-adjusted BMI ( P<0.02 ) over time than controls . The differences across groups of the age- and gender-adjusted BMI changes ( 95 % confidence interval ( CI ) ) were −0.29 ( −0.51 ; −0.07 ) kg/m2 at 3 years , −0.25 ( −0.51 ; 0.01 ) kg/m2 at 4 years . An interaction with baseline weight status was noted . The intervention had a significant effect throughout the study in initially non-overweight adolescents ( −0.36 ( −0.60;−0.11 ) kg/m2 for adjusted BMI at 4 years ) , corresponding to a lower increase in fat mass index ( P<0.001 ) . In initially overweight adolescents , the differences observed across groups at 2 years ( –0.40 ( −0.94 ; 0.13 ) kg/m2 for adjusted BMI ) did not persist over time . At 4 years , 4.2 % of the initially non-overweight adolescents were overweight in the intervention schools , 9.8 % in the controls ( odds ratio=0.41 ( 0.22 ; 0.75 ) ; P<0.01 ) . Independent of initial weight status , compared with controls , intervention adolescents had an increase in supervised physical activity ( P<0.0001 ) , a decrease of TV/video viewing ( P<0.01 ) and an increase of high-density cholesterol concentrations ( P<0.0001 ) . Conclusion : Enhancing physical activity with a multilevel program prevents excessive weight gain in non-overweight adolescents . Our study provides evidence that prevention of obesity in youth is feasible Alerts , Notices , and Case Recruitment for the 3-Carotene and Retinol Efficacy Trial ( CARET ) to Prevent Lung Cancer in Smokers and Asbestos-Exposed Workers GILBERT S. OMENN , MD , PhD , GARY GOODMAN , MD JAMES GRIZZLE , PhD , MARK THORNQUIST , PhD LINDA ROSENSTOCK , MD , SCOTT BARNHART , MD GARNET AND ERSON , PhD Seattle , Washington JOHN BALMES , MD , JAMES CONE , MD San Francisco , California MARTIN CHERNIACK , MD , MARK CULLEN , MD New Haven , Connecticut AND REW GLASS , MD , BARBARA VALANIS , PhD Portl and , Oregon JAMES KEOGH , MD Baltimore , Maryl and FRANK MEYSKENS , Jr , MD , JAMES WILLIAMS , Jr , MD Orange , California THERE ARE THREE major lung cancer chemoprevention trials under way worldwide . One , the f-Carotene and Retinol Effi- cacy Trial ( CARET ) , is recruiting subjects primarily in Cali- fornia , Oregon , and Washington . Our purpose in this article is to share information about the design of CARET and the recruitment strategy and to address some questions physi- cians may raise about their patients who participate in CARET . The investigators welcome referrals to the CARET study centers in Irvine , San Francisco-Vallejo-Santa Clara , Portl and , and Seattle ( as well as Baltimore and New Haven ) . Lung cancer is the number one cancer killer of both men and women in the United States and in an increasing number of other countries . Lung cancers account for 27 % of all can- cer deaths and 6 % of total deaths in the United States , an estimated 143,000 deaths in 1991.1 Despite aggressive ef- forts at early diagnosis and multimodality therapy , the five- year survival rate from lung cancers remains miserably low , about 15%.2 Unlike most common cancers , the causes of lung cancer are well established.35 Thus the National Can- cer Institute has placed highest priority on the prevention of lung cancer . Primary prevention requires preventing the initiation of cigarette smoking , assisting cessation of smok- ing , and protecting people from exposures to asbestos , radon , arsenic , and a few other known pulmonary chemical carcinogens . ( Omenn GS , Goodman G , Grizzle J , et al : Recruitment for the ( 3-Carotene and Retinol Efficacy Trial ( CARET ) to prevent lung cancer in smokers and in asbestos-exposed workers . West J Med 1992 May ; 156:540 - 544 ) From the Fred Hutchinson Cancer Research Center , Cancer Prevention Research Unit , and the University of Washington Schools of Public Health and of Medicine , Seattle ( Drs Omenn , Goodman , Grizzle , Thomquist , Rosenstock , Bamhart , and An- derson ) ; the Department of Medicine , University of Califomia , San Francisco ( Drs Balmes and Cone ) ; the Department of Medicine , Yale University , New Haven , Con- necticut ( Dr Chemiack ) ; Kaiser Permanente Center for Health Research , Portl and , Oregon ( Drs Glass and Valanis ) ; the Department of Medicine , University of Maryl and , Baltimore ( Dr Keogh ) ; and the Department of Medicine and Cancer Center , University of Califomia , Irvine , Orange ( Drs Meyskens and Williams ) . This project is supported by grant CA 34847 from the National Cancer Institute . Reprint requests to Gilbert S. Omenn , MD , PhD , School of Public Health and Community Medicine , SC-30 , University of Washington , Seattle , WA 98195 . Reports For tens of millions of Americans who have already in- curred decades of cigarette smoking exposure and several million Americans who have had considerable occupational exposures to asbestos , especially in West Coast seaports , so- called secondary prevention is essential to overcoming the risk factors already at work . About 75 % of men and 50 % of women between 55 and 64 years of age are current or former smokers.6 Without secondary prevention , the increased risk of lung cancer does not decline in former smokers after smoking ceases , even though the relative risks do decline compared with continuing smokers or with persons who have never smoked.7 Among workers already exposed to asbestos , 4,000 to 6,000 are projected to die of lung cancer per year at least until the year 2000 and up to 8,000 to 10,000 will die of all asbestos-related cancers per year.8'9 The rationale for cancer chemoprevention programs is based on interrupting late stages of promotion and progres- sion in the multistage process of carcinogenesis . Such actions are exactly what is needed for high-risk persons to take ad- vantage of the latent period ( or time bomb ) of 20 to 40 years between first exposure and peak risk for lung cancer . Among the multiple classes of chemicals with apparent che- mopreventive activity , vitamin A ( retinol ) and fl-carotene are leading c and i date s for efficacy in human beings . 10 - 12 As de- scribed elsewhere , studies in animals , epidemiologic analy- ses , cell culture experiments , and short-term clinical trials to reverse bronchial metaplasia or buccal mucosa cell micro- nuclei have laid a strong foundation for direct intervention trials . 13 Three potentially definitive clinical chemoprevention tri- als , supported by the US National Cancer Institute , are under way . The Harvard Physicians Study , which was initiated to assess the effect of aspirin on heart disease , was continued to ascertain the effect of f-carotene on overall cancer incidence in 22,000 physicians . The a-Tocopherol-fl-Carotene Study was established to test the combination of f-carotene plus vitamin E in the chemoprevention of lung cancer in 29,000 smokers in Finl and . Finally , the CARET trial was design ed to test the combination of f-carotene and vitamin A in 18,000 smokers and asbestos-exposed workers . The design and re- cruitment strategy for CARET are described herein . Subjects in chemoprevention trials are healthy volunteers without cancer , not patients who might tolerate considerable discomfort or risk . Because the risk of lung cancer , even among high-risk asbestos-exposed smokers , is on the order of 1 per 100 per year , it is essential that a chemopreventive regimen be shown to have no major objective or subjective side effects . Design of CARET CARET is a two-armed , double-blind , r and omized che- moprevention trial to test the hypothesis that the oral admin- istration of f-carotene , 30 mg per day , plus retinol , 25,000 IU per day , will decrease the incidence of lung cancer in heavy smokers and asbestos-exposed workers who have smoked . 14 5 Choice of Agents The presumed mechanisms of action of fl-carotene and of vitamin A ( retinol ) are attractive and complementary . OBJECTIVE : To report long-term mortality after oophorectomy or ovarian conservation at the time of hysterectomy in subgroups of women based on age at the time of surgery , use of estrogen therapy , presence of risk factors for coronary heart disease , and length of follow-up . METHODS : This was a prospect i ve cohort study of 30,117 Nurses ' Health Study participants undergoing hysterectomy for benign disease .  Multivariable adjusted hazard ratios for death from coronary heart disease , stroke , breast cancer , epithelial ovarian cancer , lung cancer , colorectal cancer , total cancer , and all causes were determined comparing bilateral oophorectomy ( n=16,914 ) with ovarian conservation ( n=13,203 ) . RESULTS : Over 28 years of follow-up , 16.8 % of women with hysterectomy and bilateral oophorectomy  died from all causes compared with 13.3 % of women who had ovarian conservation ( hazard ratio 1.13 , 95 % confidence interval 1.06–1.21 ) . Oophorectomy was associated with a lower risk of death from ovarian cancer ( four women with oophorectomy compared with 44 women with ovarian conservation ) and , before age 47.5 years , a lower risk of death from breast cancer . However , at no age was oophorectomy associated with a lower risk of other cause-specific or all-cause mortality . For women younger than 50 years at the time of hysterectomy , bilateral oophorectomy was associated with significantly increased mortality in women who had never used estrogen therapy but not in past and current users : assuming a 35-year lifespan after oophorectomy : number needed to harm for all-cause death=8 , coronary heart disease death=33 , and lung cancer death=50 . CONCLUSIONS : Bilateral oophorectomy is associated with increased mortality in women aged younger than 50 years who never used estrogen therapy and at no age is oophorectomy associated with increased survival . LEVEL OF EVIDENCE : OBJECTIVES The purpose of this study was to evaluate the effect of a school-based intervention program to reduce overweight and improve fitness in primary school children . METHODS A cluster r and omized controlled design was used over one school year with schools as unit of r and omization . In total 20 schools and 2,622 children aged 6 - 12 years ( grade s 3 - 8 ) from multi-ethnic , low income inner-city neighbourhoods in Rotterdam , Netherl and s , participated . The intervention , named Lekker Fit ! ( Enjoy being fit ! ) was a multi-component intervention based on behavioural and ecological models . Main components of the intervention are the implementation of three physical education ( PE ) sessions a week by a professional PE teacher , additional sport and play activities outside school hours and an educational program . Main primary outcome measures were weight status , body mass index ( BMI ) , waist circumference and fitness ( 20 m shuttle run ) . RESULTS Significant positive intervention effects were found for percentage overweight children ( OR 0.53 ; 95 % CI 0.36 - 0.78 ) , waist circumference ( -1.29 cm ; 95 % CI -2.16 to -0.42 cm ) and 20 m shuttle run ( 0.57 laps ; 95 % CI 0.13 - 1.01 laps ) among pupils of grade s 3 - 5 ( 6 - 9-year olds ) . The prevalence of overweight in grade s 3 - 5 increased by 4.3 % in the control group and by 1.3 % in the intervention group . No significant effects were found for BMI or for grade s 6 - 8 ( 9 - 12-year olds ) . CONCLUSIONS Our results provide evidence for the effectiveness of the multi-component intervention Lekker Fit ! among pupils of grade s 3 - 5 and adds to the growing body of evidence that school-based programs with a focus on PA are most effective in reducing childhood obesity . [ IS RCT N84383524 ] Rates of chronic diseases are high among Black South Africans but few studies have tested cognitive-behavioural health-promotion interventions to reduce this problem . We tested the efficacy of such an intervention among adolescents in a cluster-r and omised controlled trial . We r and omly selected 9 of 17 matched pairs of schools and r and omised one school in each pair to the cognitive-behavioural health-promotion intervention design ed to encourage health-related behaviours and the other to a human immunodeficiency virus (HIV)/sexually transmitted disease ( STD ) risk-reduction intervention that served as the control . Interventions were based on social cognitive theory , the theory of planned behaviour and qualitative data from the target population . Data collectors , blind to participants ’ intervention , administered confidential assessment s at baseline and 3 , 6 and 12 months post-intervention . Primary outcomes were fruit and vegetable consumption and physical activity .  Participants were 1057 grade 6 learners ( mean age = 12.4 years ) , with 96.7 % retained at 12-month follow-up . Generalised estimating equations revealed that averaged over the follow-ups , a greater percentage of health-promotion intervention participants than HIV/STD control participants met 5-a-Day fruit and vegetable and physical activity guidelines . The intervention also increased health-promotion knowledge , attitude and intention , but did not decrease substance use or substance-use attitude and intention . The findings suggest that theory based and context ually appropriate interventions may increase health behaviours among young adolescents in sub-Saharan Africa The objectives of this study are to assess the impact of pre-existing diabetes and diabetes treatment on breast cancer prognosis . 8,108 women with central ly confirmed invasive breast cancer in the Women ’s Health Initiative diagnosed between 1998 and 2013 were followed through the date of death or September 20 , 2013 . Information on diabetes and diabetes therapy were obtained via self-report and face-to-face review of current medication containers , respectively . Cox proportional hazard regression was used to estimate adjusted relative hazard ratios for overall mortality . The proportional subdistribution hazard model was used to estimate hazard ratios for breast cancer-specific mortality . Compared with women without diabetes , women with diabetes had significantly increased risk of overall mortality ( HR 1.26 95 % CI 1.06–1.48 ) , especially among those who took insulin or had longer duration of diabetes . However , diabetes was not associated with increased risk of breast cancer-specific mortality , regardless of type of treatment and duration of diabetes , despite the significant association of diabetes with unfavorable tumor characteristics . Our large prospect i ve cohort study provides additional evidence that pre-existing diabetes increases risk of total mortality among women with breast cancer . The increased total mortality associated with diabetes was mainly driven by increased risk of dying from diseases other than breast cancer . Thus , the continuum of care for breast cancer patients with diabetes should include careful attention to CVD risk factors and other non-cancer conditions PURPOSE Physical activity may protect against  breast cancer . Few prospect i ve studies have evaluated breast cancer mortality in relation to cardiorespiratory fitness ( CRF ) , an objective marker of physiologic response to physical activity habits . METHODS We examined the association between CRF and risk of death from breast cancer  in the Aerobics Center Longitudinal Study . Women ( N = 14,811 ) , aged 20 to 83 yr with no prior breast cancer history , received a preventive medical examination at the Cooper Clinic in Dallas , Texas , between 1970 and 2001 . Mortality surveillance was completed through December 31 , 2003 . CRF was quantified as maximal treadmill exercise test duration and was categorized for analysis as low ( lowest 20 % of exercise duration ) , moderate ( middle 40 % ) , and high ( upper 40 % ) . At baseline , all participants were able to complete the exercise test to at least 85 % of their age-predicted maximal heart rate . RESULTS A total of 68 breast cancer deaths occurred during follow-up ( mean = 16 yr ) . Age-adjusted breast cancer mortality rates per 10,000 woman-years were 4.4 , 3.2 , and 1.8 for low , moderate , and high CRF groups , respectively ( trend P = 0.008 ) . After further controlling for body mass index , smoking , drinking , chronic conditions , abnormal exercise ECG responses , family history of breast cancer , oral contraceptive use , and estrogen use , hazard ratios ( 95 % CI ) for breast cancer mortality across incremental CRF categories were 1.00 ( referent ) , 0.67 ( 0.35 - 1.26 ) , and 0.45 ( 0.22 - 0.95 ) ( trend P = 0.04 ) . CONCLUSIONS These results indicate that CRF is associated with a reduced risk of dying from breast cancer in women PURPOSE Although moderate-to-vigorous physical activity is related to premature mortality , the relationship between sedentary behaviors and mortality has not been fully explored and may represent a different paradigm than that associated with lack of exercise . We prospect ively examined  sitting time  and mortality in a representative sample of 17,013 Canadians 18 - 90 yr of age . METHODS Evaluation of  daily sitting time  ( almost none of the time , one fourth of the time , half of the time , three fourths of the time , almost all of the time ) ,  leisure time physical activity , smoking status , and alcohol consumption  was conducted at baseline . Participants were followed prospect ively for an average of 12.0 yr for the ascertainment of mortality status . RESULTS There were 1832 deaths  ( 759 of cardiovascular disease ( CVD ) and 547 of cancer ) during 204,732 person-yr of follow-up . After adjustment for potential confounders , there was a progressively higher risk of mortality across higher levels of sitting time from all causes ( hazard ratios ( HR ) : 1.00 , 1.00 , 1.11 , 1.36 , 1.54 ; P for trend < 0.0001 ) and CVD ( HR:1.00 , 1.01 , 1.22 , 1.47 , 1.54 ; P for trend < 0.0001 ) but not cancer . Similar results were obtained when stratified by sex , age , smoking status , and body mass index . Age-adjusted all-cause mortality rates per 10,000 person-yr of follow-up were 87 , 86 , 105 , 130 , and 161 ( P for trend < 0.0001 ) in physically inactive participants and 75 , 69 , 76 , 98 , 105 ( P for trend = 0.008 ) in active participants across sitting time categories . CONCLUSIONS These data demonstrate a dose-response association between  sitting time  and mortality from all causes and CVD , independent of leisure time physical activity . In addition to the promotion of moderate-to-vigorous physical activity and a healthy weight , physicians should discourage sitting for extended periods Objective : To investigate the relationship of body weight and its changes over time with  physical activity ( PA ) . Design : Population -based prospect i ve cohort study ( Norfolk cohort of the European Prospect i ve Investigation into Cancer and Nutrition , EPIC-Norfolk , United Kingdom).Subjects : A total of 25 639 men and women aged 39–79 years at baseline .  PA was self-reported .  Weight and height were measured by st and ard clinical procedures at baseline and self-reported at 18-month and 10-year follow-ups ( calibrated against clinical measures ) . Main outcome measure was  PA  at the 10-year follow-up . Results : Body weight and PA  were inversely associated in cross-sectional analyses . In longitudinal analyses , an increase in weight was associated with higher risk of being inactive 10 years later , after adjusting for baseline activity , 18-month activity , sex , baseline age , prevalent diseases , socioeconomic status , education , smoking , total daily energy intake and alcohol intake . Compared with stable weight , a gain in weight of > 2 kg per year in the short- , medium- and long-term was consistently and significantly associated with greater likelihood of physical inactivity after 10 years , with the most pronounced effect for long-term weight gain , OR=1.89 ( 95 % CI : 1.30–2.70 ) in fully adjusted analysis . Weight gain of 0.5–2 kg per year over long-term was substantially associated with physical inactivity after full adjustment , OR=1.26 ( 95 % CI : 1.11–1.41 ) . Conclusion : Weight gain ( during short- , medium- and long-term ) is a significant determinant of future physical inactivity independent of baseline weight and activity . Compared with maintaining weight , moderate ( 0.5–2 kg per year ) and large weight gain ( > 2 kg per year ) significantly predict future inactivity ; a potentially vicious cycle including further weight gain , obesity and complications associated with a sedentary lifestyle . On the basis of current predictions of obesity trends , we estimate that the prevalence of inactivity in Engl and would exceed 60 % in the year 2020 BACKGROUND Weight loss is recommended for overweight or obese patients with type 2 diabetes on the basis of short-term studies , but long-term effects on cardiovascular disease remain unknown . We examined whether an intensive lifestyle intervention for weight loss would decrease cardiovascular morbidity and mortality among such patients . METHODS In 16 study centers in the United States , we r and omly assigned 5145 overweight or obese patients with type 2 diabetes to participate in an intensive lifestyle intervention that promoted weight loss through decreased caloric intake and increased physical activity ( intervention group ) or to receive diabetes support and education ( control group ) . The primary outcome was a composite of death from cardiovascular causes , nonfatal myocardial infa rct ion , nonfatal stroke , or hospitalization for angina during a maximum follow-up of 13.5 years . RESULTS The trial was stopped early on the basis of a futility analysis when the median follow-up was 9.6 years . Weight loss was greater in the intervention group than in the control group throughout the study ( 8.6 % vs. 0.7 % at 1 year ; 6.0 % vs. 3.5 % at study end ) . The intensive lifestyle intervention also produced greater reductions in glycated hemoglobin and greater initial improvements in fitness and all cardiovascular risk factors , except for low-density-lipoprotein cholesterol levels . The primary outcome occurred in 403 patients in the intervention group and in 418 in the control group ( 1.83 and 1.92 events per 100 person-years , respectively ; hazard ratio in the intervention group , 0.95 ; 95 % confidence interval , 0.83 to 1.09 ; P=0.51 ) . CONCLUSIONS An intensive lifestyle intervention focusing on weight loss did not reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes . ( Funded by the National Institutes of Health and others ; Look AHEAD Clinical Trials.gov number , NCT00017953 . ) PURPOSE / OBJECTIVES To determine whether cancer survivors engage in health-promotion behaviors , to evaluate the extent of their experience of psychological distress , and to investigate the relationship between the practice of health-promotion behaviors and psychological distress . DESIGN Cross-sectional secondary data analysis . SETTING A national , face-to-face interview conducted by personnel of the U.S. Census Bureau using a r and om sampling of American adults . SAMPLE 1,784 survey respondents who reported a previous cancer diagnosis . METHODS Data from the 2009 National Health Interview Survey were used to examine the prevalence of smoking , physical inactivity , alcohol use , and reports of psychosocial distress . Interviews pertained to the amount and distribution of illness , its effects in terms of disability and chronic impairments , and the kinds of health services people receive . MAIN RESEARCH VARIABLES Age , current smoking prevalence , alcohol consumption , physical activity , and the experience of feeling hopelessness , sadness , and anxiety . FINDINGS Cancer survivors continue to smoke at a rate similar to the national average . Overall , most respondents reported no symptoms of psychological distress . However , age appears to play a major role , showing significant differences in the prevalence of current smoking , participation in physical activity , alcohol use , and reported level of distress . CONCLUSIONS This study provides estimates of the prevalence of health-promotion behaviors and experience of psychological distress among American cancer survivors . The results reveal opportunities for interventions among cancer survivors . IMPLICATION S FOR NURSING Nurses should be proactive in providing guidance to survivors regarding the adoption of healthy lifestyle behaviors . Those who encounter younger cancer survivors need to be alert to the higher potential for distress in that population , perform appropriate screenings , and be prepared to offer guidance , supportive care , and referrals for psychological care if needed Little is known about the effectiveness of school-based health promotion on physical activity inequalities among children from low-income areas . This study compared the two-year change in physical activity among 10 - 11 year-old children attending schools with and without health promotion programs by activity level , body weight status , and socioeconomic background s to assess whether health promotion programs reduce or exacerbate health inequalities . This was a quasi-experimental trial of a Comprehensive School Health ( CSH ) program implemented in schools located in socioeconomically disadvantaged neighbourhoods in Edmonton , Alberta , Canada . In the spring of 2009 and 2011 , pedometer ( 7 full days ) and demographic data were collected from cross-sectional sample s of grade five children from 10 intervention and 20 comparison schools . Socioeconomic status was determined from parent self-report . Low-active , active , and high-active children were defined according to step-count tertiles . Multilevel linear regression methods adjusted for potential confounders were used to assess the relative inequity in physical activity and were compared between groups and over-time . In 2009 , a greater proportion of students in the intervention schools were overweight ( 38 % vs. 31 % p = 0.03 ) and were less active ( 10,827 vs. 12,265 steps/day p < 0.001 ) . Two years later , the relative difference in step-counts between intervention and comparison schools reduced from -15.5 % to 0 % among low-active students , from -13.4 % to 0 % among active students , and from -15.1 % to -2.7 % among high-active students . The relative difference between intervention and comparison schools reduced from -11.1 % to -1.6 % among normal weight students , from -16.8 % to -1.4 % among overweight students , and was balanced across socioeconomic subgroups . These findings demonstrate that CSH programs implemented in socioeconomically disadvantaged neighbourhoods reduced inequalities in physical activity . Investments in school-based health promotion are a viable , promising , and important approach to improve physical activity and prevent childhood obesity , and may also reduce inequalities in health BACKGROUND As epidemiological studies have become more complex , dem and s for short , easily administered measures of risk factors have increased . This study investigates whether such a measure of physical activity is associated with the risk of death from all causes and death from specific causes . METHODS A prospect i ve follow-up study of 11,090 men and women , aged 35 - 64 years , recruited from five UK general practice s who responded to a postal question naire in 1989 .  Self-reported frequency of vigorous-intensity physical activity and data on confounding factors were collected at baseline survey . Death notifications up to 31 December 2001 were provided by the Office for National Statistics . The relative risk ( and 95 % confidence interval ) of dying associated with each level of exposure to physical activity was estimated by the hazard ratio in a series of Cox regression models . RESULTS After > 10 years ' follow-up there were 825 deaths among the 10 522 subjects with no previous history of angina or myocardial infa rct ion . Participation in vigorous exercise was associated with a significantly lower risk of all-cause mortality . Similar associations were found for ischaemic heart disease and cancer mortality , although the relationships were not significant at the 5 % level . CONCLUSIONS Simple measures of self-reported vigorous physical activity are associated with the risk of future mortality , at least all-cause mortality in a somewhat selected group . Interpretation of the finding should be treated with caution due to the reliance on self-report and the possibility that residual confounding may underlie the associations . Because moderate-intensity physical activity is also beneficial to health , short physical activity question naires should include measures of such physical activity in the future Background Today , the 5-year relative survival rate for cancer is 65 % and there are 10.5 million survivors . The largest group of survivors are those of breast cancer . Reductions in mortality are occurring at a greater rate for women under age 50 at diagnosis than among older women . Aims Our goal was to design a socio-educational intervention for 5-year survivors aged 50 or younger at diagnosis and test the hypotheses that women in the intervention group would show greater improvement than controls with respect to ( 1 ) knowledge of breast cancer , its treatment , and long-term health concerns ; ( 2 ) lifestyle habits ( i.e. , exercise and diet ) ; and ( 3 ) communication with family and physicians . Methods Using a r and omized controlled trial with a pre-post design , 404 women who were 5 years from diagnosis and cancer-free ( response rate 54 % ) were r and omly assigned to an intervention or delayed intervention ( control ) group and were assessed at pre-test ( baseline ) and 6 months later ( 96 % retention ) . The intervention consisted of three 6-h workshops over a 3 month period . Four series of workshops were held at different geographical areas in the greater San Francisco Bay Area . The workshops included activities and information to promote physical , social , emotional , and spiritual well-being . The intervention design was based on findings from focus groups and a survey of 185 cancer-free 5-year survivors that assessed changes since the early months after diagnosis in physical , social , emotional , and spiritual concerns ( response rate 73 % ) . Results Consistent with our first hypothesis , at post-test , women in the intervention group , on average , had greater knowledge regarding breast cancer , its treatment , and their own future health than did those in the control group ( p = 0.015 ) . Hypothesis 2 was partially supported as women in the intervention group were more likely than the control group to report an increased amount of physical activity ( p = 0.036 ) , but not significant dietary changes . Social support was related to increased self report of physical activity . With the exception of the last series of workshops , the intervention group did not report improved communications with family , friends , and physicians ( hypothesis 3 ) . Conclusions A short-term intervention can affect knowledge levels and physical activity but not diet or communication in the family . Implication s for Cancer SurvivorsThe intervention was related to greater knowledge related to breast cancer , and increased report of physical activity . The program was not related to changes in reported diet or family communication AIMS To determine the combined influence of leisure-time physical activity and weekly alcohol intake on the risk of subsequent fatal ischaemic heart disease ( IHD ) and all-cause mortality . METHODS AND RESULTS Prospect i ve cohort study of 11 914 Danes aged 20 years or older and without pre-existing IHD . During approximately 20 years of follow-up , 1242 cases of fatal IHD occurred and 5901 died from all causes . Within both genders , being physically active was associated with lower hazard ratios ( HR ) of both fatal IHD and all-cause mortality than being physically inactive . Further , weekly alcohol intake was inversely associated with fatal IHD and had a U-shaped association with all-cause mortality . Within level of physical activity , non-drinkers had the highest HR of fatal IHD , whereas both non-drinkers and heavy drinkers had the highest HR of all-cause mortality . Further , the physically inactive had the highest HR of both fatal IHD and all-cause mortality within each category of weekly alcohol intake . Thus , the HR of both fatal IHD and all-cause mortality were low among the physically active who had a moderate alcohol intake . Conclusion Leisure-time physical activity and a moderate weekly alcohol intake are both important to lower the risk of fatal IHD and all-cause mortality To estimate the prevalence and determinants of overweight and obesity among school children and adolescents ( 7–18 years ) , a cross-sectional study was conducted in Tianjin City of Northeast China . Five primary and middle schools were selected using a multistage r and om cluster sampling . Anthropometric measurements were taken by the research team . Then , st and ardized question naires on socioeconomic status , diet and lifestyle , parental weight and height were sent to the parents to be completed together with their child . Overall , 3,140 students were screened for overweight and associated risk factors . Body mass index classification reference proposed by the Working Group on Obesity in China was used as a screening reference to calculate the prevalence of overweight in these groups . The prevalence of overweight and obesity was found to be 12.5 % and 15.7 % , respectively . Logistic regression analysis ( overweight compared with normal weight ) showed that , overweight in children was significantly associated with male gender , parental obesity , parental educational level , mother ’s history of gestational diabetes , high birth weight , less hours of physical activity per day , urban residence , motorized transportation , and eating food not prepared at home . After adjusting for parental obesity , the odds ratio of overweight children was increased by urban residence ( rural as a reference , 2.68 , 2.16–3.32 ) , positive gestational diabetes ( 2.76 , 1.37–4.50 ) , and fast-food/restaurant food service ( 2.03 , 1.34–3.07 ) . Children who walked to school and participated in outdoor activities were 54 % and 63 % less likely to be overweight respectively . Conclusions : The prevalence of overweight and obesity is high among school children and adolescents in Tianjin .  Changes in lifestyle , high socioeconomic status , parental obesity , mother ’s history of gestational diabetes , and high birth weight are among the highly associated risk factors of overweight . An educational approach about maintaining a healthy weight should be introduced much earlier to high-risk children , parents , and women of childbearing age The greater  coronary heart disease morbidity of  sedentary as opposed to physically active workers was demonstrated many years ago by J N Morris and his colleagues in a comparison of London bus drivers and conductors . These two groups of transport workers belonged to the same social class and had similar lifestyles . They differed principally in the amount of physical activity in which they engaged when at work . The drivers were confined to a small enclosed driving compartment which rendered them almost completely immobile , whilst the conductors were continuously active , especially as they constantly had to run up and down the stairs of the doubledecker London buses . During the five-year follow-up the drivers had a CHD incidence almost double that of the conductors . The differences between the two groups became greater as their members grew older ( Table IX.1 ) . ' The finding of this untoward accompaniment of physical inactivity has been confirmed by the results of the Framingham study 2 and a 27 cohort based rigorous meta- analysis reported by Jesse Berlin and Graham Colditz . These authors found a relative risk of death from coronary heart disease of 1.9 ( CL 1.6 - 2.2 ) for sedentary as opposed to high physical activity groups , and the benefits were shown to be greater in the studies that the authors judged to be method ologically stronger.3 Conversely , in the Whitehall study of British civil servants leisure-time physical activity has been found to have cardiovascular health benefits similar to those apparently conferred on the London bus conductors by their workaday exertions . Vigorous weekend exercise apparently protected the middle-aged men from fatal heart attacks and non-fatal first episodes of coronary heart disease.4 It is probable that a r and omized and controlled prospect i ve study of the cardiovascular consequences of prolonged inactivity will never be undertaken . It would be both unethical and impractical to enforce a long-term sedentary lifestyle on a control group . However , the physiological means by which regular exercise has cardioprotective effects are now well defined . Animal studies have shown that the coronary arterial capacity becomes greater relative to the cardiac muscle mass and an increase in coronary artery diameter has been demonstrated angiographically . Capillary growth is induced and increase in coronary blood flow in response to AIM To investigate the determinants of overweight and obesity among 10- to 15-year-old schoolchildren in a population in the transitional phase in the North West Province of South Africa . METHODS A cross-sectional survey was used to investigate weight status ( anthropometric indicators ) and determinants of overweight/obesity including  dietary intake , physical activity and socio-economic status .  A single , r and om sample ( n=1257 ) , stratified for gender , type of school and ethnic group , was used . Data were collected on demographics , family circumstances , habitual physical activity , dietary intake and anthropometry to evaluate weight status and body fat content . One-way analysis of variance , the generalised linear models procedure of SAS and the Tukey post hoc honest significant difference test were used to analyse the data . RESULTS Few children were overweight or obese ( 7.8 % ) according to International Obesity Task Force ( IOTF ) st and ards ( body mass index ( BMI ) -for-age ) . These st and ards were compared with other accepted st and ard values . Both Cole 's IOTF/ BMI -for-age st and ard and the sum of skinfold thicknesses st and ard classified normal-weight status similarly at a level of 92 % ( P<0.01 ) and were found to be useful in determining overweight/obesity . The prevalence rate was higher in females and white children , and was more apparent in urban areas , smaller households and children of parents with low- or high-income occupations . Boys and pre-menarcheal girls had mean body fat percentage in the normal/optimal range , whereas that of post-menarcheal girls was moderately high . Few variables showed a significant association with high body fat percentage : in boys , only the number of members in the household and physical activity levels over the weekend ; in girls , only age . The overweight/obese boys mostly lived in smaller households , and the overweight/obese post-menarcheal girls were most inactive on both weekdays and weekends , and more overweight with increasing age . CONCLUSION Smaller households , inactivity and increasing age for girls were found to be determinants that influence the development of overweight/obesity , while female gender and age post-menarche were identified as determinants of higher body fat content . For overweight/obesity prevention , the focus should be on pre-menarcheal girls , aged 10 - 13 years , using these determinants to identify overweight/obesity risk . Preventive programmes should aim to increase the physical activity of children to improve their current and future weight status BACKGROUND There is increasing interest in the health-promoting potential of physical activity in older adults . The objective of this study was to estimate the likely costs , health benefits and consequences for the National Health Service which might result from a publicly funded programme of regular exercise made available to a population of 10,000 people over the age of 65 . METHODS Risk education data from observational studies were used to calculate the possible impact of a community-based programme of activity on hospital admissions and deaths from coronary heart disease , stroke , diabetes , femoral neck fractures and mental disorders . The avoided costs of health care and net cost per life-year saved were estimated . RESULTS Providing twice-weekly exercise classes for 10,000 participants would cost approximately 854,700 pounds per year , but would prevent 76 deaths and 230 in-patient episodes , avoiding annual health care costs of approximately 601,000 pounds . Assuming the mean expectation of life after 65 to be ten years , the programme would cost about 330 pounds per life-year saved . Under a range of more extreme assumptions , the cost per life-year saved would vary from 100 pounds to 1500 pounds . CONCLUSIONS A publicly funded programme of regular moderate exercise for over-65-year-olds could achieve important health benefits at relatively low cost . The estimates provided by this analysis should now be tested in a rigorous r and omized trial , and health commissioners should begin to think of purchasing exercise programmes alongside other health-promoting measures In a pilot r and omized controlled trial involving overweight or obese participants with type 2 diabetes , we find that  smartphone users have sharply higher adherence to self-monitoring of diet , physical activity , blood glucose , and body weight  , as compared to paper diary users . By characterizing the pattern of adherence with the probability of continuation of active and inactive sequences of self-monitoring , we find that smartphone users have longer active sequences of self-monitoring of all four behaviors that were being monitored . Smartphone users are also quicker to resume  self-monitoring of diet and physical activity after a lapse in self-monitoring , whereas paper diary users have shorter inactive sequences for monitoring blood glucose and body weight . The findings are informative for data collection methodology in this burgeoning area of research BACKGROUND Physical activity is positively associated with survival and quality of life among breast cancer survivors . Despite these benefits , the majority of breast cancer survivors are insufficiently active . The potential health benefits of reducing sedentary behaviour ( sitting time ) in this population have not been extensively investigated . The ACTIVATE Trial will evaluate the efficacy of an intervention that combines wearable technology ( the Garmin Vivofit2 ® ) with traditional behavioural change approaches to increase physical activity and reduce sedentary behaviour performed by breast cancer survivors . METHODS / DESIGN This r and omised controlled trial includes inactive , postmenopausal women diagnosed with stage I-III breast cancer who have completed their primary treatment . Participants are r and omly assigned to the primary intervention group ( Garmin Vivofit2 ® ; behavioural feedback and goal setting session ; and , five telephone-delivered health coaching sessions ) or to the wait-list control group . The primary intervention is delivered over a 12-week period . The second 12-week period comprises a maintenance phase for the primary intervention group , and an abridged intervention ( Garmin Vivofit2 ® only ) for the wait-list control group . Moderate- to vigorous-intensity physical activity ( MVPA ) and sedentary behaviour are assessed by accelerometry at baseline ( T1 ) , end of intervention ( T2 ) , and end of maintenance phase ( T3 ) . DISCUSSION The ACTIVATE Trial is one of the first studies to incorporate wearable technology into an intervention for cancer survivors . If the use of wearable technology ( in combination with behaviour change strategies , or alone ) proves efficacious , it may become an inexpensive and sustainable addition to the health promotion strategies available to health care providers in the cancer survivorship context . TRIAL REGISTRATION ACTRN12616000175471 Abstract Background Few school-based interventions have been successful in reducing physical activity decline and preventing overweight and obesity in adolescent population s. As a result , few cost effectiveness analyses have been reported . The aim of this paper is to report the cost and cost effectiveness of the Physical Activity 4 Everyone ( PA4E1 ) intervention which was a multi-component intervention implemented in secondary schools located in low-income communities .  Cost effectiveness was assessed using both the physical activity and weight status trial outcomes . Methods Intervention and Study Design : The PA4E1 cluster r and omised controlled trial was implemented in 10 Australian secondary schools ( 5 intervention : 5 control ) and consisted of intervention schools receiving seven physical activity promotion strategies and six additional strategies that supported school implementation of the intervention components . Costs associated with physical activity strategies , and intervention implementation strategies within the five intervention schools were estimated and compared to the costs of usual physical activity practice s of schools in the control group . The total cost of implementing the intervention was estimated from a societal perspective , based on the number of enrolled students in the target grade at the start of the intervention ( Grade 7 , n = 837 ) . Economic Outcomes : The economic analysis outcomes were cost and incremental cost effectiveness ratios for the following : minutes of moderate-to-vigorous physical activity ( MVPA ) per day gained , MET hours gained per person/day ; Body Mass Index ( BMI ) unit avoided ; and 10 % reduction in BMI z-score . Results The intervention cost AUD $ 329,952 over 24 months , or AUD$394 per student in the intervention group . This result ed in a cost effectiveness ratio of AUD$56 ( $ 35–$147 ) per additional minute of MVPA , AUD$1 ( $ 0.6–$2.7 ) per MET hour gained per person per day , AUD$1408 ( $ 788–$6,570 ) per BMI unit avoided , and AUD$563 ( $ 282–$3,942 ) per 10 % reduction in BMI z-score . Conclusion PA4E1 is a cost effective intervention for increasing the physical activity levels and reducing unhealthy weight gain in adolescence , a period in which physical activity typically declines . Additional modelling could explore the potential economic impact of the intervention on morbidity and mortality . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12612000382875 The objective of this study was to derive food-based dietary guidelines for the Dutch population . The dietary guidelines are based on 29 systematic review s of English language meta-analyses in PubMed summarizing r and omized controlled trials and prospect i ve cohort studies on nutrients , foods and food patterns and the risk of 10 major chronic diseases : coronary heart disease , stroke , heart failure , diabetes , breast cancer , colorectal cancer , lung cancer , chronic obstructive pulmonary disease , dementia and depression . The committee also selected three causal risk factors for cardiovascular diseases or diabetes : systolic blood pressure , low-density lipoprotein cholesterol and body weight . Findings were categorized as strong or weak evidence , inconsistent effects , too little evidence or effect unlikely for experimental and observational data separately . Next , the committee selected only findings with a strong level of evidence for deriving the guidelines . Convincing evidence was based on strong evidence from the experimental data either or not in combination with strong evidence from prospect i ve cohort studies . Plausible evidence was based on strong evidence from prospect i ve cohort studies only . A general guideline to eat a more plant food-based dietary pattern and limit consumption of animal-based food and 15 specific guidelines have been formulated . There are 10 new guidelines on legumes , nuts , meat , dairy produce , cereal products , fats and oils , tea , coffee and sugar-containing beverages . Three guidelines on vegetables , fruits , fish and alcoholic beverages have been sharpened , and the 2006 guideline on salt stayed the same . A separate guideline has been formulated on  nutrient supplements .  Completely food-based dietary guidelines can be derived in a systematic and transparent way Background Increasing prevalence of obesity and disorders associated with sedentary living constitute a major global public health problem . While previous evaluations of interventions to increase  physical activity  have involved communities or individuals with established disease , less attention has been given to interventions for individuals at risk of disease . Methods / design ProActive aims to evaluate the efficacy of a theoretical , evidence - and family-based intervention programme to increase physical activity  in a sedentary population , defined as being at-risk through having a parental family history of diabetes . Primary care diabetes or family history registers were used to recruit 365 individuals aged 30–50 years , screened for activity level . Participants were assigned by central r and omisation to three intervention programmes : brief written advice ( comparison group ) , or a psychologically based behavioural change programme , delivered either by telephone ( distance group ) or face-to-face in the family home over one year . The protocol -driven intervention programme is delivered by trained facilitators , and aims to support increases in physical activity through the introduction and facilitation of a range of self-regulatory skills ( e.g. goal setting ) . The primary outcome is daytime energy expenditure and its ratio to resting energy expenditure , measured at baseline and one year using individually calibrated heart rate monitoring . Secondary measures include self-report of individual and family activity , psychological mediators of behaviour change , physiological and biochemical correlates , acceptability , and costs , measured at baseline , six months and one year . The primary intention to treat analysis will compare groups at one-year post r and omisation . Estimation of the impact on diabetes incidence will be modelled using data from a parallel ten-year cohort study using similar measures . Discussion ProActiveis the first efficacy trial of an intervention programme to promote physical activity in a defined high-risk group accessible through primary care . The intervention programme is based on psychological theory and evidence ; it introduces and facilitates the use of self-regulatory skills to support behaviour change and maintenance . The trial addresses a range of method ological weaknesses in the field by careful specification and quality assurance of the intervention programme , precise characterisation of participants , year-long follow-up and objective measurement of physical activity . Due to report in 2005 , ProActivewill provide estimates of the extent to which this approach could assist at-risk groups who could benefit from changes in behaviours affecting health , and inform future pragmatic trials AIMS This study aims to investigate the distribution of underlying-causes-of-death ( UCOD ) among deceased patients with type 2 diabetes mellitus ( DM ) in Taiwan and assess the influence of socio-demographic characteristics on mortality in type 2 DM patients . METHODS A cohort study on patients who sought medical care for type 2 DM from 2000 to 2008 was conducted on 65,599 type 2 DM patients retrieved from the 1-million beneficiaries r and omly selected from Taiwan 's National Health Insurance Data base . The study cohort was then linked to Taiwan 's Mortality Registry to ascertain the patients who died between 2000 and 2009 . We examined the distribution of  UCOD  in the deceased subjects . The hazard ratios of mortality in relation to socio-demographic characteristics were estimated from Cox proportional hazard model . RESULTS The leading causes of death in type 2 DM included neoplasm ( 22.68 % ) , cardiovascular diseases ( 21.46 % ) , and endocrine diseases ( 20.78 % ) . Male gender and older ages were associated with significantly increased risk of mortality . In addition , lower urbanization and greater co-morbidity score were also significantly associated with an increased risk of mortality with a dose-gradient pattern . CONCLUSIONS Neoplasm accounts for the largest portion ( 22.68 % ) of deaths in type 2 DM patients closely followed by with cardiovascular diseases ( 21.46 % ) . An increased risk of mortality in type 2 DM patients in lower urbanized areas may reflect poor diabetes care in these areas BACKGROUND Regular physical activity in older adults can facilitate healthy aging , improve functional capacity , and prevent disease . However , factors associated with physical inactivity in older population s are poorly understood . This study attempts to identify social-cognitive and perceived environmental influences associated with physical activity participation in older population s. METHODS In a r and omly selected sample of 449 Australian adults age 60 and older , we assessed self-reported physical activity and a range of social-cognitive and perceived environmental factors . Respondents were classified as sufficiently active and inactive based on energy expenditure estimates ( kcal/week ) derived from self-reported physical activity . Two logistic regression models , with and without self-efficacy included , were conducted to identify modifiable independent predictors of physical activity . RESULTS Significantly more males than females were physically active . Physical activity participation was related to age with a greater proportion of those age 65 - 69 being active than those age 60 - 64 or 70 or older .  High self-efficacy , regular participation of friends and family , finding footpaths safe for walking , and access to local facilities were significantly associated with being active . CONCLUSION Identifying predictors of physical activity in older population s , particularly social support , facility access , and neighbourhood safety , can inform the development of policy and intervention strategies to promote the health of older people Background There is overwhelming evidence that behavioural factors influence health , but their combined impact on the general population is less well documented . We aim ed to quantify the potential combined impact of four health behaviours on mortality in men and women living in the general community . Methods and Findings We examined the prospect i ve relationship between lifestyle and mortality in a prospect i ve population study of 20,244 men and women aged 45–79 y with no known cardiovascular disease or cancer at baseline survey in 1993–1997 , living in the general community in the United Kingdom , and followed up to 2006 . Participants scored one point for each health behaviour : current non-smoking , not physically inactive , moderate alcohol intake ( 1–14 units a week ) and plasma vitamin C > 50 mmol/l indicating fruit and vegetable intake of at least five servings a day , for a total score ranging from zero to four . After an average 11 y follow-up , the age- , sex- , body mass– , and social class – adjusted relative risks ( 95 % confidence intervals ) for all-cause mortality(1,987 deaths ) for men and women who had three , two , one , and zero compared to four health behaviours were respectively , 1.39 ( 1.21–1.60 ) , 1.95 ( 1.70–-2.25 ) , 2.52 ( 2.13–3.00 ) , and 4.04 ( 2.95–5.54 ) p < 0.001 trend . The relationships were consistent in subgroups stratified by sex , age , body mass index , and social class , and after excluding deaths within 2 y. The trends were strongest for cardiovascular causes . The mortality risk for those with four compared to zero health behaviours was equivalent to being 14 y younger in chronological age . Conclusions Four health behaviours combined predict a 4-fold difference in total mortality in men and women , with an estimated impact equivalent to 14 y in chronological age BACKGROUND In 2007 , the World Cancer Research Fund ( WCRF ) and the American Institute for Cancer Research ( AICR ) issued recommendations on diet , physical activity , and weight management for cancer prevention on the basis of the most comprehensive collection of available evidence . OBJECTIVE We investigated whether concordance with WCRF/AICR recommendations is related to risk of death . DESIGN The current study included 378,864 participants from 9 European countries enrolled in the European Prospect i ve Investigation into Cancer and Nutrition study . At recruitment ( 1992 - 1998 ) , dietary , anthropometric , and lifestyle information was collected . A WCRF/AICR score , which incorporated 6 of the WCRF/AICR recommendations for men [ regarding body fatness , physical activity , foods and drinks that promote weight gain , plant foods , animal foods , and alcoholic drinks ( score range : 0 - 6 ) ] and 7 WCRF/AICR recommendations for women [ plus breastfeeding ( score range : 0 - 7 ) ] , was constructed . Higher scores indicated greater concordance with WCRF/AICR recommendations . Associations between the WCRF/AICR score and risks of total and cause-specific death were estimated by using Cox regression analysis . RESULTS After a median follow-up time of 12.8 y , 23,828 deaths were identified . Participants within the highest category of the WCRF/AICR score ( 5 - 6 points in men ; 6 - 7 points in women ) had a 34 % lower hazard of death ( 95 % CI : 0.59 , 0.75 ) compared with participants within the lowest category of the WCRF/AICR score ( 0 - 2 points in men ; 0 - 3 points in women ) . Significant inverse associations were observed in all countries . The WCRF/AICR score was also significantly associated with a lower hazard of dying from cancer , circulatory disease , and respiratory disease . CONCLUSION Results of this study suggest that following WCRF/AICR recommendations could significantly increase longevity Type 2 diabetes is a chronic illness that is increasing in epidemic proportions worldwide . Major factors contributing to the development of type 2 diabetes include obesity and poor lifestyle habits ( e.g. , excess dietary intake and limited physical activity ) . Despite the proven efficacy of lifestyle interventions and the use of multiple pharmacological agents , the economic and public health burden of type 2 diabetes remains substantial .  Obstructive sleep apnea ( OSA ) is a treatable sleep disorder that is pervasive among overweight and obese adults , who represent about two thirds of the U.S. population today . An ever-growing number of studies have shown that OSA is associated with insulin resistance , glucose intolerance and type 2 diabetes , independent of obesity . Evidence from animal and human models that mimic OSA provides potential mechanisms for how OSA may alter glucose metabolism . Up to 83 % of patients with type 2 diabetes suffer from unrecognized OSA and increasing severity of OSA is associated with worsening glucose control . However , it is still unclear whether OSA may lead to the development of diabetes over time . More data from large-scale longitudinal studies with rigorous assessment s of diabetes and OSA are needed . In addition , there is still controversy whether continuous positive airway pressure ( CPAP ) treatment of OSA  improves glucose metabolism . Large-scale r and omized-controlled trials of CPAP treatment of OSA with well-vali date d assessment s of insulin sensitivity and glucose tolerance are needed . These studies may reveal that OSA represents a novel , modifiable risk factor for the development of prediabetes and type 2 diabetes BACKGROUND Most studies on multiple health risk behaviors among adolescents have cross-sectionally studied a limited number of health behaviors or determinants . PURPOSE To examine the prevalence , longitudinal patterns and predictors of individual and multiple health risk behaviors among adolescents . METHODS Eight health risk behaviors  ( no regular consumption of fruit , vegetables or breakfast , overweight or obesity , physical inactivity , smoking , alcohol use and cannabis use ) were assessed in a prospect i ve population study ( second and third wave ) . Participants were assessed in three waves between ages 10 and 17 ( 2001 - 2008 ; n=2230 ) .  Multiple linear regression was used to assess the influence of gender , self-control , parental health risk behaviors , parental monitoring and socioeconomic factors on the number of health risk behaviors adjusted for preceding multiple health risk behaviors ( analysis : 2013 - 2014 ) . RESULTS Rates of > 5 health risk behaviors were high : 3.6 % at age 13.5 and 10.2 % at age 16 . Smoking at age 13.5 was frequently associated with health risk behaviors at age 16 . No regular consumption of fruit , vegetables and breakfast , overweight or obesity , physical inactivity and smoking predicted the co-occurrence of health risk behaviors at follow-up . Significant predictors of the development of multiple health risk behaviors were  adolescents ' levels of self-control , socioeconomic status and maternal smoking . CONCLUSIONS Multiple health risk behaviors are common among adolescents . Individual and social factors predict changes in multiple health risk behaviors , showing that prevention targeting multiple risk behaviors is needed . Special attention should be paid to adolescents with low self-control and families with low socioeconomic status or a mother who smokes Background Child and adolescent obesity predisposes individuals to an increased risk of morbidity and mortality from a range of lifestyle diseases . Although there is some evidence to suggest that rates of pediatric obesity have leveled off in recent years , this has not been the case among youth from low socioeconomic background s. The purpose of this paper is to report the rationale , study design and baseline findings of a school-based obesity prevention program for low-active adolescent girls from disadvantaged secondary schools . Methods / Design The Nutrition and Enjoyable Activity for Teen Girls ( NEAT Girls ) intervention will be evaluated using a group r and omized controlled trial . NEAT Girls is a 12-month multi-component school-based intervention developed in reference to Social Cognitive Theory and includes enhanced school sport sessions , interactive seminars , nutrition workshops , lunch-time physical activity ( PA ) sessions , PA and nutrition h and books , parent newsletters , pedometers for self-monitoring and text messaging for social support . The following variables were assessed at baseline and will be completed again at 12- and 24-months : adiposity , objective ly measured PA , muscular fitness , time spent in sedentary behaviors , dietary intake , PA and nutrition social-cognitive mediators , physical self-perception and global self-esteem . Statistical analyses will follow intention-to-treat principles and hypothesized mediators of PA and nutrition behavior change will be explored . Discussion NEAT Girls is an innovative intervention targeting low-active girls using evidence -based behavior change strategies and nutrition and PA messages and has the potential to prevent unhealthy weight gain and reduce the decline in physical activity and poor dietary habits associated with low socio-economic status . Few studies have reported the long-term effects of school-based obesity prevention programs and the current study has the potential to make an important contribution to the field . Trial registration Australian New Zeal and Clinical Trials Registry No : AIM To determine whether five months of guided active play in overweight or obese children and adolescents under multi-disciplinary management for weight reduction leads to increased physical activity levels in leisure time , as well as changes in aerobic fitness and body composition . METHODS Sixty overweight or obese children and adolescents were r and omly assigned to an intervention or control group . All participants received dietary advice and were encouraged to increase physical activity level . The intervention group additionally participated in 60-minute guided active play/physical activity twice a week for 5 months . Physical activity was recorded ; aerobic fitness and body composition were measured at inclusion and after cessation of intervention . RESULTS Physical activity level during weekend days was significantly higher for the intervention group compared with the controls after 5 months intervention ( p=0.04 ) . The mean reduction in percentage of body fat was 1.8 % ( 95%CI : 0.6 , 3.1 ) in the intervention group ( p=0.04 ) and not significant among the controls ( 0.9 [ -0.9 , 2.7 ] ) . There was no change in aerobic fitness . CONCLUSION Five months of guided active play was associated with increased physical activity levels during weekend days and reduced body fat , although weakly , in overweight and obese children and adolescents participating in multi-disciplinary weight reduction programmes Few studies have investigated the impact of school-based physical activity interventions on anthropometric characteristics concomitantly with aerobic and anaerobic capacities in young children . The present study aim ed to assess the effect of a 6-month physical activity program on body composition and physical fitness among primary schoolchildren . Four hundred fifty-seven children aged 6 to 10 years were r and omly assigned to the intervention group ( 229 children ) or observational group ( 228 children ) . Participants ’ height and weight were assessed , and obesity was determined using French reference curves for BMI . The sum of the four skinfolds and fat-free mass were determined . Ground tests were used to assess aerobic ( 20-m shuttle run test ) and anaerobic ( cycling peak power ) fitness before and after a 6-month physical activity intervention . The anthropometric modifications obtained over the 6 months can not be attributed to the intervention as the ANOVA revealed no group effect ( intervention vs. group ) . However , anaerobic and aerobic fitness were significantly improved , thanks to the program in both lean and obese children . A 6-month school-based physical activity intervention in 6- to 10-year-old children did not yield positive anthropometric improvements , but appears effective in terms of aerobic and anaerobic physical fitness . Two physical activity sessions per week in addition to st and ard physical education classes in primary schoolchildren bring effective results for the prevention of childhood obesity Background Over the last three decades there has been a substantial increase in the proportion of children who are overweight or obese . The Healthy Lifestyles Programme ( HeLP ) is a novel school-based intervention , using highly interactive and creative delivery methods to prevent obesity in children . Methods / Design We describe a cluster r and omised controlled trial to evaluate the effectiveness and cost effectiveness of HeLP . The intervention has been developed using intervention mapping ( involving extensive stakeholder involvement ) and has been guided by the Information , Motivation , Behavioural Skills model . HeLP includes creating a receptive environment , drama activities , goal setting and reinforcement activities and runs over three school terms . Piloting showed that 9 to 10 year olds were the most receptive and participative . This study aims to recruit 1,300 children from 32 schools ( over half of which will have ≥19 % of pupils eligible for free school meals ) from the southwest of Engl and . Participating schools will be r and omised to intervention or control groups with baseline measures taken prior to r and omisation . The primary outcome is change in body mass index st and ard deviation score ( BMI SDS ) at 24 months post baseline . Secondary outcomes include , waist circumference and percent body fat SDS and proportion of children classified as overweight or obese at 18 and 24 months and objective ly measured physical activity and food intake at 18 months . Between-group comparisons will be made using r and om effects regression analysis taking into account the hierarchical nature of the study design . An economic evaluation will estimate the incremental cost-effectiveness  of HeLP , compared to control , from the perspective of the National Health Service (NHS)/third party payer . An in-depth process evaluation will provide insight into how HeLP works , and whether there is any differential uptake or engagement with the programme . Discussion The results of the trial will provide evidence on the effectiveness and cost effectiveness of the Healthy Lifestyles Programme in affecting the weight status of children . Trial registration IS RCT Background Military service in Finl and is compulsory for all male citizens and annually about 80 % of 19-year-old men enter into the service . The elevated risk for many chronic diseases and loss of function among those who are inactive and unfit can be often detected already in youth . On the other h and , activity-induced injuries among young are true public health issue . The purpose of the present prospect i ve cohort follow-up study was to evaluate predictive associations between acute or overuse injuries and their various intrinsic risk factors . Methods Four successive cohorts of conscripts who formed a representative sample of Finnish young men were followed for 6 months . At the beginning of the service , the risk factors of injuries were measured and recorded and then the acute and overuse injuries treated at the garrison clinic were identified . Predictive associations between injuries and their risk factors were examined by multivariate Cox ’s proportional hazard models . Results Of the 1411 participants , 27 % sustained an acute injury and 51 % suffered from overuse injury . Concerning acute injuries , highest risk for severe injuries were detected among conscripts with low fitness level in both the st and ing long-jump and push-up tests ( hazard rate , HR=5.9 ; 95 % CI : 1.6‒21.3 ) . A history of good degree in school sports was not a protective factor against acute injuries . High waist circumference and , on the other h and , being underweight according to BMI increased the HR for overuse injuries . Brisk leisure time physical activity before military entry was a protective factor against overuse injuries . Poor result in Cooper ’s test was a warning signal of elevated risk of overuse injuries . Conclusion We confirmed previous findings that low level of physical fitness is predictor for musculoskeletal injuries during intensive physical training . The U-shaped relationship between body composition and overuse injuries was noticed indicating that both obesity and underweight are risk factors for overuse injuries . Persons with excellent sports skills according to their earlier degrees in school sports had similar HR for acute injuries than those with poorer degrees . This indicates that school-age sports skills and fitness do not carry far and therefore preventive programmes are needed to prevent activity-induced injuries Background According to the World Alzheimer Report ( Prince , The Global Impact of Dementia : an Analysis of Prevalence , Incidence , Cost and Trends , 2015 ) , 46.8 million people worldwide are nowadays living with dementia . And this number is estimated to approximate 131.5 million by 2050 , with an increasing burden on society and families . The lack of medical treatments able to stop or slow down the course of the disease has moved the focus of interest toward the nonpharmacological approach and psychosocial therapies for people with/at risk of dementia , as in the Mild Cognitive Impairment ( MCI ) condition . The purpose of the present study is to test an individualized home-based multidimensional program aim ed at enhancing the continuum of care for MCI and out patients with dementia in early stage using technology . Methods The proposed study is a single blind r and omized controlled trial ( RCT ) involving 30 subjects with MCI and Alzheimer ’s disease ( AD ) r and omly assigned to the intervention group ( Ability group ) , who will receive the “ Ability Program ” , or to the active control group ( ACG ) , who will receive “ Treatment As Usual ” ( TAU ) . The protocol provides for three steps of assessment : at the baseline ( T_0 ) , after treatment , ( T_1 ) and at follow-up ( T_2 ) with a multidimensional evaluation battery including cognitive functioning , behavioral , functional , and quality of life measures . The Ability Program lasts 6 weeks , comprises tablet-delivered cognitive ( 5 days/week ) and physical activities ( 7 days/week ) combined with a set of devices for the measurement and monitoring from remote of vital and physical health parameters . The TAU equally lasts 6 weeks and includes paper and pencil cognitive activities ( 5 days/week ) , with clinician ’s prescription to perform physical exercise every day and to monitor selected vital parameters . Discussion Results of this study will inform on the efficacy of a technology-enhanced home care service to preserve cognitive and motor levels of functioning in MCI and AD , in order to slow down their loss of autonomy in daily life . The expected outcome is to ensure the continuity of care from clinical practice to the patient ’s home , enabling also cost effectiveness and the empowerment of patient and caregiver in the care process , positively impacting on their quality of life . Trial registration Clinical Trials.gov ID : NCT02746484 ( registration date : 12/apr/2016 – retrospectively registered ) Increasing age , early menarche , late menopause , and nulliparity are factors associated with increased risk for breast cancer . Genetic factors also appear to be important in the cause of this disease [ 1 ] . Epidemiologic studies have indicated an association between breast cancer and diet : Obesity and a high intake of animal fat have been shown to correlate with breast cancer incidence and mortality rates [ 2 ] . The influence of body weight on prognosis after the diagnosis of breast cancer has also been studied [ 3 - 8 ] . Most investigators conclude that obese patients with breast cancer are more likely to develop recurrent disease after mastectomy and are more likely to do so sooner than their nonobese counterparts [ 3 - 8 ] . Whether obesity is an independent prognostic factor among women receiving adjuvant chemotherapy for lymph nodepositive breast cancer and how obesity relates to other prognostic indicators remain unclear . To address these questions , we investigated the correlation of obesity with probability of relapse , length of disease-free survival , and overall survival in 735 consecutive women with primary breast cancer who received surgery followed by adjuvant chemotherapy at The University of Texas M.D. And erson Cancer Center . Methods The patient sample selected for this analysis included 796 consecutive female patients with primary operable stage II ( tumor measuring < 5 cm ) or stage III ( tumor measuring > 5 cm , plus the presence of fixed or matted nodes , skin involvement , or both ) axillary lymph nodepositive breast cancer who consented to be treated using three consecutive adjuvant chemotherapy protocol s at the M. D. And erson Cancer Center between 1974 and 1982 [ 9 ] . The numbers of patients registered for these protocol s each year and included in this analysis were 5 , 43 , 83 , 98 , 67 , 77 , 114 , 122 , and 126 for the years 1974 through 1982 , respectively . All patients had histologically confirmed invasive breast cancer and no evidence of distant metastases after appropriate staging procedures . Local therapy consisted of total mastectomy with axillary dissection ; some women also received postoperative radiation therapy [ 9 ] . Adjuvant chemotherapy consisted of a combination of fluorouracil , doxorubicin ( Adriamycin , Adria Laboratories , Columbus , Ohio ) , and cyclophosphamide administered at 28-day intervals [ 10 ] . In the first two protocol s , when a cumulative dose of 300 mg/m2 of doxorubicin was achieved , therapy continued with fluorouracil , methotrexate , and cyclophosphamide until a 2-year treatment period was completed . The third protocol included vincristine , prednisone , and tamoxifen in addition to fluorouracil , doxorubicin , and cyclophosphamide , and the duration of therapy was reduced to 1 year . Adjuvant postoperative radiotherapy and nonspecific immunotherapy with bacille CalmetteGurin were given to patients in some subgroups , but this did not appear to influence outcome [ 11 ] . Detailed descriptions of these trials , including comparisons of outcome after adjusting for common prognostic indicators , have been reported [ 9 - 12 ] . Because adjusted relapse and survival rates for the three trials were remarkably similar , we pooled data for the patient groups to evaluate the effect of obesity . To supplement the st and ard computer data set maintained for patients included in adjuvant trials , medical records of all patients were review ed to obtain additional information on height and weight at the start of adjuvant therapy , smoking history , pathologic stage of disease [ 13 ] , date of first relapse , and date of last contact or death . Sixty-one patients ( 8 % ) were excluded from the analysis because information was not available on initial weight , leaving 735 patients in the study ( 182 treated in protocol 1 ; 217 in protocol 2 ; and 336 in protocol 3 ) . Nine ( 1 % ) of these patients were lost to follow-up . For each patient , ideal weight was assumed to be the upper limit of the range for a medium body frame for her height , as given by st and ard weight and height tables [ 14 ] . If the patient 's weight exceeded the ideal weight , the excess was computed as a percentage of the ideal weight . Obesity was defined as weight more than 20 % over ideal weight . No attempt was made to identify patients who weighed less than their ideal weight ; all patients weighing less than the table entry were coded as 0 . Body size , as measured by the Quetelet index ( weight in kilograms divided by height in meters , squared ) was also calculated and considered for analysis . Patients were considered to be postmenopausal if their last menses occurred more than 1 year before the diagnosis of breast cancer ; perimenopausal ( 1 to 5 years since last menses ) and postmenopausal patients were combined for this analysis . Disease-free and overall survival were measured beginning on the date adjuvant chemotherapy was initiated ( date of registration or r and omization ) . The follow-up times ranged from 2 to 17 years ( 4 patients were lost to follow-up before the fifth year and another 5 were lost after 7 years ) , and the median duration of follow-up for those patients still alive was 10.7 years . Of the 735 patients , 362 ( 49 % ) had disease recurrence and 298 ( 41 % ) died of breast cancer . An additional 51 ( 7 % ) women died of causes not related to breast cancer and , for the purpose s of this study of prognostic factors , these patients were counted as withdrawals from study ( that is , censored ) at their deaths to compute disease-free intervals and survival . Survival probabilities were estimated using the Kaplan-Meier [ 15 ] method , and differences in survival experience were evaluated by the log-rank test [ 16 ] . Regression modeling techniques [ 17 ] were used to evaluate the association of body size with risk for disease recurrence and death ; proportional-hazards assumptions were verified by graphic methods . The following terms were included in all models to control for differences in prognosis attributable to factors of recognized importance : menopausal status ( 0 = premenopause , 1 = postmenopause ) , stage of disease ( 0 = stage II , 1 = stage III ) , and number of involved axillary lymph nodes ( 0 = 3 ; 1 = 4 to 10 ; 2 = > 10 ) . Terms defining body size were evaluated by testing the significance of increase in maximized log-likelihood associated with the addition of a particular term to a model . The potential presence of interaction effects between obesity and other characteristics was tested by defining product terms for the respective factors in a regression model . The linear or quadratic nature of the association between body size and risk for disease recurrence was also evaluated using a proportional-hazards model . Chi-square tests were used to compare incidence of obesity according to other patient pretreatment characteristics . Significance levels were based on two-sided tests . Results Sixty-one percent of patients were within 10 % of their ideal weight ; 14 % weighed 10 % to 20 % more than their ideal weight ; 11 % weighed 20 % to 30 % more than their ideal weight , and 13 % weighed over 30 % more than their ideal weight . The incidence of obesity , as defined for this analysis , is presented in Table 1 for patients grouped by menopausal status , stage of disease , tumor size , and number of involved nodes . Obesity was more common among postmenopausal patients , those with stage III tumors , and those with tumors larger than 5 cm in diameter . Thus , obese patients tended to be at higher risk for recurrence because of other poor prognostic features . Information on estrogen receptor status was not available for many patients in the early clinical trials , but among the patients whose status was known ( approximately 50 % ) , 22 % with estrogen receptor-positive tumors were obese , compared with 19 % of those with estrogen receptor-negative tumors . Table 1 . Incidence of Obesity according to Other Patient and Disease Characteristics Disease-Free and Overall Survival With disease recurrence detected in 49 % of patients , the estimated 10-year disease-free survival rate for the entire patient group was 51 % ( SE = 2 % ) . Table 2 summarizes disease-free survival rates for patients grouped according to important prognostic features and two measures of body size . These results confirmed the importance of menopausal status , stage of disease , tumor size , and number of involved nodes in determining disease outcome among patients receiving adjuvant chemotherapy .  Although disease-free survival was marginally superior among patients with estrogen receptor-positive tumors , the difference according to estrogen receptor status did not approach statistical significance ( P = 0.39 ) . Statistically significant differences in disease-free survival were noted for patients classified according to body weight ( Figure 1 , Table 2 ) and Quetelet index , with excessive weight or body mass generally associated with shorter disease-free intervals . Although results do not rule out a linear association between obesity and outcome , the similarity between disease-free survival curves for the most obese patients and those 21 % to 30 % overweight suggested a constant influence of weight more than 20 % over ideal . The estimated hazard rates for treatment failure were highest between 12 and 48 months of follow-up , decreased rapidly during the subsequent 48 months , and remained stable thereafter . Most notably , after the second year there was a higher risk for disease recurrence among obese patients , which continued throughout the entire observation period . Table 2 . Disease-Free Survival Rates by Patient and Tumor Characteristics Figure 1 . Disease-free survival of all patients who received adjuvant chemotherapy  analyzed according to presence or absence of obesity ( > 20 % over ideal weight ) when therapy was initiated . Of the 735 patients , 298 women died of breast cancer , and 60 % were estimated to be alive 10 years after the initiation of adjuvant chemotherapy ( SE = 1.9 % ) . A similar analysis of obesity and overall survival results showed similar conclusions regarding the association of Background There is increasing evidence for the effectiveness of parental support programmes to promote healthy behaviours and prevent obesity in children , but only few studies have been conducted among groups with low socio-economic status . The aim of this study was to develop and evaluate the effectiveness of a parental support programme to promote healthy dietary and physical activity habits and to prevent overweight and obesity in six-year-old children in disadvantaged areas . Methods A cluster-r and omised controlled trial was carried out in disadvantaged areas in Stockholm . Participants were six-year-old children ( n = 378 ) and their parents . Thirty-one school classes from 13 schools were r and omly assigned to intervention ( n = 16 ) and control groups ( n = 15 ) . The intervention lasted for 6 months and included : 1 ) Health information for parents , 2 ) Motivational Interviewing with parents and 3 ) Teacher-led classroom activities with children .  Physical activity was measured by accelerometry , dietary intake and screen time with a question naire , body weight and height were measured and BMI st and ard deviation score was calculated . Measurements were conducted at baseline , post-intervention and at 5months follow-up . Group effects were examined using Mixed-effect Regression analyses adjusted for sex , parental education and baseline values . Results Fidelity to all three intervention components was satisfactory . Significant intervention effects were found regarding consumption of unhealthy foods ( p = 0.01 ) and unhealthy drinks ( p = 0.01 ) . At follow-up , the effect on intake of unhealthy foods was sustained for boys ( p = 0.03 ) . There was no intervention effect on physical activity . Further , the intervention had no apparent effect on BMI sds for the whole sample , but a significant difference between groups was detected among children who were obese at baseline ( p = 0.03 ) which was not sustained at follow-up . Conclusions The Healthy School Start study shows that it is possible to influence intake of unhealthy foods and drinks and weight development in obese children by providing individual parental support in a school context . However , the effects were short-lived . Therefore , the programme needs to be prolonged and /or intensified in order to obtain stronger and sustainable effects . This study is an important contribution to the further development of evidence -based parental support programmes to prevent overweight and obesity in children in disadvantaged areas Obesity in Chilean children has increased markedly over the past decades . School-based obesity prevention interventions have been launched by the Ministry of Health and academic groups to tackle this condition . We summarize the main characteristics of the interventions that we have conducted and reflect on the lessons learned . Since 2002 , we conducted 1 pilot study , a 2-y controlled intervention including 6- to 12-y-old children ( Casablanca ) , another pilot study , and a 2-y controlled intervention including teachers and their 4- to 9-y-old students ( Macul ) . Both interventions consisted of training teachers to deliver contents on healthy eating , increasing physical education classes , and , additionally in Macul , teachers participated in a wellness program .  BMI Z-score and obesity prevalence were compared among children in intervention and control schools by year and among students of intervention and control teachers . In the Casablanca study , the impact was greatest on the younger children during the first school year when the study received the full funding that was required . In Macul , although intervention teachers exhibited improvements in anthropometry and blood measures , the impact on the children was not related to their results . The main lessons learned from these experiences are r and om allocation of schools , although method ologically desirable , is not always possible ; participation of parents is very limited ; obesity is not recognized as a problem ; and increasing physical activity and implementing training programs for teachers is difficult due to an inflexible curriculum and lack of teachers ' time . Unless these barriers are overcome , obesity prevention programs will not produce positive and lasting outcomes Current physical activity and fitness levels among adolescents are low , increasing the risk of chronic disease . Although the efficacy of high intensity interval training ( HIIT ) for improving metabolic health is now well established , it is not known if this type of activity can be effective to improve adolescent health . The primary aim of this study is to assess the effectiveness and feasibility of embedding HIIT into the school day . A 3-arm pilot r and omized controlled trial was conducted in one secondary school in Newcastle , Australia . Participants ( n = 65 ; mean age = 15.8(0.6 ) years ) were r and omized into one of three conditions : aerobic exercise program ( AEP ) ( n = 21 ) , resistance and aerobic exercise program ( RAP ) ( n = 22 ) and control ( n = 22 ) . The 8-week intervention consisted of three HIIT sessions per week ( 8–10 min/session ) , delivered during physical education ( PE ) lessons or at lunchtime . Assessment s were conducted at baseline and post-intervention to detect changes in cardiorespiratory fitness ( multi-stage shuttle-run ) , muscular fitness ( push-up , st and ing long jump tests ) , body composition ( Body Mass Index ( BMI ) , BMI -z scores , waist circumference ) and physical activity motivation ( question naire ) , by research ers blinded to treatment allocation . Intervention effects for outcomes were examined using linear mixed models , and Cohen 's d effect sizes were reported . Participants in the AEP and RAP groups had moderate intervention effects for waist circumference ( p = 0.024 ) , BMI -z ( p = 0.037 ) and BMI ( not significant ) in comparison to the control group . A small intervention effect was also evident for cardiorespiratory fitness in the RAP group AIMS Drug-induced long QT syndrome ( diLQTS ) leading to Torsade de Pointes ( TdP ) is a potentially lethal condition , which has led to several post-marketing drug withdrawals in the past decade . The true incidence of diLQTS/TdP is largely unknown . One explanation is under-reporting of this potentially life-threatening adverse event by physicians and other medical staff to pharmacovigilance agencies . To gain more insight into the incidence of diLQTS and TdP , the Berlin Pharmacovigilance Center ( PVZ-FAKOS ) has actively and prospect ively identified patients who developed this particular type of drug-induced adverse event . Here , the basic characteristics of the affected patients are summarized and suspected drugs are discussed . Furthermore , an extrapolation of the Berlin incidence rates to the German St and ard Population is presented . METHODS AND RESULTS Using a Berlin-wide network of 51 collaborating hospitals ( > 180 clinical departments ) , adult patients presenting with long QT syndrome ( LQTS/TdP ) between 2008 and 2011 were identified by active surveillance of these hospitals . Drug exposures as well as other possible risk factors were obtained from the patient 's files and in a face-to-face interview with the patient . One-hundred and seventy patients of possible LQTS/TdP were reported to the Pharmacovigilance Center of whom 58 cases were confirmed in a thorough validation process . The majority ( 66 % ) of these cases were female and 60 % had developed LQTS/TdP in the outpatient setting . Thirty-five ( 60 % ) of 58 confirmed cases were assessed as drug-related based on a st and ardized causality assessment applying the criteria of the World Health Organization . Drugs assessed as related in more than two cases were metoclopramide , amiodarone , melperone , citalopram , and levomethadone . The age-st and ardized incidence of diLQTS/TdP in Berlin was estimated to be 2.5 per million per year for males and 4.0 per million per year for females . CONCLUSION While European annual reporting rates based on spontaneous reports suggest an annual diLQTS/TdP incidence of 0.26 per million in Germany , we estimated a considerably higher incidence of diLQTS/TdP in an active surveillance approach . Further measures are warranted to better sensitize physicians against this potentially life-threatening drug-induced adverse event Worldwide globalization and Westernization in social and economic aspects have led to drastic changes in South Korea during the past several decades . These changes include individual health behaviours , which were reflected as increased prevalence of non-communicable chronic diseases ( NCDs ) , such as type 2 diabetes mellitus ( T2DM ) , hypertension , obesity and cardiovascular disease ( CVD ) . These NCDs are known to be caused by both environmental risk factors and predisposing genetic factors . Population decline is another issue in South Korea ; the recorded fertility rate was 1.3 births per woman , and 10 % of the population were elderly individuals aged 65 years according to the Population and Housing Census results of 2005 - 2010 . We have also been observing an increased influx and efflux of the population due to globalization . In particular , there has been a rising tendency in the marriage-based inflow of South Asian women during the last decade . To attempt to solve public health issues result ing from these population trends and prepare for personalized and preventive health care in the future , the Korean government ( National Research Institute of Health ( NIH ) , Centers for Disease Control and Prevention and the Ministry of Health and Welfare , Korea ) initiated a large prospect i ve cohort study with government funding , named the Korean genome and epidemiology study ( KoGES ) . The study is a consortium project consisting of six prospect i ve cohort studies that would be categorized into population -based and geneenvironment model studies ( Figure 1 ) . The aim of the KoGES was to establish a genome epidemiological study platform for the research community with a health data base and biobank , to investigate the genetic and environmental aetiology of common complex diseases in Koreans ( i.e. T2DM , hypertension , obesity , metabolic syndrome , osteoporosis , CVD , and cancer ) and causes of death with longterm follow-up . The ultimate goal of the KoGES was to develop comprehensive and applicable health care guidelines for common complex diseases in Koreans , reduce the burden of chronic diseases and improve the quality of life Background This study investigates prospect i ve associations of anthropometrical and lifestyle indices with  insulin resistance ( IR ) in European children from the IDEFICS cohort . Insulin resistance ( IR ) is a growing concern in childhood obesity and a central aspect of the metabolic syndrome ( MS ) . It most likely represents the link between obesity and type 2 diabetes . Methods This longitudinal study included 3348 preadolescent children aged 3 to 10.9 years from 8 European countries who were observed from 2007/2008 to 2009/2010 . The main outcome measure in the present analysis is HOMA-IR ( homeostasis model assessment as a common proxy indicator to quantify IR ) at follow-up and in its longitudinal development .  Anthropometrical measures and lifestyle indices  , including objective ly determined physical activity  , were considered , among others factors , as determinants of IR . Prospect i ve associations between IR at follow-up and anthropometrical and lifestyle indices were estimated by logistic regression models . Results Country-specific prevalence rates of IR in the IDEFICS cohort of European children showed a positive trend with weight category . Prospect i ve multivariate analyses showed the strongest positive associations of IR with BMI z-score ( OR = 2.6 for unit change from the mean , 95 % CI 2.1–3.1 ) and z-score of waist circumference ( OR = 2.2 for unit change from the mean , 95 % CI 1.9–2.6 ) , which were analysed in separate models , but also for sex ( OR = 2.2 for girls vs. boys , 95 % CI 1.5–3.1 up to OR 2.5 , 95 % CI 1.8–3.6 depending on the model ) , audio-visual media time ( OR = 1.2 for an additional hour per day , 95 % CI 1.0–1.4 in both models ) and an inverse association of objective ly determined physical activity ( OR = 0.5 for 3rd compared to 1st quartile , 95 % CI 0.3–0.9 in both models ) . A longitudinal reduction of HOMA-IR was accompanied with a parallel decline in BMI . Conclusions This study is , to our knowledge , the first prospect i ve study on IR in a preadolescent children ’s population . It supports the common hypothesis that overweight and obesity are the main determinants of IR . Our data also indicate that physical inactivity and a sedentary lifestyle are likewise associated with the development of IR , independent of weight status . The promotion of physical activity should thus be considered as an equal option to dietary intervention for the treatment of IR in the paediatric practice The purpose of this study was to examine the independent and combined association of physical activity ( PA ) and sitting time ( ST ) with  all-cause mortality in older adults with diabetes . A total of 611 individuals representative of the Spanish diabetic population aged ≥ 60 years . Participants were selected in 2000/2001 and were prospect ively followed-up through 2011 .  PA and ST were self-reported at baseline . Study associations were summarized as hazard ratios ( HR ) and their 95 % confidence interval ( CI ) . During a mean follow-up of 8.3 years , 282 deaths occurred . The HR ( 95 % CI ) of mortality for very/moderately active individuals compared to those who were inactive/less active was 0.59 ( 0.45 , 0.78 ) . The association between ST and mortality was non-linear ( P<0.001 in spline analysis ) , and mortality was increased only among individuals who reported a ST>8 h/day ( HR=1.77 , 95 % CI 1.25 , 2.52 ) . The HR ( 95 % CI ) of mortality was 0.50 ( 0.32 , 0.77 ) in participants who either were very/moderately active or had ST≤8 h/day , and 0.32 ( 0.20 , 0.50 ) in those with both health behaviors , compared to those with none of these behaviors . In conclusion , among older adults with diabetes  , high PA and less ST are independently and jointly associated with lower risk of all-cause mortality BACKGROUND Obesity and mental health disorders are 2 major public health problems in American adolescents , with prevalence even higher in Hispanic teens . Despite the rapidly increasing incidence and adverse health outcomes associated with overweight and mental health problems , very few intervention studies have been conducted with adolescents to improve both their healthy lifestyles and mental health outcomes . Even fewer studies have been conducted with Hispanic youth . The purpose of this study was to evaluate the preliminary efficacy of the COPE ( Creating Opportunities for Personal Empowerment ) Healthy Lifestyles TEEN ( Thinking , Emotions , Exercise , and Nutrition ) program , a manualized educational and cognitive behavioral skills-building program , on Hispanic adolescents ' healthy lifestyle choices as well as mental and physical health outcomes . METHODS A cluster r and omized controlled pilot study was conducted with 19 Hispanic adolescents enrolled in 2 health classes in a southwestern high school . One class received COPE and the other received an attention control program . RESULTS Adolescents in the COPE program increased their healthy lifestyle choices and reported a decrease in depressive and anxiety symptoms from baseline to postintervention follow-up . A subset of 7 overweight adolescents in the COPE program had a decrease in triglycerides and an increase in high-density lipoproteins . In addition , these overweight adolescents reported increases in healthy lifestyle beliefs and nutrition knowledge along with a decrease in depressive symptoms . CONCLUSION The COPE TEEN program is a promising school-based strategy for improving both physical and mental health outcomes in adolescents CONTEXT Physical activity has been shown to decrease the incidence of breast cancer , but the effect on recurrence or survival after a breast cancer diagnosis is not known . OBJECTIVE To determine whether physical activity among women with breast cancer decreases their risk of death from  breast cancer  compared with more sedentary women . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve observational study based on responses from 2987 female registered nurses in the Nurses ' Health Study who were diagnosed with stage I , II , or III breast cancer between 1984 and 1998 and who were followed up until death or June 2002 , whichever came first . MAIN OUTCOME MEASURE Breast cancer mortality risk according to  physical activity  category ( <3 , 3 - 8.9 , 9 - 14.9 , 15 - 23.9 , or > or = 24 metabolic equivalent task [ MET ] hours per week ) . RESULTS Compared with women who engaged in less than 3 MET-hours per week of physical activity , the adjusted relative risk ( RR ) of death from breast cancer was 0.80 ( 95 % confidence interval [ CI ] , 0.60 - 1.06 ) for 3 to 8.9 MET-hours per week ; 0.50 ( 95 % CI , 0.31 - 0.82 ) for 9 to 14.9 MET-hours per week ; 0.56 ( 95 % CI , 0.38 - 0.84 ) for 15 to 23.9 MET-hours per week ; and 0.60 ( 95 % CI , 0.40 - 0.89 ) for 24 or more MET-hours per week ( P for trend = .004 ) . Three MET-hours is equivalent to walking at average pace of 2 to 2.9 mph for 1 hour . The benefit of physical activity was particularly apparent among women with hormone-responsive tumors . The RR of breast cancer death for women with hormone-responsive tumors who engaged in 9 or more MET-hours per week of activity compared with women with hormone-responsive tumors who engaged in less than 9 MET-hours per week was 0.50 ( 95 % CI , 0.34 - 0.74 ) . Compared with women who engaged in less than 3 MET-hours per week of activity , the absolute unadjusted mortality risk reduction was 6 % at 10 years for women who engaged in 9 or more MET-hours per week . CONCLUSIONS Physical activity after a breast cancer diagnosis may reduce the risk of death from this disease . The greatest benefit occurred in women who performed the equivalent of walking 3 to 5 hours per week at an average pace , with little evidence of a correlation between increased benefit and greater energy expenditure . Women with breast cancer who follow US physical activity recommendations may improve their survival OBJECTIVE To assess the impact of an obesity prevention intervention on use of self-induced vomiting/laxatives ( purging ) and diet pills to control weight in girls in early adolescence . DESIGN We matched and r and omly assigned 10 middle schools to an  intervention  or a  control condition  in a r and omized controlled trial . Longitudinal multivariable analyses using generalized estimating equations were conducted with data from 480 girls to examine the effects of the intervention on the risk of reporting a new case of purging or diet pill use to control weight at follow-up 21 months later , while controlling for ethnicity and school matched pairs . Girls who reported purging or using diet pills at baseline were excluded from analyses . SETTING Middle schools . PARTICIPANTS Four hundred eighty girls in early adolescence aged 10 to 14 years ( mean age , 11.5 years ) . INTERVENTION The Planet Health obesity prevention program was implemented during 2 school years and was design ed to promote healthful nutrition and physical activity and to reduce television viewing . OUTCOME Reduced risk of using self-induced vomiting/laxatives or diet pills to control weight in the past 30 days . RESULTS After the intervention , we found 14 ( 6.2 % ) of 226 girls in control schools and 7 ( 2.8 % ) of 254 girls in intervention schools reported purging or using diet pills to control their weight ( P = .003 ) . In a multivariable generalized estimating equation model , girls in intervention schools were less than half as likely to report purging or using diet pills at follow-up compared with girls in control schools ( odds ratio , 0.41 ; 95 % confidence interval , 0.22 - 0.75 ) . CONCLUSION These findings provide promising evidence that school-based interventions may effectively integrate prevention of both obesity and disordered weight-control behaviors Objective To quantify associations of chronic kidney disease stages with  major cardiovascular disease and non-vascular mortality in the general adult population . Design Prospect i ve population based cohort study . Setting Reykjavik , Icel and . Participants 16 958 people aged 33 - 81 years without manifest vascular disease and with available information on stage of chronic kidney disease ( defined by both estimated glomerular filtration rate and urinary protein ) at study entry . Main outcome measures Hazard ratios for time to major coronary heart disease outcomes and mortality . Results 1210 ( 7 % ) of participants had chronic kidney disease at entry . During a median follow-up of 24 years , 4010 coronary heart disease outcomes , 559 deaths from stroke , and 3875 deaths from non-vascular causes were recorded . Compared with the reference group ( estimated glomerular filtration rate 75 - 89 ml/min/1.73 m2 and no proteinuria ) , people with lower renal function within the normal range of glomerular filtration rate did not have significantly higher risk of coronary heart disease . By contrast , in 1210 ( 7 % ) participants with chronic kidney disease at entry , hazard ratios for coronary heart disease , adjusted for several conventional cardiovascular risk factors , were 1.55 ( 95 % confidence interval 1.02 to 2.35 ) for stage 1 , 1.72 ( 1.30 to 2.24 ) for stage 2 , 1.39 ( 1.22 to 1.58 ) for stage 3a , 1.90 ( 1.22 to 2.96 ) for stage 3b , and 4.29 ( 1.78 to 10.32 ) for stage 4 . Information on chronic kidney disease increased discrimination and reclassification indices for coronary heart disease when added to conventional risk factors ( P<0.01 ) . The incremental gain provided by chronic kidney disease was lower than that provided by diabetes or smoking ( C index increases of 0.0015 , 0.0024 , and 0.0124 respectively ) . Hazard ratios with chronic kidney disease were 0.97 ( 0.82 to 1.15 ) for cancer mortality and 1.26 ( 1.07 to 1.50 ) for other non-vascular mortality . Conclusions In people without manifest vascular disease , even the earliest stages of chronic kidney disease are associated with excess risk of subsequent coronary heart disease . Assessment of chronic kidney disease in addition to conventional risk factors modestly improves prediction of risk for coronary heart disease in this population . Further studies are needed to investigate associations between chronic kidney disease and non-vascular mortality from causes other than cancer OBJECTIVE While low physical activity and high body mass index ( BMI ) have been associated with higher endometrial cancer incidence , no previous studies have evaluated the association between physical activity and survival after endometrial cancer diagnosis , and studies on BMI and survival have not been performed in a prospect i ve cohort . METHODS We examined pre-diagnosis BMI and moderate- to vigorous-intensity physical activity in relation to overall and disease-specific survival among 983 postmenopausal women who were diagnosed with endometrial cancer in the Women 's Health Initiative Observational Study and Clinical Trials . RESULTS Over a median 5.2 ( max 14.1 ) years from diagnosis to death or end of follow-up , 163 total deaths were observed , 66 of which were due to endometrial cancer . We observed a higher all-cause mortality hazard ratio ( HR ) = 1.85 ( 95 % CI 1.19 - 2.88 ) comparing women with a BMI ≥ 35 kg/m(2 ) to women with BMI < 25 kg/m(2 ) . For endometrial cancer-specific mortality the HR = 2.23 ( 95 % CI 1.09 - 4.54 ) comparing extreme BMI categories . To examine histologic subtypes we analyzed type I endometrial tumors separately and found an HR = 1.20 ( 95 % CI 1.07 - 1.35 ) associated with all-cause mortality for each 5-unit change in BMI . Moderate- to vigorous-intensity physical activity was not associated with all-cause or endometrial cancer-specific mortality . CONCLUSIONS Pre-diagnosis BMI , but not physical activity , was associated with survival among women with endometrial cancer . Future studies should investigate mechanisms and timing of BMI onset to better underst and the burden of disease attributable to BMI PURPOSE To investigate the effect of a six-month teacher-led osteogenic physical activity program , vs. a self-led activity program , on ultrasound measurements of bone in inactive teenage girls . METHODS Ninety sedentary girls [ mean ( SD ) age 16.3 ( .6 ) years ] were identified from 300 assessed for physical activity across five schools in southeast Irel and . Schools were matched and r and omly assigned to a teacher-led physical activity ( TLPA ) program , a self-led physical activity ( SLPA ) program , or a control group .  Broadb and ultrasound attenuation ( BUA ) , speed of sound ( SOS ) , and os calcis stiffness index ( OCSI ) were measured using a portable ultrasound machine . Anthropometry , aerobic fitness , calcium intake , and physical activity were assessed , and focus groups held one month after program completion . Descriptive statistics , paired t-tests , and analysis of variance were used to analyze the data . RESULTS Both intervention groups demonstrated significant improvements ( p < .05 ) in BUA , SOS , OCSI and aerobic fitness , i.e. , TLPA : + 14.9 % , + 21.9 % , + 15.9 % , and + 8.5 % , respectively , and SLPA : + 10.6 % , + 30.3 % , + 15.6 % , and + 5.1 % , respectively , with no change in controls . Differences between intervention groups and controls were significant for BUA and OCSI ( p < .05 ) . TLPA and SLPA groups engaged in an average of 4.5 and 3.4 hours/week of physical activity , respectively , over the intervention period . The SLPA group continued to exercise after the intervention had ceased , whereas the TLPA group did not . CONCLUSIONS Previously inactive teenage girls can adhere to an  osteogenic  activity program whether supervised or directing their own activity . Longer-term , sustainable initiatives with this age group are needed and might focus on developing personal skills for physical activity PROBLEM Tobacco use is a major contributor to deaths from chronic diseases . The findings from the Global Youth Tobacco Survey ( GYTS ) suggest that the estimate of a doubling of deaths from smoking ( from 5 million per year to approximately 10 million per year by 2020 ) might be an underestimate because of the increase in smoking among young girls compared with adult females , the high susceptibility of smoking among never smokers , high levels of exposure to secondh and smoke , and protobacco indirect advertising . REPORTING PERIOD COVERED This report includes GYTS data collected during 2000 - 2007 from 140 World Health Organization ( WHO ) member states , six territories ( American Samoa , British Virgin Isl and s , Guam , Montserrat , Puerto Rico , and the U.S. Virgin Isl and s ) , two geographic regions ( Gaza Strip and West Bank ) , one United Nations administered province ( Kosovo ) , one special administrative region ( Macau ) , and one Commonwealth ( Northern Mariana Isl and s ) . For countries that have repeated GYTS , only the most recent data are included . For countries with multiple survey sites , only data from the capital or largest city are presented . DESCRIPTION OF SYSTEM GYTS is a school-based survey of a defined geographic site that can be a country , a province , a city , or any other geographic entity . GYTS uses a st and ardized methodology for constructing sampling frames , selecting schools and classes , preparing question naires , conducting field procedures , and processing data . GYTS st and ard sampling methodology uses a two-stage cluster sample design that produces sample s of students in grade s associated with students aged 13 - 15 years . Each sampling frame includes all schools ( usually public and private ) in a geographically defined area containing any of the identified grade s. In the first stage , the probability of schools being selected is proportional to the number of students enrolled in the specified grade s. In the second sampling stage , classes within the selected schools are selected r and omly . All students in selected classes attending school the day the survey is administered are eligible to participate . Student participation is voluntary and anonymous using self-administered data collection procedures . The GYTS sample design produces independent , cross-sectional estimates that are representative of each site . RESULTS The findings in this report indicate that the level of cigarette smoking between boys and girls is similar in many sites ; the prevalence of cigarette smoking and use of other tobacco products is similar ; and susceptibility to initiate smoking among never smokers is similar among boys and girls and is higher than cigarette smoking in the majority of sites . Approximately half of the students reported that they were exposed to secondh and smoke in public places during the week preceding the survey . Approximately eight in 10 favor a ban on smoking in public places . Approximately two in 10 students own an object with a cigarette br and logo on it , and one in 10 students have been offered free cigarettes by a tobacco company representative . Approximately seven in 10 students who smoke reported that they wanted to stop smoking . Approximately seven in 10 students who smoked were not refused purchase of cigarettes from a store during the month preceding the survey . Finally , approximately six in 10 students reported having been taught in school about the harmful effects of smoking during the year preceding the survey . INTERPRETATION The findings in this report suggest that interventions that decrease tobacco use among youth ( e.g. , increasing excise taxes , media campaigns , school programs in conjunction with community interventions , and community interventions that decrease minors ' access to tobacco ) must be broad-based , focused on boys and girls , and have components directed toward prevention and cessation . If effective programs are not developed and implemented soon , future morbidity and mortality attributed to tobacco probably will increase . PUBLIC HEALTH ACTION The synergy between countries in passing tobacco-control laws , regulations , or decrees ; ratifying the WHO Framework Convention on Tobacco Control ; and conducting GYTS offers a unique opportunity to develop , implement , and evaluate comprehensive tobacco-control policy that can be helpful to each country . The challenge for each country is to develop , implement , and evaluate a tobacco-control program and make changes where necessary Finl and is a Northern European ( Nordic ) country with an economy traditionally based on agriculture , particularly milk production , and forestry . After the war , the country experienced rapid industrialisation . The interplay between a growing economy and traditional habits result ed in increased consumption of fatty dairy products , with unfavourable effects on lipid metabolism and risk of CVD . High serum cholesterol levels were found to be characteristic for lumberjacks in a health survey performed in the 1950s in Eastern Finl and . Subsequently , two cohorts of Finnish men were included in a prospect i ve cross-cultural study on CHD in seven countries . Men in the Eastern cohort showed the highest intake of SFA , the highest mean serum cholesterol levels and the highest mortality in CHD among the fifteen cohorts of the study . Men in the Southwestern cohort showed lower risk levels that were comparable to the levels in the Netherl and s and the Unites States . At the same time middle-aged Finnish men were found to have the highest CHD mortality in the world according to the WHO statistics . Awareness of the association between diet and the risk of CHD has prompted the development of surveys and the monitoring of risk factors and nutrition in the Finnish population . In this special issue , the subsequent development of nutrition in Finl and over the past 30 years is review ed , mainly on the basis of the activities of the National Public Health Institute , renamed after a reorganisation in 2009 , the National Institute for Health and Welfare . The diet of population sample s from different areas of the country was surveyed in 1967–1973 , and , starting in 1982 , the food habits of sub sample s from the FINRISK risk factor surveys have been studied at 5-year intervals . The model , originally tested in the North Karelia project in two Eastern provinces , was exp and ed first to cover an area in the Southwest and subsequently the capital area in the South , and the districts of Oulu and Lapl and in the North . The most recent FINDIET 2007 survey indicated a definite improvement in the dietary habits of adult Finns , particularly in the fatty acid composition and in salt intake . Mean serum cholesterol levels have declined by 20 % during the past 25 years , and changes in dietary fat composition explain 60–65 % of the decline . A decline in the initially high CHD mortality began in the late 1960s and has continued ever since . Between 1982 and 1997 the age-adjusted mortality declined by 63 % , and 37 % of this decline was estimated to result from serum cholesterol lowering . Several factors have been involved in the positive development observed in Finl and . Availability of reduced-fat dairy and meat products has been facilitated by the product developments of the food industry . Dietary fat modification has been promoted by domestic rapeseed crops and the production of rapeseed oil , which is now the principal vegetable oil and the main ingredient of soft fat spreads used in Finl and . The increased availability of imported fruit and vegetables has reduced the seasonal variation of intakes and explains the 3to 4-fold increase in average consumption . Dietary recommendations for the population were introduced in 1981 and have been revised regularly , during recent years in collaboration with the other Nordic countries . One of the major objectives of the recommendations is to act as guidelines for planning of diets in mass catering . In Finl and , findings reflecting the influence of the recommendations include healthier food choices by people who use the catering services of worksite canteens and children who consume school meals and the more balanced diet of pre-school children attending day care outside home compared with those cared for at home . Despite the decrease in classical cardiovascular risk factors and in cardiovascular mortality , obesity and the incidence of type 2 diabetes have continued to increase in Finl and . More than 10 % of the adult Finnish population are estimated to have type 2 diabetes , about one-half of them unaware that they have the disease . The possibilities of preventing the manifestation of type 2 diabetes in atrisk individuals were highlighted in the Finnish Diabetes Prevention Study , co-ordinated by the National Public Health Institute and conducted in the five university hospital districts of Finl and . The multi-factorial programme including modest weight reduction , reduction in intakes of total fat and SFA , increased intake of fibre and regular ( .30 min/d ) physical activity  reduced the incidence of diabetes by 58 % and prevented diabetes in all those subjects who were able to fulfil four or five of the five goals of the intervention programme . The lessons learned from the present study are being applied in projects on detection and prevention of diabetes in several hospital districts across the country . The Finnish government has been slow in establishing guidelines on nutrition and incorporating them in policy , but in June 2008 the current cabinet presented a resolution on guidelines for health-enhancing physical activity and nutrition that was accepted as part of a policy programme for health promotion . The resolution suggests that promotion of health-enhancing physical activity and healthy diets should take place by influencing culture , living environments , life circumstances , food Weight loss and regain is a common pattern in modern society .  Weight gain occurs frequently , as shown by the prevalence of obesity , which is at an all-time high in the United States [ 1 , 2 ] . Weight loss is common , as suggested by the rates of dieting . It has been estimated that approximately 50 % of women and 27 % of men are dieting at any given time [ 3 ] . The rates are even higher among young women [ 4 ] , and several recent case reports have described infants who failed to thrive because they were placed on diets to prevent obesity [ 5 ] . Dieting and weight loss are not confined to obese persons . Approximately 25 % of adult American women are clinical ly overweight , but twice as many are dieting [ 13 ] . Because few diets are successful [ 6 ] , weight loss , weight regain , and repeated weight fluctuation ( weight cycling or yo-yo dieting ) occur in many people . If weight variability is associated with negative health outcomes , the public health impact could be substantial because of the number of people affected . The few studies to examine weight variability report consistent associations between weight change and negative health outcomes [ 79 ] . Weight variability was not associated with death , however , in the Baltimore Longitudinal Study of Aging [ 10 ] . One weakness of earlier studies has been the infrequent measurement of weight . In the Framingham Heart Study , for example , weights were measured every 2 years . Our study was design ed to test the hypothesis that weight change is associated with an increased risk for all-cause and cause-specific mortality in a group of men participating in a longitudinal study for whom frequent weights were available . Data from the Multiple Risk Factor Intervention Trial ( MRFIT ) permitted a more sensitive measure of weight variability than had been available in previous studies . Methods Study Sample The MRFIT was a r and omized , multicenter , primary prevention trial design ed to test whether intensive intervention would result in decreased mortality rates from coronary heart disease . Men 35 to 57 years old were screened from 1973 to 1976 at 22 clinical centers in the United States . A total of 361 662 men were screened , and 12 866 who were in the upper 10 % to 15 % of risk for coronary heart disease ( but without clinical evidence of coronary heart disease ) were selected for the trial . Men who weighed more than 1.5 times their ideal weight were excluded . Participants were assigned r and omly to either a special intervention ( SI ) or usual care ( UC ) group . The protocol s for selection , r and omization , and intervention have been described previously [ 11 , 12 ] . Of those men who were alive at the seventh anniversary of their r and omization date ( SI group , 6164 ; UC group , 6171 ) , further exclusions were made if a study participant missed both his sixth and seventh annual visits ( SI group , 432 ; UC group , 526 ) , if during the trial he had been diagnosed with present or suspected cancer ( SI group , 287 ; UC group , 328 ) , if he had three or fewer recorded weights ( SI , 67 ; UC , 78 ) , or if an error was suspected in a recorded weight ( exclusions were based on a recorded weight of 1.96 st and ard deviations greater or less than the average weight calculated from all other visits and on a recorded weight 15 % above or below the weights of the preceding and following weights ) ( 28 men in the SI group and 60 in the UC group ) . After these exclusions , 10 529 men ( 5350 in the SI group and 5179 in the UC group ) remained for analysis . Design This study was design ed to provide a chronologic separation of body weight measurement and disease end points . Measured body weights were used for the 6 to 7 years that men were in the intervention phase of the trial . Men in the UC group had weights measured at annual visits , and men in the SI group were weighed every 4 months . The analysis included deaths that occurred after a seventh annual visit if a participant had attended that visit ; otherwise , deaths occurring after the seventh anniversary of r and omization were used . Follow-up continued through 31 December 1985 ( average , 3.8 years ) . This procedure separated the temporal sequence of weight change and death . Because disease could cause weight to change and because weight change and disease could be coincidental , this separation was used to avoid confounding created by a causal link between disease and weight change . For this reason , we excluded men who were diagnosed as having cancer .  Weights were measured each time the participant attended a regularly scheduled clinic visit . Procedures for the visits , including methods for measuring weight and ascertaining levels of risk factors , have been described in detail previously [ 13 , 14 ] . Weight change during the intervention phase of the trial was measured in two ways . The first was the participant 's st and ard deviation of the weight measurements taken at each visit , called the intrapersonal st and ard deviation of weight ( ISD ) . The ISD is a continuous measure of general weight variability , which increases as the differences in weights across all visits increase . For example , a participant whose weight was 90 kg at the first visit and whose weight declined by 2 kg at each of the next six visits ( so that at his last visit his weight was 80 kg ) would have an ISD of 3.74 . If this participant lost 10 kg between the first and second visits and subsequently gained 2 kg at each of the next five visits , his ISD would be the same . This example shows that the ISD reflects magnitude of variability , not the type of weight change . For this reason , a second method was developed to measure the type of weight change within one of five categories : 1 ) No change was defined as a change of less than 5 % from baseline at all visits ; 2 ) steady loss , as a loss 5 % of a previous weight that was not regained ; 3 ) steady gain , as a gain 5 % of a previous weight that was not subsequently lost ; 4 ) cycle with last change a loss , as a loss 5 % of weight that previously had been gained ; and 5 ) cycle with last change a gain , as a gain of 5 % or more of weight that previously had been lost . In both cycle categories , multiple cycles were possible ; however , multiple cycles were difficult to detect when only 6 or 7 annual measurements were observed . Many more weight measurements were available for men in the SI group because these participants were invited to attend the clinic ( and have their weights measured ) at 4-month intervals throughout the trial . To compare results using more frequent measures of weight , some analyses were repeated only for men in the SI group using the weights from all visits to calculate ISD of weight and to note the type of weight change . Ascertainment of Death Ascertainment of death was achieved through the U.S. Social Security Administration and from the National Death Index of the National Center for Health Statistics . Death certificates were obtained and coded for underlying cause of death by two trained nosologists with the use of the International Classification of Diseases , Ninth Revision ( ICD-9 ) ; differences were adjudicated by a third nosologist . Among the 10 529 men included in this analysis , all-cause mortality  result ed in 380 deaths , and  cardiovascular disease result ed in 228 deaths ( ICD-9 390 - 459 ) . Statistical Analysis The association between weight variability and death was evaluated using Cox proportional-hazards models , adjusting for baseline covariates that were associated with variability in weight [ 15 ] . The baseline covariates included age , race , study group , physical activity , body mass index ( BMI ) , diastolic blood pressure , number of cigarettes smoked per day , serum cholesterol level , reported number of alcoholic drinks per week , and use of antihypertensive medications . We also evaluated other models in which change in weight and change in other risk factors ( blood pressure , serum cholesterol , cigarettes per day , physical activity , alcohol intake , and antihypertensive drugs ) over the intervention phase of the study were added . These findings did not material ly change the results , and only data from the former models are presented here . To reduce further the possibility that any association between weight variability and death could be explained by pre-existing disease , analyses were done with the exclusion of men who experienced nonfatal events during the trial . Because results were unchanged compared with analyses using all men , only the results from the latter analyses are reported . ( Nonfatal events included nonfatal myocardial infa rct ion , significant serial electrocardiographic changes suggestive of myocardial infa rct ion , stroke , congestive heart failure , renal failure , and digitalis use . ) Because cigarette smoking is associated with both weight and death , analyses were stratified by smoking behavior during the trial to determine whether observed associations between weight variability and mortality could be attributed to changes in smoking behavior . Three smoking groups were created : continuous smokers ( those who at every annual visit either reported smoking or had a serum thiocyanate value 17.2 mmol/L ) ; never smokers ( those who at every annual visit both reported not smoking and had a serum thiocyanate value < 17.2 mmol/L ) ; and intermittent smokers ( those who would be classified as smokers at some visits and nonsmokers at others , thus including all those whose smoking behavior changed during the trial ) . Both the continuous smokers and the never smokers had smoking behaviors that did not change during the trial . Results After exclusions , 10 529 men remained for analysis . Descriptive information on selected baseline variables and weight change during the trial for these men , stratified by smoking behavior during the trial , is shown in Table 1 . The distribution of types of weight change differed by smoking status during the trial . Compared with those whose smoking behavior never changed , intermittent smokers were most likely to gain weight without losing it and were least likely to have no change in Background Overweight and obesity among adolescents may have consequences , with potentially lasting effects on health and health-related quality of life ( HRQoL ) . Excess weight is also associated with decreases in physical activity and cardiorespiratory fitness . The aim of the current study was to investigate the short-term effects of a 12-week Internet intervention in a primary care setting intended to increase cardiorespiratory fitness and HRQoL among overweight and obese adolescents . Methods In this controlled trial , participants ( 13–15 years ) were non-r and omly allocated to an intervention- or a control group . The intervention group received 12-weeks access to an online program providing tailored physical activity counseling based on principles from Self-determination Theory and Motivational Interviewing . The control group received st and ard follow-up by the school nurses . The primary outcome measure of cardiorespiratory fitness was determined using a shuttle run test . The secondary outcomes : HRQoL , leisure time exercise , body image and self-determined motivation for physical activity and exercise , were assessed by self-report measures . Age- and gender-adjusted body mass index ( BMI ) was calculated based on measurements of height and weight . To compare pre-to post intervention differences within groups , a paired sample s t-test was used while crude differences between groups were analyzed with an independent sample s t-test . Results Of the 120 participants , 108 completed the study , 75 in the intervention group and 33 in the control group . Exposure to the intervention had a small effect on cardiorespiratory fitness ( 0.14 ; 95 % CI [ 0.01;0.28 ] ; P = 0.04 ) , and a moderate effect on HRQoL ( 5.22 ; 95 % CI [ 0.90 ; 9.53 ] ; P = 0.02 ) . Moreover , the control group increased significantly in BMI , yielding a moderate preventive effect on BMI ( −0.39 ; 95 % CI [ −0.74;−0.03 ] ; P = 0.03 ) for the intervention group . Conclusion The results suggest that the Internet intervention with tailored physical activity counseling can have beneficial short-term effect on cardiorespiratory fitness , HRQoL and BMI among adolescents with overweight and obesity . Trial Registration Clinical Trials.gov BACKGROUND AND OBJECTIVE Physical inactivity and an unhealthy diet have been implicated as risk factors for several chronic diseases that are known to be associated with periodontitis , such as cardiovascular diseases , obesity and diabetes . Studies investigating the relationship between periodontitis and physical activity and diet are limited . Therefore , this study was conducted to determine the relationship between physical activity , healthy eating habits and periodontal health status . MATERIAL AND METHODS A systematic r and om sample of 340 persons , 18 - 70 years of age , was selected from persons accompanying their relative patients who attended the outpatient clinics in the medical center of Jordan University of Science and Technology in north of Jordan . Data collected included socio-demographic and clinical characteristics , anthropometric measurements , physical activity level and dietary assessment . RESULTS Individuals who were highly physically active had a significantly lower average plaque index , average gingival index , average clinical attachment loss ( CAL ) and percentage of sites with CAL ≥ 3 mm compared to individuals with a low level of physical activity and individuals with a moderate level of physical activity . Those who had a poor diet had a significantly higher average number of missing teeth and an average CAL compared with those who had a good diet . In the multivariate analysis , a low level of physical activity and a poor diet ( diets with a healthy eating index score of < 50 points ) were significantly associated with increased odds of periodontitis . CONCLUSIONS A low physical activity level and a poor diet were significantly associated with increased odds of periodontal disease . Further studies are needed to underst and this relationship in greater detail This study analyzed time-use interviews to report levels of active and inactive behavior  during the after-school period ( 3 - 6 pm ) . Interviews were conducted on r and om days from three separate seasons during third and fourth grade . Youth with at least two interviews during third ( 356 completed 2 interviews ; 506 completed 3 interviews [ 9 yrs ; 50 % boys ] ) and fourth ( 186 completed 2 interviews ; 768 completed 3 interviews [ 10 yrs ; 50 % boys ] ) grade were included to report levels of moderate-to-vigorous physical activity ( MVPA ) , light physical activity , inactive screen time  , inactive nonscreen time , and travel by location and who the activity was undertaken with .  Reporting time outside the home and with peers ( single or group ) was related to higher levels of MVPA . While inside the home , screen and nonscreen proportions were comparable ( 38 % and 40 % , respectively ) , despite unique patterns ( screen : boys > girls ; nonscreen : girls > boys ) . Reporting time with both parents was associated with more nonscreen time ; whereas reporting time with peer groups was associated with lower screen time . Underst and ing active and inactive patterns of children 's behavior outside of school hours can be very important in contributing toward the development of innovative interventions for increasing physical activity This article describes the process of setting up a 3-year , school-based after-school physical activity intervention in elementary schools . The primary aim of the study is to determine whether adiposity and fitness will improve in children who are exposed to a fitogenic versus an obesogenic environment . Eighteen schools were r and omized to the  control ( obesogenic ) or intervention ( fitogenic ) group . The study design , program components , and evaluation of the intervention are described in detail . The intervention consists of ( a ) academic enrichment , ( b ) a healthy snack , and ( c ) physical activity in a mastery-oriented environment . Successful implementation would show the feasibility of schools ’ being able to provide a fitogenic environment . Significant differences between the groups would provide evidence that a fitogenic environment after school has positive health benefits . If feasibility and efficacy are demonstrated , implementing an after-school program like this one in elementary schools could play a major role in preventing and reducing childhood obesity PURPOSE This exploratory study tested the feasibility of conducting a novel , personalized exercise intervention based upon the current fitness levels of adolescents with type 1 diabetes ( T1DM ) . The relationships of perceptions of benefits and barriers to exercise , exercise self-efficacy and family support to exercise adherence and changes in cardiovascular ( CV ) fitness , quality of life ( QOL ) , and glycemic control were studied . METHODS Adolescents who were sedentary received a grade d exercise test to determine their current fitness level ( VO(2peak ) ) . A 16-wk personalized exercise program was developed for each adolescent based upon individual fitness level and exercise preferences . Pretest and posttest measures of exercise self-efficacy , benefits and barriers to exercise , family support , and diabetes QOL were completed . A1c levels were obtained using the DCA2000 . Adherence to exercise  was measured using the Actigraph Accelerometer . RESULTS Twelve adolescents completed the study . Accelerometry data revealed adherence to 60 min of moderate-to-vigorous physical activity ( MVPA ) per day for a mean of 45.5 ( SD = 23.9)% of the days the accelerometer was worn . Adolescents ' perceptions of family support for exercise improved following the intervention ( p = 0.03 ) . Adolescents who had more daily bouts of exercise lasting 60 min increased their CV fitness ( r = 0.59 , p = 0.04 ) . A1c remained unchanged . CONCLUSIONS Encouraging 60 min of accumulated exercise bouts/d can improve fitness levels in adolescents with T1DM , minimizing future CV risks . Although physical activity increased in adolescents , family based strategies are required to promote current physical activity recommendations Objectives Chronic low back pain ( CLBP ) affects millions of people worldwide , and appears to be increasing in prevalence . It is associated not only with pain , but also with increased disability , psychological symptoms , and reduced quality of life . There are various treatment options for CLBP , but no single therapy st and s out as being the most effective . In the past 10 years , yoga interventions have been studied as a CLBP treatment approach . The objective of this paper is to review the current literature supporting the efficacy of yoga for CLBP . Methods A literature search through the beginning of 2015 was conducted in Pub Med for r and omized control trials addressing treatment of CLBP with yoga . Results In this review we evaluate the use of yoga as a treatment for CLBP . Specifically we evaluate how yoga impacts physical functioning and disability , pain , and associated psychological symptoms . We also evaluate possible mediators of the effect of yoga and the safety of yoga . Discussion With few exceptions , previous studies and the recent r and omized control trials ( RCTs ) indicate that yoga can reduce pain and disability , can be practice d safely , and is well received by participants . Some studies also indicate that yoga may improve psychological symptoms , but these effects are currently not as well established BACKGROUND Physical inactivity and high body mass index ( weight in kilograms divided by height in square meters ) have been linked to increased risk of  colon cancer .  However , none of the few prospect i ve studies in women has shown a statistically significant reduction in colon cancer incidence or mortality associated with increased leisure-time physical activity . PURPOSE In this prospect i ve study , we asked whether leisure-time physical activity , body mass index , or body fat distribution could significantly influence the risk of colon cancer in women . METHODS The participants in this study were enrolled in the Nurses ' Health Study , which began in 1976 . Every 2 years , the women provided additional personal information and information on medical risk factors and major medical events . The time spent per week at a variety of leisure-time physical activities was determined , and the time spent at each activity was multiplied by its typical energy expenditure , expressed in terms of metabolic equivalents or METs . The result ing values for each woman were added to yield an MET-hours-per-week score . Reported diagnoses of colon cancer were confirmed by review of hospital records and pathology reports . Relative risks and associated 95 % confidence intervals were calculated . RESULTS In multivariate analyses that included body mass index , women who expended more than 21 MET-hours per week on leisure-time physical activity had a relative risk of colon cancer of 0.54 ( 95 % confidence interval [ CI ] = 0.33 - 0.90 ) in comparison with women who expended less than 2 MET-hours per week . Women who had a body mass index greater than 29 kg/m2 had a relative risk of colon cancer of 1.45 ( 95 % CI = 1.02 - 2.07 ) in comparison with women who had a body mass index less than 21 kg/m2 . A tendency toward higher colon cancer risk was observed for increasing waist-to-hip ratio ( relative risk = 1.48 [ 95 % CI = 0.88 - 2.49 ] for comparison of the highest quintile ratio [ > 0.833 ] to the lowest [ < 0.728 ] ) . CONCLUSIONS AND IMPLICATION S The significant inverse association between  leisure-time physical activity  and incidence of colon cancer in women in this study is consistent with what has been found in men . Recommendations to increase physical activity and maintain lean body weight should receive greater emphasis as part of a feasible approach to the prevention of colon cancer The purpose of this paper is to present key points of an intervention programme ( Agita São Paulo Program ) to promote physical activity in a developing country . Agita is a multi-level , community-wide intervention design ed to increase knowledge about the benefits and the level of physical activity in a mega- population of 34 million inhabitants of São Paulo State , Brazil . The main message was taken from the Centers for Disease Control/American College of Sports Medicine ( CDC/ACSM ) recommendation that : ' everyone should accumulate at least 30 minutes of physical activity , on most days of the weeks , of moderate intensity , in one single or in multiple sessions ' . Activities were encouraged in three setting s : home , transport and leisure time . Focus groups were students from elementary schools through to college , white and blue collar workers , and elderly people . Innovative aspects included : ( 1 ) a research centre leading the process , ( 2 ) scientific and institutional partnerships ( over 160 groups ) , ( 3 ) a feasible approach -- the ' one-step-ahead ' model , ( 4 ) empowerment , ( 5 ) inclusion , ( 6 ) non-paid media , ( 7 ) social marketing , and ( 8) culture-linked . Data were obtained from 645 r and om , home-based question naires over four years -- stratified by sex , age , education and socio-economic level . These data show that the Agita message reached 55.7 % of the population , and among these , 23.1 % knew the main message . Recall of Agita and knowledge of its purpose were well distributed among different socioeconomic levels , being known by 67 % of the most educated . The prevalence of people reaching the recommendation was 54.8 % ( men 48.7 % , women 61 % ) ; and risk of being sedentary was quite smaller among those who knew the Agita message ( 7.1 % ) compared with those who did not know ( 13.1 % ) . In conclusion , based upon the Agita São Paulo experience , it appears that a multi-level , community-wide intervention to promote physical activity may obtain good results if the model contains the items listed above Atherosclerotic cardiovascular disease ( ASCVD ) is the leading cause of death , decreased quality of life , and medical costs in the United States . Nearly 1 in 3 Americans die of heart disease and stroke ( 1 ) . Most ASCVD is preventable through a healthy lifestyle and effective treatment of cholesterol and blood pressure . The 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association ( ACC/AHA ) provides an evidence -based approach to reducing ASCVD risk ( 2 ) . Guideline Development Process In 2008 , the National Heart , Lung , and Blood Institute ( NHLBI ) convened the Adult Treatment Panel ( ATP ) IV to up date the 2001 ATP-III cholesterol guidelines using a rigorous systematic process to identify and review r and omized , controlled trials ( RCTs ) with cardiovascular outcomes and meta-analyses of these RCTs . The panel comprised experts and clinicians from the fields of cardiology , epidemiology , primary care , and endocrinology ( 2 ) and received support from the Lifestyle Management and Risk Assessment Work Groups ( 3 , 4 ) . Systematic evidence review s conducted according to principles recommended by the Institute of Medicine ( 5 ) were performed to answer 3 questions relevant to clinical care . Two questions focused on the evidence supporting low-density lipoprotein cholesterol ( LDL-C ) and nonhigh-density lipoprotein cholesterol ( HDL-C ) levels as targets of treatment . One question examined the reduction in ASCVD events and adverse effects for each cholesterol-lowering drug class . The panel synthesized the evidence from these 3 review s as well as from Lifestyle Management and Risk Assessment Work Groups review s ( 3 , 4 ) that addressed 5 additional critical questions . Systematic electronic search es of relevant data bases of the peer- review ed English- language literature published from 1 January 1995 through 1 December 2009 for each critical question were conducted by an NHLBI-selected independent contractor and focused on RCTs and systematic review s and meta-analyses of RCTs assessed as fair to good quality . In addition , RCTs with ASCVD outcomes that included coronary heart disease , stroke , and cardiovascular deaths published after that date were eligible for consideration through July 2013 . Evidence tables were constructed , and the strength of evidence was rated according to the NHLBI ( Table 1 of the Supplement ) . Recommendations were grade d according to criteria from the NHLBI ( Table 2 of the Supplement ) and ACC/AHA ( Table 3 of the Supplement ) . Because of the inherent differences in grading systems and the clinical questions driving the recommendations , alignment between the NHLBI and ACC/AHA formats was imperfect . A complete description of the methods used and results of the evidence review are provided in the guideline ( 2 ) and the NHLBI evidence report ( www.nhlbi.nih.gov/ guidelines /cholesterol/ser/index.htm ) . Supplement . NHLBI and ACC/AHA Criteria for Rating Strength of Evidence To help clinicians estimate ASCVD risk , the risk assessment working group developed the Pooled Cohort Equations using data from 5 NHLBI-sponsored longitudinal , population -based cohorts of African American and non-Hispanic white men and women to estimate risk for a first myocardial infa rct ion , coronary heart disease death , or fatal or nonfatal stroke on the basis of age , sex , race , smoking status , total cholesterol level , HDL-C level , systolic blood pressure , antihypertensive therapy , and diabetes ( 4 , 6 ) . These equations significantly advance ASCVD risk estimation by providing sex- and race-specific estimates and including stroke as an outcome . The earlier Framingham equations calculated only coronary heart disease risk for non-Hispanic whites . The draft recommendations were review ed by 23 experts and representatives of federal agencies identified by the NHLBI . In September 2013 , the recommendations developed by the panel were transitioned to the ACC/AHA and had additional review by 4 experts nominated by the ACC Foundation and the AHA . The governing bodies of the ACC and AHA approved the guideline , which also received endorsement from the American Association of Cardiovascular and Pulmonary Rehabilitation , American Pharmacists Association , American Society for Preventive Cardiology , Association of Black Cardiologists , Preventive Cardiovascular Nurses Association , and WomenHeart : The National Coalition for Women with Heart Disease . Recommendations The guideline focuses on treatment of blood cholesterol to reduce ASCVD risk in adults . Major recommendations are summarized here and in Table 1 . The guideline report provides a complete listing of recommendations and supporting evidence behind each recommendation ( 2 ) . Table 1 . Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults * 1 . Encourage Adherence to a Healthy Lifestyle A healthy lifestyle is the foundation for cardiovascular health . The panel endorsed the 2013 ACC/AHA Lifestyle Management Guideline ( 3 ) for a diet that is low in saturated fat , trans fat , and sodium ; emphasizes vegetables , fruits , whole grains , low-fat dairy products , poultry , fish , legumes , nontropical vegetable oils , and nuts ; and limits sweets , sugar-sweetened beverages , and red meats and engage in regular aerobic physical activity . Adults also should maintain a healthy body weight , avoid smoking , and control hypertension and diabetes when present . 2 . Statin Therapy Is Recommended for Adults in Groups Demonstrated to Benefit Strong RCT evidence shows that reduction in ASCVD events from statin therapy exceeds adverse events for 4 patient groups : those with clinical ASCVD ( acute coronary syndromes , myocardial infa rct ion , stable angina , coronary or other arterial revascularization , stroke , transient ischemic attack , or peripheral arterial disease of atherosclerotic origin ) when  statins are used for secondary prevention , and those with LDL-C levels 190 mg/dL ; those aged 40 to 75 years with diabetes and LDL-C levels 70 to 189 mg/dL ; and those aged 40 to 75 years without diabetes and with a 10-year ASCVD risk 7.5 % when statins are used for primary prevention . Moderate evidence supports consideration of statin therapy for primary prevention in individuals with a 10-year ASCVD risk of 5 % to < 7.5 % . Routine initiation of statin therapy is not recommended in adults with New York Heart Association heart failure class II to IV or those receiving maintenance hemodialysis . R and omized , controlled trials in these groups showed no reduction in ASCVD . 3 . Statins have an Acceptable Margin of Safety When Used in Properly Selected Individuals and Appropriately Monitored Strong RCT evidence supports safety of statins when they are used as directed in conjunction with regular follow-up assessment s in properly selected patients . Adjustment of statin intensity is recommended in individuals older than 75 years with a history of statin intolerance or other characteristics ( 2 ) or those receiving drug therapy that may increase statin adverse events . Routine monitoring of hepatic aminotransferase level or creatine kinase level is not recommended unless clinical ly indicated by symptoms suggesting hepatotoxicity or myopathy . Given the potential for decreasing ASCVD events and death , the relationship of muscle and other symptoms to statin treatment must be confirmed . Therefore , eliciting a history of muscle symptoms before statin initiation and carefully monitoring symptoms during statin discontinuation and rechallenge is recommended . Severe myopathy , rhabdomyolysis , and possibly hemorrhagic stroke are rare complications of statin therapy . Although statin therapy modestly increases the risk for type 2 diabetes , ASCVD risk reduction outweighs the excess risk for diabetes for high-intensity statins in secondary prevention or for 10-year ASCVD risk 7.5 % . Similarly , ASCVD risk reduction outweighs the excess risk for diabetes for moderate-intensity statin therapy in adults with a 10-year ASCVD risk 5 % . 4 . Engage in a ClinicianPatient Discussion Before Initiating Statin Therapy , Especially for Primary Prevention in Patients With Lower ASCVD Risk Decisions to initiate statin therapy in primary prevention should be based on clinical judgment and preferences of informed patients . In adults without clinical ASCVD or diabetes whose LDL-C level is < 190 mg/dL , calculating the estimated 10-year ASCVD risk should be the start of the clinicianpatient discussion and should not automatically lead to statin initiation . As the absolute risk for ASCVD events decreases , so does the net benefit of the intervention . Therefore , discussion of the potential for ASCVD event reduction , adverse effects , drugdrug interactions , and patient preferences is especially important for lower-risk primary prevention . The discussion provides the opportunity to encourage healthy lifestyle habits and control other risk factors . Additional factors may be considered when a risk-based decision is uncertain , including LDL-C levels 160 mg/dL , family history of premature ASCVD , elevated  lifetime ASCVD risk  , high-sensitivity C-reactive protein level 2.0 mg/L ,  coronary artery calcification score  > 300 Agatston units , and anklebrachial index < 0.9 . After age 75 years , comorbid conditions , anticipated longevity , safety considerations , and patient preferences should play a large role in decision making . 5 . Use the Newly Developed Pooled Cohort Equations for Estimating 10-Year ASCVD Risk The Pooled Cohort Equations are currently the best available method for estimating 10-year ASCVD risk to guide statin initiation ( 4 , 6 ) . Application of the inclusion and exclusion criteria from RCTs is cumbersome and results in underidentifying high-risk and overidentifying low-risk individuals for statin treatment . The Pooled Cohort Equations were developed using recent data from 5 NHLBI-sponsored , longitudinal , population -based cohorts of African American and white men and women ( ARIC [ BACKGROUND : It has recently been suggested that all-cause mortality is a more appropriate end point than disease specific mortality in cancer screening trials , and that disease specific mortality is biased in favour of screening . This suggestion is based partly on supposed inconsistencies between all-cause mortality results and disease specific results in cancer screening trials , and alleged increases in deaths from causes other than breast cancer among breast cancer cases diagnosed among women invited to screening . METHODS : We used data from the Swedish Two-County Trial of mammographic screening for breast cancer , in which 77 080 women were r and omised to an invitation to screening and 55 985 to no invitation .  We estimated relative risks ( RRs ) ( invited v control ) of death from breast cancer , death from other causes within the breast cancer cases , and death from all causes within the breast cancer cases . RRs were adjusted for age and took account of the longer follow up of breast cancer cases in the invited group due to lead time . RESULTS : There was a significant 31 % reduction in breast cancer mortality in the invited group ( RR 0.69 , 95 % confidence interval ( CI ) 0.58–0.80 ; p<0.001 ) . There was no significant increase in deaths from other causes among breast cancer cases in the invited group ( RR 1.12 , 95 % CI 0.96–1.31 ; p=0.14 ) . A significant 19 % reduction in deaths from all causes was observed among breast cancer cases in the group invited to screening ( RR 0.81 , 95 % CI 0.72–0.90 ; p<0.001 ) . A more conservative estimation gave a significant 13 % reduction ( RR 0.87 , 95 % CI 0.78–0.97 ; p=0.01 ) . These findings are consistent with the magnitude of the reduction in breast cancer mortality . CONCLUSIONS : Invitation to screening was associated with a reduction in deaths from all causes among breast cancer cases , consistent with high participation rates in screening . There is no significant evidence of bias in cause of death classification in the Two-County Trial , and as breast cancer mortality is the targeted clinical outcome in breast cancer screening , it is the appropriate end point in a breast cancer screening trial . All-cause mortality is a poor and inefficient surrogate for breast cancer mortality Background Although school-based interventions to promote physical activity in adolescents have been suggested in several recent review s , questions have been raised regarding the effects of the strategies and the methodology applied and for whom the interventions are effective . The aim of the present study was to investigate effects of a school-based intervention program : the HEalth in Adolescents ( HEIA ) study , on change in physical activity , and furthermore , to explore whether potential effects varied by gender , weight status , initial physical activity level and parental education level . Methods This was a cluster r and omized controlled 20 month intervention study which included 700 11-year-olds . Main outcome -variable was mean count per minute ( cpm ) derived from ActiGraph accelerometers ( Model 7164/GT1 M ) . Weight and height were measured objective ly . Adolescents reported their pubertal status in a question naire and parents reported their education level on the consent form . Linear mixed models were used to test intervention effects and to account for the clustering effect of sampling by school . Results The present study showed an intervention effect on overall physical activity at the level of p = 0.05 with a net effect of 50 cpm increase from baseline to post intervention in favour of the intervention group ( 95 % CI −0.4 , 100 ) . Subgroup analyses showed that the effect appeared to be more profound among girls ( Est 65 cpm , CI 5 , 124 , p = 0.03 ) and among participants in the low-activity group ( Est 92 cpm , CI 41 , 142 , p < 0.001 ) , as compared to boys and participants in the high-activity group , respectively . Furthermore , the intervention affected physical activity among the normal weight group more positively than among the overweight , and participants with parents having 13–16 years of education more positively than participants with parents having either a lower or higher number of years of education . The intervention seemed to succeed in reducing time spent sedentary among girls but not among boys . Conclusions A comprehensive but feasible , multi-component school-based intervention can affect physical activity patterns  in adolescents by increasing overall physical activity . This intervention effect seemed to be more profound in girls than boys , low-active adolescents compared to high-active adolescents , participants with normal weight compared to the overweight , and for participants with parents of middle education level as opposed to those with high and low education levels , respectively . An implementation of the HEIA intervention components in the school system may have a beneficial effect on public health by increasing overall physical activity among adolescents and possibly among girls and low-active adolescents in particular Background The objective of the study was to evaluate the implication s of different classifications of rheumatic heart disease on estimated prevalence , and to systematic ally assess the importance of incidental findings from echocardiographic screening among schoolchildren in Peru . Methods We performed a cluster r and omized observational survey using portable echocardiography among schoolchildren aged 5 to 16 years from r and omly selected public and private schools in Arequipa , Peru . Rheumatic heart disease was defined according to the modified World Health Organization ( WHO ) criteria and the World Heart Federation ( WHF ) criteria . Findings Among 1395 eligible students from 40 classes and 20 schools , 1023 ( 73 % ) participated in the present survey . The median age of the children was 11 years ( interquartile range [ IQR ] 8–13 years ) and 50 % were girls . Prevalence of possible , probable and definite rheumatic heart disease according to the modified WHO criteria amounted to 19.7/1000 children and ranged from 10.2/1000 among children 5 to 8 years of age to 39.8/1000 among children 13 to 16 years of age ; the prevalence of borderline/definite rheumatic heart disease according to the WHF criteria was 3.9/1000 children . 21 children ( 2.1 % ) were found to have congenital heart disease , 8 of which were referred for percutaneous or surgical intervention . Conclusions Prevalence of RHD in Peru was considerably lower compared to endemic regions in sub-Saharan Africa , southeast Asia , and Oceania ; and paralleled by a comparable number of undetected congenital heart disease . Strategies to address collateral findings from echocardiographic screening are necessary in the setup of active surveillance programs for RHD . Trial Registration Clinical Trials.gov identifier : BACKGROUND Discerning the determinants of weight loss maintenance is important in the planning of future interventions and policies regarding overweight and obesity . We have therefore systematic ally synthesized recent literature on determinants of weight loss maintenance for individuals with overweight and obesity . METHODS With the use of the Preferred Reporting Items for Systematic Review s and Meta-Analyses statement , prospect i ve studies were identified from search es in PubMed and PsycINFO from 2006 to 2016 . We included articles investigating adults with overweight and obesity undergoing weight loss without surgery or medication .  Included articles were scored on their method ological quality , and a best- evidence synthesis was applied to summarize the results . RESULTS Our search result ed in 8,222 articles of which 67 articles were selected . In total , 124 determinants were identified of which 5 were demographic , 59 were behavioural , 51 were psychological/cognitive and 9 were social and physical environmental determinants . We found consistent evidence that demographic determinants were not predictive of weight loss maintenance . Behavioural and cognitive determinants that promote a reduction in energy intake , an increase in energy expenditure and monitoring of this balance are predictive determinants . CONCLUSION This review identifies key determinants in weight loss maintenance . However , more research regarding cognitive and environmental determinants of weight loss maintenance is needed to advance our knowledge on determinants of weight loss maintenance Background Physical inactivity is recognised as a public health concern within children and interventions to increase physical activity are needed . GreatFun2Run was a school-based healthy lifestyles intervention that showed positive changes in physical activity levels and body composition immediately post-intervention . The purpose of this paper was to examine whether these changes in physical activity and body composition were maintained 18 - 20 months after the intervention ended . Method Participants ( n = 589 , aged 7 - 11 yrs ) from 4 intervention and 4 control schools took part in the 10-month intervention , of which 421 ( 71 % ) were present for follow-up . The intervention comprised a CD-rom learning and teaching re source for teachers ; an interactive website for pupils , teachers and parents ; two highlight physical activity events ( 1 mile school runs/walks ) ; a local media campaign ; and a summer activity wall planner and record . R and omisation was not possible because of local media content . Outcome measures were objective ly measured physical activity ( pedometers and accelerometers ) and body composition variables ( body mass index , waist circumference , estimated percent body fat , and sum of skinfolds ) . Teacher interviews and participant focus groups were conducted . Multi-level modelling was employed for the data analysis . Results Both control and intervention participants had increased their physical activity at follow-up but there was no group by time interaction ( control : 2726 steps per day increase ; intervention 3404 steps per day increase , p > .05 ) . There were significant increases in estimated percent body fat , sum of skinfolds , waist circumference and body mass index ( BMI ) with increasing age . In the control group , there was evidence for a plateauing in the rate of change in all body composition variables with increasing age , except BMI . In contrast , significant interaction terms suggest that the rate of change in waist circumference , BMI and BMI SDS continued to increase with age in the intervention group . Teacher interviews suggested that because of time pressures , competing re sources , curriculum dem and s and staff changes the majority of teachers had not continued to use the re sources . Conclusions While the intervention initially produced positive changes in physical activity levels and body composition , these changes were not sustained once the intervention ended . Facilitating long-term health behaviour change in children remains a challenge BACKGROUND Physical activity has been found to be associated with decreased risk of breast cancer in postmenopausal women in the majority of epidemiologic studies , but the association is inconsistent in premenopausal women . METHODS We studied the effect of physical activity at various ages on the incidence of breast cancer in 99,504 women from 30 to 49 years of age at enrollment in the Women 's Lifestyle and Health Study , a prospect i ve population -based cohort study in Norway and Sweden .  Physical activity level on an ordinal scale at age 14 , age 30 , and age at enrollment , participation in competitive sports , as well as information on other covariates was obtained using a self-administered question naire . Complete follow-up with data on incident invasive breast cancer and mortality was collected by linkage to national registries . The relation between physical activity  and time to breast cancer development was assessed using Cox proportional hazard models , controlling for potential confounders . RESULTS During an average 9.1 years of follow-up , there were 1,166 incident breast cancer cases . The mean age of the women was 41 years at enrollment , and the mean age at breast cancer diagnosis was 48 years . Compared to inactive women , women with higher levels of physical activity at enrollment had a similar risk of incident breast cancer ( adjusted relative risk , 1.24 for vigorous activity compared with no activity ; 95 % CI , 0.85 - 1.82 ) . Physical activity at age 30 or at age 14 also did not afford any significant protection from breast cancer , nor did a consistently high level of activity from younger ages to enrollment . CONCLUSIONS We did not find evidence of a protective effect of physical activity on breast cancer risk in this group of primarily premenopausal women Death rates from coronary heart disease ( CHD ) in Northern Irel and are among the highest in the world . However , no data have been available to test the hypothesis that the high prevalence of CHD is reflected by the risk status of the childhood population . A r and omly selected 2 % population sample of 1015 children aged 12 and 15 years was studied to obtain baseline information on  blood pressure , lipid profile , cigarette smoking , family history , physical activity , cardiorespiratory fitness , and dietary fat intake .  Using available criteria thresholds , 15 - 23 % displayed increased blood pressure , 12 - 25 % had unfavourable lipid profiles , and 18 - 34 % were overfat . In 15 year old children , 16 - 21 % admitted being regular smokers , 26 - 34 % displayed poor cardiorespiratory fitness , and 24 - 29 % reported little physical activity in the previous week . Dietary analysis revealed relatively low polyunsaturated to saturated fatty acid ratios and high mean fat intakes , accounting for approximately 40 % total daily energy . Despite the exclusion of family history from the analysis , 16 % of the older children exhibited three or more risk factors . These results justify major concern about the level of potential coronary risk in Northern Irel and schoolchildren . Broadly based primary prevention strategies aim ed at children are essential if future adult CHD mortality is to be reduced
There was some evidence that school-based physical activity interventions had a positive impact on four of the nine outcome measures .
Specifically positive effects were observed for duration of physical activity , television viewing , VO2 max , and blood cholesterol .
Generally , school-based interventions had little effect on physical activity rates , systolic and diastolic blood pressure , BMI , and pulse rate .
At a minimum , a combination of printed educational material s and changes to the school curriculum that promote physical activity result ed in positive effects .
Few changes in outcomes were observed in this up date with the exception of blood cholesterol and physical activity rates .
For example blood cholesterol was no longer positively impacted upon by school-based physical activity interventions .
The evidence suggests the ongoing implementation of school-based physical activity interventions at this time , given the positive effects on behavior and one physical health status measure .
BACKGROUND The World Health Organization ( WHO ) estimates that 1.9 million deaths worldwide are attributable to physical inactivity and at least 2.6 million deaths are a result of being overweight or obese .
In addition , WHO estimates that physical inactivity causes 10 % to 16 % of cases each of breast cancer , colon , and rectal cancers as well as type 2 diabetes , and 22 % of coronary heart disease and the burden of these and other chronic diseases has rapidly increased in recent decades .
OBJECTIVES The purpose of this systematic review was to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents .