Julian H. Barth

Randomised controlled trial of primary school based intervention to reduce risk factors for obesity

Abstract Objective: To assess if a school based intervention was effective in reducing risk factors for obesity. Design: Group randomised controlled trial. Setting: 10 primary schools in Leeds. Participants: 634 children aged 7-11 years. Intervention: Teacher training, modification of school meals, and the development of school action plans targeting the curriculum, physical education, tuck shops, and playground activities. Main outcome measures: Body mass index, diet, physical activity, and psychological state. Results: Vegetable consumption by 24 hour recall was higher in children in the intervention group than the control group (weighted mean difference 0.3 portions/day, 95% confidence interval 0.2 to 0.4), representing a difference equivalent to 50% of baseline consumption. Fruit consumption was lower in obese children in the intervention group (−1.0, −1.8 to −0.2) than those in the control group. The three day diary showed higher consumption of high sugar foods (0.8, 0.1 to 1.6)) among overweight children in the intervention group than the control group. Sedentary behaviour was higher in overweight children in the intervention group (0.3, 0.0 to 0.7). Global self worth was higher in obese children in the intervention group (0.3, 0.3 to 0.6). There was no difference in body mass index, other psychological measures, or dieting behaviour between the groups. Focus groups indicated higher levels of self reported behaviour change, understanding, and knowledge among children who had received the intervention. Conclusion: Although it was successful in producing changes at school level, the programme had little effect on childrens behaviour other than a modest increase in consumption of vegetables. What is already known on this topic Obesity is increasing among school children and demands preventive strategies Randomised controlled trials of school based primary prevention programmes have all used a prescriptive approach What this study adds Behavioural changes were disappointing with this programme based on the health promoting schools philosophy, despite changes at school level The only positive outcome was a modest increase in vegetable consumption The discrepancy between changes achieved at the individual and school level raises issues regarding the problems inherent in such trials

Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference?

objective Polycystic ovary syndrome (PCOS) is more prevalent in South Asian women residing in the UK than in Caucasians. Insulin resistance (IR) is central to the pathogenesis of PCOS, while type 2 diabetes is commoner in South Asians. We aimed to determine a possible ethnic difference in the clinical and biochemical characteristics of South Asian vs. Caucasian women with PCOS.

Increasing prevalence of obesity in primary school children: cohort study

From 1996 to 1999 an auxologist (JW) measured children in 10 primary schools in Leeds participating in a health promotion programme.3 Children in years 3 and 4 (age 7-9 years) were measured in July 1996 and again in July 1997 and 1998. These children were marginally more advantaged than average for Leeds, with 1-42% of pupils from ethnic minorities and 7-29% entitled to free school meals (a measure of social disadvantage). Height was measured to 0.1 cm with a free standing Magnimeter stadiometer (Raven, Dunmow). Weights were recorded to 0.1 kg without shoes or jumpers. The mean of three triceps measurements was taken.4 Body mass index (weight (kg)/(height (m)2)) was calculated and converted to standard deviation scores using the revised 1990 reference standards5 and the Tanner Whitehouse (1975) standards for skinfold thickness.4 The following conventional …

Heart-Type Fatty Acid-Binding Protein Predicts Long-Term Mortality and Re-Infarction in Consecutive Patients With Suspected Acute Coronary Syndrome Who Are Troponin-Negative

OBJECTIVES The purpose of this study was to establish the prognostic value of measuring heart fatty acid-binding protein (H-FABP) in patients with suspected acute coronary syndrome (ACS) (in particular, low- to intermediate-risk patients), in addition to troponin measured with the latest third-generation troponin assay. BACKGROUND We have previously shown that H-FABP is a useful prognostic marker in patients with proven ACS. METHODS Patients (n = 1,080) consecutively admitted to the hospital with suspected ACS were recruited over 46 weeks. Siemens Advia Ultra-TnI (Siemens Healthcare Diagnostics, Newbury, United Kingdom) and Randox Evidence H-FABP (Randox Laboratories, Ltd., Co., Antrim, United Kingdom) were analyzed on samples collected 12 to 24 h from symptom onset. After exclusion of patients with ST-segment elevation and new left bundle branch block, 955 patients were included in the analysis. RESULTS The primary outcome measure of death or readmission with myocardial infarction after a minimum follow-up period of 12 months (median 18 months) occurred in 96 of 955 patients (10.1%). The H-FABP concentration was an independent predictor of death or myocardial infarction, after multivariate adjustment. Patients with H-FABP concentrations >6.48 microg/l had significantly increased risk of adverse events (adjusted hazard ratio: 2.62, 95% confidence interval: 1.30 to 5.28, p = 0.007). Among troponin-negative patients (which constituted 79.2% of the cohort), the aforementioned cutoff of 6.48 microg/l identified patients at very high risk for adverse outcomes independent of patient age and serum creatinine. CONCLUSIONS We have demonstrated that the prognostic value of elevated H-FABP is additive to troponin in low- and intermediate-risk patients with suspected ACS. Other studies suggest that our observations reflect the value of H-FABP as a marker of myocardial ischemia, even in the absence of frank necrosis.

Children's residential weight-loss programs can work: a prospective cohort study of short-term outcomes for overweight and obese children.

Objective. The evidence base for child obesity treatment is weak. Childrens weight-loss camps, despite their popularity, have not been properly evaluated. This study evaluated the effectiveness of a residential weight-loss camp program for overweight and obese children. Methods. A total of 185 overweight children (mean age: 13.9 years) enrolled in 1 of 4 consecutive programs between 1999 and 2002 (intervention group) were compared with 94 children of similar ages who were not camp attendees, ie, 38 overweight children and 56 normal-weight children. The intervention group attended a 6-week (maximum) summer residential weight-loss camp. The program included a daily schedule of six 1-hour, skill-based, fun, physical activity sessions, moderate dietary restriction, and group-based educational sessions. All children were assessed for body weight, height, and other anthropometric measures, blood pressure, aerobic fitness, self-esteem, and selected sports skills. Results. Campers, who stayed for a mean of 29 days, lost 6.0 kg, reduced their BMI by 2.4 units, and reduced their BMI SD scores by 0.28. Fat mass decreased significantly (from 42.7 to 37.1 kg), whereas fat-free mass did not change. In contrast, both comparison groups gained weight during this period. Camp attendees also showed significant improvements in blood pressure, aerobic fitness, and self-esteem. Longer durations of stay were associated with greater improvements in outcomes. Conclusions. In the short term at least, this weight-loss program was effective across a range of health outcomes. Ongoing research is examining the maintenance of these improvements. Future research should investigate whether benefits can be generalized across weight-loss camps and how the intervention can be adapted to nonresidential, term-time settings.

Vitamin D receptor gene polymorphisms, serum 25-hydroxyvitamin D levels, and melanoma: UK case-control comparisons and a meta-analysis of published VDR data

We have carried out melanoma case-control comparisons for six vitamin D receptor (VDR) gene single nucleotide polymorphisms (SNPs) and serum 25-hydroxyvitamin D(3) levels in order to investigate the role of vitamin D in melanoma susceptibility. There was no significant evidence of an association between any VDR SNP and risk in 1028 population-ascertained cases and 402 controls from Leeds, UK. In a second Leeds case-control study (299 cases and 560 controls) the FokI T allele was associated with increased melanoma risk (odds ratio (OR) 1.42, 95% confidence interval (CI) 1.06-1.91, p=0.02). In a meta-analysis in conjunction with published data from other smaller data sets (total 3769 cases and 3636 controls), the FokI T allele was associated with increased melanoma risk (OR 1.19, 95% CI 1.05-1.35), and the BsmI A allele was associated with a reduced risk (OR 0.81, 95% CI 0.72-0.92), in each instance under a parsimonious dominant model. In the first Leeds case-control comparison cases were more likely to have a higher body mass index (BMI) than controls (p=0.007 for linear trend). There was no evidence of a case-control difference in serum 25-hydroxyvitamin D(3) levels. In 1043 incident cases from the first Leeds case-control study, a single estimation of serum 25-hydroxyvitamin D(3) level taken at recruitment was inversely correlated with Breslow thickness (p=0.03 for linear trend). These data provide evidence to support the view that vitamin D and VDR may have a small but potentially important role in melanoma susceptibility, and putatively a greater role in disease progression.

British Cardiac Society Working Group on the definition of myocardial infarction

The British Cardiac Society commissioned this report to help address inconsistencies in the terminology for acute coronary syndromes and wide variations in the threshold for the diagnosis of myocardial infarction (MI) depending on the assay performed, the precision, and the sensitivity. In addition, several publications have highlighted potential problems with the application of the European Society of Cardiology(ESC)/American College of Cardiology (ACC) consensus document published in 2000. A revision process has been initiated under the guidance of the ESC, the ACC, and the American Heart Association (AHA). The purpose of this report is to help inform the next revision of the ESC/ACC/AHA guidelines for the diagnosis of MI.

Hepatic metabolism and transporter gene variants enhance response to rosuvastatin in patients with acute myocardial infarction: the GEOSTAT-1 Study.

Background—Pharmacogenetics aims to maximize benefits and minimize risks of drug treatment. Our objectives were to examine the influence of common variants of hepatic metabolism and transporter genes on the lipid-lowering response to statin therapy. Methods and Results—The Genetic Effects On STATins (GEOSTAT-1) Study was a genetic substudy of Secondary Prevention of Acute Coronary Events—Reduction of Cholesterol to Key European Targets (SPACE ROCKET) (a randomized, controlled trial comparing 40 mg of simvastatin and 10 mg of rosuvastatin) that recruited 601 patients after myocardial infarction. We genotyped the following functional single nucleotide polymorphisms in the genes coding for the cytochrome P450 (CYP) metabolic enzymes, CYP2C9*2 (430C>T), CYP2C9*3 (1075A>C), CYP2C19*2 (681G>A), CYP3A5*1 (6986A>G), and hepatic influx and efflux transporters SLCO1B1 (521T>C) and breast cancer resistance protein (BCRP; 421C>A). We assessed 3-month LDL cholesterol levels and the proportion of patients reaching the current LDL cholesterol target of <70 mg/dL (<1.81 mmol/L). An enhanced response to rosuvastatin was seen for patients with variant genotypes of either CYP3A5 (P=0.006) or BCRP (P=0.010). Furthermore, multivariate logistic-regression analysis revealed that patients with at least 1 variant CYP3A5 and/or BCRP allele (n=186) were more likely to achieve the LDL cholesterol target (odds ratio: 2.289; 95% CI: 1.157, 4.527; P=0.017; rosuvastatin 54.0% to target vs simvastatin 33.7%). There were no differences for patients with variants of CYP2C9, CYP2C19, or SLCO1B1 in comparison with their respective wild types, nor were differential effects on statin response seen for patients with the most common genotypes for CYP3A5 and BCRP (n=415; odds ratio: 1.207; 95% CI: 0.768, 1.899; P=0.415). Conclusion—The LDL cholesterol target was achieved more frequently for the 1 in 3 patients with CYP3A5 and/or BCRP variant genotypes when prescribed rosuvastatin 10 mg, compared with simvastatin 40 mg. Clinical Trial Registration—URL: http://isrctn.org. Unique identifier: ISRCTN 89508434.

Plasma homocysteine in polycystic ovary syndrome: does it correlate with insulin resistance and ethnicity?

background  Polycystic ovary syndrome (PCOS) is associated with insulin resistance and premature coronary artery disease (CAD). Hyperhomocysteinaemia is a recognized risk factor for atherosclerosis, particularly among migrant South Asians, and has recently been shown to be correlated positively with the degree of insulin resistance/hyperinsulinaemia.

Empowering primary care to tackle the obesity epidemic: the Counterweight Programme.

Objective:To improve the management of obese adults (18–75 y) in primary care.Design:Cohort study.Settings:UK primary care.Subjects:Obese patients (body mass index ≥30 kg/m2) or BMI≥28 kg/m2 with obesity-related comorbidities in 80 general practices.Intervention:The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation.Main outcome measures:Proportion of practices trained and recruiting patients, and weight change at 12 months.Results:By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as ‘completers’ in that they attended the requisite number of appointments in 3, 6 and 12 months. ‘Completers’ achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months.Conclusion:The Counterweight programme provides a promising model to improve the management of obesity in primary care.Sponsorship:Educational grant-in-aid from Roche Products Ltd.Objective:To improve the management of obese adults (18–75 y) in primary care.Design:Cohort study.Settings:UK primary care.Subjects:Obese patients (body mass index ≥30 kg/m2) or BMI≥28 kg/m2 with obesity-related comorbidities in 80 general practices.Intervention:The model consists of four phases: (1) audit and project development, (2) practice training and support, (3) nurse-led patient intervention, and (4) evaluation. The intervention programme used evidence-based pathways, which included strategies to empower clinicians and patients. Weight Management Advisers who are specialist obesity dietitians facilitated programme implementation.Main outcome measures:Proportion of practices trained and recruiting patients, and weight change at 12 months.Results:By March 2004, 58 of the 62 (93.5%) intervention practices had been trained, 47 (75.8%) practices were active in implementing the model and 1549 patients had been recruited. At 12 months, 33% of patients achieved a clinically meaningful weight loss of 5% or more. A total of 49% of patients were classed as ‘completers’ in that they attended the requisite number of appointments in 3, 6 and 12 months. ‘Completers’ achieved more successful weight loss with 40% achieving a weight loss of 5% or more at 12 months.Conclusion:The Counterweight programme provides a promising model to improve the management of obesity in primary care.Sponsorship:Educational grant-in-aid from Roche Products Ltd.