Preventive Medicine

Published by Elsevier
Online ISSN: 1096-0260
Print ISSN: 0091-7435
Publications
The contribution of medical treatment to the health of the world's population was virtually nil until the 20th century and continues to be small. In contrast, the contribution of the prevention of disease through modification of the environment (improved ventilation, drainage, sewage disposal) has been great. This effect is seen in the dramatic rise in the population of Europe since the early 18th century. The major causes of death and disability in developed countries, however, have changed markedly during the present century. Most of the risk factors associated with these diseases are behavioral in nature (cigarette smoking, excessive caloric intake, excessive alcohol consumption, inadequate exercise, etc.). Accordingly, modifying the environment is no longer enough--one must modify the behavior of the individual. To do this, one needs an effective technology for modifying behaviors that have important health consequences. Such a behavioral technology is being developed. Some of the principles underlying this technology will be illustrated by their application to one modern scourge--cigarette smoking.
 
A controlled long-term study to evaluate the efficacy of the periodic health examination, utilizing automated multiphasic screening techniques, is being conducted. A representative sample of approximately 5000 persons aged 35–54 was selected in 1964 and has been urged to undergo annual examinations. The morbidity, mortality, and disability, as well as the utilization of medical care, in this group are being compared to a similar group of persons who have been allowed to seek medical care on their own initiative within the same medical care program. The study design, characteristics of the study population, and the experience in examining the population are described in this report. At the start of the study the population was relatively healthy and experienced very little disability. Approximately 65% of the study group is being examined each year, and 78% of the original group were still under surveillance after 7 years.
 
Habitual levels of occupational and leisure time physical activity vary widely between populations; the former are unrelated to population rates of coronary heart disease (CHD). The proportion of men in sedentary occupations is unrelated to 10-year incidence of CHD in the Seven Countries, for any CHD, hard CHD, or CHD deaths. Coronary heart disease rates are not significantly different between active and sedentary U.S. railroad employees on adjustment for other risk factors. Noncoronary deaths are much higher in active railroad employees. The proportion of sedentary men in populations is negatively related to 10-year deaths from all causes in the Seven Countries Study. In addition, there are wide differences in the relationship of occupational activity to CHD incidence, being unrelated in the United States, negatively related in Italy and Holland, in a U-shaped relationship in Yugoslavia, and in an inverted U-shaped relationship in Finland, where sedentary and very active men had similar coronary disease rates, and moderately active men had double their coronary disease rates. Habitual occupational activity is strongly and inversely related to deaths from all causes in Finland. None of the Seven Countries data bear on the protective effect of anaerobic exercise. “Peasants never get short of breath.” Physical activity, diet uncontrolled, can change many CHD risk factors in a “favorable” direction, i.e., weight, blood pressure, glucose tolerance, and blood lipids. This provides the rationale for attempts to encourage increased activity in sedentary affluent populations. The primary prevention of elevated risk factors requires the engineering of regular activity into work and leisure time of affluent societies.
 
This paper reports on physical activity of students in grades 3, 7, and 11 from two surveillance studies (from 2001 and 2005). Randomly selected students (Study1 n=1730; Study2 n=2341) from randomly selected schools in Nova Scotia participated. Physical activity was measured for seven consecutive days using Actigraph accelerometers. Descriptive statistics were calculated for moderate, hard, and very hard intensity, and total minutes of physical activity. Between study, grade, and sex differences were determined using univariate Analyses of Variance. Students in Study2 were significantly less active (mean [SD]=531.0 [392.3] min/week) than Study1 (662.2 [495.1] min/week). Girls were significantly less active (525.4 [419.1] min/week) than boys (657.1 [460.3] min/week). Students in grade 11 were significantly less active (225.2 [171.1] min/week) than students in grade 7 (457.5 [227.2] min/week) who were significantly less active than students in grade 3 (1038.4 [387.6] min/week). A significant study-grade interaction indicated that compared to students in grades 7 and 11, the level of physical activity in students in grade 3 was considerably lower in Study2 compared to Study1. Given the lower level of physical activity found in Study2, efforts at informing public policy and strategies that promote physical activity in children and youth should be made.
 
Descriptive characteristics of the two study samples in relation to gender.
Children's body mass index and prevalence of overweight and obesity by TV viewing in 1992/93 and 2006/07.
To examine secular changes in anthropometric measurements and blood pressure (BP) in 1st-grade children in Crete, Greece, during 1992/93 and 2006/07. Children (aged 5.7-7.8 years) from two representative cross-sectional cohorts participated during 1992/93 (n=606) and 2006/07 (n=361). Body weight, body-mass-index (BMI), waist circumference (WC), waist-to-hip (WHpR) and waist-to-height (WHtR) ratios, BP, 20 m-shuttle-run test (20 mSRT), and moderate-to-vigorous-physical-activity (MVPA) were assessed. There was a significant increase (P<0.01) in body weight (+10.2% and +6.7%), BMI (+6.9% and +4.0%), WC (+5.6% and +5.1%), WHpR (+3.0% and +3.4%), and WHtR (+4.2% and +3.8%), for boys and girls, respectively, and in the proportion of overweight/obese boys (19.4% vs. 33.7%; P<0.001) between 1992/93 and 2006/07. Both genders had decreased BP measurements in 2006/07 compared to 1992/93 (P<0.001). In both periods, BP was higher in obese compared to overweight and normal children (P<0.001), but there was no relationship between BP and physical activity (PA). A substantial decrease in BP was observed in Cretan children over a 15-year period, despite a concurrent increase in obesity and anthropometric indices. This may be attributed to lifestyle and dietary changes and does not support the hypothesis that the obesity epidemic in children has resulted in proportionate increases in BP levels.
 
Until now it has been difficult to ascertain how much passive inhalation of tobacco smoke affects bronchopulmonary function. To answer this question, an investigation involving 1,351 white collar workers was carried out. Information about active and passive tobacco smoke exposure was obtained by a standardized questionnaire. This made it possible to subdivide the overall group into five subgroups: Never smokers, passive smokers, ex-smokers, current smokers, and other smokers. Forced expiratory vital capacity (FVC) and maximal expiratory flow-volume (MEFV) curves were used for lung function analysis. From these curves FVC, forced mid-expiratory flow (FEF 25/75), forced end-expiratory flow (FEF 75/85), and maximal mid-expiratory flow (MEF 25/75) were determined and standardized for sex, age, height, and body weight. Passive smokers evaluated by this method showed essentially no decrease in parameters describing ventilatory function. It is concluded from the dose-and time-effect relationships obtained in active smokers between the lung function parameters and the duration of tobacco smoke exposure on the one hand and the daily consumption of cigarettes on the other that passive smoking in small doses may have no essential effect on pulmonary function.
 
Although colorectal cancer is not one of the major tobacco-related cancers, a possible association with tobacco has been suggested following the observation of a relationship between cigarette smoking and colorectal adenomas. The issue of a long latency of tobacco on colorectal carcinogenesis has also been suggested, since elevated relative risks were observed in long-term smokers. The association between colorectal cancer and cigarette smoking has been investigated using data from a case-control study conducted in northern Italy between 1985 and 1991 on 955 cases of colon and 629 cases of rectal cancer and 2,879 controls in hospital for acute, nonneoplastic, nondigestive tract, nontobacco-related diseases. Odds ratios (OR), and the corresponding 95% confidence intervals, of colorectal cancer according to various measures of tobacco smoking were derived from multivariate models, including terms for sex, age, total calorie intake and selected dietary variables, alcohol consumption, and family history of colorectal cancer. No association between smoking and colorectal cancer was observed. Compared with people who had never smoked, the overall multivariate OR for colorectal cancer was 0.9 in ex-smokers and 0.7 in current smokers. No relationship was found with number of cigarettes smoked (OR = 0.7 for both < 15 and 15-24, and 0.8 for > or = 25 cigarettes per day), age at starting (OR = 0.7 for < 20, 0.8 for 20-29, and 0.9 for > or = 30 years), duration (OR = 0.8 for < 10, 0.7 for 10-19, 0.8 for 20-29, and 0.7 for > or = 30 years), and time since starting (OR = 0.7, for < 30, 0.8 for > or = 30 years) and since stopping (OR = 1.1 for < 10, 0.7 for > or = 10 years). There was no evidence of a trend in risk with increasing lifelong pack-years (OR for > or = 40 pack-years = 0.8 for colon and rectum), pack-years before age 30 (OR = 0.7 for > or = 20 pack-years), or pack-years after age 30 (OR = 0.8 for > or = 30 pack-years). The results were similar for males and females. The findings of this study indicate that smoking was not a strong risk factor for colorectal cancer, even after a long induction period.
 
Objective: This study assessed the workday step counts of lower active (<10,000 daily steps) university employees using an automated, web-based walking intervention (Walk@Work). Methods: Academic and administrative staff (n=390; 45.6±10.8years; BMI 27.2±5.5kg/m(2); 290 women) at five campuses (Australia [x2], Canada, Northern Ireland and the United States), were given a pedometer, access to the website program (2010-11) and tasked with increasing workday walking by 1000 daily steps above baseline, every two weeks, over a six week period. Step count changes at four weeks post intervention were evaluated relative to campus and baseline walking. Results: Across the sample, step counts significantly increased from baseline to post-intervention (1477 daily steps; p=0.001). Variations in increases were evident between campuses (largest difference of 870 daily steps; p=0.04) and for baseline activity status. Those least active at baseline (<5000 daily steps; n=125) increased step counts the most (1837 daily steps; p=0.001), whereas those most active (7500-9999 daily steps; n=79) increased the least (929 daily steps; p=0.001). Conclusions: Walk@Work increased workday walking by 25% in this sample overall. Increases occurred through an automated program, at campuses in different countries, and were most evident for those most in need of intervention.
 
To compare pedometer steps of university students who used public transport and private motor vehicles to travel to and or from The University of Western Australia (UWA). 103 undergraduate students in 2006 recruited by e-mail and snowballing wore a pedometer for five consecutive university days, and completed a travel and physical activity diary. Compared with private motor vehicle users, public transport users performed more daily steps (11443 vs. 10242 steps/day, p=0.04) After adjusting for gender, age group and average daily minutes of self-reported leisure-time physical activity, the odds of achieving 10,000 steps/day was higher in public transport users compared with private motor vehicle users (OR 3.55; 95% CI 1.34-9.38, p=0.01). Walking associated with public transport use appeared to contribute to university students achieving higher levels of daily steps. Encouraging public transport use could help increase and maintain community physical activity levels.
 
The association between baseline risk factors and death from coronary heart disease (CHD) after 10.5 years was investigated for cigarette smokers and nonsmokers who entered the Multiple Risk Factor Intervention Trial (MRFIT). Rates per thousand person-years of CHD mortality were higher for smokers than for nonsmokers at every level of baseline risk factors examined. There were significant associations between CHD mortality and plasma low-density lipoprotein and high-density lipoprotein cholesterol for smokers and nonsmokers. The inverse association between CHD mortality and high-density lipoprotein cholesterol was significantly stronger among nonsmokers compared with that among smokers and was attributable to a very strong association for former smokers. An inverse relationship between CHD and body mass index was evident for smokers and nonsmokers. Rates of CHD death rose sharply when levels of fasting glucose exceeded 140 mg/dl, and there was a significant association between CHD mortality and blood sugar levels for nonsmokers but not for smokers. For both smokers and nonsmokers, an inverse univariate association between alcohol consumption and CHD mortality was evident. This association, however, did not persist after adjustment for plasma high-density lipoprotein cholesterol. Intervention on blood pressure and blood lipids is particularly important among cigarette smokers because of their increased risk of CHD death. The different associations between high-density lipoprotein cholesterol, fasting serum glucose, and CHD mortality for smokers and nonsmokers requires further investigation.
 
The California Environmental Protection Agency (Cal/EPA) recently completed a health effects assessment of exposure to environmental tobacco smoke (ETS) which resulted in California listing ETS as a Toxic Air Contaminant in January 2006. As part of the assessment, studies on the association between exposure to ETS and breast cancer were reviewed. Twenty-six published reports (including 3 meta-analyses) evaluating the association between ETS exposure and breast cancer were reviewed. A weight-of-evidence approach was applied to evaluate the data and draw conclusions about the association between breast cancer and ETS exposure. The published data indicate an association between ETS and breast cancer in younger primarily premenopausal women. Thirteen of 14 studies (10 case-control and four cohort) that allowed analysis by menopausal status reported elevated risk estimates for breast cancer in premenopausal women, seven of which were statistically significant. Our meta-analyses indicated elevated summary relative risks ranging from OR 1.68 (95% C.I. 1.31, 2.15) for all 14 studies to 2.20 (95% C.I. 1.69, 2.87) for those with the best exposure assessment. Cal/EPA concluded that regular ETS exposure is causally related to breast cancer diagnosed in younger, primarily premenopausal women and that the association is not likely explained by bias or confounding.
 
As invasive cervical cancer is preventable when screening and treatment of pre-invasive lesions are timely and appropriate, several past studies attempted to enumerate the quality of preventive care invasive cervical cancer subjects received before diagnosis. Objectives of the present study were to review and to summarize the findings of these studies in a meta-analysis. Data from 42 studies were used to estimate DerSimonian and Laird random effects models for the various failures in care along the cancer care continuum. Analyses were also conducted within strata characterized by variables deemed to account for heterogeneity in meta-regression analyses. Poor Pap screening frequency was the primary factor attributable to development of invasive cervical cancer. On average, 53.8% (95% confidence interval: 43.6-66.3) of invasive cervical cancer subjects had inadequate screening histories and 41.5% (95% confidence interval: 35.4-48.7) were never screened. There was significant temporal improvement in the proportion of women screened at least once over a lifetime but not in the proportion with overall deficient histories. An estimated 29.3% (95% confidence interval: 21.2-40.4) of failures to prevent invasive cervical cancer can be attributed to false-negative Pap smears and 11.9% (95% confidence interval: 9.0-15.6) to poor follow-up of abnormal results. Appropriate assessment of the effect of combined failures in the process of care must be done in comprehensive audit studies.
 
The purpose of this study was to perform an ecological analysis of the relationship between low levels of ultraviolet B (UVB) irradiance and age-standardized incidence rates of endometrial cancer by country, controlling for known confounders. The contributions of UVB irradiance, cloud cover, intake of energy from animal sources, proportion of population overweight, skin pigmentation, per capita cigarette consumption, per capita health expenditure, and total fertility rates, to age-standardized incidence rates of endometrial cancer in 107 countries were assessed using multiple regression. Incidence rates were higher at higher latitudes (R2=0.47, p<0.01). According to multiple regression, UVB irradiance adjusted for cloud cover was negatively associated with incidence rates (p=0.02), while proportion of population overweight (p=0.004), intake of energy from animal sources (p=0.01) and per capita health expenditure (p<0.0001) were positively associated with incidence rates (overall R2=0.73, p<0.0001). An association was found between low UVB irradiance, high intake of energy from animal sources, per capita health expenditure, proportion of population overweight, and incidence rates.
 
Objective: This study aims to examine the associations between parenting quality and children's screen-time. Methods: Data from the US National Institute Study of Early Child Care and Youth Development, collected in 2001, were analysed. Videotaped interaction tasks of 874 mother-child dyads were rated for ten parenting qualities (i.e., agency, persistence, negativity, affection, felt security, affective mutuality, autonomy granting, stimulation of cognitive development, quality of assistance & hostility). Children (aged 10-11yrs) self-reported television viewing on weekdays and weekends. Associations between parenting quality and television viewing were examined using logistic regression. Results: Greater felt security was associated with lower odds of watching >2h of television on weekdays among boys (p=0.05). High agency was associated with greater odds of watching >2h of television per day on weekdays among girls (p=0.02). High supportive presence and quality of child assistance were associated with lower odds of watching >2h of television on Saturdays (p=0.05) among girls. Conclusion: Child agency (i.e., self-direction and confidence) was associated with greater television viewing whereas parenting characterised by perceived security, support and structured yet flexible guidance was associated with lower television viewing. Parent-child interactions and communication may be an appropriate target for sedentary behaviour interventions.
 
To determine whether adolescent attitudes towards sports, exercise, and fitness predict moderate-to-vigorous physical activity 5 and 10 years later. A diverse group of 1902 adolescents participating in Project Eating and Activity in Teens, reported weekly moderate-to-vigorous physical activity and attitudes toward sports, exercise, and fitness in Eating and Activity in Teens-I (1998-99), Eating and Activity in Teens-II (2003-04), and Eating and Activity in Teens-III (2008-09). Mean moderate-to-vigorous physical activity was 6.4, 5.1, and 4.0 hours/week at baseline, 5-year, and 10-year follow-up, respectively. Attitudes toward sports, exercise, and fitness together predicted moderate-to-vigorous physical activity at 5 and 10 years. Among the predictors of 5- and 10-year moderate-to-vigorous physical activity, attitude's effect size, though modest, was comparable to the effect sizes for sports participation and body mass index. Adolescents with more-favorable attitudes toward sports, exercise, and fitness engaged in approximately 30%-40% more weekly moderate-to-vigorous physical activity at follow-up (2.1 hour/week at 5 years and 1.2 hour/week at 10 years) than those with less-favorable attitudes. Adolescents' exercise-related attitudes predict subsequent moderate-to-vigorous physical activity independent of baseline behavior suggesting that youth moderate-to-vigorous physical activity promotion efforts may provide long-term benefits by helping youth develop favorable exercise attitudes.
 
Specific hypotheses regarding putative mechanisms by which stressful life events might be related to smoking initiation among adolescents have been tested cross-sectionally on a cohort of 1598 grade 6 students in Scarborough, Canada. The purpose of this study was to examine the utility of these cross-sectional models in accounting for current smoking as compared to never smoking when this cohort was in grades 8 and 11. Current smoking was defined as reported regular or occasional smoking. Logistic regression and multiple regression models were tested separately for each gender and grade with variables entered in prespecified steps. Current smoking is more strongly related to psychosocial variables and environmental variables among older male adolescents as compared to younger ones. In older female adolescents, current smoking appears to be more strongly related to attitude variables and less strongly related to psychosocial variables than among younger female adolescents. There is some evidence that grade 11 males may use cigarettes as a coping strategy for depression. Male and female students differ in how stress and a range of psychosocial factors are interrelated with regards to current smoking and these relationships appear to change over time.
 
To examine associations between 9/11-related exposures, posttraumatic stress disorder (PTSD), and subsequent development of heart disease (HD). We prospectively followed 39,324 WTC Health Registry participants aged ≥18 on 9/11 for an average of 2.9 years. HD was defined as self-reported physician-diagnosed angina, heart attack, and/or other HD reported between study enrollment (2003-2004) and a follow-up survey (2006-2008) in enrollees without previous HD. A PTSD Checklist (PCL) score ≥44 was considered PTSD. We calculated adjusted hazard ratios (AHR) and 95% confidence intervals (CI) to examine relationships between 9/11-related exposures and HD. We identified 1162 HD cases (381 women, 781 men). In women, intense dust cloud exposure was significantly associated with HD (AHR 1.28, 95% CI 1.02-1.61). Injury on 9/11 was significantly associated with HD in women (AHR 1.46, 95% CI 1.19-1.79) and in men (AHR 1.33, 95% CI 1.15-1.53). Participants with PTSD at enrollment had an elevated HD risk (AHR 1.68, 95% CI 1.33-2.12 in women, AHR 1.62, 95% CI 1.34-1.96 in men). A dose-response relationship was observed between PCL score and HD risk. This exploratory study suggests that exposure to the WTC dust cloud, injury on 9/11 and 9/11-related PTSD may be risk factors for HD.
 
To characterize the pattern of activity in boys and girls across weekdays and weekend days. Physical activity was recorded every 2 s by uniaxial accelerometry in 84 children, aged 9-11 years, for up to four weekdays and two weekend days. Activity bouts (>or= 4 s and >or= 5 min) greater than light (>or= LIGHT), moderate (>or= MOD) and vigorous (>or= VIG) intensity were recorded. The study took place in the South-West of England in 2007. The mean duration of activity bouts decreased as intensity increased from 11.0+/-1.3 s for >or= LIGHT activity to 6.1+/-1.0 s for >or= VIG activity. The frequency, duration and intensity of bouts were greater in boys than girls, and the frequency and duration of bouts were greater on weekdays than weekend days. Girls accumulated more activity sporadically than boys, whereas boys accumulated more activity in >or= 5-min bouts. Sex differences and weekday/weekend differences in activity were largely due to the intensity of the most frequent bouts of activity and frequency of the most intense bouts. Information regarding the pattern of children's habitual activity can be used to inform activity interventions and assess the aspects of the activity pattern that are related to health.
 
The objective of this study was to determine whether parenting styles and practices are associated with children's physical activity. Cross-sectional survey of seven hundred ninety-two 10- to 11-year-old UK children in Bristol (UK) in 2008-2009 was conducted. Accelerometer-assessed physical activity and mean minutes of moderate-to-vigorous physical activity (mean MVPA) and mean counts per minute (mean CPM) were obtained. Maternal parenting style and physical activity parenting practices were self-reported. In regression analyses, permissive parenting was associated with higher mean MVPA among girls (+6.0 min/day, p<0.001) and greater mean CPM (+98.9 accelerometer counts/min, p=0.014) among boys when compared to children with authoritative parents. Maternal logistic support was associated with mean CPM for girls (+36.2 counts/min, p=0.001), while paternal logistic support was associated with boys' mean MVPA (+4.0 min/day, p=0.049) and mean CPM (+55.7 counts/min, p=0.014). Maternal permissive parenting was associated with higher levels of physical activity than authoritative parenting, but associations differed by child gender and type of physical activity. Maternal logistic support was associated with girls' physical activity, while paternal logistic support was associated with boys' physical activity. Health professionals could encourage parents to increase logistic support for their children's physical activity.
 
Recent studies suggest that parental sun protective behaviors and communication influence their adolescents. However, there is limited information on sun protection for parents of adolescents. A telephone-based, nationally representative prevalence study of sun exposure among youth, aged 11-18, and their parents living in households was conducted in 1998. Separate, independent responses were collected. Weighted prevalence estimates and 95% confidence intervals were estimated and presented for parents only (n = 1187). Approximately one-third of parents planned activities to avoid the sun and used sunscreen. Among parents who used sunscreen, 70% applied it while at the beach or pool, but not as often during other outdoor activities. Almost one-third of parents were participating in water or non-water recreational activities during their most serious sunburn. Differences in sun protection and sunburn experiences were observed by age, gender, sun sensitivity, race and ethnicity, and educational attainment. Parents have adopted sun protection habits, but have not surpassed national sun-protection goals. Combined use of sun protection behaviors may reduce sunburn prevalence and number of incident skin cancers. These data may be useful for developing or enhancing current sun protection programs for effective sun protection that include parents and their adolescents.
 
To evaluate the risk of postnatal HIV transmission among women in Abidjan, Côte d'Ivoire offered alternatives to prolonged breastfeeding, and to assess the impact of the breastfeeding pattern and duration on this risk. In 2001-2003, HIV-infected pregnant women received peri-partum antiretroviral prophylaxis and were counselled antenatally regarding infant feeding options: formula feeding or exclusive breastfeeding with early cessation from 4 months of age. The primary outcome was HIV postnatal transmission by 18 months of age, defined by a positive HIV test after a negative test > or =30 days. The effect of the pattern (mixed feeding, defined as breastmilk plus food-based fluid, solid food or non-human milk) and duration (less vs. more than 6 months) of breastfeeding on postnatal transmission was assessed. Of 622 live-born infants who were HIV uninfected at or after 30 days, 15 were infected postnatally, 13/324 among breastfed, and 2/298 among formula-fed infants. The 18-month probability of remaining free from HIV infection was 0.95 [95% CI, 0.92-0.97] and 0.99 [95% CI, 0.97-1.00] in the breastfeeding and formula-feeding groups respectively (p<0.001). In adjusted analysis, breastfeeding for more than 6 months and mixed feeding during the first month of life were independently associated with a 7.5 (AOR 95% CI, 2.0-28.2, p=0.003)- and a 6.3 (95% CI, 1.1-36.4, p=0.04)-fold increase of postnatal transmission among breastfed children. Mixed feeding during the first month of life and breastfeeding beyond 6 months are strong determinants of HIV transmission and should be avoided when replacement feeding after breastfeeding cessation can be safely and sustainably provided.
 
To examine the relationship between perceived family support and other selected correlates of physical activity (PA) with changes in PA over time. A total of 421 girls in South Carolina completed questionnaires at 8th, 9th and 12th grades (1998-2003). Family support for PA, PA self-efficacy, perceived behavioral control, attitudes, availability of equipment, and PA were measured. Growth curve analysis showed that family support, perceived behavioral control, and self-efficacy were independently related to age-related changes in PA as reflected by total METs. Girls who reported lower family support at the 8th grade measure had more rapid declines in PA, and a unit change in family support was related to approximately 1/3 of a standard deviation change in total METs. Maintenance of support from family members may reduce the decline in PA independent of girls' self-efficacy and perceived behavioral control.
 
Cervical cancer screening by surveys overestimate coverage because of selection and reporting biases. The prepared Inter-Mutualistic Agency dataset has about 13 million records from Pap smears, colposcopies, cervical biopsies and surgery, performed in Belgium between 1996 and 2000. Cervical cancer screening coverage was defined as the proportion of the target population (women of 25-64 years) that has had a Pap smear taken within the last 3 years. Proportions and incidence rates were computed using official population data of the corresponding age group, area and calendar year. Cervical cancer screening coverage, in the period 1998-2000, was 59% at national level, for the target age group 25-64 years. Differences were small between the 3 regions. Variation ranged from 39% to 71%. Coverage was 64% for 25-29 year old women, 67% for those aged 30-39 years, 56% for those aged 50-54. The modal screening interval was 1 year. In the 3-year period 1998-2000, 3 million smears were taken from the 2.7 million women in the age group 25-64. Only 1.6 million women of the target group got one or more smears in that period and 1.1 million women had no smears, corresponding to an average of 1.88 smears per woman. Coverage reached only 59%, but the number of smears used was sufficient to cover more than 100% of the target population. Structural reduction of overuse and extension of coverage is warranted.
 
Sun protection behaviors are important to the prevention of skin cancers, but little is known about changes over time in attitudes and behavior. Cross-sectional surveys were carried out among university students in thirteen European countries in 1990 (n = 10,241) and 2000 (n = 10,161). Sun protection behavior and beliefs about the importance of sunscreen use for health were measured. There was little change in the proportion of men and women who sunbathed, but use of sun protection increased over the 10-year interval from 52% to 63% in men and 80% to 87% in women. There was wide variation in sun protection use and strength of health beliefs between countries. The association between strength of beliefs and behavior was more marked in 2000 than 1990. Sun protection behavior was positively associated with the socioeconomic background of participants. The use of sunscreen increased among educated young Europeans from several countries over the 1990s, but important sex differences remain. Awareness of the risk to health of unprotected sunbathing is high, but there is scope of strengthening attitudes to sunscreen use.
 
Prevalence of tobacco use reported by students aged 13-15, by Palestine refugee and residence status (UNRWA living in camp, UNRWA living out of camp), and host country/ geographic region residents), Global Youth Tobacco Survey (GYTS) 2008.
Prevalence of tobacco use by students aged 13-15, by gender, UNRWA fields of operation, Global Youth Tobacco Survey (GYTS) 2008.
The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) has made tobacco use prevention a primary health issue. UNRWA provides education, health, relief and social services in five fields of operation: Jordan, Lebanon, Syria, Gaza Strip and the West Bank. The purpose of this paper is to compare tobacco use among Palestine refugee students and students in the general population of the five fields of operation. Global Youth Tobacco Survey (GYTS) data were collected from representative samples of students in UNRWA schools in each of the five fields of operation in 2008. For comparison, previous data are included from GYTS conducted in Gaza Strip, Lebanon, and the West Bank (2005) and in Jordan and Syria (2007). Data are presented for three groups of students: refugees attending schools within and outside the camps and non-refugee students in the general population. In each of the five fields of operation, there was no difference in current cigarette smoking, current use of shisha, or susceptibility to initiate smoking among the three groups of students. Cigarette smoking and susceptibility was lowest in the Gaza Strip and highest in the West Bank; shisha use was lowest in the Gaza Strip but over 30% in Lebanon, Syria, and the West Bank. Exposure to secondhand smoke in public places was greater than 60% in almost all sites. Exposure to indirect advertising was almost 10%. The similarity in tobacco use among the three groups of students suggests that a coordinated plan between the UNRWA and the governmental authority could be most beneficial in reducing the burden of tobacco-related morbidity and mortality.
 
To examine whether children compensate for participating in physically active behaviors by reducing activity at other times (the 'activitystat' hypothesis); or alternatively become more active at other times (activity synergy). In 2002-2006, 345 British children (8-13 years) completed activity diaries and wore accelerometers. This generated 1077 days of data which we analyzed between-children (comparing all days) and within-child (comparing days from the same child). On week and weekend days, each extra 1% of time in PE/games, school breaks, school active travel, non-school active travel, structured sports and out-of-home play predicted a 0.21 to 0.60% increase in the proportion of the day in moderate-to-vigorous physical activity (MVPA). None of these behaviors showed evidence of reduced MVPA at other times, i.e. activity compensation (all p>0.15). Moreover, each 1% increase in weekday non-school active travel predicted 0.38% more time in MVPA at other times (95% CI 0.18, 0.58). This activity synergy reflected children using active travel for playing and visiting friends. Contrary to the 'activitystat' hypothesis, we found no evidence of activity compensation. This suggests that interventions increasing activity in specific behaviors may increase activity overall. The activity synergy of non-school active travel underlines the need for further research into this neglected behavior.
 
A school and community based intervention to influence health behavior and cardiovascular disease (CVD) risk factors in 13- to 15-year-old children was carried out in North Karelia, Finland. The intervention was carried out on two levels: (a) an intensive intervention (II) in two schools and (b) a county-wide intervention (CI) in the rest of North Karelia. For the evaluation three matched pairs of schools were chosen: the two schools of the II, two schools to represent the CI and two schools from a reference county (R). 851 children, their parents, and their teachers were studied at the outset in 1978 and after the intervention in 1980. During the program the proportion of boys reporting to smoke at least 1–2 times per month increased 12.6% in II, 8.2% in CI and 29.7% in the R schools (P < 0.001 between II and R) and in girls 9.0%, 18.0% and 20.0%, respectively, (P < 0.05 between II and R). The mean serum total cholesterol was 5.1 mmol/liter in 1978 and it decreased among boys 0.5 mmol/liter in all three school groups. Among girls, the decrease was 0.43 mmol/liter (II), 0.35 mmol/liter (CI), and 0.21 mmol/liter (R) (P < 0.01 between II and R). The mean amount of fat from milk and butter changed among boys −8 g (II), 0 g (CI), and +3 g (R) and among girls −16 g, −2 g, and −5 g, respectively (both P < 0.01 between II and R). The intervention had no effect on blood pressure although there was some reported reduction in the salt consumption in the intervention schools. A relative decrease according to the intervention level was observed among North Karelian children in occurrence of psychosomatic symptoms. The effects were not related to increases in health knowledge or changes in attitudes and did not lead, on an average, to any harmful emotional consequences.
 
Physical activity (PA) is critical for children's normal growth and development. The purpose of this study was to assess potential correlates of physical activity in a US national sample of youth aged 9-13 years. A nationally representative telephone survey of parent-child pairs was conducted from April through June 2002. The questions assessed organized and free-time physical activity behavior and psychosocial and environmental variables that are potentially related to youth physical activity. Children's positive outcome expectations or beliefs about the benefits of participating in physical activity and parent's beliefs that participating in physical activity is important were related to participation in both organized and free-time physical activity. Children's perception of parental support and parent's reports of direct support were strongly related to organized physical activity. Feeling safe, having lots of places to be active, and parental participation with their child were strongly related to free-time physical activity. Messages and interventions aiming to increase children and adolescent's participation in organized and free-time physical activity should continue to focus on promoting the benefits that are associated with being active, the importance of parental support, and the provision of safe and enjoyable opportunities to be active.
 
Data on young people's knowledge about cancer prevention are not currently available for many populations, including Mexican young people, although cancer is the second most common cause of death among the Mexican population. A questionnaire was applied to 13,293 public school students aged 11-24 years in Morelos, Mexico. A knowledge-based scale was constructed from survey answers about risk factors for cancer. Data were analyzed using multivariate logistic multinomial models. Knowledge levels were low: 78% of male and 74% of female students had only wrong answers to questions about risk factors for cancer. A significant dose-response gradient was observed between age and knowledge of cancer risk factors (P < 0.001), with a higher prevalence in young women at all ages (female students OR 4.6, 95% CI 3.81-5.66). Students 18 years old and older knew more than 13-year-olds (OR = 2.39; 95% CI 1.89-3.01). Sexually active students (OR 2.10; 95% CI 1.70-2.58), especially those who consistently used condoms (OR 2.84; 95% CI 1.00-8.07), knew more about cancer prevention. Tobacco smoking was the most frequently recognized cancer risk factor, and smokers also recognized this as an important cause of cancer (OR 1.37; 95% CI 1.44-2.52). Our results reveal a poor level of knowledge about cancer prevention among adolescents. These data are the first step in the development of an intervention based on empirical findings that will be susceptible to evaluation.
 
Prospective data of cardiovascular mortality in relation to the systolic blood pressure of women are scarce, especially when combined with other risk factors. The association between systolic blood pressure and cardiovascular mortality was therefore studied in a 10-year follow-up of a population of 13,740 Dutch women, born between 1911 and 1925 who participated in a population-based breast cancer screening project (the DOM Project). Age-adjusted mortality rates over the 10-year follow-up period suggest a J-shaped pattern of cardiovascular mortality according to level of systolic blood pressure. Age-adjusted total cardiovascular, coronary, and cerebrovascular mortality rate ratios were significantly greater than 1.0 among women with elevated systolic blood pressure. Within categories of other risk factors (obesity index, diabetes mellitus, current smoking, and use of antihypertensive medicines) the age-adjusted cardiovascular rate ratios did not show confounding by any of these variables. A very high increase in cardiovascular mortality was observed among hypertensive diabetic women. This study shows that elevated systolic blood pressure is associated with increased rates of cardiovascular mortality for women in this age group.
 
There is an accumulating body of research showing that smoking causes hearing loss; however, the results of these studies have been inconsistent. Original English articles were retrieved by MEDLINE search using key words "smoking" and "hearing" (1966-2003). Of 166 relevant studies, those that investigated the risk for hearing loss in smokers identified by pure-tone average were selected for review. Studies with an occupational noise-exposed population were excluded. Methodological quality was assessed by a standardized checklist, and then a meta-analysis was performed on studies with discrete numbers of hearing loss among smokers and nonsmokers. A total of 15 (10 cross-sectional, 4 cohort, and one case-control) observational studies were identified; the quality scores of the 9 studies with positive associations between smoking and hearing loss were comparable to those of the remaining 6 studies with insignificant associations. Concerning eight analyzable studies, risk ratios (95% confidence intervals) for hearing loss in smokers were 1.33 (1.24, 1.44) for cross-sectional studies, 1.97 (1.44, 2.70) for cohort studies, and 2.89 (2.26, 3.70) for case-control studies, respectively. The evidence was suggestive of a positive association between smoking and hearing loss. It is possible that smoking cessation may be a useful strategy for maintaining hearing acuity.
 
Active and passive smoking have been found to be associated with clinical atherosclerotic disease. To explore the effects of smoking on atherogenesis, we investigated the relationship of past and current active and passive smoking to carotid atherosclerosis in middle-aged adults. The study population consisted of 2,073 middle-aged residents of Washington County, Maryland. Information on active smoking and exposure to environmental tobacco smoke (ETS) was obtained from a 1975 census and from the baseline visit of the Atherosclerosis Risk in Communities (ARIC) Study in 1987-1989. Carotid artery intimal-medial wall thickness, measured by B-mode ultrasound methods in 1987-1989, was used as an indicator of carotid atherosclerosis. Mean intimal-medial wall thickness (IMT) was adjusted for age, gender, cardiovascular risk factors, and education using multiple linear regression. The lowest mean IMT was found among never smokers who had never been exposed to ETS (mean +/- standard error: 0.706 +/- 0.013 mm). Exposure to ETS in one or both time periods was associated with increased IMT among never smokers (ETS in 1975 only: 0.731 +/- 0.022; ETS in 1987-1989 only: 0.738 +/- 0.011; ETS in both periods: 0.734 +/- 0.012). Active smoking in 1975 was also associated with increased IMT. The greatest mean intimal-medial wall thickness was found among persons who were current smokers in both time periods (0.807 +/- 0.009). Both past and current passive and active smoking are associated with increased carotid intimal-medial wall thickness.
 
This study examined the influence of appearance and social acceptance esteem, awareness and internalization of media stereotypes, body size acceptance, and teasing on the weight loss and muscle-gaining behaviors of 10- to 14-year-old boys and girls. Male (n = 670) and female (n = 788) students were drawn from one of four public senior middle schools (grades 6-8) in Southern Ontario as part of a longitudinal outcome-based study. Students' baseline self-report questionnaires, measuring the above variables, were analyzed for the purposes of this study. A higher percentage of girls reported engaging in weight loss behaviors, whereas a higher percentage of boys admitted to muscle gaining and the use of specific weight control methods such as laxative use and vomiting. Regression analyses revealed that internalization of media messages and body size acceptance were equally predictive of boys' weight loss and muscle-gaining behaviors, while teasing was found to also predict their muscle-gaining behavior. Among the girls, appearance esteem, internalization of media stereotypes, and body size acceptance were predictive of weight loss behaviors. None of the study variables were predictive of girls' muscle-gaining behavior. Weight loss and muscle-gaining behaviors appear to have their onset in children as young as 10 years. The findings support the need for prevention programs that focus on media literacy and ways to decrease weight-based teasing in the school setting.
 
Eating behavior is an etiologic factor in the development of lifestyle-related diseases. Knowledge about the stability of eating behavior during the transition from adolescence to early adulthood has implication for dietary interventions for children and young adolescents. Dietary data were collected by means of a short food frequency questionnaire as part of a Norwegian longitudinal cohort study on health behavior, lifestyle, and self-reported health of adolescents. Of 885 14-year-old baseline participants, 521 21-year-olds participated and 40% completed all surveys at each time point. Mean weekly frequency of consumption of fruit and vegetables decreased by 1-2.5 times per week between ages 14 and 21, whereas that of sugar-containing soft drinks increased by almost 1 time per week between ages 15 and 16. Tracking of consumption patterns into young adulthood was seen for all four foods (P < 0.05 for differences in means between the tracking groups). The proportions of individuals remaining in the same tracking categories at the major transition stages were 50-70%. Yet, some changed in the opposite direction of the observed trends. Despite the overall changes in mean weekly frequency of consumption and prevalence of daily consumers, relative ranking by frequency at age 14 indicated some stability of eating behavior into young adulthood.
 
As part of the international Know Your Body program 1,016 Dutch schoolchildren (response rate, 85%) were examined for CHD risk indicators. In both boys and girls, the plasma cholesterol level was lower at age 14 than at age 10. However, the decrease was larger in boys than in girls. A comparison with the results of other studies showed that the mean plasma cholesterol level in Dutch schoolchildren was lower in 1979 than in the period 1973–1976. The mean systolic blood pressure level increased 2–3 mm Hg per year in boys from age 10 to 14. In girls there was a 5 mm Hg increase from age 10 to 11. After a small increase from age 11 to 12 the mean blood pressure level in girls remained constant. Among all boys the prevalence of occasional and daily cigarette smokers was approximately 12 and 4%, respectively. For girls, these percentages were 8 and 3, respectively. Frankly high levels of plasma cholesterol (>5.7 mmol/liter or 220 mg/dl), systolic blood pressure (> 140 mm Hg), and daily smoking were found to be present in 7%, 2% and 4% of all boys and 8%, 2% and 3% of all girls, respectively. Combined frankly high risk indicator levels were observed in three children. It was concluded that frankly high levels of risk indicators did not aggregate in schoolchildren aged 10–14 years.
 
To determine the feasibility of population-based screening for metabolic syndrome (MetS) in primary care with self-measurement of waist circumference (WC) as first step, and the prevalence of MetS in a Dutch city. A survey of 14,000 people on the list of primary care physicians in the city of IJsselstein. All adults between 20 and 70 years on July 1st, 2006 were asked to measure their WC using a mailed tape measure. Participants with a high WC (>88/102 cm for women/men) were invited for assessment of other factors defining MetS. For patients already known with cardiovascular risk factors, these data were collected from medical records. 11,862 subjects were invited, of whom 6843 (58%) measured their WC. 2004 had a WC>88/102 cm and 1721 participated in all examinations. In 473 MetS was detected. The sensitivity of the screening was 77%, the negative predictive value 96%. The prevalence of MetS, including patients known with cardiovascular risk factors, was 15.5%. A primary care physician-driven population screening with self-measurement of WC can identify adults with MetS. The estimated prevalence of MetS is 15.5%. This procedure creates possibilities for targeted screening, prevention and treatment of people who are at increased cardiovascular risk.
 
To determine the specific features of representations of cholesterol and hypercholesterolemia according to the educational level (EL) and gender among hypercholesterolemic (HC) subjects. The knowledge, beliefs and personal opinions of 1579 hypercholesterolemic patients [58% males; 40% low EL; mean age 58.3 (SD = 11.5)], recruited by their general practitioners, were analyzed from the responses to a self-administered questionnaire. In comparison with women, and after adjusting for EL, men were less likely to know the acceptable total cholesterol level (OR = 0.80; P < 0.05), more likely to perceive hypercholesterolemia as not being a serious disorder (OR = 1.33; P < 0.05), mainly due to overweight (OR = 1.74; P < 0.001), modern (OR = 1.41; P < 0.01), and carefree lifestyle (OR = 1.80; P < 0.01), and less able to commit themselves to a therapeutic project (diet is only possible if shared by the spouse or family, OR = 1.25; P < 0.05). In comparison with subjects with a middle/high EL, and after adjusting for gender, the least educated subjects exhibited lower dietary knowledge (P < 0.001) and less right beliefs (the presence of cholesterol in blood is normal, OR = 0.48; P < 0.001), expressed the most misconceptions concerning hypercholesterolemia and its attendant risks (high cholesterol can induce cancer, OR = 1.63, P < 0.01, or rheumatism, OR = 3.64; P < 0.001; it is possible to perceive high cholesterol levels before seeing the results of blood tests, OR = 1.48; P < 0.001), exhibited lower self-efficacy (it is discouraging to know that heredity plays a role in a health problem, OR = 1.42; P < 0.001) and were the least convinced by and motivated for treatment (treatment may be limited in time, OR = 1.32; P < 0.05, dieting is impossible if one has an active lifestyle including eating out, OR = 1.64; P < 0.001). For distinctive reasons, male gender and low educational level, which are already recognized as cardiovascular risk factors, emerged from our study as limiting patient's personal involvement in the management of hypercholesterolemia. They attest to the need to support educational and informational messages aimed at alerting, convincing and motivating. To heighten the impact of such efforts, it would seem necessary to target specific messages to men and patients with low educational level.
 
Participant characteristics for the Canadian 2005/06 Health Behaviour in School-Aged Children Survey.
Prevalence and repeated measures cumulative rate ratios (95% confidence intervals) for engagement in MRB in the longitudinal sample according to television, computer, and video game use within the Canadian 2005/06 Health Behaviour in School-Aged Children Survey.
To examine television, computer, and video game use as possible determinants of multiple risk behaviors (MRB) among Canadian youth. Results are based on the Canadian 2005/06 Health Behaviour in School-Aged Children Survey. This survey included a representative cross-sectional sample of 8215 youth in grades 6-10, and a 1-year longitudinal sample of 1424 youth in grades 9-10. Total hours per week of television, video games, and computer use were calculated and participants were grouped into quartiles. Six risk behavior variables (smoking, drunkenness, non-use of seatbelts, cannabis use, illicit drug use, non-use of condoms) were combined to form a MRB score. Ordinal and repeated measure logistic regression models were used to examine associations between screen time and MRB variables. High computer use (top quartile) was associated with approximately a 50% increased engagement of MRB in both samples. High television use was also associated with modestly increased engagement in MRB in the cross-sectional sample. High computer use was the screen time behavior that was mostly strongly and consistently associated with engagement in MRB. Future research is needed to understand the relationship between specific screen time behaviors and adolescent health to help strengthen current screen time guidelines for youth.
 
To assess the cumulative impact of environmental and individual factors associated with adolescent alcohol misuse and their correlation with self-reported consequences of drinking. Cross-sectional school-based survey of a nationally representative sample of 7548 post-mandatory school students and apprentices aged 16-20 years, Switzerland 2002. Alcohol misuse defined by frequency of alcohol use, episodes of drunkenness and driving while drunk. Fifteen significant risk factors were identified among both boys, and girls. An individual score of cumulated risk factors was created by adding the risk factors. The association between the score and the likelihood of being engaged in alcohol misuse was highly significant and dose-dependent (p<.001). A significant proportion of adolescents report perceived adverse consequences of their alcohol consumption. A linear trend (p<.001) was found between the score of risk factors and the proportion of respondents reporting problems related to drinking such as diminished school performance, physical hazard, relational problems and current risky sexual behavior. Risk factors for adolescent alcohol misuse are cumulative and can be synthesized into an individual score correlated with the likeliness of misuse. A further indication of the validity of this score is its linear relationship with self-reported problems related to drinking.
 
The purpose of this study was to develop measures of perceived social support specific to health-related eating and exercise behaviors. In Study I, specific supportive and nonsupportive behaviors were identified through interviews with 40 individuals making health-behavior changes. In Study II, items derived from the interviews were administered to 171 subjects. Support from family and friends was assessed separately for both diet and exercise habits. Meaningful factors were identified for each of the four scales, and some factors were similar for family and friend scales. Both test-retest and internal consistency reliabilities were acceptable, and six factors can be used as subscales. Social support scales were correlated with respective self-reported dietary and exercise habits, providing evidence of concurrent criterion-related validity. A measure of general social support was not related to the specific social support scales or to reported health habits. These scales are among the first measures of social support behaviors specific to dietary- and exercise-habit change.
 
Light infantry soldiers (N = 218) completed a 161-km cross-country march over 5 days carrying an average +/- SD load mass (i.e., the weight of all equipment and clothing) of 47 +/- 5 kg. Prior to the march, height, weight, body fat, and physical fitness (3.2-km run, sit-ups, push-ups) were measured. Soldiers completed a demographic questionnaire which included questions on age and tobacco use history. Thirty-six percent (78/218) of the soldiers suffered one or more injuries. Of the total injuries, 48% presented were blisters and 18% were foot pain (not otherwise specified). Eight percent (17/218) of the soldiers were unable to complete the march because of injuries. Thirty-five percent (27/78) of the injured soldiers had 1 or more limited duty days for a total of 69 days. Risk of injury was higher among smokers (risk ratio = 1.8, P = 0.03 compared to nonsmokers) and lower among older soldiers (risk ratio = 3.2, P = 0.02, < 20 years compared to > 24 years). Carrying heavy loads over long distances can result in a high injury incidence to the lower body, since 36% of soldiers were injured during the 161-km march. Smoking and younger age (< 20 years) were independent risk factors for injuries.
 
Top-cited authors
David Revalds Lubans
  • The University of Newcastle, Australia
Neville Owen
  • Baker Heart and Diabetes Institute
Julie Makarski
  • McMaster University
Peter Littlejohns
  • King's College London
Louise Zitzelsberger