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1.  The possible absence of a healthy-worker effect: a cross-sectional survey among educated Japanese women 
BMJ Open  2012;2(5):e000958.
Despite being highly educated in comparison with women in other member countries of the Organisation for Economic Cooperation and Development, Japanese women are expected to assume traditional gender roles, and many dedicate themselves to full-time housewifery. Women working outside the home do so under poor conditions, and their health may not be better than that of housewives. This study compared the self-rated health status and health behaviours of housewives and working women in Japan.
Cross-sectional survey.
A national university in Tokyo with 9864 alumnae.
A total 1344 women who graduated since 1985 and completed questionnaires in an anonymous mail-based survey.
Primary and secondary outcome measures
Health anxiety and satisfaction, receipt of health check-ups, eating breakfast, smoking, and sleep problems according to job status and family demands: housewives (n=247) and working women with (n=624) and without (n=436) family demands. ORs were used for risk assessment, with housewives as a reference.
After adjustment for satisfaction with present employment status and other confounding factors, working women were more likely than housewives to feel health anxiety (with family demands, OR: 1.68, 95% CI1.10 to 2.57; without family demands, OR: 3.57, 95% CI 2.19 to 4.50) and health dissatisfaction (without family demands, OR: 3.50, 95% CI 2.35 to 5.21); they were also more likely than housewives to eat an insufficient breakfast (with family demands, OR: 1.91, 95% CI 1.22 to 3.00; without family demands, OR: 4.02, 95% CI 2.47 to 6.57) and to have sleep problems (ORs: 2.08 to 4.03).
No healthy-worker effect was found among Japanese women. Housewives, at least those who are well educated, appear to have better health status and health-related behaviours than do working women with the same level of education.
PMCID: PMC3467618  PMID: 22964114
2.  Comparing health-related quality of life of employed women and housewives: a cross sectional study from southeast Iran 
BMC Women's Health  2012;12:41.
Quality of life differs for different people in different situations and is related to one's self-satisfaction with life. Considering the role of women in family and social health and the specific cultural characteristics of our province, we aimed to compare the quality of life of employed women with housewives in Zahedan, Iran.
This cross-sectional study was carried out during 2009–2010 in Zahedan, Iran. The sample consisted of 110 housewives and 110 employed women selected randomly from ten health care centers. Health-related quality of life was assessed using the SF-36. Analysis of covariance (ANCOVA) was used to compare quality of life in housewives and employed women while controlling for age, education and income.
The mean (±SD) age of participants was 33.87± 8.95 years. Eighty-eight women (40%) had a university degree with a mean (±SD) official education of 10.8 (±4.9) years. The results indicated that employed women scored higher than housewives in all measures except for physical functioning. The differences were found to be remarkable for vitality, mental health and role emotional. However, after controlling for age, education and family income, none of differences reached significant level.
After controlling for potential confounders, the findings from this study indicated that there were no significant differences in quality of life between employed women and housewives. However, employed women scored higher on the SF-36, especially on the role emotional, vitality, and mental health. The findings suggest that associations exist between some aspects of health-related quality of life and employment. Indeed improving health-related quality of life among housewives seems essential.
PMCID: PMC3559256  PMID: 23173572
3.  High carbohydrate diet and physical inactivity associated with central obesity among premenopausal housewives in Sri Lanka 
BMC Research Notes  2014;7:564.
Prevalence of obesity and overweight is rising in developing countries, including Sri Lanka at a rapid pace due to dietary and lifestyle changes. This study aimed to assess the association between high carbohydrate diet, physical inactivity and central obesity among premenopausal housewives in Sri Lanka.
This study was conducted as a cross-sectional study. A sample of 100 premenopausal women with home duties aged between 20 to 45 years were selected randomly from two divisional secretariats (DS), representing urban and rural sectors in Sri Lanka. Data on basic characteristics, anthropometric measurements, dietary assessment and physical activity were collected. We defined central obesity as a waist circumference ≥80 cm, which is the WHO recommended cut-off. Independent sample t test was used to compare the mean values. Linear and binary logistic regression analyses were performed to find out the relationship and the magnitude of association between central obesity and percentage of energy contributed from carbohydrate and physical activity level, respectively.
The women reported an average of 18 starch portions per day, which was well above the national recommendations. Seventy percent of energy in the diet came from carbohydrate. The mean BMI and waist circumference of total sample was 25.4 kgm-2 and 78.5 cm, respectively. Prevalence of overweight, obesity and centrally obesity among total sample was 38%, 34% and 45%, respectively. A significant positive correlation observed between high carbohydrate diet and waist circumference (r = 0.628, p < 0.0001). There was a significant negative correlation between energy expenditure from physical activity and waist circumference (r = -0.742, p < 0.0001). High carbohydrate diet and physical inactivity were significantly associated with central obesity (OR = 6.26, p = 0.001, 95% CI-2.11-18.57, OR = 3.32, p = 0.028, 95% CI-1.14-9.68).
High carbohydrate diet and physical inactivity are possible explanations for the high prevalence of central obesity. There is an urgent need to implement effective specific public health interventions at household level to reverse this trend among the housewives in Sri Lanka.
PMCID: PMC4148929  PMID: 25150690
Central obesity; Premenopausal; Housewives; High carbohydrate diet
4.  Checking the determinants of physical activity based on the theory of planned behavior in the housewives 
Sedentary life has been recognized as a serious problem in today's Iranian society. Promoting the lifestyle with increased physical activity and prevention of cardiovascular disease (CVD) is imperative. The purpose of this study was identifying the determinants of physical activity in the housewives of Nain city in 2012 based on the theory of planned behavior.
Materials and Methods:
In this cross-sectional study, 120 housewives were selected by simple random sampling method. Data collection tool was a questionnaire designed based on a standardized and fabricated questionnaire and consisted of four parts. The questionnaire included awareness variables, theory of structures, planned behavior, and physical activity. Data analysis was performed using the SPSS software version 18 and associated statistical tests.
The 120 housewives under study had a mean age of 34.58 ± 6.86 years. The mean scores of awareness, attitude, motivation to perform, subjective norms, and perceived behavioral control variables were 74.1 ± 18.5, 82.6 ± 12.1, 59.4 ± 21.7, 63.2 ± 21.2, and 48.1 ± 12.9 respectively. There was a significant relationship between the motivation for physical activity among women and knowledge (P = 0.02) attitude (P = 0.04) subjective norms (P = 0.002) perceived behavioral control (P = 0.001), and physical activity (P = 0.04).
It seems that the housewives, despite being aware of and having a positive attitude on the benefits of physical activity, had a poor lifestyle. Perhaps further studies can help in finding the causes of this issue and the barriers to physical activity such as the conditions and plan for greater measures for improving physical activity, in order to promote women's health which has a significant role in family and community health.
PMCID: PMC4165126  PMID: 25250360
Housewives; physical activity; theory of planned behavior
5.  Association between vitamin D insufficiency and adverse pregnancy outcome: global comparisons 
Vitamin D insufficiency has been associated with a number of adverse pregnancy outcomes, and has been recognized as a public health concern.
The objective of this study was to determine the impact of vitamin D deficiency on maternal complications like gestational diabetes mellitus (GDM), anemia, iron deficiency, and preeclampsia among pregnant women.
Subjects and methods
This was a cohort study undertaken at antenatal clinics at the Women’s Hospital of Hamad Medical Corporation in Doha. A total of 2,487 Arab pregnant women above 24 weeks’ gestation with any maternal complication were approached, and 1,873 women (75.3%) consented to participate in the study. Data on sociodemographic and clinical characteristics by interview and biochemistry parameters were retrieved from medical records. Multivariate logistic regression analysis was performed to determine the associated risk factors.
Of the studied pregnant women, nearly half of them had vitamin D deficiency (48.4%). Younger women below 30 years old (43.2%, P = 0.032), housewives (65.3%, P = 0.008), and those on low monthly household incomes (QR5,000–9,999) (49.2%, P = 0.03) were significantly more likely to have lower vitamin D compared with those who had sufficient vitamin D levels. Exposure to sunlight (63.4%, P = 0.05), daily physical activity (64.4%, P = 0.05), and vitamin D supplement intake (89.7%, P < 0.001) were significantly lower in deficient pregnant women. In the study sample of pregnant women, 13.9% had GDM, 11.5% had anemia, 8.6% had iron deficiency, and 6.9% had preeclampsia. Severe vitamin D deficiency was significantly higher in pregnant women with GDM (16.5% vs 11%), anemia (17.1% vs 11%), iron deficiency (18.5% vs 11.2%), and preeclampsia (19.8% vs 11.4%) when compared to the uncomplicated group. Socioeconomic status was low in pregnant women with complications like GDM, anemia, iron deficiency, and pre-eclampsia. Pregnancy complications like GDM (52.7%), anemia (53.2%), iron deficiency (55.6%), and preeclampsia (51.9%) were higher in Qataris. Also, GDM (66.2%), anemia (66.2%), iron deficiency (68.5%), and preeclampsia (58.1%) were observed more commonly among housewives compared to working women. Obesity was significantly more common in pregnant women with GDM (41.5%) and preeclampsia (41.1%).
The study findings revealed that maternal vitamin D deficiency in pregnancy is significantly associated with elevated risk for GDM, anemia, and preeclampsia. The risk of vitamin D deficiency was higher in Qataris, housewives and those with low monthly household income.
PMCID: PMC3772690  PMID: 24043954
pregnant women; vitamin D deficiency; GDM; anemia; iron deficiency; preeclampsia
6.  Combined Impact of Lifestyle-Related Factors on Total and Cause-Specific Mortality among Chinese Women: Prospective Cohort Study 
PLoS Medicine  2010;7(9):e1000339.
Findings from the Shanghai Women's Health Study confirm those derived from other, principally Western, cohorts regarding the combined impact of lifestyle-related factors on mortality.
Although cigarette smoking, excessive alcohol drinking, obesity, and several other well-studied unhealthy lifestyle-related factors each have been linked to the risk of multiple chronic diseases and premature death, little is known about the combined impact on mortality outcomes, in particular among Chinese and other non-Western populations. The objective of this study was to quantify the overall impact of lifestyle-related factors beyond that of active cigarette smoking and alcohol consumption on all-cause and cause-specific mortality in Chinese women.
Methods and Findings
We used data from the Shanghai Women's Health Study, an ongoing population-based prospective cohort study in China. Participants included 71,243 women aged 40 to 70 years enrolled during 1996–2000 who never smoked or drank alcohol regularly. A healthy lifestyle score was created on the basis of five lifestyle-related factors shown to be independently associated with mortality outcomes (normal weight, lower waist-hip ratio, daily exercise, never exposed to spouse's smoking, higher daily fruit and vegetable intake). The score ranged from zero (least healthy) to five (most healthy) points. During an average follow-up of 9 years, 2,860 deaths occurred, including 775 from cardiovascular disease (CVD) and 1,351 from cancer. Adjusted hazard ratios for mortality decreased progressively with an increasing number of healthy lifestyle factors. Compared to women with a score of zero, hazard ratios (95% confidence intervals) for women with four to five factors were 0.57 (0.44–0.74) for total mortality, 0.29 (0.16–0.54) for CVD mortality, and 0.76 (0.54–1.06) for cancer mortality. The inverse association between the healthy lifestyle score and mortality was seen consistently regardless of chronic disease status at baseline. The population attributable risks for not having 4–5 healthy lifestyle factors were 33% for total deaths, 59% for CVD deaths, and 19% for cancer deaths.
In this first study, to our knowledge, to quantify the combined impact of lifestyle-related factors on mortality outcomes in Chinese women, a healthier lifestyle pattern—including being of normal weight, lower central adiposity, participation in physical activity, nonexposure to spousal smoking, and higher fruit and vegetable intake—was associated with reductions in total and cause-specific mortality among lifetime nonsmoking and nondrinking women, supporting the importance of overall lifestyle modification in disease prevention.
Please see later in the article for the Editors' Summary
Editors' Summary
It is well established that lifestyle-related factors, such as limited physical activity, unhealthy diets, excessive alcohol consumption, and exposure to tobacco smoke are linked to an increased risk of many chronic diseases and premature death. However, few studies have investigated the combined impact of lifestyle-related factors and mortality outcomes, and most of such studies of combinations of established lifestyle factors and mortality have been conducted in the US and Western Europe. In addition, little is currently known about the combined impact on mortality of lifestyle factors beyond that of active smoking and alcohol consumption.
Why Was This Study Done?
Lifestyles in regions of the world can vary considerably. For example, many women in Asia do not actively smoke or regularly drink alcohol, which are important facts to note when considering practical disease prevention measures for these women. Therefore, it is important to study the combination of lifestyle factors appropriate to this population.
What Did the Researchers Do and Find?
The researchers used the Shanghai Women's Health Study, an ongoing prospective cohort study of almost 75,000 Chinese women aged 40–70 years, as the basis for their analysis. The Shanghai Women's Health Study has comprehensive baseline data on anthropometric measurements, lifestyle habits (including the responses to validated food frequency and physical activity questionnaires), medical history, occupational history, and select information from each participant's spouse, such as smoking history and alcohol consumption. This information was used by the researchers to create a healthy lifestyle score on the basis of five lifestyle-related factors shown to be independently associated with mortality outcomes in this population: normal weight, lower waist-hip ratio, daily exercise, never being exposed to spouse's smoking, and higher daily fruit and vegetable intake. The score ranged from zero (least healthy) to five (most healthy) points. The researchers found that higher healthy lifestyle scores were significantly associated with decreasing mortality and that this association persisted for all women regardless of their baseline comorbidities. So in effect, healthier lifestyle-related factors, including normal weight, lower waist-hip ratio, participation in exercise, never being exposed to spousal smoking, and higher daily fruit and vegetable intake, were significantly and independently associated with lower risk of total, and cause-specific, mortality.
What Do These Findings Mean?
This large prospective cohort study conducted among lifetime nonsmokers and nonalcohol drinkers shows that lifestyle factors, other than active smoking and alcohol consumption, have a major combined impact on total mortality on a scale comparable to the effect of smoking—the leading cause of death in most populations. However, the sample sizes for some cause-specific analyses were relatively small (despite the overall large sample size), and extended follow-up of this cohort will provide the opportunity to further evaluate the impact of these lifestyle-related factors on mortality outcomes in the future.
The findings of this study highlight the importance of overall lifestyle modification in disease prevention, especially as most of the lifestyle-related factors studied here may be improved by individual motivation to change unhealthy behaviors. Further research is needed to design appropriate interventions to increase these healthy lifestyle factors among Asian women.
Additional Information
Please access these Web sites via the online version of this summary at
The Vanderbilt Epidemiology Center has more information on the Shanghai Women's Health Study
The World Health Organization provides information on health in China
The document Health policy and systems research in Chinacontains information about health policy and health systems research in China
The Chinese Ministry of Healthalso provides health information
PMCID: PMC2939020  PMID: 20856900
7.  Women health heart project: Methodology and effect of interventional strategies on low education participants 
Cardiovascular diseases (CVD) are the most common cause of mortality and morbidity in women. Intervention programs aimed at improving the lifestyle can reduce the incidence of these diseases and their factors. The purpose of this study was to evaluate the difference of the interventions impact on CVD risk factors and the women's physical and biochemical indicators based on education levels.
Materials and Methods:
As part of Isfahan Healthy Heart Program after identifying the status of women over the age of 18 and over five years, a large educational or environmental intervention was performed in different methodologies and in order to improve the lifestyle. Some organizations such as health care centers and the Literacy Campaign Organization have cooperated for low educated women. Demographic data and risk factors such as obesity, hypertension, diabetes and serum lipids were investigated and compared during the first and last phase. Data were entered in SPSS-15 software and were analyzed by using T-test in two independent samples, Chi-square test and Fisher exact test.
Findings of this study showed that performing the five years interventions could reduce physical and biochemical indexes such as nutrition, lipid profile, waist circumference and waist-to-hip ratio in both groups (P < 0.005). In the pre-intervention phase, 6391 subjects and after the intervention 4786 women participated. After Interventions, women with higher educational levels were showed significant decrease in Body Mass Index (BMI) (P = 0.01) and dyslipidemia (P = 0.02).
The present study showed that the community-based interventions even in low-literate women could cause effective changes on improving lifestyle and CVD risk factors. Due to the greater impact of interventions in literate women, effective interventions should be considered in the society to decrease the prevalence of Non-Communicable Diseases (NCDs).
PMCID: PMC4165102  PMID: 25250369
Education level; lifestyle modification; literacy movement; risk factors; women
8.  Comparative study of major depressive symptoms among pregnant women by employment status 
SpringerPlus  2013;2:201.
The objectives of our study were to compare the prevalence of major depressive symptoms between subgroups of pregnant women: working women, women who had stopped working, housewives and students; and to identify risk factors for major depressive symptoms during pregnancy. The CES-D scale (Center for Epidemiological Studies Depression scale) was used to measure major depressive symptoms (CES-D score ≥23) in 5337 pregnant women interviewed at 24–26 weeks of pregnancy. Multivariate logistic regression models were developed to identify risk factors associated with major depressive symptoms. Prevalence of major depressive symptoms was 11.9% (11.0–12.8%) for all pregnant women. Working women had the lowest proportion of major depressive symptoms [7.6% (6.6–8.7%); n = 2514] compared to housewives [19.1% (16.5–21.8%); n = 893], women who had stopped working [14.4% (12.7–16.1%); n = 1665], and students [14.3% (10.3–19.1%); n = 265]. After adjusting for major risk factors, the association between pregnant women’s employment status and major depressive symptoms remained significant for women who had stopped working (OR: 1.61; 95% CI 1.26 to 2.04) and for housewives (OR: 1.46; 95% CI 1.10 to 1.94), but not for students (OR: 1.37; 95% CI 0.87 to 2.16). In multivariate analyses, low education, low social support outside of work, having experienced acute stressful events, lack of money for basic needs, experiencing marital strain, having a chronic health problem, country of birth, and smoking were significantly associated with major depressive symptoms. Health professionals should consider the employment status of pregnant women when they evaluate risk profiles. Prevention, detection and intervention measures are needed to reduce the prevalence of prenatal depression.
PMCID: PMC3657078  PMID: 23705107
Pregnancy; Employment status; Major depressive symptoms; Risk factors
9.  Incidence rates of surgically treated idiopathic carpal tunnel syndrome in blue- and white-collar workers and housewives in Tuscany, Italy 
Rates of surgically treated carpal tunnel syndrome (CTS) among blue- and white-collar workers and housewives in the general population were compared.
Surgically treated cases of idiopathic CTS were investigated among 25–59-year-old residents of Tuscany, Italy, during 1997–2000, based on obligatory discharge records from all Italian public/private hospitals, archived according to residence on Tuscany’s regional database. Population data were extracted from the 2001 census.
After excluding repeat admissions, 8801 eligible cases were identified. Age-standardised rates (per 100 000 person-years) of surgical CTS were: “blue-collar women”, 367.8; “white-collar women”, 88.1; “housewives”, 334.5; “blue-collar men”, 73.5; and “white-collar men”, 15.3. Compared with reference categories (same-sex white-collar workers): female blue-collar workers experienced a 4.2-fold higher standardised rate; housewives, a 3.8-fold excess; and male blue-collar workers, a 4.8-fold excess (all p<0.001). Male and female blue-collar workers showed approximately three to sevenfold higher age-specific rates compared to their white-collar counterparts (all p<0.001). Housewives’ rates were similar to those of blue-collar female workers up to 40–44 years of age, after which they were significantly lower (p<0.002). At all ages, housewives’ rates were much higher (p<0.001) than those of white-collar women.
Surgically treated CTS was three to seven times more common (depending on age/gender) in blue-collar than in white-collar workers, which is difficult to explain by differences in body weight or other individual factors. Thus, occupational risk factors seem relevant throughout working life. The high rates for full-time housewives suggest that domestic chores should be investigated as a possible risk factor for CTS.
PMCID: PMC2664992  PMID: 19254910
10.  Prevention of non-communicable disease in a population in nutrition transition: Tehran Lipid and Glucose Study phase II 
Trials  2009;10:5.
The Tehran Lipid and Glucose Study (TLGS) is a long term integrated community-based program for prevention of non-communicable disorders (NCD) by development of a healthy lifestyle and reduction of NCD risk factors. The study begun in 1999, is ongoing, to be continued for at least 20 years. A primary survey was done to collect baseline data in 15005 individuals, over 3 years of age, selected from cohorts of three medical heath centers. A questionnaire for past medical history and data was completed during interviews; blood pressure, pulse rate, and anthropometrical measurements and a limited physical examination were performed and lipid profiles, fasting blood sugar and 2-hours-postload-glucose challenge were measured. A DNA bank was also collected. For those subjects aged over 30 years, Rose questionnaire was completed and an electrocardiogram was taken. Data collected were directly stored in computers as database software- computer assisted system. The aim of this study is to evaluate the feasibility and effectiveness of lifestyle modification in preventing or postponing the development of NCD risk factors and outcomes in the TLGS population.
Design and methods
In phase II of the TLGS, lifestyle interventions were implemented in 5630 people and 9375 individuals served as controls. Primary, secondary and tertiary interventions were designed based on specific target groups including schoolchildren, housewives, and high-risk persons. Officials of various sectors such as health, education, municipality, police, media, traders and community leaders were actively engaged as decision makers and collaborators. Interventional strategies were based on lifestyle modifications in diet, smoking and physical activity through face-to-face education, leaflets & brochures, school program alterations, training volunteers as health team and treating patients with NCD risk factors. Collection of demographic, clinical and laboratory data will be repeated every 3 years to assess the effects of different interventions in the intervention group as compared to control group.
This controlled community intervention will test the possibility of preventing or delaying the onset of non-communicable risk factors and disorders in a population in nutrition transition.
Trial registration
PMCID: PMC2656492  PMID: 19166627
11.  Self-Medication Patterns and Drug Use Behavior in Housewives Belonging to the Middle Income Group in a City in Northern India 
The objective was to assess the self-medication patterns and drug use behavior in housewives belonging to the middle income group in a city of Haryana State in Northern India.
Materials and Methods:
A detailed questionnaire designed to assess the self-medication patterns and drug use behavior and interview technique was used to elicit the requisite information. One hundred housewives of the middle income group were interviewed in Rohtak.
Most of the housewives were in the habit of keeping the medicines though only 73% of them were in the habit of using it without any prescription. Also it was seen that those housewives who were taking self-medication were better educated than those not indulged in self-medication. All of them were using allopathic drugs on a regular basis while other modes of medications were less used. The self-medication was most commonly based on the previous prescriptions issued by the doctors followed by the suggestions from friends, advertisement on the television, and newspapers. For most of them the reasons for self-medication were financial restraints and lack of time to go to the medical practitioner.
The study delineates the difference in the self-medication patterns and drug use behavior in housewives in a city of Northern India. The results emphasize the need for comprehensive measures for intervention strategies to promote rational drug therapy by improving prescribing patterns and influencing self-medication.
PMCID: PMC3326801  PMID: 22529534
Drug use behavior; housewives; rational therapy; self-medication
12.  Lifestyle in Iranian Patients with Breast Cancer 
One of the most commonly diagnosed cancers is breast cancer that leads to mortality and morbidity among Iranian women. Behavioural risk factors, such as common lifestyle patterns are often associated with risk of breast cancer incidence.
This study aimed to investigate lifestyle of breast cancer patients admitted to Cancer Research Center of Mazandaran University of Medical Sciences.
Materials and Methods
This descriptive cross-sectional study was conducted using convenient sampling method. Sample size consisted of 150 cancer patients, and data collection tool included a researcher-made questionnaire on dimensions of lifestyle containing four dimensions of self-care, exercise and physical activity, diet and coping with stress. Maximum score in different dimensions, based on 100% of marks earned, was evaluated in three categories of undesirable, relatively desirable and desirable. Data were analysed with SPSS-19 software using descriptive statistics (relative and absolute frequencies, mean and standard deviation).
In total of 150 women, the mean age of patients was 51.9 ± 1.04 (27-78). The majority of participants were married, housewives, with high school education. Among the four parts of healthy lifestyle, desirable level of physical activity and exercise had the least participants, and in the dimensions of physical activity and exercise, the lowest level related to walking, followed by daily exercise. Most of the participants had undesirable level of self-care and lowest frequency related to mammography after 40-year-old, followed by annual check-up and Pap-smear. With regard to nutrition, most of them were at desirable level.
The results indicated undesirable levels in two lifestyle dimensions (self-care and physical activity and exercise) in the majority of participants for a year before contracting breast cancer. Primary prevention programs should be implemented with a comprehensive approach, thus, effective strategies are required to modify lifestyle.
PMCID: PMC4573022  PMID: 26393190
Mortality and morbidity; Neoplasms; Risk factors
13.  The impact of obesity on hypertension and diabetes control following healthy Lifestyle Intervention Program in a developing country setting 
The aim of this study was to evaluate the impact of obesity and overweight on diabetes mellitus (DM) and hypertension (HTN) control in a healthy lifestyle intervention program in Iran.
Within the framework of the Isfahan Healthy Heart Program (IHHP), a community trial that was conducted to prevent and control cardiovascular disease and its risk factors, two intervention counties (Isfahan and Najafabad) and one reference county (Arak) were selected. Demographic information, medical history, anti-diabetic and anti-hypertensive medications use were asked by trained interviewers in addition to physical examination and laboratory tests for 12514 adults aged more than 19 years in 2001 and were repeated for 9572 adults in 2007.
In women, the frequency of HTN control change significantly neither in normal weight nor in those with high body mass index (BMI), waist circumference (WC) or waist to hip ratio (WHR). In men, the frequency of HTN control was only significant among those with high WHR, whereas the interaction between changes in intervention compared to reference area from 2001 to 2007 was significant in men with normal or high WC or WHR. In intervention area, the number of women with high BMI who controlled their DM increased significantly from 2001 to 2007 (p = 0.008), however, this figure decreased in men. In reference area, obesity indices had no significant association with DM control. The percentage of diabetic subjects with high WC who controlled their DM decreased non-significantly in intervention area compared to reference area in 2007. A non-significant increase in controlled DM among men and women with high WHR was observed between intervention and reference areas.
Our lifestyle interventions did not show any improving effect on HTN or DM control among obese subjects based on different obesity indices. Other lifestyle intervention strategies are suggested.
PMCID: PMC3252770  PMID: 22247721
Hypertension; Diabetes; Obesity; Control; Prevention; Iran
14.  Long-Term Risk of Incident Type 2 Diabetes and Measures of Overall and Regional Obesity: The EPIC-InterAct Case-Cohort Study 
PLoS Medicine  2012;9(6):e1001230.
A collaborative re-analysis of data from the InterAct case-control study conducted by Claudia Langenberg and colleagues has established that waist circumference is associated with risk of type 2 diabetes, independently of body mass index.
Waist circumference (WC) is a simple and reliable measure of fat distribution that may add to the prediction of type 2 diabetes (T2D), but previous studies have been too small to reliably quantify the relative and absolute risk of future diabetes by WC at different levels of body mass index (BMI).
Methods and Findings
The prospective InterAct case-cohort study was conducted in 26 centres in eight European countries and consists of 12,403 incident T2D cases and a stratified subcohort of 16,154 individuals from a total cohort of 340,234 participants with 3.99 million person-years of follow-up. We used Prentice-weighted Cox regression and random effects meta-analysis methods to estimate hazard ratios for T2D. Kaplan-Meier estimates of the cumulative incidence of T2D were calculated. BMI and WC were each independently associated with T2D, with WC being a stronger risk factor in women than in men. Risk increased across groups defined by BMI and WC; compared to low normal weight individuals (BMI 18.5–22.4 kg/m2) with a low WC (<94/80 cm in men/women), the hazard ratio of T2D was 22.0 (95% confidence interval 14.3; 33.8) in men and 31.8 (25.2; 40.2) in women with grade 2 obesity (BMI≥35 kg/m2) and a high WC (>102/88 cm). Among the large group of overweight individuals, WC measurement was highly informative and facilitated the identification of a subgroup of overweight people with high WC whose 10-y T2D cumulative incidence (men, 70 per 1,000 person-years; women, 44 per 1,000 person-years) was comparable to that of the obese group (50–103 per 1,000 person-years in men and 28–74 per 1,000 person-years in women).
WC is independently and strongly associated with T2D, particularly in women, and should be more widely measured for risk stratification. If targeted measurement is necessary for reasons of resource scarcity, measuring WC in overweight individuals may be an effective strategy, since it identifies a high-risk subgroup of individuals who could benefit from individualised preventive action.
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, more than 350 million people have diabetes, and this number is increasing rapidly. Diabetes is characterized by dangerous levels of glucose (sugar) in the blood. Blood sugar levels are usually controlled by insulin, a hormone that the pancreas releases after meals (digestion of food produces glucose). In people with type 2 diabetes (the commonest form of diabetes), blood sugar control fails because the fat and muscle cells that normally respond to insulin by removing sugar from the blood become insulin resistant. Type 2 diabetes can be controlled with diet and exercise, and with drugs that help the pancreas make more insulin or that make cells more sensitive to insulin. The long-term complications of diabetes, which include an increased risk of heart disease and stroke, reduce the life expectancy of people with diabetes by about 10 years compared to people without diabetes.
Why Was This Study Done?
A high body mass index (BMI, a measure of body fat calculated by dividing a person's weight in kilograms by their height in meters squared) is a strong predictor of type 2 diabetes. Although the risk of diabetes is greatest in obese people (who have a BMI of greater than 30 kg/m2), many of the people who develop diabetes are overweight—they have a BMI of 25–30 kg/m2. Healthy eating and exercise reduce the incidence of diabetes in high-risk individuals, but it is difficult and expensive to provide all overweight and obese people with individual lifestyle advice. Ideally, a way is needed to distinguish between people with high and low risk of developing diabetes at different levels of BMI. Waist circumference is a measure of fat distribution that has the potential to quantify diabetes risk among people with different BMIs because it estimates the amount of fat around the abdominal organs, which also predicts diabetes development. In this case-cohort study, the researchers use data from the InterAct study (which is investigating how genetics and lifestyle interact to affect diabetes risk) to estimate the long-term risk of type 2 diabetes associated with BMI and waist circumference. A case-cohort study measures exposure to potential risk factors in a group (cohort) of people and compares the occurrence of these risk factors in people who later develop the disease and in a randomly chosen subcohort.
What Did the Researchers Do and Find?
The researchers estimated the association of BMI and waist circumference with type 2 diabetes from baseline measurements of the weight, height, and waist circumference of 12,403 people who subsequently developed type 2 diabetes and a subcohort of 16,154 participants enrolled in the European Prospective Investigation into Cancer and Nutrition (EPIC). Both risk factors were independently associated with type 2 diabetes risk, but waist circumference was a stronger risk factor in women than in men. Obese men (BMI greater than 35 kg/m2) with a high waist circumference (greater than 102 cm) were 22 times more likely to develop diabetes than men with a low normal weight (BMI 18.5–22.4 kg/m2) and a low waist circumference (less than 94 cm); obese women with a waist circumference of more than 88 cm were 31.8 times more likely to develop type 2 diabetes than women with a low normal weight and waist circumference (less than 80 cm). Importantly, among overweight people, waist circumference measurements identified a subgroup of overweight people (those with a high waist circumference) whose 10-year cumulative incidence of type 2 diabetes was similar to that of obese people.
What Do These Findings Mean?
These findings indicate that, among people of European descent, waist circumference is independently and strongly associated with type 2 diabetes, particularly among women. Additional studies are needed to confirm this association in other ethnic groups. Targeted measurement of waist circumference in overweight individuals (who now account for a third of the US and UK adult population) could be an effective strategy for the prevention of diabetes because it would allow the identification of a high-risk subgroup of people who might benefit from individualized lifestyle advice.
Additional Information
Please access these web sites via the online version of this summary at
The US National Diabetes Information Clearinghouse provides information about diabetes for patients, health care professionals, and the general public, including detailed information on diabetes prevention (in English and Spanish)
The US Centers for Disease Control and Prevention provides information on all aspects of overweight and obesity (including some information in Spanish)
The UK National Health Service Choices website provides information for patients and carers about type 2 diabetes, about the prevention of type 2 diabetes, and about obesity; it also includes peoples stories about diabetes and about obesity
The charity Diabetes UK also provides detailed information for patients and carers, including information on healthy lifestyles for people with diabetes, and has a further selection of stories from people with diabetes; the charity Healthtalkonline has interviews with people about their experiences of diabetes
More information on the InterAct study is available
MedlinePlus provides links to further resources and advice about diabetes and diabetes prevention and about obesity (in English and Spanish)
PMCID: PMC3367997  PMID: 22679397
15.  Association of Occupational & Prediabetes Statuses with Obesity in middle aged Women 
Background: The association between Type 2 Diabetes Mellitus and Obesity is very close. The prediabetes status i.e Impaired Fasting Glucose (IFG) reflects an intermediate condition between normality and diabetes. The socioeconomic position (SEP) is one of the non traditional determinants of type 2 DM. The occupational status, which is a good indicator of the socioeconomic status, also indicates the level and the type of stress that they are exposed to, as well as the individual lifestyle choices. The present work was planned to study the relationship of the prediabetic status with obesity and the occupational status by estimating the Fasting Blood Glucose (FBG) levels.
Objectives: To study the association of the occupational status with the fasting blood glucose levels and obesity in middle aged women.
Method: The Fasting Blood Glucose levels and the BMI were estimated in 300 asymptomatic middle aged women who had no family history of Type 2 Diabetes Mellitus (D.M.), who had been divided into the Control (I), the Pre – obese (IIa) and the Obese groups (IIb). The occupational status was broadly divided into the categories of housewives and service women. The results was analysed statistically by using the correlation coefficient and the ‘z’ test.
Result: The mean FBG levels in the pre – obese and the obese groups were higher than those in the control group. We found significant differences in the FBG levels in the normal weight, the pre – obese as well as in the obese groups among the service women, but no significant correlation was found in the pre – obese and the obese groups. Among the housewives, we found significant differences in the FBG levels of the normal weight and the obese groups, but not in the pre – obese group. Also, no significant correlation was found in the pre – obese and obese groups among the service women.
Conclusion: The BMI may be good risk predictor for Type 2 D.M. irrespective of the occupational status, especially in middle aged women.
PMCID: PMC3749623  PMID: 23998053
Occupation; Prediabetes status & Obesity
16.  Epidemiological differences of lower urinary tract symptoms among female subpopulations and group level interventions 
1) To study the risk factor profiles of lower urinary tract symptoms (LUTS) among adolescent girls, housewives and working women and its socioeconomic and quality of life losses. 2) To undertake risk factor modifications using the adolescent girls.
Design and Setting:
Cross-sectional descriptive study followed by educational intervention.
Statistical Methods:
Cluster sampling, Proportions, confidence intervals, Chi square and t-Tests and Logistic regression.
Materials and Methods:
House to house survey was done in two villages and one urban ward. Seventy-five housewives, 75 working women and 180 adolescent girls were asked about the risk factors and losses due to LUTS. Three teams of adolescent girls were utilized to bring about behavioral modifications. Impact was measured through user perspectives obtained from the participants.
Risk factors, social, economic and quality of life losses were different among the three female populations. Overall prevalence of LUTS among the three groups is 61(18.5%). Improper anal washing technique, malnutrition, presence of vaginal discharge, use of unsanitary menstrual pads, pinworm infestation and use of bad toilets were the significant causes among girls. Presence of sexually transmitted diseases was a contributing factor among housewives and working women. Prolonged sitting the posture was also contributing to LUTS among working women. Seventy-four per cent of beneficiaries expressed that intervention is useful.
The causes for LUTS and their consequences were differing among the three female subpopulations. Specific group level interventions using trained girls were successful.
PMCID: PMC2684399  PMID: 19468505
Karimnagar district; lower urinary tract symptoms; working women; socioeconomic and quality of life losses
17.  Housewives’ Obesity Determinant Factors in Iran; National Survey - Stepwise Approach to Surveillance 
Women suffer more from obesity than men in Iran do. In this study, we compared obesity risk and its contributors regarding the job categories as housewives (HWs) or employees to deeply explore the risk of obesity in housewives in Iran.
Based on WHO stepwise approach, in 2005, 33472 women aged 15 to 65 years old (excluding all men) were examined for the major risk factors for non-communicable diseases. Obesity was determined by Body Mass Index>30kgm−2 in adults (>20 years) and by girl BMI percentiles according to WHO 2007 Growth Reference 5–19 years in adolescents. We modeled obesity by logistic regression and entered all the known/potential predictors, including job categories.
The participation rate was more than 99%. The weighted prevalence of overweight and obesity in HWs were 34.5% and 24.5% respectively. Employed women were about 4% and 10% less overweight and obese than the HWs, respectively (P< 0.01). HWs vs. employed women had the adjusted OR 1.39 (CI95%, 1.18–1.63) for obesity. Older women, with higher educational level and socioeconomic status, lower physical activities and those living in urban areas were at risk of obesity. In comparison to HWs, working as an Official Clerk (OR=0.66) associated with a decrease in odds of obesity significantly, while others did not.
Being as HW is an independent significant factor for obesity in women. Preventive health care programs to reduce risk of obesity in women should be applied, considering their occupation for achieving more effectiveness.
PMCID: PMC3481779  PMID: 23113077
Women; Housewife; Occupation; Obesity; Overweight
18.  Breast cancer risk reduction - is it feasible to initiate a randomised controlled trial of a lifestyle intervention programme (ActWell) within a national breast screening programme? 
Breast cancer is the most commonly diagnosed cancer and the second cause of cancer deaths amongst women in the UK. The incidence of the disease is increasing and is highest in women from least deprived areas. It is estimated that around 42% of the disease in post-menopausal women could be prevented by increased physical activity and reductions in alcohol intake and body fatness. Breast cancer control endeavours focus on national screening programmes but these do not include communications or interventions for risk reduction.
This study aimed to assess the feasibility of delivery, indicative effects and acceptability of a lifestyle intervention programme initiated within the NHS Scottish Breast Screening Programme (NHSSBSP).
A 1:1 randomised controlled trial (RCT) of the 3 month ActWell programme (focussing on body weight, physical activity and alcohol) versus usual care conducted in two NHSSBSP sites between June 2013 and January 2014. Feasibility assessments included recruitment, retention, and fidelity to protocol. Indicative outcomes were measured at baseline and 3 month follow-up (body weight, waist circumference, eating and alcohol habits and physical activity). At study end, a questionnaire assessed participant satisfaction and qualitative interviews elicited women’s, coaches, and radiographers’ experiences. Statistical analysis used Chi squared tests for comparisons in proportions and paired t tests for comparisons of means. Linear regression analyses were performed, adjusted for baseline values, with group allocation as a fixed effect.
A pre-set recruitment target of 80 women was achieved within 12 weeks and 65 (81%) participants (29 intervention, 36 control) completed 3 month assessments. Mean age was 58 ± 5.6 years, mean BMI was 29.2 ± 7.0 kg/m2 and many (44%) reported a family history of breast cancer.
The primary analysis (baseline body weight adjusted) showed a significant between group difference favouring the intervention group of 2.04 kg (95% CI −3.24 kg to −0.85 kg). Significant, favourable between group differences were also detected for BMI, waist circumference, physical activity and sitting time. Women rated the programme highly and 70% said they would recommend it to others.
Recruitment, retention, indicative results and participant acceptability support the development of a definitive RCT to measure long term effects.
Trial registration
The trial was registered with Current Controlled Trials (ISRCTN56223933).
Electronic supplementary material
The online version of this article (doi:10.1186/s12966-014-0156-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4304617  PMID: 25516158
Breast cancer; Physical activity; Body weight; Alcohol; Sedentary time
19.  The Relation between Early Pregnancy Anthropometric Indices among Primiparous Women and Macrosomia 
Journal of Caring Sciences  2012;1(3):153-158.
Introduction: The prevalence of obesity is increasing in both developed and developing nations. Body mass index (BMI) is the most common index for obesity assessment and its relation with most complications among non-pregnant and pregnant women is known. However, no study has evaluated the relation between abdominal obesity and macrosomia among pregnant women. Methods: In this prospective study, anthropometric indices including weight, height, and waist circumference (WC) of 1140 nulliparous pregnant women during their first trimester of pregnancy (6th-10th weeks) were measured by the researcher. According to the classification of the World Health Organization, women with BMI > 25 kg/m2 were considered as overweight or obese. Abdominal obesity was defined as WC ≥ 88 cm. Finally, mothers were followed up and fetal macrosomia was recorded in a checklist. Data was analyzed in SPSS15. Results: The results showed that 77.5% of women aged 20-35 years and 92.7% were housewives. The mean (SD) values of BMI and WC were 24.32 (4.08) kg/m2 and 81.84 (9.25) cm, respectively. The prevalence of overweight (BMI = 25-29.9 kg/m2) and obesity (BMI > 29.9 kg/m) was 27.6% and 8.8%, respectively. Abdominal obesity based on WC was found in 34.8% of the subjects. Conclusion: Findings of this study revealed obesity in over one third of nulliparous pregnant women during their first trimester. Moreover, the high prevalence of macrosomia, in these women confirmed the importance of maternal education about obesity-related complications in order to change their lifestyle and prevent obesity.
PMCID: PMC4161076  PMID: 25276690
Body mass index; Waist circumference; Macrosomia; Pregnancy
20.  Changes in weight and health behaviors after pregnancies complicated by gestational diabetes mellitus: The CARDIA Study 
Obesity (Silver Spring, Md.)  2013;21(6):1269-1275.
We compared pre- to post-pregnancy change in weight, body mass index (BMI), waist circumference, diet and physical activity in women with and without gestational diabetes mellitus (GDM).
Using the Coronary Artery Risk Development in Young Adults (CARDIA) study we identified women with at least one pregnancy during 20 years of follow-up (n=1,488 with 3,125 pregnancies). We used linear regression with generalized estimating equations to compare pre- to post-pregnancy changes in health behaviors and anthropometric measurements between 137 GDM pregnancies and 1,637 non GDM pregnancies, adjusted for parity, age at delivery, outcome measure at the pre-pregnancy exam, race, education, mode of delivery, and interval between delivery and post-pregnancy examination.
Compared with women without GDM in pregnancy, women with GDM had higher pre-pregnancy mean weight (158.3 vs. 149.6 lb, p=0.011) and BMI (26.7 vs. 25.1 kg/m2, p=0.002), but non-significantly lower total daily caloric intake and similar levels of physical activity. Both GDM and non GDM groups had higher average postpartum weight of 7–8 lbs and decreased physical activity on average 1.4 years after pregnancy. Both groups similarly increased total caloric intake but reduced fast food frequency. Pre- to post- pregnancy changes in body weight, BMI, waist circumference, physical activity and diet did not differ between women with and without GDM in pregnancy.
Following pregnancy women with and without GDM increased caloric intake, BMI and weight, decreased physical activity, but reduced their frequency of eating fast food. Given these trends, postpartum lifestyle interventions, particularly for women with GDM, are needed to reduce obesity and diabetes risk.
PMCID: PMC3735637  PMID: 23666593
21.  Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. 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 Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site,, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
To assess the effectiveness of behavioural interventions for the treatment and management of urinary incontinence (UI) in community-dwelling seniors.
Clinical Need: Target Population and Condition
Urinary incontinence defined as “the complaint of any involuntary leakage of urine” was identified as 1 of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home. Urinary incontinence is a health problem that affects a substantial proportion of Ontario’s community-dwelling seniors (and indirectly affects caregivers), impacting their health, functioning, well-being and quality of life. Based on Canadian studies, prevalence estimates range from 9% to 30% for senior men and nearly double from 19% to 55% for senior women. The direct and indirect costs associated with UI are substantial. It is estimated that the total annual costs in Canada are $1.5 billion (Cdn), and that each year a senior living at home will spend $1,000 to $1,500 on incontinence supplies.
Interventions to treat and manage UI can be classified into broad categories which include lifestyle modification, behavioural techniques, medications, devices (e.g., continence pessaries), surgical interventions and adjunctive measures (e.g., absorbent products).
The focus of this review is behavioural interventions, since they are commonly the first line of treatment considered in seniors given that they are the least invasive options with no reported side effects, do not limit future treatment options, and can be applied in combination with other therapies. In addition, many seniors would not be ideal candidates for other types of interventions involving more risk, such as surgical measures.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Description of Technology/Therapy
Behavioural interventions can be divided into 2 categories according to the target population: caregiver-dependent techniques and patient-directed techniques. Caregiver-dependent techniques (also known as toileting assistance) are targeted at medically complex, frail individuals living at home with the assistance of a caregiver, who tends to be a family member. These seniors may also have cognitive deficits and/or motor deficits. A health care professional trains the senior’s caregiver to deliver an intervention such as prompted voiding, habit retraining, or timed voiding. The health care professional who trains the caregiver is commonly a nurse or a nurse with advanced training in the management of UI, such as a nurse continence advisor (NCA) or a clinical nurse specialist (CNS).
The second category of behavioural interventions consists of patient-directed techniques targeted towards mobile, motivated seniors. Seniors in this population are cognitively able, free from any major physical deficits, and motivated to regain and/or improve their continence. A nurse or a nurse with advanced training in UI management, such as an NCA or CNS, delivers the patient-directed techniques. These are often provided as multicomponent interventions including a combination of bladder training techniques, pelvic floor muscle training (PFMT), education on bladder control strategies, and self-monitoring. Pelvic floor muscle training, defined as a program of repeated pelvic floor muscle contractions taught and supervised by a health care professional, may be employed as part of a multicomponent intervention or in isolation.
Education is a large component of both caregiver-dependent and patient-directed behavioural interventions, and patient and/or caregiver involvement as well as continued practice strongly affect the success of treatment. Incontinence products, which include a large variety of pads and devices for effective containment of urine, may be used in conjunction with behavioural techniques at any point in the patient’s management.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials that examined the effectiveness, safety, and cost-effectiveness of caregiver-dependent and patient-directed behavioural interventions for the treatment of UI in community-dwelling seniors (see Appendix 1).
Research Questions
Are caregiver-dependent behavioural interventions effective in improving UI in medically complex, frail community-dwelling seniors with/without cognitive deficits and/or motor deficits?
Are patient-directed behavioural interventions effective in improving UI in mobile, motivated community-dwelling seniors?
Are behavioural interventions delivered by NCAs or CNSs in a clinic setting effective in improving incontinence outcomes in community-dwelling seniors?
Assessment of Quality of Evidence
The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Executive Summary Table 1 summarizes the results of the analysis.
The available evidence was limited by considerable variation in study populations and in the type and severity of UI for studies examining both caregiver-directed and patient-directed interventions. The UI literature frequently is limited to reporting subjective outcome measures such as patient observations and symptoms. The primary outcome of interest, admission to a LTC home, was not reported in the UI literature. The number of eligible studies was low, and there were limited data on long-term follow-up.
Summary of Evidence on Behavioural Interventions for the Treatment of Urinary Incontinence in Community-Dwelling Seniors
Prompted voiding
Habit retraining
Timed voiding
Bladder training
PFMT (with or without biofeedback)
Bladder control strategies
CI refers to confidence interval; CNS, clinical nurse specialist; NCA, nurse continence advisor; PFMT, pelvic floor muscle training; RCT, randomized controlled trial; WMD, weighted mean difference; UI, urinary incontinence.
Economic Analysis
A budget impact analysis was conducted to forecast costs for caregiver-dependent and patient-directed multicomponent behavioural techniques delivered by NCAs, and PFMT alone delivered by physiotherapists. All costs are reported in 2008 Canadian dollars. Based on epidemiological data, published medical literature and clinical expert opinion, the annual cost of caregiver-dependent behavioural techniques was estimated to be $9.2 M, while the annual costs of patient-directed behavioural techniques delivered by either an NCA or physiotherapist were estimated to be $25.5 M and $36.1 M, respectively. Estimates will vary if the underlying assumptions are changed.
Currently, the province of Ontario absorbs the cost of NCAs (available through the 42 Community Care Access Centres across the province) in the home setting. The 2007 Incontinence Care in the Community Report estimated that the total cost being absorbed by the public system of providing continence care in the home is $19.5 M in Ontario. This cost estimate included resources such as personnel, communication with physicians, record keeping and product costs. Clinic costs were not included in this estimation because currently these come out of the global budget of the respective hospital and very few continence clinics actually exist in the province. The budget impact analysis factored in a cost for the clinic setting, assuming that the public system would absorb the cost with this new model of community care.
Considerations for Ontario Health System
An expert panel on aging in the community met on 3 occasions from January to May 2008, and in part, discussed treatment of UI in seniors in Ontario with a focus on caregiver-dependent and patient-directed behavioural interventions. In particular, the panel discussed how treatment for UI is made available to seniors in Ontario and who provides the service. Some of the major themes arising from the discussions included:
Services/interventions that currently exist in Ontario offering behavioural interventions to treat UI are not consistent. There is a lack of consistency in how seniors access services for treatment of UI, who manages patients and what treatment patients receive.
Help-seeking behaviours are important to consider when designing optimal service delivery methods.
There is considerable social stigma associated with UI and therefore there is a need for public education and an awareness campaign.
The cost of incontinent supplies and the availability of NCAs were highlighted.
There is moderate-quality evidence that the following interventions are effective in improving UI in mobile motivated seniors:
Multicomponent behavioural interventions including a combination of bladder training techniques, PFMT (with or without biofeedback), education on bladder control strategies and self-monitoring techniques.
Pelvic floor muscle training alone.
There is moderate quality evidence that when behavioural interventions are led by NCAs or CNSs in a clinic setting, they are effective in improving UI in seniors.
There is limited low-quality evidence that prompted voiding may be effective in medically complex, frail seniors with motivated caregivers.
There is insufficient evidence for the following interventions in medically complex, frail seniors with motivated caregivers:
habit retraining, and
timed voiding.
PMCID: PMC3377527  PMID: 23074508
22.  Incidence rates of surgically treated rhegmatogenous retinal detachment among manual workers, non-manual workers and housewives in Tuscany, Italy 
Candidate risk factors for idiopathic rhegmatogenous retinal detachment (RRD) include heavy manual handling (requiring Valsalva’s maneuver). We assessed incidence rates of surgically treated idiopathic RRD among manual workers, non-manual workers and housewives resident in Tuscany, Italy.
We retrieved all hospital discharge records bearing a principal diagnosis corresponding to RRD coupled with retinal surgery for any resident of Tuscany during 1997–2009. After elimination of repeated admissions and patients with coexistent, associated conditions (including recent trauma), subjects aged 25–59 years were classified as manual workers, non-manual workers or housewives. Population data were extracted from the 2001 census.
We identified 1,946 eligible cases (1,142 men). Among men, manual workers experienced a 1.8-fold higher age-standardized rate per 100,000 person-years than non-manual workers [17.4 (95 % confidence interval (CI) 16.1–18.7) vs. 9.8 (95 % CI 8.8–10.8)]. Age-standardized rates among women were 1.9-fold higher for manual workers [11.1 (95 % CI 9.8–12.3)] and 1.7-fold higher for housewives [9.5 (95 % CI 8.3–10.8)] than in non-manual workers [5.7 (95 % CI 4.8–6.6)].
This large population-based study suggests that manual workers are affected by idiopathic RRD requiring surgical treatment more often than non-manual workers. The higher rates of surgically treated RRD experienced by manual workers are in accord with the hypothesis that heavy manual handling may have a causal role.
PMCID: PMC3855483  PMID: 23893253
Manual work; Retinal surgery; Patient discharge; Incidence study
23.  Incidence rates of surgically treated rhegmatogenous retinal detachment among manual workers, non-manual workers and housewives in Tuscany, Italy 
Candidate risk factors for idiopathic rhegmatogenous retinal detachment (RRD) include heavy manual handling (requiring Valsalva’s maneuver). We assessed incidence rates of surgically treated idiopathic RRD among manual workers, non-manual workers and housewives resident in Tuscany, Italy.
We retrieved all hospital discharge records bearing a principal diagnosis corresponding to RRD coupled with retinal surgery for any resident of Tuscany during 1997-2009. After elimination of repeated admissions and patients with coexistent, associated conditions (including recent trauma), subjects aged 25–59 years were classified as manual workers, non-manual workers or housewives. Population data were extracted from the 2001 census.
We identified 1,946 eligible cases (1,142 men). Among men, manual workers experienced a 1.8-fold higher age-standardized rate per 100,000 person-years than non-manual workers (17.4 [95% CI, 16.1–18.7] vs. 9.8 [95% CI, 8.8–10.8]). Age-standardized rates among women were 1.9-fold higher for manual workers (11.1 [95% CI, 9.8–12.3]) and 1.7-fold higher for housewives (9.5 [95% CI, 8.3–10.8]) than in non-manual workers (5.7 [95% CI, 4.8–6.6]).
This large population-based study suggests that manual workers are affected by idiopathic RRD requiring surgical treatment more often than non-manual workers. The higher rates of surgically treated RRD experienced by manual workers accord with the hypothesis that heavy manual handling may have a causal role.
PMCID: PMC3855483  PMID: 23893253
manual work; retinal surgery; patient discharge; incidence study
24.  ALIFE@Work: a randomised controlled trial of a distance counselling lifestyle programme for weight control among an overweight working population [ISRCTN04265725] 
BMC Public Health  2006;6:140.
The prevalence of overweight is increasing and its consequences will cause a major public health burden in the near future. Cost-effective interventions for weight control among the general population are therefore needed. The ALIFE@Work study is investigating a novel lifestyle intervention, aimed at the working population, with individual counselling through either phone or e-mail. This article describes the design of the study and the participant flow up to and including randomisation.
ALIFE@Work is a controlled trial, with randomisation to three arms: a control group, a phone based intervention group and an internet based intervention group. The intervention takes six months and is based on a cognitive behavioural approach, addressing physical activity and diet. It consists of 10 lessons with feedback from a personal counsellor, either by phone or e-mail, between each lesson. Lessons contain educational content combined with behaviour change strategies. Assignments in each lesson teach the participant to apply these strategies to every day life.
The study population consists of employees from seven Dutch companies. The most important inclusion criteria are having a body mass index (BMI) ≥ 25 kg/m2 and being an employed adult.
Primary outcomes of the study are body weight and BMI, diet and physical activity. Other outcomes are: perceived health; empowerment; stage of change and self-efficacy concerning weight control, physical activity and eating habits; work performance/productivity; waist circumference, sum of skin folds, blood pressure, total blood cholesterol level and aerobic fitness. A cost-utility- and a cost-effectiveness analysis will be performed as well.
Physiological outcomes are measured at baseline and after six and 24 months. Other outcomes are measured by questionnaire at baseline and after six, 12, 18 and 24 months.
Statistical analyses for short term (six month) results are performed with multiple linear regression. Analyses for long term (two year) results are performed with multiple longitudinal regression. Analyses for cost-effectiveness and cost-utility are done at one and two years, using bootstrapping techniques.
ALIFE@Work will make a substantial contribution to the development of cost-effective weight control- and lifestyle interventions that are applicable to and attractive for the large population at risk.
PMCID: PMC1513206  PMID: 16723021
25.  The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees 
PLoS Medicine  2012;9(10):e1001320.
Surveying women and children from refugee camps in Algeria, Carlos Grijalva-Eternod and colleagues find high rates of obesity among women as well as many undernourished children, and that almost a quarter of households are affected by both undernutrition and obesity.
Households from vulnerable groups experiencing epidemiological transitions are known to be affected concomitantly by under-nutrition and obesity. Yet, it is unknown to what extent this double burden affects refugee populations dependent on food assistance. We assessed the double burden of malnutrition among Western Sahara refugees living in a protracted emergency.
Methods and Findings
We implemented a stratified nutrition survey in October–November 2010 in the four Western Sahara refugee camps in Algeria. We sampled 2,005 households, collecting anthropometric measurements (weight, height, and waist circumference) in 1,608 children (6–59 mo) and 1,781 women (15–49 y). We estimated the prevalence of global acute malnutrition (GAM), stunting, underweight, and overweight in children; and stunting, underweight, overweight, and central obesity in women. To assess the burden of malnutrition within households, households were first classified according to the presence of each type of malnutrition. Households were then classified as undernourished, overweight, or affected by the double burden if they presented members with under-nutrition, overweight, or both, respectively.
The prevalence of GAM in children was 9.1%, 29.1% were stunted, 18.6% were underweight, and 2.4% were overweight; among the women, 14.8% were stunted, 53.7% were overweight or obese, and 71.4% had central obesity. Central obesity (47.2%) and overweight (38.8%) in women affected a higher proportion of households than did GAM (7.0%), stunting (19.5%), or underweight (13.3%) in children. Overall, households classified as overweight (31.5%) were most common, followed by undernourished (25.8%), and then double burden–affected (24.7%).
The double burden of obesity and under-nutrition is highly prevalent in households among Western Sahara refugees. The results highlight the need to focus more attention on non-communicable diseases in this population and balance obesity prevention and management with interventions to tackle under-nutrition.
Please see later in the article for the Editors' Summary
Editors' Summary
Good nutrition is essential for human health and survival. Insufficient food intake causes under-nutrition, which increases susceptibility to infections; intake of too much or inappropriate food, in particular in interaction with sedentary behaviour, can lead to obesity, which increases the risk of non-communicable diseases such as diabetes. During the past 30 years, the prevalence (the proportion of a population affected by a condition) of obesity has greatly increased, initially among adults in industrialized countries, but more recently among children and in less-affluent populations. Now, worldwide, overweight people outnumber under-nourished people. Furthermore, some populations are affected by both under-nutrition and obesity, forms of malnutrition that occur when the diet is suboptimal for health. So, for example, a child can be both stunted (short for his or her age, an indicator of long-term under-nutrition) and overweight (too heavy for his or her age). The emergence of this double burden of malnutrition has been attributed to the nutrition transition—the rapid move because of migration or urbanization to a lifestyle characterized by low levels of physical activity and high consumption of refined, energy-dense foods—without complete elimination of under-nutrition.
Why Was This Study Done?
Refugees are one group of people in whom under-nutrition and obesity sometimes coexist. Worldwide, in 2010, 15.4 million refugees were dependent on host governments and international humanitarian agencies for their food security and well-being. It is essential that these governments and organizations provide appropriate food assistance programs to refugees—policies that are appropriate during acute emergencies may not be appropriate in protracted emergencies and may contribute to the emergence of the double burden of malnutrition among refugees. Unfortunately, the extent to which the double burden of malnutrition affects refugees in protracted emergencies is unknown. In this cross-sectional study (an investigation that looks at the characteristics of a population at a single time), the researchers assessed the double burden of malnutrition among people from Western Sahara who have been living in four refugee camps near Tindouf city, Algeria, since 1975.
What Did the Researchers Do and Find?
The researchers used data from a 2010 survey that measured the height and weight of children and the height, weight, and waist circumference of women living in 2,005 households in the Algerian refugee camps. For the children, they estimated the prevalence of global acute malnutrition (which includes thin, “wasted” children, as indicated by a low weight for height based on the World Health Organization growth standards, and those with nutritional oedema), stunting, and underweight and overweight (low and high weight for age and gender, respectively). For the women, they estimated the prevalence of stunting, underweight (body mass index less than 18.5 kg/m2), overweight (body mass index greater than 25 kg/m2), and central obesity (a waist circumference of more than 80 cm). Among the children, 9.1% had global acute malnutrition, 29.1% were stunted, 8.6% were underweight, and 2.4% were overweight. Among the women, 14.8% were stunted, 53.7% were overweight, and 71.4% had central obesity. Notably, central obesity and overweight in women affected more households than global acute malnutrition, stunting, and underweight in children. Finally, based on whether a household included members with under-nutrition or overweight, alone or in combination, the researchers classified a third of households as overweight, a quarter as undernourished, and a quarter as affected by the double burden of malnutrition.
What Do These Findings Mean?
These findings indicate that there is a high prevalence of the double burden of malnutrition among households in Western Saharan refugee camps in Algeria. Although this study provides no information on men and does not investigate whether the obesity seen in these camps leads to an increased risk of diabetes and other non-communicable diseases, these findings have several important implications for the provision of food assistance and care for protracted humanitarian emergencies. For example, they highlight the need to promote long-term food security and to improve nutrition adequacy and food diversity in protracted emergencies. In addition, they suggest that current food assistance programs that are suitable for acute emergencies may not be suitable for extended emergencies. They also highlight the need to focus more attention on non-communicable diseases in refugee camps and to develop innovative ways to provide obesity prevention and management in these settings. However, as the researchers stress, careful policy and advocacy work is essential to ensure that efforts to deal with the threat of obesity among refugees do not jeopardize support for life-saving food assistance programs for refugees.
Additional Information
Please access these websites via the online version of this summary at
Wikipedia provides background information about the Western Sahara refugee camps near Tindouf, Algeria (note that Wikipedia is a free online encyclopedia that anyone can edit)
The World Health Organization provides information on all aspects of nutrition and obesity (in several languages)
The United Nations World Food Programme is the world's largest humanitarian agency fighting hunger worldwide; its website provides detailed information about hunger and information about its work in the Western Sahara refugee camps in Algeria, including personal stories and photographs of food distribution
The United Nations High Commissioner for Refugees is the United Nations body mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide; its website provides detailed information about its work in the Western Sahara refugee camps in Algeria
Oxfam also provides detailed information about its work in the Algerian refugee camps, a description of the camps, and personal stories from people living in the camps
An article published by the Food and Agriculture Organization of the United Nations explains the double burden of malnutrition
PMCID: PMC3462761  PMID: 23055833

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