Urbanization in developing countries comes along with changes in food habits and living conditions and with an increase in overweight and associated health risks. The objective of the study was to describe dietary patterns of adults in Ouagadougou and to study their relationship with anthropometric status of the subjects.A qualitative food frequency questionnaire was administered to 1,072 adults living in two contrasted districts of Ouagadougou. Dietary patterns were defined by principal component analysis and described by multivariate analysis. Logistic regression was used to study their association with overweight.2). A higher "modern foods" score was associated with a higher prevalence of overweight when confounding factors were accounted for (OR = 1.19 [95% CI 1.03-1.36]) but there was no relationship between overweight and the "snacking" score.The diet was mainly made of cereals, vegetables and fats from vegetable sources. The two first components of the principal component analysis were interpreted respectively as a "snacking" score and as a "modern foods" score. Both scores were positively and independently associated with the economic level of households and with food expenditures (p ≤ 0.001 for both). The "snacking" score was higher for younger people (p = 0.004), for people having a formal occupation (p = 0.006), for those never married (p = 0.005), whereas the "modern foods" score was associated with ethnic group (p = 0.032) and district of residence (p < 0.001). Thirty-six percent of women and 14.5% of men were overweight (Body Mass Index > 25 kg/mModernisation of types of foods consumed was associated with the living conditions and the environment and with an increased risk of overweight. This should be accounted for to promote better nutrition and prevent non communicable diseases. Urbanization is a fast-expanding phenomenon in developing countries. Projections are that urban populations in those countries will more than double between 2000 and 2025 . UrbanizIn Burkina Faso (West Africa), urban population has been multiplied by seven since 1975 and urban annual growth rate is very high: + 5.15% per year over the 2000-2005 period ,14. In 2The objectives of our study were: (i) to identify and describe dietary patterns according to individual characteristics; (ii) to examine their relationship with the anthropometric status of the subjects.Institut Supérieur des Sciences de la Population (ISSP) [Higher Institute of Population Sciences]. These districts have been purposely chosen as different: Wemtenga is a structured district  of about 2,500 inhabitants, located near the centre of the town; Taabtenga is a non-structured district  of about 3,500 inhabitants, located at the periphery of the city. In each district, 300 women and 300 men aged 20 to 65 years were randomly selected from an exhaustive list of inhabitants. Both study areas and sampling technique have already been described elsewhere [A cross-sectional survey took place in April/May 2005 (dry season) in two districts of Ouagadougou, on a sub-sample of the population monitored by the Demographic Monitoring System carried out by the cereals, roots/tuber, nuts and seeds, beans and pulses, vitamin A rich fruits and vegetables, other fruits, other vegetables, fatty/processed meats, non fatty meats and poultry, liver, fresh fish, dried fish, eggs, milk/yoghurt, cheese, animal source fats, vegetal source fats, red palm oil, fried foods, sugar/sweetened products, sweetened drinks, alcohol. Frequencies of consumption of each food group per week were finally computed and used in the analyses.A qualitative food frequency questionnaire (q-FFQ) was carefully designed, pre-tested on a similar population and then administered to all subjects of the study. This q-FFQ included all locally available foods, identified by their local names: 27 dishes, 9 sauces, 30 snacks and 16 drinks. Interviewees were asked to spontaneously recall all dishes, sauces, snacks and drinks they had consumed over the previous week and to estimate their frequency of consumption. They were then prompted for each item that had not been cited. When items were not consumed during the previous week but were part of the usual diet, and for rarely consumed or seasonal foods, frequencies of consumption per month were estimated and were then turned into frequencies per week over a year. Any food item that was not initially included into the questionnaire but was consumed by a subject during the survey period was then added to the list. The composition of mixed dishes, sauces or snacks was detailed by the interviewees. Then all food items were coded into one or more food groups, using the following list of 22 food groups: Dietary patterns were determined by principal component analysis (PCA) performed on normalized frequencies of consumption of the 22 food groups (z-scores). The PCA method allows data reduction by identifying, in a multidimensional space, components that summarize the maximum of variability between subjects ,22. ThesA section of the questionnaire focused on social, economic and demographic characteristics of households and individuals, and another section focused on dietary habits such as the number of meals per day, snacking habits, eating outside the home.number of persons per room, quality of the wall and roof materials, electricity, piped water, source of drinking water, type of toilets and shower, waste evacuation, owning of TV set, telephone, refrigerator, video tape recorder and means of transportation. This method projects all subjects on to a multidimensional space according to modalities taken by the variables of interest. Modalities associated with a low economic status  were projected negatively on the first factor and modalities associated with a good economic status  were projected positively. The score of every household on the first factor of the multiple correspondence analysis was interpreted as a continuous economic score which has been divided into tertiles to determine low, medium or high economic level.At the household level, an economic score was constructed by multiple correspondence analysis  using thwalking, having a physically-demanding profession, practicing a sport, carrying water, crushing cereals, hand-washing clothes, and other physically-demanding activities. Each variable was arbitrarily given a score  and the final score was the sum of them (range 0-21). The score has been divided into tertiles to determine low, medium or high physical activity level.An individual physical activity score was also computed, based on the frequency of various physical activities: Home food stocks were estimated by the subjects from the quantities of all food items stocked at home (bought at least two days before) and their price. All prices were added up with the help of the field workers to obtain a monetary value of home food stocks.2. Overfatness, or excess of body fat, was defined by a BFP superior to the gender and age-specific cut-offs defined by Gallagher for African-American subjects [Anthropometric measurement procedure met the WHO recommendations . Measuresubjects . PregnanEpi-data software, version 3.1 , was used for data entry, which was made in double to limit data-entry errors. Further data quality checks, data cleaning and statistical analyses were performed with the SAS system, version 9.1 . Individuals with incomplete observations for the FFQ (n = 12) and one outlier were excluded from the analysis.The description of the two dietary patterns according to food habits, food access and socio-demographic characteristics was performed by multivariate linear regression using a manual backward stepwise procedure. The adjusted mean and the standard error of the mean were calculated for each characteristic. Associations between overweight or overfatness and the two dietary patterns were studied by logistic regression, controlling for confounding factors. As the two scores were continuous variables, values of the odds ratios are associated with an increase of one point of the score. The confounding factors were defined as variables that were associated with both anthropometrics and dietary patterns with a type I error of 0.20 and that did not belong to the causal pathway between them. In all other analyses, the level of significance was set at p < 0.05.The study protocol received the approval of the National Committee of Ethics  and written informed consent was obtained from all participants.One thousand and seventy-two individuals aged 15-65 years were surveyed: 276 women and 261 men lived in Wemtenga (structured district) and 281 women and 254 men lived in Taabtenga (unstructured district).The diet was mainly made of cereals and vegetables (more than 3 times daily) and to a lesser extent of oil from vegetable sources (more than twice daily) figure . Sweetentype of foods consumed (regardless food habits).The two first components of the PCA accounted for 28.5% of the total variance in the data set. The first component, which explained most of the variability between individual dietary consumptions , was interpreted as a pattern of snacking: first, almost all food groups and most of foods were positively represented on this first component which means that subjects with high positive scores on the first component tended to consume frequently many sorts of food groups/foods and thus had a high frequency of food intakes; second, food items with the highest scores on this first component were foods commonly consumed outside the main meals  , and the loading on the second component was used as a "modern foods" score .Regarding food habits and access, subjects declaring the highest occurrences of food intakes between meals and the highest number of meals eaten per day had a significantly higher "snacking" score table . This scThe "modern foods" score was significantly higher when the number of meals eaten per day was lower and when frequency of food intakes between meals was less frequent (p < 0.001). It was positively associated with the daily household food expense per person (p < 0.001) and the economic score (p = 0.001). Subjects who lived in the structured district, who did not belong to the Islam religion nor to the Mossi ethnic group had a higher "modern foods" score . Consumption of dishes outside the home, food stocks, occupation, schooling, age and marital status were not associated with the modern aspect of foods consumed after adjustment for confounding variables.2 among women and 21.8 ± 3.1 kg/m2 among men; 36.0% of women and 14.5% of men were overweight or obese. The mean BFP was 36.1 ± 8.6% among women and 16.3 ± 5.3% among men; 56.1% of women and 17.3% of men were overfat. The "snacking" score was neither associated with overweight nor with overfatness, after adjustment for confounding factors  to the same data from the representative sample of Ouagadougou used by the most recent DHS 2003) . When se03 . WhenA-posteriori methods to derive dietary patterns have some limitations: first, researchers have to take quite subjective decisions at various stages of the process; second, results are very population-specific and not reproducible across different sample [a-priori method such as the use of pre-defined indices. Indeed, these types of indices are based on existing knowledge about relationship between a type of diet and health outcomes and must also be adapted to the specific population behaviours [a-posteriori methods, we chose PCA over cluster analysis to insist on similarities rather than on differences between diets. However, both methods have proved to reveal similar dietary patterns [t sample ,34. Howehaviours . To our patterns .types of snack were different: traditional snacks in the non structured district and more modern snacks in the structured one. This highlights the role of environment and food availability in the choice of foods consumed, as described by many authors [Our results showed interesting relationships between the living conditions of individuals and the level of the two scores characterizing their diet. First, snack consumption was associated with the less structured living conditions such as those of younger and single subjects: older and married subjects are more likely to have an organised life with planned meals. Likewise, working people, especially those working in the formal sector, ate snack foods more frequently, probably due to the little time available and the organisation of the day outside their home. Second, while the district of residence was not associated with the "snacking" score, it was associated with the "modern foods" score. These results mean that snacking was encountered in both districts but  authors ,37. LikeAlthough definitions and interpretation of traditionalism, modernity or snacking vary quite a lot across dietary pattern studies, other studies described a pattern close to our description of the traditional/modern foods pattern, while very few studies identified a snacking pattern. In a review summarizing 30 studies that reported dietary patterns derived from factor analysis , 19 of tOne other important result of our study is that the "modern foods" score was positively associated with overweight and with overfatness. Similar results were obtained with BMI and BFP used as continuous variables (results not shown). This is in line with the concept of dietary transition described by the literature, and suggests that in Ouagadougou, changes in types of food eaten would be one explanation among others for the nutrition transition. Many other studies, in different settings, focused on the relationship between dietary patterns and anthropometric status. A review reported that 19 studies out of 30 showed a relationship between western food patterns and overweight . In urbaIn Ouagadougou, more in-depth investigation is still required to identify what exactly in the consumption of modern types of foods leads to increased overweight. Possible explanations are quantities consumed, food habits, macronutrient balance or energetic content of modern types of foods. To investigate all these possible explanations, a quantitative study describing the nutrient content of modern foods is required. The assessment of their energy and micronutrient densities would help to clarify the relationship between the "modern foods" pattern and overweight. Since the "modern foods" score was negatively associated with the number of main meals in the day and with the frequency of food consumption in between, eating more modern types of foods does not seem to be explained by a multiplication of food intake occasions. This is in line with the fact that the "snacking" score, which is independent of the "modern foods" score by construction, was not associated with an increased risk of overweight. Alternate hypothesis would be that quantities consumed at each food intake are more substantial and/or that most of modern foods are energy-dense, leading to unbalanced diet. The latter hypothesis is supported by a study conducted in Ouagadougou, which showed that obesity was associated with a higher consumption of micronutrient-, protein-, and sugar-rich foods . An inteOur study showed that in a setting where dietary patterns remain largely traditional, there was some evidence of a higher risk of being overweight and overfat associated with consumption of modern types of foods but not with snacking. While consumption of modern foods, known to be more frequent in urban settings, appeared to be still limited in our sample, it must be noticed that another study in Ouagadougou identified worrying rates of non communicable food related diseases ,42. ThisThe authors declare that they have no competing interests.Y.M-P., M.S., S.T. and H.D. designed the study. M.S., P.D. and Y.M-P. collected the data. E.B. and Y.M-P. performed the data analysis and drafted the manuscript. All authors participated in the interpretation and discussion of the results and critically revised the manuscript. All authors read and approved the final manuscript.Factor loadings of the food items (supplementary variables) on the first two principal components identified. Table alternative to figure Click here for file


Aggregatibacter actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg) in periodontitis were associated with a prothrombotic state.Periodontitis is associated with cardiovascular diseases (CVD). In our previous studies a prothrombotic state has been observed in periodontitis, which contributes to the risk of CVD. The aim of this study was to investigate whether serum IgG levels against Aa and anti-Pg IgG and plasma levels of markers of prothrombotic state . Multivariate analyses were performed considering several major potential contributing factors.Patients with moderate (n = 38) and severe periodontitis (n = 30) and controls (n = 24) were recruited. We explored correlations between serum anti-Aa IgG (p = 0.015) than controls but not for Pg (p = 0.320). In periodontitis patients, body mass index and anti-Aa IgG showed a positive correlation with vWF .Periodontitis patients showed higher anti-Aa together with other well accepted risk factors for CVD, may play a role in increasing the risk for prothrombotic state.In periodontitis, infection with  Periodontitis is a chronic infectious disease of the supporting tissues of the teeth and it has been consistently associated with cardiovascular diseases (CVD) ,2. One eAggregatibacter actinomycetemcomitans (Aa) and Porphyromonas gingivalis (Pg) have been shown in blood and biopsies from atherosclerotic plaques ), smoking, education level, age, gender, body mass index (BMI), total cholesterol, triglycerides, ethnicity, anti-Aa and anti-Pg IgG levels. In the latter explorative parametric tests, for the non-normal distributed variables, the log-transformed values were employed. Similarly, a secondary explorative multivariate analysis was performed, but now including also controls. For all analyses, p < 0.05 values were considered statistically significant.Statistical analysis of data was performed with the SPSS package version 16.0 . Means, standard deviations, medians, interquartile ranges and frequency distributions were calculated for background variables, markers of a prothrombotic state and serum IgG's. Normal distribution of data was assessed by Kolmogorov-Smirnov goodness-of-fit test. Whenever non-normal distribution was found (p = 0.017) and showed lower educational level (p = 0.019). Periodontitis patients had a lower number of teeth (25.7 for the severe group and 26 for the moderate group) in comparison with controls . Periodontitis patients showed higher levels of PAI-1 in comparison to controls (p = 0.009); they also showed higher values for vWF and F1+2 and lower values for D-dimer, but the differences were not statistically significant. IgG levels against Aa were significantly higher in patients than controls (p = 0.015). Values of IgG against Pg show a trend for increased levels in periodontitis . Female gender and age were significantly associated with F1+2 and a trend for an association between IgG levels against Pg and F1+2 . For PAI-1, severity of periodontitis showed a positive correlation , but there was no association with IgG against Aa and Pg. Also for D-dimer both female gender and BMI showed positive correlations, while cholesterol showed a negative correlation; IgG against Pg was retained in the final model, with a negative correlation (β = -0.190), but this association did not reach a statistical significance (p = 0.085). When the multivariate analyses were repeated including also the control subjects without periodontitis, we observed that the association between IgG against Aa and levels of vWF did not reach level of significance , demonstrating that indeed the exposure to a periodontal pathogen has an association with the prothrombotic marker.Assuming that only in periodontitis patients an infection with Aa and Pg were explanatory for these findings.In a previous study, our group showed that systemically healthy periodontitis patients, in comparison to subjects without periodontitis, displayed higher levels of 2 markers of prothrombotic state, PAI-1 and vWF . Based oAa and Pg have been associated with CVD. In particular, a 13-year prospective study from Pussinen et al. (2004) showed a strong association between anti-Aa and anti-Pg IgG's at baseline and the development of stroke later on. Furthermore Aa and Pg have been found in human specimens of atherosclerotic plaques [Aa and Pg with a prothrombotic state. So far, only in vitro or ex vivo studies are available. More specifically, Aa showed to have capability to induce ex vivo platelet aggregation in humans [Pg showed capability to induce in vitro coagulation [in vitro infection of aortic endothelial cells with the Pg strain 381 [This question was raised by the evidence in the literature, which shows that levels of IgG against  plaques -10. Howen humans , while Pgulation  and to erain 381 .Aa correlated with levels of vWF after correction and including several other potential confounding factors. Notably, this association was not longer significant when we included in the study population also the controls. This strengthens the assumption that in periodontitis patients, where the exposure to the periodontal pathogens is stronger, infection with Aa may trigger a prothrombotic effect. In fact, this effect seems to be diluted by adding in our multivariate model subjects without periodontitis and with a relatively low response to Aa. We confirm that also BMI, age, female gender, smoking and cholesterol play an important role [Aa in the mechanism that may provoke a prothrombotic state, we may speculate that the lipopolysaccharide (LPS) produced by Aa may trigger the endothelial cells to produce more vWF [Aa itself may invade endothelial cells and then stimulate the release of vWF [The main finding of the current study was that in patients affected by periodontitis, in the multivariate analysis levels of IgG against ant role . Neverthmore vWF  or, altee of vWF .Pg. An explanation could be the fact the Roth et al. studied selectively the production of PAI-1 by endothelial cells in vitro; however, in vivo, PAI-1 is produced not only by endothelial cells but also in the liver and by adipocytes. Yet, in our multivariate analysis we found in periodontitis patients a trend for a positive correlation between F1+2 and IgG levels against Pg and an inverse correlation between levels of IgG against Pg and levels of D-dimer. F1+2 is a peptide formed during the conversion of prothrombin into thrombin in the coagulation cascade and D-dimer is a marker of the turnover of fibrin dissolution in fibrinolysis, the process of breakdown of the blood clot. This might suggest that Pg may play some role in enhancing coagulation and suppressing fibrinolysis. These suggestions need to be confirmed in further research with larger populations.In contrast with the findings of Roth et al. (2006), we did not find a correlation between PAI-1 activity and serum IgG against Aa and Pg. Unfortunately, for a number of the original study subjects these measurements could not be performed because of exhaustion of available serum. Lack of serum for some individuals (both patients and controls) led to the exclusion of these subjects and as a consequence a reduction in the population size, in comparison to the original population. Another point of discussion is the lack of information about subgingival presence of Aa and Pg in the study population. However we consider the levels of IgG against Aa and Pg as a reliable indicator of a possible infection with these periodontal pathogens. This is currently a widely used method in the literature [Aa IgG and the number of colony-forming units of Aa cultured from subgingival flora . Similar results were obtained for Pg .There are some limitations in this study that need to be discussed. As already mentioned, this study population was retrieved from the population of our previous investigation. Now we determined the IgG levels against terature ,12,14. NAa may also play an important role, while infection with Pg is suggestive. Further research will be necessary to confirm the findings of the current study. In general it needs to be considered that bacterial infection in addition to traditional parameters may also contribute to a prothrombotic state.In conclusion, this pilot study confirms that well accepted risk factors for CVD correlate with markers of prothrombotic state; these include BMI, gender, age, smoking and cholesterol. However we also propose that at least periodontal infection with BMI: Body Mass Index; hsCRP: high sensitive C-reactive protein; NS: not significant; NT: not tested; vWF: von Willebrand factor; PAI-1: plasminogen activator inhibitor-1; F1+2: prothrombin fragment 1+2; IgG: Immunoglobulins G; AU: Arbitrary Units.The authors declare that there are no conflicts of interest in this study. This study was supported in part by the author's institution and in part by Philips Oral Healthcare EMEA.Aa and Pg. UvdV provided intellectual contribution in the interpretation of the data and participated in drafting the manuscript. MLL assisted in ELISA's and the statistical analyses and helped to draft the manuscript. BGL participated substantially in the design, analyses and interpretation of data and participated in drafting the manuscript.SB participated in the design, the conduction of the study and data collection, performed the statistical analysis and he is the main author of the manuscript. EAN researched, designed and carried out the ELISA's on IgG's against All authors read and approved the final manuscript.


A previous study showed that combination of zinc and vitamin A reduced sputum conversion time in pulmonary tuberculosis (TB) patients.We studied the efficacy of which single micronutrient contributed more to the sputum conversion time.In a double-blind randomized community trial, newly sputum smear positive pulmonary TB patients were assigned randomly to receive zinc, vitamin A, zinc + vitamin A or placebo on top of TB treatment. Patients were asked to deliver their sputum on weekly basis to measure positivity of the bacteria. Nutritional status, chest x-ray, hemoglobin, C-reactive protein (CRP), retinol and zinc level were examined prior to, after 2 and 6 months of treatment.2). Patients in the zinc + vitamin A group showed earlier sputum conversion time (mean 1.9 weeks) compared with that in the other groups; however the difference was not significant. Also, no benefit could be demonstrated of any of the used supplementations on clinical, nutritional, chest x-ray, or laboratory findings.Initially, 300 patients were enrolled, and 255 finished the treatment. Most patients were severely malnourished (mean BMI 16.5 ± 2.2 Kg/mThis study among severely malnourished TB patients, did not confirm that single or combined supplementation of zinc and vitamin A significantly reduced sputum conversion time or had other significant benefit. The presence of micronutrient deficiencies among tuberculosis (TB) patients has led to the question whether micronutrient supplementation would give additional benefits for the patients on top of the TB treatment. In a prVitamin A, as found as retinol in plasma, is one of important micronutrient which has specific immune function . The preZinc is a trace mineral, which is essential for the function of cells of the immune system, and a miMycobacterium tuberculosis in sputum culture. Conversion of sputum smears to AFB-negative status is only used in resource-limited countries[Mycobacterium tuberculosis (MTB) in sputum culture [As in other programs for the combat against TB, the National Tuberculosis Program in Indonesia states that the disappearance of acid-fast bacilli (AFB) from sputum after treatment is basic in pulmonary TB patients' management. The presence of AFB in sputum can be assessed by direct visualization using the light microscope, and can be confirmed by growth of countries while in culture .The effectiveness of anti-TB therapy is determined by several factors, including the burden of mycobacteria, underlying immune status, adherence to treatment, and drug susceptibility. In the face of new threats to combat tuberculosis, i.e. multidrug and extensively drug resistance MTB, and also immunosuppressive diseases ; the studies on micronutrients as modulator of the immune system are important. It would provide more evidence to the importance of supplementation against tuberculosis. Following the previous finding in Jakarta, the present study aimed to investigate the effect of single supplementation of zinc or vitamin A or the combinations, on the sputum conversion time and the health status of newly diagnosed pulmonary TB patients. The study was done in Nusa Tenggara Timur (NTT) province which was selected on purpose, because of its relatively poorer than in Jakarta with high prevalence of malnutrition and vulnerable of food insecurity as reported by the ministry of health in 2005.The design of the study was a double-blind, randomized community trial. Prior to the study, randomization was done using a computer program, in which a treatment code was given to a subject. Every district had its random allocation table consisted 60 patients plus additional randomization for another 50 patients, to anticipate if one district had more patient than the other.Patients were given standard treatment for TB and randomly divided into four supplementation groups: zinc alone, vitamin A alone, zinc + vitamin A, and placebo. The supplementation was taken daily and the patients were followed up until 6 months.The primary outcome of the study was sputum conversion time. Secondary outcomes were: nutritional status , abnormalities on chest x-ray, and results of blood examinations .The study was conducted in Nusa Tenggara Timur (NTT) Province, Indonesia, covering four districts in Timor and Rote Island, namely Kupang City , Kupang District, Timor Tengah Utara  district and Rote-Ndao district, from January 2004 until December 2005.2 Accounting for a 40% drop-out rate, each group in the intervention study comprised at least 56 subjects.Subjects were newly diagnosed sputum smear-positive (SS+) TB patients aged 15-55 years. Prior and during the study, all pregnant or lactating females and subjects who had underlying chronic or degenerative disease, were excluded. All eligible patients were given information regarding the study including problems that might occur; and were asked to sign an informed consent for their participations in the study. The sample size was calculated based on the ability to determine a difference with α = 0.05 and 1-β = 0.80 in sputum conversion time, nutritional status (BMI) and plasma concentrations of retinol and zinc. As plasma retinol concentration was the parameter requiring the largest sample size, it was calculated that with a minimum sample size of 40 in each group, a between-group difference of 0.12 μmol/L in plasma retinol level could be detected based on the previous study.Supplements and placebo were prepared by Kimia Farma Ltd, Indonesia, in the form of capsules. Each micronutrient capsule contained 1500 retinol equivalents (5000 IU) vitamin A (as retinyl acetate) and/or 15 mg zinc (as zinc sulfate) in a lactose matrix. Dosage of zinc was determined based on the recommended daily allowances for adult Indonesians. Based on the previous study in Jakarta, dosage of zinc was 15 mg in a form of zinc sulfate . The vitAll patients underwent physical examination, chest x-ray, nutritional and food intake assessment as described in other study , and bloDuring the first 2 months of the study, the patients were asked to come to the clinic every week to deliver their sputum for direct AFB smear examination. Three early morning sputum specimens were taken from the patients and examined by direct microscopy after Ziehl-Neelsen staining in each Health Centre. The time was noted when the first of three weeks' consecutive sputum smears of good quality was negative. In the case that either, not all sputum samples were delivered, or the sputum was not of adequate quality, the data were considered missing.2) as described before[Chest X-rays were performed at diagnosis on all patients and were evaluated by calculating the visible lesion area in both lungs. In patients with cavities, the total area of exposed cavity wall was calculated from the radius of visible cavities πr as descrNutritional status was determined based on anthropometric measurements and micronutrient concentrations in the plasma. The anthropometrics measurements were: body weight, height, body mass index, skinfold thickness and percentage of body fat.2). Mid upper arm circumference (MUAC) was measured using a flexible measurement tape. Skinfold thickness was measured at 4 sites: biceps, triceps, sub-scapular, and supra-iliac regions, with a slim guide skinfold callipers , recorded to the nearest 0.2 mm. The percentage of total body fat was based on the skinfold data, and calculated using the Durnin and Wormesley equations[Body weight was assessed using an electronic platform model weighing scale  to the nearest 0.1 kg. Height was recorded to the nearest 0.1 cm using a microtoise. BMI was calculated as body weight divided by height squared  containing EDTA and heparin. Zinc and vitamin A concentration were measured in plasma. C-reactive protein (CRP) was measured to adjust the micronutrient deficiency in the statistical analysis. Plasma was separated after centrifugation at 750 × g for 10 minutes at room temperature, and then stored at minus 20°C until analyzed for CRP, retinol, and zinc concentration at the SEAMEO-TROPMED Laboratory, Jakarta. C-reactive protein (CRP) was measured using enzyme-linked immunosorbent assay (ELISA) method with a normal value < 10 mg/L. Plasma retinol concentration was measured by high performance liquid chromatography (HPLC), values less than 0.70 μmol/L were regarded as indicating deficiency, and values between 0.70 μmol/L and 1.4 μmol/L indicates marginal deficiency. Plasma A one-sample Kolmogorov-Smirnov test was used to determine whether the variables were normally distributed. Data on the characteristics of the subjects at enrollment for their age and gender distribution, nutritional status, blood concentrations, and results of radiological signs were summarized and used to assess the comparability of the patients randomly assigned to the four treatment groups. Different means between groups were tested for significance using one-way ANOVA when normally distributed, and Kruskal-Wallis test when not-normally distributed. An extended analysis (ANCOVA) was further applied for determining predictors of outcome. Different proportions between groups were tested using chi-squared test. Within group changes were tested using paired student-t test for normally distributed data and the Wilcoxon signed-rank when for not-normally distributed. A p value less than 0.05 were considered significant. An intention to treat analysis was applied. Statistical analyses were performed using computer software SPSS for Windows PC version 14.0 [This study adhered to the Council for International Organizations of Medical Sciences guidelines . Data were collected after subjects agreed to participate in the study and gave written informed consent voluntarily. The research proposal was approved by the Ethics Committee of the Faculty of Medicine, University of Indonesia.A total of 300 patients were enrolled into the study and randomly grouped into 4 categories of intervention, i.e. supplementation of zinc (n = 76), vitamin A (n = 72), combined zinc + vitamin A (n = 66) and placebo (n = 86). After two months 274 patients were still in the study and analyzed, while 255 patients completed the study after 6 months and were analyzed. Figure . Of all Patients' mean age was 31.5 years and 63% of them were men  and normal nutritional status (17%). The mean value of MUAC and percentage body fat were extremely low.Mean BMI for the four groups varied from 16.4 - 16.6 and was 16.5 for all 300 patients, indicating severe malnutrition Table . Fifty pAfter 2 months of treatment, there were significant improvements of micronutrient status within groups compared with the initial levels, particularly in patients given combined vitamin A and zinc supplementation or placebo Table . The proIn this double-blind randomized community trial, supplementation with zinc and vitamin A, either alone or combined, failed to show superiority over placebo. This was unexpected, as we could not confirm the results of the previous study in Jakarta, in which vitamin A and zinc supplementation was beneficial in terms of sputum conversion time. ResultsHow can we explain the discrepancy between the results of the Jakarta study and the current results? The first explanation might be found in retinol concentrations and inflammatory response at baseline. In the Jakarta study, higher mean retinol concentrations  were found than in the current study . The meaThe second explanation may be connected to the differences in the chest radiographs and the grading of sputum AFB positivity, an important predictor of sputum conversion. The numThe severity of TB in our patients is witnessed by the fact that 40% had sputum AFB positivity grade 3 prior to treatment whereas in the Jakarta study 68% had grade 1 (for both supplemented and placebo groups) and this can be expected to lead to longer sputum conversion time. It may retinol cosentration in plasma, with an alpha = 0.05 and 1-beta = 0.95 with use of a one-tailed test for concentrations of hemoglobin in blood, and of retinol and zinc in plasma."[The third explanation for the difference between the current study and the previous study in Jakarta is related to the sample size. In Jakarta, the sample size was estimated "on the ability to determine a difference of  plasma." The find2 as compared to 18.5 Kg/m2 in the Jakarta study[Another explanation may be related to the observation that the patients in the current study were more malnourished than the patients in the Jakarta study. Mean BMI of our cohort was 16.5 Kg/mrta study. Such a rta study. As founNeither of low intake or wasting is directly affected by supplementation of micronutrients and hence it may not be remarkable that we failed to show an effect in this study. Beside macronutrient deficiencies, there was also the possibility that additional micronutrients deficiency were present in the study population, which could not be corrected with zinc and vitamin A.For example, vitamin D has been implicated in defense against TB, but vitamin D deficiency is a worldwide problem. Furthermore there might be a link between vitamin D deficiency with ethnicity. In the Jakarta study, the patients were mainly from Java, Sunda and Sumatra, with a minority of others, the current study consists mainly of patients indigenous to Timor and Rote islands. We founWe conclude that the patient groups studied here, were suffering from severe tuberculosis with cavities in at least one third of the patients, and high sputum positivity grade. The patients were vitamin A deficiency whereas zinc was at borderline but sufficient to support the immune system and perhaps more important, also severely malnourished. It was also important to notice that the supplementation could not elevate the level of retinol and zinc plasma higher than its borderline. Against this background we were not able to replicate the results of the Jakarta study that demonstrated a beneficial effect of vitamin A and zinc in tuberculosis. This means that the previous findings in Jakarta cannot be generalized. For further studies, a larger sample size will be required, and higher dosages of the zinc and vitamin A supplementations should be considered. Also, in patients with very low BMI, the effect of protein supplementations needs further study.AAS: (atomic absorption spectrometry); AFB: (acid fast bacilli); ANOVA; ANCOVA: ; BMI(body mass index); CIOMS: ; CRP(C reactive protein); ELISA: (enzyme-linked immunosorbent assay); ESR: (erythrocyte sedimentation rate); HIV(Human immunodeficiency virus); HPLV: (high performance liquid chromatography); MUAC(mid upper-arm circumference); NTT: (East Nusa Tenggara Province); RDA; SPSS: ; SS(sputum smear); TB: (tuberculosis); TTU: ; WBC: (white blood cell); WHO: We declared that there is no competing interest, neither financial aspect nor other aspects, in pursuing and publish the research.TAP lead the data collection in the field, did the analysis and writing up the manuscript. EK was the primary investigator who designed the study. NMDS, MS and ND gave contribution in patient management and monitoring. HB helped in the statistical analysis. KvdV, WMVD, and JvdM helped in supervising the analysis, assessment of the findings, and writing up the whole trial. All authors have read and approved of the final version of the manuscript.The study was the continuation of the previous one published in Am J Clin Nutr 2002;75:720-7 when EK got her promotion from the Radboud University Nijmegen Medical Center, under the supervision of JvdM. The first author was a candidate doctor under the supervisions of JvdM, KvdV and WMVD.


Fish consumption is considered the primary pathway of methylmercury (MeHg) exposure for most people in the world. However, in the inland regions of China, most of the residents eat little fish, but they live in areas where a significant amount of mercury (Hg) is present in the environment.We assessed concentrations of total Hg and MeHg in samples of water, air, agricultural products, and other exposure media to determine the main exposure pathway of Hg in populations in inland China.We selected Guizhou Province for our study because it is highly contaminated with Hg and therefore is representative of other Hg-contaminated areas in China. We selected four study locations in Guizhou Province: three that represent typical environments with severe Hg pollution , and a village in a remote nature reserve (Leigong).The probable daily intake (PDI) of MeHg for an adult population based on 60 kg body weight (bw) was considerably higher in Wanshan than in the other three locations. With an average PDI of 0.096 μg/kg bw/day , approximately 34% of the inhabitants in Wanshan exceeded the reference dose of 0.1 μg/kg bw/day established by the U.S. Environmental Protection Agency. The PDI of MeHg for residents in the three other locations were all well below 0.1 μg/kg bw/day . In all four areas, rice consumption accounted for 94–96% of the PDI of MeHg.We found that rice consumption is by far the most important MeHg exposure route; however, most of the residents (except those in Hg-mining areas) have low PDIs of MeHg. All over the world, mercury (Hg) is present in various environmental media and foods  at levels that can adversely affect humans and wildlife. Methylmercury (MeHg), one of the most toxic of the organic Hg forms, is readily bioavailable and biomagnifies in the food chain so that fish at higher trophic levels regularly have Hg concentrations a million-fold higher than the water in which they live . Of MeHgSituated in the center of the circum-Pacific mercuriferous belt, Guizhou is known as the “mercury capital” of China . The totCoal combustion and zinc (Zn) smelting are also important sources of anthropogenic Hg in Guizhou. Approximately 80% of total energy demand in the province is provided by coal combustion . The Hg 2+ is reduced to elementary Hg and evaporated. A large quantity of Hg is thereby released to the environment, resulting in additional serious Hg contamination to the local environment  Zn-smelting activities (using an indigenous method) have been ongoing for at least a century in Guizhou, with a large number of smelters scattered throughout the northwestern parts of the province . Because of the geological background of the mercuriferous belt, significant amounts of Hg have been found in Zn sulfide ores from these areas. During Zn-smelting processes, Hgironment .2+ but not MeHg. These observations suggest that MeHg produced in the paddy soil might be easily taken up in the rice plant.All of these large anthropogenic Hg emissions sources, in addition to a general elevated natural background level, result in much higher amounts of Hg in the environment, even in pristine regions of Guizhou, compared with undisturbed regions in North America and Europe . Under cPoorer segments of the population are less able to avoid exposure to pollutants and thereby protect themselves from elevated Hg pollution. Guizhou is an undeveloped region in inland China, and for rural households in this area, the annual per capita net income is only 1,985 CNY . More than 27 million people live in the rural areas of Guizhou, accounting for 72.5% of its total population .0 concentrations up to 1,100 ng/m3 in ambient air (n = 228), with only one fish exceeding 0.5 mg/kg, the maximum MeHg limit for fish set by the Standardization Administration of the People’s Republic of China .Serious Hg contamination has been reported in different environmental media in Guizhou, including elevated Hgient air , total mient air , and 790ient air  from Hg-of China . FurtherIn the present study, we selected four locations representing typical rural areas in Guizhou province where inhabitants eat mainly local agricultural products they have planted themselves. The four areas are Wanshan (representing areas impacted by Hg-mining and smelting activities), Qingzhen , Weining , and Leigong Natural Reserve (representing areas with no direct Hg contamination sources) . We asse2 in both Wanshan and Qingzhen areas. We collected samples of agricultural products  directly from the fields, and drinking water samples (water samples collected only in Wanshan and Leigong) from domestic wells and reservoirs for human consumption. In Wanshan, we also measured total gaseous mercury (TGM) in situ. Sampling was carried out during September 2007 in Wanshan and Qingzhen, during August 2008 in Weining, and during September 2008 in Leigong. Data from the present study and from the literature are summarized in Building on previous published data from the four selected locations  for air The edible part of the grain (rice and corn) and vegetable samples were dried in an oven at 40°C until they reached constant weight. We then crushed the edible part of the samples and sieved them through a 150-mesh sieve. For THg analysis, the sieved samples (0.1–0.2 g) were digested at 95°C with a fresh mixture of nitric acid/sulfuric acid (vol/vol 4:1) . ConcentTo determine MeHg and THg exposure via drinking water, inhalation, and food consumption, we calculated PDI values for the general adult population according to the following formula:C is the concentration of exposed medium; IR is intake rate , and i = intake of air, water, rice, fish, vegetable, corn, meat, and poultry.where PDI is given in micrograms per kilogram of body weight (bw) per day; bw = 60 kg; This calculation is based on the assumption that MeHg exposure from other routes  was much lower than that for Japanese women who consumed a high-fish diet [0.21  μg/kg bw/day] , despiteThe average ratio of the MeHg PDI to the THg PDI for the population of Guizhou was 5–29% , which dThe adult population of Wanshan has a much lower MeHg exposure  but a muAs noted above, we observed that Hg concentrations in fish were very low not only from environments devoid of direct contamination  but also2+ by the human body through food consumption has been estimated to be only 7%  , with onBecause rural residents in Guizhou rarely eat fish, MeHg exposure is mainly through rice consumption. Thus, for an adult who consumes 600 g of rice daily, according to the RfD of 0.1 μg/kg bw/day , the limRice does not contain the same important micronutrients associated with fish, such as docosahexaenoic acid , arachidonic acid (an omega-6), and iodine, all of which enhance neurodevelopment . BecauseIn addition to Wanshan, there are 11 other Hg mining and smelting areas in Guizhou , with poActually, rice is the staple food of more than half the world’s population . In AsiaIn the present study we found that the general adult population in Guizhou is exposed to low levels of MeHg that may not pose serious health risks to most of the population. Nevertheless, in a small portion of the population in heavily contaminated Hg-mining areas, MeHg exposure may exceed the tolerable intake for pregnant women. Rice consumption is the predominant pathway of MeHg exposure to the general population of Guizhou. Moreover, fish consumption contributes only 1–2% of their MeHg exposure, which is much lower than reported in Japan, North America, and Europe. However, inhabitants in Hg-mining areas were exposed to high levels of both MeHg and inorganic Hg. Studies are needed to determine whether dose–response relationships established for MeHg through fish and seafood consumption is valid for populations exposed through rice consumption.


P = .015, in 1996 P = .007, in 2004 P = .001). The biggest difference at the end of the followup between men and women was found in participation in supervised exercise classes . Most popular forms of physical activity were walking and calisthenics at home. Men undertook more modes of physical activity than women. The importance of physical activity declined during the followup in both gender groups but more among women than men. The most common obstacles to physical activity were poor health and lack of interest. The promotion of health maintained it's place as the most important reason for physical activity over the follow-up period.We studied changes of physical activity among noninstitutionalized 65 years and older persons over a sixteen-year follow-up period. The focus of our interest was on changes in involvement, frequency, intensity, and various modes of physical activity. Furthermore, we studied changes in perceived importance, motives for, and obstacles to participation in physical activity. The results showed that the proportion of those reporting less frequent and intensive activities increased. Men were more active than women over the follow-up time (in 1988  Physical activity has an important role in the well-being of aging people. its importance for maintaining physical capacity and health during a person's lifetime has been well documented –7. FurthThe modes, regularity, and intensity of physical activity change with increasing age, so that the total time spent in physical activity and, particularly, the regularity and intensity of the activity clearly decline after 75–80 years of age –12. HealTo be able to develop physical activity interventions for older people, it is important to know how different aspects of physical activity change with increasing age. What happens to attitude, motives, and barriers to physical activity. Although the number of studies on older people's physical activity is growing rapidly, longitudinal studies of physical activity of older people are still very rare.Different aspects of physical activity have been covered in several international longitudinal studies –17 but iHealth refers often to the most important motive for physical activity among older people –24. AccoIn this study, the concept of physical activity is defined according to Caspersen et al.  as a bodn = 7600) were 65 and over. At the baseline, the target population comprised 1600 residents of Jyväskylä born in 1904–23. Two representative random samples of 800 respondents, men and women aged 65 to 74 and 75 to 84, were drawn from the population register. Approximately 80% of them (n = 1224) took part in the baseline interview. At baseline, only those who were living in their own homes were included in the study. The final sample size was 1185. The data from the younger cohort, born 1914–23 is used in this article because of the small number of survivors in the older cohort in 2004. In 1988, 635 persons from the younger age cohort, representing 81% of the target group (n = 800), took part in the baseline interview. The study plan has been described in more detail elsewhere [The data reported in this article is part of a larger, regionally representative 16-year follow-up study of the Evergreen project consisting of elderly people's health, functional capacity, and well-being. The study was carried out among residents aged 65 and over in a medium-sized town, Jyväskylä, in central Finland. The total population of Jyväskylä at the time of the baseline survey, in 1988, was 65 000, of whom 11.6%   during the follow-up period.The first follow-up study in 1996 consisted of those who had been interviewed in 1988 and still lived in the same town. The follow-up study in 2004 consisted of those who participated in 1988 and in 1996 as well as 21 persons, who had participated in 1988, but not in 1996. In the both follow-up interviews, we also interviewed those, who had been institutionalized . Regarding barriers to physical activity, we asked participants to mention three factors in order of importance. We classified the responses into five groups: lack of time , lack of interest, poor health , social factors , and other obstacles . The classified variable was then used in the follow-up questionnaires.For further knowledge of physical activity of older people, we studied modes of physical activity by asking the respondents to identify the activities, in which they took part in order to maintain their health and physical fitness. The modes of physical activity listed in the questionnaire were walking for fitness, callisthenics at home, swimming, cycling, cross-country skiing, dancing, supervised physical activities classes, and other. We measured the frequency of different modes of physical activity using a 6-point scale: (1) almost daily, (2) 2-3 times a week, (3) weekly, (4) 2-3 times per month, (5) once a month or more rarely, and (6) nonparticipation. The importance of physical activity was assessed using a five-point scale question “The aim of the next question is to clarify the importance of physical activity to you”  was analysed using the McNemar test. During the 16-year follow-up period (three points of time), the Cochran Q-test was used. The choice of statistical test was based on the scale of measurement. Due to insufficient number of responses in some categories, reclassification was done where warranted by the contents. To compare men and women, and participants who were interviewed in 2004 with those who had died during the follow-up period, n = 241) of the participants were male and 62%  (n = 394) were female. The mean age of participants was 69 years in 1988, 76 years in1996, and 84 years in 2004. During the sixteen-year follow-up period, 54%  (n = 346) people died and 4%  (n = 25) moved away from Jyväskylä. Results show that at baseline 38%  (χ2 (5) = 14, P = .015), in 1996 (χ2(5) = 16, P = .007), and in 2004 (χ2(5) = 16, P < .001). Those men and women, who died during the follow-up period, had been physically less active at baseline than those, who participated in all of the assessments in 1988, 1996, and 2004 (P < .001 (Not in table)). Most popular forms of physical activity among participants were walking and calisthenics at home. P < .001) and callisthenics at home which was, however, not statistically significant  in the proportion of women who considered physical activity to be very important. No significant change among men was observed. Most of the participants considered physical activity to be at least somewhat important . HoweverThe most common obstacles to physical activity reported at baseline in 1988 by both gender groups included poor health (19%), lack of interest (6%), lack of time (2%), and other reasons (2%). About half  of the respondent did not name any obstacle. During the 8-year and 16-year follow-up studies, the percentage of people, who faced some barrier to physical activity increased. In 2004, the obstacles most often mentioned in order of importance among men and women were poor health and lack of interest. The reasons for physical activity were similar in 1988, 1996, and 2004. The most important reason given at every point of measurement was the promotion of good health . Participants also mentioned social reasons , and the satisfaction derived from physical activity as motivating factors. In this study, physical activity declined both in the 8- and 16-year follow-up studies, though less among men than women. However, almost 70% of the 81–90-year-old men and over 40% of women reported walking several times a week or even at times engaging in more intensive levels of physical activity. Men took part actively in supervised exercise classes and they reported a wider range of activities than women at the end of the study in 2004. Although a considerable proportion of elderly people were physically active, over half of women and one third of men reported low levels of activity. Also, the proportion of those women, who considered physical activity to be very important, declined significantly during the follow-up periods. In contrast, most men still considered physical activity to be very important at the end of the follow-up. During the first part of the follow-up, in the 8-year follow-up study, physical activity remained at almost the same level in men but decreased in women. The results are in line with the survey by Gauthier and Smeeding , who notOne reason for high level of participating supervised exercise classes may be the well-organized community-based exercise programs for different age groups including great number of supervised exercise classes for over 65-year-old people in the town, where the study was executed. During the follow-up time, perceived importance of physical activity declined among women. In women still living in the community, this pattern may reflect the time pressures they face in their multiple roles at this life stage and in earlier life. Long working hours and responsibilities at home may have prevented women from performing physical activity in earlier life, thus hindering their efforts to develop a proper physical activity routine in later life. In this study, poor health was the most often mentioned obstacle to physical activity. These results are in line with some previous studies , 32, whiIn addition to health status, earlier studies mention weather conditions , lack ofThe value of the current descriptive study is in its long follow-up time, which made it possible to investigate changes in adherence concerning physical activity and levels of involvement in physical activity over the course of 16 years among the same group of elderly people. The sample represents the normal adult population. The same procedure in data collection was used in all follow-ups, which may also cause some problems during the study. New methods are developed during the follow-up time, but to be able to follow the change researchers are tight to use the methods, which have been chosen at the baseline. The collection of physical activity information using postal questionnaire has been criticized and includes some well-known limitations . In popuA good quality of life is an important aim at the end of one's life, and the importance of physical activity for promoting physical, psychological, and social health is generally understood. While older people who keep up their functional and mobile capacity maintain the autonomy –40, our


In 2003 the NIH perceived a need to strengthen teaching about tuberculosis (TB) to health professions students. The National Tuberculosis Curriculum Consortium (NTCC) was funded to meet this need. The purpose of this study was to survey students enrolled in NTCC schools prior to NTCC-developed educational materials being made available to faculty.A self-administered survey for students in NTCC schools to establish a baseline level of knowledge, attitudes, and confidence about tuberculosis.1480/2965 (50%) students in 28 programs in 20 NTCC schools completed the survey. If public health students are eliminated from totals , the overall response proportion for the seven clinically-related disciplines was 64.5%. The majority (74%) were in schools of medicine (MD/DO), undergraduate nursing (BSN), and pharmacy (PharmD); others were in programs for physician assistants (PA), advanced practice nursing (NP/APN), respiratory therapy (RT), clinical laboratory sciences (MT/CLS), and public health (MPH). Almost 90% had attended at least one lecture about TB. Although 91.4% knew TB was transmitted via aerosols, about one-third did not know the method for administering tuberculin, or that Bacillus Calmette-Guerin (BCG) vaccine was not a contraindication to TB skin testing. Fewer than two-thirds knew that about 10% of people in the U.S.A. who have latent tuberculosis infection (LTBI) and a normal immune system will develop TB disease, or that BCG is not part of the routine vaccination program in the U.S.A. because it complicates surveillance for new TB infection.There is room for improvement in knowledge, attitudes, and confidence about TB by health professions students surveyed. The NTCC-developed educational products may be used by faculty to improve student performance to be assessed with future surveys. Between 1985 and 1992, there was a dramatic increase in the incidence of tuberculosis (TB) in the United States, and the epidemiology of TB changed . AlthougSince the resurgence of TB almost two decades ago, there has been increasing concern about education and competence of healthcare providers to deal with specialized issues of TB prevention and treatment. Many educational materials on all aspects of TB are produced by national and international agencies such as the Centers for Disease Control and Prevention, the National Institute of Allergy and Infectious Diseases, the World Health Organization, and the International Union Against Tuberculosis and Lung Diseases; health departments; educational and research institutions; and non-profit organizations such as the American Thoracic Society. With the wealth of materials on all content areas of TB, it is disconcerting that clinicians still make frequent errors in TB treatment  and therAppendix). The NTCC is funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health for five years (10/03 – 9/08). The goal of the NTCC is to improve knowledge of tuberculosis in students in health professions schools throughout the U.S.A. The NTCC is organized around sets of competencies for students in eight health disciplines: medicine (MD/DO) [A major step in improving TB education in the U.S. involved the creation of the National Tuberculosis Curriculum Consortium (NTCC) consisting of over 40 multi-disciplinary educators and leaders in 25 academic institutions and affiliates throughout the U.S. ( (MD/DO) , undergr (MD/DO) , advance (MD/DO)  to faculTo assess students for basic knowledge of TB and how confident they feel about taking care of persons with latent tuberculosis infection (LTBI) or active TB, a Student TB Survey was developed and administered in 2005. The purpose of the initial survey described in this article was to provide a baseline level of knowledge, attitudes, and confidence about tuberculosis by surveying students enrolled in NTCC schools prior to NTCC-developed educational materials being made available to faculty.A total of 2965 students in 28 programs in 20 NTCC schools were potential subjects for the study.The Core Curriculum on Tuberculosis [Self-Study Modules on Tuberculosis [The survey instruments were designed by members of the NTCC using materials that included content and questions from two Centers for Disease Control and Prevention publications, rculosis  and the rculosis . In addiPrior to administration, a master protocol was submitted to and approved by the University of California San Diego Institutional Review Board (IRB). The master protocol and UCSD approval letter were made available to NTCC members via the NTCC website  for use Data reported in this article are limited primarily to responses to the 18 questions common across all eight versions of the survey administered to students in 28 programs in 20 NTCC schools.Of the 2965 students enrolled in the 28 programs surveyed, about half 1480) completed the survey. Table 480 complTable Although almost all students knew TB was most commonly transmitted from person-to-person via aerosols (Question 6), about one-third did not know the correct method for administering tuberculin (Question 7) or that BCG was not a contraindication to TB skin testing (Question 8). Fewer than two-thirds knew that about 10% of people in the U.S. who have LTBI and a normal immune system will go on to develop TB at some point in their lives (Question 9), or that the reason BCG is not part of routine vaccination programs in the U.S. is because it complicates surveillance for LTBI (Question 10).outside the U.S.A. or Canada (are you foreign born)?" was asked as a general question. Among the 1469 students who responded to this question, almost one-quarter (22.9%) reported they were born outside the U.S.A. or Canada. Of the foreign-born, the majority (72%) were in medicine and pharmacy programs. As expected, a significantly higher proportion of foreign-born students had been diagnosed with LTBI (14.9% vs. 3.9%), had been treated for LTBI (6.5% vs. 1.7%), and had received BCG vaccine (33.6% vs. 1.3%).It is well-established that LTBI and active TB are more common among foreign-born individuals, and that foreign-born students are more likely to have received BCG vaccine than students born in the U.S. . To evalTable Table M. tuberculosis is transmitted by coughing . This is similar to our overall findings wherein almost 10% did not know TB organisms were most commonly transmitted from person-to-person via aerosols. Among our medical students, however, most of whom were near completion of their training, 95% knew the correct answer which is more consistent with Teixeira et al.'s findings for medical students in their late clinical years.In a recent editorial, Jensen  commenteWe were pleased that most students believed TB education was important to their academic program  declare that they have no competing interests.All authors were responsible for the conception and design of the study, and for development and refinement of the survey instrument. MJ analyzed the data and drafted the manuscript. All authors participated in review and revision of the manuscript. All authors read and approved the final manuscript. All authors confirm that the content has not been published elsewhere and does not overlap or duplicate their published work.NTCC Participating SchoolsAdministration: University of California, San Diegobold italicsCurriculum Centers for each Region are in Western Region:University of Southern California, Los Angeles• • University of California, Berkeley• Stanford University, Palo Alto, CA• Western University, Pomona, CA• University of Washington, Seattle• WA State Department of Health, Seattle• University of Colorado, DenverNortheast Region:Columbia University, New York, NY• • Long Island University, Brooklyn, NY• Northeastern University, Boston, MA• NY College of Osteopathic Medicine, Old WestburySoutheast Region:University of Arkansas, Little Rock• • Georgia State University, Atlanta• Johns Hopkins University, Baltimore, MD• University of Maryland, BaltimoreNorth Central Region:Wayne State University, Detroit, MI• • University of Illinois at Chicago• University of Michigan, Ann Arbor• Midwestern University, Downers Grove, IL• Rush University, Chicago, IL• University of Nebraska, OmahaSouth Central Region:University of Texas Health Science Center, Houston• • University of Texas, San Antonio• Tulane University, New Orleans, LAThe pre-publication history for this paper can be accessed here:


In order to investigate the prevalence of physical, mental, and chronic fatigue syndrome-(CFS-) related fatigue and its relation to lifestyle, 1,225 adolescents  aged 11 to 16 years were asked to complete a self-reported questionnaire on fatigue status and lifestyle in the past one month. There was no gender difference in physical and mental fatigue scores, but CFS-related scores were significantly higher in females than in males. These scores were found to increase with the increase of age. After adjusting for age and gender, multiple regression analysis showed that physical and mental fatigue scores were associated with sleeping hours, extracurricular sports activity, food balance, the frequencies of snacks between regular meals, intake of sugar-sweetened beverages, and visits to the nurse's room. This paper is the first large cross-sectional study on fatigue in healthy adolescents in Japan, albeit there were numerous such studies in Western countries. Easy fatigability is a problem commonly seen in modern society . Among f There are several studies on fatigue in populations of healthy adolescents and children in Western countries. These studies have demonstrated a wide variety of prevalence depending upon the study population and definition of fatigue , 11, 12.This study was carried out in Nara city in the spring of 2008 with 1,225 participants. Nara is an urban city in Japan with a population of approximately 370,000. Among them, the approximate population of children and adolescents aged between 3 and 17 years was 45,000. The mean annual income of each household was almost similar to the average of Japan . The participants included 421 students in the 6th grade of elementary school (11 years), 226 in the 1st grade (12 years) and 243 in the 3rd grade (14 years) of junior high school, and 335 in the 2nd grade of senior high school (16 years). There were 591 males and 634 females. At school, they were asked to complete a questionnaire about their fatigue status and lifestyles on average over the past one month. We obtained consent from all students beforehand for using their data in our study. In addition, their parents were informed of this survey beforehand. This project was approved by the ethical and epidemiological committee at Nara Women's University.We devised our own questionnaire as shown in the appendix. There were 4 questions each on physical and mental fatigue. Each question was scored from 0 to 3: 0, not at all; 1, a few times per month; 2, a few times per week; 3, almost every day. The scores given by the participant were then summed to calculate physical and mental fatigue scores separately (range: 0–12). Subjects were also asked about seven CFS-related elements based on the diagnostic criteria of the disease [Before starting the survey, we have checked the validity and the reliability using 100 female students aged 18–20 years at Nara Women's University. They were asked to answer anonymously our questionnaire on their fatigue and Chalder's scale simultaneously. The items of the original Chalder's scale were translated into Japanese by the chief investigator, M. Kubota. t-test and one-way analysis of variance (ANOVA), respectively. The association of these scores with various lifestyle elements and BMI was evaluated by multiple regression analysis. The total population was divided into two groups by the total fatigue score , and association with demographic factors, lifestyles, visit to the nurse's room or BMI was estimated by logistic regression analysis. A statistical analysis was made by “StatMate IV” . P-values less than .05 were considered significant.Differences in mean physical and mental fatigue, and CFS-related scores according to gender and age were examined by Student's αs for physical, mental, and total fatigue scores were 0.76, 0.72, and 0.83, respectively. These values  are considered to be good for the internal consistency and to satisfy the reliability. Next, we evaluated the reliability of our questionnaire in comparison with the same subscales in the Chalder's scale, which was already validated. Correlation coefficients were 0.76 for physical fatigue scores, 0.64 for mental fatigue scores, and 0.78 for physical + mental fatigue scores. This fact supports the construct validity of our questionnaire.Since we have devised our own questionnaire, we first evaluated the reliability and the validity of the questionnaire in female students at our university. Cronbach's P < .01). There was no gender difference in physical and mental fatigue scores, whereas CFS-related scores were significantly higher in females except for 12-year-olds. In the present participants, Cronbach's αs for physical, mental, and total fatigue scores were 0.76, 0.74, and 0.85, respectively. This fact also showed the good internal consistency.Subject numbers according to age and gender are shown in By multiple regression analysis after adjusting for age and gender, these scores were found to be associated with all lifestyles except for snacks between meals in CFS-related scores . ShorterP < .001), sleep duration (P < .001), food balance score (P < .001), frequencies of snacks and sugar-sweetened beverages (P < .05), and visits to the nurse's room (P < .001) revealed significant association with the total fatigue score.In order to evaluate the total quality of life, we have summed up the physical and mental fatigue scores as the total fatigue score. Then, the total population was divided into two groups according to the total fatigue score, that is, low fatigue (scores 0–12) and high fatigue (scores 13–24). Logistic analysis was carried out to determine associations of either group with demographic factors, lifestyle, visits to the nurse's room or BMI. As shown in Fatigue in adolescents has been an important issue of research in recent decades. There are objective markers newly invented for evaluation of fatigue . Althoug In the present study, we devised our own questionnaire, since the nuance of some questions in the previously validated questionnaire such as “Do you feel weak?” is difficult to be translated into Japanese accurately. In addition, those questionnaires have their own disadvantages. Since the CIS questionnaire consists of seven scales for each question, it is rather difficult for children to find an appropriate answer . Inclusi There are a number of limitations in the present study. First, as mentioned above, we developed and used our own questionnaire. This makes it difficult to compare our results with those of previous studies. Second, this is a cross-sectional study done in a single period of spring, 2008. Since the degree of fatigue in an individual may change among different seasons of the year, a longitudinal study for at least one year is warranted . Finally In conclusion, we carried out the large cohort study on the present fatigue status in healthy Japanese adolescents. The finding that there was not any significant gender difference in both physical and mental fatigue scores should be paid attention considering the female dominance in previous reports from Western countries. This might be partly explained by the inherent cultural background in Asian countries. However, generalization of our data directly to other Asian counties should be cautious. In spite of the limitations, we still believe that our findings will be useful for understanding the similarities and differences of fatigue among healthy adolescents in different developed countries. A further followup study to investigate whether chronic or severe fatigue in adolescents is connected with CFS or CFS-like illness in later life is necessary.


Yucheng City is located in northwestern Shandong Province, China, and is situated on the Huang-Huai-Hai Plain, the largest alluvial plain in China. In this study, 86 surface soil samples were collected in Yucheng City and analyzed for cation exchange capacity (CEC), soil organic matter (SOM), pH, available phosphorus (avail. P), phosphorus (P), aluminum (Al), and iron (Fe). These soils were also analyzed for ‘total’ chromium (Cr), nickel (Ni), copper (Cu), zinc (Zn), arsenic (As), mercury (Hg), cadmium (Cd), and lead (Pb), together with 92 wheat samples and 37 corn samples. There was no obvious heavy metal contamination in the soil and irrigation water. But the long-term accumulation of heavy metals in soil has lead to an increase of Ni, As, Hg and Pb concentrations in some of wheat and corn samples and Cd in wheat samples. Because of the numerous sources of soil heavy metals and the lower level of heavy metal in irrigation water, there is no significant relation between soil heavy metal concentrations and irrigation water concentrations. Cr, Ni were mainly from the indigenous clay minerals according to multivariate analysis. Little contribution to soil heavy metal contents from agricultural fertilizer use was found and the local anomalies of As, Cd, Hg, Pb in wheat and corn grain are attributed to the interactive effects of irrigation and fertilizer used. Aerial Hg, however may also be the source of Hg for soil, wheat and corn. The industrial sector has contributed much to economic development in the last three decades, but agriculture has been the main base for China’s economy, especially in the intensively farmed areas. The rapid development of industry, however, has resulted in a lot of waste going into drains, which contaminates rivers, streams, and local channels. Streams, rivers, and channels are the primary sources of water for irrigation . IrrigatThe Huang-Huai-Hai Plain (North China Plain) is the largest alluvial plain in China, and supports an important agricultural industry that accounts for ~23% of national food production . Since tHeavy metals are ubiquitous in the environment, either naturally or anthropogenically. Pollution from industrial emissions, wastewater irrigation, and fertilizer waste are the main sources of heavy metal pollution in China and have been intensively studied . However2.2.1.2, and the population is 500 thousand. It is also located on the Yellow River alluvial plain . The industrial and mining land use contributed most to total increment of the construction land area and achieved 18.84% of total land use in Yucheng in 2005 . There a2.2.Soil samples (86) were collected from different locations in June, 2008, based on the irrigation water and fertilizer used in the study area just before wheat harvest . Before The soils were air dried at ambient temperature and crushed to pass a 2 mm stainless steel sieve. Portions of soil samples (about 50g) were ground to pass a 0.149-mm sieve, then stored in plastic bags prior to chemical analysis. All samples of wheat and corn were washed with deionized water to remove soil particles or dusts adhering to the grain surface. All wheat and corn samples were oven-dried at 60 °C for 24 hours, then ground in a stainless steel mill to a fine powder and stored in plastic bags for further chemical analysis.3 solution at pH 8.5 according to Olsen et al. , and corn . Accuracy of the analytical method was given as percent recoveries for each of the elements. The results are reported in 2.3.Statistical analysis and PCA were performed using SPSS 16.0 and Statistica 6.0. Assessment of the normal distribution of the analytical data was carried out through 1-sample K-S test. Non-normal data were log-transformed to improve normal distribution and to reduce the influence of high analytical data. Correlation (r) and analysis of variance (ANOVA) were performed on log-transformed soil analytical data.Correlation analysis and PCA, based on the correlation matrix, were conducted for the soil chemical data set. The aim of using PCA was to ascertain any patterns in the soil samples in relation to these chemical characteristics, and then make a preliminary conclusion to the possible relationship between heavy metal concentrations and soil properties and fertilizer inputs types. Univariate analysis of variance was used to determine the significant differences of heavy metal concentrations in the irrigation water. Multivariate analysis of variance (MANOVA) was used to identify the exact sources and demonstrate the significant differences of heavy metal concentrations in soil and crops (wheat and corn grain) resulting from soil parent material, the irrigation water, fertilizer or their interactive effects.3.3.1.Data were evaluated by comparing heavy metals in surface soils of Yucheng City  with soi−1. The range is between 43.05 and 250.43 mmol·kg−1, implying that soil in Yucheng City had the moderate capacity to retain and supply fertility [−1), though a comparison of the 1980 and 2003 levels indicates that SOM is being elevated year by year [pr < 0.001). This indicates heavy metal contamination in the agricultural soils of Yucheng City due to long-term agricultural activities. However, we did not see elevated soil average heavy metal concentrations over the National Environmental quality standards, though Ni, Cu, Zn, As, Hg, and Cd concentrations seemed higher than the National Grade One standards. This implies that heavy metals in soil of Yucheng City are at a safe level on the whole due to the high soil pH and low SOM.Median, mean, minimum (Min) and maximum (Max) heavy metal and soil fertility concentrations of the surface soil sampled in Yucheng City are reported in  by year . This ma by year ,28. Howe by year . The low by year . As for 3.2.The concentrations of heavy metals in soil and their impact on ecosystems can be influenced by many factors, such as parent material, climate and anthropogenic activities . Heavy m−1), and 67% is in severe phosphorus deficiency (available P < 5 mg·kg−1) [In the 86 soils sampled , all heamg·kg−1) . So largThe PCA  showed t3.3.Concentrations of heavy metals in wheat and corn grain varied very much, so median value of heavy metal concentrations was presented in Cu and Zn were the most abundant metals in wheat and corn grains, as they were the essential micronutrients for plants ,35. The Though Cr was also abundant in soil, Cr in wheat and corn was much lower due to their lower mobility as is shown by their lower BCF values. The results strongly agree with the observation of ,36 who fCd is usually considered a highly mobile heavy metal in regard to moving from soil to plant. So Cd concentration of one wheat grain sample exceeded the MPC though that of soil was still lower. It is interesting to find that As in wheat grain showed higher concentrations than that as reported . This maThe BCF of Hg was 0.328 in wheat and 0.046 in corn, which ranked second in wheat and third in corn. It is notable that Hg is not easily transferred from soil to plant, but plants absorb Hg not only from soil but also from aerosols , so the Cr, Ni, Cu, Zn, As, Cd and Pb in wheat and corn may mainly come from the soil in which they were grown. However, aerial Hg may also be the main source for Hg in wheat and corn. The difference of As concentrations between wheat and corn lies in the selective adsorption of heavy metal from soil . It sugg3.4.In order to identify the sources of heavy metal  levels of different heavy metals in soils and crops (wheat and corn grain) irrigated with water from different sources and fertilized with different manure were assessed separately.Local rivers, ground water, and the Yellow River are the major sources of the agricultural irrigation in Yucheng City. Heavy metal concentrations in the irrigation water of Yucheng City are shown in The heavy metal concentrations in soil, wheat and corn grain are shown in Heavy metal concentrations in soil, wheat, and corn are shown in eta-squared, η2) describes the ratio of variance explained in the dependent variable by a predictor while controlling for other predictors within the context of MANOVA [η2 values output from MANOVA for soil heavy metal contents. It is easy to find that pH, SOM, CEC contributed least to all heavy metals in soil , which is consistent with the results of PCA. Al, Fe contributed most to soil Cr, Ni . It is reported that generally, anthropic inputs of Cr, Ni in fertilizers, limestone, manure and irrigation water are lower than the concentrations already present in the soil [p < 0.05)  as covariates in the MANOVA to discuss the exact sources of heavy metals in soil based on the prior analysis. Estimate of effect sizes , and lea4.pr < 0.001). This indicates heavy metal contamination of the agricultural soils of Yucheng City due to long-term agricultural activities.We used the 1980s heavy metal concentrations in the surface soil of the lower Yellow River as the soil background level of Yucheng City. Heavy metals in soil samples were all significantly higher than the background level except for As  in wheat and corn. Aerial Hg, however may also be the source of Hg for soil, wheat and corn. As for the numerous sources of soil heavy metals and the unobvious contamination of irrigation water, there is no significant relation between soil heavy metal concentrations and irrigation water concentrations. This study should be helpful for ensuring ecological safety and managing the agricultural development of Yucheng city, the Huang-Huai-Hai Plain, and China in general.


The association between excess body weight, impairment of health and different co-morbidities is well recognized; however, little is known on how excess body weight may affect the quality of life in the general population. Our study investigates the relationship between perceived health-related quality of life (HRQL) and body mass index (BMI) in the urban population of Belgrade.The research was conducted during 2005 on a sample of 5,000 subjects, with a response of 63.38%. The study sample was randomly selected and included men and women over 18 years of age, who resided at the same address over a period of 10 years. Data were collected by means of a questionnaire and nutritional status was categorized using the WHO classification. HRQL was measured using the SF-36 generic score. Logistic regression analysis was used to compare HRQL between subjects with normal weight and those with different BMI values; we monitored subject characteristics and potential co-morbidity.The prevalence of overweight males and females was 46.6% and 22.1%, respectively. The prevalence of obesity was 7.5% in males and 8.5% in females.All aspects of health, except mental, were impaired in males who were obese. The physical and mental wellbeing of overweight males was not significantly affected; all score values were similar to those in subjects with normal weight.By contrast, obese and overweight females had lower HRQL in all aspects of physical functioning, as well as in vitality, social functioning and role-emotional.The results of our study show that, in the urban population of Belgrade, increased BMI has a much greater impact on physical rather than on mental health, irrespective of subject gender; the effects were particularly pronounced in obese individuals. In an era of epidemiological and nutritional transition obesity has become an important public health problem, affecting different populations and population groups almost at a pandemic scale -4. ApartAccordingly, evaluation of the quality of life has become a focus of interest not only in population studies, but also in clinical medicine , particuWe carried out a cross-sectional analysis of the quality of life in the urban population of central Belgrade which, according to a recent census, has about 50,000 inhabitants. The study group consisted of a systematic sample (k = 10) of 5,000 subjects over the age of 18 who resided permanently in the area over the last 10 years.All subjects were handed questionnaires with cover letters which contained information detailing the objectives and methodology of research and consent forms. The participants were then asked to give their written informed consent to join the study, and a timetable was agreed with the interviewers who subsequently collected the completed questionnaires at the appointed time.The survey was anonymous and consisted of two parts. The first part contained questions referring to demographic characteristics of the subject such as sex, age, education, profession, health habits, details of body height and mass, exercise habits, as well as information on possible diseases.The level of education was divided into four categories which include the following: I – elementary, II – secondary school, III – college and IV – university-level education. A question was asked to ascertain whether the subject was an active smoker.Physical exercise was divided into two major categories: any form of exercise, excluding walking, lasting a minimum of 30 minutes per day, and walking alone, again for a minimum period of 30 minutes. Both groups where then subdivided according to frequency: 1 – never, 2 – once a month, 3 – once a week, 4 – several times a week and 5 – daily.The second part of the questionnaire consisted of a short version of the SF-36 generic assessment scale for the quality of life, as an internationally accepted questionnaire on health self-assessment, which has been translated and adapted for the use in Serbian .The SF-36 questionnaire contains 8 scales designed to evaluate physical health as well as mental functioning of the subject. The first four  are used to assess physical health whilst the others deal with issues of vitality, social functioning, role-emotional and mental health. The subjects are asked to give answers on a numerical scale; those answers are then coded and assigned a score on a scale of 0–100; a higher score represents a better result in view of the subjective perception of physical and mental health .2 for obesity [Based on the reported data on body height and mass, BMI values were calculated as the ratio of body mass in kilograms and the square of height in meters. Nourishment status was then evaluated according to the internationally recognized WHO classification: BMI = 18.5–24.9 for normal weight, BMI = 25–29.9 for overweight and BMI >30 kg/mThe subjects were divided into three groups according to nourishment status: normal weight, overweight and obese. For the purpose of sample description, all variables were presented as mean ± SD or frequency, where appropriate. The comparison of results within mean values was carried out by a one-way analysis of variance, with a Bonferroni correction adjusted for multiple comparisons to allow for the three BMI groups. The chi-square test was applied for variables measured on nominal scales.A stepwise multivariable logistic regression analysis, as a classification tool, was performed to test the association between BMI categories  and the 8 scales of SF-36  (model 1). Three additional regression models have been tested, adjusting for different sets of covariates: socio-demographic variables, life style variables and health status variables.P < 0.05 was considered to be statistically significant. All data were recorded and tabulated for analysis using the SPSS 15 for Windows statistical package.Adjustments were made for age and education (model 2) and age, education, smoking, physical exercise other than walking and walking (model 3). Model 4 included the former and major morbidity such as hypertension, diabetes and coronary artery disease. All models, expressed as odds ratios and their 95% confidence interval, were tested separately for men and women. The study was reviewed and given ethical approval by the Belgrade Medical School Ethics Committee.A total of 5,000 questionnaires were distributed; 3169 were completed and returned (a 63.38% return). Of this number 343 questionnaires were excluded as incomplete so that, ultimately, the sample group consisted of 2,826 subjects who had answered all questions.The results related to nourishment status are illustrated in Table The prevalence of overweight and obese females was 22.1% and 7.5% respectively. There was a significant difference in age between normal weight, overweight and obese women (p = 0.001). Obese woman had a lower level of education than normal weight and overweight women (p = 0.001). There was a significant proportion of smokers among overweight and normal weight by comparison to obese women (p = 0.001). Physical exercise other than walking and walking were practiced less by obese and overweight females when compared to normal weight women (p = 0.001). The incidence of illness increased with higher BMI values; arterial hypertension was most prevalent among obese individuals of both sexes (p = 0.001), followed by hypercholesterolemia (p = 0.001), hypertriglyceridemia (p = 0.001) and coronary artery disease .Comparison of the mean scores of the SF-36 questionnaire on health-related quality of life by body mass index is presented in Table In female subjects all scores for physical and mental health tended to decrease with the rise in BMI values. Scores on all physical health scales differed significantly both in overweight and obese females by comparison to women with normal weight (p < 0.001). Also significant (p < 0.001) were differences between overweight and obese women in scores for physical functioning and bodily pain. The assessment of mental functioning in female participants showed much lower score values in overweight (p < 0.01) and obese subjects (p < 0.01), except on the mental health scale.Table p < 0.001), role-physical (p < 0.001), bodily pain (p < 0.001), social functioning (p < 0.05) and role-emotional (p < 0.01) were much lower in comparison to normal weight woman. After adjustment, as outlined above for models 2, 3 and 4, the odds ratio differences were eliminated.Table Our study is the first to address the link between perceived HRQL and self-reported weight status in the Serbian urban population, and the first to use the SF-36 generic assessment scale outside the clinical setting ,29. We wThe prevalence of overweight and obese individuals in our sample is compatible with general data on the Serbian population contained in the latest WHO report  and withOur conclusions that increased values of BMI affect the quality of life, and particularly the physical health of the individual, coincide with those of other authors who also found that overweight and obesity have a greater impact on physical rather than mental health ,35,37-40Overweight, as a nutritional status, appears to have little impact on the subjective perception of physical health in male subjects, except in the realm of physical functioning, a finding also borne out by other authors ,41-45. HWe confirmed the association between obesity and lower HRQL in male participants, highlighted by other authors ,45,49-51Age is also an important determinant of the quality of life, both from the standpoint of physical health and that of mental wellbeing. In our study, overweight female subjects were older than overweight males, who were usually younger and had a better quality of life on all scales, as shown in other studies ,35,53,54Increased BMI values have a lesser influence on mental health, which may indicate that vitality, emotional changes, social isolation and mental health impairment are a consequence, rather than a cause of the increase in body mass ,34,35. VThe results of our study were confirmed by a logistic regression model which linked high BMI values to lower quality of life. The effect of overweight was particularly prominent in the realm of physical functioning, which was confirmed in both sexes after adjustments for age and education (Model 2). However, after adjustments for age, education, smoking, physical exercise other than walking and walking (Model 3), the lower HRQL was independently linked to overweight only in females. Similar results were obtained in model 4 which also included adjustments for diabetes, hypertension and coronary artery disease (Model 4). Adjustments for exercise behaviour or leisure time physical activity were used by other authors ,41,63; wThe link between obesity and lower physical functioning, role-physical and bodily pain scores was demonstrated in both sexes; in addition, obese female participants had lower social functioning and role-emotional scores. However, after adjustment for other variables  no association persisted between obesity and HRQL.There appeared to be no independent link between various aspects of physical and mental health and the high BMI values in obese individuals, with the exception of physical functioning, which remained related to BMI in both sexes after adjustment for age and education (model 2). However, in male participants this association disappeared after adjustment for lifestyle variables (model 3). The results, therefore, indicate that socio-demographic and lifestyle variables play a more important role in determination of HQRL scores than BMI value, which could be regarded as an intermediate variable.Although our results are compatible with those of similar research in other population groups/other countries, there are some limitations inherent in our methodology. Firstly, our study was cross-sectional; there was no follow-up of participants to show whether changes in body weight and health behaviour brought about a change of the perceived quality of life. In addition, we used a generic instrument to measure HRQL, not an obesity-specific questionnaire. Hence, we feel that it would be extremely useful to analyze the quality of life on a sample of obese subjects undergoing obesity treatment, compared to a general population sample, to include measurements of body weight and height, using both an SF-36 questionnaire and a specific Impact of Weight on Quality of Life scale. Our aim would be to determine the differences in the quality of life of the overweight and obese, with and without co-morbidities, and reassess and compare the self-reported and measured data. Such an analysis would probably make it possible to ascertain the subtle differences which contribute to a change in the perceived quality of life in individuals with increased body weight, and particularly in the obese.The SF-36 questionnaire can be used to in the assessment of physical and mental health in relation to perceived body weight in the urban population of Belgrade. The results of our study confirm that BMI values are associated with the quality of life in both males and females. Results of this type of research, conducted on population samples in diverse natural, social, economic and cultural environments, should be compared to identify the factors leading to increased body weight and obesity and, consequently, to the impairment of health-related quality of life.The authors declare that they have no competing interests.NV did the study concept and design. SR participated in data integration and data analysis accuracy. JM and NK were responsible for statistical analysis and data presentation. MM completed the interpretation of data. GSM carried out a critical revision of the manuscript for important intellectual content. JT was involved in administrative and technical support. All authors had full access to all data, read the manuscript and approved the final version.