Human-activity recognition (HAR) and energy-expenditure (EE) estimation are major functions in the mobile healthcare system. Both functions have been investigated for a long time; however, several challenges remain unsolved, such as the confusion between activities and the recognition of energy-consuming activities involving little or no movement. To solve these problems, we propose a novel approach using an accelerometer and electrocardiogram (ECG). First, we collected a database of six activities  of 13 voluntary participants. We compared the HAR performances of three models with respect to the input data type  parameters). The best recognition performance was 96.35%, which was obtained with some selected HRV parameters. EE was also estimated for different choices of the input data type (with or without HRV parameters) and the model type (single and activity-specific). The best estimation performance was found in the case of the activity-specific model with HRV parameters. Our findings indicate that the use of human physiological data, obtained by wearable sensors, has a significant impact on both HAR and EE estimation, which are crucial functions in the mobile healthcare system. As mobile healthcare systems have become widely used, users have begun to expect increasingly accurate performance with better appearance. The appearance of the mobile healthcare system relies highly on the development of sensing devices, either external or wearable. Due to many limitations of external sensing devices, wearable sensors have increasingly attracted the interest of both users and researchers. Recently, many wearable sensors have been developed for many applications, such as medical, sports, and commercial fields (see a recent review in ). For reTo guarantee the performance of the mobile healthcare system, two crucial functions are required: human-activity recognition (HAR) and energy-expenditure (EE) estimation. The former, which is also called the HAR problem, has attracted many researchers since the late ‘90s . WithThe most frequently used sensor in the mobile healthcare system is the tri-axial accelerometer. Single or multiple accelerometers are broadly used for the HAR problem and EE estimation. However, as mentioned in a recent review by Lara and Labrador , physiolBiomedical sensors for physiological signals have continuously developed. On the other hand, as reviewed by Liu and Liu, recent biomedical sensors have become wireless, portable, and wearable on the platform of mobile phone. Yet, the method of analyzing the collected physiological signals is still a challenge .Based on these considerations, we expect that such physiological signals may provide us with additional information for better recognition of human activities and prediction of EE, even for such cases. To the best of our knowledge, no study has been performed yet to solve these drawbacks for both issues (HAR and EE estimation) with an approach that exploits human physiological signals.In this study, we aim to recognize human ambulatory activities and estimate EE using our database composed of accelerometer and physiological signals, collected from 13 voluntarily participating subjects in a laboratory environment. To investigate the role of physiological signals in both issues, we compare the recognition and estimation performances with and without ECG data.The organization of the paper is as follows. We first give a brief review of some of the existing approaches for HAR and EE estimation using wearable sensors. Then, we introduce our database and the wearable sensors used in this study. Next, we describe our approaches and experimental results of HAR and EE estimation. Finally, we conclude this paper with a discussion.The HAR problem, especially for ambulatory activities, has been widely investigated with tri-axial accelerometers. The use of an accelerometer is accompanied by several issues, such as the number of sensors, attachment locations, and classification methods.First, in terms of sensor quantity and locations, Bao and Intille used five locations of accelerometers  with 84% recognition accuracy but reported high obtrusiveness . Khan etSecond, classification methods are diverse but almost always operate in a supervised fashion. For example, decision trees , supportIn this study, we aim to investigate the effect of a human physiological signal, specifically ECG signal, on HAR and EE estimation and propose a novel paradigm for the mobile healthcare system using wearable sensors. Only a few studies were found on the use of a physiological signal for an additional sensor. Tapia et al.  reportedThere are several existing methods to measure human physical activities: self-reporting, indirect calorimetry, double-labeled water (DLW), and portable monitors (such as ECG and accelerometers) . Among tBouten et al. used a tri-axial accelerometer to estimate EE for both sedentary  and walking (intensity varies from 3 to 7 km/h) activities with correlation coefficients of 0.82 and 0.96, respectively . Puyau eHowever, as reported in , acceler2) estimation models combining an accelerometer and HR monitor [Some researchers have already used additional physiological signals such as heart rate (HR) for more accurate estimation. Crouter et al. predicted EE using a heart-rate monitor with an accelerometer . Altini  monitor . Brage e monitor . Their rBased on these findings, we hypothesized that features extracted from ECG and accelerometer signals can be commonly used for both HAR and EE estimation, which enables to develop the integrated healthcare monitoring system with both functions. Therefore, we suggest a novel approach simultaneously taking HAR and EE estimation into considerations based on both accelerometer and ECG. 2 sensor and the gain of the O2 sensor to ensure the accuracy of the measurement. The flow/volume calibrations are performed by moving the piston in and out for 10 inspiratory and expiratory strokes using a 3-L calibration syringe. After the calibration procedures are complete, the software displays whether the results are within the acceptable range. If one or more values are outside of the acceptable range the calibration must be repeated. Shimmer3 is an accurate high-performance IMU that integrates 10-degree-of-freedom inertial sensing via accelerometer, gyroscope, magnetometer, and altimeter. The sampling rate is set to 128 Hz, which is high enough to capture the details of human daily movements. This sensor offers a strap and a snap clip, providing full mobility, unrestricted movement and comfort for a participant, even during dynamic activities such as running. T-Rex TR100A is a wearable ECG sensor with a disposable patch-type electrode. The sampling rate is set to 256 Hz. This sensor is light and provides comfort for a participant and a patch-type electrode offers good adhesion without the feeling of irritation. Moreover, it maintains stable mounting state when performing dynamic activities. In this study, we use heart-rate variabilities (HRV) calculated from raw signals obtained by the ECG sensor. We acquire 31 HRV parameters from raw ECG signals using Kubios HRV software [The wearable sensors used in this study are shown in software , which iThirteen subjects  were recruited for this study. Subjects were asked to fast and avoid caffeine-containing beverages and nicotine for 4 h prior to the experimental tasks. They were also asked to abstain from alcohol and vigorous exercise 24 h prior to each experiment . Each paThe experimental task was approved by the institutional review board at the Korea Institute of Science and Technology (2016-009).During the tasks, participants wore two IMU sensors on both of their arms, but only the data from each individual’s dominant arm were used for further analysis. Raw data from the dominant arm were segmented with a time window of 2 s without overlap. Then, four widely used time- and frequency-domain features were extracted for every time window: RMS, standard deviation, dominant frequency, and energy . The typp-value) of the training data. We used the Mann-Whitney U test, which is a nonparametric method for data whose probability distribution is not normal, frequently used to assess the differences in HRV parameters.As our first experiment, we examined the activity-recognition performance with respect to the input data compositions using support vector machines with a linear kernel (Linear SVM) and a radial basis function kernel (RBF SVM), k-nearest neighbors (kNN) and linear discriminant analysis (LDA). We set up three recognition scenarios to evaluate performance as follows and applied the four aforementioned classification methods to these scenarios: (1) IMU only: input data are composed of four time- and frequency-domain features extracted from the accelerometer data acquired from IMU sensors. (2) IMU + ECG: input data are composed of four features from IMU sensors (same as (1)) and 31 HRV parameters extracted from the ECG data. (3) IMU + selected ECG: input data are composed of four features from IMU sensors (same as (1)) and selected HRV parameters extracted from the ECG data. The selection criterion is based on the statistical significance  and kNN  for every scenario. Additionally, validation data were also used to find the optimal number of ECG features in the Scenario III. We used the LIBSVM toolbox for the classification  and MatlIn this recognition scenario, we used four-dimensional input data, and features were extracted from IMU data only. In this recognition scenario, we used four-dimensional input data from IMU data and additional 31-dimensional HRV parameters from ECG data. In other words, the input-data dimension in this scenario is 35. As a result, the recognition accuracy of linear SVM improves to 91.73%, while RBF SVM outperforms it with an accuracy of 92.31%. LDA has the largest improvement with the highest accuracy of 94.81%. kNN improves to 87.50% with an optimal k as 1. The result shows that all methods experience improvement, large or small, due to the additional data. Compared to the previous scenario, the confusion table shows that WK is no longer confused with AS with ECG data, but SI and ST are still confused with each other, although this is slightly improved see .We used a statistical test to select better ECG features to solve the drawbacks observed by previous scenarios. The Mann-Whitney U test was used for the evaluation of all univariate differences in HRV parameters between the SI and ST classes, and between the WK and AS classes. To observe the effect of feature selection, we drew two scatter plots before and after feature selection using training samples with their known labels. Samples before feature selection have 31 dimensions and thus cannot be drawn in 2-D or 3-D, so we apply principal component analysis to reduce their dimensions only for the purpose of drawing the plots. Samples after feature selection are represented by two-dimensional vectors because the highest validation accuracy is obtained when two ECG features are used. Specifically, selected features are exactly the same for every 13 folds, mean R-R interval (mRRI) and mean heart rate (mHR). The classification accuracies for all three scenarios are summarized in n, the estimated energy  of the i-th sample, k-th regression coefficient, k-th input feature of the i-th sample, and K-dimensional vector In the second experiment, we proposed a novel approach to estimate EE during six activities . As mentioned in Using this method, we set up four models to compare estimation performances from two perspectives: data and model types. Hereafter, we refer to them as (1) the single model with IMU data only (Model I), (2) the single model with both IMU and ECG data (Model II), (3) the activity-specific model with IMU data only (Model III), and (4) the activity-specific model with both IMU and ECG data (Model IV). For all models, anthropometric features (weight and height) and accelerometer features from IMU data  are commonly used for the initial regression variables. Model II and IV additionally use physiological features (31 HRV parameters).By comparison of the four models, we expected effects due to (1) the addition of physiological features in EE (data type) and (2) the methods of model construction . The effect of (1) can be seen by comparing Models I and II and comparing Models III and IV. The effect of (2) can be seen by comparing Models I and III and comparing Models II and IV.p-value < 0.05) in the regression model generated by training data. To evaluate each model’s estimation performance, we used the root-mean-square error (RMSE) between the EE values  predicted by a model and the values actually observed by the metabolic gas analysis system.Among multi-sensory features, the selection criterion of regression variables is based on the statistical significance  and model type consisted of two levels (single and activity-specific).First, we investigated the effect of data type on EE performance. The models without physiological features are Models I and III, while the models with additional physiological features are Models II and IV. As mentioned above, the initial features of Models I and III are two anthropometric features and four accelerometer features, and they are used to construct least-squares fits of their models to the training data. Models II and IV used additional physiological features from ECG data, i.e., a 37-dimensional feature vector in total, to construct a least-squares fit. The EE estimation performances of Models III and IV are described in p < 0.001, indicating a significant difference in RMSEs between the models with IMU only  and models with IMU + ECG . This result shows that the models with additional physiological features could significantly improve the estimation performance, relative to the models without physiological features.The main effect of data type yielded an F ratio of F = 38.69, Next, we compared two types of models in EE estimation. In Models I and III, one single model is generated by the training data for all six activities. In Models II and IV, unlike in the single model, we generated two regression models for each activity type: static and dynamic. Static activities include SI, ST and REST, while dynamic activities are WA, AS and RU.p < 0.005, indicating a significant difference in RMSEs between the single models  and the activity-specific models . This result shows that the activity-specific model could improve the estimation performance significantly, relative to the single model. The EE estimation performance of Models II and IV are described in The main effect of model type yielded an F ratio of F = 8.58, p-value = 0.90).We confirmed that both effects are statistically significant on the EE estimation performance. In other words, the addition of physiological features and the use of an activity-specific model have significant impacts on the performance improvement. By comparing these two effects, we can see that data type has a greater impact on the EE estimation performance than the effect of model type. However, there was no significant interaction effect between data and model types  and each activity (static and dynamic). Representatively, As mentioned earlier, HAR and EE estimation are important information provided by the mobile healthcare system. The HAR problem has been investigated for a long time by many researchers, and the reported performances of existing approaches seem to be sufficiently high, even for commercialization. The reason we tried to propose a novel approach for this widely known problem is that it is crucial to understand different characteristics of static and dynamic activities for accurate HAR and EE estimation in our daily lives. The accelerometer, as is also well known, has been a good tool for HAR and EE estimation, but we found significant drawbacks, such as the confusion of some activities (SI/ST and WK/AS) and in estimating energy expenditures for activities involving little or no movement (but obviously consuming energy). In this study, we found a significant role of human physiological signals  for both problems and an impact of the activity-specific model on EE estimation.Our findings show that selected ECG features indeed improved classification performance dramatically, especially for some labels that were confused when we used IMU features only. Moreover, the selected ECG features are the same for all 13 folds. In other words, the power of the selected ECG features is verified with different training data. Therefore, it is necessary to further consider the details of these two selected features: mRRI and mHR.p-value = 5.51 × 10−6). This means that the interval between R-R peaks is longer for a sitting activity than for a standing activity, and the longer RR interval indicates slower heartbeat due to that activity. We can observe a statistically significant difference in mRRI values between the WK and AS classes . In the same way, the ascending activity makes the heart beat faster than walking.By definition, mRRI is the average interval of two successive R peaks. Differences between the mRRI values for the SI and ST classes are shown to be statistically significant by the Mann-Whitney U test . Moreover, we can clearly interpret these trends with mHR, the mean heart rate. The mHR values also show such differences for both pairs of activity classes  ECG-only, and (5) selected ECG-only, and tested these scenarios with LDA which yielded the highest performance in previous scenarios. As a result, we obtained 68.65% (σ = 6.74) with scenario IV, and 69.04% (σ = 7.11). Specifically, predicted labels in scenario V showed that there is no misclassification at all between the SI and ST classes, and between the WK and AS classes, as we statistically investigated above. However, low classification performance of these new scenarios was due to the confusion between static activity classes (SI and ST) and WK classes.According to these findings, our physiological signals, especially some of HRV parameters associated with the information of the heartbeat, can help to recognize more accurately some activities for which movements are not easily recognizable with accelerometer signals only. In conclusion, the characteristics of the ECG and the IMU are complementary in terms of HAR, so that using these features together can improve performance than using each of them.p-value = 9.71 × 10−7, t = 5.83, for Model II; μ = 1.02, σ = 0.54, for Model IV; μ = 0.55, σ = 0.26). This result indicates that the proposed model has made a significant improvement in EE estimation for activities involving little or no physical movement, as expected.In EE estimation, we generated four models with respect to the data and model types. The effects of data and model types on EE estimation performance were statistically significant in terms of RMSE with reference data from the metabolic gas analysis system. Moreover, the effect of data type was greater than the effect of model type. However, the effect of model type was a dramatic improvement, in static activities specifically. Comparing the RMSEs for static and dynamic activities separately, the difference between Models II and IV was statistically significant for static activities only . Surprisingly, mHR, which had a great impact on activity recognition as well, was selected by all 13 folds. In other words, the additional information about heart rate is also useful in EE estimation. The crucial role of mHR in both problems means a lot in terms of system construction. By simply computing the average heart rate, we can improve EE estimation performance for static and dynamic activities that reflect daily life.We proposed a novel approach to recognize human ambulatory activities and estimate EE using our database composed of IMU and ECG signals, collected from 13 subjects. We have successfully demonstrated that using additional ECG signals, especially adding specific HRV parameters, has resulted in performance improvements for both issues. However, there is obvious limitation that our database has been collected under controlled laboratory environment with subject at specific ages. For broader application of the proposed system, it should be verified with different subject groups such as age, gender, race etc. Because the characteristic of physiological signals providing useful information on heart is highly dependent on these effects. Therefore, system performance may also be enhanced with more sample numbers of the same group with the testing subject.Considering daily life monitoring using our approach, our database may be limited to a few activities classes. However, we set up the models not for every single activity class but for each activity category (static or dynamic), even though there are other activities beyond six activity classes that we used, our system is expected to yield reasonable performance by applying either static or dynamic model. Moreover, to adapt continuously collected daily life data, system should be updated regularly with new training data. In other words, how to effectively process the vast amount of data and incorporate them into the system will be a new challenge. Future work can be done to address these issues with active learning or selective sampling to regularly update individual models.


Artemisia annua L. Artemisinin is a kind of effective antimalarial drug being extracted from A. annua. Because of artemisinin, Sweet wormwood herb earns a reputation. Based on the Pharmacopoeia of the People's Republic of China (PPRC), Sweet wormwood herb can be used to resolve summerheat-heat, and prevent malaria. Besides, it also has other medical efficacies. A. annua, a medicinal plant that is widely distributed in the world contains many kinds of chemical composition. Research has shown that compatibility of artemisinin, scopoletin, arteannuin B and arteannuic acid has antimalarial effect. Compatibility of scopoletin, arteannuin B and arteannuic acid is conducive to resolving summerheat-heat. Chemical constituents in A. annua vary significantly according to geographical locations. So, distribution of A. annua may play a key role in the characteristics of efficacy and chemical constituents of Sweet wormwood herb. It is of great significance to study this relationship.Daodi-herb is a part of Chinese culture, which has been naturally selected by traditional Chinese medicine clinical practice for many years. Sweet wormwood herb is a kind of Daodi-herb, and comes from A. annua that come from different provinces in china, and analyzed the relationship between chemical constituents and spatial distribution, in order to find out the relationship between efficacy, chemical constituents and distribution.We mainly analyzed the relationship between the chemical constituents  with special efficacy in A. annua plant samples. A global positioning system (GPS) was used for obtaining geographical coordinates of sampling sites. Chemical constituents in A. annua were determined by liquid chromatography tandem an atmospheric pressure ionization-electrospray mass spectrometry. Relationship between chemical constituents including proportions, correlation analysis (CoA), principal component analysis (PCA) and cluster analysis (ClA) was displayed through Excel and R software version2.3.2(R), while the one between efficacy, chemical constituents and spatial distribution was presented through ArcGIS10.0, Excel and R software.A field survey was carried out to collect p = 0), and a strong negative correlation with artemisinin content (p = 0). Scopoletin content presented a strong positive correlation with artemisinin content (p = 0), and a strong negative correlation with artemisinic acid content (p = 0). According to the results of PCA, the first two principal components accounted for 81.57% of the total accumulation contribution rate. The contribution of the first principal component is about 45.12%, manly including arteannuin B and artemisinic acid. The contribution of the second principal component is 36.45% of the total, manly including artemisinin and scopoletin. According to the ClA by using the principal component scores, 19 provinces could be divided into two groups. In terms of provinces in group one, the proportions of artemisinin are all higher than 80%. Based on the results of PCA, ClA, percentages and scatter plot analysis, chemical types are defined as "QHYS type", "INT type" and "QHS type."According to the results of CoA, arteannuin B content presented a strong positive correlation with artemisinic acid content (As a conclusion, this paper shows the relationship between efficacy, chemical constituents and distribution. Sweet wormwood herb with high arteannuin B and artemisinic acid content, mainly distributes in northern China. Sweet wormwood herb with high artemisinin and scopoletin content has the medical function of preventing malaria, which mainly distributes in southern China. In this paper, it is proved that Sweet wormwood Daodi herb growing in particular geographic regions, has more significant therapeutical effect and higher chemical constituents compared with other same kind of CMM. And also, it has proved the old saying in China that Sweet wormwood Daodi herb which has been used to resolve summerheat-heat and prevent malaria, which distributed in central China. But in modern time, Daodi Sweet wormwood herb mainly has been used to extract artemisinin and prevent malaria, so the Daod-region has transferred to the southern China. Pharmacopoeia of the People's Republic of China (PPRC),most kind of CMM has varieties of clinical efficacies, which is based on the chemical composition within the CMM. There is an obvious difference in the chemical composition of CMM in different areas. It is geographical locations of its growth that determines the different chemical composision of medicinal plants, hence presenting different efficacy.According to theory of traditional Chinese medicine, Daodi-herb acquires same unique characteristics, which hArtemisia annua L. Based on the PPRC, Sweet wormwood herb can be used to resolve summerheat-heat, prevent malaria, and relieve jaundices [As a kind of Daodi-herb, Sweet wormwood herb comes from the dried aerial parts of aundices . Since taundices . BecauseA. annua is a kind of medicinal plant that is widely distributed around the world and there are many kinds of chemical composition in it. Studies have shown that A. annua contains more than 100 types of chemical constituents [Plants within the same species show few differences in morphology, but they present significant variation in secondary metabolites based on their geographical locations. These variations are the result of genetic and environmental interaction, and a manifestation of biodiversity within a same plant species . A. annutituents , with a tituents .A. annua are widespread species, of which chemical constituents vary significantly according to geographical location. Studies have shown that A. annua is naturalized in many countries in Europe, northern Africa and North America [A. annua samples collected from different regions have been reported [A. annua may play a key role in the characteristics of its efficacy and chemical constituents. We therefore hope to study the relationship between those chemical constituents,  with special efficacy in A. annua growing in different provinces in china, and explore the relationship between chemical constituents and spatial distribution, in order to find out the relationship between efficacy, chemical constituents and distribution, and prove the unique characteristics of Daodi Sweet wormwood herb. America . Signifireported , 9. The A. annua plant samples, 250 sampling sites were selected in 19 provinces in China, and 5 aerial parts of A. annua plant samples were collected in each sampling site, which were then dried under natural conditions. A. annua is one of the widespread species, distributed widely in various ecological environments. From July 2011 to August 2011, a total of 1,250 A. annua plant samples were obtained in 19 provinces in China, plant samples were no specific permissions were required for these locations. A. annua plant samples were identified by Dong Zhang from Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences. Geographical coordinates of those sampling sites were obtained by global positioning system (GPS).A field survey was carried out to collect A. annua plant samples were determined by liquid chromatography tandem, an atmospheric pressure ionization-electro spray mass spectrometry. 5 μL of each sample was separated on an Agilent Zorbax SB-C18 column  with an isocratic system acetonitrile–0.3% acetic acid water . The column temperature was 35°C and the flow rate was 0.3 mL/min. The optimized MS conditions for MS detector were as follows: capillary voltage, 3500 V; fragmentor voltage, 70 V; drying gas flow rate, 9.0 L/min; nebulizer pressure, 35 psig; drying gas temperature, 350°C. The selected ion monitoring (SIM) scanning mode was employed for quantification in negative and positive mode simultaneously. The detected protonated molecular ions were set at m/z 283, 249, and 193 respectively for artemisinin, arteannuin B, and scopoletin. However, as for artemisinic acid, the detected deprotonated molecular ions were set at m/z 233.Chemical constituents in The relationship between chemical constituents , was analyzed through Excel and R, a sophisticated open-source software for managing statistical calculations. Methods include correlation analysis (CoA), principal component analysis (PCA) and cluster analysis (ClA). The relationship between efficacy, chemical constituents and spatial distribution was presented through ArcGIS10.0, Excel and R software based on the geographical coordinates of 250 sampling sites, principal component and cluster analysis results.p = 0), while there is a strong negative correlation between arteannuin B and artemisinin content (p = 0). Correlation analysis results also show that there is a strong positive correlation between scopoletin and artemisinin content (p = 0), while there is a strong negative correlation between scopoletin and artemisinic acid content (p = 0). A more complete description of the relationship among chemical constituents is shown in A. annua growing in the same region with higher artemisinin content has higher scopoletin content, while arteannuin B and artemisinic acid contents are lower.According to the results of correlation analysis, there is a strong positive correlation between arteannuin B and artemisinic acid content  with eigenvalue greater than one and cumulative contribution rate greater than 80%. The first two principal components accounted for 81.57% of the accumulation contribution rate. The contribution of the first PC is about 45.12%, and the eigenvalue is 1.3433839. The contribution of the second PC is 36.45%, while the eigenvalue is 1.2075314. These results indicate that most of the characteristics in the chemical composition of the four chemical components were reflected in the two PCs. The main characteristics of the four chemical components can be expressed using the following two models:The first model shows that the most influential variables on the variance of PC one were arteannuin B and artemisinic acid. Research has shown that compounds scopoletin, arteannuin B and arteannuic acid can be used to resolve summerheat-heat. Thus, the first PC can be applied as a measure to resolve summerheat-heat. It interpreted that Sweet wormwood herb’s summerheat-heat resolving efficacy is based on the first principal component, mainly due to arteannuin B and artemisinic acid.The second model shows that the most influential variables on the variance of PC one were artemisinin and scopoletin. Research has shown that both artemisinin and scopoletin can be used to treat malaria. Thus, the second PC can be used as a measure to prevent malaria. It interpreted that Sweet wormwood herb’s malaria preventing efficacy is based on the second principal component, mainly because of the artemisinin and scopoletin.A. annua plant samples collected from 19 provinces could be classified into two groups based on cluster analysis. Group one include samples collected from seven provinces and cities including Jiangxi, Hubei, Chongqing Guangxi, Guangdong and Guizhou provinces. Group two include 12 provinces including Jilin, Helongjiang, Shandong, Henan, Xinjiang, Shanxi, Inner Mongolia, Hebei, Qinghai, Gansu, Liaoning and Jiangsu. A more complete description of the clustering results among provinces is shown in The principal scores of the first two PCs were performed by standardized data, which is used to classify A. annua samples collected from 19 different provinces, Excel was used to show the percentage of each principal component. The percentage of each PC’s main chemical constituents is shown in A. annua varies widely in samples collected in different provinces. According to the results of cluster and percentage analysis, samples could be divided into three groups based on their geographical locations, which means that there may have three chemical constituent patterns in A. annua.In order to analyze the patterns of chemical constituent in Pattern one, the percentage of artemisinin and scopoletin in samples collected inseven provinces and cities including Jiangxi, Hubei, Chongqing Guangxi, Guangdong and Guizhou in group one are all greater than 80%, Pattern two, percentage of artemisinin and scopoletin in samples collected in six provinces in group two are all greater than 50% and less than 80%, including Jilin, Helongjiang, Shandong, Hebei, Liaoning and and Jiangsu. Pattern three, the percentage of artemisinin and scopoletin in samples collected in provinces in group two are all less than 50%, including Henan, Xinjiang, Shanxi, Inner Mongolia, Qinghai and Gansu.A. annua of this group was defined as "QHYS type", of which the arteannuin B content is particular higher. The sampling sites from provinces of pattern two mainly distributed near the origin of scatter plot, with similar scores in both PCs. Chemical type in A. annua of this group was defined as "INT type", of which the artemisinin and arteannuin B contents are closer. The sampling sites from provinces of pattern three mainly distributed along the y-axis. The chemical type in A. annua of this group was defined as "QHS type", of which the artemisinin content is particular higher.A scatter plot obtained by the first and second PC's scores using Excel, based on the 250 sampling sites from 19 provinces is shown in According to the results of correlation analysis, there is a strong correlation of chemical constituent with its distribution and ecological environment factors. A more complete description of the relationship is shown in p = 0), and artemisinic acid content (p = 0), while there is a strong negative correlation between latitude, scopoletin content (p = 0), and artemisinin content (p = 0). The result of correlation analysis also shows that there is a strong negative correlation between altitude, arteannuin B content (p = 0), artemisinic acid content (p = 0), and scopoletin content (p = 0). Arteannuin B and artemisinic acid in the first PC presented a strong negative correlation with rainfall, temperature and altitude (p = 0). Scopoletin and artemisinin in the second PC, presented a strong positive correlation with rainfall, temperature and humidity (p = 0).According to It can be interpreted that Sweet wormwood herb with excellent quality using to resolve summerheat-heat contents higher arteannuin B and artemisinic acid s, which mainly distributed in northern China, at temperate zones with lower altitudes. The Sweet wormwood herb with excellent quality using for preventing malaria has higher content of scopoletin and artemisinin, which mainly distributed in southern China, at subtropical zone with lower altitudes. A summary of the relationship between chemical constituents, efficacy and the distribution of Sweet wormwood herb is shown in Collection of the Medical Records of the Palace of the Qing Dynasty, Daodi Sweet wormwood herb  were obtained mainly from ancient Jingzhou (now the areas around Hubei province) [A. annua covered in all the three chemical types can be found in these areas. The Sweet wormwood herb produced at these regions has been used to resolve summerheat-heat and cure malaria in ancient China. But in modern time, much more attentions are paid in efficacy of preventing malaria; thus Sweet wormwood herb are mainly used to extract artemisinin to treat malaria. Sweet wormwood herb with higher content of artemisinin is Daodi-herb. According to the previous studies and this paper, artemisinin content in Sweet wormwood herb growing in Chongqning, Guangxi and other southern provinces or cities is higher. So, the Daodi-region  of Sweet wormwood herb has transferred to Chonqning, Guangxi and other southern provinces.According to the records from the rovince) . AccordiA. annua is usually in the fall when flowers are in full bloom. Studies have indicated that arteannuin B and artemisinic acid are probable biochemical precursors to artemisinin [A. annua in northern China, large amounts of arteannuin B and artemisinic acid remain unconverted to artemisinin at the end of the summer, compared to the plants in the south that have higher content of artemisinin. In fact, it has been reported that if the growth period of A. annua in Heilongjiang province (at the extreme northeast of China) is extended, the content of artemisinin will increase [A. annua from southern China could be used to resolve summerheat-heat, and arteannuin B could be extracted from the plant, through the harvest of A. annua earlier in the summer.The harvest time period for emisinin . Becauseincrease . It is sA. annua plays a key role in displaying characteristics of chemical constituents. In the same region, there are some A. annua has higher proportion of artemisinin and scopoletin, and lower arteannuin B and artemisinic acid contents, while there are others with higher arteannuin B and artemisinic acid content and lower artemisinin and scopoletin content. Thus, the first PC, distributing in northern China, can be used as a measure of resolving summerheat-heat. Such a medical efficacy is determined by the first principal component, mainly due to arteannuin B and artemisinic acid. The second PC, distributing in southern China, can be used as a measure to prevent malaria, which is determined by the second principal component, mainly because of artemisinin and scopoletin. This paper also proved the Chinese ancients saying that Daodi Sweet wormwood herb has been used to resolve summerheat-heat and preventing malaria, which was distribute in central China. But in modern time, the Daodi-region of Sweet wormwood herb has transferred to chongqing, guangxi and other southern provinces.In conclusion, this paper shows the relationship between distribution, efficacy and chemical constituents. The distribution of S1 File(XLS)Click here for additional data file.


Toxics Travel Award. It was not an easy task to select the top candidate. Nevertheless, with the assistance of our editorial board members, we have identified one outstanding candidate. Thus, as Editor-in-Chief of Toxics, I am pleased to announce the winner of the Toxics Travel Award for 2018 was granted to Dr. Joaquim Rovira, a post-doctoral researcher in Dr. Marta Schuhmacher’s lab at Rovira i Virgili University, Spain  28th annual meeting conference held in Rome between 13 and 17 May 2018.Born on 28 November 1981 in Reus, Spain, Joaquim Rovira is a graduate in Chemistry and Biochemistry , and obtained his PhD degree on March 2013.His thesis was entitled “Impact on human health of the use of alternative fuels in cement factories”. Currently, he is a post-doctoral researcher in the Environmental, Food, and Toxicological Technology Centre (TecnATox) at “Pere Virgili” Institute of Health Research (IISPV) and “Rovira i Virgili” University (URV), both located in Spain, in the laboratory of Prof. Marta Schuhmacher. Dr Rovira’s main areas of research are: Environmental and human (bio)monitoring of heavy metals, persistent organic pollutants (POPs) and endocrine disruptors; exposure and human health risk assessment; and optimization of monitoring methods through active and passive sampling of atmospheric contaminants . He has co-authored 26 papers in international peer-reviewed journals, and four book chapters and is supervising two pre-doctoral theses. He has been involved in several national and European projects: SCARCE, RISKCYCLE, TDS-Exposure, HBM4EU and HEALS. Currently, Dr Rovira is involved in several research projects one of them regarding prenatal exposure to endocrine disruptors in a cohort of pregnant women in a reference hospital in the region. Thanks to the Toxics Travel Award. Toxics is proud to support Dr. Joaquim Rovira working in the field of toxicology and wish him further success in his career. We are grateful to all who submitted applications—thank you for letting us get to know you and your work. The future of toxicology looks very bright indeed. Finally, we are grateful to MDPI for their generous support of young scholars, helping them to share their work on the international stage.The editors, managing editor and editorial board members join me in congratulating Dr. Joaquim Rovira on winning 2018


Chronological age is not a good indicator of how each individual ages and thus how to maintain good health. Due to the long lifespan in humans and the consequent difficulty of carrying out longitudinal studies, finding valid biomarkers of the biological age has been a challenge both for research and clinical studies. The aim was to identify and validate several immune cell function parameters as markers of biological age. Adult, mature, elderly and long-lived human volunteers were used. The chemotaxis, phagocytosis, natural killer activity and lymphoproliferation in neutrophils and lymphocytes of peripheral blood were analyzed. The same functions were measured in peritoneal immune cells from mice, at the corresponding ages  in a longitudinal study. The results showed that the evolution of these functions was similar in humans and mice, with a decrease in old subjects. However, the long-lived individuals maintained values similar to those in adults. In addition, the values of these functions in adult prematurely aging mice were similar to those in chronologically old animals, and they died before their non-prematurely aging mice counterparts. Thus, the parameters studied are good markers of the rate of aging, allowing the determination of biological age. The chronological age, defined as the time elapsed since birth, fails to be an accurate indicator of the rate of the aging process , which sMost work on biological age has not included parameters of the immune system, which is a homeo-static system that contributes to the appropriate function of the organism. It is well known that with aging there is an increased susceptibility to infectious diseases, autoimmune processes and cancer, which indicates the presence of a less competent immune system, exerting a great influence on age-related morbidity and mortality , 14. SinIn order to validate a potential set of parameters as markers of biological age, it is necessary to confirm that the levels shown in particular subjects reveal their real health and senescent conditions and consequently, their rate of aging. This has to be demonstrated by meeting two requirements. The first is that if an adult individual shows values characteristic of a chronologically old individual, he/she should die prematurely. The second is that a long-lived individual, known to have experienced healthy aging, should have a value of these biomarkers similar to that of an adult . The firphagocytes, their ability to migrate towards the focus of infection (chemotaxis) and their capacity to ingest foreign particles (phagocytosis); in natural killer (NK) cells, their capacity to destroy tumor cells and in lymphocytes, their ability to migrate towards the site of antigen recognition (chemotaxis) and to proliferate in response to mitogens (lympho-proliferation).Among all the possible functions of immune cells, we have focused on the ones that are the most relevant in the immune response and are known to experience an age-related decrease . In phagThus, in order to validate the above mentioned immune functions as markers of biological age and predictors of longevity, these functions were studied in leukocytes isolated from peripheral blood of human subjects in a cross-sectional study, from their 30s until their 100s. In addition, the same functions were analyzed in leukocytes obtained from peritoneum of mice without killing them, enabling a longitudinal study to be performed, starting at the adult age and following each animal until its death. The same functional parameters were also assessed in peritoneal leukocytes from adult PAM and NPAM.In this study, in order to identify and validate several functions of immune cells as markers of biological age and predictors of longevity, their age-related changes were measured in leukocytes from both humans and mice.P<0.001) in old individuals in comparison to those in adults. These lower values were also shown in mature subjects . In addition, to further explore the relationship between the age and the immune parameters analyzed, Pearson's correlations were carried out (Table P<0.001) between the age of the subjects and the values of all the immune functions evaluated.The results obtained in the functions studied in isolated human blood neutrophils (chemotaxis and phagocytic capacities) and mononuclear cells, principally lymphocytes and NK cells (the anti-tumor cytotoxic activity of NK cells as well as the chemotaxis and proliferative response of lymphocytes to mitogens), obtained from adult, mature, old and long-lived subjects are shown in Fig. P<0.001) in the values of all the functions studied at old age with respect to those when they were adults. This decrease was also appreciated at mature age . Therefore, the results revealed that these immune functions of murine peritoneal leukocytes present a similar age-related evolution to those in human blood immune cells.In peritoneal leukocytes from mice these immune functions, analyzed at the corresponding ages to humans, but in a longitudinal study, changed in a similar manner Fig.. Thus, tP<0.05 in neutrophil chemotaxis and lymphoproliferation; P<0.001 in neutrophil phago-cytosis, NK activity and lymphocyte chemotaxis).Considering the state of these functions in subjects which reach a high longevity, and consequently have attained successful aging, both humans and mice showed in general, more similar values to those observed at adult age than to those at old age, primarily in mice Fig. . Thus, hP<0.001) but lower neutrophil chemotaxis (P<0.001), NK activity and lympho-proliferation (P<0.05), whereas no statistically significant differences were found between centenarians and adults in lymphocyte chemotaxis. Long-lived mice also showed a significant increase in all the functions analyzed with respect to when they were old . No statistically significant differences were found in mice between when they are adult and long-lived in macrophage chemotaxis and phagocytosis, NK activity and lymphocyte chemotaxis, whereas long-lived mice showed a decrease in lymphoproliferation (P<0.05) with respect to the adult age.Comparing to adults, human centenarians showed a higher phagocytosis (P<0.001) in relation to their adult NPAM counterparts  in chemotaxis of macrophages, NK activity and lympho-proliferation, as well as in phagocytosis (P<0.01). The values in PAM were similar to those observed in chronologically old mice. Moreover, PAM exhibited a shorter life span (P<0.01) than NPAM , which are expected to have withstood the detrimental effects of the aging process better than those individuals who do not live to extreme old age. In addition, mice, which at the adult age already have similar immune function values to those of chronologically old animals, achieve a shorter lifespan. Although this second aspect has not been addressed in humans, since the age-related evolution of these immune functions is similar in both mice and humans, it can be assumed that those humans showing immune parameters at the levels of older subjects have a higher biological age and consequently they will not live so long. In fact, the present study reveals that there is an age-related decline in the immune function parameters analyzed in both human blood neutrophils and lymphocytes, as well as in peritoneal macrophages and lymphocytes from mice, with the lowest values in elderly humans (65-79 years of age) and old mice (72 weeks of age). This age-related decline was further supported by the strong negative correlation coefficients obtained in humans.Recent studies have suggested that a big cohort of parameters is needed in order to accurately estimate the biological age . The preA total of 140 human volunteers  between 30-103 years old were studied and divided into four different experimental groups: adult , mature , old  and long-lived subjects . All the participants are members of the Spanish population. The inclusion criteria were that the subject should be in a healthy condition . All participants have given written consent for the use of their blood samples for the purposes of this study. All procedures were carried out according to the Declaration of Helsinki.Mus musculus) were used in this study. Animals were purchased from Janvier Labs (Germany) at the adult age (32±4 weeks), and were placed and acclimatized in the Animal Facility at the Faculty of Biology (UCM). Mice were housed at 4-5 per cage and maintained in standard laboratory animal conditions for pathogens, temperature (22±2°C) and humidity (50-60%), on a 12/12 h reversed light/dark cycle (lights on at 20:00 h) to avoid circadian interferences. Mice had access to tap water and standard pellets  ad libitum. One group of animals (n=40) was used for the longitudinal study. The collection of peritoneal suspensions was at the adult , mature , old  and long-lived  ages. Another group of animals were classified as prematurely aging mice (PAM) (n=10) and non-prematurely aging mice (NPAM) (n=10) according to their different behavior in a T-maze, as previously described [Female ICR/CD1 ex-reproductive mice , one group of adult female ICR/CD1 mice (33±4 weeks) were classified as PAM and NPAM according to their different behavior in a T-maze, as previously described , 24. ThiPeripheral blood samples (10 mL) were collected using vein puncture and sodium citrate-buffered Vacutainer tubes , between 9:00 to 10:00 a.m. to avoid circadian variations in immune para-meters. Neutrophils and lymphocytes cells were isolated from whole blood following a previously described method , using 1in vivo situation. The peritoneal suspensions were adjusted to a specific number of macrophages, lymphocytes or total leukocytes, depending on the parameter analyzed as described in the corresponding section.Murine peritoneal suspensions were collected between 8.00 am and 10.00 a.m., to minimize circadian variations of the immune parameters studied. The use of peritoneal cell sample has the main advantage of not having to sacrifice the animals. Without using anesthesia, mice were held by cervical skin, the abdomen was cleansed with 70% ethanol (Sigma-Aldrich), and 2 ml of sterile Hank's solution, previously tempered at 37°C, was injected into the peritoneum . After m−8 M, Sigma-Aldrich), deposited in the lower compartment of the chamber, was counted in the lower face of the filter that separates the two compartments of the chamber. This number was expressed as Chemotaxis Index.The induced mobility or chemotaxis of neutrophils, macrophages and lymphocytes was evaluated according to the method previously described , 40. CelPhagocytosis of inert particles  was assayed in phagocytes (neutrophils and macrophages) following a method previously described , 40. CelThe natural killer (NK) cell cytotoxicity was evaluated following an enzymatic colorimetric assay  based on the determination of lactate dehydrogenase (LDH) released by the cytolysis of targets cells (human K562 lymphoma cells or murine YAC-1 lymphoma cells), using tetrazolium salts , 40. The2, 2.5 μCi 3H-thymidine  were added to each well, followed by another incubation of 24 h. Cells were harvested in a semiautomatic harvester  and thymidine uptake was measured in a beta counter  for 1 min. The results were calculated as 3H-thymidine uptake  for basal and stimulated conditions, and were expressed as lymphoproliferation capacity (%) giving 100% to the cpm in basal conditions.The proliferation capacity of lymphocytes was evaluated by a standard method, previously described , 40. ThePearson correlation coefficient was used to test for correlation between parameters. Two-sided P<0.05 was considered the minimum level of significance. Differences in life span were studied through the Kaplan-Meier test, with a minimum significance level  also set at P<0.05.SPSS 21.0  was used for the statistical analysis of the results. All data are expressed as the mean ± standard deviation (SD) of the values corresponding to subjects, being each value the mean of duplicate assays. The normality of the samples and the homogeneity of variances were checked by the Kolmogorov–Smirnov and Levene analyses, respectively. Differences due to age were studied through Student's t test for independent samples. The


Background: Adherence to a Mediterranean diet seems to be inversely associated with C-reactive protein (CRP) concentration. A 14-point Mediterranean Diet Adherence Screener (MEDAS) has been developed to assess dietary compliance. Objective: The aim of this study was to assess whether each of the MEDAS questions as well as their final score were associated with the levels of CRP in general Spanish population. Methods: Cross-sectional analysis of 1411 subjects  randomly selected from the general population. CRP levels were determined by a commercial ELISA kit. Adherence to the Mediterranean diet was measured by the 14-point MEDAS. Results: There was an inverse correlation between adherence to the Mediterranean diet and the CRP concentration, even after adjusting by age, gender, hypertension, metabolic syndrome, body mass index, statin treatment and hypertension treatment (p = 0.041). Subjects who consume ≥2 servings of vegetables per day (p = 0.003), ≥3 pieces of fruit per day (p = 0.003), ≥1 serving of butter, margarine, or cream per day (p = 0.041) or ≥3 servings of fish/seafood per week (p = 0.058) had significantly lower levels of CRP. Conclusions: Adherence to a Mediterranean-type diet measured by a simple questionnaire is associated with lower CRP concentration. However, this association seems to be particularly related to a higher consumption of vegetables, fruits, dairy products, and fish. Low-grade systemic inflammation seems to play a role in the development of obesity, metabolic syndrome, diabetes, and cardiovascular disease . C-reactSeveral factors influence CRP levels. Its concentration is increased in smokers and diabetics, and correlates directly with age, body mass index, triglycerides, blood pressure and inversely with exercise frequency and high-density lipoprotein (HDL)-cholesterol . Diet alThe association between adherence to a Mediterranean diet and levels of CRP, as a marker of subclinical inflammation, has been previously investigated ,9,10,11.On the other hand, there is numerous evidence reporting the association between lower CRP plasma levels and intake patterns characterized by a high consumption of vegetables and fruits in both adults and children ,15,16. WThus, the aim of this study was to assess whether each of the MEDAS questions as well as their final score were associated with the levels of CRP in a Spanish general population.This is a substudy of a broader project, the Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study, which has been described in detail elsewhere ,19. The Participants were scheduled in the outpatient clinic of the Hospital Carlos III after an overnight fast. Upon arrival, and after signing a consent form, a fasting blood analysis was obtained for measuring the blood levels of glucose, creatinine, and lipids and lipoproteins. Sociodemographic variables , family history of prevalent diseases , self-reported cardiovascular risk factors , comorbidities, and current treatments, were recorded in all individuals. Patients were considered current smokers if they had regularly smoked during the past 6 months.All participants had a physical examination with the determination of height, weight, waist circumference (midway between the lowest rib and the iliac crest), and blood pressure (the mean of the last 2 measurements after 3 determinations 5 min apart). Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters.Glucose, creatinine, cholesterol, and triglycerides were determined by standard methods. CRP levels were determined by a commercial ELISA kit .Baseline adherence to the Mediterranean diet was measured by the 14-point Mediterranean Diet Adherence Screener (MEDAS) developed and validated by the PREDIMED study . The MEDp < 0.10 . To study the independent association of each of the questions included in the 14-points MEDAS with CRP concentration, a logistic regression analysis was used adjusting for the same variables. The statistical significance threshold was established at p < 0.05. Statistical processing of the data was performed with SPSS for Windows, v.19.0; IBM Corp, Armonk, NY, USA.The normality of distribution of variables was determined with the Kolmogorov-Smirnov test. Since the CRP does not have a normal distribution, a logarithmic transformation was made for the statistical calculations, but to gain clarity, the CRP values are expressed in the text and in the tables as they were before the transformation. Quantitative variables are shown as means ± SD. Qualitative variables are shown as percentages. Comparisons between quantitative variables were performed with one-way analysis of variance (ANOVA) test, and comparisons between qualitative variables with the χ2 test. Multiple linear regression was used to evaluate the association between MEDAS score and CRP concentration after adjusting by age, gender, and those variables that in the univariate analysis showed significance levels of All subjects gave written informed consent, and the study was approved by the Committee on Ethics and Research of the Hospital Carlos III (code P18/10) in Madrid. The study complied with the International Guidelines for Ethical Review of Epidemiological Studies .Baseline characteristics of the population and by tertiles of CRP concentration are shown in p < 0.001) and inversely correlated with statin treatment (p = 0.004) (p = 0.019) even after adjusting by age, gender, hypertension, metabolic syndrome, body mass index, statins treatment and hypertension treatment ), p = 0.042)  . There w= 0.042) .p = 0.058).C-reactive protein levels depending on the answer to each point of the 14-point MEDAS are shown in In our population-based sample, including subjects between 45 and 74 years, adherence to a Mediterranean-type diet, determined by a simple questionnaire of 14 questions, was inversely related to CRP levels. These lower levels of CRP were associated with a greater consumption of some typical components of Mediterranean diet  and dairy products.Dietary patterns may influence the risk of diseases through the effects of CRP, a marker of subclinical inflammation and predictor of cardiovascular disease . SeveralIn the present study, subjects who consumed ≥2 servings of vegetables per day had lower CRP levels, even after adjusting for different covariates. The association between a higher intake of fruit and vegetables and lower CRP levels appears to be consistent in both adults and children ,15,16,17Fish consumption is a common component of the Mediterranean diet. In our population, the consume ≥3 servings of fish/seafood per week was associated with lower CRP levels. Fish intake is the main dietary source of omega-3 fatty acids. Some studies have associated omega-3 intake with a reduction in plasma biomarkers of inflammation such as CRP ,21. DietThe effect of dairy products on inflammatory markers is inconclusive. In fact, it has been reported that dairy products can have a beneficial, neutral, or harmful effect on inflammation . We founWe have not found association between CRP levels and the consumption of nuts or olive oil, two important components of the Mediterranean diet. Although a PREDIMED substudy did not find a relationship between CRP concentration and the consumption of olive oil , a recenOur study has several limitations. First, the study was cross-sectional designed and may therefore be susceptible to reverse causality. Second, defining a dietary pattern with a questionnaire including only 14 questions can be inaccurate. Third, the answers of the participants may not be related to their actual intake. Another possible limitation was the lack of information on consumption of antioxidant supplements in our population that could be a potential confounder in the association of the MEDAs with the CRP concentrations. Finally, CRP is only a surrogate marker of inflammation sometimes used as a predictor of cardiovascular risk. Nevertheless, our study has the strength of including a large sample size from a homogeneous population representative of the general population.Therefore, adherence to a Mediterranean-type diet measured by a simple questionnaire of 14 questions is associated with a decrease in the CRP concentration, even after adjusting by confounders. Some components of this Mediterranean-type diet  seem to be responsible for this association.


Multivariate Cox proportional hazard model analysis showed that type of work, cigarette smoking, excess body weight, and obesity were risk factors for hypertension (p < 0.05). After risk factors such as type of work, cigarette smoking, alcohol consumption, and body mass index (BMI) were controlled, the hypertension risk  in the high occupational stress group was 1.549 (1.072–2.236) compared to the low exposure group, and 2.337 (1.191–4.585) in female subjects. Our study indicated that an increase in occupational stress was associated with an increased risk of hypertension after other factors were adjusted.The purpose of this study was to assess the major risk factors for hypertension in oil workers, and investigate the effect of occupational stress on the incidence of hypertension after controlling for other risk factors. A prospective cohort approach was used following enrollment of 1354 oil workers. The occupational stress experienced by oil workers was higher than for the general population in China. By the end of the cohort study, 231 new cases of hypertension among the oil workers had been diagnosed. The cumulative incidence of hypertension was 17.06%. There were 44, 112, and 75 workers who developed hypertension in the low, intermediate, and high occupational stress groups, which represented a 12.0%, 15.6%, and 20.3% cumulative incidence, respectively (chi-square value = 9.812,  Hypertension is a major global health issue due to its magnitude and associated risks, difficulty of control, high medical and social costs, and the fact that it causes severe cardiovascular and renal complications . In 2010In recent years, agricultural and industrial advances have impacted lifestyle and social interaction, leading to greater psychological pressure. Epidemiologic studies have shown the workplace to be a high-pressure environment. The imbalance between work demand and work control in modern society is considered to be an important risk factor for hypertension in men  and womeOccupational stress combined with other risk factors is associated with a higher incidence of hypertension compared to occupational stress alone . FurtherPrevious studies often applied a cross-sectional approach and short-term follow-up to explore the relationship between occupational stress and blood pressure. In China, relevant studies have only recently been completed and cross-sectional studies have been limited. In addition, the cultural background, labor organization, and sources of stress in China differ from other countries. Therefore, the role of occupational stress in hypertension amongst the Chinese working population warrants more specific studies. The objective of this study was to investigate the correlation between occupational stress and hypertension in oil workers in Kelamayi City through a prospective cohort study.Chinese Hypertension Prevention and Treatment Guides: Version 2004 [This prospective cohort study enrolled oil workers from seven oil companies in Kelamayi City. The data were collected at two time points (baseline (2013–2014) with a follow-up period of two years (2014–2016). Baseline data included blood pressure , and a questionnaire assessing occupational stress state and hypertension risk factors was completed by the subjects. The inclusion criteria were as follows: (1) oil workers from one of the seven companies who had physical examinations in the hospital between 2013 and 2014 and completed the occupational stress questionnaire; and (2) voluntary consent to participate in the study after being informed of the objective and significance of the study (informed consent). The exclusion criteria were as follows: (1) previous diagnosis of hypertension; (2) family history of hypertension; (3) rejection of follow-up; and (4) incomplete relevant information and data. The diagnostic criteria of new hypertension cases were based on the ion 2004 . New hypThe OSI-R Scale  was used to evaluate the occupational stress of study participants. The scale was originally developed by Osipow in 1981  and reviOSI-R is a multiple-dimension scale. Each item has five Likert-type scales . The raw scores range from 1–5. The higher the score of the ORQ and PSQ, the higher the occupational stress and psychological strain; the higher the score of the PRQ, the higher the capacity of the subject to cope with stress. For ORQ and PSQ scales, higher scores are associated with a high level of occupational stress. Grouping methods used to divide participants into low, intermediate, and high levels were set according to the corresponding references . SpecifiChina Chronic Disease Surveillance Project [Blood pressure was measured by a physician using an electronic blood pressure monitor. Before measurement, the subjects were asked to remain seated for at least 15 min. The right upper arm SBP and DBP were measured twice for each subject. There was a 2-min interval between the two measurements, and the final blood pressure was the average value of the two measurements. If the blood pressure was ≥140/90 mmHg, the subject was asked to rest for 15 min, BP was retaken twice, and the average of the two measurements was the final result. The above measurement method was performed according to the  Project , publishChinese Adult Overweight and Obesity Prevention and Control Guideline [2 was considered as “normal weight”, BMI ≥ 24 kg/m2 as “overweight” and BMI ≥ 28 kg/m2 as “obesity”. In addition, some key demographic characteristics, such as age, gender, ethnicity, educational level, number of years worked, marital status, income, and work shift, were also included. In the current study, these factors were considered to be confounding factors and controlled in the analysis.Cigarette smoking, alcohol consumption, body mass index (BMI), salt intake, and a sedentary lifestyle are considered to be risk factors for hypertension. Smoking status was categorized as follows: non-smoker; previous smoker ; and current smoker (at least 1 cigarette per day for >1 year). Alcohol consumption status was categorized as follows: none; occasional; and regular consumption (at least twice per week for >1 year). Physical exercise status was categorized as follows: none; occasional; and regular (≥3 times per week for ≥30 min each session). BMI was categorized as follows, according to the criteria of the uideline : BMI < 2t-test. ANOVA was used for comparison of the means of multiple groups. If the overall difference was significant, then a least significant difference t-test was used for pairwise comparisons. Count data are presented as a percentage (n %). A Chi-square test was used for inter-group comparisons and the effect of occupational stress on the risk of hypertension was analyzed using a multivariate Cox proportional hazards regression model. The significance level (α) was set at 0.05. The data were analyzed using SPSS 17.0 .Numeric data with a normal distribution were presented as the mean ± standard deviation. Comparison of the means of two groups was performed using an independent sample The general demographic characteristics of the subjects are shown in p < 0.05; The results demonstrated that the occupational role, personal strain and personal resource scores of oil workers were significantly higher than the Chinese norm . Moreover, there were significant differences in gender, cigarette smoking history, alcohol consumption history, and BMI between the hypertensive and non-hypertensive groups (p < 0.05). With respect to type of work, no significant difference was observed between the two groups with respect to work shift or physical exercise , there were 231 (17.06%) new cases of hypertension in 1354 follow-up subjects. The number of isolated systolic hypertension, isolated diastolic hypertension, and systolic-diastolic hypertension cases was 21, 113 and 97, respectively . The agep < 0.05). With respect to personal resources, there was no significant difference between the two groups . Model 2 is a multivariate model that was constructed by adjusting the factors that may be related to the risk for hypertension (confounding factors). The HR in the high occupational stress group was 1.549 . The risk for hypertension in the subjects with high occupational stress was 1.549-fold greater than subjects with low occupational stress (p < 0.05), the HR in the high occupational stress group was 2.337 (1.191–4.585) in model 2 , with genetic factors as well as the interaction between genetic factors and the environment not covered. Furthermore, occupational stress is a form of chronic psychological stress, promoting constant stimulation of the hypothalamus-pituitary-adrenal (HPA) axis leading to accelerated secretion of adrenaline, norepinephrine and other substances. These substances can increase blood pressure, heart and respiratory rate, and when secreted and accumulated in an abnormal manner this can lead to metabolic disorders.Important advantages of this study include the following: (1) The subjects were oil workers in a special work environment, and the sample size was large; (2) Preliminary studies provided reliable supporting data for the present study; (3) In addition to occupational stress, the current study also investigated other lifestyle factors that may affect the incidence of hypertension. By controlling other confounding factors, the study clarified the relationship between occupational stress and hypertension.The correlation between occupational stress and the pathogenesis of hypertension revealed in this study may have an important impact on the health of the population. At the population level, a decrease of 2 mmHg from the average SBP reduces the number of deaths due to stroke and cardiovascular diseases by approximately 10% and 7%, respectively . TherefoLifestyle behaviors  and occupational stress  are major risk factors for hypertension in oil workers. After controlling for other factors except occupational stress, our results suggest that an increased level of occupational stress could increase the risk of hypertension. Occupational stress may be an independent risk factor for hypertension in oil workers; however, this conclusion needs to be verified by further large-size samples and longer follow-up studies.


Background. Aim was to investigate whether the degree of patient activation of patients with type 2 diabetes (T2D) is different between men and women. Furthermore, we investigated which factors are associated with patient activation in men and women. Methods. This cross-sectional study included 1615 patients with T2D from general practices. Patient activation was measured with the Patient Activation Measure (PAM) questionnaire. Multivariate linear regression analyses were used to investigate the association between gender and patient activation. Stratified analyses according to gender were performed to investigate which factors are associated with patient activation. Results. No association between gender and PAM score was found after adjustment for all selected confounders (p = 0.094). In men, lower age (p = 0.001), a higher WHO-5 score (p < 0.001), and a lower BMI (p = 0.013) were associated with a higher PAM score. In women, a higher WHO-5 score (p < 0.017) and the absence of macrovascular complications (p < 0.031) were associated with a higher PAM score. Conclusion. There is no difference in the degree of patient activation of men and women with T2D. Age, well-being, and BMI were found to be associated with patient activation in men, whereas well-being and macrovascular complications were found to be associated with patient activation in women. Patient participation is essential to achieve and maintain good overall and diabetes control. The Association of American Diabetes Educators (AADE) has defined 7 self-care behaviours, which are essential for successful and effective diabetes self-management. These are healthy eating, being active, taking medication, monitoring, problem solving, healthy coping, and reducing risks of diabetes-related complications .Not all subjects with type 2 diabetes (T2D) are equally capable of performing these self-care tasks as performing these tasks requires knowledge, discipline, and perseverance. To measure someone's ability to take control of his or her own health, Hibbard et al. developed the Patient Activation Measure (PAM) questionnaire . They haA lower PAM level could possibly lead to poorer health outcomes, as studies have shown that a lower PAM level is associated with poorer HbA1c control, fewer feet checks and eye examinations, lower rates of regular physical exercise, and more use of hospital resources –6.Studies concerning differences in patient activation between men and women with chronic diseases show contradictory results –10. Two The study population consisted of patients with T2D who were treated in primary care in three regions in the eastern part of the Netherlands. These patients were approached for a quality assessment concerning patient satisfaction performed by Medrie, an organization which facilitates and supports general practitioners (GPs). All patients were asked by their care provider to fill out a survey including questionnaires on quality of life, level of patient activation, and experience with the received care. Patients were included in the period from July 2014 until April 2015. A total of 5925 sets of questionnaires were sent to all general practices in the regions together. All general practices were asked to invite patients with T2D to fill out these questionnaires. Finally, 2319 patients with T2DM gave written informed consent. The other patients refused participation or the GPs did not include the requested number of patients. The final study sample consisted of 1688 (72.8%) patients; see for more details the flowchart in In this study the Dutch version of the PAM was used which was validated by NIVEL  . The queAll patients filled out a survey which consisted of the PAM questionnaire for measuring degree of patient activation, the WHO-5 for measuring well-being, and the EQ5D for measuring quality of life –17. The Demographic and clinical data were collected from the personal health record systems of the GPs. These data were collected during the annual check-up of the patients by their GP and were already routinely sent to the Diabetes Centre  for benchmark and study purposes. Clinical data that were collected in the period from 9 months before till 5 months after the questionnaire were used. The following data were extracted: age, gender, diabetes duration, BMI, smoking status, HbA1c, use of glucose lowering medication, and the presence of micro- and/or macrovascular complications. The presence of microvascular complications was defined as having microalbuminuria, diabetes retinopathy, and/or diminished sensibility of the feet. The presence of macrovascular complications was defined as (a history of) angina pectoris, myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, stroke or transient ischemic attack, or the use of thrombocyte aggregation inhibitors.p value of <0.05. The association between gender and patient activation was investigated with multivariate linear regression using the continuous PAM score. Four models were used: (1) a crude model, (2) a model adjusted for age, (3) a model adjusted for age, well-being, quality of life, BMI, smoking, presence of macrovascular complications (MVC), and the use of insulin, and (4) an explorative model with all variables in model (3) and the following diabetes-related factors: HbA1c, diabetes duration, use of oral glucose lowering drugs, and the presence of microvascular complications. These diabetes-related confounders were added to investigate whether the burden of T2D may confound the relation between gender and PAM. Interaction was tested at the 0.10 probability level between gender and well-being, gender and quality of life, gender and BMI, and gender and smoking in models (3) and (4). Interaction terms were only tested if interaction was plausible based on theoretical grounds, and they were only included in the fully adjusted model when they were statistically significant. Stratified analyses according to gender were performed to investigate which factors are associated with patient activation in men and women. For this purpose, model (3) and model (4) were used. The degree to which the different models determined the PAM score was evaluated by the explained variance, shown as adjusted R2. Before analyses, the WHO-5 and EQ5D scores were tested for presence of multicollinearity.Statistical analyses were performed using SPSS version 22 . Multiple imputations were used for missing data on the independent variables, assuming that data was missing at random (MAR) or completely at random (MCAR). Ten imputed datasets were created and the pooled results are described. The patient characteristics are expressed as mean with standard deviation (SD) or median with interquartile range (IQR) for normally distributed and nonnormally distributed data, respectively. Categorical variables are described in numbers and percentages. Differences were considered to be significant at a All patients gave written informed consent for the use of the survey data and the clinical data. According to Dutch guidelines this research does not fall under the scope of the Medical Research Involving Human Subjects Act, and therefore this study does not need a formal approval of an accredited METC .p < 0.001). Men had significantly higher scores on the WHO-5 and EQ5D questionnaires compared to women. Men smoked more frequently and they had also more often micro- and macrovascular complications compared to women. The BMI was significantly higher in women. A higher percentage of men used oral glucose lowering drugs.The patient characteristics are described in p = 0.294). The results of the regression analyses are described in b = −0.13; p < 0.001), a higher WHO-5 score , and a lower BMI  were associated with a higher PAM score. No interaction was found between gender and WHO-5 score, gender and EQ5D score, gender and BMI, and gender and smoking. In the explorative model (model (4)), all diabetes-related factors  were not associated with the PAM score. Adding these diabetes-related variables did not significantly affect the results of model (3).The median PAM score and the distribution of the PAM levels are described in b = −0.18; p = 0.001), a higher WHO-5 score , and a lower BMI  were associated with a higher PAM score in model (3) (R2 8.5%). In women, a higher WHO-5 score  and the absence of macrovascular complications  are associated with a higher PAM score in model (3) (R2 10.7%). In the explorative model (model (4)), no associations were found between HbA1c, diabetes duration, use of oral glucose lowering drugs, the presence of microvascular complications, and the PAM score in men or women.Stratified analyses according to gender are described in The results of this study show that no difference in degree of patient activation was found between men and women with T2D treated in primary care. Within men, age, well-being, and BMI were found to be associated with degree of patient activation whereas, in women, well-being and MVC were related to patient activation.Although some studies have investigated differences in patient activation between men and women –10, our We found that a lower degree of well-being was associated with a lower level of patient activation in both men and women. It attributed for 73% and 90% to the explained variance in the final model in men and women, respectively (data not shown). Although a strong association between well-being and patient activation seems to be present, the effect of well-being is rather small as the total explained variance was only 8.4% and 10.4% in the final models for men and women, respectively. A low degree of well-being could indicate the presence of depression, which was found to be associated with patient activation in a previous Dutch study among patients with chronic diseases . This asSome limitations need to be mentioned. Due to the cross-sectional design, causal conclusions could not be drawn. Furthermore, although we have investigated important confounders, still some potentially important factors were not taken into account. We were not able to adjust for educational level, socioeconomic status, and marital status. Inclusion of those variables might increase the explained variance. Educational status and financial distress, which could be used as markers for socioeconomic status, were associated with patient activation in a previous Dutch study . In the As no differences between patient activation level between men and women exist, there is no indication that the approach to men and women with respect to self-management tasks should be different. However, this does not directly mean that the same self-care tasks could be given to men and women, as the effectiveness of self-care interventions could still be different. This should be investigated in further research.There is no difference in the degree of patient activation of men and women with T2D. Furthermore, no significant influence was found for well-being, quality of life, BMI, and smoking on the relationship between gender and patient activation. Age, well-being, and BMI were found to be associated with patient activation in men, whereas well-being and macrovascular complications were found to be associated with patient activation in women. Based on these results, there is no indication that different levels of self-management tasks should be given to men and women with T2D.


The aim of this study was to determine the effects of active video games and music-accompanied aerobic and callisthenic exercises on body mass index (BMI), body fat ratio, physical performance tests, psychosocial status, and self-respect in overweight and obese adolescents.Fifty  slightly overweight and obese participants with no chronic disorder and of an average age of 12.16±0.99 years were included in the study. The percentile values for BMI, triceps skinfold thickness, waist circumference measurements, and physical performance tests were evaluated. The effects of obesity on psychological wellness were evaluated using the depression scale for children (DSC) and the Piers-Harris Children’s Self-Concept Scale for self-esteem. Following these evaluations, the participants were subjected to an exercise program in five groups of 10 people, 3 days a week for a duration of 8 weeks. Each exercise session lasted 45 minutes. Participants were re-evaluated at the end of the exercise program. The data collected both before and after the exercise program were analyzed using the SPSS 18.0 program.According to BMI reference values, 28% of the 50 participants  were assessed to be overweight and 72% to be obese . Following the exercise program, 14% of the participants  were assessed as normal, 46%  as slightly overweight, and 40%  as obese. It was determined that the decrease in BMI values (p<0.05) was higher in male participants than in female participants and that the frequency of obesity was higher in the females. A statistically significant decrease in BMI values was found after the exercise program (p<0.01). Following the exercise program, statistically significant differences have also been observed in the self-esteem (p<0.01), psychological wellness (p=0.025), triceps skinfold thickness, as well as in waist circumference and BMI values of the participants compared to the pre-exercise phase (p<0.01).An exercise program applied with active video games was found to have positive effects on the obese state as well as on the psychosocial status and self-esteem of obese individuals, indicating that exercise and physical activity have an important role in improvement of the obese state in childhood as well as having positive contributions to self-esteem and psychological wellness state. Children at risk of overweight have been shown to benefit from increased physical activity administered as a structured program. However, children can get bored of exercise quickly so it is essential to make those exercises interesting.After applying an exercise program which was accompanied by active video games, we found significant difference in self-esteem, psychological wellness, performance tests, and body mass index compared to the pre-exercise phase.Obesity is a result of an imbalance between nutrient intake and energy expenditure . Due to Obesity is a condition which leads to various health problems. Its frequency is increasing rapidly amongst adults, children, and adolescents all over the world ,4. It haWhile determination of obesity among adults is calculated by BMI, this may not be appropriate for very young children. Weight and height values for age and gender are also evaluated in assessment of obesity in children. It is also important that local standard curves, if available, are used in this assessment .Although many studies have been conducted to clarify the etiopathogenesis of obesity, all of them have pointed to a multiple etiology . ObesityFurthermore, being overweight and obese affects self-confidence, general appearance, and social activity. A study revealed that depression, lack of self-confidence, and behavior problems were more frequent among clinically obese adolescents . It has Daily energy need varies with respect to age, gender, occupation, genetic, and physiological characteristics. In order to maintain a healthy weight, the amount of energy that is ingested needs to be balanced to the amount that is spent. Healthy nutrition and adequate physical activity have primary roles in maintaining this balance and in increasing quality of life. Regular physical activity is fundamental for children and adolescents to grow up to be a healthy adult. It is also helpful in avoiding acquisition of bad habits, in being social, and in protection from various chronic diseases .Pharmacotherapy options for the treatment of pediatric obesity are very limited. Therefore, a comprehensive management program that includes exercise and behavior modification is crucial . It is eThis study was implemented within the scope of Supporting Scientists Program of the Scientific and Technological Research Council of Turkey (TÜBİTAK). After obtaining parental consent, primary school students were screened for suitability to participate in our study. Our target number was 50 overweight and obese participants. Evidence of chronic disease was an exclusion criterion.During the evaluation process, the height and weight of the participants were measured using sensitive scales with sensitivities within 1 cm and 100 grams. BMI values were calculated as weight in kilograms divided by height in meters squared; children with BMI over the 85th percentile were included in the study. The reference percentile values for Turkish children were used in the evaluation of the data . Tricepsth but less than the 95th percentile for age and gender are considered as overweight and those with a BMI greater than the 95th percentile as obese  Warm-up exercises: Breathing exercises and slow-paced walking for 10 minutes.2) Exercise program: Calisthenic and aerobic exercises aimed to target all muscle groups using visual biofeedback with music and active video games for 25 minutes. Three video games that last approximately 6 minutes each were used. Videos were displayed via projection devices and each of the dance moves for the music was demonstrated in the video by an instructor. Between the videos, breathing exercises were implemented combined with slow-paced walking with marked times.3) Cool-down exercise: Mild stretching, slow-paced walking, and breathing exercises for 10 minutes. The program was completed with a relaxation posture.The video games were transferred to CDs and distributed to the participants at the end of the 8-week training period in order to maintain the continuity of the exercises and enable them to acquire regular exercising habits.The data acquired before and after the exercise program were evaluated using the SPSS 18.0 program . The relationship between categorical variables was evaluated using the chi-square test, the relationship between gender and the continuous variables was evaluated using the Mann-Whitney U test, and the comparison of the data before and after the exercise program was evaluated using the Wilcoxon signed-rank test. A p-value <0.05 was considered statistically significant.We screened 80 adolescents for participation in the study and 50 participants met all the eligibility requirements and were included in the study .The dietary habits, daily meal times, and family obesity history of the participants were examined. It was determined that 56% of the study subjects were receiving a balanced diet and the remaining 44% did not. Number of meals per day was only 2 in 10% of the participants, 64% had 3 meals per day, 24% ate 4 meals per day, and 2% ate 5 or more times per day. Examination of family history revealed that 42% of the participants had a first-degree relative with obesity.We determined that 14 (28%) of the participants were overweight and 36 (72%) were obese before the exercise program. After the exercise program, the BMI values of the subjects had decreased significantly (p<0.05) .Triceps skinfold thickness measurement values as well as waist circumference measurements also showed a decrease after the exercise program (p<0.05) .The 50 meter run time, the number of squats in 120 seconds (s), the time to ascend and descend 20 stairs, and the number of times jumping over a rope in 30 seconds had all improved after the exercise program (p<0.05) .Before the exercise program, 18 participants exhibited depressive findings, whereas after the exercise program, the number had decreased to 13. We determined that children demonstrated affirmative development in their psychological wellness after the exercise program (p<0.05) .A significant difference was recorded in the Piers-Harris Self-Respect sub-components of behavior, intelligence, school status, popularity, happiness, physical appearance, and anxiety levels after the exercise program (p<0.05) .In the evaluation form that we drew up to evaluate their dietary habits, the participants were asked whether they had a balanced nutrition, meaning eating natural homemade foods at regular times, and how many meals they had daily. Twenty-eight out of 50 participants (56%) answered “yes” when asked whether they had a balanced nutrition.Upon evaluating the answers to these questions gender-wise, no statistical differences were recorded between the answers by the male and female participants.Improved diet, increased exercise, and change in eating habits as well as involving the family in the treatment process are essential to prevent the continuation of obesity. The addition of behavior treatment to the exercise and diet treatment already used to correct childhood/adolescent weight problems has proven to produce better results .Since obese people are inclined to move less, exercise should not be neglected during their treatment. The purpose of exercise for obese people is not only to lose weight but also help them acquire a behavioral change for a healthier life style . For impBy means of an 8-week exercise program, a highly significant decrease in triceps skinfold thickness and waist circumference measurements were observed in the participants of this study. These results may have long-term implications for our participants. Lack of physical activity leads uninformed adolescent and obese adults into a sedentary life which will increase the risk of cardiovascular, pulmonary, and metabolic diseases. Furthermore, obesity itself can cause chronic complications such as hypertension, stroke, cardiac diseases, thrombogenesis, pulmonary diseases, endometrial and colon cancers, sleep apnea, dyslipidemia, gallbladder stone, type 2 diabetes, gout and pain, or dysfunction in the locomotor system. These complications lead to a decrease in the life expectancy of the obese individual . Early iIn our study, 36% of the participants were found to be depressed. Their self-esteem was also observed to be low. These results agree with a study by Pınar  that exa2 max). The exercises help burn esterified fatty acids. For obese people, exercises that do not involve a strain on body weight such as swimming, cycling, and mat exercises (exercises on the mattress) should be chosen. Ergometric exercises result in 10-12% fat loss. All the training programs should be rhythmic exercises that do not push the respiratory and circulatory systems too far. For other obese individuals, mildly intense exercises are advised (65% VO2 max). These exercises stimulate the breakdown of intramuscular triglycerides. In addition, walking, dancing, treadmill use, water sports, gardening, and house chores are recommended . Furthermore, we found that male participants had greater changes than female participants . GeneralIn conclusion, the results of this study showed that the exercise program accompanied by active video that we applied had positive effects on the obese state as well as on the psychosocial status and self-esteem of our participants. In this study, exercises were made enjoyable for the participants, which caused them to become more active and willing. This finding was noted especially in the boys. We know that physical activity has a major role in preventing childhood obesity and can lead to a healthy and active lifestyle. Our study showed that active video game participation in exercise is effective for the improvement of the obese state and possibly for prevention of obesity in children.Ethics Committee Approval: The study protocol was approved by the Ethics Committee of Mustafa Kemal University Faculty of Medicine at 13.01.2014, Informed Consent: Informed consent was obtained from all parents.Peer-review: Externally peer-reviewed.