The mechanisms involved in the generation of oxidative damage and lung inflammation induced by physical exercise are described. Changes in lung function induced by exercise involve cooling of the airways, fluid evaporation of the epithelial surface, increased contact with polluting substances, and activation of the local and systemic inflammatory response. The present work includes evidence obtained from the different types of exercise in terms of duration and intensity, the effect of both acute performance and chronic performance, and the influence of special conditions such as cold weather, high altitude, and polluted environments. Levels of prooxidants, antioxidants, oxidative damage to biomolecules, and cellularity, as well as levels of soluble mediators of the inflammatory response and its effects on tissues, are described in samples of lung origin. These samples include tissue homogenates, induced sputum, bronchoalveolar lavage fluid, biopsies, and exhaled breath condensate obtained in experimental protocols conducted on animal and human models. Finally, the need to simultaneously explore the oxidative/inflammatory parameters to establish the interrelation between them is highlighted. When doing physical exercise, the usual levels of organic performance are exceeded. However, we are designed to execute the exercise, depending on its variety, duration, intensity, and the environmental conditions under which it is done. The physiological and pathological processes will be activated, which can lead to the generation of an oxidative imbalance and the establishment of an inflammatory process , 2. The When exercising, the mobilized air flow or pulmonary ventilation increases. This is explained by the increase of the respiratory rate, the tidal volume, and the appearance of bronchodilation. In addition to this, the pulmonary vascular bed will vasodilate to receive a greater blood flow. These changes, taken together, aim to increase gas exchange. Large air flows entering the lung during exercise will cause a modification of the breathing pattern towards one predominantly oral, favoring the evaporation of the fluid covering the pulmonary epithelium and the decrease of temperature of the airways. As a result, the pulmonary passages will cool down and the osmolarity of the epithelium will increase . It shouAs mentioned previously, physical exercise induces changes in the redox/inflammatory state of the organism, at both systemic level and the different organs. In this regard, lung is one of the less studied organs in this context. In the following paragraphs, the most relevant results regarding pulmonary oxidative damage and inflammation caused by exercise are summarized. In this review, the work carried out in healthy subjects was privileged. Regarding the special conditions, hypoxia, water contaminants (chlorine), and cold have been included, leaving aside air pollutants, because there are several reviews regarding this subject , 49. The2 [1). Other studies showed no changes in the eNO after exercise; Font-Ribera et al. [A direct relationship has also been reported during exercise, between the acute exercise intensity and the volume of exhaled nitric oxide (VNO), namely, volume minute (VE) multiplied by exhaled nitric oxide (eNO), for sedentary healthy –87, 90 a2 , 75 and 2 , 86, 92.2  showed c2  observed2  reported2 , 88, 91.2  found in2  found ana et al.  found noa et al.  and in ha et al. , 94 or ta et al. .2O2 and thiobarbituric acid reactive substances (TBARs). Araneda et al. [2O2 in EBC after three maximal cycle ergometries of 1 min in elite cyclists carried out at 670 and 2160 masl, but malondialdehyde (MDA) was higher at 2160 meters. Marek et al. [2O2 concentration in EBC [2O2 after exercise. On the same prooxidant, Mercken et al. [2O2 when healthy subjects performed a cycle ergometry with one leg (40%  Pmax) during 20 min [2O2 in EBC were higher when the exercise was carried out in a cold environment. Recently an increase in H2O2 and nitrite concentrations and correlations between both metabolites in the EBC of 21 and 42.2 km race participants were found. Also in this study, while nitrite increased in EBC, plasmatic nitrite showed no modifications and no correlations between these variables, which suggests a probable localized origin of this process [Through the exhaled breath condensate (EBC) analysis, to observe the oxidative effects of the moderate acute exercise, Nowak et al.  subjectea et al.  found nok et al. , in two n in EBC ; howevern et al.  found ang 20 min . Marek eg 20 min  found th process .2max. Prigol et al. [2max) showed no changes in TBARs in rats [Until now, only two studies have determined one of the potential sources of prooxidants; thus, it has been described as an increment of xanthine oxidase activity in the pulmonary homogenate of rats that performed strenuous exercise (~15 min) on a treadmill (20 m/min), besides MDA and NO . Likewisl et al.  and Akill et al.  found inl et al.  found inl et al. . The saml et al. . A stren in rats .α of supernatant of bronchoalveolar lavage fluid (BALF) after 50 min of running [In healthy horses, no differences were observed in isoprostane 8-epi-PGF2 running . An incr running  after an running .2max showed no changes in the activity of GSH-Px and SOD [2max. Strenuous exercise increased the activity of GSH-Px, with no changes in GR [With regard to the pulmonary antioxidant enzymes, after an hour of acute moderate exercise protocols on treadmills, young rats' lungs showed an increase in the activity of enzymes superoxide dismutase (SOD) of the type CuZn-SOD, Mn-SOD, of the catalase (CAT), without changes in the glutathione peroxidase (GSH-Px). The mRNA expression for these enzymes did not show differences . Lin et  and SOD . In acut and SOD  found an and SOD  found in and SOD  found in and SOD  describees in GR . In a rees in GR , rats th2max until fatigue, no variations were found in the homogenized lung GSH [Acute exercise has also altered the levels of nonenzymatic antioxidants; an increase of uric acid has been described, with no changes in total glutathione, in GSH, and in GSSG in BALF, after 50 min of incremental exercise in healthy horses . In a stlung GSH . In ratslung GSH ; in thislung GSH .Thus, the increase in lung prooxidants and its consequences (lipid peroxidation) due to acute exercise appear to be related to the high intensity and duration of the effort, in terms of either minute ventilation or oxygen consumption, and are enhanced by a hostile environment . However, a mainly enzymatic antioxidant adaptive response is still controversial. In contrast, the use of vitamin reducers (C and E) allows the antioxidant capacity to be increased and oxidative damage to be controlled , compared to control rats. In another study, Menegali et al. [max (60 min/d and 5 d/week) increases of GSH-Px were observed without changes of expression of CuZn-SOD, Mn-SOD, and Ec-SOD, studied in sections of pulmonary tissue [The chronic exercising has also had as a subject of study the potential changes of the expression/activity of the enzymes and nonenzymes pulmonary antioxidant. Likewise, Reis Gonçalves et al.  found ani et al.  found any tissue . In anoty tissue . Finallyy tissue  observedThis reflects the fact that oxidative stress induced by chronic pulmonary exercise in animals is closely associated with high-intensity protocols, but not with those of moderate intensity see . However4, and LTE4 were also detected, subsequent to acute exercise during the precompetitive phase versus the competitive phase [2 prostaglandin and B2 thromboxane in EBC after exercise were found in men [max in healthy subjects.In horses, Kirschvink et al.  found nove phase . Chimentve phase , in a 20ve phase . In roweve phase . In swimve phase . In a chve phase . Larssonve phase  found and in men . The leud in men ; thus, ad in men . Also ind in men  found nopH) is a potential marker of pulmonary inflammation that has been used in pathologies that have this condition. In acute exercise, the results have been variable; thus, Marek et al. [pH of amateur athletes. Bikov et al. [pH of healthy subjects after exercise, while there are other reports that show increases in pH after outdoor exercise [max) exercise (~30 min) in nonathlete healthy subjects [pH [pH was observed [pH after running 1.6 km.The pH in EBC  after acute exercise in humans. A factor that probably influences this is the duration of the exercise, as the increase in PMNs was found only in protocols involving longer periods see . Cellulaα) together with promoting a decrease of interferon gamma in pulmonary tissue samples [max for 24 weeks (5 d/week), no variation was observed in the number of macrophages in BALF, but it was possible to see a decrease of the capacity of these cells to form free radicals [2max) generates a reduction of the inflammatory response after the completion of ischemia and pulmonary reperfusion, which was evidenced as a decrease of the release of interleukin 1β and tumor necrosis factor-alpha (TNF-α) at plasmatic level in a model performed in rats [α, interleukin 10, monocyte chemotactic protein, and interleukin 1 receptor antagonist, quantified in lung sections of mice, after training to 50%  Vmax for 1 h/day, 5 days per week, for 24 weeks.Studies in animals have shown that training during 120 min/d for a week on treadmill at 25 m/min increases the expression of mRNA to tumor necrosis factor-alpha  presented a higher concentration of eNO and a higher count of eosinophils and of epithelial cells when compared to the group that had negative results on this test [In studies conducted in humans, it has been reported that the participation in a long distance race training program over the course of a year generates a persistent inflammatory process with no apparent clinical repercussion and an increase in PMNs and in IL-8 concentrations, leukotriene E samples . Subject samples . The sam samples . In the  samples . High pehis test ; among ohis test . Elite shis test . The ceshis test . The comhis test ; the samhis test . Chronichis test .α and myeloperoxidase in BALF compared to nonathlete control subjects [In skiers, who trained 435 h/year, increase of lymphocytes and mast cells has been found, with no differences in the concentration of TNF-subjects . Karjalasubjects  reportedsubjects .α. Human studies have focused on subjects who have greater contact with irritants in the airway due to the specificity of their sport, whether runners (large ventilation volumes), skiers (cold), or swimmers (chlorine gas in the pool room). In these subjects, permanent tissue infiltration of granulocytes, macrophages, and lymphocytes has been observed. Evidence of these changes has been found in both noninvasive samples, such as induced sputum, and in biopsies in the bronchial region. At the same time, an increased presence of soluble proinflammatory substances has been reported. Overall, this suggests that these athletes in particular may suffer from persistent changes in tissue (chronic inflammation and airway remodeling) that have been associated with pulmonary symptoms and functional changes . Now, regarding prooxidants, a systematic increase in humans is observed after more than thirty minutes of exercise. It is noteworthy that, in acute exercise in animals, reports of an increase in lung lipid peroxidation are the majority, while it has not been observed in humans, except for intense exercise at high altitudes. This may be partially explained by the techniques used: while tissue samples were analyzed in animals, EBC samples were analyzed in humans; in another aspect, the change with greater support in relation to the enzymatic activity corresponds to the maintenance or decreased levels of GSH-Px and to the increase in SOD.In summary, we found that in acute exercise (see Tables α) subsequent to chronic exercise. The oxidative damage was observed in animals following moderate chronic exercise (>4 sem), specifically in older rats, and cold or altitude environment. In humans, only one study showed oxidative damage by altitude training [With regard to chronic exercise (training) and its effects  should be studied and the knowledge of the status of antioxidant systems, particularly in humans, where there are no records available, should be improved. Regarding inflammatory parameters, the study of soluble mediators of inflammation should be extended; in addition, the effect of both substances with antioxidant and anti-inflammatory effect should be explored. Furthermore, it is necessary to generate research projects which explore the parameters of oxidative/inflammatory mechanisms simultaneously in order to establish the interrelation mechanisms between both processes. It is also necessary to characterize the effect of time and intensity of performed exercise, the role of environmental conditions, and the level of training of the subjects on oxidative damage/lung inflammation by exercise. Finally, to advance the resolution of this problem, it is urgent to improve the technical conditions to allow obtaining representative samples of lung environment in its different compartments, and it is also necessary for these methods to be noninvasive and contribute to monitoring the athletes.


The progression of heart failure is affected by several factors, including chronic stimulation of the β-adrenoceptor. This clinical study was designed to measure the effects of thoracic epidural analgesia (TEA) on the plasma levels of norepinephrine (NE), cAMP, and cGMP in patients with heart failure and assess the clinical implication of TEA.Forty patients with heart failure were randomly assigned to TEA (TEA plus standard care) and control groups (standard care). The plasma concentrations of cAMP, cGMP, brain natriuretic peptide (BNP), and NE were measured using ELISA before treatment, the second and fourth weeks of treatment.The plasma concentrations of cAMP, cGMP, BNP, and NE in the TEA group were significantly reduced by the fourth week compared to their initial concentrations  and the control group . The values for left ventricular end diastolic diameter (LVEDD), ejection fraction (EF), and fractional shortening (FS) in the TEA group improved significantly compared to their initial values and the control group. However, the changes in levels for these indices in the control group were no statistical significant compared to the initial levels.TEA can effectively decrease the plasma concentrations of cAMP and cGMP and improve cardiac function in patients with heart failure. The decreased levels of NE and cAMP occurred before the improvement in cardiac function, indicating that the abnormal epidural signal transduction can be corrected in patients with heart failure. ELISA also was used to assay the plasma concentrations of norepinephrine (NE) and brain natriuretic peptide (BNP). The biochemical tests were performed by experienced laboratory assistants that were unaware of the group assignments for the patients and other laboratory test results.All patients underwent cardiac ultrasonography the day prior to and following treatment. The left ventricular end diastolic diameter (LVEDD), ejection fraction (LVEF), and fractional shortening (FS) were measured at these times. The ultrasonography was performed by an experienced ultrasound technician. The GE Vivid5 color ultrasonic diagnostic instrument was used, with the probe frequency 1.7-3.6 MHz. By using M-type ultrasonic, we measured the ejection fraction, fractional shortening, and left ventricular end diastolic diameter for each patient.Statistical analyses were performed using the statisitical package SPSS 19.0 . Enumeration data were compared with the chi-square test. Measurement data were presented as mean ± standard deviation (SD) after a normality and homogeneity of variance test. A natural logarithm transform was performed on the non-normal-distributed data. Multiple group comparisons were performed using one-way ANOVA analysis of variance with Bonferroni correction. Comparisons of changes in cardiac functions before and after treatment between the TEA group and the control group were performed using a two-tailed paired Student’s t test. The statistical significance level was set to p < 0.05. A retrospective power analysis was performed for non-significant results.The baseline characteristics for patients in each group are presented in Table Plasma levels of NE, cAMP, and cGMP in patients two weeks after TEA treatment was initiated were significantly lower than the pre-treatment levels Figure ; plasma No significant changes were observed between the two groups in the etiology of heart failure. The heart rate and blood pressure of the patients in the TEA group were decreased after the injection of lidocaine. The angina and dyspnea and other signs of heart failure in these patients gradually improved with the treatment. After four weeks of treatment, the heart function by each patient was re-evaluated. In both groups, heart function improved compared to the initial measurement but there was only a significant improvement in the TEA group.Based on test results for each treatment group, the control group included 10 patients in class IV, six in class III, and four in class II; the TEA group included three patients in class IV, five in class III, and 12 in class II. It is worth noting there was a statistically significant difference between the two groups with respect to classification of the patients.EF and FS increased, and the LVEDD decreased after TEA treatment Table , a findiet al. [et al. [Data that has previously been collected indicates the activation of the sympathetic nervous system, as a compensatory response to restore cardiac output, exists in the early stage of heart failure, even prior to clinical symptoms . In addiet al.  reported [et al.  reported [et al. ,17,18. Bet al. [In recent years, patients with heart failure have been treated with β-receptor blockers to block abnormal sympathetic signal transduction, which has resulted in a notable improvement in cardiac function and clinical outcome . Luzza eet al.  suggesteet al. ,21, therResults of this study demonstrated plasma concentrations of NE, cAMP, and cGMP in patients with heart failure within the TEA group were significantly lower than the pre-treatment and showed a time-dependent improvement. It is speculated that these results are involved with the decrease in production of sympathetic impulses, decreased synthesis and release of NE, inhibition of NE-β-receptor-cAMP signal transduction, and decreased synthesis and release of cAMP. As expected, cardiac function of patients with heart failure improved significantly with decreased concentrations in NE and cAMP. This finding is in agreement with observations made in several other studies ,23 where2+ channels, cGMP-dependent protein kinase, and cGMP-regulated cAMP phosphodiesterases [It is well known that cGMP can reduce myocardial metabolism, inotropy, and function ,24. The sterases . TherefoBNP, which is synthesized and secreted by ventricular myocardium, has been used as a heart failure marker when the ventricular load and ventricular wall tension are increased. In recent years, BNP has been recognized to have a significant application value in the early diagnosis and assessment of severity, prognosis, and therapeutic outcome in patients with heart failure -29. In tTEA could lead to complications like hypotension, respiratory depression, bleeding or hematomas, infectious or abscesses, venous thromboembolism, paraplegia, and even cardiac arrest. The most common complication was hypotension, and the blood pressure patients had improved after infusion. In this study, only one patient in the TEA group had the complication of bleeding, which was improved after the compression; no patients withdrew from the study because of complications.TEA may decrease the levels of plasma NE, cAMP, and cGMP, the first messenger and second messenger of signal transduction, block the over-activated sympathetic signal transduction, and improve cardiac systolic function. It is inferred that correcting abnormal signal transduction through blocking the sympathetic nervous system is a potential treatment for patients with heart failure.The authors declare that they have no competing interests.QL participated in the design of the study and performed the statistical analysis, carried out the immunoassays, and drafted the manuscript. FL conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Polycystic ovary syndrome (PCOS) is a common reproductive endocrinological disease with heterogeneous phenotype. Obesity contributes to the increased prevalence and severity of PCOS. Whether the intakes of major nutrients are higher in Chinese PCOS patients is still unknown.To study the intakes of total energy, protein, fat and carbohydrate in Southwest Chinese PCOS patients.1854 women were included in the cross-sectional study. A population-based case-control study was conducted. The dietary habits and nutrients intake status of 169 PCOS patients and 338 age-matched controls were investigated by the method of semi-quantitative food frequency questionnaire.P = 0.01) and fat (P = 0.01) were higher, but carbohydrate was lower (P = 0.01) in PCOS patients as compared with the controls. The energy percentage supplied by protein  and carbohydrate  were lower in Southwest Chinese PCOS patients than those of control, however, the energy percentage supplied by fat was higher  in PCOS.The actual intake of total energy (Limit the intake of total energy and fat shall be recommended to the Southwest Chinese PCOS patients. Women with PCOS in Southwest China shall consult with the nutritionist for improving the dietary structure. Polycystic ovary syndrome (PCOS) is a common but complex reproductive endocrinology disease, affecting both the adolescent and reproductive women. It involves reproductive system, endocrinologic system, metabolic system, gynecological cancer and obstetric events, which are characterized by irregular menstrual cycle, infertility, hirsutism, acne, obesity, insulin resistance, diabetes mellitus, dyslipidemia, endometrium carcinoma, gestational diabetes mellitus and preterm delivery . PCOS maObesity is a prevalent characteristic of PCOS, with a pooled estimated prevalence of 49% . AbdominGiven the association between obesity, insulin resistance and the presentation of PCOS, weight management is a key initial treatment strategy for PCOS which can improve the reproductive, metabolic and psychological performance . NutritiThe intakes of total energy, protein, fat and carbohydrates were investigated between Chinese women with PCOS and control women in present study to clarify the relationship among them.0 = 0.04) for sample size calculation. The calculated sample size was 1475. Considering a dropout rate of 10%, our final sample size was 1623. The age constituent ratio of women obtained from the population census in the 2004 Yearbook of Sichuan Province was used to calculate the number of participants needed in each age group. Five communities, two universities and three middle schools from nine districts of Chengdu city were randomly cluster sampled to collect the participants.A population-based case-control study was carried out in Chengdu, Sichuan. The study protocol of the cross-sectional survey has already been partly published in our previous article including sample size calculation, random cluster sampling, participants’ selection, questionnaire investigation, ultrasound examination, blood collection and experimental tests . Sample The PCOS patients identified from the cross-sectional study were collected as the case group in the case-control study. The control number was calculated based on the number of PCOS patients with the ratio of 1:2 in each age group, respectively.The study was approved by the Human Ethics Committee of West China Second University Hospital. Information and consent forms were obtained from all the subjects or their guardians.1854 women, aged 12–44 years, who have had menses for at least 2 years, who have lived in Chengdu for at least 6 months, and who agree to answer the questionnaires were included in the cross-sectional study. Participants who had used hormones or drugs which could apparently affect endocrinological function in the previous three months were excluded. Participants with the history of diabetes mellitus, hypertension, heart disease, cerebrovascular disease, liver and kidney diseases, cancer, organ transplantation, nutrition-related diseases were excluded, pregnant or lactation women were also excluded.The diagnosis of PCOS was based on the Rotterdam criteria, with the association of at least two of the three following criteria . CushingAnthroposomatology indexes including height, body weight, body mass index, hip circumference, waist circumference, waist hip ratio (WHR), systolic and diastolic blood pressure were measured; meanwhile acne, hirsutism, baldness and acanthosis nigricans were evaluated individually by two trained investigators.−20°C until assay. Estradiol (E2), testosterone (T), free testosterone (FT), progesterone (P), follicle-stimulating hormone (FSH), luteinizing hormone (LH), fasting insulin (FINS) and fasting plasma glucose (FPG) were measured by chemiluminescence method, glucose oxidase method and radioimmunoassay, respectively, with inter- and intra-assay coefficients of variation of <15% and <10%. Serum FT was measured using radioimmunoassay method , FINS and T were measured using chemiluminescence method  All of above tests were performed by professional laboratorian in the clinical test center of our hospital. It had been accredited by ISO 15189 in 2006. At the same day, transvaginal or transabdominal ultrasound was examined by a professional doctor to measure the endometrium and ovaries. Ultrasound criteria for PCO: in the early follicular phase, one or both ovaries with the number of small follicles (diameter of 2–9 mm) ≥ 12, and/or ovarian volume ≥ 10 ml. Ovarian volume was calculated according to a simplified formula for an ellipsoid (0.5×length×width×thickness).Overnight fasting blood samples (15 ml) were collected from all the participants. Hormonal and metabolic assessments were made between the 2nd and 10th days of the menstrual cycle or on any day if the patient was amenorrhea. The plasma was separated and stored at 2 or WHR≥0.8 were classified to be obesity or abdominal obesity in Chinese, respectively [Participants with fasting glucose >6.1 mmol/L and fasting insulin >15 mU/L were defined as hyperglycemia and hyperinsulinemia respectively . Particiectively . Insulinectively .General situation, childbearing history, menstrual history, family history, psychological state, medical conditions and dietary habits were investigated. The survey was conducted by using the combination of face-to-face interview and telephone inquiries. If the face-to-face interview was unavailable, telephone interview was applied as the supplemental method, and detailed records were taken. The participants were ought to be surveyed by face-to-face interview at the first time, if the content of the questionnaire had to be further clarified, then telephone interview could be applied. Investigators received a 1-day on-site training, and they could take part in the survey after passing the examination. Pre-survey among investigators was carried out before the formal investigation to ensure that they have known the communication skill. All of the participants were ensured to get an integral and clear questionnaire. Quality control of the investigation was carried out by the inspectors who were in charge of checking the data of each questionnaire. Two staffs input the data independently using the Epidata3.1 software and would check the data again before inputting. If inconsistencies were found, the questionnaires were checked and the participants were phoned immediately for clarification.Semi-quantitative food frequency questionnaire (SQFFQ) could effectively reflect the dietary habits and nutrients intake status of the target population, and was an economical and reliable method in the large sample population surveys , 16. TheP<0.05Results were expressed as mean±SD or median and interquartile range (IQR) depending on their normal or skewed distribution. Comparisons between the two groups were analyzed by Student’s t-test or Mann-Whitney U test. Mann-Whitney U test was only used for the comparison of actual nutrient intake including energy, protein, fat and carbohydrate. Comparisons between ratios were carried out with the use of the Chi-square test. Multivariate logistic regression analyses were used to determine the independent effect of dietary nutrients with PCOS as dependent variable. All analyses were performed with the Statistical Package for the Social Sciences, version 16 (SPSS). Data from SQFFQ was entered in duplicate in Epidata software, version 3.1 (Epidata Association) and subsequently transported to SPSS for analysis. Data was considered to be significant at P = 0.979), BMI , WHR , systolic blood pressure , diastolic blood pressure , ln HOMA , and age of menarche  were not different between participant with PCOS and controls. The birth weight was lower  in PCOS patients than those of controls. The clinical characteristics between the groups were showed in 169 PCOS patients, 338 age and cluster matched control participants were enrolled in present case-control study. The baseline characteristics including age . The prevalence of baldness among the male relatives of PCOS patients was 23.08%, and 9.17% for control group (P = 0.01). Logistic regression analysis showed that the family history of diabetes  and baldness  were related to the occurrence of PCOS.The prevalence of obesity, hyperglycemia, IR, diabetic and baldness family history in PCOS group were higher than those in the control group, however, the abdominal obesity (WHR≥0.8), hyperinsulinemia, psychiatric and epilepsy family history were not significantly different between groups . The pre2 and FINS  and fat (P = 0.01) in Southwest Chinese PCOS patients were higher than those in control group (P = 0.23). However, decreased level of carbohydrate intake was found in PCOS group (P = 0.01). Median and interquartile range were used to express the intake of energy and macronutrients for the skewed distribution.The actual intake of total energy (ol group . The proP<0.001) and carbohydrate  were lower in southwest Chinese PCOS patients than those of controls, however, the energy percentage supplied by fat was higher . Carbohydrate was still the first major nutrient supplying energy for both the PCOS and control, but the ratios for the PCOS patients were lower than the normal level, which was recommended to be 70%. The energy percentage provided by fat for PCOS patients was higher than the recommended level of 25%. The energy percentage supplied by the macronutrients for the PCOS patients in Southwest China were diverged from the levels recommended by the nutritionist.The energy percentage supplied by protein  = 1.002, 95%CI 1.001, 1.002), higher intake of fat  = 1.022, 95%CI 1.005, 1.039) and lower intake of carbohydrate  = 1.004, 95%CI 1.001, 1.007) were found to be related to the incidence of PCOS.Intakes of fat, carbohydrate, cholesterol, diet fiber, riboflavin, niacin, vitamin E, calcium, magnesium, ferrum as gram, and total energy intake as kilo joule (KJ) were analyzed to assess their roles in the incidence of PCOS. BMI was chosen to be the adjusted factor while analyzing, but confounding influence of BMI was not found. Higher intake of total energy (P = 0.519), apple , pork , lean hogs , colza oil , and soy bean sauce  were not different between PCOS and control, except for the noodle .Top 20 food items were found to be different for supplying fat, carbohydrate and protein between PCOS and control subjects respectively, which were listed in The dietary status in adolescent and reproductive-age Southwest Chinese PCOS patients was explored in present population-based case-control study for the first time. Increased intake of total energy and fat, decreased intake of carbohydrate were found in PCOS patients in present study. The energy percentage provided by fat was higher, but carbohydrate was lower for Southwest Chinese PCOS patients. High intake of total energy and fat, low intake of carbohydrate were correlated with the PCOS. No difference was found for protein intake between PCOS and control in present study. The nutrients components for the PCOS patients in Southwest China were found to be diverged from the levels recommended by the nutritionist.P<0.001) and percentage energy from fat significantly higher  for lean PCOS than lean controls, which was in accordance with the results of our study. No difference was found on the percentage energy from cholesterol, fat and protein for obese participants. PCOS participants were not meeting dietary recommendations for fat or carbohydrate intake in this study, which was accordance to the results of our study.The nutrients intake of PCOS patients have been previously studied in Caucasian population. Increased actual fat intake but low intake of carbohydrate was also found by two studies , 21. WilP = 0.96) and BMI  were comparable between groups. The PCOS group consumed 49.5% energy from carbohydrate and 34.8% energy from fat. The control group consumed 52.9% energy from carbohydrate and 31.0% energy from fat. The PCOS group consumed less carbohydrate (P = 0.33) and more total fat (P = 0.22) than did control-group women, but these differences were not statistically significant. Percentage energy from carbohydrate intake was lower but percentage energy from fat was higher in PCOS patients, which was accordance with the results of our study. The PCOS group consumed significantly more white bread and tended to consume more fried potatoes. The reliability and validity of dietary questionnaire used in this study were unclear, and the investigated duration of dietary status was not reported. The dietary situation in the previous six months was surveyed by Wright et al. for 40–50 years old PCOS patients and controls using block food frequency questionnaire with good reliability and validity [P<0.001), carbohydrates (P = 0.004), protein (P = 0.001) and fat (P = 0.003). However, the limitation of the survey was hospital-based and the participants were perimenopausal. Dietary intakes in 10 hypothalamic amenorrhea women and 8 PCOS patients with the age of 18–35 years were surveyed by means of a food frequency questionnaire and a seven-day food diary [2 vs. 19.9±2.3 kg/m2, P = 0.006). A similar macronutrient distribution for women with PCOS or hypothalamic amenorrhea was found . However, the comparison between PCOS patients and normal controls was not performed in this study. Diet composition of overweight or obese premenopausal women reporting weight control was estimated by a modification of the semi-quantitative Harvard Service Food Frequency Questionnaire [P = 0.869), proportion of fat (37%), carbohydrate (46%) and proteins (18%) in PCOS patients were not different from controls. Both groups of women maintained higher fat intakes than those currently recommended. Lean participants weren’t included in this study, and the confounding influence of weight management couldn’t be ruled out. PCOS patients and controls with 14–35 years old were investigated for the dietary intake by using a food frequency questionnaire previously validated [P = 0.288). The calorie (P = 0.024) consumption of PCOS women was greater than that of the control group regardless of age and BMI, but without differences among the intake of carbohydrate (52%), fat (25%) and protein (15.5%). Obese or overweight (BMI >25 kg/m2) women with PCOS and control were investigated by means of the 7 days food diary. Diet did not differ between the two groups regarding energy, protein, fat and carbohydrate, but PCOS individuals had higher consumption of high-GI foods [However, no significant differences were found in the actual intakes of protein, fat and carbohydrate between PCOS and control in the other Caucasian studies , 22–25. ionnaire . Particialidated . The preP = 0.002) and carbohydrate , but higher fat intake  compared with those with non–PCOS-related infertility. However, no difference was found for the intake of protein  between groups. BMI  was significantly higher in the PCOS group than that in the control group. The results of percentage energy were accordance with those of our study. However, the reliability and validity of dietary questionnaire used in this study were unclear, and the dietary intake between PCOS and normal participants were not compared in this study.Only one study was found to investigate the dietary intake of Asian PCOS patients (age 25–40 years) and infertility controls using a 3-d dietary record . TaiwaneThe limitation of the above previous studies were hospital-based case-control study, the reliability and validity of dietary questionnaire were unclear, the investigated duration of dietary status was not reported, using hypothalamic amenorrhea women or infertility patients as controls, respectively. No study explored the dietary status of Southwest Chinese PCOS patients with population-based case-control study in previous years.The results of above studies exploring the dietary status of PCOS patients are contradictory. These data should be interpreted with caution, because of different dietary habits as well as ethnic origins among different countries, which could account for the differences among the studies. The difference might also be induced by the different proportions of overweight and obese women with PCOS in included participants.Nowadays, with the widespread application of the weight management for PCOS, a better dietary intake was reported to be applied by PCOS patients, as reflected by improved diet quality, lower saturated fat and glycemic index intake and higher fiber and micronutrient intake, but a higher energy intake and increased amount of sedentary time compared with controls .2) reported by a large sample size cross-sectional study conducted across China [The present study demonstrated that women with PCOS had much more proportion of oligo-anovulation, hirsutism and polycystic ovary, which was consistent with clinical characteristics of PCOS. The prevalence of oligo-anovulation, hyperglycemia, hirsutism, acne, polycystic ovary, obesity and IR were 94.67%, 47.93%, 40.24%, 41.42%, 63.91%, 16.57% and 35.5%, respectively. The BMI of PCOS patients in present study was similar to the BMI  and colored food atlas to help the subjects recall, making the estimation of the food more objective and more realistic. The study was based on the actual eating habits of the female residents in Chengdu.All the investigations were carried out by well-trained and experienced investigators, making most of the interviews processed successfully. In addition, without the restrictions of time and traffic, telephone interviews greatly improved the acceptance and compliance of the subjects.However, our study had a few limitations. The 2002 China Food Composition Table failed to include all foods took by Southwest Chinese women in the questionnaire, so an objective calculation based on that table might affect some nutrient intake results. Personal memory is influenced by the educational background, physical condition, gender and mood. The participants’ recall bias was an important factor that affected the results in our investigation. An important limitation of our study was that it was a cross sectional investigation of the association of dietary factors with the PCOS. Prospective cohort study isn’t conducted; it is difficult to draw the definite conclusions about the effect of diet in this population. Until large prospective studies firmly establish the effects of diet on PCOS features, cross-sectional analyses like the present report might provide potentially useful insights in the association between diet and PCOS characteristics.Limitation the intake of total energy and fat shall be recommended to the Southwest Chinese PCOS patients. Women with PCOS in Southwest China shall consult with the nutritionist for improving the dietary components. Cohort study excluding the influence of obesity shall be carried out to explore the relationship between the dietary factors and PCOS in future.


Background: The USDA child meal programs (CMPs) , School Breakfast Program (SBP), and Summer Food Service Program (SFSP) were established in 1946 (NSLP) and 1975 (SBP and SFSP) to improve the diet and nutritional health of US children. There is concern that participation in these programs may in fact be a contributor to the current childhood obesity epidemic. Objective: The purpose of this study was to determine if the CMPs are meeting their intended goal by reviewing the historical changes to nutrition standards of the CMPs in correspondence with the literature that examines the nutritional adequacy of meals served as part of these programs, as well as the dietary intakes and nutritional status of participants. Methods: Public Law and the Federal Register were reviewed and websites and online databases were systematically searched. Results: NSLP and SBP first underwent updates to the nutrition standards in 1994 and subsequently 2010, whereas SFSP last underwent modifications in 2000. The majority of data, all collected prior to 2010, demonstrate that meals served as part of the NSLP and SBP are not meeting nutrition standards. In addition, the dietary intakes of NSLP and SBP participants are high in calories, fat, saturated fat, and sodium, and low in fiber. Studies examining the weight status and other nutrition-related health outcomes of NSLP and SBP participants have produced mixed results. In contrast, no studies published in the peer-reviewed literature have been conducted examining the nutritional adequacy of SFSP meals or the dietary intakes or nutritional health of SFSP participants. There are public reports available on the nutritionally adequacy of SFSP meals, however, they are severely outdated (1988 and 2003). Due to this dearth of information, a case study on a sample SFSP menu from summer 2015 was conducted; results showed that the meals are high in carbohydrate and protein content and insufficient in vegetable servings. Conclusions: There is critical need for policy change that would enable updates to the SFSP nutrition standards to match those of the NSLP and SBP. In addition, strategies are needed to facilitate development of CMP menus that meet current nutrition standards. Finally, rigorously designed studies are needed to understand the direct impact of CMP participation on child diet and health, particularly the SFSP for which there is limited published data. There has been a major shift in the nutritional status of our nation’s children over the past century from emaciation to obesity. The early 1900s were plagued with underfed children due to the consequences of two World Wars and the Great Depression. Feeding programs date back to the late 1700s, however, formal federal intervention did not occur until the 1930s during the Great Depression when there was a surplus of food produced from farms. At that time (1935), Public Law 320 was passed by Congress that enabled the government to purchase excess foods from the market and channel them elsewhere [Fortunately, despite the lack of resources, Congress recognized the need for such child feeding programs, making the halt to the expansion of school lunch programs only temporary. In 1946, Congress signed into law the National School Lunch Act (NSLA), which first established the National School Lunch Program (NSLP) ,3. In thThe NSLP, SBP, and SFSP are intended to address issues of malnutrition and food insecurity from a social ecological theory approach . To thisWhile CMPs were introduced with the goal of improving the diet and nutritional health of US children, there is concern that participation in these programs, due in part to the inadequate nutrition standards of the meals, may in fact be a contributor to the current childhood obesity epidemic—which affects 17% of US youth —and poorTo assess the historical progress of the USDA CMPs (Enactments and Nutrition Standards Revisions), Public Law and the Federal Register were reviewed. The Library of Congress was referenced to obtain Public Law records for the NSLA of 1946 and the CNA of 1966 ,4. For ti.e., other food assistance programs were jointly assessed with SBP and NSLP); (2) studies pertaining only to the feasibility of universal-free SBP; (3) limited scope of dietary outcomes ; and (4) untrustworthiness of data presented . This resulted in a total of 19 articles that were included in this review. An overview of these studies is provided in For the review of nutritional adequacy of CMP meals and dietary intakes and nutritional outcomes of CMP participants, an extensive search of online databases was conducted to gather published articles. PubMed , ScienceFor the final portion of this study, due to the finding that there is a dearth of information related to the SFSP, a case study was conducted to assess the nutritional adequacy of SFSP breakfasts and lunches. Using the Nutrition Data System for Research (NDSR) , a nutriSince the establishment of the NSLP 1946) and SBP 1975), the meal requirements and nutritional standards of these CMPs have changed significantly. 6 and SBP, the meaThe first changes to the nutrition standards of the NSLP and SBP meals were made in 1994 as a result of USDA’s launch of the School Meals Initiative for Healthy Children which required nutritional improvements to school meals based on the new dietary guidelines . The proFrom 2000 to 2004, minor changes to the NSLP and SBP nutrition standards were made, though they did not involve altering nutrient content of the meals  ,14,15. IThe Healthy, Hunger-Free Kids Act of 2010 required the USDA to update NSLP and SBP nutrition standards . SignifiAfter the enactments of the NSLA and CNA, several independent researchers began investigating the potential biological effects of the universal school feeding programs. One study assessed first, second, and sixth graders in elementary schools in Baltimore City, MD over the course of a year to determine potential nutritional effects of NSLP participation by assessing height, weight, and hematocrit, an indicator of iron status that is commonly used to assess overall nutritional status . Sixty pp < 0.01) [p < 0.05) [p < 0.05; p < 0.05) [et al. found no association between NSLP participation and overweight status among second and fifth graders in New York City [Within the indicated timeframe, a few studies examined NSLP and SBP participation and associations with weight status. Anthropometric data were assessed for participants in the National Evaluation of School Nutrition Programs (NESNP) study to determine if NSLP and SBP participation were associated with height-for-age, weight-for-age, and triceps skinfold (indicator of body fat). Results indicated that NSLP participants’ weight-for-age and body fat were significantly greater compared to non-participants (both  < 0.01) . With re < 0.05) . In a st < 0.05) . Contrarork City .Nutrition analyses of NSLP and SBP meals served and dietary intakes of children were also investigated within the given period of time. In the NESNP study, the impacts of federally funded nutrition programs were assessed . AccordiResults from the first School Nutrition Dietary Assessment (SNDA) study indicated that the average percentage of calories from fat in NSLP lunches was 38% and only 1% of schools provided lunches that reached the target of <30% calories from fat . The SBPIn contrast to the NSLP and SBP, no studies published in the peer-reviewed literature examining the nutritional adequacy of SFSP meals or the diet and health of SFSP participants within the given timeframe were identified. A 1988 USDA ERS report utilizing a national dataset demonstrated that the vast majority of SFSP lunches contained the required meal components, though nutritional adequacy was not evaluated . Plate wEleven studies were included in this review that examined school meals and the nutritional outcomes of school meal participants after the new, revised nutritional standards were implemented in 1994. Two studies examined the nutritional content of the meals served, three studies examined the actual dietary intake of the children, and the remaining studies examined weight status.p = 0.008; p = 0.003; p = 0.022; p = 0.038), fat , and protein  were significantly greater than SBP and NSLP guidelines [et al. compared the nutritional content of meals offered and meals actually served. Approximately 23% and slightly less than half of surveyed schools actually served breakfasts and lunches, respectively, that met nutritional standards for calories [Both regional and national samples of schools were used when assessing the nutritional content of the school meals. A nutritional analysis of menus in one urban and one rural school district in Mississippi was conducted and compared to SBP and NSLP nutritional standards. Calories, fat, protein, and sodium all surpassed recommended amounts. For both grade groups, K-6 and 7–12, in both the urban and rural districts, calories , the oldest of these three data sets. From this nationally representative sample of 6–18 year olds, it was found that NSLP participants compared to non-participations consumed significantly more calories (p < 0.01), total fat (p < 0.01), saturated fat (p < 0.01), protein (p < 0.01), thiamin (p < 0.05), riboflavin (p < 0.01), Vitamin B6 (p < 0.01), Vitamin B12 (p < 0.01), calcium (p < 0.01), phosphorus (p < 0.01), magnesium (p < 0.01), zinc (p < 0.01), cholesterol (p < 0.01), and sodium (p < 0.01) and significantly less added sugars (p < 0.01) and total carbohydrates (p < 0.01) at lunch, as well as over an entire 24-h period [et al. When examining all school-aged children, 80% and 92% consumed excessive amounts of saturated fat and sodium, respectively [p < 0.01), calcium (p < 0.05), and fiber (p < 0.01) and less magnesium (p < 0.01) and phosphorus (p < 0.001) compared to non-participants [p < 0.05) compared to non-participants [Three different national data sets were utilized in the studies examining the dietary intakes of school aged children, including both CMP (NSLP and SBP) participants and non-participants. Gleason h period . Similarectively . SBP andicipants . Additioicipants .et al. examined overall diet quality by applying the Healthy Eating Index (HEI) scoring system to data derived from the NHANES 2003–2008 survey. HEI is a validated measure of overall diet quality comprised of component scores for total fruit, whole fruit, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, and empty calories [p < 0.01) and milk (p < 0.01) component scores were significantly higher, and whole grains (p < 0.01), saturated fat (p < 0.05), and sodium (p < 0.05) component scores were significantly lower than non-participants [The final study utilized a national data set and took a slightly different approach, but demonstrated similar trends with regards to sodium, fat, and caloric intake. Hanson calories ,37. Highicipants .p > 0.072). However, data indicated that children who ate breakfast in the classroom had significantly higher BMI-percentiles compared to children who ate breakfast in the cafeteria (p = 0.012) [p < 0.01), NSLP (p < 0.0001), and combined (p < 0.0001) participation and caloric intake [p = 0.05) and a negative, significant relationship between NSLP participation and BMI (p = 0.001) [Findings regarding weight status were inconsistent across the reviewed studies. Investigators in South Carolina assessed the relationship between SBP and NSLP participation and BMI-percentile and found that there was no significant relationship between SBP, NSLP, or combined participation and BMI-percentile (= 0.012) . Two stu= 0.012) , while t= 0.012) . In the = 0.012) . Howeverc intake . Results= 0.001) .p < 0.05) relationship was determined between SBP participation and BMI z score [et al. To this end, the PSID data set showed participation in NSLP was associated with a significantly higher BMI-percentile (p < 0.05) and being overweight (p < 0.10) in unadjusted models; however, when adjusted for demographical characteristics, the associations did not hold [et al. examined the relationship between food assistance program participation weight status across groups of varying levels of household food security. Results from this study indicated that food insecure girls who participated in the NSLP or both the SBP and NSLP had 74% and 58% reduced odds of being overweight compared to food insecure non-participants [Results from studies that utilized national data sets were slightly more consistent, except with regard to SBP participation. In a study using the SNDA III data set, the relationships between SBP and NSLP participation and weight status were assessed. A negative, significant  or very unhealthy (p = 0.057) compared to parents who perceived the meals to be very healthy [p < 0.0001) and significant decreases in milk selection and consumption  after the new nutritional standards were implemented [p < 0.0001), and vegetable consumption increased significantly by 16.2% or 0.2 cups (p < 0.0001) [Since the most recent revisions to the NSLP and SBP nutritional standards, only two studies have been published in the peer-reviewed literature. One study aimed to understand parents’ perceptions of the meals served at school and how these perceptions may relate to participation . The odd healthy . The oth healthy . Resultslemented . Entrée  0.0001) . Though  0.0001) .Due to the finding that there are no data published in the peer-reviewed on the nutritional adequacy of SFSP meals, and given that the public reports on the SFSP are severely outdated , which resulted in contradicting findings with regards to school meal participation and weight status. In one of the studies, no significant relationships were seen between school meals participation—SBP, NSLP, or combined—and BMI-percentile [In the papers reviewed for the current study, findings regarding the relationship between school meal participation and weight status varied. Several studies found positive but insignificant relationships between NSLP or combined SBP and NSLP participation and weight status ,40,43. Trcentile . These cet al. also contradicts findings from two other studies. Consistent with Versmeersch et al. Gleason and colleagues found an inverse, significant relationship between SBP participation and BMI z score [The latter finding of a positive, significant relationship between SBP participation and BMI-percentile by Paxton-Aiken  z score . Breakfa z score ,49,50,51 z score ,53,54. Ivs. non-participants are children from families in which health is prioritized and, thus, their overall dietary and other health behaviors are optimal, not just during school hours in which they access the quality foods provided by the SBP and NSLP. However, that conclusion cannot be made from these studies and should be investigated further. Second, children who ate breakfast in the classroom had significantly higher BMI-percentiles compared to children who ate breakfast in the cafeteria [Two other interesting findings regarding school meal participation and weight status were demonstrated in the current study. First, food insecure girls who participated in the NSLP or both the SBP and NSLP had a reduced odds of being overweight compared to food insecure non-participants . This fiafeteria . ReasonsSignificant changes were made to the nutritional standards for the NSLP and SBP in 2010 . Within Results from the current study demonstrate that the nutritional requirements for SFSP meals have not progressed equivocally. There are multiple notable differences in the school verses summer meal requirements for the CMPS that could significantly impact the nutritional quality of the meals served and consumed by the children. To this end, unlike the summer meal requirements, the school meals requirements include separate fruit and vegetable specifications, daily vegetable requirements, specification of a variety of fruits and vegetables, age-specific requirements, whole grain requirement, and fat, saturated fat, and sodium restrictions. The current SFSP requirements most similarly reflect the original meal pattern-based SBP and NSLP requirements demonstrating the critical need for policy change that would enable updates to the SFSP nutrition standards to match the requirements of the NSLP and SBP.i.e., deficiencies were noted for both breakfast and lunch and across all grade group categories) related to protein and carbohydrate (in excess) and fiber (insufficient), which if consumed at these levels could lead to weight gain, which is particularly troubling given the current trends of excess weight gain during the summer months among disadvantaged children living in the US [Due to the discovery that there are severely limited and outdated data on the nutritional quality of meals served as part of the SFSP, we conducted a case study on a sample SFSP menu from summer 2015 that included both breakfast and lunches. The nutritional analysis of this one-week menu demonstrated that SFSP meals met current SBP and NSLP standards for certain nutrients , and failed to meet the standards for others. The most concerning results  for the basis of potential policy updates; as well as (b) to direct the “next steps” for future research in this area of inquiry. Even though the research studies under review in the current study were not specifically designed to assess the impact of changes to the programs on (a) nutritional adequacy of program meals; (b) dietary intakes of participants; and (c) nutritional outcomes of participants, examining the research along a time continuum in correspondence with the changes in nutrition standards to the programs allows for the opportunity to observationally examine if the changes in standards over time have led to improvements in the diet and health of its participants, which could serve as preliminary for a larger, more rigorously designed study.Several unique findings from this review should be investigated in follow up studies, such as the potential protective effect of SBP participation, the environmental effect of where breakfast is consumed, and differences in food security and potential protective effects of school meals participation on weight status. Researchers should also consider utilizing biomarkers to provide more concrete evidence as to the nutritional status of SBP, NSLP, and SFSP participants compared to non-participants, while assuring similarity between groups in demographic, health, and nutritional characteristics at baseline.In addition, more research needs to be conducted in several key areas. First, meal quality, dietary intake, and nutritional outcomes should be investigated as a result of the more stringent nutritional requirements implemented in 2010. Secondly, due to the complete dearth of research conducted on the SFSP, investigators should explore the nutritional quality and variety of foods served during the SFSP, as well as the impacts on nutritional outcomes such as dietary intake, weight status, and other anthropometrics as a potential avenue for policy change to improve the nutritional state of our country’s children today.


Several studies have shown that parity is associated with oral health problems such as tooth loss and dental caries. In Japan, however, no studies have examined the association. The purpose of this study was to determine whether parity is related to dentition status, including the number of teeth present, dental caries and filled teeth, and the posterior occlusion, in a Japanese population by comparing women with men.A total of 1,211 subjects, who participated both in the Japan Public Health Center-Based (JPHC) Study Cohort I in 1990 and the dental survey in 2005, were used for the study. Information on parity or number of children was collected from a self-completed questionnaire administered in 1990 for the JPHC Study Cohort I, and health behaviors and clinical dentition status were obtained from the dental survey in 2005. The association between parity or number of children and dentition status was analyzed, by both unadjusted-for and adjusted-for socio-demographic and health behavioral factors, using a generalized linear regression model.Parity is significantly related to the number of teeth present and n-FTUs , regardless of socio-demographic and health behavioral factors, in female subjects. The values of these variables had a significantly decreasing trend with the rise of parity: numbers of teeth present (p for trend = 0.046) and n-FTUs (p for trend = 0.026). No relationships between the number of children and dentition status were found in male subjects.Higher-parity women are more likely to lose teeth, especially posterior occluding relations. These results suggest that measures to narrow the discrepancy by parity should be taken for promoting women’s oral health. Delivery of appropriate information and messages to pregnant women as well as enlightenment of oral health professionals about dental management of pregnant women may be an effective strategy. Pregnancy and parturition have a tremendous effect on maternal health. Complications of pregnancy include bleeding, premature rupture of the membranes, puerperal endometritis and anemia,2. In thIn a Danish study, the numThe third National Health and Nutritional Examination Survey (NHANES III) demonstrated that parity was related to tooth loss among American women. Among BTo date, there is a paucity of research on the relationship between parity and oral health status. In Japan, in particular, no studies have been conducted to examine this association. Further, this kind of research will become more difficult in the future due to the declining birthrate in Japan; the birthrate in 2012 was 1.41. TherefoIn 1990, the Japan Public Health Center-Based (JPHC) Study Cohort I was launched in order to prospectively follow the morbidity and mortality of diseases, such as cancer and cardiovascular diseases, in a large population-based Japanese sample. In 2005We mailed invitation letters to 15,782 eligible residents, aged 55 to 75 years as of May, 2005, to inform them about the purposes and procedures of the study. From July, 2005 through January, 2006, a total of 1,518 subjects underwent a self-administered dental questionnaire and clinical oral examination. Information on parity was collected from a self-completed questionnaire administered in 1990 for the JPHC Study Cohort I. The final number of subjects used for the analysis was 1,211, after excluding those with missing data for either the outcome or any explanatory variable. Ethical approval of this study was granted by the Ethics Committee of the National Cancer Center in Tokyo and the Tokyo Medical and Dental University Ethical Committee, Japan.Female subjects were asked their number of childbirths, and male subjects were asked their number of children. The parity or number of children was then divided into five categories: 0, 1, 2, 3, and 4 or more.A self-completed dental questionnaire administered in 2005 inquired about health behaviors such as intake of sweet snacks or drinks , presence of a family dentist (yes or no) and smoking status .Standardized clinical oral examinations of the dentition (excluding third molars) were performed in 2005 by 43 participating dentists using the World Health Organization guidelines. TraininFollowing the examinations, n-FTUs , defined as the sum of pairs of opposing natural teeth , was calculated. Carious teeth with extensive coronal destruction and missing teeth were regarded as non-functional. Because two opposing premolars were defined as one FTU and two opposing molars as two FTUs, a person with a complete occluding dentition had 12 FTUs.Oral hygiene of teeth or dentures was evaluated by visually examining all teeth or the dentures and was scored as: 1) good = plaque covering less than one-third of tooth surfaces; 2) fair = plaque covering more than one-third but less than two-thirds of tooth surfaces; and 3) poor = plaque covering more than two-thirds of tooth surfaces. The worst score was recorded as representative for the person.The linear trend of parity or number of children  with demographics, health behaviors and oral hygiene was analyzed by a linear regression model for continuous data and by the Mantel-Haenzel’s chi-square test for categorical data. The adjusted mean of clinical dental outcome variables  and linear trend by parity or number of children were assessed using a generalized linear regression model. The analysis was performed both unadjusted-for and adjusted-for age (continuous), education level , intake of sweet snacks and drinks , presence of a family dentist (yes or no), smoking , and oral hygiene of teeth or dentures . All analyses were conducted using SAS 9.0 software .The numbers of subjects according to the parity 0, 1, 2, 3, and 4 or more among females were 36 (5.5%), 68 (10.5%), 371 (57.2%), 150 (23.1%) and 24 (3.7%), and those by the number of children among males were 25 (4.5%), 53 (9.4%), 336 (59.8%), 130 (23.1%) and 18 (3.2%), respectively  and n-FTUs (p for trend = 0.026) were significantly related with parity in female subjects. The values of these variables had a significantly decreasing trend with increasing parity. No significant associations were observed in male subjects.This report revealed that parity in Japanese women was related to the dentition status, regardless of socio-demographic and health behavioral factors. Such relationships were not observed in men after adjustment. Association between number of children and oral hygiene or n-FTUs found in bivariate analysis might be intermediated by the socioeconomic factors. Current results imply that higher-parity women are more likely to lose teeth than lower-parity women, probably due to periodontal disease as well as dental caries, which are two major causes for tooth extraction in Japanese adults. Women wAggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia/nigrescens, Tannerella forsythia, Parvimonas micra, Campylobacter rectus and Fusobacterium nucleatum[Several biological mechanisms to explain the lower number of teeth present with parity have been proposed. Pregnancy has a detrimental impact on oral tissues because various biological alterations occur in the oral cavity during the prenatal period. Fluctuations of pregnancy hormones, such as progesterone and estrogen, increase the vascular permeability in the oral cavity and decrease host immunity, increasing the susceptibility of pregnant women to oral infections,14. Furtnucleatum. Hormonanucleatum,17. The nucleatum, and proPrevious studies demonstrated that parity was related to untreated dental caries in the United States, and theAnother plausible reason for aggravation of dental diseases in females, other than biological alterations, is that women with many children may have various reasons for having difficulties getting treatment. Pregnancy and maternity may alter dental utilization patterns. Similarly, dentists’ attitudes and behavior may change when treating pregnant women. Former studies indicate that about half of the pregnant women with dental problems sought no dental care, or postIn this study, lower number of n-FTUs was found in higher-parity women. This finding indicates that loss of teeth affects posterior occluding relationships, especially occlusion with natural teeth. The number of FTUs is closely related with masticatory performance,34. TherOne limitation in the study is that intra- or inter-examiner reliability assessments were not carried out. Another limitation is that the subjects had voluntarily participated in the examination, and therefore, may not be a representative sample. Nonetheless, the present study demonstrates that Japanese women with high parity have a higher risk for dental diseases and are more likely to lose teeth, especially posterior occluding relations, compared to those with low parity.Parity in Japanese women was related to the dentition status. There are pathological as well as socio-behavioral reasons why parity is related with such dental problems. Therefore, further efforts are needed to narrow the discrepancy in parity-related oral health. To reduce the gap associated with parity, and to promote better oral health in women, it will be necessary to deliver appropriate information and messages to pregnant women and also enlighten oral health professionals about dental management of pregnant women.The authors declare that they have no competing interests.MU: conceived of the study and conducted statistical analyses and manuscript writing. SO: made contributions to conception and design of the study. MI and ST: contributed to interpretation of data and helped to draft the manuscript. YK: involved in writing the manuscript critically for important intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/993/prepub


Further evidence into the effects of social relationships on health  is needed in Japan. The Yabu Cohort Study was launched in 2012 to identify the associations between social relationships and health among community-dwelling older Japanese people and to evaluate population approaches for preventive long-term care in the community. This report describes the study design and the profile of the participants at baseline.The Yabu Cohort Study is a prospective study of community-dwelling individuals aged 65 years and older in Yabu, Hyogo Prefecture, Japan. The baseline survey, using a mailed self-administered questionnaire, was conducted from July through August 2012. It included information on socioeconomic status, general and psychological health, and social relationships . Survival time, long-term care insurance certification, and medical and long-term care costs after the baseline survey will be followed.Of 7271 questionnaires distributed, a total of 6652 were returned (91.5% response rate), and 6241 were included in the analysis. Mean age was 71.9 ± 5.2 years, 43.2% were men, and 83.8% had lived in their neighborhood for more than 40 years. Approximately 45.2% expressed general trust. About 82.4%, 49.9%, and 55.5% have participated in neighborhood association activities, municipal seminars for preventive long-term care, and salon activities in the community, respectively.The study is expected to provide valuable evidence on the effects of social relationships on health and to suggest the usefulness of population approaches for preventive long-term care in Japanese communities. Research suggests that efforts to improve community health should focus on the background risks of illness and unhealthy conditions. Social relationships  are considered part of these social determinants of health. A previous study using a meta-analysis reported that one’s social network and social support had comparable influence to well-established risk factors such as smoking and drinking on risk of mortality.3 Further, a review of the literature showed that stronger social capital at the community level generally appeared to have a positive influence on individuals’ health status.4The relevance of social determinants of health has been globally recognized as “solid fact.”5–7 Therefore, social relationships may influence not only people’s perceptions and behaviors but also their health status. Moreover, rural areas tend to be more collectivist than urban areas in Japan.8 This suggests that the characteristics of traditional Japanese society may remain stronger in the former context. Epidemiological studies can promote understanding of the effects of social relationships on health, and several Japanese longitudinal studies examining the link between social relationships and health outcomes have been published thus far.9–13 However, no study in a traditional rural community exists. Investigation in highly collectivist communities could enable comparison with findings from previous studies and contribute to understanding the mechanisms by which social relationships, both at the individual and community level, affect health.It is widely known that Japan, one of the countries with the highest longevity in the world, has a relatively collectivist society characterized by intense group ties within the community.Many cohort studies fail to pay attention to evaluating a population approach for preventive long-term care. To evaluate this approach, a community-based and long-term evaluation design with appropriate outcomes  should be prepared. However, few population studies have been evaluated in this way.14Given these considerations, we launched the Yabu Cohort Study in 2012 to prospectively identify the associations between social relationships and health among community-dwelling older Japanese individuals and to evaluate population approaches for preventive long-term care in the community. Here, we describe the study design and the profile of the participants at the baseline of the study. For the present report, we referred to a previous article on the design and the profile of participants at baseline of another cohort study.n = 1386) and those who died between June 1 and the date of the questionnaire dispatched in July (n = 16) were excluded, a total of 7271 questionnaires (the eligible population) were distributed. To combine the data from the questionnaire survey with the data from the follow-up survey (described below), we added a label with identification number and participant’s name, sex, and address to the questionnaire. However, our researchers were able to use only anonymous data. Before the survey, local residents were informed about the survey through the Yabu City bulletin. A reminder was sent to non-respondents in August 2012 to reduce response bias.In this prospective study, the source population comprised all community-dwelling people aged 65 years and older in the city of Yabu, Hyogo Prefecture, Japan. The baseline survey was conducted from July through August 2012 using a mailed self-administered questionnaire. 2. The proportion of people aged 65 years and older was approximately 32.6%. In Yabu, 8.2% of workers were employed in primary industries, 28.2% in secondary industries, and 63.0% in tertiary industries .15 From April 2011 through March 2012, total numbers of inflow (people moving to Yabu) and outflow (people moving from Yabu) were 428 and 699, and the rates of inflow and outflow were 1.63% and 2.66% , respectively.16Yabu is located in the northern part of Hyogo Prefecture and is about 100 km northwest of Osaka and Kyoto. As of July 1, 2012, it had a population of 26 642  and a population density of 63.0 persons/kmYabu has focused on community-based population approaches for years. For example, Yabu has conducted preventive long-term care seminars for all community-dwelling elderly individuals to enhance the levels of knowledge and behaviors regarding preventive long-term care among its older population . Staff of the community comprehensive support center have traveled around all administrative neighborhoods to collaborate with local neighborhood associations on conducting the seminar smoothly and effectively. Further, the city has trained health volunteers and encouraged their activities in local neighborhoods. “Salon” activities have also been developed in many neighborhoods, and many volunteers work in their neighborhood salons to promote social interaction and social ties among the elderly.Table 2). Food intake frequency included 10 kinds of foods .17We collected information on living arrangements, years of residence in the neighborhood, birthplace, and socioeconomic status. Socioeconomic status includes subjective poverty level, educational attainment, and annual household income. Other background information asked about in the questionnaire included history of physician-diagnosed diseases , smoking status, frequency of drinking, frequency of regular exercise, height, weight, and food intake frequency. Body mass index was calculated from height and weight .20–22 Subjective social isolation was assessed by the question, “How often do you feel that you are isolated from others?”We also solicited information regarding self-rated health, depressive mood, well-being, and subjective social isolation. Self-rated health was assessed using the question “How would you rate your current overall health?” The 15-item Geriatric Depression Scale (GDS) short-form23Activities of daily living were assessed, including basic ADL (BADL) and higher-order competence of independence. BADL was measured using five items: walking, eating, bathing, dressing, and toileting. To measure higher-order competence, we used the Tokyo Metropolitan Institute of Gerontology Index of Competence (TMIG-IC), which consists of three subscales: instrumental self-maintenance, intellectual activity, and social role.24,25 The index score range is 0–15, and a higher score indicates a greater likelihood of frailty. The cut-off point was set between 3 and 4, and a score of ≥4 was classified as frailty.Frailty was assessed using the kaigo-yobo (preventive care) checklist to screen for frailty, which consists of 15 items.We assessed social relationships, including social network, social support, and cognitive and structural aspects of social capital. We asked about the frequency of contact with family/relatives and friends, apart from cohabitating family members, as a measure of social network. Social support included availability of instrumental support (“Is there anyone who can help you when you are in trouble?”), informational support (“Is there anyone who can give you information and knowledge that you need?”), emotional support (“Is there anyone who can share your worries and feelings?”), and appraisal support (“Is there anyone who can give you appreciation and encouragement?”). Cognitive social capital included social trust and norms of reciprocity. Structural social capital included social participation in several organizations . As all residents in Yabu belong to neighborhood associations, we asked whether they had ever participated in neighborhood association activities. In addition, we asked about their frequency of participation in municipal seminars for preventive long-term care and salon activities.Neighborhood environments, including neighborhood social capital and neighborhood living environment, was assessed by asking about respondents’ perceptions of their local living environment using several items, including accessibility to non-residential facilities, safety, and landscape. Yabu consists of 161 administrative neighborhoods. We aggregated individual-level responses on social capital and living environment in every neighborhood as an indication of neighborhood-level environmental measures.We will follow four types of outcomes: survival time, LTCI certification, medical cost on national health insurance, and long-term care cost. To monitor these outcomes since the baseline survey, we will confirm information on the date of death or movement out of the study area, LTCI certification status (the date and the level of LTCI certification), and medical and long-term care costs every month. This information will be provided by the city of Yabu.The study protocol was reviewed and approved by the Ethical Committee of the Tokyo Metropolitan Institute of Gerontology . All participants gave informed consent prior to inclusion in the study: a statement attached to the questionnaire explained the purpose of the study, the voluntary nature of participation, and a promise of anonymity in the analysis. Returning the questionnaire was viewed as consent to participate in the survey.Of 7271 questionnaires distributed, 6652 were returned (91.5% response rate). Excluding 186 questionnaires from respondents who did not actually live in the city or were admitted to hospital or residing in nursing homes, 41 questionnaires that were almost or completely blank, and 4 with missing identification labels, 6421 were finally identified as the study population and included in the analysis at an individual level  .Table Table 26–28 Regarding cognitive social capital, approximately 45% and 51% of our participants answered that they have general trust and share norms of reciprocity, respectively. This can be contrasted to findings in another cohort study, which showed these proportions to be about 27% and 30%, respectively, in the general older population.26,27 In terms of structural social capital, about 82% had participated in the activities of neighborhood associations in our study, in contrast to reports that the proportion of participation in these activities was 30%–60% in previous generations.28 Because about 85% of our study participants have lived in their neighborhood for 40 years or more and about 77% were born within the city, they are likely to have strong social connections with other local people and organizations. However, although Yabu has intense community cohesion on average, the proportion of people with high social capital at the neighborhood level was widely distributed. This suggests that it is possible to compare the effect of neighborhood-level social capital on people’s health among the neighborhoods using multilevel analysis.We have described the study design and baseline profile of participants in the Yabu Cohort Study, which was launched in 2012. We found relatively high levels of social capital in our study population compared with the populations in other Japanese cohort studies.The Yabu Cohort Study has some strengths. First, our baseline survey was conducted for all community-dwelling elderly persons (except those with LTCI certification levels 1–5), and the response rate was high. Therefore, there should be relatively little possibility of selection or response bias. By linking the baseline and follow-up data, we were able to assess various associations and outcomes that will reflect the actual conditions of the source population, including an evaluation of the effect of using population-based approaches for preventive long-term care. Second, various measures were assessed in the baseline survey. We were therefore able to explore the effects of social relationships on health from several perspectives, allowing us to make recommendations about effective population-based health promotion and preventive long-term care strategies.Several study limitations also warrant mention. First, we collected the data using a self-administered questionnaire. Particularly among the variables on social relationships, the items have not been adequately validated. Second, this study was conducted in one city in a rural area, so the target population was limited in size. Care should therefore be taken when generalizing the findings. However, our study focuses on a unique Japanese area with high community cohesion. Further, Yabu has a large proportion of elderly people. Therefore, our findings may indeed prove useful in developing health promotion and preventive long-term care strategies in other areas that have rapidly aging populations.In conclusion, the Yabu Cohort Study was launched in 2012 to prospectively identify the association between social relationships and health among community-dwelling elderly Japanese and to evaluate population approaches for preventive long-term care in the community. Information on survival time, LTCI certification, and medical and long-term care costs will be collected in the planned follow-up survey.Abstract in Japanese.


Background. Relative to Europeans, Asian Indians have higher rates of type 2 diabetes and cardiovascular disease. Whether differences in body composition may underlie these population differences remains unclear.  Methods. We compared directly measured anthropometric data from the Chennai Urban Rural Epidemiology Study (CURES) survey of southern Indians (I) with those from three US ethnic groups  from NHANES III . A total of 15,733 subjects from CURES and 5,975 from NHANES III met inclusion criteria .  Results. Asian Indian men and women had substantially lower body mass index, waist circumference, hip circumference, waist-to-hip ratio, and body surface area relative to US groups . In contrast, the mean (±se) waist-weight ratio was significantly higher (P < 0.001) in I (men 1.35 ± 0.002 and women 1.45 ± 0.002) than in all the US groups ).  Conclusions. Compared to the US, the waist-weight ratio is significantly higher in men and women from Chennai, India. These results support the hypothesis that Southeast Asian Indians are particularly predisposed toward central adiposity. The number of people with type 2 diabetes in India is highest in the world and is predicted to increase 150% by year 2025, when the projected 69.9 million cases will comprise almost a quarter of the world's diabetic population  and coroThe World Health Organization has addressed this paradox of low obesity and high chronic disease risk in Asian populations by setting lower thresholds of BMI to identify those who may be at high risk . HoweverTo address the potential influence on chronic disease risk of high abdominal fatness relative to total body fatness in AI, we propose waist-to-weight ratio (WWR), as a single continuous index, to distinguish differences between cultures in the propensity to store fat in the visceral depots, consistent with differences in insulin resistance, diabetes, and cardiovascular disease (CVD). Therefore, we hypothesized that the WWR will be higher in Indian men and women than in US men and women. This hypothesis was tested by comparing anthropometric characteristics between young adults of the National Health and Nutrition Examination Survey (NHANES III)  to youngNHANES III  is a larCURES  is a larIn NHANES III, height was measured to the nearest 0.1 cm with calibrated stadiometer, without shoes. Weight was measured to the nearest 0.1 kg with calibrated scale, allowing light clothing. WC was measured to the nearest cm with tape measure at the highest point on the iliac crest, while the subject was at minimum respiration, allowing light clothing. HC was measured to the nearest cm with a tape measure at maximum extension of the buttocks, allowing light clothing. In CURES, height was measured to the nearest cm with a tape measure, subjects standing upright without shoes. Weight was measured to the nearest 0.5 kg with a calibrated scale, allowing light clothing. Waist was measured to the nearest cm with a tape measure at the smallest horizontal girth between the costal margins and the iliac crest at minimal respiration. Hip was taken as the greatest circumference at the level of greater trochanters (the widest portion of the hip) on both sides. It was measured to the nearest cm with a tape measure. In order to compare the sex-specific prevalence of overweight and obesity among the four ethnic groups, we used the currently accepted definitions based on BMI and WC cutoffs . These i2 . There were a total of 21,705 subjects  who met the inclusion criteria.In order to minimize the likelihood of bias due to age-cohort effects and the potential impact of clinical or subclinical illness on anthropometry, we implemented the following exclusion criteria: (1) missing or aberrant values for anthropometric variables , (2) missing race/ethnicity or race/ethnicity other than African American, Caucasian, or Mexican American , (3) age < 20 or >39 , (4) blood sugar < 50 mg/dL or >200 or known diabetes , and (5) BMI < 14 kg/mP values are 2-sided. Estimates were not weighted according to the NHANES sampling scheme because our aim was to make comparisons to the CURES population sample and not to make estimations for the entire US population.All analyses were sex-stratified and performed using SAS version 9.1 . We compared the unadjusted prevalence of overweight and obesity, based on BMI and waist categories, between AI and the three US race groups using chi-square analysis. General linear regression models were used to estimate unadjusted and adjusted least squares means (±se) of the anthropometric variables (dependent) by race and sex group. All P values <0.0001). Asian Indian men had a lower mean waist-to-hip ratio compared to the Caucasian and Mexican American men (P < 0.0001) but slightly larger mean waist-to-hip ratio than the African American men (P = 0.03). Asian Indian women had a higher mean waist-to-hip ratio compared to the African American and Caucasian women (P < 0.0001) but similar to the Mexican American women (P = 0.43).Race- and sex-stratified sample sizes and unadjusted anthropometric characteristics are shown in P < 0.0001 for all sex-stratified comparisons). This remained true even after applying lower cutoffs for the Asians Indians as suggested by the WHO Expert Committee recommendations [P value = 0.69), slightly less than Mexican American women  and significantly less than Caucasian women . In P < 0.0001). When applying the ethnicity driven IDF cutoffs, the differences between the AI and other groups were attenuated but remained statistically significant (P < 0.0001), even with the lower cutoffs suggested for the Asian Indian men.In men and women alike, as shown in ndations , except Of note, age and height adjustment did not alter the correlations in magnitude or direction in any considerable manner (data not presented). In contrast, as presented in Tables P < 0.0001) in the AI than in US for both sexes. The attenuation of these differences by age and height adjustment was minimal.To further evaluate possible differences between populations in central adiposity while taking into account differences in total body mass, we computed the WC to body weight ratio. The WWR followed a normal distribution for all sex and population groups. The median WWR was highest among men and women from India and was in fact higher than the 75th percentile of all other groups. The means of WWR before and after adjustment for height are shown in The present study compares a number of traditional anthropometric factors between young adults of the US representative NHANES III survey, including three race/ethnic groups, and the population-based CURES survey of AI. Our observations confirm the findings of others that the AI tend to be much smaller than the US population in all traditional anthropometric measurements—body weight, body height, BMI, body surface area, hips, and WC. In contrast, we observed the WHR, which some studies have found to be higher in AI than in other groups , 24, 26,It is possible, therefore, that if AI have a propensity towards excess accumulation of visceral body fat, it is being masked, perhaps especially in the men, by large differences in overall body size between populations. Based on the findings of the present study, it appears that our novel measurement, WWR, is a simple anthropometric index capturing population differences in propensity for intra-abdominal fat storage. The WWR would appear to sufficiently account for the large confounding influence of overall body size and general adiposity. For any given body weight, larger WC could reflect larger intra-abdominal fat depots. Individuals with relatively high body weights who tend to carry much of their weight in muscle and subcutaneous fat depots peripherally would be expected to have lower WWR and lower risk for diabetes and CVD, hypothetically. Based on our observations, the distribution of WWR in young adults from Chennai, India, is considerably shifted to the right in comparison to similarly aged adults from three race/ethnic groups of the US population.r =  ~0.9) in WC is explained by BMI, whereas in Chennai, India, these two parameters shared less than 40% common variance (r =  ~0.60). This observation helps us to understand the basis for the higher WWR in Chennai than in US. At any given BMI there is clearly much more variation in the WC of Asian Indian young adults than in US young adults. Indeed, the variance of WWR in the Chennai men and women was threefold higher than that of the US men and women (0.03 versus 0.01). This observation suggests that AI may have a heightened propensity for accumulating central adiposity, for any given body size, than other populations.An intriguing observation from comparisons performed in present study was the vastly different correlation between WC and BMI between young adults of Chennai, India, compared to those from three US race/ethnic groups. In the US over 80% of the variation  a waist-to-BMI ratio (WBR). This ratio differentiated the two populations on an ecological level in a similar manner as did the WWR. Using such ratio did not seem to provide any added benefit to the WWR, while it may be fraught with a number of conceptual and statistical problems discussed by others , 36. AnoStrengths of the present study are multiple. It is a population-based and a large-scale study of AI who have a high risk of diabetes; the study compares them with the three main ethnic groups of the US NHANES population. The high quality standardization of anthropometric measurements in both cohorts minimizes measurement errors and biases. Despite several practical advantages of ecologic studies, including low cost, there exist several methodological limitations to any ecological study in its ability to make causal inferences . EcologiWe believe that our findings in this study are provocative and should stimulate further research into novel anthropometric features that may differentiate populations at very high risk for chronic disease, despite relatively low adiposity. The findings should motivate future coordinated research on complex exposures, their social and behavioral determinants, and possible interventions. Certainly, the WWR should be validated using more precise clinical methods of measuring fat depots, including DEXA and CT scan. The WWR should be investigated in other studies in order to address possible influences of age, ethnicity, gender and nutritional status, and its relation to chronic diseases and mortality.