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The available health indicators show that the health status of Somalis is poor in almost every aspect erectile dysfunction young adults treatment discount priligy 60mg online. Vaccine preventable diseases continue to erectile dysfunction treatment in usa cheap 30 mg priligy with amex be a leading cause of death and morbidity among children (International Crisis Group erectile dysfunction pills for diabetes buy cheap priligy 60mg line, 2010) erectile dysfunction pump ratings purchase priligy amex, and an estimated 72% of all deaths are caused by communicable diseases. Maternal mortality is high, at 1,044 per 100,000 live births, only 33% of births are attended by skilled health personnel, and antenatal care coverage is 26%. Cases continued to occur in Bakool, with approximately 140 cases reported annually from 2002 to 2004. A marked increase to 1,002 patients was observed in 2006, 80% of which came from two districts, Haddur and Tijeglow, in Bakool (Raguenaud et al. World Vision also collected data towards the end of the outbreak, and had 153 cases admitted for treatment between July 2008 and February 2009. Among these cases there were 20 deaths; 42 confirmed cases defaulted before being admitted to treatment (Personal communication, Sharif Mohamed, World Vision). The low case fatality rate and paediatric profile of this outbreak differ from the general East African profile of high mortality and a high infection rate in adults (Marlet et al. In 2010, no activities were conducted in January, but from February through April 45 cases were treated. Additionally, the fact that people are regularly forced to move between geographic areas means that it is often unclear where cases originate or where exactly transmission occurs (Ruiz Postigo, 2010). Dry food rations are provided to patients that are not from Baidoa twice a month during treatment. Because treatments take 30 days, and many patients travel from far away, food rations prevent patients from defaulting on treatment, which used to occur frequently. The rations allow patients to contribute food to the families they stay with in the town and provide an incentive to stay for the full length of treatment. Due to lack of resources and funding, activities are presently only implemented in Tijeglow district; past activities also included Bay region. North Sudan is one of the largest countries in Africa, covering an area of over 1,865,800 2 km and with a population of approximately 33. A large portion of the country is dominated by desert while the rest consists mostly of Savannah grassland. The rainy season is from July to September in the north, but starts a little later in the southern areas. The main endemic area is in the east between the White Nile and the Ethiopian border, including White Nile state, the Blue Nile river basin and Atbara and Rahad tributaries in Kassala, Gedarif and Sennar states, and reaches across the border of Southern Sudan into Upper Nile state (Siddig et al. Scattered cases have also been reported from the Nuba mountains in South Kordofan state, from areas along the Nile north of Khartoum, and from western Darfur (Osman et al. Anthroponotic transmission via sandflies is also likely, especially during epidemics. In villages near Dinder National Park in Gedarif and Sennar states, both near the Ethiopian border, there is intense transmission with a significant number of individuals being asymptomatic carriers, indicating that humans are a reservoir for the disease in this area (Ibrahim et al. The area has a savannah climate with acacia/balanite forests and cracked alluvial ‘black cotton’ soil, a short rainy season (July to October) and dry hot season (November to June). In response, the Sudan KalafiAzar Commissions was established, operating from 1909 to 1913 (Zeese and Frank, 1987). Over the following years, Kassala and Fung in Blue Nile state were identified as endemic areas (Kirk, 1939, ElfiSafi et al. In Wad Arud, Blue Nile state, a small outbreak in a military patrol was recorded in 1928 (Kirk, 1939). Further cases then occurred during the resettlement of people from Wadi Halfa, Northern State, during an agricultural programme in 1930, resulting in the death of over one sixth of the population (Hoogstral and Heyneman, 1969). More cases were recorded in WadegafiKurmuk in Blue Nile state and neighbouring Upper Nile state during the 1950s (Hoogstral and Heyneman, 1969). A major epidemic then occurred in Fung, Blue Nile state, from 1956fi60 in which thousands of people died and the tribe most affected, the Jum Jum, experienced a mortality rate of over 50% (Sati, 1958, de Beer et al. By 1985, approximately 1,300 patients were being reported in Sudan each year, 75% of which from Gedarif and Hawata (Zeese and Frank, 1987). The numbers of cases in the east began to decline from 1985, but rose again from 1991 onward particularly around the Rahad and Dinder rivers (Zijlstra et al. Further outbreaks were recorded in Dinder National Park, Gedarif state, from 1988 to 1989 and from 1994 to 1995 following the transfer of game wardens from the southern region to the park. In 1996, another larger outbreak occurred in Gedarif state spreading to Eritrea and northwest Ethiopia, continuing through 1998fi9 (Osman et al. Half of the cases originated from a single village, Barbar El Fugara (ElfiSafi 51 Leishmaniasis in eastern Africa: Situation and Gap Analysis et al. The majority of cases were children, suggesting a high level of immunity among adults, indicating a longfiterm presence of the disease in the area. Highfiincidence villages were clustered around the Atbara and Rahad rivers and in areas of low altitude and high rainfall (Elnaiem et al. Gedarif currently has two main endemic zones: a low endemicity zone in the central region around Gedarif city and a high endemicity zone around the Rahad and Atbara rivers, both tributaries of the Blue Nile (Elnaiem et al. The second focus includes villages near Dinder National Park on the Ethiopian border, where the high degree of transmission and significant number of asymptomatic human carriers suggest anthroponotic transmission (Ibrahim et al. Central An outbreak occurred on the western bank of the White Nile in 1983, 100 km south of Khartoum (Khalil et al. No further cases were reported in the area until 2006, when there was another outbreak, possibly caused by resurgence of the sandfly population due to refigrowth of the acacia/balanite trees after a period of drought, intense grazing and tree felling (Khalil et al. A major outbreak occurred in Unity State, Southern Sudan between 1984 and 1994, which may have been triggered by nomadic pastoralists from Blue Nile importing the disease from the north (see section on Southern Sudan). Other factors that have been found to reduce risk of infection include the lack of cattle ownership and presence of the Azadirachta (neem) tree (Bucheton et al. The first outbreak occurred from 1976fi77 in the Shendifi Atbara region north of Khartoum province (Abdalla and Sherif, 1978). The second outbreak started in Khartoum in 1985 on Tuti, an island of about 20,000 inhabitants at the junction of the White and Blue Nile rivers; approximately 10,000 cases were recorded between 1985 and 1987. The third epidemic occurred along the main Nile, north of Khartoum up, to the border with Egypt; all age groups were affected (el Safi and Peters, 1991). Only 78 sporadic and isolated cases have been reported since the disease was first described by Christopherson in 1914 (elfiHassan et al. Leishmaniasis focal persons have also been appointed in some of the endemic states. Parasitological confirmation via a lymphfinode or bone marrow aspirate is recommended. Splenic aspirate has been shown to have a sensitivity of at least 92% in Sudan (Van Peenen and Reid, 1962, Siddig et al. Lymph node aspirate is a safer method, but reports of sensitivity have varied from 58. The use of amphotericin B is not recommended due to possible side effects, although permitted in unavoidable circumstances. One study reported that 47% of patients were not cured after wellfisupervised treatment (Osman et al. Relapse rates after treatment have varied from 1% to 18% (Sati, 1958, Osman et al. However, incomplete treatment and suboptimal dosing have both been implicated in the occurrence of complications after treatment. This suggests that treatment outcomes could be improved through better training and implementation of correct treatment (Zijlstra et al. The trial is taking place in Kenya and in North Sudan at the Doka health centre in Gedarif, and is scheduled to finish in June 2011. There was no difference between the group who received the vaccine (without adjuvant) and the group who received the placebo (Khalil et al. A referendum to decide whether Southern Sudan will remain part of the Republic of the Sudan is scheduled for January 2011. The terrain consists of flat savannah grasslands with scattered acacia/balanite forests. The rainy season lasts from April to November and causes large parts of the country to become flooded and inaccessible.

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For example erectile dysfunction drugs purchase priligy with american express, pursuant to erectile dysfunction at age 30 buy priligy 60 mg fast delivery the provisions of the Convention between the Government of the United States of America and the Government of the State of Israel with respect to impotence ruining relationship buy cheapest priligy Taxes on Income erectile dysfunction doctors in colorado order priligy 60 mg online, as amended, or the U. Such exemption will not apply if: (i) such person holds, directly or indirectly, shares representing 10% or more of our voting power during any part of the 12-month period preceding such sale, exchange, or disposition, subject to particular conditions; (ii) the capital gains from such sale, exchange, or disposition are attributable to a permanent establishment in Israel; or (iii) such person is an individual and was present in Israel for 183 days or more during the relevant tax year. In such case, the capital gain arising from the sale, exchange, or disposition of our ordinary shares would be subject to Israeli tax, to the extent applicable; however, under the U. Shareholders may be required to demonstrate that they are exempt from tax on their capital gains in order to avoid withholding at source at the time of sale. It should be noted that in the event that the real capital gain realized by an individual shareholder is not exempt from tax in Israel, the tax rates applicable to Israeli resident individual shareholders should generally apply. In some instances where our shareholders may be liable for Israeli tax on the sale of their ordinary shares, the payment of the consideration may be subject to the withholding of Israeli tax at source. As of January 1, 2012 and thereafter, the tax rate applicable to such dividends is generally 25%. With respect to a person who is a “substantial shareholder” (as defined above) at the time the dividend is received or at any time during the preceding 12-month period, the applicable tax rate is 30%. Dividends paid from income derived from Preferred Enterprises and Preferred Technology Enterprises will generally be subject to income tax at a rate of 20%. For this purpose, taxable income includes taxable capital gains from the sale of our shares and taxable income from dividend distributions. Dividends paid to an Israeli resident individual shareholder on our ordinary shares will generally be subject to withholding tax at the rates corresponding with the income tax rates detailed above unless we are provided in advance with a withholding tax certificate issued by the Israel Tax Authority stipulating a different rate. Notwithstanding the above, dividends paid to an Israeli resident “substantial shareholder” (as defined above) on publicly traded shares, like our ordinary shares, which are held via a “nominee company” (as defined under the Israeli Securities Law), are generally subject to Israeli withholding tax at a rate of 25%, unless a different rate is provided under an applicable tax treaty, provided that a certificate from the Israel Tax Authority allowing for a reduced withholding tax rate is obtained in advance. If the dividend is attributable partly to income derived from a Preferred Enterprise or a Preferred Technology Enterprise and partly to other sources of income, the tax rate will be a blended rate reflecting the relative portions of the various types of income. Israeli resident companies are generally exempt from tax on the receipt of dividends paid on our ordinary shares. Non-Israeli Residents Unless relief is provided in a treaty between Israel and the shareholder’s country of residence, non-Israeli residents are generally subject to Israeli income tax on the receipt of dividends paid on our ordinary shares at the rate of 25%. With respect to a person (including a corporation) who is a “substantial shareholder” (as defined above) at the time of receiving the dividend or at any time during the preceding 12-month period, absent treaty relief as mentioned above, the applicable Israeli income tax rate is 30%. Notwithstanding the above, dividends paid from income derived from Preferred Enterprises will be subject to Israeli income tax at a rate of 20%. In addition, dividends distributed by a Preferred Technology Enterprise that are paid out of Preferred Technology Income are subject to tax at the rate of 20%, but if they are distributed to a foreign company and at least 90% of the shares of the distributing company are held by foreign resident companies then the tax rate may be as low as 4%, subject to the fulfillment of certain conditions. In this regard, dividends paid to a non-Israeli resident shareholder on our ordinary shares will generally be subject to withholding tax at the rates corresponding with the income tax rates detailed above unless we are provided in advance with a withholding tax certificate issued by the Israel Tax Authority stipulating a different rate. Notwithstanding the above, dividends paid to a non-Israeli resident “substantial shareholder” (as defined above) on publicly traded shares, like our ordinary shares, which are held via a “nominee company” (as defined under the Israeli Securities Law), are generally subject to Israeli withholding tax at a rate of 25%, unless a different rate is provided under an applicable tax treaty, provided that a certificate from the Israel Tax Authority allowing for a reduced withholding tax rate is obtained in advance. If the dividends are sourced from income derived during a period for which we are entitled to the reduced tax rate applicable to a Preferred Enterprise or a Preferred Technology Enterprise under the Investment Law, to the extent that the first two conditions detailed above are met, the Israeli tax rate applicable to such dividends should be 15%. We cannot assure you that we will designate the profits that are being distributed in a way that will reduce shareholders’ tax liability. Israeli law also does not presently impose gift taxes upon the transfer of assets to Israeli resident individuals so long as it is demonstrated to the satisfaction of the Israel Tax Authority that the transfer was executed in good faith. Federal Income Tax Consequences the following summary describes certain material U. The discussion below is based upon the Code, final, temporary and proposed Treasury regulations promulgated thereunder, applicable administrative rulings and judicial interpretations thereof, and the U. Except to the limited extent discussed below, this summary does not consider the U. The tax consequences to such a partner or partnership are not considered in this summary and partners and partnerships should consult their tax advisors with respect to the U. However, we do not expect to maintain calculations of our earnings and profits under United States federal income tax principles. The amount of the dividend will generally be treated as foreign-source dividend income to U. Such gain or loss will generally be ordinary income or loss and United States source income for U. Subject to certain significant conditions and limitations, including potential limitations under the U. Preferential tax rates for long-term capital gain will generally apply to non-corporate U. Failure to comply with these and other reporting requirements could result in the imposition of significant penalties. Passive income for this purpose generally includes dividends, interest, rents, royalties, annuities, income from certain commodities transactions and from notional principal contracts, and the excess of gains over losses from the disposition of assets that produce passive income. Passive income also includes amounts derived by reason of the temporary investment of funds, including those raised in a public offering. Assets that produce or are held for the production of passive income include cash, even if held as working capital or raised in a public offering, marketable securities, and other assets that may produce passive income. The amount allocated to each other taxable year would be subject to tax at the highest rate in effect for individuals or corporations, as appropriate, for that taxable year, and an interest charge would be imposed on the amount allocated to that taxable year. We have delisted our ordinary shares from the Tel Aviv Stock Exchange and the last date of trading of our ordinary shares was on October 29, 2018. Medicare Tax on Investment Income In addition to the income taxes described above, U. Information reporting and backup withholding will not apply with respect to payments made to certain exempt recipients, such as corporations and tax-exempt organizations. Backup withholding is not an additional tax and may be claimed as a credit against the U. Transferor of Property to a Foreign Corporation) to report a transfer of cash or other property to us. As a foreign private issuer, we are exempt from the rules under the Exchange Act related to the furnishing and content of proxy statements, and our officers, directors and principal shareholders will be exempt from the reporting and short-swing profit recovery provisions contained in Section 16 of the Exchange Act. Market risk represents the risk of loss that may impact our financial position due to adverse changes in financial market prices and rates. Our market risk exposure is primarily a result of fluctuations in foreign currency exchange rates and interest rates. A material portion of our research and development is conducted through collaboration agreements denominated in U. To date, we have not entered into any hedging arrangements with respect to foreign currency risk or other derivative financial instruments. In the future, we may enter into currency hedging transactions to decrease the risk of financial exposure from fluctuations in the operating currencies. These measures, however, may not adequately protect us from the material adverse effects of such fluctuations. Interest Rate Risk At present, our investments consist primarily of cash and cash equivalents in short-term deposits. The primary objective of our investment activities is to preserve our capital to fund our operations. Our investments are exposed to market risk due to fluctuation in interest rates, which may affect our interest income and the fair market value of our investments, if any. Due to the short-term maturities, if any, of our investments to date, their carrying value has always approximated their fair value. We believe that our exposure to interest rate risk is not significant and a 1% change in market interest rates would not have a material impact on our assets. The Bank of New York Mellon’s principal executive office is located at 240 Greenwich, New York, New York 10286. The depositary collects fees for making distributions to investors by deducting those fees from the amounts distributed or by selling a portion of distributable property to pay the fees. The depositary may collect its annual fee for depositary services by deduction from cash distributions or by directly billing investors or by charging the book-entry system accounts of participants acting for them. Based on such evaluation, those officers have concluded that, as of the Evaluation Date, our disclosure controls and procedures are effective in recording, processing, summarizing and reporting, on a timely basis, information required to be included in periodic filings under the Exchange Act and that such information is accumulated and communicated to management, including our principal executive and financial officers, as appropriate to allow timely decisions regarding required disclosure. Internal control over financial reporting is defined in Rule 13a-15(f) or 15d-15(f) promulgated under the Exchange Act as a process designed by, or under the supervision of, the company’s principal executive and principal financial officers and effected by the company’s board of directors, management and other personnel, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles and includes those policies and procedures that: fi pertain to the maintenance of records that in reasonable detail accurately and fairly reflect the transaction and dispositions of the assets of the company; fi provide reasonable assurance that transactions are recorded as necessary to permit preparation of financial statements in accordance with generally accepted accounting principles, and that receipts and expenditures of the company are being made only in accordance with authorizations of management and directors of the company; and fi provide reasonable assurance regarding prevention or timely detection of unauthorized acquisition, use or disposition of the company’s assets that could have a material effect on the financial statements. Because of its inherent limitations, internal control over financial reporting may not prevent or detect misstatements.

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Upregulation of surface proteins in Leishmania donovani isolated from patients of post kala-azar dermal leishmaniasis erectile dysfunction treatment yoga purchase 60 mg priligy visa. Mucocutaneous leishmaniasis in Colombia: Leishmania braziliensis subspecies diversity erectile dysfunction pills from india discount priligy 90mg line. Epidemiologic diabetes and erectile dysfunction health order priligy uk, genetic erectile dysfunction in young guys purchase 90mg priligy mastercard, and clinical associations among phenotypically distinct populations of Leishmania (Viannia)in Colombia. Pathogenicity and protective immunogenicity of cysteine proteinase-deficient mutants of Leishmania mexicana in nonmurine models. Leishmania major: differential regulation of the surface metalloprotease in amastigote and promastigote stages. Multiclonal Leishmania braziliensis population structure and its clinical implication in a region of endemicity for American tegumentary leishmaniasis. The mitochondrial genome of kinetoplastid protozoa: genomic organization, transcription, replication and evolution. Leishmania (Viannia) braziliensis: biological behavior in golden hamsters of isolates from Argentine patients. Diagnostic and prognostic value of K39 recombinant antigen in Indian leishmaniasis. Leishmania chagasi: lipophosphoglycan characterization and binding to the midgut of the sand fiy vector Lutzomyia longipalpis. Lipophosphoglycan is a virulence factor distinct from related glycoconjugates in the protozoan parasite Leishmania major. Proceedings of the National Academy of Sciences of the United States of America 97, 9258–9263. Genomic organization, chromosomal location and transcription of dispersed and repeated tubulin genes in Leishmania major. Philosophical Transactions of the Royal Society of London, Series B: Biological Sciences 354, 701–710. Sequence heterogeneity and polymorphic gene arrangements of the Leishmania guyanensis gp63 genes. From genome to vaccines for leishmaniasis: screening 100 novel vaccine candidates against murine Leishmania major infection. Mixed leishmanial infections in Rhombomys opimus: a key to the persistence of Leishmania major from one transmission season to the next. Experimental pathogenicity of viscerotropic and dermotropic isolates of Leishmania infantum from immunocompromised and immunocompetent patients in a murine model. The evolutionary biology and population genetics underlying fungal strain typing. Comparative proteome analysis of Leishmania donovani at different stages of transformation from promastigotes to amastigotes. Genetic epidemiology of parasitic protozoa and other infectious agents: the need for an integrated approach. Human genetic diversity and the epidemiology of parasitic and other transmissible diseases. Towards a population genetics of microorganisms: the clonal theory of parasitic protozoa. A clonal theory of parasitic protozoa: the population structures of Entamoeba, Giardia, Leishmania, Naegleria, Plasmodium, Trichomonas,andTrypanosoma and their medical and taxonomical consequences. Proceedings of the National Academy of Sciences of the United States of America 87, 2414–2418. Proceedings of the National Academy of Sciences of the United States of America 90, 1335–1339. Antigen genes for molecular epidemiology of leishmaniasis: polymorphism of cysteine proteinase B and surface metalloprotease glycoprotein 63 in the Leishmania donovani complex. In vitro promastigote fitness of putative Leishmania (Viannia) braziliensis/Leishmania (Viannia) peruviana hybrids. Human infectivity trait in Trypanosoma brucei:stability, heritability and relationship to sra expression. High-throughput approaches to study salivary proteins and genes from vectors of disease. Plasticity of gp63 gene organization in Leishmania (Viannia) braziliensis and Leishmania (Viannia) peruviana. The gp63 gene locus, a target for genetic characterization of Leishmania belonging to subgenus Viannia. Complexity of the major surface protease (msp) gene organization in Leishmania (Viannia) braziliensis: evolutionary and functional implications. The Ity/Lsh/ Bcg locus: natural resistance to infection with intracellular parasites is abrogated by disruption of the Nramp1 gene. Clonal composition of Staphylococcus aureus isolates at a Brazilian university hospital: identification of international circulating lineages. Comparison of the haemagglutination activities in gut and head extracts of various species and geographical populations of phlebotomine sandfiies. Identification of developmentallyregulated proteins in Leishmania panamensis by proteome profiling of promastigotes and axenic amastigotes. The agglutination of erythrocytes and Leishmania parasites by sandfiy gut extracts: evidence for lectin activity. Coinfection of visceral leishmaniasis and Mycobacterium in a patient with acquired immunodeficiency syndrome. Genomic fingerprinting by arbitrarily primed polymerase chain reaction resolves Borrelia burgdorferi into three distinct phyletic groups. The importance of gene rearrangement in evolution: evidence from studies on rates of chromosomal, protein, and anatomical evolution. Proceedings of the National Academy of Sciences of the United States of America 71, 3028–3030. The Leishmania genome comprises 36 chromosomes conserved across widely divergent human pathogenic species. Proceedings of the National Academy of Sciences of the United States of America 79, 6999–7003. Evidence of sexual reproduction in the protozoan parasite Leishmania of the Old World. Genetic polymorphism within the Leishmania donovani complex: correlation with geographic origin. Loss of virulence in Leishmania donovani deficient in an amastigote-specific protein, A2. Proceedings of the National Academy of Sciences of the United States of America 94, 8807–8811. Characterization of the A2–A2rel gene cluster in Leishmania donovani: involvement of A2 in visceralization during infection. In vivo selection for Leishmania donovani miniexon genes that increase virulence in Leishmania major. Comparison of the A2 gene locus in Leishmania donovani and Leishmania major and its control over cutaneous infection. Endemic kala-azar in eastern Sudan: a longitudinal study on the incidence of clinical and subclinical infection and post-kala-azar dermal leishmaniasis. During a blood meal, an infected phlebotomine sand fiy releases metacyclic promastigotes into vertebrate hosts such as humans. The parasites are then phagocytosed by host macrophages and change into amastigotes. After amastigote multiplication and rupture of the macrophage, the amastigotes invade neighbouring macrophages. The life cycle is complete when a phlebotomine female is infected while feeding on the blood of an infected host. Three features make them easy to recognize: when at rest, they characteristically hold their wings at an angle above the abdomen; they are hairy; and, when coming to feed, they typically hop around on the host before settling down to bite. Differences in the gene expression of parasites in inoculum and tissue were also elucidated. Differences in the amastin, the key glycoprotein on the surface on intracellular-stage parasites, are apparent between the inoculum and tissue parasites, which may reflect microenvironment adaptation. These experiments are among the first attempts to in vivo transcriptome sequence mice and Leishmania simultaneously, a powerful approach giving insight to action and reaction. However, these techniques are not without challenge, such as low parasite read counts. First and foremost, I would like to thank Professor Jeremy Mottram, for his endless hard work patching up the holes in my experimental design, lab work, thesis, and well – everything!

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The leading causes of death in obese families impotence at 55 cheap priligy 90 mg overnight delivery, they are well positioned to erectile dysfunction buy cheap priligy 60 mg on-line help turn adults include ischemic heart disease erectile dysfunction causes mnemonic buy generic priligy from india, diabetes erectile dysfunction doctor maryland buy discount priligy 30 mg, the tide on the obesity epidemic. Low physical fitness and insulin resistance Stigma Many factors complicate efforts to address Mobility limitations Hepatic steatosis Teasing and bullying overweight, obesity, and the promotion of Reduced academic Hypertension healthier diets and lifestyles. Some barriers performance 3,5-9 Hyperuricemia and gout identified by physicians include: Reduced productivity Menstrual abnormalities • Insufficient time during visits for screenUnemployment Orthopedic problems ing and counseling Lack of available referral services for patients Reduction of cerebral • blood flow • Perception that patients will not be willing Sleep apnea or able to make lifestyle changes Poor reimbursement for nutrition and Type 2 diabetes • weight-management counseling Institute of Medicine. Accelerating progress in obesity prevention: Solving the • Reluctance to discuss weight among physiweight of the nation. OverSome of the leading causes of preventable weight and obesity result from an energy death among adults are obesity-related condisurplus over time that is stored in the body as tions such as heart disease, stroke, type 2 diafat. How genetic and environmental factors betes, and some types of cancer (endometrial, contribute to overweight and obesity is not well breast, colon). However, women with limOverweight and obesity, and associated ited education and lower incomes tend to be at health problems, account for a significant greater risk of obesity. In 2008 some racial and ethnic groups more than othdollars, medical costs, both direct and indirect, ers. Among children ages 2 to 4 years are obese are more likely than those of normal in low-income households, the prevalence of weight to face discrimination at work and in obesity and extreme obesity appear to have other settings. Hispanic boys cations to treat it confer a propensity toward are significantly more likely to be obese than weight gain and disordered eating. Many agents, including beta blockers, corticosteroids, diabetes drugs, and psychoactive drugs, are known to cause weight gain. Prescribing these medications may be unavoidable, but patients should be told that weight gain is a side effect and encouraged to take steps to prevent it. Approxidisease, other atherosclerotic diseases, cardiomately 34% of adults meet the criteria for vascular risk factors, type 2 diabetes, or sleep metabolic syndrome, and the risk increases with apnea increases the risk for complications and age. Blood pressure and lipid levels should factors is an important addition to weightbe measured, and fasting glucose tested. Amelioration of risk factors (Table 2) will reduce the risk for cardiovascular disease Table 2. Increased waist circumference can be a marker for increased disease risk, even in persons of normal weight. Conditions such as osteoarthritis, gallDiagnostic Criteria for Metabolic Syndrome* stones, stress incontinence, amenorrhea, and menorrhagia are also associated with obesity Measure (any 3 of 5 criteria and are often the reasons patients visit their constitute diagnosis of 4 metabolic syndrome) Categorical Cut Points physicians. These visits provide a valuable opportunity to help patients understand the Elevated waist circumference >102 cm (>40 in) in men connections between nutrition, physical activ>88 cm (>35 in) in women ity, and health. Table 3 lists five criteria for metabolic syn*Three of the criteria must be present to make the diagnosis. The predominant underlying risk factors for metabolic syndrome are abdominal obesity and insulin resistance. Although many patients may be genetically susceptible to metabolic Informing a patient that he or she has syndrome, it rarely develops in the absence of metabolic syndrome can generate a valuable obesity and physical inactivity. For example, underthe key emphasis in management is mitigation standing the likely progression from metabolic of modifiable risk factors, specifically obesity, syndrome to type 2 diabetes may motivate physical inactivity, atherogenic diet, and smokpatients to take steps to reduce their weight ing, through lifestyle changes. In the trial, intensive lifestyle modiease has been well-documented and provides fication decreased progression to diabetes by the rationale for management of obesity. Behavioral obesity, making physical activity recommendainterventions included meeting with individual tions, and providing referrals to weight-loss case managers, group and individual counselgroups or programs. Imperfect goal attainment is to patients to reduce and manage their weight by be expected and should be handled with empamonitoring and modifying their food intake, thy and tact. This can be achieved by comincreasing their physical activity level, and recmunicating that the goal, not the patient, is at ognizing and controlling cues that trigger overissue. Behavioral-based treatment programs and take a problem-solving approach to help have been shown to improve weight-loss results, whether administered individually or in a group setting, at least in the short term. In addition, higher treatment intensity Food intake and physical activity in context of health risks was associated with greater weight loss. Higherand appropriate dietary approach intensity interventions include self-monitoring, Medications that affect weight or satiety goal setting, and planning to address barriers to Readiness to change behavior and stage of change maintaining lifestyle changes over time. With ment plan these patients, motivational interviewing may If patient chooses diet, physical activity, and/or medication, be a better approach. In motimodification guide vational interviewing, physicians ask questions Provide Web resources based on patient interest and need that lead patients to identify healthy choices Identify method for self-monitoring. Telling patients that Review food and activity diary on follow-up (reassess if initial they are overweight and must diet often leads to goal is not met) defensiveness and resistance. In contrast, asking Arrange Follow-up appointments to meet patient needs patients how they feel about their current weight Referral to registered dietitian and/or behavioral specialist for gives them an opportunity for self-examination individual counseling/monitoring or weight-management that may lead to the realization that they can do class more to improve their health. Weight loss toward goal achievement should be assessed, strategies that really work. Components and Examples of Motivational Interviewing Component Sample Statements Rationale Agenda setting “Would you mind if I talked with you about your weightfi Losing even a modest amount of weight can lower long-term health outcomes; indicates your risk. In the end, longterm success depends on the degree to which Another key to successful weight loss is stimupatients embrace the goals, and the extent to lus control — identifying and modifying cues which the goals satisfy their needs for autonthat trigger unhealthy habits such as overeating omy and competency. Learning to control these cues is helpful not only for short-term weight loss but also for long-term maintenance. Patients are eating only at the dining table; not eating while asked to observe and record target behaviors. Ultimately, with lifestyle coaches in addition to quarterly the best diet is one that the patient will be able office visits), and enhanced lifestyle counselto follow consistently over time. Adding to the difficulty tory is an important step in helping overweight is the reality that weight loss leads to a reducand obese patients identify and adapt healthier tion in energy expenditure. One such resource is the webcompared with that predicted by body composite Patients who are interested in more in-depth education can be referred to a registered dietitian for counseling (if that Lessons From the National Weight Control Registry resource is not available in the family physician’s Patients need reassurance that they can be successful in managing their office). Thus, it may be helpful to share data from the National Weight ics (formerly the American Dietetic Association) Control Registry. The registry includes individuals who have lost an averis a resource for finding registered dietitians. This series summarizes • Being physically active for at least 60 to 90 minutes per day the evidence base for dietary recommendations • Eating a lowfat diet that is rich in complex carbohydrates such as controlling portion sizes, increasing • Eating breakfast every day fruit and vegetable consumption, and decreas• Weighing themselves frequently (most at least weekly) ing saturated fat. A descriptive study of individuals successful at long-term maintenance of substantial weight loss. Persons successful it is essential to convey that these tips will at long-term weight loss and maintenance continue to consume a low-calorie, aid weight loss only when accompanied by an low-fat diet. However, commercial weight-loss health benefits of physical activity outweigh posprograms can be expensive and only occasionsible adverse outcomes. Adults with very low fitally have been evaluated in long-term clinical ness levels can start with 10-minute increments trials. Duration and intensity can be increased appear to carry any greater risks than other over time as fitness improves. Therefore, patients can be not just formal exercise — count and can be encouraged to choose the program they feel is beneficial for weight control. Small changes that best suited to their needs and that can be intemost patients can incorporate into their regular grated into their lifestyle. Physicians should routinely recommend reguWith regard to weight control, however, lar physical activity to all patients, not only to vigorous-intensity activity is far more timethose who are overweight or obese. For American College of Sports Medicine has begun example, an adult who weighs 165 lb (75 kg) an initiative to recommend that assessment of will burn 560 calories from 150 minutes of physical activity be considered a vital sign and brisk walking at 4 miles per hour (these calobe incorporated into routine health screening ries are in addition to the calories normally and maintained in the medical record. That person can the 2008 Physical Activity Guidelines for burn the same number of calories in 50 minAmericans recommend that adults perform at utes by running 5 miles at a pace of 6 miles per least 150 minutes of moderate-intensity or 75 hour. While 560 calories is easily conAerobic activity should be performed for at least sumed, it is not easily expended and, although 10 minutes per session and should be spread data is mixed with respect to the relationship throughout the week. For additional health benbetween appetite and exercise, most people efits, adults should increase their aerobic physiexperience a subjective increase in appetite with cal activity to 300 minutes of moderate-intensity the addition of exercise to their lifestyle. Adults should also engage important for maintaining weight loss over the in muscle-strengthening activities of moderate long term (and for preserving lean body mass to high intensity that involve all major muscle during dieting). Many of meta-analysis of trials that included patients the trials, however, were of short duration and with and without diabetes found that patients had high attrition rates.

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