Romanticism Resource Page

After reviewing the Romanticism resource page, list three characteristics of Romanticism. Also, identify three authors of the Romantic period. Using the Transcendentalism resource page, list three characteristics of Transcendentalism. How did Transcendentalists feel about nature? What did Transcendentalists feel about the inherent nature of human beings (were humans inherently good or evil)? Transcendentalists believe that individuals â€Å"transcend† by learning from and living in harmony with nature.Thoreau put this philosophy into practice by living alone in a cabin he built himself at Walden Pond for two years (1845 -1847). Thoreau's experiences during this period provided him with the material for his masterwork Walden (1854). The quote below is from Walden. Describe two specific things Thoreau learned about life by translating the lines below in your own words: â€Å"I went to the woods because I wished to live deliberately, to front only the essential facts of life, an d see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived†¦.I wanted to live deeply and suck out all the marrow of life. † (Walden) Which two great passive resistance leaders were influenced by the premise of Transcendentalism through the works of Thoreau and Emerson? Click on the following link to read Edgar Allan Poe's â€Å"Annabel Lee† Annabel Lee by Edgar Allan Poe After reviewing the Romanticism resource page and the poem, identify two characteristics of Romanticism found in this poem. Identify specific examples (lines) in the poem that represent each of the characteristics you have chosen.After identifying the lines, explain (in your own words) how the lines represent the characteristics of Romanticism. For example: line 3 â€Å"my love was a love† is an example of idealism because†¦ Using the links below, find one quote from Emerson and one from Thoreau that best exemplifies your definition of Tr anscendentalism. Be sure to include your explanation of why each of these quotes relates to your perception of Transcendentalism†¦

Book to Movie Comparison

The Beowulf legend has endured for centuries, having been retold time and time again. Dating back to the 8th century, this epic heroic poem employs many features that have long appealed to countless storytellers, authors, graphic novelists, and filmmakers. In Robert Zemeckis’s film Beowulf, modern technology allows a centuries-old story to be retold in a vivid, dynamic way. Still, in this day and age, it would be nearly impossible to translate a literal translation of the poem to the screen without making certain changes. Zemeckis’s film is no different. Some of these changes are obvious, while others remain curious diversions from the text.Whatever the case, each new retelling of Beowulf says as much about the time when it was created as it does about the narrative aspects that have survived throughout the centuries. Zemeckis, who has done similar experiments with computer-generated storytelling in his film The Polar Express, apparently believes that Beowulf is ripe fo r a contemporary facelift. While the actors and action are all animated, the technology is not the only thing that is advanced. The story has been updated as well, keeping some aspects intact while completely rewriting others.The film retains the complex family lineages and historical contexts that root the poem in reality. It also keeps most of the main characters (Beowulf, King Hrothgar, Grendel, Grendel’s mother) but explains their motivations in ways the poem did not. One of the major differences between the film and the original poem is the treatment of Grendel and Grendel’s mother; when Beowulf kills Grendel, the monster is reduced to a sniveling, frightened child. It is also worth noting that Beowulf fights Grendel in the nude, which is not described in the poem.The comparisons between Grendel and the Biblical Cain are completely thrown out as well, making Grendel more of a misunderstood Frankenstein’s monster than a true monster, ugly inside and out. The fifty-year gap between Beowulf visiting Grendel’s mother’s cave is also depicted in the film, whereas it is only alluded to in the poem. This allows the filmmakers to expand the poem into a feature-length film, in order to â€Å"fill in the gaps† with what they imagined occurred. This calls into question if Beowulf, who tells his story in the poem, is actually telling the truth.His relationship with Grendel’s mother is far different than in the story, wherein she is simply slain. Grendel’s mother is drawn as a strangely beautiful woman (Angelina Jolie) who seduces Beowulf. This change, like the others, is played for entertainment purposes. Like Beowulf’s physique, Grendel’s mother is his equal in physical form and advertising value. The film also makes a curious addition in that Hrothgar is the father of Grendel and Beowulf is the father of the dragon, which make sense in a Hollywood sort of way, but do not add anything new or powerf ul back to the original poem.These additions are simply to give characters more motivation, though it is difficult to say whether they gain any new depth. Most mentions of God and allusions to Biblical characters have been stripped away, despite the kingdom of Beowulf becoming Christian. It is as though Zemeckis has tried to make Beowulf as â€Å"un-literary† as possible. He has turned an epic poem into a comic book adventure. In many ways, the poem almost becomes secondary to the spectacle. Zemeckis desperately wants to render the world of Beowulf into one that fans of Lord of the Rings can identify with.The becomes more a springboard for special effects. The poem’s narrative is stretched so thin that it is impossible not to add to the original story, though the changes never add anything that matters. The story is sometimes as hollow and empty as the animated characters; it is all superficial. Beowulf never celebrates the poem as being truly great and proves that fil ms can never been grander than their source material. Works Cited Beowulf. Dir. Robert Zemeckis. Perf. Ray Winstone, Anthony Hopkins, Angelina Jolie. Paramount, 2007. Heaney, Seamus. Beowulf: A New Verse Translation. New York : W. W. Norton & Co. , 2001.

Giorgio Armani: Elegance Without Excess.

GIORGIO ARMANI: Elegance Without Excess. Giorgio Armani is a household name synonymous with not only style and design but also incredible corporate success and branding. The fashion house of Armani is reportedly the most financially successful Italy has ever produced. The master tailor first made headlines by redefining the rules of precision and reinventing the tailored jacket. For Armani, simplicity is key. This doesn’t only apply to his unparalleled craftsmanship and subtle ingenuity however, but also his image and personal life. Unlike many established designers, the name Giorgio Armani bears relatively little published material to his work, as well as no serious in-depth analysis of his aesthetic. Born in Picanza in 1934, there had always been early evidence of the Giorgio Armani prodigy. A sensitive and unusually fastidious child, Armani enjoyed a stable childhood in a hardworking middleclass family. His mother was a great influence in his life, as she dressed elegantly but disdained fashion. It was not surprising to learn that her favourite colours were cream, white, taupe and grey – colours that we know today represent signature Armani. He completed his studies at the University of Bologna, after which he took a job as an assistant window dresser, and then a fashion buyer, in 1954. In 1960s, he worked at menswear company Nino Cerruti as a designer, where he developed his knowledge and understanding of tailoring, fabrics and production. It was a decade later that he met Sergio Galeotti, his partner, with whom he launched his first collection. A pioneer of the fashion industry of the 20th century in many respects, Giorgio Armani himself is the epitome of etiquette, poise and grace – highly reflective in his designs. The Armani loyalty began with the design of the menswear tuxedo, applauded for its timeless elegance and superb fit. To wear Armani was to reflect self-confidence, power, and elegant ease. To many, it represents a status symbol. Despite this haute position in luxury, Giorgio Ar mani did not design for the traditional, and his designs were far from untouchable. He was in fact highly adamant in the notion of wearability, and the importance of being in tune with the times. He considers it an achievement to design clothes for everyday, as that’s how he believes fashion should be in relation to its consumer – accessible, and comfortable. A signature Armani garment should not only portray elegance, but also comfort. Armani gained his fame as he challenged the ideas of rigid jackets – as well as rigid ideals. He redesigned the menswear blazer so that it patterned much simpler, with no lining, no padding, and most importantly, no stiffness. He also extended its length, slimming lapels and creating baggy pockets to give a more modern, refined illusion. As the popularity of signature Armani skyrocketed, so did his reputation and following. It was not long before women were insistent for these menswear elements in their clothing; thus was born the Giorgio Armani Womenswear line. He deconstructed the man’s jacket and reconstructed it on the more curvaceous lines of a womens body, offering the working woman (a new concept at the time) a symbiosis of understatement and sensuality, femininity and power-dressing. Timing was perfect. People were overcoming the â€Å"Flowerpower† phase and Armani facilitated the gap by giving women clothing that was more adapted to the future. It was Armani that developed the concept of androgyny. Armani, quite plainly, redefined early ready to wear with his radically simplistic ideas. He contrasted overdramatized French fashion with more classic Italian fashion, claiming that wome n need a lot less in their clothing these days. The Armani vision was to eliminate the superfluous, emphasize the comfortable, and stress the harmony of the most essential details – in design, materials as well as cut. With his debut of WRTW he intended to create clothing that truly reflected the lives of the women who wear it – real women. Before Giorgio Armani, fashion was constricted, not easy, and outdated. In the world of Mr. Armani, practical and co mfortable are two words that remains an illustration of important fashion prerequisites. Through his childhood Armani had developed a love of textiles. He thus emphasized the importance of quality fabrics. Leather, linen, silk and textural weaves became inherent in his designs. The Armani colour palette rom birth has always been a combination of understated sophistication, bearing a predominant blend of muted and neutral hues. Fascinated by fabrics, he consistently played with the notions of masculinity and femininity. His craftsmanship was immaculate, and he eventually reigned in the indulgence and luxury of eveningwear. The 1970s proved to be a year of success for Armani, as it was around this time that his designs were first brought into the U. S via Barneys New York. His success in the city that never sleeps cemented his future. While Europe was still set on traditional ideals, the American consumer was significantly more open-minded and experimental. Till today, Giorgio Armani says that the American woman was his first client, as his silhouette depicted the casual feeling of American tailoring and fabrication. By 1999, the Giorgio Armani brand had 250 stores on five continents. His knack for business led him to lead the company on a more corporate wavelength. Armani today comprises of several lines, 9 fragrances, and a range of licenses in products from watches to umbrellas. Many of the lines Armani designs for are run rather commercially, where he bases much creativity according to the market. Regardless, Giorgio Armani consistently manages to maintain his design and style philosophy while simultaneously keeping fresh and current. Despite evolving trends and commercial/market demand, Armani has always been loyal to his elegant, timeless aesthetic. While he acknowledges fashion, he is not dominated by the need of novelty in every collection – and remains a critique of the flamboyancies and increased sexuality of the works of his industry peers. The key to his inspiration behind each collection was â€Å"renewal without rejecting the past†. Despite his love for the simplistic 30s and 40s, an era he was always influenced by, he began to play with various ethnicities and cultures in his designs. Giorgio Armani was always fascinated by the orient, fond of the pureness, colours and hues of the Japanese culture. He believes that touches of ethnicity soften the rigidity of a garment, adding to his vision of a women’s relationship to her clothes – the fulfillment of a dream.

Abacus Distribution plc Research Paper Example | Topics and Well Written Essays - 1000 words

Abacus Distribution plc - Research Paper Example With these acquisitions, it is believed that there would be a major thrust in the financial markets. This has also resulted in the consolidation of the product markets by Abacus and it is now positioned as the 5th largest distributor of electronic components in the industrial markets in Europe. (Annual Report and Accounts. 2006).The changes from GAAP to IFRS have brought about a major transformation in the treatment of Goodwill in accounting records. In the earlier accounting periods, goodwill was amortized through the profit and loss account, along with other intangible assets, but under IFRS, good will valuation is reviewed through a yearly goodwill impairment evaluation method. (Amortisation of Acquired Intangibles andCapital: On 30/9/2006, the Net Bank debt was to the tune of 61.4 Million due to the amounts of 12.1 million and also 1.8 million acquired from Deltron and Axees Technologies. A sum of 6.9 million was also paid towards purchase consideration for the acquisition of Axe es Tech. (Cash flow and working capital. 2006).These factors have increased the operating capital requirements for the Company. During earlier years, the Deltron business had reduced working capital to such an extent that the needs of the customers were not being met, with the integration of these companies into the Abacus fold, the situation would improve considerably in future years. Since Abacus enjoys invoice discounting facilities with the banks, there are reduced pressures for the minimizing the debtors levels. However, there is further need for exercising greater control over the working capital needs, and to bring it down to lower levels once the integration is totally carried out. The financial policy of the company has been to make sure that adequate financial resources are made available in a cost-effective manner. At Abacus, no speculative transactions are carried out and all foreign currency transactions are recorded at their projected levels. Dividends: Dividends: the dividends declared by the Company are as follows: 1. In the year 2002 - 9.7 Pence 2. In the year 2003 -10.2 Pence 3. In the year 2004 - 10.5 Pence 4. In the year 2005 - 7.2 Pence 5. In the year 2002 - 7.2 Pence (Annual Review and Accounts. 2006). The fall in the dividend rate is a major matter of concern for the shareholders. it is found that the dividend rate has remained unaltered in 2005 - 2006. The management feels that with increased operational performance, in future years the rate of dividend could be improved in future years. Question 2 Market Value Added The Market value added could be seen as the difference between the market value of Abacus stock - the equity capital of shareholders. In this case, the market capitalization value is 53. 32M on 13.11.2007. (Abacus Group PLC; Holding(s) in Companies.( 2007). The equity capital available to shareholders is 80.2M Therefore the MVA = 80.2-53.32 = 26.88 (In the absence of market cap. figures for 2005 and 2006 the figures could not be provided) Market Book Values During 2004, EPS stood at 5.4 p (Abacus Group) (Abacus Group plc. 2004). and the Book value of the share price=0.5p, therefore, the Market Book Value would be 5.4 X 0.5 =2.7 During 2005, the EPS stood at 14.1p (Financial review: earnings per share 2005). and the Book value of the share price=0.5p, therefore, the Market Book Value would be 14.1x 0.5 = 7.05 (Note: In the absence of Market Value of Abacus share as on 30.11.2004 & 2005, the calculation has been based on EPS valuation) Again the Market book value could be Market Price per share/ Book value per share In this case it is seen Market

Creative accounting practices and the unethical auditor Essay

Creative accounting practices and the unethical auditor - Essay Example The occurrence of creative accounting practices threatens society’s trust in the profession, and also means lack of the trust in the published financial data and the profession reports that, as a result, make the expectation gap wider between the profession and consumers and interested persons. The auditor’s mistakes in facing the risk of the creative accounting practices, such as discovering and reporting them, leads to very public prosecution, which reduces credibility even more. The auditor is responsible for the risk of the creative accounting practices of the financial data-discovering and reporting. It will be argued that the response to creative accounting cannot just come through increasing regulation and rules for the profession. That the obstacles and the challenges that led to the failure of the profession in reducing the risk of creative accounting practices demands increase in effectiveness of the professional individual. A greater part of the response should be through seeking ways to change the individual professional’s ethical and moral approach to auditing, before there can be any effective regulation. This way the credibility of accounting information can be increased and the expectations and credibility gap narrowed and trust in the profession can be strengthened. Unethical accounting or auditing can lead to destructive results for a Company. A horrible example of Enron’s fraud was a serious impact for employees of the company and shareholders. There were huge losses of billions of dollars and thousands of jobs were lost. Therefore, the US government made numerous attempts to prevent the occurrence of such cases. Corporate America should have changed something in their policies, otherwise failures are unavoidable. In the field of auditing it was relevant to avoid intentional preparation of the wrong financial documents. The companies very often do not pay a proper attention to ethical behaviour of their employees. Concerning

Bioresorbable screws Essay Example | Topics and Well Written Essays - 1000 words

Bioresorbable screws - Essay Example It is necessary to examine the three stages of the process and anticipate probable flaws in the final product resulting from decisions made at each stage. The melting phase of injection molding is essential to achieve the most even blending possible of the injected material. Too low a temperature may prevent the material from blending into a homogeneous mixture. If the temperature is too high there is a possibility that some material will be lost through evaporation, or combustion under the right circumstances. In any event, excess temperature would result in an inefficient process where energy is wasted, thus raising costs unnecessarily. The speed of the injection of the melt represents a danger as well, too slow and there is a possibility that a portion of the melt may partially solidify before the mixture is sealed into the pressure. Still there is the question of how fast the process absolutely needs to be for industrial efficiency. When the desired mixture is achieved, the press ure inside the injection mold must be intense enough to allow solidification while an optimum distribution of molecules is present, to ensure homogeneity. One possible experimental design is to locate the melting point of hydroxyapatite and then deliver five samples into separate heating elements at ascending 10Â ° increments above that melting point. ... ptimal temperature is determined in this method, material samples heated to the same temperature can be injected into new samples at five different speeds in progressively faster increments which are then sealed prior to hardening. Using the same stress testing, the optimal temperature at the optimal injection speed could then be used in a third experiment involving five samples at different increments of pressure. The stress tests can be repeated. In terms of power analysis, this design allows adjustability and the potential for precision. Five samples for each phase of testing create an experiment that permits the investigator to pinpoint the optimal conditions most conducive to the structural outcome desired. Five samples in 2Â ° increments allow inference of the optimal conditions without redundancy. If at either of these experimental phases there are inconclusive findings in stress testing, then the increment requiring the least amount of energy should be recommended. This prop osed experimental design could be evaluated using logistic regression. If the goal is to assess whether the product will break at a certain level of pressure, then whether breakage occurs is a categorical dependent variable, but this experiment proposes continuous data based upon temperature, injection speed, and mold pressure. This statistical method should provide insights concerning the optimal combination of factors to inform an attempt at reliability testing. For the purposes of this experiment, the continuous gradations in terms of temperature, injection speed, and mold pressure are necessary to provide a range of information that optimizes the probability of finding the most advantageous method. A repetition of these tests can be used to reduce the probability of anomalies and

Research Proposal Assignment Example | Topics and Well Written Essays - 750 words

Research Proposal - Assignment Example Why the difference in that, because logically as the millers make profit the farmers should also enjoy from the profit. Does it mean that the millers are behind the rise in the poverty level of the farmers or the farmers are the source to there poverty. The millers should always be in support of the farmers, this is because farmers need to be motivated to increase the amount off the cane production and this intern will lead to the millers’ increment in production. If the farmers are demoralized, they my opt for production of other food staffs hence may lead to the collapse of the sugar industries due to lack of raw material for production. The third argument is that the poverty experienced in the sugarcane farmers maybe as a result of the poor cane production skills (Evenson and Pingali, 2009). Due to these, farmers may use huge amount of capital for sugarcane production but having little return during the harvesting, hence need to reduce the cost of cane production. However for this to be achieved, the need for the farmers and millers working together is very important which in most cases is not easy as millers are only determined in maximizing on the profit and not concerned of the wellbeing of the farmers. The Kenyan government should deploy extension officers at various regions in the sugar belt who should have an initiative of giving farmers the skills in sugarcane management and production. This may improve the quality and quantity of the cane being produced in the region hence intern reducing the poverty level of the sugarcane farmers. One argument that is to be analyzed in this research topic is the issue whether the millers should also be concerned with the wellbeing of the sugarcane farmers or just concentrate on profit maximization in the expenses of the farmers. It is always advisable that the millers should treat the farmers with grate importance as this will determine the amount of profit they make.

UK Fashion and Media Industry Essay Example | Topics and Well Written Essays - 3500 words

UK Fashion and Media Industry - Essay Example This industry for many years has grown tremendously becoming one of the notable industry in the UK. According to Fridson 2011, he provides that UK fashion and Media industry has a significant impact on the social and economic impact in the country. The fashion industry in the UK has become integrated into its citizens live hood. This has become turned fashion to be a possible trivial and enjoyable thus becoming more attractive to the potential and the prospective customers (Fridson 2011). This analysis is essential in the assessment of any market if it is worth to invest in it. This comprises the examination of the external macro-environment which is an important aspect of a company before preparing a business plan. The external environment examination is important in the decision-making process. It is also appropriate to carry out this analysis over sometime to ensure that all the uncertainties and the dynamic nature of the industry are addressed in the context of fashion industry market in the United Kingdom (Dransfield 2005). The fashion industry in the UK is considered one of the competitive markets the world. Big fashion companies such as Burberry, Marks & Spencer, TopShop, French Connection, and Supergroup. It is important to note that marketing consultancies and the media in the context fashion industry have a greater opportunity, in the provision of goods and services. This translates into the need for more consultancies and sound marketing techniques and strategies. Therefore it is a perfect consideration to acquire a UK marketing media agency. Most of the companies in the current corporate world consider growing their businesses by acquiring another company as a way of expansion. This is attributed to most new companies which are in their boom opting for mergers or acquisition. It is important for the buying company to take into consideration several factors before acquiring.

Risk and Mental Health Coursework Example | Topics and Well Written Essays - 8000 words

Risk and Mental Health - Coursework Example Risk definition, assessment and devising strategic approaches,tactics,models and even algorithms to deal with each of these specific risks on either stand alone or grouped basis has turned a major concern for the medical care providers dealing with cases of mental health. The task becomes formidable as the incidence of such mental health cases is substantial in most jurisdictions. Take the instance of incidence of traumatic brain injuries or even mild traumatic brain injuries. Globally millions of affected persons are treated each year for severe head injury. (Jennett, 1996) Various best practices guidelines have defined head injuries. National Institute for Clinical Excellence has the following definition: 'Head injury' is defined as any trauma to the head, other than superficial injuries to the face. (National, 2003) Of the millions hit by head injuries each year; the most common incidents causing these injuries are falls, road traffic accidents and assaults (such as fights). Youth (15 years and over) and children are more susceptible to head injuries due to an active and mobile lifestyle. However most of the sustained head injuries are diagnosed mild and do not lead to admission as in-patients. About nine out of ten people seen in hospital have a mild or minor head injury and will go home without being admitted to hospital. This itself may be an indication of gross under evaluation of the risk associated with the mental health of the patient. However the illness states f these patients is technically termed as mild traumatic brain injury (MTBI).MTBI patients, even if admitted to hospital, are discharged within of after 48 hours. Only a fraction of the total number of people who have had head injuries (often placed at lesser than one in a hundred) do suffer from a severe injury to their brain. The general argument offered is that the severe brain injury is rare as the scalp and skull of human head play protective roles and absorb much of the impact of the inj ury. However symptoms including bleeding swelling or bruising can occur both inside the skull and inside the brain. Where the damage is located and what has been the extent of such damage is decided by the force and speed of the blow. Therefore, it is often said that a timely and speedy treatment of a severe injury to the brain may result in complete recovery; however, no medical care system can guarantee against serious disability or even fatality as a result of such severe head injuries -particularly if the treatment is delayed and/or misplaced as well. (National,2003).All such cases present themselves as living examples of deficient treatment of risks involved in mental health situation. To make the matters worse, and continuing with the most extreme and delicate state of mental ill health i.e. traumatic brain

Association football Essay Example for Free

Association football Essay 1. intro write about the game 2. what it is special about? famous in world , world class team, have won many championship 3. who are the special/outstanding players in the team? 4. what are their special abilities score alot goals, can run and driblle the ball I am just disagree with the way of writing this essay. It is probably out of topic, if i am not wrong. However, i have done an essay based on the notes given. Pls check and remark for me. If possible, help me think of the REAL and BETTER way to write this essay. Your help is greatly appreciated, thank you. A game is an activity involving one or more players. Games are played primarily for entertainment or enjoyment, but may also serve as exercise. Everyone in this world has their own favorite games, so do I. My favorite game is football . I often play this with my friend in the evening. I like this game because it is exciting and challenging. Football is a team sport played between two teams of eleven players each. It is a ball game played on a rectangular grass field with a goal at each end. The objective of the game is to score by maneuvering the ball into the opposing goal. The winner is the team which has scored most goals at the end of the match. Football is played at a professional level all over the world, and millions of people regularly go to football stadium to follow their favorite team, whilst millions more avidly watch the game on television. A very large number of people also play football at an amateur level. In many parts of the world football evokes great passions and plays an important role in the life of individual fans, local communities, and even nations; it is therefore often claimed to be the most popular sport in the world. There are many worldwide international competition of football. One of the major international competitions in football is the World Cup organized by Fà ©dà ©ration Internationale de Football Association. Over 190 national teams compete in qualifying tournaments within the scope of continental confederations for a place in the finals. The finals tournament, which is held every four years, now involves 32 national teams competing. The next World Cup takes place in Germany 2006. The star I admired most in football is Edson Arantes do Nascimento, nicknamed Pelà ©, is a former Brazilian football player and thought by many to be the finest player of all time. Often considered the complete attacking player, he was completely two-footed, a prolific finisher, exceptional at dribbling and passing, and was a remarkably good tackler for a forward. He was also famed for his speed and strength on the ball. Since his full retirement he has served as an ambassador for the sport. There is many reason football is my favorite game. I wish to become a professional football player. I learnt teambuilding, discipline as well as teamwork through playing football. A game is an activity involving one or more players. Games are played primarily for entertainment or enjoyment, but may also serve as exercise. Everyone in this world has their own favorite games, so do I. My favorite game is football. I often play this with my friends in the evening. I like this game because it is exciting and challenging. Football is a team sport played between two teams of eleven players each. It is a ball game played on a rectangular grass field with a goal at each end. The objective of the game is to score by maneuvering the ball into the opposing teams goal. The winner is the team which has scored the most goals at the end of the match. Football is played at a professional level all over the world. , and m Millions of people regularly go to football stadiums to follow their favorite team, whilst millions more avidly watch the game on television. A very large number of people also play football at an amateur level. In many parts of the world, football evokes great passions and plays an important role in the life of individual fans, local communities, and even nations; it is therefore often claimed to be the most popular sport in the world. There are many worldwide international football competitions of football. One of thesethe major international competitions in football is the World Cup organized by Fà ©dà ©ration Internationale de Football Association. Over 190 national teams compete in qualifying tournaments within the scope of continental confederations for a place in the finals. The finals tournament, which is held every four years, now involves 32 national teams competing. The next World Cup takes place in Germany 2006. The football star I admired most in football is Edson Arantes do Nascimento, nicknamed Pelà ©. ,Pele is a former Brazilian football player and thought by many to be the finest player of all time. Often considered the complete perfect attacking player, he was completely two-footed, a prolific finisher, exceptional at dribbling and passing, and was a remarkably good tackler for a forward. He was also famed for his speed and strength on the ball. Since his full retirement he has served as an ambassador for the sport. There are is many reasons football is my favorite game. I wish to become a professional football player. I learnt teambuilding, discipline as well as teamwork through playing football. ANIKET AMAN.

Effect of School Based Obesity Interventions

Effect of School Based Obesity Interventions ABSTRACT Introduction Background Obesity in both adult and children is fast becoming one of the most serious public health problems of the 21st century in developed and developing countries alike. It is estimated that approximately 10% of school age children. The prevalence of childhood overweight and obesity is ever on the increase in the UK as in the rest of the world. It is estimated that the prevalence of overweight and obesity among 2 10 year old children in the UK rose from 22.7%-27.7% and 9.9%-13.7% respectively between 1995 and 2003; these figures are set to increase unless something is done. School-based interventions offer a possible solution in halting obesity prevalence, because the school setting provides an avenue for reaching out to a high percentage of children (especially in the western world), opportunity for constant monitoring of children and the resources for anti-obesity interventions. Objectives To systematically review the evidence of the impact of school-based interventions to prevent childhood obesity on: Adiposity (primary objective) Knowledge, physical activity levels and diet (secondary objectives) Methods The review was done following the Cochrane collaboration guidelines. In addition to searching electronic databases, first authors of all included studies were contacted. A recognised critical appraisal tool was used to assess the quality of included studies. Results Three RCTs and one CCT met the inclusion criteria for the review. All four studies had a control and intervention group; with various study limitations. While none of the studies found statistically significant BMI changes in intervention groups when compared with control group post-intervention, all of them recorded either a significant change in diet, or an increase in physical activity levels. INTRODUCTION BACKGROUND Obesity is generally understood as abnormal accumulation of fat to the extent that presents health risk (Kiess, Marcus et al. 2004), and was added to the international classification of diseases for the first time in 1948 (Kipping, Jago et al. 2008). The worldwide clinical definition of adult obesity by the WHO is body mass index (BMI) ≠¥ 30kg/m2 (WHO 2006). In children however, because of the significant changes in their BMI with age (Cole, Bellizzi et al. 2000), there is no universally accepted definition of obesity (Parizkova and Hills 2004; Bessesen 2008) and it therefore varies from country-to-country. The most commonly used definition of childhood obesity is the US definition which measures overweight and obesity in a reference population using the cut off points of 85th and 95th centiles of BMI for age (Ogden, Yanovski et al. 2007). In the UK, overweight and obesity are diagnosed using a national reference data from a 1990 BMI survey of British children (Stamatakis, Prima testa et al. 2005). Children whose weights are above the 85th centile are classed as overweight and over the 95th centile are considered obese (Reilly, Wilson et al. 2002). Recent estimates suggest that obesity has reached epidemic proportions globally with about 400 million adults being clinically obese, a figure projected to rise to about 700 million by 2015 (WHO 2006). In children, the current WHO estimates are that about 22 million children globally under age 5 are overweight (WHO 2008). In the UK, evidence suggests that obesity is set to be the number one preventable cause of disease in a matter of time (Simon, Everitt et al. 2005). In the last three decades, the scale as well as the prevalence of obesity have grown rapidly amongst all age, social and ethnic groups in the UK, as well as globally (Table 1)(Kipping, Jago et al. 2008). Estimates suggest that in the UK, between 1984 and 2002/2003, the prevalence of obesity in boys aged 5-10 rose by 4.16%, and by 4.8% in girls (Stamatakis, Primatesta et al. 2005). There is therefore there is an urgent need for the development and implementation of effective intervention strategies to halt the ever increasing obesity prevalence (Summerbell Carolyn, Waters et al. 2005). OBESITY CAUSATION The primary risk factors associated with the increase in prevalence of childhood obesity are ever increasing involvement in sedentary lifestyles and an increase also in the consumption of high energy dense food and drink (Ebbeling, Pawlak et al. 2002; Sekine, Yamagami et al. 2002; Speiser, Rudolf et al. 2005; Topp, Jacks et al. 2009). The underlying mechanism of obesity formation is an imbalance between energy input and expenditure (Moran 1999; Kipping, Jago et al. 2008) Genetic and environmental factors greatly influence the bodys energy balance. Nevertheless, genetic conditions which either cause production of excessive fat in the body or reduce the rate at which it is broken down, of which Prader-Willi syndrome is an example account for less than 5% of obese individuals (Speiser, Rudolf et al. 2005), with environmental factors accounting for a very high percentage (French, Story et al. 2001). The major cause of the rising obesity problem is arguably changes in physical and social environments (French, Story et al. 2001). In recent times, there has been a remarkable shift towards activities that do not promote energy expenditure, for example, most children would travel to school in cars rather walk, in contrast to what obtained in the 1970s (Popkin, Duffey et al. 2005; Anderson and Butcher 2006). There is evidence to suggest that obese children are less active than their non-obese counterparts, hence promoting physical activity such as walking or exercising will help prevent obesity in children (Hughes, Henderson et al. 2006). Media time (television viewing, playing video games and using the computer) has been identified as one of the significant environmental changes responsible for the surge in childhood obesity. Besides promoting physical inactivity, it encourages energy input via excessive snacking and inappropriate food choices as a result of television advertisements (Ebbeling, Pawlak et al. 2002; Speiser, Rudolf et al. 2005). Robinson in his study reveals that â€Å"between ages 2 and 17, children spend an average of 3 years of their waking lifetime watching television alone† (Robinson 1998). Parents play a significant role in where, what and how much their children eat and to an extent, how physically active their children are. In most homes, children make their food choices based on the options they are presented with by their parents, and they characteristically would go for wrong option, more so if they have an obese parent (Strauss and Knight 1999). Other changes within the family such as physical inactivity and working patterns of parents have contributed somewhat to the obesity epidemic. In a family where the parents work full-time, there tends to be very little time for them to prepare wholesome home-made meals and this could possibly explain the increasing demand for eating out (Anderson and Butcher 2006) thereby increasing intake of high energy dense food. Childrens attitude to and participation in physical activities depends largely on how physically active their parents are. Thus children of sporty parents embrace exercise heartily and are therefore less prone to becoming obese.(Sallis, Prochaska et al. 2000). In addition to these family factors, societal factors such as high crime rate, access to safe sports/recreational facilities, transportation and fewer physical education programs in schools significantly impact on energy balance (Koplan, Liverman et al. 2005; Popkin, Duffey et al. 2005; Topp, Jacks et al. 2009). French summarizes the environmental influence on obesity by opining that â€Å"The current epidemic of obesity is caused largely by an environment that promotes excessive food intake and discourages physical activity† (French, Story et al. 2001) CONSEQUENCES OF OBESITY Evidence suggests that childhood obesity and/or overweight has a great impact on both physical and psychological health; causing effects such as behavioral problems and low self esteem, with a higher risk in girls than in boys (Reilly, Methven et al. 2003). Although most of the serious consequences do not become evident until adulthood, research has shown childhood obesity to be linked to metabolic disorders such as insulin resistance and type 2 diabetes, stroke and heart attacks, sleep apnea, nonalchoholic fatty liver disease, higher incidence of cancers, depression, dyslipidaemia, increased blood clotting tendency, etc (Ebbeling, Pawlak et al. 2002; Reilly, Methven et al. 2003; Kiess, Marcus et al. 2004; D. A. Lawlor, C. J. Riddoch et al. 2005; Daniels 2006; WHO 2006). One of the long-term serious consequences of childhood obesity is that obese children are twice more likely to grow into obese adults than their non-obese counterparts (Moran 1999); however, this largely depends on factors such as age of onset, severity of the disease and the presence of the disease in one parent (Moran 1999; Campbell, Waters et al. 2001; Kiess, Marcus et al. 2004; WHO 2006). Other long term consequences include early death and adverse socio-economic consequences such as poor educational attainment and low/no income in adulthood (Reilly, Methven et al. 2003; Fowler-Brown and Kahwati 2004; Kiess, Marcus et al. 2004). Obesity-related morbidity places a huge and growing financial demand on governments. In the UK alone, the Department of Health has reported that obesity costs the NHS and the UK economy as a whole about  £1b and between  £2.3b  £2.6b annually respectively, with the cost to the NHS projected to rise to  £3.6b by 2010 (DH 2007). TREATMENT AND PREVENTION The treatment of obesity requires a multidisciplinary approach due to the multi-faceted nature of the condition (Parizkova and Hills 2004). This is aimed at reducing caloric intake and increasing energy expenditure through physical activity (Ebbeling, Pawlak et al. 2002). These interventions are more likely to be successful if the patients family is involved and the treatment tailored to individual needs and circumstances (Fowler-Brown and Kahwati 2004). In extreme cases, options such as surgical and pharmacological treatments could be exploited. These options are very unpopular and usually not recommended because the associated health risks outweigh the benefits by far (Epstein, Myers et al. 1998; Ebbeling, Pawlak et al. 2002). Considering the huge costs and high levels of treatment failure associated with obesity treatment (Stewart, Chapple et al. 2008), the axiom by Benjamin Franklin cannot describe any other condition better than it describes obesity management. â€Å"An ounce of prevention is worth a pound of cure† Dietz et al confirm this by saying that prevention remains the best and most effective management of obesity (Dietz and Gortmaker 2001). Obesity prevention interventions are usually set either in the home or at school with an objective of eliminating peer pressure and, by so doing effect behavioral change (Ebbeling, Pawlak et al. 2002). Literature suggests that the school has so far remained the choice setting for these preventive interventions despite the very limited evidence on its effectiveness (Birch and Ventura 2009). Why is the school setting a good focus of intervention? Approximately 90% of children are enrolled in schools in developed countries (Baranowsk, Cullen et al. 2002) Children spend a substantial amount of time in school and therefore consume a considerable proportion of their daily calories at school (Katz, OConnell et al. 2005) School related activities present an opportunity to educate children on the concept of energy balance, healthy living and how to make appropriate food choices (Ebbeling, Pawlak et al. 2002; Koplan, Liverman et al. 2005) It offers opportunity for continuity and constant monitoring via frequent contact (Baranowski T 2002) Schools have an availability of existing manpower and facilities needed for anti-obesity interventions (Kropski, Keckley et al. 2008) In a nut shell, â€Å"Schools offer many other opportunities for learning and practicing healthful eating and physical activity behaviors. Coordinated changes in the curriculum, the in-school advertising environment, school health services, and after-school programs all offer the potential to advance obesity prevention† (Koplan, Liverman et al. 2005). PREVIOUS SYSTEMATIC REVIEWS Systematic reviews have been conducted on the effectiveness of school-based interventions in the prevention of childhood obesity. Campbell et al (2001), conducted a systematic review of 7 randomised control trials (RCTs) (6 were school-based, varying in length of time, target population, quality of study and intervention approach). The review found that dietary and physical education interventions have an effect on childhood obesity prevalence. However, success varied with different interventions amongst different age groups. Two of the three long term studies that focused on a combination of dietary education and physical activity, and dietary education respectively reported an effect on obesity prevalence reduction. Similarly, 1 out of the 3 school based short-term interventions that focused only on reducing sedentary activity also found an effect on obesity prevalence. While this review shows that dietary and physical activity interventions based at school are effective against th e risk factors of obesity, the question of generalisability and reproducibility arises as the review reports the majority of the included primary studies were carried out in the US. Most of the studies used BMI as a measure of adiposity, and BMI as has been documented varies across ethnic and racial groups (Rush, Goedecke et al. 2007), thus, it will be inappropriate to apply the findings of US-based obesity prevention interventions to children in middle and low income countries where conditions are different. There are also concerns about the methodology and study design. For example the school-based study by Gotmaker et al (1999) had limitations such as low participation rate (65%) and the researchers were unable to adjust for maturity in boys and there was also poor assessment of dietary intake. All these limitations could have been responsible for a high percentage of the reported intervention effect thus affecting the validity of the results of the study (Gortmaker, Peterson et al. 1999). The authors of the review however concluded that there is currently very limited high quality evidence on which to draw conclusions on the effectiveness of anti-obesity programmes. A Cochrane review which is an update of the Campbell et al (2001) study by Summerbell et al (2005) has examined the impact of diet, physical activity and/or lifestyle and social support on childhood obesity prevention. Their review examined the effectiveness of childhood obesity prevention interventions which included school based interventions. Their study included 10 long-term (a minimum duration of 12 months) and 12 short-term (12weeks 12 months) clinical trials (randomised and controlled). 19 out of the 22 studies that met their inclusion criteria were school/pre-school based. The study chose the appropriate study type; more than one reviewer was involved in the entire process of data collection, extraction and selection of included studies. In general, the study found that most of the school-based interventions (dietary and/or physical activity) reported some positive changes in targeted behaviours, but however had very little or no statistically significant impact on BMI. The reviewers stated that none of the 22 studies fulfilled the quality criteria because of some form of methodological weakness which includes measurement errors. For instance, the study by Jenner et al (1989) had no valid method of measuring food intake. The studies by Crawford et al (1994), Lannotti et al (1994) and Sallis et al (2000) had similar measurement errors. Reporting error was identified in studies by Little et al (1999) and Macdiarmid et al (1998). There were also reliability concerns about the secondary outcomes measurement in some of the included studies. The reviewers therefore expressed the need for further high quality research on effectiveness. Kropski et al (2008) reviewed 14 school-based studies that were designed to effect a life style change, a change in BMI, decrease overweight prevalence through a change in nutrition, physical activity or a combination of both. Of the 14 studies, three were done in the UK, one in Germany and 10 in the US. The right type of studies were chosen for this review and the whole process was done by more than one reviewer, however they were unable to draw strong conclusions on the efficacy of school-based interventions because of the limited number of primary studies available and methodological or design concerns which include: small sample size (Luepker, Perry et al. 1996; Mo-suwan, Pongprapai et al. 1998; Nader, Stone et al. 1999; Warren, Henry et al. 2003), no intention-to treat analysis (Danielzik, Pust et al.; Sallis, McKenzie et al. 1993; Sahota, Rudolf et al. 2001; Warren, Henry et al. 2003), possibility of type I (Coleman, Tiller et al. 2005) and type II errors (Warren, Henry et al. 2003), unit of analysis errors (Sallis, McKenzie et al. 1993) and inconsistent results (Mo-suwan, Pongprapai et al. 1998; Caballero, Clay et al. 2003; Coleman, Tiller et al. 2005). Despite their inability to draw a conclusion on effectiveness, overall, the review found that a combination of nutritional and physical activity interventions had the most effect on BMI and prevalence of overweight, with the result largely varying from community-to-community. The nutrition only and physical activity only interventions appeared to have had a change on lifestyles of participants but either had no significant effect on the measures of overweight or no BMI outcomes were measured. Another systematic review on the effectiveness of school-based interventions among Chinese school children was carried out by M.Li et al (2008). The authors included 22 primary studies in their review. The review reported that the primary studies showed that there are some beneficial effects of school-based interventions for obesity prevention; the reviewers however expressed their concerns that most of the studies included in the review had what they considered to be serious to moderate methodological weaknesses. Sixteen of the 22 studies included studies were cluster control trials, and there was no mention by any of the researchers that cluster analysis was applied to any of the 16 studies. In addition to lack of cluster analysis, no process evaluation was conducted in any of the studies. Only one study performed an intention to treat analysis. Twelve studies experienced dropouts, but there was incomplete information on the study population at the end of the trial and the reason f or the dropouts. Additionally, none of the studies explained the theory upon which they based their intervention. There was also potential recruitment and selection bias in all the primary studies as identified by the reviewers. They stated that none of the studies reported the number of subjects that were approached for recruitment into the study. As none of the RCTs included described the method they used in randomization, neither did they state if the studies were blinded or not. The methodological flaws in a high percentage of the included primary studies could impact on the validity of the findings of the review. Again, the authors failed to reach a conclusion on the effectiveness of the interventions because of the intrinsic weaknesses found in the primary studies, and as a result state the need for more primary studies that would address the methodological weaknesses that is highly present in nearly all existing primary studies conducted on this topic so far. The study of the efficacy of school-based interventions aimed at preventing childhood obesity or reducing the risk factors is a rather complex one. Pertinent issues on effectiveness of school-based interventions to prevent the risk factors of obesity remain that there is very limited/weak evidence on which to base policies on. Heterogeneity of primary research (in terms if age of study population, duration of intervention, measurement of outcomes and outcomes measured) makes further statistical analysis nearly impossible. BMI is currently the most widely used measure of overweight and obesity in children. However, BMI has no way of distinguishing between fat mass and muscle mass in the body and might therefore misdiagnose children with bigger muscles as obese. Another disadvantage of using BMI in overweight measurement is its inability of depicting the body fat composition (Committee on Nutrition 2003), other surrogate indicators of adiposity may be needed. Most authors that have carried out a review on this topic so far have expressed the need for further research on this topic to add to the existing body of evidence. RATIONALE FOR THIS STUDY All the systematic reviews on this subject so far have focused mainly on the United States. Lifestyle differences such as eating habits between American and British children possibly affect generalisability and reproducibility of US findings to the UK. For example, in the US, research has shown that 0.5% of all television advertisements promote food, and that about 72% of these food advertisements promote unhealthy food such as candy and fast food (Darwin 2009). In the UK paradoxically, the government in 2007 enforced regulations banning television advertisement of unhealthy foods (foods with high fat, salt, and sugar content) during television programmes aimed at children below 16 years of age (Darwin 2009). Thus US children are at a higher risk of becoming obese than their UK counterparts as a result of higher rate of exposure to TV junk food advertisements. Another lifestyle difference between American and British children is physical activity. In the UK, a high percentage of children aged 2 to 15 achieve at least 60 minutes of physical activity daily (about 70% of males and 60% of females) (DoH 2004), as opposed to the US where only about 34% of school pupils achieve the daily recommended levels of physical activity daily (CDC 2008). These differences highlight the importance of public health policies being based on the local population characteristics rather than on imported overseas figures. There is therefore need to review the evidence of UK school-based obesity interventions to inform policy relevant to the UK population. To the best of my knowledge following an extensive literature search, no systematic review has been conducted on the effectiveness of school-based intervention in preventing childhood obesity in the UK, despite the high prevalence of the condition and its public health significance in this country. This research aims to bridge this gap in knowledge by focusing on UK based studies to evaluate the efficacy of school-based interventions in the UK population. This study therefore stands out insofar as it will be assessing the effectiveness of school-based interventions in the reducing the risk factors of obesity in the UK, with a hope of providing specific local recommendations based on UK evidence. This type of review is long overdue in the UK, considering that the governments target to reduce childhood obesity to its pre-2000 levels by the year 2020 (DoH 2007) will require local evidence of effective interventions to succeed. The next stage of this review will describe in detail the research methodology to be used to conduct the proposed systematic review. Also included will be research strategy details to be adopted, study selection criteria, data collection and analysis. AIMS AND OBJECTIVES The aim of this research is to: Systematically review school-based intervention studies in the UK aimed at reducing the risk factors of childhood obesity among school children. Objectives are: To assess the efficacy of school-based anti-obesity interventions in the UK. To identify the most effective form of school-based interventions in the prevention of childhood obesity amongst school children in the UK. CRITERIA FOR INCLUDING STUDIES IN THIS REVIEW METHODS This review was performed as a Cochrane review. The Cochrane guidance on systematic reviews and reporting format were as far as possible adhered to by the author (Green, Higgins et al. 2008). The entire review process was guided by a tool for assessing the quality of systematic reviews, alongside the accompanying guidance (health-evidence.ca 2007a; health-evidence.ca 2007b). TYPES OF STUDY In the search for the effectiveness of an intervention, well conducted randomised control trials (which are the best and most credible sources of evidence) will be the preferred source of studies for this review. However, because of the limited number of RCTs conducted on this topic so far, this study will include controlled clinical trials if there is insufficient availability of RCTs. TYPES OF PARTICIPANTS School children under 18 years of age TYPES OF INTERVENTIONS Interventions being evaluated are those that aim to: Reduce sedentary lifestyle Effect nutritional change Combine the two outcomes above Reduce obesity prevalence Effect an attitude change towards physical activity and diet Studies that present a baseline and post intervention measure of primary outcome. Interventions not included in this study are: Those with no specified weight-related outcomes Those that involved school-age children but were delivered outside of the school setting, as our focus is based on school-based interventions aimed at obesity prevention. Studies done outside the UK Studies with no specified interventions Non-RCTs or CCTs For each intervention, the control group will be school children not receiving the intervention(s). TYPES OF OUTCOMES MEASURED Primary outcomes Change in adiposity measured as BMI and/or skin fold thickness Secondary outcomes Knowledge Physical activity levels Diet SEARCH METHODS FOR IDENTIFICATION OF STUDIES Electronic searches The electronic databases OVID MEDLINE ® (1950-2009), PsycINFO (1982-2009), EMBASE (1980-2009) and the British Nursing Index (1994-2009) were all searched using the OVID SP interface. The Wiley Interscience interface was used to search the following databases: Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects. There was also a general search of internet using Google search engine, in an attempt to identify any ongoing studies or unpublished reports before proceeding to search grey literature sources. Grey literature For references to childhood obesity prevention in schools, the following grey literature sources were searched: British Library Integrated Catalogue (http://catalogue.bl.uk/F/?func=filefile_name=login-bl-list) ISI index of Conference Proceedings (http://wok.mimas.ac.uk/) SCIRUS (http://www.scirus.com/) System for Information on Grey Literature (http://opensigle.inist.fr/) ZETOC (http://zetoc.mimas.ac.uk) Additionally, current control trials database at http://www.controlled-trials.com/ was searched for any ongoing research. The UK national research register was also searched at https://portal.nihr.ac.uk/Pages/NRRArchive.aspx. All the links to the grey literature databases were tested at the time of this review and found to be working. Hand searches It was not possible to conduct a hand search of journals due to pragmatic reasons. Reference lists Reference lists of retrieved studies were searched for other potential relevant studies that might have been omitted in the earlier search. Correspondence First author of all included studies were contacted with a view to seeking more references. DATA COLLECTION AND ANALYSIS Selection of studies The abstracts and titles of the hits from the electronic databases searched were screened for relevance by a single assessor. Those that were thought to be potentially relevant were retrieved and downloaded unto EndnoteTM to make the results manageable and also avoid loss of data. At the end of the search, all databases were merged into one single database and duplicated records of the same study were removed. Subsequently, the assessor then sought and obtained the full text of, and reviewed the relevant studies that were considered eligible for inclusion. Multiple reports of same study were linked together. No further data were sought for studies not included in the review. Data extraction Data extraction from included studies was done by a single reviewer and the data recorded on a data extraction form. A summary of each included study was described according to these characteristics: Participants (age, ethnicity etc.), study design, description of school-based interventions, study quality and details such as follow-ups and date, location, outcomes measured, theoretical framework, baseline comparability and results Assessment of methodological quality of included studies A number of researchers (Jackson, Waters et al. 2005) and the Cochrane guidelines for systematic reviews of health promotion and public health interventions (Rebecca Armstrong, Waters et al. 2007) strongly advise using the Quality Assessment Tool for Quantitative Studies (2008a) developed by the Effective Public Health Practice Project in Canada and the accompanying dictionary (to act as a guideline) (2008b) in assessing methodological quality. Based on criteria such as selection bias, study design, blinding, cofounders, data collection methods, withdrawals and drop-outs and intervention integrity, the tool which is designed to cover any quantitative study employs the use of a scale (strong, moderate or weak) to assess the quality of each study included in the review. Analysis Considering the small number of studies included in the review and heterogeneity in terms of interventions, delivery methods, intensity of interventions, age of participants, duration of intervention and outcomes measured, it was not statistically appropriate to undertake a Meta analysis, which admittedly would have been the preferred method of analysing and summarising the results of the studies. A narrative synthesis of the results was done instead. RESULT DESCRIPTION OF STUDIES Results of the search The search of electronic sources identified 811 citations out of which 97 potential studies were retrieved. A reference management software EndnoteTM was used to search for and remove duplicate citations. Further screening of title and abstract reduced the number of citations to 17 potential studies. Full texts of the 17 studies were sought, 13 were excluded, and four met the inclusion criteria and were therefore included in the review. Authors of the four studies were then conta Effect of School Based Obesity Interventions Effect of School Based Obesity Interventions ABSTRACT Introduction Background Obesity in both adult and children is fast becoming one of the most serious public health problems of the 21st century in developed and developing countries alike. It is estimated that approximately 10% of school age children. The prevalence of childhood overweight and obesity is ever on the increase in the UK as in the rest of the world. It is estimated that the prevalence of overweight and obesity among 2 10 year old children in the UK rose from 22.7%-27.7% and 9.9%-13.7% respectively between 1995 and 2003; these figures are set to increase unless something is done. School-based interventions offer a possible solution in halting obesity prevalence, because the school setting provides an avenue for reaching out to a high percentage of children (especially in the western world), opportunity for constant monitoring of children and the resources for anti-obesity interventions. Objectives To systematically review the evidence of the impact of school-based interventions to prevent childhood obesity on: Adiposity (primary objective) Knowledge, physical activity levels and diet (secondary objectives) Methods The review was done following the Cochrane collaboration guidelines. In addition to searching electronic databases, first authors of all included studies were contacted. A recognised critical appraisal tool was used to assess the quality of included studies. Results Three RCTs and one CCT met the inclusion criteria for the review. All four studies had a control and intervention group; with various study limitations. While none of the studies found statistically significant BMI changes in intervention groups when compared with control group post-intervention, all of them recorded either a significant change in diet, or an increase in physical activity levels. INTRODUCTION BACKGROUND Obesity is generally understood as abnormal accumulation of fat to the extent that presents health risk (Kiess, Marcus et al. 2004), and was added to the international classification of diseases for the first time in 1948 (Kipping, Jago et al. 2008). The worldwide clinical definition of adult obesity by the WHO is body mass index (BMI) ≠¥ 30kg/m2 (WHO 2006). In children however, because of the significant changes in their BMI with age (Cole, Bellizzi et al. 2000), there is no universally accepted definition of obesity (Parizkova and Hills 2004; Bessesen 2008) and it therefore varies from country-to-country. The most commonly used definition of childhood obesity is the US definition which measures overweight and obesity in a reference population using the cut off points of 85th and 95th centiles of BMI for age (Ogden, Yanovski et al. 2007). In the UK, overweight and obesity are diagnosed using a national reference data from a 1990 BMI survey of British children (Stamatakis, Prima testa et al. 2005). Children whose weights are above the 85th centile are classed as overweight and over the 95th centile are considered obese (Reilly, Wilson et al. 2002). Recent estimates suggest that obesity has reached epidemic proportions globally with about 400 million adults being clinically obese, a figure projected to rise to about 700 million by 2015 (WHO 2006). In children, the current WHO estimates are that about 22 million children globally under age 5 are overweight (WHO 2008). In the UK, evidence suggests that obesity is set to be the number one preventable cause of disease in a matter of time (Simon, Everitt et al. 2005). In the last three decades, the scale as well as the prevalence of obesity have grown rapidly amongst all age, social and ethnic groups in the UK, as well as globally (Table 1)(Kipping, Jago et al. 2008). Estimates suggest that in the UK, between 1984 and 2002/2003, the prevalence of obesity in boys aged 5-10 rose by 4.16%, and by 4.8% in girls (Stamatakis, Primatesta et al. 2005). There is therefore there is an urgent need for the development and implementation of effective intervention strategies to halt the ever increasing obesity prevalence (Summerbell Carolyn, Waters et al. 2005). OBESITY CAUSATION The primary risk factors associated with the increase in prevalence of childhood obesity are ever increasing involvement in sedentary lifestyles and an increase also in the consumption of high energy dense food and drink (Ebbeling, Pawlak et al. 2002; Sekine, Yamagami et al. 2002; Speiser, Rudolf et al. 2005; Topp, Jacks et al. 2009). The underlying mechanism of obesity formation is an imbalance between energy input and expenditure (Moran 1999; Kipping, Jago et al. 2008) Genetic and environmental factors greatly influence the bodys energy balance. Nevertheless, genetic conditions which either cause production of excessive fat in the body or reduce the rate at which it is broken down, of which Prader-Willi syndrome is an example account for less than 5% of obese individuals (Speiser, Rudolf et al. 2005), with environmental factors accounting for a very high percentage (French, Story et al. 2001). The major cause of the rising obesity problem is arguably changes in physical and social environments (French, Story et al. 2001). In recent times, there has been a remarkable shift towards activities that do not promote energy expenditure, for example, most children would travel to school in cars rather walk, in contrast to what obtained in the 1970s (Popkin, Duffey et al. 2005; Anderson and Butcher 2006). There is evidence to suggest that obese children are less active than their non-obese counterparts, hence promoting physical activity such as walking or exercising will help prevent obesity in children (Hughes, Henderson et al. 2006). Media time (television viewing, playing video games and using the computer) has been identified as one of the significant environmental changes responsible for the surge in childhood obesity. Besides promoting physical inactivity, it encourages energy input via excessive snacking and inappropriate food choices as a result of television advertisements (Ebbeling, Pawlak et al. 2002; Speiser, Rudolf et al. 2005). Robinson in his study reveals that â€Å"between ages 2 and 17, children spend an average of 3 years of their waking lifetime watching television alone† (Robinson 1998). Parents play a significant role in where, what and how much their children eat and to an extent, how physically active their children are. In most homes, children make their food choices based on the options they are presented with by their parents, and they characteristically would go for wrong option, more so if they have an obese parent (Strauss and Knight 1999). Other changes within the family such as physical inactivity and working patterns of parents have contributed somewhat to the obesity epidemic. In a family where the parents work full-time, there tends to be very little time for them to prepare wholesome home-made meals and this could possibly explain the increasing demand for eating out (Anderson and Butcher 2006) thereby increasing intake of high energy dense food. Childrens attitude to and participation in physical activities depends largely on how physically active their parents are. Thus children of sporty parents embrace exercise heartily and are therefore less prone to becoming obese.(Sallis, Prochaska et al. 2000). In addition to these family factors, societal factors such as high crime rate, access to safe sports/recreational facilities, transportation and fewer physical education programs in schools significantly impact on energy balance (Koplan, Liverman et al. 2005; Popkin, Duffey et al. 2005; Topp, Jacks et al. 2009). French summarizes the environmental influence on obesity by opining that â€Å"The current epidemic of obesity is caused largely by an environment that promotes excessive food intake and discourages physical activity† (French, Story et al. 2001) CONSEQUENCES OF OBESITY Evidence suggests that childhood obesity and/or overweight has a great impact on both physical and psychological health; causing effects such as behavioral problems and low self esteem, with a higher risk in girls than in boys (Reilly, Methven et al. 2003). Although most of the serious consequences do not become evident until adulthood, research has shown childhood obesity to be linked to metabolic disorders such as insulin resistance and type 2 diabetes, stroke and heart attacks, sleep apnea, nonalchoholic fatty liver disease, higher incidence of cancers, depression, dyslipidaemia, increased blood clotting tendency, etc (Ebbeling, Pawlak et al. 2002; Reilly, Methven et al. 2003; Kiess, Marcus et al. 2004; D. A. Lawlor, C. J. Riddoch et al. 2005; Daniels 2006; WHO 2006). One of the long-term serious consequences of childhood obesity is that obese children are twice more likely to grow into obese adults than their non-obese counterparts (Moran 1999); however, this largely depends on factors such as age of onset, severity of the disease and the presence of the disease in one parent (Moran 1999; Campbell, Waters et al. 2001; Kiess, Marcus et al. 2004; WHO 2006). Other long term consequences include early death and adverse socio-economic consequences such as poor educational attainment and low/no income in adulthood (Reilly, Methven et al. 2003; Fowler-Brown and Kahwati 2004; Kiess, Marcus et al. 2004). Obesity-related morbidity places a huge and growing financial demand on governments. In the UK alone, the Department of Health has reported that obesity costs the NHS and the UK economy as a whole about  £1b and between  £2.3b  £2.6b annually respectively, with the cost to the NHS projected to rise to  £3.6b by 2010 (DH 2007). TREATMENT AND PREVENTION The treatment of obesity requires a multidisciplinary approach due to the multi-faceted nature of the condition (Parizkova and Hills 2004). This is aimed at reducing caloric intake and increasing energy expenditure through physical activity (Ebbeling, Pawlak et al. 2002). These interventions are more likely to be successful if the patients family is involved and the treatment tailored to individual needs and circumstances (Fowler-Brown and Kahwati 2004). In extreme cases, options such as surgical and pharmacological treatments could be exploited. These options are very unpopular and usually not recommended because the associated health risks outweigh the benefits by far (Epstein, Myers et al. 1998; Ebbeling, Pawlak et al. 2002). Considering the huge costs and high levels of treatment failure associated with obesity treatment (Stewart, Chapple et al. 2008), the axiom by Benjamin Franklin cannot describe any other condition better than it describes obesity management. â€Å"An ounce of prevention is worth a pound of cure† Dietz et al confirm this by saying that prevention remains the best and most effective management of obesity (Dietz and Gortmaker 2001). Obesity prevention interventions are usually set either in the home or at school with an objective of eliminating peer pressure and, by so doing effect behavioral change (Ebbeling, Pawlak et al. 2002). Literature suggests that the school has so far remained the choice setting for these preventive interventions despite the very limited evidence on its effectiveness (Birch and Ventura 2009). Why is the school setting a good focus of intervention? Approximately 90% of children are enrolled in schools in developed countries (Baranowsk, Cullen et al. 2002) Children spend a substantial amount of time in school and therefore consume a considerable proportion of their daily calories at school (Katz, OConnell et al. 2005) School related activities present an opportunity to educate children on the concept of energy balance, healthy living and how to make appropriate food choices (Ebbeling, Pawlak et al. 2002; Koplan, Liverman et al. 2005) It offers opportunity for continuity and constant monitoring via frequent contact (Baranowski T 2002) Schools have an availability of existing manpower and facilities needed for anti-obesity interventions (Kropski, Keckley et al. 2008) In a nut shell, â€Å"Schools offer many other opportunities for learning and practicing healthful eating and physical activity behaviors. Coordinated changes in the curriculum, the in-school advertising environment, school health services, and after-school programs all offer the potential to advance obesity prevention† (Koplan, Liverman et al. 2005). PREVIOUS SYSTEMATIC REVIEWS Systematic reviews have been conducted on the effectiveness of school-based interventions in the prevention of childhood obesity. Campbell et al (2001), conducted a systematic review of 7 randomised control trials (RCTs) (6 were school-based, varying in length of time, target population, quality of study and intervention approach). The review found that dietary and physical education interventions have an effect on childhood obesity prevalence. However, success varied with different interventions amongst different age groups. Two of the three long term studies that focused on a combination of dietary education and physical activity, and dietary education respectively reported an effect on obesity prevalence reduction. Similarly, 1 out of the 3 school based short-term interventions that focused only on reducing sedentary activity also found an effect on obesity prevalence. While this review shows that dietary and physical activity interventions based at school are effective against th e risk factors of obesity, the question of generalisability and reproducibility arises as the review reports the majority of the included primary studies were carried out in the US. Most of the studies used BMI as a measure of adiposity, and BMI as has been documented varies across ethnic and racial groups (Rush, Goedecke et al. 2007), thus, it will be inappropriate to apply the findings of US-based obesity prevention interventions to children in middle and low income countries where conditions are different. There are also concerns about the methodology and study design. For example the school-based study by Gotmaker et al (1999) had limitations such as low participation rate (65%) and the researchers were unable to adjust for maturity in boys and there was also poor assessment of dietary intake. All these limitations could have been responsible for a high percentage of the reported intervention effect thus affecting the validity of the results of the study (Gortmaker, Peterson et al. 1999). The authors of the review however concluded that there is currently very limited high quality evidence on which to draw conclusions on the effectiveness of anti-obesity programmes. A Cochrane review which is an update of the Campbell et al (2001) study by Summerbell et al (2005) has examined the impact of diet, physical activity and/or lifestyle and social support on childhood obesity prevention. Their review examined the effectiveness of childhood obesity prevention interventions which included school based interventions. Their study included 10 long-term (a minimum duration of 12 months) and 12 short-term (12weeks 12 months) clinical trials (randomised and controlled). 19 out of the 22 studies that met their inclusion criteria were school/pre-school based. The study chose the appropriate study type; more than one reviewer was involved in the entire process of data collection, extraction and selection of included studies. In general, the study found that most of the school-based interventions (dietary and/or physical activity) reported some positive changes in targeted behaviours, but however had very little or no statistically significant impact on BMI. The reviewers stated that none of the 22 studies fulfilled the quality criteria because of some form of methodological weakness which includes measurement errors. For instance, the study by Jenner et al (1989) had no valid method of measuring food intake. The studies by Crawford et al (1994), Lannotti et al (1994) and Sallis et al (2000) had similar measurement errors. Reporting error was identified in studies by Little et al (1999) and Macdiarmid et al (1998). There were also reliability concerns about the secondary outcomes measurement in some of the included studies. The reviewers therefore expressed the need for further high quality research on effectiveness. Kropski et al (2008) reviewed 14 school-based studies that were designed to effect a life style change, a change in BMI, decrease overweight prevalence through a change in nutrition, physical activity or a combination of both. Of the 14 studies, three were done in the UK, one in Germany and 10 in the US. The right type of studies were chosen for this review and the whole process was done by more than one reviewer, however they were unable to draw strong conclusions on the efficacy of school-based interventions because of the limited number of primary studies available and methodological or design concerns which include: small sample size (Luepker, Perry et al. 1996; Mo-suwan, Pongprapai et al. 1998; Nader, Stone et al. 1999; Warren, Henry et al. 2003), no intention-to treat analysis (Danielzik, Pust et al.; Sallis, McKenzie et al. 1993; Sahota, Rudolf et al. 2001; Warren, Henry et al. 2003), possibility of type I (Coleman, Tiller et al. 2005) and type II errors (Warren, Henry et al. 2003), unit of analysis errors (Sallis, McKenzie et al. 1993) and inconsistent results (Mo-suwan, Pongprapai et al. 1998; Caballero, Clay et al. 2003; Coleman, Tiller et al. 2005). Despite their inability to draw a conclusion on effectiveness, overall, the review found that a combination of nutritional and physical activity interventions had the most effect on BMI and prevalence of overweight, with the result largely varying from community-to-community. The nutrition only and physical activity only interventions appeared to have had a change on lifestyles of participants but either had no significant effect on the measures of overweight or no BMI outcomes were measured. Another systematic review on the effectiveness of school-based interventions among Chinese school children was carried out by M.Li et al (2008). The authors included 22 primary studies in their review. The review reported that the primary studies showed that there are some beneficial effects of school-based interventions for obesity prevention; the reviewers however expressed their concerns that most of the studies included in the review had what they considered to be serious to moderate methodological weaknesses. Sixteen of the 22 studies included studies were cluster control trials, and there was no mention by any of the researchers that cluster analysis was applied to any of the 16 studies. In addition to lack of cluster analysis, no process evaluation was conducted in any of the studies. Only one study performed an intention to treat analysis. Twelve studies experienced dropouts, but there was incomplete information on the study population at the end of the trial and the reason f or the dropouts. Additionally, none of the studies explained the theory upon which they based their intervention. There was also potential recruitment and selection bias in all the primary studies as identified by the reviewers. They stated that none of the studies reported the number of subjects that were approached for recruitment into the study. As none of the RCTs included described the method they used in randomization, neither did they state if the studies were blinded or not. The methodological flaws in a high percentage of the included primary studies could impact on the validity of the findings of the review. Again, the authors failed to reach a conclusion on the effectiveness of the interventions because of the intrinsic weaknesses found in the primary studies, and as a result state the need for more primary studies that would address the methodological weaknesses that is highly present in nearly all existing primary studies conducted on this topic so far. The study of the efficacy of school-based interventions aimed at preventing childhood obesity or reducing the risk factors is a rather complex one. Pertinent issues on effectiveness of school-based interventions to prevent the risk factors of obesity remain that there is very limited/weak evidence on which to base policies on. Heterogeneity of primary research (in terms if age of study population, duration of intervention, measurement of outcomes and outcomes measured) makes further statistical analysis nearly impossible. BMI is currently the most widely used measure of overweight and obesity in children. However, BMI has no way of distinguishing between fat mass and muscle mass in the body and might therefore misdiagnose children with bigger muscles as obese. Another disadvantage of using BMI in overweight measurement is its inability of depicting the body fat composition (Committee on Nutrition 2003), other surrogate indicators of adiposity may be needed. Most authors that have carried out a review on this topic so far have expressed the need for further research on this topic to add to the existing body of evidence. RATIONALE FOR THIS STUDY All the systematic reviews on this subject so far have focused mainly on the United States. Lifestyle differences such as eating habits between American and British children possibly affect generalisability and reproducibility of US findings to the UK. For example, in the US, research has shown that 0.5% of all television advertisements promote food, and that about 72% of these food advertisements promote unhealthy food such as candy and fast food (Darwin 2009). In the UK paradoxically, the government in 2007 enforced regulations banning television advertisement of unhealthy foods (foods with high fat, salt, and sugar content) during television programmes aimed at children below 16 years of age (Darwin 2009). Thus US children are at a higher risk of becoming obese than their UK counterparts as a result of higher rate of exposure to TV junk food advertisements. Another lifestyle difference between American and British children is physical activity. In the UK, a high percentage of children aged 2 to 15 achieve at least 60 minutes of physical activity daily (about 70% of males and 60% of females) (DoH 2004), as opposed to the US where only about 34% of school pupils achieve the daily recommended levels of physical activity daily (CDC 2008). These differences highlight the importance of public health policies being based on the local population characteristics rather than on imported overseas figures. There is therefore need to review the evidence of UK school-based obesity interventions to inform policy relevant to the UK population. To the best of my knowledge following an extensive literature search, no systematic review has been conducted on the effectiveness of school-based intervention in preventing childhood obesity in the UK, despite the high prevalence of the condition and its public health significance in this country. This research aims to bridge this gap in knowledge by focusing on UK based studies to evaluate the efficacy of school-based interventions in the UK population. This study therefore stands out insofar as it will be assessing the effectiveness of school-based interventions in the reducing the risk factors of obesity in the UK, with a hope of providing specific local recommendations based on UK evidence. This type of review is long overdue in the UK, considering that the governments target to reduce childhood obesity to its pre-2000 levels by the year 2020 (DoH 2007) will require local evidence of effective interventions to succeed. The next stage of this review will describe in detail the research methodology to be used to conduct the proposed systematic review. Also included will be research strategy details to be adopted, study selection criteria, data collection and analysis. AIMS AND OBJECTIVES The aim of this research is to: Systematically review school-based intervention studies in the UK aimed at reducing the risk factors of childhood obesity among school children. Objectives are: To assess the efficacy of school-based anti-obesity interventions in the UK. To identify the most effective form of school-based interventions in the prevention of childhood obesity amongst school children in the UK. CRITERIA FOR INCLUDING STUDIES IN THIS REVIEW METHODS This review was performed as a Cochrane review. The Cochrane guidance on systematic reviews and reporting format were as far as possible adhered to by the author (Green, Higgins et al. 2008). The entire review process was guided by a tool for assessing the quality of systematic reviews, alongside the accompanying guidance (health-evidence.ca 2007a; health-evidence.ca 2007b). TYPES OF STUDY In the search for the effectiveness of an intervention, well conducted randomised control trials (which are the best and most credible sources of evidence) will be the preferred source of studies for this review. However, because of the limited number of RCTs conducted on this topic so far, this study will include controlled clinical trials if there is insufficient availability of RCTs. TYPES OF PARTICIPANTS School children under 18 years of age TYPES OF INTERVENTIONS Interventions being evaluated are those that aim to: Reduce sedentary lifestyle Effect nutritional change Combine the two outcomes above Reduce obesity prevalence Effect an attitude change towards physical activity and diet Studies that present a baseline and post intervention measure of primary outcome. Interventions not included in this study are: Those with no specified weight-related outcomes Those that involved school-age children but were delivered outside of the school setting, as our focus is based on school-based interventions aimed at obesity prevention. Studies done outside the UK Studies with no specified interventions Non-RCTs or CCTs For each intervention, the control group will be school children not receiving the intervention(s). TYPES OF OUTCOMES MEASURED Primary outcomes Change in adiposity measured as BMI and/or skin fold thickness Secondary outcomes Knowledge Physical activity levels Diet SEARCH METHODS FOR IDENTIFICATION OF STUDIES Electronic searches The electronic databases OVID MEDLINE ® (1950-2009), PsycINFO (1982-2009), EMBASE (1980-2009) and the British Nursing Index (1994-2009) were all searched using the OVID SP interface. The Wiley Interscience interface was used to search the following databases: Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects. There was also a general search of internet using Google search engine, in an attempt to identify any ongoing studies or unpublished reports before proceeding to search grey literature sources. Grey literature For references to childhood obesity prevention in schools, the following grey literature sources were searched: British Library Integrated Catalogue (http://catalogue.bl.uk/F/?func=filefile_name=login-bl-list) ISI index of Conference Proceedings (http://wok.mimas.ac.uk/) SCIRUS (http://www.scirus.com/) System for Information on Grey Literature (http://opensigle.inist.fr/) ZETOC (http://zetoc.mimas.ac.uk) Additionally, current control trials database at http://www.controlled-trials.com/ was searched for any ongoing research. The UK national research register was also searched at https://portal.nihr.ac.uk/Pages/NRRArchive.aspx. All the links to the grey literature databases were tested at the time of this review and found to be working. Hand searches It was not possible to conduct a hand search of journals due to pragmatic reasons. Reference lists Reference lists of retrieved studies were searched for other potential relevant studies that might have been omitted in the earlier search. Correspondence First author of all included studies were contacted with a view to seeking more references. DATA COLLECTION AND ANALYSIS Selection of studies The abstracts and titles of the hits from the electronic databases searched were screened for relevance by a single assessor. Those that were thought to be potentially relevant were retrieved and downloaded unto EndnoteTM to make the results manageable and also avoid loss of data. At the end of the search, all databases were merged into one single database and duplicated records of the same study were removed. Subsequently, the assessor then sought and obtained the full text of, and reviewed the relevant studies that were considered eligible for inclusion. Multiple reports of same study were linked together. No further data were sought for studies not included in the review. Data extraction Data extraction from included studies was done by a single reviewer and the data recorded on a data extraction form. A summary of each included study was described according to these characteristics: Participants (age, ethnicity etc.), study design, description of school-based interventions, study quality and details such as follow-ups and date, location, outcomes measured, theoretical framework, baseline comparability and results Assessment of methodological quality of included studies A number of researchers (Jackson, Waters et al. 2005) and the Cochrane guidelines for systematic reviews of health promotion and public health interventions (Rebecca Armstrong, Waters et al. 2007) strongly advise using the Quality Assessment Tool for Quantitative Studies (2008a) developed by the Effective Public Health Practice Project in Canada and the accompanying dictionary (to act as a guideline) (2008b) in assessing methodological quality. Based on criteria such as selection bias, study design, blinding, cofounders, data collection methods, withdrawals and drop-outs and intervention integrity, the tool which is designed to cover any quantitative study employs the use of a scale (strong, moderate or weak) to assess the quality of each study included in the review. Analysis Considering the small number of studies included in the review and heterogeneity in terms of interventions, delivery methods, intensity of interventions, age of participants, duration of intervention and outcomes measured, it was not statistically appropriate to undertake a Meta analysis, which admittedly would have been the preferred method of analysing and summarising the results of the studies. A narrative synthesis of the results was done instead. RESULT DESCRIPTION OF STUDIES Results of the search The search of electronic sources identified 811 citations out of which 97 potential studies were retrieved. A reference management software EndnoteTM was used to search for and remove duplicate citations. Further screening of title and abstract reduced the number of citations to 17 potential studies. Full texts of the 17 studies were sought, 13 were excluded, and four met the inclusion criteria and were therefore included in the review. Authors of the four studies were then conta