The association between obesity and quality of life: a retrospective analysis of a large-scale population-based cohort study.

BACKGROUND: The relationship between obesity and health-related quality of life (HRQoL) may be confounded by factors such as multimorbidity. The aim of the study was to explore this relationship, controlling for long-term conditions and other health, lifestyle and demographic factors in a general adult population. There was specific interest in the impact of high weight status, measured by body mass index (BMI) levels (obesity, morbid obesity) compared with individuals of normal weight. METHODS: Health, lifestyle and demographic data were collected from 64,631 individuals aged 16 years and over registered in the Yorkshire Health Study; a long-term cohort study. Data were collected in 2 waves: from patients attending GP surgeries in the South Yorkshire region; and using online recruitment across the entire Yorkshire and Humber area. Univariable and multivariable regression methods were utilised to identify factors associated with HRQoL as measured by the EQ-5D summary score. Long-term conditions were tested as both covariates and mediating factors on the causal pathway between obesity and HRQoL. RESULTS: Increasing levels of obesity are associated with reduced HRQoL, although this difference is negligible between those of normal weight and those who are overweight. Individuals with obesity and morbid obesity score 4.9 and 11.3 percentage points less on the EQ-5D summary scale respectively than those of normal weight. Concurrent physical, and particularly mental health-related long-term conditions are substantively related to HRQoL: those with 3 or more reported mental or physical health conditions score 29.8 and 14.6 percentage points less on the EQ-5D summary scale respectively than those with fewer conditions. Long-term conditions can be conceptualised as lying on the causal path between obesity and HRQoL, but there is weak evidence for a partial mediating relationship only. CONCLUSIONS: To conclude, in agreement with the established literature we have found a clear inverse relationship between increasing weight status and decreasing HRQoL and confirmed the mediating role of long-term conditions in the reduction of HRQoL in people with obesity. Nevertheless, a high BMI remains independently related to HRQoL, suggesting that 'healthy people with obesity' may be in transition to an unhealthy future.

Who are the obese? A cluster analysis exploring subgroups of the obese.

BACKGROUND: Body mass index (BMI) can be used to group individuals in terms of their height and weight as obese. However, such a distinction fails to account for the variation within this group across other factors such as health, demographic and behavioural characteristics. The study aims to examine the existence of subgroups of obese individuals. METHODS: Data were taken from the Yorkshire Health Study (2010-12) including information on demographic, health and behavioural characteristics. Individuals with a BMI of ≥30 were included. A two-step cluster analysis was used to define groups of individuals who shared common characteristics. RESULTS: The cluster analysis found six distinct groups of individuals whose BMI was ≥30. These subgroups were heavy drinking males, young healthy females; the affluent and healthy elderly; the physically sick but happy elderly; the unhappy and anxious middle aged and a cluster with the poorest health. CONCLUSIONS: It is important to account for the important heterogeneity within individuals who are obese. Interventions introduced by clinicians and policymakers should not target obese individuals as a whole but tailor strategies depending upon the subgroups that individuals belong to.

'Fish out of water': a cross-sectional study on the interaction between social and neighbourhood effects on weight management behaviours.

OBJECTIVE: To analyse whether an individual's neighbourhood influences the uptake of weight management strategies and whether there is an interaction between individual socio-economic status and neighbourhood deprivation. METHODOLOGY: Data were collected from the Yorkshire Health Study (2010-2012) for 27 806 individuals on the use of the following weight management strategies: 'slimming clubs', 'healthy eating', 'increasing exercise' and 'controlling portion size'. A multi-level logistic regression was fit to analyse the use of these strategies, controlling for age, sex, body mass index, education, neighbourhood deprivation and neighbourhood population turnover (a proxy for neighbourhood social capital). A cross-level interaction term was included for education and neighbourhood deprivation. Lower Super Output Area was used as the geographical scale for the areal unit of analysis. RESULTS: Significant neighbourhood effects were observed for use of 'slimming clubs', 'healthy eating' and 'increasing exercise' as weight management strategies, independent of individual- and area-level covariates. A significant interaction between education and neighbourhood deprivation was observed across all strategies, suggesting that as an area becomes more deprived, individuals of the lowest education are more likely not to use any strategy compared with those of the highest education. CONCLUSIONS: Neighbourhoods modify/amplify individual disadvantage and social inequalities, with individuals of low education disproportionally affected by deprivation. It is important to include neighbourhood-based explanations in the development of community-based policy interventions to help tackle obesity.

Interventions employing mobile technology for overweight and obesity: an early systematic review of randomized controlled trials.

Obesity is a global epidemic with major healthcare implications and costs. Mobile technologies are potential interventions to promote weight loss. An early systematic review of this rapidly growing area of research was conducted. Electronic databases were searched for articles published between January 1998 and October 2011. Data sources included Medline, Embase and the Cochrane Central Register of Controlled Trials. Ongoing research was searched for using clinical trials databases and registers. Out of 174 articles retrieved, 21 met the inclusion criteria of randomized controlled trials (RCTs) on mobile technology interventions facilitating weight loss in overweight and obese adults with any other comparator. A narrative synthesis was undertaken. Seven articles were included and appraised using the Cochrane risk of bias tool: four presented a low risk of bias and three presented a high risk of bias. There is consistent strong evidence across the included multiple high-quality RCTs that weight loss occurs in the short-term because of mobile technology interventions, with moderate evidence for the medium-term. Recommendations for improving the reporting and quality of future trials are made including reporting weight loss in percent to meet clinical standards, and including features such as long-term follow-up, cost-effectiveness and patient acceptability.

A qualitative study of cardiac rehabilitation patients' perspectives on making dietary changes.

BACKGROUND: Making healthier food choices is recognised as being important in the secondary prevention of coronary heart disease (CHD) and the provision of information about making dietary changes should be included in cardiac rehabilitation (CR), a secondary prevention strategy. Studies indicate that patients do not always make the recommended dietary changes, although research on CR patients' perspectives on dietary change appears to be limited. The present study aimed to explore CR patients' perspectives on making and maintaining dietary changes. METHODS: Following ethical approval, in-depth, audiotaped, qualitative interviews were conducted with 15 post-myocardial infarction CR patients (11 men and four women) who had completed a hospital-based CR programme. Participants comprised White British individuals aged 42-65 years, from a variety of socioeconomic backgrounds. Interview topics included perspectives on CHD and lifestyle changes, including diet. Follow-up interviews with 10 patients, conducted approximately 9 months later, explored whether their perspectives had changed. RESULTS: Patients tended to only make and maintain dietary changes if they perceived their diet to be a cause of their CHD. The only dietary changes patients reported involved 'cutting things out' of their diet; patients did not make dietary changes if they considered that they did not need to 'cut things out'. CONCLUSIONS: These findings suggest that, despite receiving information about eating a balanced diet, CR patients may perceive dietary change in terms of whether or not they need to 'cut things out' of their diet. Greater emphasis may be needed in dietary information on increasing the proportion of healthy foods consumed and choosing healthier alternatives.

From consumerism to active dependence: Patterns of medicines use and treatment decisions among patients with atopic dermatitis.

In this article, findings from in-depth interviews with 12 people diagnosed with atopic dermatitis (AD) are described. The findings describe the range of strategies used to manage atopic dermatitis, including use of conventional medicines. A strong theme identified in informants' accounts centred on concerns about the risks of illness and long-term use of conventional medicines, which acted as a strong incentive for patients to seek alternatives to conventional treatments. However, despite their significant efforts to do so, patients were eventually forced to return to and rely on conventional medicines because of their efficacy in alleviating and treating symptoms. These findings are discussed in relation to the sociological literature on consumerism, risk and reflexivity in health. We argue that our findings exemplify how living with and managing a chronic illness may not be straightforward and the choices of treatment at hand may be limited. Consequently, this may limit the potential opportunities accruing from adopting a reflexive or consumerist approach to managing illness.

'Islands' and 'doctor's tool': the ethical significance of isolation and subordination in UK community pharmacy.

Empirical ethics research is increasingly valued in offering insights into how ethical problems and decision-making occur in healthcare. In this article, the findings of a qualitative study of the ethical problems and decision-making of UK community pharmacists are presented, and it is argued that the identified themes of pharmacists' relative isolation from others and their subordination to doctors are ethically significant. Semi-structured interviews were conducted with 23 community pharmacists in England, UK. Analysis of interviews revealed that isolation involved separation of pharmacists from their peers, other healthcare professionals, patients and customers. Such isolation is argued to be inimical to ethical practice - impeding ethical discourse as understood by Habermas, resulting in a form of anomie that inhibits the transmission of professional values, leading to a lack of proximity between pharmacist and patient or customer that may impede ethical relationships and resulting, psychologically, in less ethical concern for those who are less close. Pharmacists' subordination to doctors not only precipitated some ethical problems but also allowed some pharmacists to shift ethical responsibility to a prescribing doctor, as in the case of emergency hormonal contraception. The emergence of atrocity stories further supports a culture of subordination that may cause ethical problems. The study has implications for community pharmacy practice in terms of supervision issues, developments such as prescribing responsibilities and how ethical values can be taught and communicated. The potential for isolation and subordination in other healthcare professions, and resultant ethical problems, may also need to be addressed and researched.

Ethical decision-making, passivity and pharmacy.

BACKGROUND: Increasing interest in empirical ethics has enhanced understanding of healthcare professionals' ethical problems and attendant decision-making. A four-stage decision-making model involving ethical attention, reasoning, intention and action offers further insights into how more than reasoning alone may contribute to decision-making. AIMS: To explore how the four-stage model can increase understanding of decision-making in healthcare and describe the decision-making of an under-researched professional group. METHODS: 23 purposively sampled UK community pharmacists were asked, in semi-structured interviews, to describe ethical problems in their work and how they were resolved. Framework analysis of transcribed interviews utilised the four decision-making stages, together with constant comparative methods and deviant-case analysis. RESULTS: Pharmacists were often inattentive and constructed problems in legal terms. Ethical reasoning was limited, but examples of appeals to consequences, the golden rule, religious faith and common-sense experience emerged. Ethical intention was compromised by frequent concern about legal prosecution. Ethical inaction was common, typified by pharmacists' failure to report healthcare professionals' bad practices, and ethical passivity emerged to describe these negative examples of the four decision-making stages. Pharmacists occasionally described more ethically active decision-making, but this often involved ethical uncertainty. DISCUSSION: The four decision-making stages are a useful tool in considering how healthcare professionals try to resolve ethical problems in practice. They reveal processes often ignored in normative theories, and their recognition and the emergence of ethical passivity indicates the complexity of decision-making in practice. Ethical passivity may be deleterious to patients' welfare, and concerns emerge about improving pharmacists' ethical training and promoting ethical awareness and responsibility.

Causes of preventable drug-related hospital admissions: a qualitative study.

OBJECTIVE: To explore the causes of preventable drug-related admissions (PDRAs) to hospital. DESIGN: Qualitative case studies using semi-structured interviews and medical record review; data analysed using a framework derived from Reason's model of organisational accidents and cascade analysis. PARTICIPANTS: 62 participants, including 18 patients, 8 informal carers, 17 general practitioners, 12 community pharmacists, 3 practice nurses and 4 other members of healthcare staff, involved in events leading up to the patients' hospital admissions. SETTING: Nottingham, UK. RESULTS: PDRAs are associated with problems at multiple stages in the medication use process, including prescribing, dispensing, administration, monitoring and help seeking. The main causes of these problems are communication failures (between patients and healthcare professionals and different groups of healthcare professionals) and knowledge gaps (about drugs and patients' medical and medication histories). The causes of PDRAs are similar irrespective of whether the hospital admission is associated with a prescribing, monitoring or patient adherence problem. CONCLUSIONS: The causes of PDRAs are multifaceted and complex. Technical solutions to PDRAs will need to take account of this complexity and are unlikely to be sufficient on their own. Interventions targeting the human causes of PDRAs are also necessary--for example, improving methods of communication.

Supplementary prescribing by community and primary care pharmacists: an analysis of PACT data, 2004-2006.

BACKGROUND AND OBJECTIVE: Pharmacist prescribing is a relatively new initiative in the extension of prescribing responsibilities to non-medical healthcare professionals. Pharmacist supplementary prescribing was introduced in 2003 and allowed prescribing in accordance with a clinical management plan agreed with a medical practitioner and patient to improve patient access to medicines and better utilize the skills of healthcare professionals. The objective of this research was to examine the volume, cost and trends in pharmacist prescribing in community and primary care using Prescription Analysis and Cost (PACT) data and to suggest possible reasons for the trends. METHODS: Using PACT data at national, chapter and subchapter level for 2004-2006 the volume, costs and trends for pharmacist prescribing were obtained. Supplemental data and statistical analysis from other sources, relating to prescribing of individual drugs, were also utilized. RESULTS: The total number of items prescribed by pharmacists in community and primary care increased from 2706 in 2004 to 31 052 in 2006. In 2006, pharmacist prescribing represented only 0.004% of all prescribing in the community and primary care setting. Cardiovascular medicines were the most frequently prescribed therapeutic class followed by central nervous system, respiratory, endocrine and gastrointestinal medicines. CONCLUSION: Pharmacist prescribing is increasing but represents an extremely small proportion of primary care prescribing. PACT data between 2004 and 2006 reflects pharmacist supplementary prescribing alone and has been in the anticipated therapeutic areas of drugs which treat chronic conditions such as hypertension.

How do parents' child-feeding behaviours influence child weight? Implications for childhood obesity policy.

BACKGROUND: Parents have some responsibility for children's dietary habits and they are often the focus of public health interventions designed to improve children's diets and thereby reduce the prevalence of childhood obesity. The current UK interventions promote awareness of healthy food choices, but offer little guidance for parents on child-feeding behaviours. METHODS: A review of recent literature regarding child-feeding behaviours and child weight. RESULTS: Parents report using a wide range of child-feeding behaviours, including monitoring, pressure to eat and restriction. Restriction of children's eating has most frequently and consistently been associated with child weight gain. Furthermore, there is substantial evidence for a causal relationship between parental restriction and childhood overweight. CONCLUSIONS: Parents may inadvertently promote excess weight gain in childhood by using inappropriate child-feeding behaviours. We recommend the development of interventions to increase awareness of the possible consequences of inappropriate child-feeding behaviours. Parents who are concerned about their child's weight will also require guidance and support in order to adopt more appropriate child-feeding behaviours.

A new prescription for empirical ethics research in pharmacy: a critical review of the literature.

Empirical ethics research is increasingly valued in bioethics and healthcare more generally, but there remain as yet under-researched areas such as pharmacy, despite the increasingly visible attempts by the profession to embrace additional roles beyond the supply of medicines. A descriptive and critical review of the extant empirical pharmacy ethics literature is provided here. A chronological change from quantitative to qualitative approaches is highlighted in this review, as well as differing theoretical approaches such as cognitive moral development and the four principles of biomedical ethics. Research with pharmacy student cohorts is common, as is representation from American pharmacists. Many examples of ethical problems are identified, as well as commercial and legal influences on ethical understanding and decision making. In this paper, it is argued that as pharmacy seeks to develop additional roles with concomitant ethical responsibilities, a new prescription is needed for empirical ethics research in pharmacy-one that embraces an agenda of systematic research using a plurality of methodological and theoretical approaches to better explore this under-researched discipline.

Appropriateness measurement: application to advice-giving in community pharmacies.

Awareness of variations in the delivery of medical care has resulted in considerable research activity focused on developing measures to assess the appropriateness of health service provision both internationally and within Great Britain. As in other areas of health service provision there is evidence of variation in advice provided alongside sales of non-prescription medicines and variation in response to requests for advice about the treatment of minor ailments within community pharmacies in Great Britain. However, there is little research which has explored the extensive methodological problems associated with developing criteria to assess the appropriateness of these-two activities. Following a critical review of relevant existing research, this paper describes a methodology and empirical findings from a study which aimed to develop criteria to measure the appropriateness of advice provided in community pharmacies. Firstly, details of advice-giving episodes occurring between consumers and pharmacists or medicines counter assistants were captured and documented using a combination of audio tape-recording and non-participant observation. Secondly, the nominal group technique was used to develop a set of explicit criteria for assessing the appropriateness of advice. Thirdly, an assessment instrument was developed in order to operationalise the criteria. The devised criteria include both process and output components. We discuss the utility of these criteria in relation to developments in self-medication practice affecting community pharmacy and the deregulation of medicines within the UK. The criteria have been subject to rigorous statistical testing to establish standards of validity and reliability (Ward, Bissell & Noyce, 2000a [Ward, P. R., Bissell, P. & Noyce, P. R. (2000a). Criteria for assessing non-prescription drug therapy in community pharmacy, Annals of Pharmacotherapy (in press).]). The developed criteria will allow us to identify dimensions of both appropriate and inappropriate advice provided in community pharmacies and provide the basis for education and training initiatives identified as a result of the research. In addition, we suggest that this research is highly relevant to informing the content, structure and operationalisation of protocols and/or guidelines associated with the management of minor ailments and the sale of medicines through community pharmacies.

Criteria for assessing the appropriateness of patient counseling in community pharmacies.

OBJECTIVE: To develop valid, reliable criteria for assessing the appropriateness of the management of common ailments and nonprescription drug therapy in community pharmacies in the UK. METHODS: The criteria were developed by an expert panel using the nominal group technique. The validity of the criteria was tested by surveying a random sample of pharmacists who were asked to rate the importance of each criterion on a semantic differential scale from 1 (low) to 7 (high). Subsequently, the reliability of the criteria was assessed: a random sample of pharmacists were each asked to apply the criteria to four vignettes of patient counseling on two separate occasions. RESULTS: All assessment criteria exceeded our predefined level of face, content, and consensual validity. In reliability testing, the overall assessment of appropriateness, along with five component assessment criteria, surpassed our predefined level of reliability. Three criteria, however, did not meet our predefined standard. These criteria were rational content of advice, rational product choice, and referral to another health professional. CONCLUSIONS: This represents the first systematic attempt to develop an instrument of general applicability for assessing the appropriateness of patient counseling and to subject it to rigorous validity and reliability testing. We suggest that further work is required to refine the criteria that did not meet reliability standards and to understand the decision-making processes underlying the assessment of vignettes of patient counseling.

Parotitis associated with Eikenella corrodens in a healthy adult.

Eikenella corrodens is a gram-negative, facultatively anaerobic rod that is part of the normal oral flora. Although its pathogenicity was uncertain until recently, E corrodens has been implicated in a variety of human infections, usually in mixed culture, and commonly in patients predisposed by virtue of trauma, malignant neoplasms, antecedent surgery, or parenteral drug abuse. Parotitis due to E corrodens occurred in a healthy 72-year-old woman. Therapy with high-dose intravenous oxacillin sodium had been without effect, but surgical drainage plus antibiotic therapy directed against E corrodens produced prompt resolution.