Pragmatic trial of a multidisciplinary lung cancer care model in a community healthcare setting: study design, implementation evaluation, and baseline clinical results.

BACKGROUND: Responsible for 25% of all US cancer deaths, lung cancer presents complex care-delivery challenges. Adoption of the highly recommended multidisciplinary care model suffers from a dearth of good quality evidence. Leading up to a prospective comparative-effectiveness study of multidisciplinary vs. serial care, we studied the implementation of a rigorously benchmarked multidisciplinary lung cancer clinic. METHODS: We used a mixed-methods approach to conduct a patient-centered, combined implementation and effectiveness study of a multidisciplinary model of lung cancer care. We established a co-located multidisciplinary clinic to study the implementation of this care-delivery model. We identified and engaged key stakeholders from the onset, used their input to develop the program structure, processes, performance benchmarks, and study endpoints (outcome-related process measures, patient- and caregiver-reported outcomes, survival). In this report, we describe the study design, process of implementation, comparative populations, and how they contrast with patients within the local and regional healthcare system. Trial Registration: ClinicalTrials.gov Identifier: NCT02123797. RESULTS: Implementation: the multidisciplinary clinic obtained an overall treatment concordance rate of 90% (target >85%). Satisfaction scores were high, with >95% of patients and caregivers rating themselves as being "very satisfied" with all aspects of care from the multidisciplinary team (patient/caregiver response rate >90%). The Reach of the multidisciplinary clinic included a higher proportion of minority patients, more women, and younger patients than the regional population. Comparative effectiveness: The comparative effectiveness trial conducted in the last phase of the study met the planned enrollment per statistical design, with 178 patients in the multidisciplinary arm and 348 in the serial care arm. The multidisciplinary cohort had older age and a higher percentage of racial minorities, with a higher proportion of stage IV patients in the serial care arm. CONCLUSIONS: This study demonstrates a comprehensive implementation of a multidisciplinary model of lung cancer care, which will advance the science behind implementing this much-advocated clinical care model.

Inhaled medication usage in post-menopausal women and lifetime tobacco smoke exposure: The Women's Health Initiative Observational Study.

OBJECTIVE: While active smoking is a causal agent in respiratory disease, the independent role of secondhand smoke (SHS) merits further investigation. We investigated associations between lifetime active smoking and exposure to secondhand smoke - studied independently - and current use of 1 or more inhaled medications as a surrogate for prevalent pulmonary disease in post-menopausal women. STUDY DESIGN: Information on lifetime active and passive tobacco exposure and inhaled pulmonary medication usage at enrollment was collected from 88,185 postmenopausal women aged 50-79 enrolled in the Women's Health Initiative Observational Study from 1993 to 1998 at 40 centers in the United States. Participants were recruited from localities surrounding the study centers using a variety of methods, including informational mailings and mass media campaigns. MAIN OUTCOME MEASURES: Multivariate adjusted regression models were used to estimate odds ratios and 95% CI according to levels of active smoking and SHS exposure, and trends were tested across categories. RESULTS: Ever active smokers had an overall OR of 1.97 (95% CI 1.58-2.45) for having one or more prescribed inhaled medication compared with never-smoking women not exposed to active or passive smoke. The overall OR for using inhalers for never-smoking women exposed to any SHS compared with the same reference group was 1.33 (95% CI 1.07-1.65). In a quantified analysis of SHS, never-smoking women with the highest levels of lifetime SHS exposure had an estimated risk of inhaled medication usage of 1.74 (95% CI 1.32-2.30). CONCLUSIONS: The risk of requiring one or more prescribed inhaled medications for pulmonary disease was significantly higher in post-menopausal women who ever smoked or who had lifetime exposure to SHS.

Efficacy of a smoking quit line in the military: baseline design and analysis.

Thirty percent of all military personnel smoke cigarettes. Because of the negative health consequences and their impact on physical fitness, overall health, and military readiness, the Department of Defense has identified the reduction of tobacco use as a priority of US military forces. This study aims to evaluate the one-year efficacy of a proactive versus reactive smoking quit line in the US military with adjunctive nicotine replacement therapy (NRT) in both groups. This paper reports on the baseline variables of the first 1000 participants randomized, the design, and proposed analysis of the randomized two-arm clinical trial "Efficacy of a Tobacco Quit Line in the Military". Participants are adult smokers who are Armed Forces Active Duty personnel, retirees, Reservist, National Guard and family member healthcare beneficiaries. All participants are randomized to either the Counselor Initiated (proactive) group, receiving 6 counseling sessions in addition to an 8-week supply of NRT, or the Self-Paced (reactive) group, in which they may call the quit line themselves to receive the same counseling sessions, in addition to a 2-week supply of NRT. The primary outcome measure of the study is self-reported smoking abstinence at 1-year follow-up. Results from this study will be the first to provide evidence for the efficacy of an intensive Counselor Initiated quit line with provided NRT in military personnel and could lead to dissemination throughout the US Air Force, the armed forces population as a whole and ultimately to civilian personnel that do not have ready access to preventive health services.

Drinking and driving and riding with an alcohol impaired driver among United States Air Force recruits.

OBJECTIVE: To identify the prevalence and correlates of binge drinking, driving after drinking, and riding in a vehicle with a driver who had consumed alcohol in US Air Force active duty recruits. METHODS: A military cohort (N = 31,108; 25.1% female) was analyzed to identify variables associated with binge drinking, drinking and driving, and riding with a driver who had consumed alcohol. RESULTS: Results indicated that 53 percent (including 45% of those under the legal drinking age) reported alcohol use in the month prior to entering basic military training (BMT). Thirty-eight percent of all active duty recruits reported binge drinking (ie, consuming 5 or more drinks on a single occasion) at least one time in the past 30 days. Nearly 1 in 4 (23%) reported 1 to 3 episodes of binge drinking. Three percent of reported alcohol users drove after consuming five or more drinks, and 9 percent rode as a passenger in a vehicle with a driver who had been drinking heavily. CONCLUSIONS: Several demographic, behavioral, and attitudinal correlates of risky drinking patterns were identified. Prevention efforts are needed to address the implications of these findings because they influence the health, safety, and military readiness of active duty personnel.

Impact of differing definitions of dual tobacco use: implications for studying dual use and a call for operational definitions.

INTRODUCTION: Concomitant use of two forms of tobacco is an increasing public health concern, yet there is little consensus regarding a consistent definition of so-called "dual use." We defined dual use as cigarette and smokeless tobacco (ST) consumption with either product used daily or nondaily. METHODS: We analyzed a cohort of 36,013 Air Force recruits. We categorized dual tobacco use across 2 dimensions, type of tobacco products (cigarettes, ST, or others), and the frequency of use (daily vs. nondaily). We determined how varying the definition impacted the prevalence estimates and evaluated the prevalence estimate based on our recommended definition of dual use. Multivariate logistic regression analysis was used to evaluate the risk profile of dual users of ST and cigarettes versus mono users of ST and mono users of cigarettes. RESULTS: Varying definitions of dual use vary prevalence estimates 50-fold (0.5%-25.3%). Including only ST and cigarettes narrows the prevalence estimate to less than 4-fold (2.0%-9.7%). Dual users are more likely to be young Caucasian males, with lower education, and from families with relatively higher incomes. Compared with mono users, dual users of cigarettes and ST have a distinct pattern of risk profiles. CONCLUSIONS: Depending on the definition of dual use, markedly different prevalence and risk profiles are observed. Dual users of ST and cigarettes are a unique group of tobacco users. We propose a common definition of dual use to advance our understanding of this unique group.

Tobacco use harm reduction, elimination, and escalation in a large military cohort.

OBJECTIVES: We evaluated changing patterns of tobacco use following a period of forced tobacco abstinence in a US military cohort to determine rates of harm elimination (e.g., tobacco cessation), harm reduction (e.g., from smoking to smokeless tobacco use), and harm escalation (e.g., from smoking to dual use or from smokeless tobacco use to smoking or dual use). METHODS: Participants were 5225 Air Force airmen assigned to the health education control condition in a smoking cessation and prevention trial. Tobacco use was assessed by self-report at baseline and 12 months. RESULTS: Among 114 baseline smokers initiating smokeless tobacco use after basic military training, most demonstrated harm escalation (87%), which was 5.4 times more likely to occur than was harm reduction (e.g., smoking to smokeless tobacco use). Harm reduction was predicted, in part, by higher family income and belief that switching from cigarettes to smokeless tobacco is beneficial to health. Harm escalation predictors included younger age, alcohol use, longer smoking history, and risk-taking. CONCLUSIONS: When considering a harm reduction strategy with smokeless tobacco, the tobacco control community should balance anticipated benefits of harm reduction with the risk of harm escalation and the potential for adversely affecting public health.

Differences between intermittent and light daily smokers in a population of U.S. military recruits.

INTRODUCTION: Few studies have assessed differences between intermittent and light smokers, particularly among young adults. Exploring these differences promotes a systematic approach to research and treatment in low-level smokers. This study explored demographic, tobacco-related, and psychosocial predictors of intermittent nondaily smoking relative to light smoking among basic military training (BMT) recruits. The impact of smoking status on abstinence rates at follow-up was also assessed. METHODS: Participants were 5,603 U.S. Air Force BMT intermittent nondaily (n = 3,134) or light daily (n = 2,469) smoking recruits participating in a population-based group randomized trial targeting tobacco use prevention and cessation (Klesges et al., 2006, Efficacy of a tailored tobacco control program on long-term use in a population of U.S. military troops. Journal of Consulting and Clinical Psychology, 74, 295-306.). Participants completed baseline measures assessing demographics; tobacco use and history; and common social, attitudinal, and behavioral risk factors for tobacco use. Flights of recruits were randomly assigned to a tobacco use intervention or health education control intervention. At the 1-year follow-up, participants reported 7-day point prevalence and continuous abstinence. RESULTS: Intermittent nondaily smoking relative to light daily smoking was associated with lesser perceived addiction, intermittent and daily use of smokeless tobacco, nonsmoking male and female heads of household, lesser likelihood of smoking while stressed or while bored, and higher likelihood of intentions to quit smoking. Intermittent smokers were significantly more likely than light daily smokers to report abstinence at follow-up. DISCUSSION: Intermittent and daily light smokers differ on several tobacco-related and psychosocial variables. Attending to these factors in prevention and cessation programs may enhance abstinence in both groups.

Psychiatric disorders and cognitive dysfunction among older, postmenopausal women: results from the Women's Health Initiative Memory Study.

OBJECTIVE: To estimate the frequency of depressive symptoms and selected psychiatric disorders in the Women's Health Initiative Memory Study (WHIMS) cohort and related them to cognitive syndromes. DESIGN: WHIMS was a randomized, double-blinded, placebo-controlled prevention clinical trial examining whether opposed and unopposed hormone therapy reduced the risk of dementia in healthy postmenopausal women. Participants scoring below a designated cutpoint on a cognitive screener received a comprehensive neuropsychiatric workup and adjudicated outcome of no cognitive impairment, mild cognitive impairment, or probable dementia. PARTICIPANTS: Seven thousand four hundred seventy-nine WHIMS participants between age 65 and 79 years and free of dementia at the time of enrollment in WHIMS. Five hundred twenty-one unique participants contributed complete data required for these analyses. MEASURES: Depressive symptoms were measured with the 15-item Geriatric Depression Scale and the presence of selected psychiatric disorders (major depression, generalized anxiety, and panic and alcohol abuse) was made using the PRIME-MD. RESULTS: The 18% of women had at least one psychiatric disorder with depression being the most common (16%) followed by general anxiety or panic (6%) and alcohol abuse (1%). Depression and the presence of a psychiatric disorder were associated with impaired cognitive status. Participants having a psychiatric disorder were more than twice as likely to be diagnosed with cognitive impairment as those with no psychiatric disorder (odds ratio = 2.06, 95% confidence interval = 1.17-3.60). Older age, white race, and diabetes were also associated with cognitive impairment. CONCLUSION: The frequency of a psychiatric disorder is associated with poorer cognitive functioning among older women enrolled in WHIMS. That approximately one in five women had a probable psychiatric disorder, most typically depression, highlights the need for greater detection and treatment efforts in this population.

Do we believe the tobacco industry lied to us? Association with smoking behavior in a military population.

Despite the dangers of smoking, tobacco companies continue to impede tobacco control efforts through deceptive marketing practices. Media campaigns that expose these practices have been effective in advancing anti-industry attitudes and reducing smoking initiation among young people, yet the association between knowledge of industry practices and smoking cessation and relapse has not been studied. In a large military sample entering Air Force Basic Military Training (BMT), where tobacco use is prohibited, we investigated (i) the prevalence of agreement with a statement that tobacco companies have misled the public about the health consequences of smoking and (ii) the association of this acknowledgement with smoking status upon entry into BMT (N = 36 013). At baseline, 56.6% agreed that tobacco companies have been deceptive, and agreement was a strong predictor of smoking status [smokers less likely to agree, odds ratio (OR) = 0.39, P < 0.01]. At 12-month follow-up, we examined the association between industry perception at baseline and current smoking status (N = 20 672). Recruits who had been smoking upon entry into BMT and who had acknowledged industry deception were less likely to report current smoking (OR = 0.84, P = 0.01). These findings suggest that anti-industry attitudes may affect smoking relapse following cessation.

Relationship between smoking status and body weight in a military population of young adults.

The purpose of the present study was to determine the association between smoking and body weight in a cohort of young U.S. Air Force recruits (mean age=20 years) enrolled in basic military training (N=35986). Twenty-two percent of recruits smoked daily prior to basic military training (n=8087) and were compared to never smokers, former smokers, and experimental or nondaily smokers. A three-way interaction among smoking status, gender and ethnicity suggested a small effect for daily smoking among White male recruits only and no significant differences for female recruits or members of any other ethnic group. Although there was a statistically significant relationship between smoking and body weight in White males, the effect size was approximately 1 kg. These results suggest that the energy balance differences in body weight between young smokers and nonsmokers are minimal and that it would take decades to accrue the differences typically seen in adult smokers.

Gambling and health risk-taking behavior in a military sample.

This study examined the gambling of a cohort of U.S. Air Force recruits (N = 31,104) and the relationship between their gambling and health-risk behaviors. Participants provided self-report data regarding gambling and health-related behaviors. Results suggest that 10.4% of participants gambled weekly or more often, 6.2% reported gambling problems, and 1.9% acknowledged loss of control over gambling. Men were more likely than women to report weekly gambling and possible problematic gambling. Minorities, compared to Caucasians, were more likely to experience gambling problems and report loss of control. Seven health-risk behaviors were significant predictors of frequent gambling; however, considerably fewer health behaviors were uniquely related to problematic gambling. These results suggest that gambling-related problems within the military warrant further attention.

Demographics and risky lifestyle behaviors associated with willingness to risk sexually transmitted infection in Air Force recruits.

PURPOSE: To investigate sexually transmitted infection (STI) risk-taking behaviors relative to other lifestyle and risk-taking behaviors. DESIGN: The study design is cross sectional. SETTING: Lackland Air Force Base in San Antonio, Texas. SUBJECTS: Participants (N = 32,144) were 100% of Air Force recruits beginning basic military training from August 1995 to August 1996. MEASURES: Recruits completed a questionnaire that included rating the statement "Sex without condoms is sometimes worth the risk of possibly getting AIDS or sexually transmitted diseases." Risky behaviors, such as risk taking, rebelliousness, seat belt use, smoking, alcohol use and binge drinking, opinions of illicit drug use, and lifestyle behaviors, such as dietary intake and physical activity, were also assessed. ANALYSIS: Univariate and multivariate logistic regression analyses examined the relationships between participant characteristics and willingness to risk STI. RESULTS: Sixteen percent stated willingness to risk STI to have sex without a condom. Women and white/non-Hispanic participants were less likely to agree with the statement than men and minority participants. Those who reported willingness toward risky sexual behaviors were less likely to use seat belts, were more likely to binge drink, had more positive views of illicit drugs, and reported eating fewer fruits and vegetables. CONCLUSION: Results of this study suggest the importance of continued education on condom use and the possibility that multiple risk behavior interventions include sexual risk components.

Prevalence of alternative forms of tobacco use in a population of young adult military recruits.

Recent evidence suggests that the popularity of certain alternative forms of tobacco may be increasing in adolescents. Little is known, however, about the use of these products among young adults. This study examined the use of alternative tobacco products including bidis, cigars, kreteks (clove cigarettes), pipes, and smokeless tobacco in a large sample of young adult military recruits (N=31107). Overall, 18.5% of participants were using some form of alternative tobacco product prior to entry into Basic Military Training. Results revealed a relatively high prevalence of cigar (12.3%) and smokeless tobacco use (6.7%). Use of other products was less common, including 1.1% for pipes, 2.0% for bidis, and 3.0% for kreteks. With the exception of kreteks, which did not differ by gender, the prevalence of use of alternative tobacco products was greater for males than for females (p<.001). Patterns of use also differed according to other demographic characteristics including race, ethnicity, age, and income. Implications for surveillance and tobacco control efforts are discussed.

Trial design: blood pressure control and weight gain prevention in prehypertensive and hypertensive smokers: the treatment and prevention study.

BACKGROUND: Cigarette smokers with elevated blood pressure (BP) are at substantially higher risk for cardiovascular events compared to normotensive smokers. Although smoking cessation should be a primary treatment goal for these patients, increases in body weight accompanying smoking abstinence may further increase BP. Intervention strategies that facilitate smoking cessation and modify adverse changes in body weight and BP are needed. METHODS: We describe an ongoing multi-site, two-phase, five-year randomized clinical trial. Participants are cigarette smokers with Prehypertension or Stage I Hypertension. In the first phase, participants receive a smoking cessation intervention combining behavioral counseling and nicotine replacement in an open-label fashion. In the second phase, participants who successfully quit smoking are randomly assigned to one of three lifestyle interventions: 1) weight gain prevention, 2) blood pressure control, or 3) usual lifestyle. Participants are followed for one year to assess changes in blood pressure, body weight, dietary intake, and physical activity. CONCLUSIONS: Results from the proposed study will provide important insights into the efficacy of various approaches to lifestyle modification in smokers at increased risk for cardiovascular events.

Characteristics of Air Force personnel who choose pharmacological aids for smoking cessation following an involuntary tobacco ban and tobacco control program.

OBJECTIVE: The objective of this study was to compare characteristics of smokers who did and did not report use of cessation aids as part of a tobacco control program in a military setting (n = 8994). DESIGN: The study is a longitudinal epidemiological study where the relationship between smoking status at follow-up and use of pharmacologic aids to quit smoking were assessed. MAIN OUTCOME MEASURES: Smoking cessation, post baseline use of cessation aids to quit smoking. RESULTS AND CONCLUSIONS: Individuals remaining abstinent were 70% less likely to have used NRT/pharmacological aids compared to those that relapsed. NRT/pharmacological aid users were more likely to report plans to smoke after military training, to have friends who smoke, and to accept a cigarette from a friend. NRT/pharmacological aid users were more likely to believe that using NRT was safer than smoking and to have engaged in harm reduction strategies. Our findings suggest that selection bias related to such characteristics may explain some of the discrepancies between effect sizes reported in efficacy compared to effectiveness studies of NRT and smoking outcomes currently reported in the literature.

Cigarette use among two cohorts of U.S. Air Force recruits, compared with secular trends.

This study provides a comparison of cigarette smoking among two cohorts of U.S. Air Force recruits. The first cohort, Air Force 1, entered the military between August 1995 and August 1996. The second cohort, Air Force 2, entered between October 1999 and September 2000. Cigarette use significantly increased among both men (7.0-percentage point increase) and women (7.3-percentage point increase) between the two cohorts. This difference remained statistically significant in models adjusted for demographic differences between the two groups of recruits. Direct standardization methods were then used to compare rates in both Air Force surveys with rates of current smoking reported for a national sample from the Behavioral Risk Factor Surveillance System surveys from the same years. Although the average number of cigarettes smoked and years of smoking decreased between the two cohorts, troops from Air Force 2 reported being less motivated to quit. This study suggests that efforts to reduce smoking among junior enlisted troops in the Air Force should be bolstered.

The validity of self-rated health as a measure of health status among young military personnel: evidence from a cross-sectional survey.

BACKGROUND: Single item questions about self ratings of overall health status are widely used in both military and civilian surveys. Limited information is available to date that examines what relationships exist between self-rated health, health status and health related behaviors among relatively young, healthy individuals. METHODS: The current study uses the population of active duty United States Air Force recruits (N = 31,108). Participants completed surveys that asked about health behaviors and health states and were rated their health on a continuum from poor to excellent. RESULTS: Ratings of health were consistently lower for those who used tobacco (F = 241.7, p < .001), reported binge drinking (F = 69.0, p < .001), reported drinking and driving (F = 19.4, p < .001), reported taking health risks (F = 109.4, p < .001), were depressed (F = 256.1, p < .001) and were overweight (F = 39.5, p < .001). CONCLUSION: Given the consistent relationship between self-rated overall health and factors important to military health and fitness, self-rated health appears to be a valid measure of health status among young military troops.

Waterpipe smoking among American military recruits.

BACKGROUND: Waterpipe smoking, a traditional Middle Eastern tobacco use method, has increased dramatically among Arab adolescents and young adults. Anecdotal evidence also suggests that usage is on the rise among young people in the U.S., but epidemiological data are lacking. METHODS: From self-report health surveys collected during 1999-2002, we examined the prevalence and predictors of waterpipe use among U.S. Air Force recruits (n = 20,673; mean age = 20.0 years; range = 17-35). RESULTS: Waterpipe use was reported by 0.3% (n = 59) of recruits and was unrelated to age, gender, ethnicity, or family income. Compared to non-users, waterpipe users were more likely to plan to smoke cigarettes in the coming year (P value < 0.05) and to believe that switching from cigarettes to other tobacco products reduces smoking-related health risks (P values < 0.002). Multivariate (logistic regression) analyses revealed several factors that distinguished waterpipe users from non-users, including higher education level (odds ratio [OR] = 1.94), having experimented with cigarettes before Basic Military Training (BMT; OR = 1.99), and using cigarettes (OR = 2.17) and other tobacco products (OR = 13.81) at the time of entry into BMT. Compared to recruits who used cigarettes only, waterpipe smokers were more educated (OR = 1.83), more likely to have engaged in experimental (OR = 3.30) or regular (OR = 3.87) use of tobacco products other than cigarettes prior to BMT, and less likely to have been a current (OR = 0.10) or former (OR = 0.11) smoker at the time of entry into BMT. CONCLUSION: Despite concerns that waterpipe smoking is increasing among young people in the U.S., use was low among military recruits.

Efficacy of a tailored tobacco control program on long-term use in a population of U.S. military troops.

The authors evaluated the effect of a brief tailored smoking control intervention delivered during basic military training on tobacco use in a population of military personnel (N = 33,215). Participants were randomized to either a tobacco use intervention (smoking cessation, smokeless tobacco use cessation, or prevention depending on tobacco use history) or a health education control condition. Results indicated that smokers who received intervention were 1.16 (95% confidence interval [CI] = 1.04, 1.30) times (7-day point prevalence) and 1.23 (95% CI = 1.07, 1.41) times (continuous abstinence) more likely to be abstinent than controls from smoking cigarettes at the 1-year follow-up (p < .01); the cessation rate difference was 1.60% (31.09% vs. 29.49%) and 1.73% (15.47% vs. 13.74%) for point prevalence and continuous abstinence, respectively. Additionally, smokeless tobacco users were 1.33 (95% CI = 1.08, 1.63) times more likely than controls (p < .01) continuously abstinent at follow-up, an overall cessation rate difference of 5.44% (33.72% vs. 28.28%). The smoking prevention program had no impact on smoking initiation. These results suggest potential for large-scale tobacco control efforts.

An assessment of obese and non obese girls' metabolic rate during television viewing, reading, and resting.

While childhood obesity has been linked to television (TV) viewing, specific mechanisms are not well understood. Obesity related to TV viewing might plausibly be related to decreased physical activity, increased food intake, reductions in metabolic rate, or combinations of these. The current investigation sought to ascertain the metabolic effects of quiet rest, listening to a story, watching a passive TV program, and watching an active TV show. Counter-balanced conditions were presented to 90 pre-pubertal girls ranging in body mass index from underweight to obese. In addition, effects between resting energy expenditure (REE) and race, body mass index, skinfold measures, physical activity, pubertal stage and average hours spent viewing TV were explored. Results indicated no significant differences in metabolic rate between weight groups nor between activity conditions (story listening and TV viewing) and rest conditions. A significant dose-response relationship was found in which REE decreased as average weekly hours of TV viewing increased, after adjusting for body mass index and puberty stage. Additionally, later stages of pubertal development compared to earlier stages were related to higher levels of REE. Results of this study suggest that metabolic rate alone cannot account for the consistently observed relationship between television viewing and obesity. Future studies should focus on energy intake, physical inactivity, or combinations of these with metabolic rate in seeking specific mechanisms responsible for television viewing related to obesity.