Validation of a Score for the Detection of Subjects with High Risk for Severe High-Altitude Illness.

PURPOSE: A decision tree based on a clinicophysiological score (severe high-altitude illness (SHAI) score) has been developed to detect subjects susceptible to SHAI. We aimed to validate this decision tree, to rationalize the prescription of acetazolamide (ACZ), and to specify the rule for a progressive acclimatization. METHODS: Data were obtained from 641 subjects in 15 European medical centers before and during a sojourn at high altitude. Depending on the value of the SHAI score, advice was given and ACZ was eventually prescribed. The outcome was the occurrence of SHAI at high altitude as a function of the SHAI score, ACZ prescription, and use and fulfillment of the acclimatization rule. RESULTS: The occurrence of SHAI was 22.6%, similar to what was observed 18 yr before (23.7%), whereas life-threatening forms of SHAI (high-altitude pulmonary and cerebral edema) were less frequent (2.6%-0.8%, P = 0.007). The negative predictive value of the decision tree based was 81%, suggesting that the procedure is efficient to detect subjects who will not suffer from SHAI, therefore limiting the use of ACZ. The maximal daily altitude gain that limits the occurrence of SHAI was established at 400 m. The occurrence of SHAI was reduced from 27% to 12% when the recommendations for ACZ use and 400-m daily altitude gain were respected (P < 0.001). CONCLUSIONS: This multicenter study confirmed the interest of the SHAI score in predicting the individual risk for SHAI. The conditions for an optimized acclimatization (400-m rule) were also specified, and we proposed a rational decision tree for the prescription of ACZ, adapted to each individual tolerance to hypoxia.

[Medical prescription of physical activity]. / Ordonnance de prescription de l'activité physique.

Medical prescription of physical activity. The prescription is "a therapeutic recommendation, possibly prescribed, made by a doctor". Up-to-date recommendations exist, relayed by the authorities which formalized this act of prescription by a law for long-term ailments. The medical prescription of physical activity and sports is directed to carriers of chronic pathologies for which it will have a therapeutic action and an action of prevention of the complications. It will include, at best, besides the precision of the four parameters characterizing this activity (type, intensity, duration and frequency of the sessions), advice of daily struggle against the sedentary lifestyle. It should be personalized, to consider the patient's condition and a possible risk incurred. It remains however to provide the skills to the prescribers, informed but not always trained, and to ensure the possibilities of practical realization of the exercises appearing on the medical prescription.

Ordonnance de prescription de l'activité physique. La prescription est « une recommandation thérapeutique, éventuellement consignée sur ordonnance, faite par un médecin ¼. Des recommandations actualisées existent, relayées par les pouvoirs publics, qui ont officialisé cet acte de prescription par une loi pour les affections de longue durée. L'ordonnance de prescription d'activité physique et sportive (APS) s'adresse à des patients atteints de pathologies chroniques avec un but de prise en charge thérapeutique et un but de prévention des complications. Elle inclut, au mieux, outre la précision des quatre paramètres caractérisant cette activité (type, intensité, durée et fréquence des séances), des conseils de lutte quotidienne contre la sédentarité. Elle doit être personnalisée pour tenir compte de l'état du patient et d'un éventuel risque encouru. Il reste cependant à fournir les compétences aux prescripteurs, informés mais pas toujours formés, et à s'assurer des possibilités de réalisation pratique des exercices figurant sur l'ordonnance.

Physical Activity, Inactivity, and Sedentary Behaviors: Definitions and Implications in Occupational Health.

Based on the increasing evidence linking excessive sedentary behaviors and adverse health outcomes, public health strategies have been developed and constantly improved to reduce sedentary behaviors and increase physical activity levels at all ages. Although the body of literature in this field has grown, confusion still exists regarding the correct definition for sedentary behaviors. Thus, there is a need to provide a clear definition in order to distinguish sedentary behaviors from physical activity and inactivity. This paper will briefly review the most recent and accepted definitions of these concepts and illustrate their relationships. Nowadays, since most working adults spend a high proportion of their waking hours in increasingly sedentary tasks, there will be a particular focus on the field of occupational health. Finally, simple modifications in the workplace will be suggested in order to decrease sedentary behaviors.

Isoprostanes as markers for muscle aging in older athletes.

INTRODUCTION: Production of isoprostanes (IsoPs) is enhanced after acute, intense, and prolonged exercise, in untrained subjects. This effect is greater in older subjects. The present study aims to delineate the profile of acute-exercise-induced IsoPs levels in young and older endurance-trained subjects. METHODS: All included subjects were male, young (n = 6; 29 yrs ± 5.7) or older (n = 6; 63.7 yrs ± 2.3), and competitors. The kinetics of F2-IsoPs in blood-sera was assessed at rest, for the maximal aerobic exercise power (MAP) corresponding to the cardio-respiratory fitness index and after a 30-min recovery period. RESULTS: No significant time effect on F2-IsoPs kinetics was identified in young subjects. However, in older athletes, F2-IsoPs blood-concentrations at the MAP were higher than at rest, whereas these blood-concentrations did not differ between rest and after the 30-min recovery period. CONCLUSION: Because plasma glutathione (GSH) promotes the formation of some F2-IsoPs, we suggest that the surprising decrease in F2-IsoPs levels in older subjects would be caused by decreased GSH under major ROS production in older subjects. We argue that the assessment F2-IsoPs in plasma as biomarkers of the aging process should be challenged by exercise to improve the assessment of the functional response against reactive oxygen species in older subjects.

Determination of Cardiac Output in Pulmonary Hypertension Using Impedance Cardiography.

BACKGROUND: Cardiac output (CO) is a prognostic factor in pulmonary hypertension (PH). Right heart catheterisation using the direct Fick method or thermodilution (TD) is the reference technique for CO measurement. Impedance cardiography (IPc) is a known non-invasive method of measuring CO. OBJECTIVES: In our study, we assume that the measurement of CO by IPc using the PHYSIOFLOW® system is as accurate as TD or using the direct Fick method in patients with PH in group 1 or group 4. METHODS: A total of 75 patients were enrolled in a prospective study carried out at the hypertension reference centre of Toulouse University Hospital. Right heart catheterisation was performed for the diagnosis or follow-up of the disease. CO was measured using the Fick method, TD, and IPc simultaneously. A Bland-Altman analysis was plotted. RESULTS: CO was 5.7 ± 1.9 L/min as measured by the Fick method, 5.4 ± 1.5 L/min by TD, and 5.5 ± 1.7 L/min by IPc. The bias between CO measurements by IPc and the direct Fick method was 0.149 L/min (95% CI, -0.298 to 0.596). The bias between CO measurements by IPc and the TD method was -0.153 L/min (95% CI, -0.450 to 0.153). The correlation decreased with the more extreme CO values (< 3 L/min or > 7 L/min). A few factors changed the agreement between measurements (BMI or membership in group 4). CONCLUSION: To conclude, this study shows that the measurement of CO by IPc in PH patients is reliable compared to the direct Fick method and TD obtained by right heart catheterisation. This accuracy decreases for extreme CO values.

Whole-body strength training with Huber Motion Lab and traditional strength training in cardiac rehabilitation: A randomized controlled study.

BACKGROUND: Isometric strengthening has been rarely studied in patients with coronary heart disease (CHD), mainly because of possible potential side effects and lack of appropriate and reliable devices. OBJECTIVE: We aimed to compare 2 different modes of resistance training, an isometric mode with the Huber Motion Lab (HML) and traditional strength training (TST), in CHD patients undergoing a cardiac rehabilitation program. DESIGN: We randomly assigned 50 patients to HML or TST. Patients underwent complete blinded evaluation before and after the rehabilitation program, including testing for cardiopulmonary exercise, maximal isometric voluntary contraction, endothelial function and body composition. RESULTS: After 4 weeks of training (16 sessions), the groups did not differ in body composition, anthropometric characteristics, or endothelial function. With HML, peak power output (P=0.035), maximal heart rate (P<0.01) and gain of force measured in the chest press position (P<0.02) were greater after versus before training. CONCLUSION: Both protocols appeared to be well tolerated, safe and feasible for these CHD patients. A training protocol involving 6s phases of isometric contractions with 10s of passive recovery on an HML device could be safely implemented in rehabilitation programs for patients with CHD and improve functional outcomes.

[Promoting exercise and sports activities among the elderly]. / Des activités physiques et sportives en faveur des aînés.

The fight against sedentariness and encouraging older people to exercise is a major public health objective. The aim is to preserve the health of the elderly, to avoid the excessive cost of care and to prevent the loss of autonomy.

Medical and pharmacological approach to adjust the salbutamol anti-doping policy in athletes.

BACKGROUND: Salbutamol abuse detection by athletes is based on a urinary upper threshold defined by the World Anti-Doping Agency (WADA). However, this threshold was determined in healthy, untrained individuals and after a dose of salbutamol inhaled that might not really mirror the condition of asthmatic athletes and the experts's guidelines for asthma management. We aimed to revise this threshold in accordance with recommended clinical practice (that appear to be different from the actual WADA recommendation) and in exercise conditions. METHODS: For the present open-label design study, we included 12 trained male cyclists (20 to 40 y/o) with asthma. Differently from the previous pharmacokinetic study supporting the actual salbutamol urinary upper threshold, we decided to administer a close to recommended clinical practice daily dose of 3x200 µg.d(-1) inhaled salbutamol (instead of 1600 µg.d(-1) as authorized by the anti-doping policy). Urine salbutamol concentration was quantified by liquid chromatography-tandem ion trap mass spectrometry and corrected for urine density, at rest and after a 90-min cycling effort at 70-80 % of the maximal aerobic power. RESULTS: The maximum urine salbutamol concentration value peaked after the cycling effort and was 510 ng.mL(-1). That is twice lower than the actual WADA threshold to sanction salbutamol abuse, this "legal" threshold being based on pharmacokinetic data after a daily dose that is 8 fold the total dose sequentially administrated in our study. Considering its 95 % confidence interval, this threshold value could be more stringent. CONCLUSION: By using conditions in accordance with the experts' clinical and safety guidelines for asthma management in athletes undergoing an intense exercise bout, our study suggests that the urine salbutamol concentration threshold could be lowered to redefine the rule supporting the decision to sanction an athlete for salbutamol abuse.

[Sport and health, a necessary combination]. / Sport et santé, une nécessaire association.

While there is no lack of evidence demonstrating the benefits of carrying out regular physical activity which is adapted to our age, our lifestyles are nevertheless too sedentary. What place does sport, a major determining element of our physical and mental health, hold today?

Prevalencia de lesiones en triatletas de una liga francesa / Prevalence of injuries in triathletes from a French league

Objetivo: Evaluar la prevalencia de traumatismos en triatletas y buscar los factores contribuyentes implicados. Método: Se envió por correo un cuestionario anónimo sobre los casos de traumatismos durante la temporada pasada a 788 triatletas de una liga francesa. Resultados: El 52,4% de los triatletas que respondieron notificaron que habían sufrido como mínimo una lesión durante la temporada pasada y el 17% varias lesiones. El 83,5% de las lesiones se produjeron durante el entrenamiento, sobre todo corriendo (72,5%). Los casos notificados con más frecuencia fueron tendinopatías (44,5%) y lesiones musculares (35%). Las zonas anatómicas notificadas con más frecuencia fueron el tobillo (20,6%), la rodilla (18,3%), el muslo (15%), la región lumbar (12,6%) y el hombro (8,3%). El 77% de los triatletas lesionados pudieron seguir entrenando, sobre todo haciendo natación (71%) y ciclismo (61,5%), mientras que en el 85,5% de los casos tuvieron que dejar de correr. Los triatletas que habían sufrido lesiones notificaron que dedican un tiempo significativamente menor al calentamiento que los triatletas ilesos (respectivamente, 13,7min frente a 18min) (p<0,01). El tiempo dedicado a los estiramientos también era inferior en los lesionados en comparación con los ilesos (respectivamente, 8,3min frente a 10,6min) (p<0,01). Se observó la misma asociación entre el tiempo empleado en el calentamiento y el estiramiento y la prevalencia de tendinopatías. La prevalencia de lesiones musculares se asoció de manera significativa con el número de horas de entrenamiento semanales (p<0,05) y con la distancia de entrenamiento semanal nadando, haciendo ciclismo y corriendo (p<0,05). Conclusión: Las lesiones observadas en triatletas amateurs son lesiones musculoesqueléticas por «abuso», producidas sobre todo durante el entrenamiento, principalmente al correr(AU)

Objective: To assess the prevalence of trauma injuries in triathletes and look for contributing factors involved. Method: An anonymous questionnaire about trauma history during the past season was sent by post to 788 triathletes from a French league. Results: 52.4% of triathletes responding reported having been injured at least once during the past season, for 17% of them several times. 83.5% of injuries occurred during training, mostly in running (72.5%). The tendinopathies (44.5%), and muscle injuries (35%), were the most frequently reported. The anatomical sites most frequently reported were the ankle (20.6%), knee (18.3%), thigh (15%), lumbar region (12.6%) and shoulder (8,3%). 77% of injured triathletes were able to keep training, mainly in swimming (71%) and cycling (61.5%), while running was stopped in 85.5% of cases. Injured triathletes reported devote significantly less time to warm-up than uninjured triathletes (respectively 13.7min vs. 18min) (p<0.01). Time devoted to stretching was also lower for injured vs. uninjured (respectively 8.3min vs. 10.6min) (p<0.01). The same association was also found between time spent warming up and stretching and the prevalence of tendinopathies. The prevalence of muscle injuries was significantly associated with number of training hours per week (p<0.05) and weekly training distance swimming, cycling and running (p<0.05). Conclusion: Injuries encountered in amateur triathletes are musculoskeletal injuries of «overuse», occurring mainly in training, especially running(AU)

[Physical activities and sport; implications for health and society]. / Les activités physiques et sportives--la santé--la société.

The practice of physical and sporting activities (PSA) throughout life is now known to increase healthy life expectancy, to delay the onset of dependency, and to be an effective complementary treatment for many disorders, particularly obesity and disability. The notion of a "sedentary death syndrome " [SeDS] has been evoked on the other side of the Atlantic. Although the beneficial effects of PSA have long been known, statistical analyses have only recently confirmed at the group level what was often disputed at the individual level. Knowledge of the impacts of PSA on cellular, tissular and metabolic functions has improved considerably. PSA is no longer seen simply as a leisure activity but is now considered necessary for a healthy body and mind. PSA also has considerable social, educational and integrative implications. Can any society ignore these evident health benefits with impunity? The aims of this article are 1) to provide a quick overview of the advantages of regular, measured and reasonable PSA, as well as the potential risks of excess; 2) to discuss the quantity of PSA providing the optimal balance between benefits and risks, and the means of achieving this balance; 3) to highlight the lack of enthusiasm for PSA among the French population, and to analyze its causes, and 4) to propose a new organization designed to help more of our fellow citizens to adopt PSA, in the interests of their health and well-being.

The interest of gait markers in the identification of subgroups among fibromyalgia patients.

BACKGROUND: Fibromyalgia (FM) is a heterogeneous syndrome and its classification into subgroups calls for broad-based discussion. FM subgrouping, which aims to adapt treatment according to different subgroups, relies in part, on psychological and cognitive dysfunctions. Since motor control of gait is closely related to cognitive function, we hypothesized that gait markers could be of interest in the identification of FM patients' subgroups. This controlled study aimed at characterizing gait disorders in FM, and subgrouping FM patients according to gait markers such as stride frequency (SF), stride regularity (SR), and cranio-caudal power (CCP) which measures kinesia. METHODS: A multicentre, observational open trial enrolled patients with primary FM (44.1 ± 8.1 y), and matched controls (44.1 ± 7.3 y). Outcome measurements and gait analyses were available for 52 pairs. A 3-step statistical analysis was carried out. A preliminary single blind analysis using k-means cluster was performed as an initial validation of gait markers. Then in order to quantify FM patients according to psychometric and gait variables an open descriptive analysis comparing patients and controls were made, and correlations between gait variables and main outcomes were calculated. Finally using cluster analysis, we described subgroups for each gait variable and looked for significant differences in self-reported assessments. RESULTS: SF was the most discriminating gait variable (73% of patients and controls). SF, SR, and CCP were different between patients and controls. There was a non-significant association between SF, FIQ and physical components from Short-Form 36 (p = 0.06). SR was correlated to FIQ (p = 0.01) and catastrophizing (p = 0.05) while CCP was correlated to pain (p = 0.01). The SF cluster identified 3 subgroups with a particular one characterized by normal SF, low pain, high activity and hyperkinesia. The SR cluster identified 2 distinct subgroups: the one with a reduced SR was distinguished by high FIQ, poor coping and altered affective status. CONCLUSION: Gait analysis may provide additional information in the identification of subgroups among fibromyalgia patients. Gait analysis provided relevant information about physical and cognitive status, and pain behavior. Further studies are needed to better understand gait analysis implications in FM.

Physical activity and sarcopenia.

Physical activity can be a valuable countermeasure to sarcopenia in its treatment and prevention. In considering physical training strategies for sarcopenic subjects, it is critical to consider personal and environmental obstacles to access opportunities for physical activity for any patient with chronic disease. This article presents an overview of current knowledge of the effects of physical training on muscle function and the physical activity recommended for sarcopenic patients. So that this countermeasure strategy can be applied in practice, the authors propose a standardized protocol for prescribing physical activity in chronic diseases such as sarcopenia.

[What illegal substances are used by sportsmen? a study in Midi-Pyrénées Doping Preventing Medical Centre (AMPD-MP)]. / Consommation de substances interdites chez le sportif: étude à l'Antenne Médicale de Prévention du Dopage de Midi-Pyrénées (AMPD-MP).

OBJECTIVE: Doping Preventing Medical Centres (Antennes Médicales de Prévention du Dopage) were established in France in 2000 in order to help sportsmen using illegal substances. These services are also information centres on illegal substances (drugs or others) used in sport. The aim of the study was to analyze the characteristics of sportsmen outpatient clinics in Antenne Médicale de Prevention du Dopage Midi-Pyrénées (AMPD-MP). METHODS: We present the results of outpatient clinics in AMPD-MP from 2002 to 2008. A descriptive analysis of demographic data, substances used and sports practised were performed. RESULTS: During this 7 year-period, 35 outpatient clinics were performed [32 men, 3 women, mean age: 28 years (extreme values: 18-47; 10 patients ≥ 30 years)]. They were mainly involved in national (16), international (8) or regional (7) competitions. The main sports involved were rugby (9) followed by cycling (5), athletics (3) and body-building (3). The most frequently used illegal substances were cannabis (15) followed by glucocorticoïds (9), androgens (4), indirect sympathomimetics amphetaminics (4), beta 2 adrenergic agonists (2) and NSAIDs (2). Two veterinary substances (clenbuterol, boldone-veterinaire) were also found in body-builders. CONCLUSION: This study shows a clear under use of Doping Preventing Medical Centres by sportsmen and practitioners. It also indicates a relative high age for sportsmen referred to the centre. The main sports involved were rugby and cycling. Cannabis and glucocorticoïds were the drugs more often involved in doping behaviours.

Lipid oxidation in overweight men after exercise and food intake.

Fat oxidation (FO) is optimized during low- to moderate-intensity exercise in lean and obese subjects, whereas high-intensity exercise induces preferential FO during the recovery period. After food intake during the postexercise period, it is unknown if FO differs according to the intensity exercise in overweight subjects. Fat oxidation was thus evaluated in overweight men after low- and high-intensity exercise during the recovery period before and after food intake as well as during a control session. Ten healthy, sedentary, overweight men (age, 27.9 +/- 5.6 years; body mass index, 27.8 +/- 1.3 kg m(-2); maximal oxygen consumption, 37 +/- 3.9 mL min(-1) kg(-1)) exercised on a cycloergometer (energy expenditure = 300 kcal) at 35% (E35) or 70% (E70) maximal oxygen consumption or rested (Cont). The subjects were fed 30 minutes after the exercise with 300 kcal (1256 kJ) more energy in the exercise sessions than in the Cont session. Respiratory quotient and FO were calculated by indirect calorimetry. Blood samples were analyzed to measure plasma glycerol, nonesterified fatty acid, glucose, and insulin. During exercise, mean respiratory quotient was lower (P < .05) and FO was higher (P < .01) in the E35 than in the E70 session (FO [in mg min(-1)]: E35 = 290 +/- 12, E70 = 256 +/- 38, and Cont = 131 +/- 7). Conversely, FO was higher in the E70 than in both the E35 session and the Cont session during the immediate recovery as well as during the postprandial recovery period (P = .005 for all; FO from the end of the exercise to the end of the session [in grams]: E70 = 45.7 +/- 8.9, E35 = 38.2 +/- 6.8, and Cont = 36.0 +/- 4.3). Blood parameters did not differ between the 3 sessions but changed according to the absorption of the nutrients. In overweight subjects, high-intensity exercise increased FO during the postexercise period even after food intake compared with the low-intensity exercise and the control session.

Nitric oxide and carbon monoxide lung transfer in patients with advanced liver cirrhosis.

In advanced cirrhosis, decreased lung transfer for carbon monoxide (TLCO) and increased alveolar-arterial oxygen tension difference (PA-aO(2) >or=15 mmHg while breathing ambient air) are frequently detected. Pulmonary membrane diffusion capacity for CO (DmCO) and pulmonary capillary blood volume (Vcap) can be derived from the simultaneous measurement of TLCO and lung transfer for nitric oxide (TLNO). Measurements of single-breath TLNO and TLCO were performed in 49 cirrhotic patients with advanced liver cirrhosis and in 35 healthy controls to derive Vcap, DmCO, and TLNO:TLCO ratio. Twenty-five patients had increased PA-aO(2), of whom 11 had hepatopulmonary syndrome (HPS). Compared with controls, non-HPS patients with normal PA-aO(2) had a significant approximately 10% decrease in TLCO, DmCO, and Vcap but similar TLNO:TLCO ratios. Compared with non-HPS patients with normal PA-aO(2), non-HPS patients with increased PA-aO(2) had lower Vcap and higher TLNO:TLCO ratio but similar DmCO. HPS patients had lower Vcap and higher TLNO:TLCO ratios than both subgroups of non-HPS patients. In cirrhotic patients, TLNO:TLCO ratios correlated positively, and TLCO (percentage of the predicted value) and Vcap (percentage of the predicted value) correlated negatively with PA-aO(2) (r(2) = 0.25, P = 0.0003, r(2) = 0.48, P < 0.0001 and r(2) = 0.57, P < 0.0001, respectively). We concluded that, in cirrhotic patients, lower TLCO and increased PA-aO(2) are associated with lower Vcap. In addition, high TLNO:TLCO ratios in patients with increased PA-aO(2) suggest a decreased thickness of the capillary blood layer in these patients.

[Physiological changes in microgravity]. / Modifications physiologiques en microgravité.

Microgravity affects the different organ systems to various degrees. In particular, a thoracocephalic fluid shift occurs through suppression of the hydrostatic gradient. Sensory conflict leads to space motion sickness, which is frequent early in the flight, and the musculo-skeletal system is perturbed by the lack of stimuli. The respiratory system seems to be less affected. These changes do not seem to impair health or performance. Humans seem able to adapt to long-term exposure to microgravity, but disorders can occur on return to Earth. In-flight preventive measures need be developed.

Lipid oxidation according to intensity and exercise duration in overweight men and women.

OBJECTIVE: Our objective was to compare the effect of different exercise intensities on lipid oxidation in overweight men and women. RESEARCH METHODS AND PROCEDURES: Nine young, healthy, overweight men and women were studied (age, 31.4 +/- 2.3 and 26.7 +/- 2.1 years; BMI, 27.9 +/- 0.4 and 27.2 +/- 0.5; for men and women, respectively). On one study day, the subjects first performed 30 minutes of cycling exercise at 30% of their maximal oxygen uptake (Vo(2max); E1 session), followed by 30 minutes of exercise at 50% Vo(2max) (E2 session). On a second study day, a similar E1 session was followed by 30 minutes of exercise at 70% Vo(2max) (E3 session). From the gas exchange measurements, the respiratory exchange ratio (RER) and the fat oxidation rate (FOR) were calculated. Plasma concentrations of glycerol and non-esterified fatty acids (NEFAs) were assayed. RESULTS: RER was significantly lower for women during only the E1 session. For both sexes, RER decreased over time during the E2 and E3 sessions. During the E1 session, the FOR per kilogram of lean mass (LM) was higher among women, and it did not change over time despite an increase in plasma NEFAs. FOR per kilogram of LM was higher during the E2 exercise for both sexes. During E2 and E3 sessions, as the exercise time was prolonged, the FOR/kg LM increased simultaneously with the increase in the plasma glycerol. DISCUSSION: Lipid oxidation during exercise is optimized for moderate and lengthy exercise. The enhancement of lipid oxidation occurring over time during moderate- and high-intensity exercises could be, in part, linked to the improvement of lipid mobilization. This fact is discussed to shed light on exercise modalities as a tool for the management of overweight.