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Worksite interventions can effi- ior and that the magnitude of the effect is related to the inten- ciently include a wide variety of health promotion activities sity of the intervention (Pignone and others 2003) buy nifedipine 20mg low cost heart attack 42 year old. Identifying because workers spend a large portion of their waking hours patients who are overweight or obese nifedipine 20mg lowest price hypertension essential, or who are gaining and eat a large percentage of their food there 20 mg nifedipine free shipping blood pressure medication that doesn't cause ed. Interventions can weight but are not yet overweight, is an initial step in prevent- include educating employees; screening them for behavioral ing and treating overweight. In 1965, city planners adopted a bus lines run almost every 90 seconds and can carry up to master plan that promoted development along designated 270 passengers each. Compared with other Brazilian cities corridors along with a bus system so efficient that it has of its size, Curitiba uses 30 percent less gasoline per capita, virtually eliminated the need for automobiles. Transportation Policy and Environmental Design developed to discourage private automobile use and to promote public transportation, walking, and bicycling (see Transportation policies and the design of urban environments box 44. Singapore has long been in the lead in relation to are fundamental determinants of physical activity and there- such efforts: a combination of limiting the number of licenses fore influence the risks of obesity and other chronic diseases. In wealthy countries, the are now enacting similar road pricing systems or congestion automobile has strongly influenced the trend toward low- taxes. Since its inception in 2003, the charge has reduced few services within walking distance and are usually not linked congestion in the city and is expected to channel funds back to public transporationt. In a prospective study in eight provinces in taken a different approach to their future transportation needs. China, 14 percent of households acquired a car between 1889 Government initiatives that encourage families to buy automo- and 1997, and the likelihood of men becoming obese during biles include lowering taxes, simplifying registration proce- the same period was twice as great in households that acquired dures, and allowing foreign financing. In the United States, low taxes on gasoline, free Promote Walking and Bicycle Riding. Walking or cycling for parking, and wide streets encourage car ownership: almost transportation and leisure are effective and practical means of 92 percent of U. In Bangkok and contrast, in most of Western Europe, narrow streets, limited Manila, only 25 percent of travel is by car, motorcycle, or taxi, parking, and high gasoline prices make the costs of automobile compared with 75 percent by public transportation or walking use almost double those in the United States (Pucher and (Pendakur 2000). As a result, Europeans walk or bike more and ulation travels by private, motorized transportation; 22 per- use their cars approximately 50 percent less than their cent of people walk; 20 percent bike; and the rest use public American counterparts. In China, approximately public transportation creates a vicious cycle: poor public trans- 90 percent of the urban population walks or rides a bicycle to portation systems lead to more dependency on the automobile. As car use grows, injuries and deaths associated with auto- Walking or biking is more likely to be prevalent in smaller mobile accidents also grow. In China, the number of four- cities—that is, those with 1 million to 5 million people—than wheeled vehicles increased from about 60,000 to more than in larger ones. In contrast, almost Prevention of Chronic Disease by Means of Diet and Lifestyle Changes | 839 Box 44. The Safe Routes to School The program also sponsors walk- and bike-to-school days, program (http://www. Sprawl begun and can perhaps be forestalled by policies that benefit adversely affects the elderly in particular because they are walkers and cyclists rather than drivers. The so-called smart growth movement has resulted from Many Western European countries have taken steps to concerns about urban sprawl and unsustainable development increase safety for cyclists and walkers. In Germany and the and is encouraging governments worldwide to rethink how Netherlands, bike paths serve as travel routes, not just weekend they develop new areas and redevelop older suburbs and cities. The Smart growth principles include mixing land uses, using com- former countries have invested heavily in bike paths and have pact building designs, including a range of transportation and also created extensive car-free areas in cities, with well-lit side- housing choices, building walker-friendly neighborhoods in walks, clearly marked crosswalks, and pedestrian islands that attractive communities with a distinctive sense of place, and have improved safety. Both countries have increased the num- implementing a philosophy of directing development toward ber of bicycle-friendly streets (on which cars are permitted but existing communities and the preservation of open space bicycles have the right of way) and have created systems to sep- (Office of the Administrator 2001) (box 44. A meta-analysis of selected traffic-calming studies in many portation planning and building design is becoming more countries reported reductions in traffic speed, accidents, common. In Edinburgh, a health impact assessment conducted injuries, and fatalities and an increase in bicycle use and walk- on proposed options for transportation policy showed the ing (Bunn and others 2003). Handy and included new spending on pedestrian safety, a citywide bicycle others’ (2002) comprehensive assessment of recent research on network, more greenways and park-and-ride programs, and urban planning concludes that a combination of urban design, more rail transportation or bus services. Priorities are to bene- land-use patterns, and transportation systems that promotes fit pedestrians first, cyclists second, public transportation users walking and bicycling will help create active, healthier, and third, freight and delivery people fourth, and car users last. In densely developed cities that Establishing criteria for building design can also lead to have been built around public transportation rather than away increases in physical activity. For example, increasing signage from it, individuals are much more likely to take public transit, promoting stair use, as well as the attractiveness of the facilities walk, or bicycle than in other areas and to weigh less and be less themselves, encourages people to use the stairs (Boutelle and likely to suffer from hypertension (Ewing, Schieber, and Zegeer others 2001) (box 44. Those living in walker-friendly neighborhoods also appear Improved Food Supply to be more mentally healthy and are more likely to know their neighbors, to be socially active, and to participate in the politi- People’s diets can be enhanced by improving the food supply. In contrast, urban sprawl has been The usual position of the food industry is that it simply 840 | Disease Control Priorities in Developing Countries | Walter C. These communities are expressways are being removed to create parks, sidewalks, intended to become new job-creation centers and to shift and bikeways (http://www. The program was launched in 1996 to heard about Agita, 37 percent knew its purpose, and those increase the public’s knowledge of the benefits of exercise who knew of the program’s purpose were more likely to be and expand participation in physical fitness activities by active. Agita appears to have played a role in increasing encouraging people to do 30 minutes of moderate activity activity in the region (Matsudo and others 2002). As elsewhere, program designers closely linked to a national program to promote healthy perceived a lack of time as the major factor preventing diets and active lifestyles by nutritional content labeling, daily exercise. They chose three settings as places to pro- promotion of healthy diets in schools, communication of mote activity: home (gardening, chores, avoidance of tele- guidelines for healthy eating, and encouragement of inno- vision watching); transportation (walking, taking the vative community-based initiatives (Coitinho, Monteiro, stairs); and leisure time (dancing). Much of companies said that they would reduce or eliminate trans fats, this sum goes to promote foods with adverse health effects, and and many more are planning to do so (U. In Mauritius, the government required a change in the commonly used cooking oil from mostly palm Improving Processing and Manufacturing. Altering the oil to soybean oil, which changed people’s fatty acid intake and manufacturing process can rapidly and effectively improve reduced their serum cholesterol levels (Uusitalo and others diets because such action does not require the slow process of 1996). Omega-3 fatty acid intakes can be increased by hydrogenation of vegetable oils, which destroys essential incorporating oils from rapeseed, mustard, or soybean into omega-3 fatty acids and creates trans fatty acids. Food and tion in salt consumption will usually require changes at the Prevention of Chronic Disease by Means of Diet and Lifestyle Changes | 841 manufacturing level, because processed food is a major salt Another strategy is to protect consumers from aggressive source. If the salt content of foods is reduced gradually, the marketing of unhealthy foods. Coordination among lars a year encouraging children to consume foods that are manufacturers or government regulation is needed; otherwise detrimental to their health.

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It is widely considered the second most common cause of dementia after Alzheimer’s disease generic 20mg nifedipine with mastercard arrhythmia heart failure. Symptoms may vary generic 20 mg nifedipine amex blood pressure ranges hypotension, depending on the types of brain changes involved and the brain regions affected cheap nifedipine 30 mg online heart attack x factor, and may be similar to or even indistinguishable from those of Alzheimer’s or another dementia. As brain changes gradually spread, they often begin to affect 2 mental functions, including memory and the ability to pay attention, make sound judgments and plan the steps needed to complete a task. It causes changes in the central area of the brain, which affect movement, mood and thinking skills. Misfolded prion protein destroys brain cells, resulting in damage that leads to rapid decline in thinking and reasoning as well as involuntary muscle movements, confusion, difficulty walking and mood changes. As individuals with Down syndrome age, they have a greatly increased risk of developing a type of dementia that’s either the same as or very similar to Alzheimer’s disease. It is most commonly caused by alcohol misuse, but certain other conditions can also cause the syndrome. In addition to nerve cells, the brain includes cells specialized to support and nourish other cells. Keeping everything running requires coordination as well as large amounts of fuel and oxygen. Scientists believe Alzheimer’s disease prevents parts of a cell’s factory from running well. As damage spreads, cells lose their ability to do their jobs and, eventually, die. The role of plaques and tangles The brains of individuals with Alzheimer’s have an abundance of plaques and tangles. Plaques are deposits of a protein fragment called beta-amyloid that build up in the spaces between nerve cells. Tangles are twisted fibers of another protein called tau that build up inside cells. Though autopsy studies show that most people develop some plaques and tangles as they age, those with Alzheimer’s tend to develop far more and in a predictable pattern, beginning in the areas important for memory before spreading to other regions. Scientists do not know exactly what role plaques and tangles play in Alzheimer’s disease. Most 5 experts believe that they disable or block communication among nerve cells and disrupt processes the cells need to survive. The destruction and death of nerve cells causes memory failure, personality changes, problems in carrying out daily activities and other symptoms of Alzheimer’s disease. How Alzheimer’s spreads in the brain Plaques and tangles begin in brain areas involved in memory. However, they have identified certain risk factors that increase the likelihood of developing Alzheimer’s. One in nine people in this age group and nearly one-third of people age 85 and older have Alzheimer’s. Research has shown that those who have a parent, brother or sister with Alzheimer’s are more likely to develop the disease than individuals who do not. Familial Alzheimer’s and genetics Two categories of genes influence whether a person develops a disease: risk genes and deterministic genes. Risk genes increase the likelihood of developing a disease but do not guarantee it will happen. Deterministic genes directly cause a disease, guaranteeing that anyone who inherits one will develop a disorder. The reason for these differences is not well understood, but researchers believe that higher rates of vascular disease in these groups may also put them at greater risk for developing Alzheimer’s. Other risk factors Age, family history and genetics are all risk factors we can’t change. However, research is beginning to reveal clues about other risk factors that we may be able to influence. There appears to be a strong link between serious head injury and future risk of Alzheimer’s. It’s important to protect your head by buckling your seat belt, wearing a helmet when participating in sports and proofing your home to avoid falls. One promising line of research suggests that strategies for overall healthy aging may help keep the brain healthy and may even reduce the risk of developing Alzheimer’s. These measures include eating a healthy diet, staying socially active, avoiding tobacco and excess alcohol, and exercising both the body and mind. The risk of developing Alzheimer’s or vascular dementia appears to be increased by many conditions that damage the heart and blood vessels. These include heart disease, diabetes, stroke, high blood pressure and high cholesterol. Work with your doctor to monitor your heart health and treat any problems that arise. Studies of donated brain tissue provide additional evidence for the heart-head connection. These studies suggest that plaques and tangles are more likely to cause Alzheimer’s symptoms if strokes or damage to the brain’s blood vessels are also present. The first step in following up on symptoms is finding a doctor with whom a person feels comfortable. There is no single type of doctor that specializes in diagnosing and treating memory symptoms or Alzheimer’s disease. In some cases, the doctor may refer the individual to a specialist, such as a: » Neurologist, who specializes in diseases of the brain and nervous system. The workup is designed to evaluate overall health and identify any conditions that could affect how well the mind is working. When other conditions are ruled out, the doctor can then determine if it is Alzheimer’s or another dementia. Experts estimate that a skilled physician can diagnose Alzheimer’s with more than 90 percent accuracy. Physicians can almost always determine that a person has dementia, but it may sometimes be difficult to determine the exact cause. The doctor will also obtain a history of key medical conditions affecting other family members, especially whether they may have or had Alzheimer’s disease or other dementias. Evaluating mood and mental status Mental status testing evaluates memory, the ability to solve simple problems and other thinking skills.

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Prevalence may change over ethics committees should not fund or approve study time and future policymaking and planning require designs that are faulty in this respect buy generic nifedipine 30 mg on line pulse pressure blood pressure. Apart from For studies that correctly sample a subset of screen tracking changes in disease prevalence and incidence buy generic nifedipine 20mg prehypertension dizziness, negatives order nifedipine 20 mg with visa blood pressure 60 over 0, journals should not publish fndings until descriptive surveys can be used to estimate access results are weighted back in the analysis to account for to care, and the cost of health and social services different sample fractions. While It is both reassuring, and somewhat puzzling, that this may indicate an increase in the true underlying no clear effect on dementia prevalence of incorrect prevalence over time, Wu et al. Neglecting to sample screen negatives, and/ particularly the diagnostic criteria applied. A higher or weight back should always tend to underestimate prevalence was recorded in studies using more recent true prevalence. It will, in between the frst (screening) and second (diagnostic) truth, be diffcult defnitively to disentangle these two phases. Its effect is diffcult to predict; true dementia competing explanations for the striking temporal trend cases would need to be under-represented among observed in the region. Our decision, to focus in our losses between the two phases to counteract the likely regional meta-analysis on more recent studies from effect of incorrect application of the two phase design. China (post-2005), was justifable, in our view, in either Attrition can be minimised by shortening any delay case. Multiple imputation could Methodological variability can be reduced through be used to correct for the lost diagnostic data in the standardisation of study procedures. We have been able to perform a detailed diagnosis, and although it is not fully operationalised, it is possible to do so(35). It would also be desirable quality assessment of Chinese studies, which was not possible in our previous reviews. These raise concerns to reach an international consensus regarding what over the quality of studies from that region, with only constitutes cognitive impairment, what constitutes 5% of multistage designs applied correctly and only social and occupational impairment, and how these 15% of studies using a comprehensive diagnostic should be measured. Efforts need to be but these criteria have yet to be widely adopted, and their validity are not established(36-38). Of course, made internationally to ensure dissemination of good research practice, possibly including the development cultural adaptations may need to be applied. Accurate delineation of temporal A fundamental assumption, implicit in the modelling trends will require studies that maintain a constant approach in this review, was that the prevalence methodology over time (see Chapter 4). This could then be estimated from the available evidence and applied to all countries in that region. Prevalence Studies of Dementia in Mainland China, Hong Kong and Heterogeneity has slightly decreased for some regions, Taiwan: A Systematic Review and Meta-Analysis. Epidemiology of Alzheimer’s disease and other forms of dementia of development, and demographic compositions in China, 1990-2010: a systematic review and analysis. The We were only able to explore the possible factors prevalence of dementia in the People’s Republic of China: a explaining heterogeneity in two regions, Western systematic analysis of 1980-2004 studies. Cognitive impairment and dementia in elderly District, New Valley Governorate, Egypt. A nationwide survey on the prevalence of dementia and mild cognitive impairment in South Korea. Subramaniam M, Chong S, Vaingankar J, Abdin E, Chua B, algorithm, compared with the 10/66 dementia algorithm and a Chua H, et al. Prevalence of Dementia in People Aged 60 Years clinician diagnosis: a population validation study. Period, birth cohort and prevalence of dementia in mainland China, Hong Kong and Taiwan: a meta-analysis. Prevalence of Dementia and Alzheimer’s Disease in a Havana Municipality: A Community-Based Study among Elderly Residents. We found 39 North American studies, underrepresentation of Africa potentially eligible studies, of which 34 were fully and East Asia, and no evidence at all for South or eligible to be included in the meta-analysis. A better America Central, Latin America Tropical, Caribbean, understanding of the pattern and level of incidence in Australasia, Asia Pacifc, and West Sub-Saharan different world regions is essential. Dementia incidence appeared The systematic review on the incidence of dementia to be higher in countries with high incomes (doubling followed a similar process to the review of prevalence every 5. We aimed The total number of new cases of dementia each year to identify population-based studies of the incidence worldwide was then estimated to be nearly 7. The following physical/neurological examination, standardised search strategy was used to identify relevant papers questionnaire, clinical evaluation, other). Where not provided, epidemiology) numerator and denominator could then be calculated Chinese Database Search from any of these combinations. Papers were excluded at this stage only when the abstract clearly demonstrated that the paper did not 3. These papers were published in English, (Poisson) model to assess the effect of age on the Spanish and Portuguese, all of which could be read by incidence of dementia. Age was coded as the mean for who compared their study selection at each stage of each age group reported. Eleven of these had 8 Overall sample size to be excluded from the meta-analysis because case 9 Response rate (numerator) and person-years (denominator) data 10 Case ascertainment (community survey only or could not be extracted(2-12). America dominated, 26 of the 62 studies were from outside these regions, and 23 studies were conducted in low- or middle-income countries. The incidence of dementia appears to be higher Asia now has two studies (both from India) where in countries with high incomes (doubling every 5. There was North American studies 24%, the East Asian studies signifcant heterogeneity in the incidence estimates 16%, and the Latin American studies 13%. In Europe interpreted cautiously since sub-Saharan Africa, Asia and the Americas peak incidence is among those Pacifc and Australasia were each only represented by aged 80-89 years, in Asia it is among those aged one or two studies. The minus numbers with prevalent dementia), and then by regional distribution is similar to that which we had applying the appropriate incidence rate, as following: previously reported, with 4. Likewise, While systematically reviewing the evidence for the African continent is currently still only represented dementia incidence in population-based surveys, we by one study. Only one of countries with high incomes, a non-statistically those regions (South Asia) was not represented in our signifcant difference. Alzheimer Disease More research into the incidence of dementia is and Associated Disorders. Incidence of dementia among participants coverage in regions where some studies have been and nonparticipants in a longitudinal study of cognitive aging. Life-course socioeconomic position and incidence the most sensitive indicator of the success of primary of dementia and cognitive impairment without dementia in older Mexican Americans: results from the Sacramento Area prevention programs that seek to reduce dementia Latino Study on Aging. Prevalence and incidence rates of dementia and cognitive impairment no dementia in the Mexican References population: data from the Mexican Health and Aging Study.

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Y. Copper. Texas A&M University, Kingsville.

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