Screening for Heat Related Illness in Pregnant People: Sample Case Study for Clinician Education

Climate change has significant implications for pregnant people. The Heat-Related Illness Screening Tool was developed by faculty in the nurse-led Center for Climate Change, Climate Justice, and Health at the MGH Institute of Health Professions. In an effort to integrate content on the health effects of climate change on pregnant people, faculty in the Women's Health/Gender-Related Nurse Practitioner program in the School of Nursing developed a case study that incorporated heat and environmental exposures in pregnancy into an existing module on preterm birth. The case study aims to increase awareness about the intersections between climate change, social determinants of health, structural racism, and potential adverse pregnancy outcomes. Together this case study and screening tool for heat-related illness represent innovations for health professions educators and clinicians to detect intensifying risks to already vulnerable people who are pregnant.

Development of a screening tool for assessment of climate change-related heat illness in the clinical setting

ABSTRACT

Extreme heat contributes to heat-related illnesses resulting from heat intolerance, which is the inability to maintain a thermal balance to tolerate heat stress. In the United States, heat-related mortality for older persons has almost doubled in the past 20 years. Other populations at risk for heat-related illness (HRI) include children, pregnant people, those who work outside, young people participating in outdoor sports, and at-risk populations such as Black, indigenous, and populations of color. The classic heat tolerance test used for decades monitoring physiological responses to repetitive motions is impractical across large and potentially health challenged populations and does not identify environmental or social factors or specific vulnerable populations. To address this issue, we developed a heat-related illness screening tool (HIST) to identify individuals at risk for HRI morbidity and mortality based on their physical, environmental, and social vulnerabilities with an emphasis on populations of concern. The HIST has the potential to be used as routine clinical screening in the same way as other commonly used screening tools. Heat intolerance affects patient outcomes and quality of life; therefore, early screening with a simple, easy-to-administer screening tool such as the HIST can identify people at risk and refer them to services that address heat exposure and/or create safety nets to prevent heat-related illnesses.

Use of Dolutegravir for Antiretroviral Therapy for Women of Childbearing Age

The purpose of this article is to offer an update on the use of antiretroviral therapy (ART) for HIV among women of childbearing age. We focus specifically on the use of dolutegravir (DTG) because of a recently identified potential safety issue related to neural tube defects in the fetuses of women who used DTG at the time of conception. Nurses and advanced practice registered nurses should engage in shared decision-making processes for reproductive life planning with women of childbearing age who are living with or are at risk for HIV. During these processes, exploration of the full range of ART regimens is essential. Consistent and reliable contraception is necessary with the use of DTG because it is not recommended in the first trimester of pregnancy.

Developing partnerships for research: training workshops for mental health service users, carers and workers

Aims and Method

We aimed to introduce mental health service users, carers and workers to working as research partners with an academic unit, and provide training to facilitate participation. We achieved this by running workshops covering different stages of the research process.

Results

Service users, carers and workers attended the workshops, although carers were under-represented. Feedback was generally positive, and some participants have since become involved as researchers with projects at the Academic Unit.

Discussion

Detailed planning was crucial for deciding the course content, recruiting participants, responding to participant feedback and ensuring future research opportunities were available.

Paediatric CT dose: a multicentre audit of subspecialty practice in Australia and New Zealand

OBJECTIVES

To evaluate paediatric CT dosimetry in Australia and New Zealand and calculate size-specific dose estimates (SSDEs) for chest and abdominal examinations.

METHODS

Eight hospitals provided data from 12 CT systems for 1462 CTs in children aged 0-15. Imaging data were recorded for eight examinations: head (trauma, shunt), temporal bone, paranasal sinuses, chest (mass) and chest HRCT (high-resolution CT), and abdomen/pelvis (mass/inflammation). Dose data for cranial examinations were categorised by age and SSDEs by lateral dimension. Diagnostic reference ranges (DRRs) were defined by the 25th and 75th percentiles. Centralised image quality assessment was not undertaken.

RESULTS

DRRs for 201 abdominopelvic SSDEs were: 2.8-4.7, 3.6-11.5, 8.5-15.0, 7.6-15, and 10.6-16.2 for the <15 cm, 15-19 cm, 20-24 cm, 25-29 cm and >30 cm groups, respectively. For 147 chest examinations using these body width categories, SSDE DRRs were 2.0-4.4, 3.3-7.9, 4.0-9.4, 4.5-12, and 6.5-12. Kilovoltage peak (kVp), but not AEC or IR, was associated with SSDE (parameter estimate [standard error]: 0.12 (0.03); p < 0.0001).

CONCLUSIONS

Australian and New Zealand paediatric CT DRRs and abdominal SSDEs are comparable to international data. SSDEs for chest examinations are proposed. Dose variations could be reduced by adjusting kVp.

KEY POINTS

• SSDEs can be calculated for all patients, CT systems, and practices • Kilovoltage peak (kVp) has the greatest association with dose in similar-sized patients • Paediatric DRRs for CT are now available for use internationally.

Cancer detection in primary care: insights from general practitioners

Background:

General practitioners (GPs) have a key role in cancer detection as the usual first point of contact for patients with potential cancer symptoms. Nevertheless, there is limited work that investigates their perceptions of their role in the early detection of cancer. To address this gap, we aimed to gain an in-depth understanding of cancer diagnosis from the perspective of GPs.

Methods:

Individual face-to-face semi-structured interviews were conducted with 55 GPs from the North and North East of England and Greater London. All interviews were recorded and professionally transcribed verbatim. Repeated reading and co-coding engendered systematic thematic analysis across the interview material.

Results:

Three main themes emerged from the analysis of our data. First, we identified the burden of early cancer detection in general practice, both related to the anxiety and symptoms patients bring to GPs and the need for GPs to recognise patterns of cancer symptoms and refer appropriately; second, this burden is intensified by a perceived fragmentation of services within the National Health Service (NHS); and third, it is made more complex by the interface between general practice and public health.

Conclusions:

GPs occupy a challenging but pivotal role in cancer detection. It is crucial that this role be supported by policy and research.

Support matters: a mixed methods scoping study on the use of assistant staff in the delivery of community nursing services in England

Background

Community nursing (and health) services are faced with the growing challenge of caring for increasingly dependent patients with chronic conditions and complex care needs. Over the past decade there have been changes in the composition of the community nursing workforce with increasing numbers of assistants yet there is a lack of published literature on the roles, contribution and impacts of community nursing assistants to the delivery of care and services.

Design

We adopted a three-stage approach for the scoping study using mixed quantitative and qualitative methods. First, we established contact with senior managers in provider organisations where we had research governance approval (n = 76; 75% of total provider organisations) to determine whether or not (a) they employ assistants within community nursing teams and (b) they would be interested in participating in the study. Second, we carried out a short telephone interview with all senior managers who indicated a willingness to participate (census approach). We also analysed secondary data (using the NHS iView data source, from the Electronic Staff Record Data Warehouse) to scope the national use of community nursing assistant roles. Finally, we conducted telephone interviews with a purposive sample of managers from 10 organisations that participated in stage two to gain an in-depth understanding of assistant roles in community nursing teams

Setting

Community nursing provider organisations in England, UK.

Participants

Thirty-seven senior managers were interviewed for stage two (49% of all contacted). Thirty managers (20 service-level managers and 10 senior managers) were interviewed for stage three.

Results

Assistants promote flexibility in the community nursing workforce so as to respond to the changing demands on these services. However, the lack of consensus in defining the role of community nursing assistants has created inconsistency in the national deployment and development of these roles. These roles have tended to develop ad hoc, creating variations in numbers of assistants, the roles that they play and preparation for practice across different provider organisations and nursing teams. There is general enthusiasm among managers about the contribution of assistants. Their employment is regarded as fundamental to the ability of community nursing teams to deliver acceptable and appropriate services. However, the role may not always support career progression and development for those assistants who require this. The maturity and life experience of assistants is greatly valued in the nursing team to support care delivery and to offer stability and support to other members of the nursing team. Line management, responsibility and accountability in managing the work of assistants were highlighted as important for managing risk associated with an unregulated role. These have to be balanced with promoting flexibility in use and innovation.

Conclusions

Our scoping study highlights the opportunities and challenges associated with the use of assistants to deliver care by the community nursing team. Further attention at national and local levels is required to support and mediate the development of these roles in the future so as to promote the delivery of quality, safe and acceptable care. As provider organisations plan for delivering an ambitious community services agenda in the future, the role of the assistant is likely to have increasing importance.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill

Promoting 'care closer to home' for ill children is a policy and practice objective internationally. Progress towards this goal is hampered by a perceived lack of evidence on effectiveness and costs. The aim of the work reported here was to establish the strength of current international evidence on the effectiveness and costs of paediatric home care by updating and extending an earlier systematic review. A systematic review following Centre for Reviews and Dissemination guidelines involved updating electronic searches, and extending them to cover paediatric home care for short-term acute conditions. Twenty-one databases were searched from 1990 to April 2007. Hand searching was also carried out. Pairs of team members, guided by an algorithm, selected randomized controlled trials (RCTs), other comparative studies and studies including health economics data. A third reviewer resolved any disagreements. The quality of RCTs was assessed, but a 'best-evidence' approach was taken overall. Data were extracted into specifically designed spreadsheets and a second team member checked all data. Narrative synthesis was used throughout. This paper reports findings from RCTs and studies with health economics data. In total, 16 570 publications were identified after de-duplication. Eleven new RCTs (reported in 17 papers) and 20 papers with health economics data were included and reviewed. Evidence on costs and effectiveness of paediatric home care has not grown substantially since the previous review, but this updated review adds weight to the conclusion that it can deliver equivalent clinical outcomes for children and not impose a greater burden on families. Indeed, in some cases, there is evidence of reduced burden and costs for families compared with hospital care. There is also growing evidence, albeit based on weaker evidence, that paediatric home care may reduce costs for health services, particularly for children with complex and long-term needs.

Examining the family-centred approach to genetic testing and counselling among UK Pakistanis: a community perspective

WHO advice suggests a family-centred approach for managing the elevated risk of recessively inherited disorders in consanguineous communities, whilst emerging policy recommends community engagement as an integral component of genetic service development. This paper explores the feasibility of the family-centred approach in the UK Pakistani origin community. The study took place within a context of debate in the media, professional and lay circles about cousin marriage causing disability in children. Using qualitative methods, a total of six single-sex focus group discussions (n = 50) were conducted in three UK cities with a high settlement of people of Pakistani origin. Tape-recorded transcripts were analysed using framework analysis. Kinship networks within Pakistani origin communities are being sustained and marriage between close blood relatives continues to take place alongside other marriage options. Study participants were critical of what was perceived as a prevalent notion that cousin marriage causes disability in children. They were willing to discuss cousin marriage and disability, share genetic information and engage with genetic issues. A desire for accurate information and a public informed about genetic issues was articulated whilst ineffective communication of genetic risk information undermined professionals in their support role. This study suggests a community that is embracing change, one in which kinship networks are still active and genetic information exchange is taking place. At the community level, these are conditions supportive of the family-centred approach to genetic testing and counselling.

How professionals define medicines management: a preliminary qualitative investigation

Focal points

Involving South Asian patients in clinical trials

OBJECTIVES

To investigate how South Asian patients conceptualise the notion of clinical trials and to identify key processes that impact on trial participation and the extent to which communication difficulties, perceptions of risk and attitudes to authority influence these decisions. Also to identify whether 'South Asian' patients are homogeneous in these issues, and which factors differ between different South Asian subgroups and finally how professionals regard the involvement of South Asian patients and their views on strategies to increase participation.

DATA SOURCES

A review of the literature on minority ethnic participation in clinical trials was followed by three qualitative interview studies. Interviews were taped and transcribed (and translated if required) and subjected to framework analysis. Face-to-face interviews were conducted with 25 health professionals; 60 South Asian lay people who had not taken part in a trial and 15 South Asian trial participants.

RESULTS

Motivations for trial participation were identified as follows: to help society, to improve own health or that of family and friends, out of obligation to the doctor and to increase scientific knowledge. Deterrents were concerns about drug side-effects, busy lifestyles, language, previous bad experiences, mistrust and feelings of not belonging to British society. There was no evidence of antipathy amongst South Asians to the concept of clinical trials and, overall, the younger respondents were more knowledgeable than the older ones. Problems are more likely to be associated with service delivery. Lack of being approached was a common response. Lay-reported factors that might affect South Asian participation in clinical trials include age, language, social class, feeling of not belonging/mistrust, culture and religion. Awareness of clinical trials varied between each group. There are more similarities than differences in attitudes towards clinical trial participation between the South Asian and the general population. Important decisions, such as participation in clinical trials, are likely to be made by those family members who are fluent in English and younger. Social class appears to be more important than ethnicity, and older South Asian people and those from working class backgrounds appear to be more mistrustful. Approachable patients (of the same gender, social class and fluent in English) tend to be 'cherry picked' to clinical trials. This practice was justified because of a lack of time and resources and inadequate support. South Asian patients might be systematically excluded from trials owing to the increased cost and time associated with their inclusion, particularly in relation to the language barrier. Under-representation might also be due to passive exclusion associated with cultural stereotypes. Other characteristics such as gender, age, educational level and social class can also affect trial inclusion.

CONCLUSIONS

Effective strategies for South Asian recruitment to clinical trials include: using multi-recruitment strategies; defining the demographic and social profiles of the population to be included; using focus groups to identify any potential barriers; consulting representative community members to provide assistance in the study; ensuring eligibility criteria are set as wide as possible; developing educational and recruitment approaches to attract ethnic minority health professionals; ensuring health professionals are adequately trained in culturally and ethnically orientated service provision; determining the most effective mass media to use in study promotion and recruitment; and targeting inner-city, single-handed practices likely to have high ethnic minority populations. Future research should consider: responses when invited to participate; the role of methodological and organisational barriers to recruitment; the complexities of recruitment from a health professional perspective; developing culturally sensitive research methods; the magnitude of the problem of under-recruitment; strategies to encourage inner-city, single-handed GP participation; and other factors affecting trial inclusion, such as age, gender, educational level and socio-cultural background.

Living a 'normal' life: young people coping with thalassaemia major or sickle cell disorder

This qualitative paper explores the strategies and resources young people use to cope with sickle cell disorder or thalassaemia major, two haemoglobin disorders with serious implications for health and survival. By focusing on coping strategies, we explore how young people attempt to take control over their lives. The respondents, largely of South Asian and African Caribbean origin, aged between 10 and 19 years, valued maintaining a normal' life and struggled to achieve this normalcy. Strategies were employed to minimise difference from peers but these strategies remained vulnerable. Coping occurred in a dynamic space, involving negotiation and engagement with both personal and structural factors. Threats to normalcy did not always reside in the condition; life transitions, changes in social relationships and racist. disablist or sexist marginalisation also threatened coping strategies.

Screening and counselling for sickle cell disorders and thalassaemia: the experience of parents and health professionals

Shortfalls in haemoglobinopathy provision result in patients and their carers receiving inadequate support. This paper, by drawing on material from a project evaluating service provision to families caring for a child with a sickle cell disorder or thalassaemia, discusses screening and counselling services. It explores the perspectives of parents, front-line practitioners, managers and health commissioners. Poor quality care, inadequate information and professionals' insensitivity were salient themes in parental accounts. The parents' experience also confirms the problems faced by minority ethnic people in having their welfare needs recognised, more generally. Although our focus in on genetic conditions affecting minority communities in the UK, the issues we address are at the heart of the 'new genetics'.

Genetic screening and haemoglobinopathies: ethics, politics and practice

The increasing availability of information on the human genetic makeup presents both individuals and society with difficult decisions. This paper explores the ethical and practical issues raised by genetic screening for sickle cell and thalassaemia major, by examining the emerging tension between allowing people to make informed choices, on the basis of genetic information, and prevention of haemoglobinopathies. Within this broad context, the paper also explores the more practical issues of providing genetic screening for haemoglobinopathies, such as the meaning of counselling and screening for the general population; the psychological and social implications for people identified as carriers; and the organisation and delivery of services. It concludes that screening is not always informed by a commitment to informed decision making.

Were practice nurses distributed equitably across England and Wales, 1988-1995?

OBJECTIVE

To examine whether variations in the number of whole-time equivalent (wte) practice nurses across family health services authorities (FHSAs) can be explained by population characteristics and the organisation of general practice.

METHODS

Analysis of nine health and 16 social indicators for 98 FHSAs identified three factors underlying health care needs. These factors and seven practice characteristics were analysed by stepwise regression. A formula for allocating health care resources and a logistic growth model were used to estimate the 'expected' number of nurses.

RESULTS

Past trends indicate an eventual (wte) practice nurse workforce of 12,500 (95% CI +/- 3500). Although geographical disparities have declined, there was a two-fold variation in nurse numbers across FHSAs. Around 2000 (wte) posts would be required to bring under-provided areas, mostly in northern England and metropolitan districts, up to the highest level of provision. There were more nurses in areas with higher proportions of elderly people but fewer where deprivation, morbidity and mortality levels were above average. The number of general practitioners was the most significant predictor of practice nurse provision (t = 5.0); population needs and practice characteristics explained 24% of the variation.

CONCLUSIONS

The distribution of practice nurses scarcely corresponded with health care needs at the FHSA level. Despite a lack of evidence that nurses are a cost-effective addition to the primary health care team, their role and numbers will be driven by the extent to which they take on responsibilities performed by doctors. Achieving equity in practice nurse provision probably requires explicit consideration in a formula for allocating primary care funds, backed by audit of the services they provide.

Staying single in the 1990s: single-handed practitioners in the new National Health Service

The U.K. health care system is organised around independent medical practitioners who work in community settings and act as gatekeepers for acute health interventions. Recent developments in U.K. health policy have revolutionised the environment within which all general medical practitioners (GPs) operate. The last five years in the U.K. have seen the most fundamental health service reforms since the inception of the National Health Service (NHS) in 1946: namely, the development of the internal market, an increasing emphasis on primary health care, and changes to the GP Contract in 1990. Single-handed GPs (practitioners not in partnership with other GPs) traditionally work in the most deprived areas with the greatest health and social problems. The current restructuring and the subsequent organisational and policy initiatives present particular problems for single-handed practitioners. How single-handed practitioners respond to the reforms raises particularly important debates that are significant both for themselves and for the populations they serve. Drawing upon a range of sources, this paper discusses three central issues that emerge. First, how do single-handed practices relate to the more managerial role envisaged for authorities responsible for supporting primary health care? Second, given the development of the internal market, how do single-handed practices fare in influencing local policy and priority setting? Third, to what extent can single-handed practitioners take advantage of the opportunities to hold their own budgets? Overall, in the context of recent U.K. health care reforms, what is the future for "staying single in the 1990s"?

Postmarketing surveillance of oral terbinafine in the UK: report of a large cohort study

1. The safety profile of terbinafine, the first orally active allylamine, was monitored in the UK in a post-marketing setting. The study recruited 10,361 patients, a number which is approximately 5% of the population who received oral terbinafine in the UK during the period of the study. 2. Follow-up data were available on 9,879 patients. During the course of the study 14.5% patients reported medical events. 49% were thought to be possibly or probably related to terbinafine treatment. Seventy-four of the events (< 1%) were classified as 'serious' and of these only five were assessed as possibly or probably related to treatment. 3. Taste disturbance occurred in 0.6% of the patients and emerged as the only new adverse reaction probably attributable to terbinafine: this was significantly commoner in females and reversible on stopping treatment, with a median time to recovery of 42 days. 4. The study approach successfully combined hospital based dermatology outpatient and general practice centres. Source data verification was conducted on 13% of the cohort selected randomly. 5. Overall, the denominator-based description of the safety profile in actual practice shows terbinafine to be well-tolerated against a wide background of age and coexisting illness.

Neutropenia and agranulocytosis in patients receiving clozapine in the UK and Ireland

BACKGROUND

Clozapine can cause reversible agranulocytosis and neutropenia. This study documents the occurrence of blood dyscrasias and identifies predisposing risk factors.

METHOD

An analysis was made of the haematological, demographic, and dosage data from a central database on 6316 patients receiving clozapine over four and a half years in the UK and Ireland.

RESULTS

During the study period, 2.9% of the patients developed neutropenia and 0.8% developed agranulocytosis. The peak incidence of both disorders was in the first 6-18 weeks of treatment. Fatal agranulocytosis occurred in 0.03% of patients. After the first year of treatment, the incidence of agranulocytosis significantly decreased to the order noted with some phenothiazines.

CONCLUSIONS

The use of a patient monitoring service kept the haematological risks associated with using clozapine within acceptable limits, particularly in view of the benefits of this medication in treatment-resistant schizophrenia.

Negotiating the role of the practice nurse in general practice

The debate about the role of the practice nurse is not only about practice nursing per se, but raises broader issues about the organization of primary health care. Two related issues emerge as significant: the role of the practice nurse in providing primary health care; and the effective use of the practice nurse resource in the 'new' National Health Service. This paper, by drawing on material from a qualitative study, specifically examines the type of work performed by practice nurses and the factors that influence this. The responses of practice nurses, general practitioners, Family Health Service Authority (FHSA) advisers, community nurse purchasers and managers of community nursing provider units suggest that a consensus on the future development of practice nursing is unlikely. The different stakeholders emphasized different issues, reflecting their own priorities and backgrounds. Practice nurses' accounts of the future, for example, focused on professional issues. General practitioners stressed the importance of role development which met their General Medical Service responsibilities. Purchasing agencies, provider units and FHSAs adopted a wider perspective and were more concerned to develop an effective and integrated primary health care service. The tensions generated by their different interests and perspectives, and the subsequent organizational and policy initiatives that emerge, will provide the context in which the role of practice nurses will be negotiated.

The role of the practice nurse in primary health care: managing and supervising the practice nurse resource

This paper, by drawing on material from a qualitative study funded by the Department of Health and Welsh Office, examines the supervision and management of the practice nurse in general practice. In doing so it explores the perspectives of practice nurses, the GPs who employ them, representatives from FHSAs, those responsible for commissioning community nursing services, and managers of community nursing provider units. Within this context the paper explores the nature of the supervisory relationship between GP and practice nurse, and the wider role of the FHSA, commissioners of community nursing services and managers of community nursing provider units.

Training and education in practice nursing: the perspectives of the practice nurse, employing general practitioner and Family Health Service Authority

Continuing training and education, although fundamental to the development of practice nursing, is subject to considerable debate. This paper, by drawing on material from a national qualitative study funded by the Department of Health and Welsh Office, explores the role of continuing training and education from the perspectives of practice nurses, general practitioners, representatives from Family Health Service Authorities (FHSAs), commissioners of community nursing services and managers of community nursing provider units. The paper demonstrates how practice nurses make use of a variety of education and training opportunities and do not seem particularly disadvantaged in their training pathways. Problems, however, have began to emerge. The informal arrangements covering training and education have been felt by many practice nurses, to leave them in a potentially needs might not be so easily accommodated. More generally, the paper concludes that debates about training and education cannot take place without referring to the type of work it is appropriate for a practice nurse to perform. The role expected of general medical services and the general development of primary health care provision, therefore, will influence practice nurses' training and educational needs.

The role and self-perceived training needs of nurses employed in general practice: observations from a national census of practice nurses in England and Wales

This paper outlines the results of a national census of practice nurses in England and Wales. It not only shows that the numbers of practice nurses have increased dramatically in recent years but also demonstrates how their role has evolved. Many practice nurses are now involved in health promotion, and home visiting, as well as advice and counselling. The findings also indicate that many practice nurses express a need for training. Continuing education for practice nurses is important in ensuring practice nurses are fully qualified and trained for the tasks they undertake. In addition, it also enables them to develop their role and work alongside other community health professionals.

Community nursing: nurses' effectiveness in supporting carers

This article outlines the results of a research project to evaluate the effectiveness of service support to informal carers. There are many ways in which community nurses can support carers, and carers frequently report the benefits of the service. The potential significance of the community nursing service in this role, however, is yet to be realised as nursing is still highly task-orientated, with priority given to specific medical interventions. As a result, some carers face difficulties in obtaining nursing support.

Current comment. (xix). Why don't general practitioners refer their disabled Asian patients to district nurses?

Research into the needs of disabled people in Central Birmingham and their use of community health and social services has shown that Asian people are 'underusers' of these services, particularly district nursing. We have found that in this district, general practitioners (GPs) refer the majority of district nurses' disabled patients, but they are not referring Asians. Possible explanations--that elderly Asians have low contact rates with GPs, lack knowledge about the district nursing services, or refuse to use the service--are not supported by the research data. More likely explanations are offered--that GPs hold stereotyped views about Asians and their needs, have a misunderstanding of the role and function of the district nurse and inflexible assumptions about the 'typical' patient seen by the district nurse. Attention is drawn to the urgent need for GPs to address these issues and for further research as the numbers of older Asians are set to rise sharply.

Weight reduction in a normal population

Weight loss of more than 2 kg under the guidance of a trained nurse was achieved over a 12-month period in 38% of overweight hospital and transport workers. Males over 50 were the subgroup most successful in losing weight. Weight loss achieved by older males with an "off-hand" as compared with an "energetic" approach was similar up until nine months, after which the "energetic" approach was more effective. Females on an "energetic" diet were successful up until nine months only. The "off-hand" approach is acceptable to more people and is less time-consuming. It should therefore be seriously considered by a public health authority which seeks to promote weight reduction in the general community.