We previously reported widespread insecticide exposure during pregnancy among inner-city women from New York City. Here we report on a pilot intervention using integrated pest management (IPM) to reduce pest infestations and residential insecticide exposures among pregnant New York City African-American and Latina women (25 intervention and 27 control homes).The IPM consisted of professional cleaning, sealing of pest entry points, application of low-toxicity pesticides, and education. Cockroach infestation levels and 2-week integrated indoor air samples were collected at baseline and one month postintervention. The insecticides detected in the indoor air samples were also measured in maternal and umbilical cord blood collected at delivery.p = 0.016) after the intervention among intervention cases but not control households. Among the intervention group, levels of piperonyl butoxide (a pyrethroid synergist) were significantly lower in indoor air samples after the intervention (p = 0.016). Insecticides were detected in maternal blood samples collected at delivery from controls but not from the intervention group. The difference was significant for trans-permethrin (p = 0.008) and of borderline significance (p = 0.1) for cis-permethrin and 2-isopropoxyphenol (a propoxur metabolite).Cockroach infestations decreased significantly (To our knowledge, this is the first study to use biologic dosimeters of prenatal pesticide exposure for assessing effectiveness of IPM. These pilot data suggest that IPM is an effective strategy for reducing pest infestation levels and the internal dose of insecticides during pregnancy. TherefoIntegrated pest management (IPM) is considered an environmentally sustainable pest control strategy. It aims to reduce pest populations by identifying and understanding the biology and behavior of the insects and rodents; selecting and implementing a set of environmentally safe and effective control strategies; and monitoring the effectiveness of the strategies . TechniqThe current study is the first to use bio-markers and air monitoring to document changes in insecticide exposure after an IPM intervention. The IPM strategy used here was adapted from the Columbia Intervention to Reduce Indoor Allergens Study . The aimRecruitment and enrollment efforts for the intervention study occurred from August 2002 through April 2004. Thirty women were recruited from obstetrics and gynecology (OB/GYN) clinics located in New York Presbyterian and Harlem Hospitals. Eligibility was restricted to women 18–35 years of age who self-identified as either African American or Latina (Dominican or Puerto Rican) and reported using high-toxicity insecticides  during pregnancy. Further, eligible subjects must have resided in northern Manhattan (north of 110th Street) or the South Bronx (south of Fordham Road) for at least 1 year before pregnancy and must not be planning to move from the community before delivery. From the 30 subjects who completed the screening and consent forms, 5 women dropped from the study between enrollment and monitoring . Samples collected from the subjects before the intervention will be referred to as preintervention, and samples collected after the intervention will be referred to as postintervention. From the remaining 25 women, 25 (100%) completed the prenatal questionnaire, 25 (100%) participated in pre- and postintervention indoor air monitoring, and biologic samples were collected from 21 (84%) subjects. Nineteen (76%) completed pre- and postintervention assessment of pest infestation.The control group was selected from participants in an ongoing prospective cohort study designed to validate biomarkers of prenatal insecticide exposure. As part of this study, insecticide levels were measured in 2-week integrated indoor air samples collected continuously over the last 2 months of pregnancy. Blood samples were collected from the mother and newborn at delivery. Enrollment for this study occurred in the OB/GYN clinics located in New York Presbyterian Hospital and Harlem Hospital from October 2001 through July 2004. The recruitment strategy and eligibility criteria for the controls were identical to those for the cases. From the total of 110 women fully enrolled in the biomarker validation study, 27 were selected as controls for the intervention study. Control selection aimed to match case subjects on year of enrollment (2002–2004) and self-reported use of high-toxicity insecticides  during pregnancy. Baseline and follow-up integrated air samples were selected to match the pre- and postintervention samples in the cases. Questionnaire data were available for 100% of subjects. Baseline and follow-up indoor air data were available for 24 (88%) subjects; blood samples were collected from 17 (63%) subjects. Fourteen (52%) subjects completed the initial pest infestation levels. Follow-up samples were available for only six (22%) subjects.The institutional review board of the Columbia Presbyterian Medical Center approved the study, and we obtained written informed consent from all study subjects.The intervention commenced at the conclusion of the 2-week preintervention monitoring period. This IPM consisted of three main components: an extensive cleaning with minor building repairs, a low-toxicity insecticide application, and behavioral/health education. The kitchen, bathroom, and living room areas of the intervention apartments were professionally cleaned using low-toxicity, citrus-based cleaning products. Pest entry points were sealed with caulking compounds and/or metal screens. A professional insecticide placement company injected low-toxicity insecticides, 2.15% hydramethylnon , or small amounts of boric acid directly into the cracks and holes before sealing and placed glue traps for cockroaches throughout the kitchen, bathroom, and problem areas. Hydramethylnon has low toxicity and low vapor pressure and has been shown previously to be effective for long-term cockroach control . Using aA 45-minute questionnaire was administered to the intervention and control groups in each woman’s home by a trained bilingual interviewer during the third trimester of pregnancy. The questionnaire included information on demographics, home characteristics including housing disrepair and pest infestation levels, lifetime residential history, history of active and passive smoking, occupational history, maternal education and income level, alcohol and drug use during pregnancy, and history of residential insecticide use. Information about insecticide use included whether or not any pest control measures were used by an exterminator or by others  during pregnancy and, if so, what types of measures were used and at what frequency , 2003.Before the intervention, a baseline 2-week integrated indoor air sample was collected from the homes of subjects in the intervention and control groups. Monitoring commenced in each home at the end of the second or beginning of the third trimester of pregnancy using a BGI pump with a 0.5-L/min flow-rate . The pump was attached to a URG  polyurethrane foam (PUF) sampler with a 2.5-μm inlet cut fitted with a 30-mm quartz fiber filter and a foam cartridge backup to capture semivolatile vapors and aerosols. The pumps were attached to a battery and operated continuously over the 2 weeks. The monitoring equipment was placed in the main living area of the apartment, with the pump in a secure box and the sampler (located inside a protective wire cage) placed at least 60 cm from wall surfaces at a height of 135 cm. The sampler height was chosen to represent the average between the woman’s sitting and standing heights, because residential insecticide air concentrations have been shown to vary with height, being greatest near the floor . Study sApproximately 4 weeks after the intervention, a follow-up 2-week integrated indoor air sample was collected from intervention and control homes. Protocols for the follow-up air monitoring were identical to those for the baseline sample. The monitoring was targeted to occur during the 38th to 40th week of pregnancy; however, because of premature births or postponements, some subject’s homes were monitored immediately after delivery.To monitor cockroach infestation levels, six pheromone glue traps  were placed in standardized locations throughout the kitchens of each subject during the 2-week baseline and follow-up indoor air monitorings. After 2 weeks, traps were collected and the number of adult and nymph cockroaches caught in each trap was counted.We used blood collection procedures validated in our prior research studies to ensure that blood samples  were collected from women in the intervention and control groups at delivery . A sampl14 as a recovery surrogate, extracted with 6% diethyl ether in hexane for 16 hr and concentrated to 1.0 mL in 10% ether in hexanes. Extracts were stored frozen below −4°C. Insecticides are stable in the extract under these conditions. We determined the amounts of the target insecticides in samples using Agilent 6890/5973 gas chromatography/mass spectrometry  in selected ion mode. Paired pre- and postintervention air samples were available on 25 cases and 39 controls. The target insecticides that were measured in the indoor air samples were bendiocarb, carbaryl, carbofuran, cis- and trans-permethrin, malathion, methyl parathion and propoxur. In addition, piperonyl butoxide, a synergist added to natural and synthetic pyrethroid insecticides, was measured as an indicator of pyrethroid insecticides. Chlorpyrifos and diazinon were not assessed because most of the women were enrolled in the study after the federal ban on their residential use and our prior data indicate that the ban was effective at reducing use and exposures to these insecticides among inner-city women in New York City  a value of 0.5 × LOD. For hypothesis testing, variables were treated as continuous or categorical depending on their distributional properties. Continuous variables were initially log-transformed as appropriate to normalize the distribution. However, in almost all cases, the data could not be normally distributed after log-transformation, so nonparametric statistics were used. The differences in pest infestation levels and air insecticide levels between pre- and postintervention in both cases and controls were normally distributed, so we used parametric statistics to evaluate whether these differences varied significantly between the intervention and control group. Analyses were also undertaken to determine whether the intervention and control groups differed in terms of demographic characteristics or season and year of delivery. No significant differences were seen.t-test to determine whether the differences in pest infestation levels between pre- and postintervention observed in the intervention group were significantly different from the differences in pest infestation levels observed in the control group.For pest infestation levels, we used the Wilcoxon signed-rank test to assess the differences between pre- and postintervention pest infestation levels in both intervention and control groups. Because the differences in pest infestation levels were normally distributed, we used the independent sample t-tests and regression analyses controlling for race/ethnicity, season, and year of delivery to compare whether the change in air insecticide levels between pre- and postintervention differed significantly between the intervention and control groups. For insecticide levels in maternal and cord blood samples, we compared differences in detection frequencies between intervention and control subjects using chi-square analyses (Fisher’s exact test). Results were considered significant at p < 0.05 (two-tailed).For 2-week integrated air insecticide levels, we compared detection frequencies as well as detection levels. We used McNemar’s test to examine the change in detection frequency of insecticide levels in air between pre- and postintervention in both the intervention and control groups. We used the Wilcoxon signed-rank test to examine the change in insecticide levels between pre- and postintervention for both groups. Finally, we used the independent sample p = 0.008, 0.05, and 0.012, respectively). Participants included 25 intervention cases and 27 nonintervention controls. Demographic characteristics were compared between cases and controls and were generally comparable between the two groups . Discrepp = 0.016) (p = 0.006) and nymph cockroaches decreased by 44% (p = 0.033). By contrast, control households showed no significant reduction of adult or nymph cockroaches between baseline and follow-up  . Adult cw-up see . Howeverw-up see .cis- and trans-permethrin in approximately 30% of pre- and 15% of postintervention samples and 24 and 16% of baseline control samples and 17 and 13% of follow-up control samples, respectively. In addition, piperonyl butoxide was detected in 71% of pre- and postintervention samples and 72 and 57% of baseline and follow-up control samples, respectively. The mean levels for these compounds in pre- and postintervention 2-week integrated indoor air samples are presented in Of the nine insecticides measured in 2-week integrated indoor air samples, five insecticides  were not detected or were found in < 10% of either intervention or control samples. Of the remaining insecticides, propoxur was detected in 92% of pre- and postintervention case samples and 100% of baseline and follow-up control samples; and p = 0.016). Of the 23 intervention homes with available air sampling, a decrease in piperonyl butoxide was seen in 74% (17/23) of homes, whereas an increase was seen in 26% (6/23) of homes. Piperonyl butoxide levels also decreased in control homes, but not significantly (p = 0.08). The difference between pre- and postintervention levels of piperonyl butoxide in the intervention group was not significantly different from the difference between baseline to follow-up levels in the controls .Among the intervention group, only piper-onyl butoxide decreased significantly after the intervention . The meacis- and trans-permethrin (two isomers of the pyrethroid insecticide permethrin). These insecticides were detected in plasma samples from the control group but not from the intervention group. Specifically, 2-isopropoxy-phenol was detected in 0% of maternal blood samples from the intervention group and in 12% of maternal blood samples from controls . Cis- and trans-permethrin were detected in 0% of maternal blood samples from intervention group and 12 and 29% of maternal blood samples from controls, differences that were significant for trans-permethrin  (= 0.008) . None ofThis pilot intervention study demonstrates that IPM can have a significant effect on pest infestation levels and appears to reduce residential insecticide exposures during pregnancy. Our findings showing significant reductions in cockroach populations are consistent with those of other intervention studies that focused on reducing either pest infestations or allergen levels related to pest infestation . To our Success of IPM interventions has been attributed to simultaneous application of multiple nonchemical approaches to pest control, including education, repair, least-toxic exterminations, reinforcement, and repetition . In our Despite the dual goal of IPM to reduce cockroach and insecticide exposures, most IPM evaluations have focused on the reduction of pests. Data on the effectiveness of reducing insecticide exposure are limited, and documented in only two studies. A building-wide intervention in New York City public housing found resident’s use of spray insecticides and Chinese Chalk, an illegal insecticide, dropped to zero after a building-wide IPM intervention that included education about the safe use of insecticides . An IPM intervention in Canada found decreases in both personal use of spray insecticides and resident requests for exterminators to use spray insecticides in their apartment, requesting instead lower-toxicity pastes or gels . Althougcis-permethrin and trans-permethrin, and the pyrethroid synergist piperonyl butoxide. Selection of these insecticides was based on evidence that they were widely used for residential pest control (trans-isomer of permethrin were lower in maternal plasma samples collected from the intervention group than in controls.In the present study, target insecticides in indoor air samples included the carbamate, propoxur, the pyrethroids  control . Detecti control , 2004. T control . In our However, these findings should be interpreted with caution, particularly because results for propoxur do not mirror those seen for piperonyl butoxide. Specifically, propoxur levels in indoor air samples decreased in follow-up compared with baseline air samples among control households, but not among intervention households. Propoxur is a carbamate licensed for residential pest control and has not been subject to regulatory restrictions, as have the organophosphates, chlorpyrifos, and diazinon. However, our prior data suggest that propoxur use in inner-city communities in New York City may be decreasing. Specifically, we found a highly significant decrease in propoxur levels between 1999 and 2001 in personal air samples collected from African-American and Dominican women in New York City during pregnancy and in the corresponding blood samples collected from the mothers and newborns at delivery , 2004. UAlthough this pilot intervention indicated that IPM is effective at reducing pest infestation and the internal dose of the insecticides during pregnancy, limitations in the study design should be noted. The primary limitation of the study is the small sample size and the short time elapsed between pre- and postintervention monitoring. Many intervention studies allow 6 months to 1 year between samplings to determine if the intervention is both successful and sustainable. However, the current intervention was conducted during pregnancy and was thus limited in follow-up time. Further, the controls were selected from an ongoing biomarker validation study that followed women only during pregnancy. Thus we were not able to evaluate the sustainability of the intervention over an extended period. In addition, the optimal design for an intervention study is to match the intervention subjects to control subjects and have all data collected and analyzed simultaneously. This was not possible here because the controls were selected from ongoing research. However, the intervention and control groups were comparable in terms of years of enrollment and self-reported pesticide use.A principal goal of the pilot study was to assess whether environmental and biologic measures can be used in evaluating the efficacy of IPM interventions in reducing residential pesticide exposures. These initial results are promising, although additional research is warranted given the small sample size and inconsistency in some of the findings. Environmental measures for the targeted pesticides are not necessarily associated with the biologic measures. Therefore, a lack of meaningfully different results in air levels of pesticides between the intervention and control groups does not influence the expected results in maternal plasma between the two groups. Subsequent research could also draw on our study design to devise an IPM intervention that can be conducted by household members themselves and that is both feasible and affordable. Such an intervention could be applied to entire apartment buildings or complexes to determine the effects of larger-scale interventions, as opposed to individual units. In the current study, cleaning and home repairs were completed by a professional cleaning crew to allow comparability and consistency. However, the supplies and techniques are similar to those available in the community. In conclusion, we believe that this intervention protocol using IPM can be successfully adapted for use by individuals within households in this community to reduce pest infestation levels and residential pesticide exposure.


The prevalence of asthma and allergic diseases has increased in industrialised countries, and it is known that rates vary according whether the area is urban or rural and to socio-economic status. Surveys conducted in some urban settings in Latin America found high prevalence rates, only exceeded by the rates observed in industrialised English-speaking countries. It is likely that the marked changes in the environment, life style and living conditions in Latin America are responsible for these observations. The understanding of the epidemiological and immunological changes that underlie the increase in asthma and allergic diseases in Latin America aimed by SCAALA studies in Brazil and Ecuador will be crucial for the identification of novel preventive interventions.The Salvador-SCAALA project described here is a longitudinal study involving children aged 4–11 years living in the city of Salvador, Northeastern Brazil. Data on asthma and allergic diseases (rhinitis and eczema) and potential risk factors will be collected in successive surveys using standardised questionnaire. This will be completed with data on dust collection (to dust mite and endotoxin), skin test to most common allergens, stool examinations to helminth and parasites, blood samples , formaldehyde, physical inspection to diagnoses of eczema, and anthropometric measures. Data on earlier exposures when these children were 0–3 years old are available from a different project.It is expected that knowledge generated may help identify public health interventions that may enable countries in LA to enjoy the benefits of a "modern" lifestyle while avoiding – or minimising – increases in morbidity caused by asthma and allergies. The prevalence of asthma and allergic diseases (rhinitis and eczema) has increased in industrialised countries in the last 2 decades -3; in thAmong environmental exposures that may have contributed to the trends in allergy prevalence, those that have attracted most interest are the fall in exposures to infectious diseases. The so-called "hygiene hypothesis" proposed that increases in the prevalence of allergic diseases were explained by improvements in living conditions, use of antibiotics and childhood vaccinations leading to a reduction in exposure to infections in early life . DiffereWhatever the mechanisms involved the strong evidence that the temporal allergy trends are related to changes in lifestyle and living conditions raises the possibility that preventive interventions against allergic diseases can be identified. The understanding of the epidemiological and immunological changes that underlie the increase in asthma and allergic diseases will be crucial for the identification of novel preventive interventions.International studies of the asthma prevalence have been conducted with the International Study of Asthma and Allergies in Childhood (ISAAC) study group using a standardised written questionnaire for self-reported asthma and respiratory symptoms. In these surveys, some Latin American settings  had very high prevalence rates, that were exceeded only by industrialised English-speaking countries . These rThe study described here is part of a larger ongoing research programme being conducted in Brazil  and Ecuador. Populations in both countries have experienced recent changes in living conditions and life style . This research programme is funded by The Wellcome Trust through the programme of Major Awards to Centres of Excellence in Latin America and has adopted the name SCAALA . This paper specifically deals with the methodological aspects of the cohort study being conducted in Salvador, Brazil.The Salvador cohort study has two main objectives. Firstly, to investigate the associations between the prevalence of asthma and other allergic diseases  and potential risk factors that includes living conditions and early life and current exposures to infections, and secondly, to investigate how the association between environment factors, allergic diseases and markers of atopy  are mediated by serum interleukins. In contrast, the study in Ecuador aims to study frequency of atopy and allergic diseases and exposure to potential risk factor in rural populations and in migrants from rural to urban areas; and examine how these may explain the risk of atopic diseases in migrants from rural to urban areas. This study will be described in a separate paper.Salvador, the capital of the State of Bahia, in the Northeast Brazil has approximately 2.5 million inhabitants, and is located in the poorest region in the country. Over 80% of the population is black or mixed-race (mulatto). There is a high degree of social inequality: GINI coefficient was 0.66 in 2000 . The citChildren in this research project have been part of a study conducted earlier to evaluate the impact of the sanitation programme on the occurrence of childhood diarrhoea. This first study was originally designed to enrol three separate cohorts of children aged 0–3 years recruited from 24 small geographical areas selected to represent the population without sanitation in Salvador, called sentinel-areas ,17 TheseTo take advantage of these three cohorts , the children who were aged 4–11 years and had complete follow-up information (e.g. stool examination conducted at 3 different time points) were selected for the present study.Follow-up during the current study on asthma and allergic diseases consists of two additional surveys to be conducted between 2005 and 2006, and again in 2008. The two surveys will assess children from the three previous cohort studies and will: (i) update information collected in the baseline surveys (ii) collect information on additional risk factors, (iii) collect stool samples for diagnosis of intestinal parasitic infections, (iv) collect blood samples for immunological analysis, (v) collect dust to measure allergen exposure, (vi) collect data on formaldehyde and particulate levels indoors and outdoors and (vii) collect data on asthma and allergic diseases . The information collected during previous surveys and follow-up will be used in the present study to investigate early risk factors relating to infectious disease exposures and living conditions of the children from birth. All children from the previous 3 cohort studies were eligible to enter the present study.The total number of children recruited in the first resurvey with questionnaires completed was 1,445. Given this total number of children recruited, the magnitude of the prevalence rate ratio to be estimated with at least 80% of study power and 95% precision for selected characteristics were calculated by comparing proportions in STATA (command "sampsi"). This was done assuming an estimate of asthma prevalence of 10% , signifiAsthma, rhinitis and eczema will be defined according to the International Study of Allergy and Asthma in Childhood (ISAAC) . Atopy wThe field work of the surveys in 2005 and 2008 involves 7 different activities, each conducted by different field teams and supervised by at least one of the co-investigators. Application of the main questionnaire, anthropometric survey, and stool and dust sample collection were completed in 2005. The activities were:1. Questionnaire: mostly based on the ISAAC Phase II questionnaire , transla2. An anthropometric survey with two independent measures of height and weight collected in a standardised way conducted by trained nutritionists, taking the mean value as the final measure, as recommended by WHO: z-scores for weight-for-age, weight-for-height and height-for-age were calculated using the EPINUT program  (details published elsewhere ).3. Stool samples collected for helminths and parasites with two different samples for each child, 2 days apart. Stools were analysed using the gravitational sedimentation technique of Hoffman, Pons & Janner to detect helminth eggs, protozoan cysts and oocysts. Two slides were examined for each stool sample. Quantification of helminth eggs was performed using the Kato-Katz technique . All chi2 area, adjacent to the head side. The filters were weighed before and after collection of the dust samples. Fibres and large particles were removed from the dust with forceps and the fine particulated dust samples were weighed, aliquotted as 100 mg samples and cryo-preserved at -20°C. Temperature and air humidity were recorded at the bedroom with a thermohygrometer .4. Dust samples collected using a residential vacuum cleaner  containing a nylon 25 um micromesh sock filter . The chiA. lumbricoides, T. trichura, Toxoplasma gondii and Toxocara canis, and (iii) cytokines IFN-gamma, IL-13 and IL-10 and TGF-β in supernatant fluids collected from antigen-stimulated whole blood cultures.5. Blood samples: An aliquot of 10 mL collected to measure (i) total and allergen specific IgE , (ii) IgG antibodies to Hepatitis A virus, Herpes simplex, Herpes zoster, and Epstein-Barr viruses, Dermatophagoides pteronyssinus, Blomia tropicalis, Blattella germanica, Periplaneta americana, fungi, dog and cat epithelia. Saline and histamine was used as negative and positive controls, respectively. Wheal sizes will be read after 15 minutes and reactions will be considered positive if the mean of the two larger perpendicular diameters of the reaction is at least three millimeters superior to the mean of the two larger perpendicular diameters of the negative control reaction area.6. Skin prick test (SPT) carried out by allergen skin prick testing of the right forearm of each children using extracts  of 7. Skin inspection for flexural dermatitis performed by trained observers using the ISAAC phase II protocol  will comBlomia tropicalis Blo t 5, Dermatophagoides pteronyssinus Der p 1, Blatella germanica Bla g 2, Cat Fel d1, Dog Can f1Bacterial endotoxin and fungal b-glucan will be measured using the Limulus Amebocyte Lysate (LAL) assay (Cambrex Bio-Ciência do Brasil Ltda) following the manufacturers' instructions.Aeroallergens will be quantified from dust samples by capture ELISA using commercially available kits  for the following aeroallergens: Ascaris lumbricoides (10 μg/ml); Blomia tropicalis (40 μg/ml); Dermatophagoides pteronyssinus (5 μg/ml). Pookweed mitogen  diluted at 1/1000 will be used as a positive control and media alone as negative control. House dust mites cultivated in fish food will be purified, lysed in pH 7.4 phosphate saline (PBS) with the use of a blender . The A. lumbricoides antigen will be obtained by trituration of liquid nitrogen frozen adult worms obtained from a child treated with albendazole, in a blender as stated above in the presence of PBS. After centrifugation, the supernatants will be cryopreserved for storage before use. All antigens will be depleted of endotoxin by treatment with triton-114  and the protein contents will be determined by the Lowry method. Whole blood cultures will be cultivated at 5% CO2, for 24 hours for detection of IL-10 and for 5 days for the detection of IL-13, TGF-β and IFN-gamma. Cytokines in supernatant fluids will be measured using Pharmigen BD antibody pairs and recombinant standards  by capture ELISA following the manufacturer's instructions. Cytokines will be estimated by interpolation of standard curves of recombinant standards.Heparinised whole blood will be cultivated at a dilution at 1:4 in RPMI  containing 10 mM glutamine , 100 μg/ml of gentamicyn , and stimulated with the following antigens: Total IgE will be measured as follows: COSTAR high binding microassay plates  will be coated with 4 μg/ml of an anti- human -IgE antibody  overnight at 4C. Plates will be blocked with 0.15 M phosphate-buffered saline, pH 7.2 (PBS), containing 20% of dried skimmed milk (DSM) and 0.05% of Tween 20  overnight, at 4°C. Sera to be tested and IgE antibody standards . will be diluted 1:10 in PBS containing 10% of DSM and 0.05% of Tween 20 and incubated overnight at 4°C. A goat anti-human IgE-peroxidase conjugate , and an anti-goat immunoglobulin-peroxidase conjugate , will be diluted at 1:2000 and 1:10.000, respectively, and incubated for 60 minutes at room temperature. The results will be expressed in International Units (IU). A pool of parasite infected patients' sera will be used as positive control. Umbilical cord serum from a non-atopic and non-parasited mother will be used as negative control.Dermatophagoides pteronyssinus, Blomia tropicalis, Blatella germanica, dog and cat epithelia main allergens using the RAST system .Determination of specific IgE serum concentration will be done for A. lumbricoides IgG4 will be detected by an indirect ELISA using wells of high binding microassay plates , sensitized with 20 μg/ml, of the parasite antigen as stated above, diluted in carbonate-bicarbonate pH 9,6 buffer. The sera will be diluted at 1:50 in PBS containing 10% skimmed milk and 0,1 % tween 20 (PBS/SM/T). The reaction will be detected using a biotinylated anti-human-IgG4/, streptoavidin/peroxidase  and H2O2 e OPD . The assay cut-off will be the mean plus 3 SD of negative controls . Anti-Toxocara IgG antibodies will be detected using 20 μg/ml of larvae excretorial-secretorial antigen obtained by cultivation of the larva as described by De Savigny et al. [A. lumbricoides; the development of the reaction will be done as described for A. lumbricoides IgG4 except for the conjugate that will be a biotinylated anti-human IgG. The assay cut of will be the mean plus 3 SD of negative controls . Anti-Toxoplama gondii IgG and IgM will be detected using commercially available ELISA kits , following the manufacturer's instructions. IgG antibody against the following virus will measured: Herpes simplex, Herpes zoster, Epstein-Bahr and Hepatitis A virus. Detection will be done using commercially available ELISA kits , following the manufacturers' instructions.Detection of anti-parasite antibodies. Anti-y et al.  (The serData for study variables were collected either (i) during the 3 previous baseline surveys and that will be updated in the 2 forthcoming surveys (2005 and 2008), or (ii) are new data to be collected in these 2 forthcoming surveys. Table In the earlier cohorts no data was collected regarding asthma and hence incidence cannot be estimated in the first survey (2005). In the second survey (2008) a measure of incidence will be estimated reflecting new cases arising between 2005 and 2008. However, establishing asthma diagnosis in infancy is difficult. Additional information on occurrence of episodes of shortness of breath, fever and cough that are available for a year following the baseline surveys will also be used. This information may be more accurate than prevalence estimates estimated from data collected using a later questionnaire for asthma symptoms in infancy.Statistical analysis will be conducted according to a conceptual framework defining a proposed causal pathway. Bivariate association analysis will be carried out by calculating prevalence ratios and 95% confidence intervals to measure the strength of the association between each potential risk factor and the outcomes of interest. At his stage, the main outcomes of interest are atopy , asthma and allergy). Multivariate analysis will be taken out in several steps. First, within each level, multivariate data reduction techniques  will be applied to summarise highly correlated variables to index variables . Secondly, for each level, multivariate regression models will be fitted to estimate association parameters adjusted for confounding factors of the same level. In addition, multi-level modelling and robust variance estimation techniques will be used to adjust for intra-subject correlation due to repeated measures on the same individual and/or geographical areas. Finally, to address the complex inter-relationships between risk factors of different levels and outcomes according to our pre-defined conceptual framework, we will apply the following analysis strategies: i) A hierarchical effect decomposition strategy fitting a sequence of regression models each including different blocks of covariates, similar to an approach suggested by other authors ; ii) LogEthical approval was obtained from the Brazilian National Ethical Committee in 2004. Written informed consent was obtained from the legal guardian of each subject. It details all the procedures in the course of the project. All the clinical relevant results will be sent to the subjects parents, and specific recommendations will be done by a trained clinician after reviewing each case.The SCAALA programme that includes the Salvador and the Ecuador project, is expected to provide important new information and contribute to our understanding of why the prevalence of asthma and allergies appear to be so high in urban settings in LA. The two studies have different objectives and designs, but they have similar conceptual frameworks and share expertise and operational resources. These projects require extensive co-ordination, involve expertise from several different disciplines  and complex logistics . Study designs used include surveys and case-control studies making possible the comparison of prevalence and risk factors for asthma and other allergic diseases between urban and rural environments (the Ecuador study) and a longitudinal study of the effects of early life exposures of an urban population on asthma and other allergic diseases . The laboratory component will explore the relative importance of different immunological mechanisms in mediating the effects of environment exposures (with emphasis on helminths and other infectious diseases of childhood) on the risk of asthma and allergic diseases. Statistical analysis will involve the use of strategies that link data from different levels  and will use advanced statistical techniques to deal with this complex frameworkThe Salvador study is the continuation of three different cohorts initiated several years ago with objective of studying the effects in changes in sanitation on the risk of infectious diseases The earlier data collected for these cohort studies, therefore, will provide important information that will allow the study to examine the importance of the 'hygiene hypothesis' in determining allergy risk in an poor urban centre of LA Theses cohorts provide prospective data over a period of 12 months from between birth and 3 years of age. Data was collected through home visits every 2 on diarrhoea, reported fever, cough and shortness of breath. Demographic, socio-economic, sanitation-related environmental data was collected also. Each child was weighed, height was measured, and a stool sample was collected for parasitologic assessment. Second, although data was collected at the individual level, the use of "sentinel areas" throughout Salvador made possible the collection of community level aggregate data and or census dataIn summary, the proposed programme aims to clarify the social and biological mechanisms mediating the effect of population changes on the frequency of atopic disease in LA. Latin America is undergoing a rapid process of population change, including urbanization, migration, economic development and adoption of a "modern" lifestyle. Efforts to improve water supply, sanitation, rubbish collection and other hygienic measures are common to the different LA countries. It is expected that knowledge generated may thus help identify public health interventions that may enable countries In LA to enjoy the benefits of a "modern" lifestyle while avoiding – or minimising – increases in morbidity caused by asthma and allergies.ISAAC: International Study of Asthma and Allergies in ChildhoodSCAALA: Social Change, Allergy and Asthma in Latin AmericaThe author(s) declare that they have no competing interests.MLB conceived of the study, and participated in its design and coordination and lead the drafting of the manuscript, SSC participated in the design, coordinated the study, participate on the plan of analysis and helped draft this manuscript; NAN carried out the stool sample studies and the allergens studies; LPC carried out the immunological studies; AAC carried out all clinical investiagtion, RTS participated inthe drafting on the manuscript; BG lead the development of plan of analysis, PJC participated in the conception of the study design and plan of analysis, LCR conceived of the study, participated in its design and plan of analysis and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Eating patterns in Western industrialized countries are characterized by a high energy intake and an overconsumption of (saturated) fat, cholesterol, sugar and salt. Many chronic diseases are associated with unhealthy eating patterns. On the other hand, a healthy diet (low saturated fat intake and high fruit and vegetable intake) has been found important in the prevention of health problems, such as cancer and cardio-vascular disease (CVD). The worksite seems an ideal intervention setting to influence dietary behavior. The purpose of this study is to present the effects of a worksite environmental intervention on fruit, vegetable and fat intake and determinants of behavior.A controlled trial that included two different governmental companies (n = 515): one intervention and one control company. Outcome measurements (short-fat list and fruit and vegetable questionnaire) took place at baseline and 3 and 12 months after baseline. The relatively modest environmental intervention consisted of product information to facilitate healthier food choices  value of foods in groups of products was translated into the number of minutes to perform a certain  activity to burn these calories).Significant changes in psychosocial determinants of dietary behavior were found; subjects at the intervention worksite perceived more social support from their colleagues in eating less fat. But also counter intuitive effects were found: at 12 months the attitude and self-efficacy towards eating less fat became less positive in the intervention group. No effects were found on self-reported fat, fruit and vegetable intake.This environmental intervention was modestly effective in changing behavioral determinant towards eating less fat , but ineffective in positively changing actual fat, fruit and vegetable intake of office workers. Lifestyles in Western industrialized countries are characterized by a decreasing level of physical activity -3, a higA healthy diet  has also been found important in the prevention of health problems, such as some types of cancer and cardiovascular disease (CVD) -8. MoreoWorksites are an effective channel to promote healthy food habits among employees by means of comprehensive worksite health promotion programs (WHPP's), because they provide access to a large proportion of the adult population and people spend a great deal of their time at the worksite. In many WHPP's, traditional methods  to increase knowledge and skills are used to stimulate healthy behavior -13. HoweTherefore, a worksite intervention (i.e. FoodSteps) solely consisting of relatively modest environmental changes was developed to stimulate physical activity, but also healthy food habits of office-workers. The purpose of this study is to present the effects of this intervention on determinants of dietary behavior and on self-reported fat, fruit and vegetable intake.2) in women and a BMI ≤ 23 (kg/m2) in men. In order to select a population at higher risk for disease associated with overweight, the inclusion criterion of a BMI ≤ 23 was applied in our study. Subjects who were pregnant or became pregnant during intervention year, or had severe cardiovascular/musculoskeletal disorders were excluded. Employees received a leaflet by company internal mail system in which they were asked to participate in the study and they had to return a written reply form to be included in the study. On the reply form a number of screening questions (including self-reported body weight and body height) had to be filled out. A written informed consent was obtained from the subjects and this study had the approval from the medical ethics committee of the VU University Medical Center.In this controlled longitudinal trial, two different government companies in The Hague (the Netherlands) were used: one intervention and one control company. These worksites were chosen because of the similar job-descriptions of the employees. The inclusion criteria for participating in the study were; (1) office worker, (2) the ability to climb the stairs, (3) a body mass index (BMI) ≤ 23 and (4) a contract for at least the duration of the intervention. In a review on the public health burden of obesity of Visscher et al , a numbeThe questionnaires were distributed among subjects at both worksites at baseline (October 2003), at three months (April 2004) and 12 months (November 2004).The FoodSteps intervention consisted of two parts, one part focusing on food  and one on physical activity . The food-intervention took place over 12 months (January 2004–December 2004) in the company canteen of the intervention company and mostly consisted of placing informational sheets near food products, to stimulate healthier food choices. Every four weeks one group out of six groups of products was chosen to be highlighted. Each group was repeated once during the year. On the informational sheets the caloric  value of a product was translated into the number of minutes to perform a certain  activity . The product-groups were: (1) dairy products  (2) warm snacks, (3) fruit-vegetables-salads, (4) cold ready-to-eat sandwiches (including fillings) (5) sandwich fillings  and (6) pastry. On three vending machines similar information sheets were placed, on which the snacks  offered in the machines were highlighted. The sheets on the vending machines were not changed during the intervention year. Additionally, an information stand was placed in the canteen with brochures and leaflets on healthy food, blood pressure and cholesterol. Finally, every two months during one day a week a buffet with healthy products was offered to the customers of the company canteen.Psychosocial determinants of eating more fruit, vegetables and less fat were measured applying the 'attitude-social influence- (self-)efficacy model' (ASE model) ,22. All The validated Short Fruit and Vegetable questionnaire was used to measure fruit and vegetable consumption. This questionnaire consists of 10 questions: 6 about fruit consumption and 4 about vegetable consumption . SubjectIn this study the validated Fat list  was used2).The following data were collected by questionnaire: the highest achieved level of education, age, smoking (yes/no), number of alcoholic units per week, hours per week at the office, whether or not following a diet, whether or not being a regular visitor of the company canteen (at least once week purchasing food in the canteen) and whether or not taking lunch to work every day of the week. Additionally, as a part of the study, subjects were invited to attend a physical examination at all follow-ups where among other variables, body height (cm) and body weight (kg) were measured with subjects in underwear. The Body Mass Index (BMI) as measured at baseline was also used as a covariate in this study. BMI was calculated by dividing body weight (kg) by body height (m) squared (= kg/mBoth the short-term (3 months) and the long-term (12 months) effect of the intervention were analyzed by multivariate linear regression analysis. In this analysis the outcome at respectively 3 and 12 months was corrected for the baseline value. The regression-coefficient of the group allocation  variable reflects, the difference in change over time between worksites in the outcome variable. Linear regression analysis excludes subjects with missing data. Only subjects with baseline data and data on at least one follow-up were included in the analysis. Baseline values that differed (according to independent t-test) between intervention and control subjects at baseline, as well as a set of predefined variables  were checked as possible confounders. As possible effect modifiers were considered baseline data on: gender, BMI, whether or not taking lunch to work, being a regular visitor of the company canteen, smoking and alcoholic intake. Effect modification was defined as a significant (p < 0.10) interaction term between the group allocation variable and the variable of interest.In figure Although, a higher number of included subjects (about 900) was intended, with a power of 0,8 en alpha of 0,05, a difference of about a half (0.42) piece of fruit and 20.7 grams of vegetables can still be demonstrated with a total number of 515 participants.Questionnaire return-rates in the intervention site were 88.9% and 78.3% and in the control site 90.4% and 88.9%, at 3 and 12 months respectively. The baseline demographics of the total population are described in Table Table In addition, a significant negative interaction was found with BMI at baseline. This can be interpreted as an increasing intervention effect regarding the attitude to eat less fat at work for subjects with a higher BMI at baseline. No significant effects on any of the other psychosocial determinants were found.Table In Table The purpose of this study was to analyze the effects of a worksite environmental intervention on determinants of dietary behavior regarding eating more fruit and vegetables and eating less fat and on actual (self-reported) fat, fruit and vegetable intake.The results of this controlled trial showed that this environmental intervention only had a modest effect on determinants of dietary behavior. A significant effect was found on the perceived social support from colleagues regarding eating less fat. This determinant significantly increased at the short-term and borderline significant at long-term. However, also counterintuitive effects were found. First, at 12 months the attitude toward eating less fat decreased in the intervention group and decreased even more for subjects with a higher BMI at baseline. Second, self-efficacy towards eating less fat at work decreased significantly in the intervention group. The intervention was ineffective in significantly increasing fruit, vegetable intake and decreasing fat intake of the intervention group. An interesting finding was, however, that in the intervention group at short term the subgroup of workers who did not take their lunch to work every day significantly increased their fat intake compared to those in the control group.Just as in our study, in a controlled trial of Steenhuis et al  a similaOther worksite health promotion programs (WHPP's) did show positive results on self-reported fruit-vegetable and fat intake. These trials -29 were This difference in study population is an important point that might explain our poor results. In our study a primarily white-collar and highly educated population participated. White-collar populations are known to have in general more favorable food patterns (i.e. they eat more fruit-vegetables and less fat)  ThereforAnother explanation for the lack of positive results could be that in our study the same questionnaires as in the study of Steenhuis et al  were useA weak point in this study was that a relatively large proportion of the study population was not a regular visitor to the company canteen (about 40%). Because of this, the food intervention did not have the full impact it could have had. However, at follow-up no interaction was found between whether or not being a regular visitor to the canteen, and fruit-vegetable and fat intake. Also, the food intervention might have been too modest to sort any effect. As mentioned in the method section, only one product group at the time was highlighted by means of larger information sheets near the products included in the selected group. No information was put directly on the products and no clear-cut distinction between healthy or unhealthy products was made (for instance labeling products with either red or green colors), like in a study of Larsson et al . LarssonA limitation of this study might be the fact that no randomization was performed. Bias introduced by possible differences between worksites, might have been prevented if a randomization at the level of the individual could have been performed. However, due to the nature of the intervention this kind of randomization was not possible. Moreover, the main reason for not performing randomization at the level of the worksite was that, at the moment that the FoodSteps research proposal was approved, one worksite had already agreed to participate. In order to speed up the preparations of the intervention, this worksite was chosen as the intervention worksite. During this preparation period the control worksite still had to be found.In conclusion, this relatively modest environmental intervention was effective in significantly changing behavioral determinants towards eating less fat , but ineffective in significantly changing actual fat, fruit and vegetable intake of office workers. Negative changes in attitude and self-efficacy towards eating less fat at work were found. In future research it needs to be investigated if the food habits of employees can be changed by a more intensive environmental intervention.The author(s) declare that they have no competing interests.WVM is primary responsible for the study as presented in this paper. He made a significant intellectual contribution to the manuscript and has been involved in drafting and revising the manuscript critically.LE is the executive researcher of the FoodSteps project as presented in this article. He was responsible for preparing and implementing the intervention, collecting and analysing the data and writing of the manuscript.MVP made substantial contribution to the conception and the design of the study. In addition, MVP has been involved in drafting and revising the manuscript critically.MCAP made a substantial contribution to the conception and the design of the study, analysing the data, drafting and revising the manuscript critically.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The four ligating atoms comprise the hydoxylate and carboxylate O atoms from two independent benzilate ligands, each of which forms a five-membered chelating ring, spanning an axial and an equatorial site about the Sb atom. The hydroxylate atoms occupy the two equatorial sites, and the carboxylate atoms are in the pseudo-axial sites; the O—Sb—O angle is 147.72 (5)°. One carboxylate group shows quite different bond lengths from those of the other group; one O atom is clearly the carbonyl atom and the other O atom the hydroxylate atom. In the other ligand, there is less distinction in the C—O bonds. This is presumably related to the carbonyl O atom being the acceptor atom of a strong N—H⋯O hydrogen bond, which links the ammonium cation to the Sb complex anion.The coordination around the Sb atom in the title compound, (C DOI: 10.1107/S1600536809054853/pb2016Isup2.hkl            Structure factors: contains datablocks I. DOI:  crystallographic information; 3D view; checkCIF report            Additional supplementary materials:


The increased prevalence of overweight and obesity warrants preventive actions, particularly among people in transitional stages associated with lifestyle changes, such as occupational retirement. The purpose is to investigate the effect of a one year low-intensity computer-tailored energy balance programme among recent retirees on waist circumference, body weight and body composition, blood pressure, physical activity and dietary intake.A randomised controlled trial was conducted among recent retirees . Outcome measures were assessed using anthropometry, bio-impedance, blood pressure measurement and questionnaires.Waist circumference, body weight and blood pressure decreased significantly in men of the intervention and control group, but no significant between-group-differences were observed at 12 or at 24-months follow-up. A significant effect of the programme was only observed on waist circumference (-1.56 cm (95%CI: -2.91 to -0.21)) at 12 month follow up among men with low education (n = 85). Physical activity and dietary behaviours improved in both the intervention and control group during the intervention period. Although, these behaviours changed more favourably in the intervention group, these between-group-differences were not statistically significant.The multifaceted computer-tailored programme for recent retirees did not appear to be effective. Apparently the transition to occupational retirement and/or participation in the study had a greater impact than the intervention programme.Clinical Trials NCT00122213. The increasing prevalence of overweight and obesity also affects the older population  and prevIdeally, a behavioural intervention for this purpose should aim for small though sustainable changes to prevent gradual weight gain . PreferaWe developed and evaluated a one-year multifaceted programme including these factors using computer tailored feedback on physical activity and diet . The proSubjects were eligible for participation in the WAAG-Study (Wageningen Approach against fat Accumulation and weight Gain) if they were recent retirees (date of retirement maximum six months before or after baseline measurement), aged 55-65 years, and not undergoing any medical treatment that might affect body composition. Participants were recruited from pre-retirement workshops as offered by employers to approximately 10% of the Dutch retiring population. During such a five-day workshop several topics are discussed in order to prepare retirees for the new phase in life, e.g. changes in the household after retirement, health and vitality. Workshops were held all across The Netherlands. Approximately 1,100 workshop attendees were invited to participate in the WAAG-Study from September 2003 to mid March 2004. First follow-up measurements were conducted from September 2004 to the end of February 2005, and final follow-up measurements were conducted from September 2005 to the end of February 2006. The Medical Ethics Committee of Wageningen University approved the study protocol and all participants gave written informed consent upon enrolment after they received written and verbal information about the trial . In totaAll persons attending one single workshop (cluster) who were willing to participate were physically examined at the location of the workshop. Furthermore, questionnaires on demographics, physical activity, dietary intake and psychosocial determinants were handed out. Within one week after the workshop the clusters were randomly allocated to either the intervention or the control group. Cluster randomisation was performed in order to avoid induction of favourable behaviour change of individuals in the control group through their contacts with fellow participants in the intervention group. A randomisation list was generated beforehand by an independent person and took into account the number participants per workshop and the number of included clusters per week. Due to the nature of the study it was not blinded.Follow-up physical examinations were scheduled 12 ± 0.5 months (on average 11.9 ± 0.5 (mean ± SD); range 10.0-14.8 months) and 24 ± 1.0 months  after the baseline examinations. At 12 months follow-up 94% and at 24 months follow-up 84% of the participants returned for re-examination. Drop out was mostly due to planning problems, since not all participants could be scheduled for an appointment within the set limits. There were no differences between those who dropped out  and those who remained.The intervention programme  was deveFive programme modules were provided to participants of the intervention group during the one year intervention period as shown in Figure During the total study period of two years, the control group was provided with newsletters with general information about the study, such as study progress, and information about art exhibitions and city trips for instance. They could not login to the website and had access to the general information about the study design only .Baseline physical examinations were performed at the site of the pre-retirement workshop, between 11 am and 2 pm. Follow-up examinations were conducted at various community health centres across the Netherlands at the same time of day. Examinations were carried out by the same two trained researchers over the total study period. Most participants (76%) were examined by the same researcher at baseline and 12 months follow-up and at the 24 months follow-up one researcher performed all examinations. Physical activity, diet, demographic and utilisation information were assessed by questionnaire. Questionnaires were handed out (baseline) and sent by mail (follow-up measurements) and were either returned in pre-paid envelopes (baseline) or handed in at follow-up physical examinations (12 and 24 months).Date of birth, date of retirement, physical activity level of their last job, and educational level were assessed by questionnaire. Activity level of the former job was based on four types of activities and ranged from non-active, e.g. administrative job, to very active, e.g. postmen. Highest attained education was categorised as 'low' , 'medium'  or 'high' .We also collected information on the use of the different modules of the intervention. Participants self-reported at all follow-up measurements whether or not they have used the modules once, twice or more. This is stated as utilisation per module and presented as a proportion of participants that returned the questionnaire.All anthropometrical measurements were performed while participants wore underwear only. Body weight was measured to the nearest 0.2 kg after regular calibration and height to the nearest 0.1 cm . Circumferences of the upper-arm, waist, hip, thigh, and calf were measured twice to the nearest 0.1 cm with a non-stretchable plastic measuring tape on the non-dominant side of the body, according to standard protocol ,18. AbdoTBW (kg) = 2.896 + 0.366*HEIGHT2(cm)/RESISTANCE100 kHz + 0.137*WEIGHT(KG) + 2.485*SEX  [WEIGHT -TBW)/0.732)/WEIGHT[A single frequency (100 kHz), tetra polar, body impedance analyser  was used to estimate total body water according to = women) . From to2)/WEIGHT.Blood pressure was assessed with participants in supine position using the average of two standard automatic blood pressure measurements .Changes in physical activity were assessed with the validated Dutch version of the Physical Activity Scale for the Elderly (PASE) . This brTotal PASE score was computed by multiplying the amount of time spent per activity (hours/day) and participation in the household activities by the item weights and then summing these products. The item weights indicate the contribution of each item to the overall PASE score; highest weights were assigned to the more strenuous types of activities . Six queFurther, we derived total time (min/week) spent on bicycling and walking as an indicator for routine daily activities and total time (min/week) spent on moderate and high intensity and muscle strengthening activities as an indicator of recreational and sports activities.Changes in the diet were assessed with a validated, semi-quantitative food frequency questionnaire (FFQ). The FFQ has been developed to estimate intake of fat, fatty acids, cholesterol and energy in adults using a reference period of four  weeks . All FFQFruit intake (g) was calculated by summing the amounts of fresh fruits. Vegetable intake (g) was calculated by summing the amounts of cooked, fried and raw vegetables. The sum of fruit and vegetable intake (g) was adjusted for energy intake (MJ). Furthermore, total fat intake (en%) and total energy intake (MJ/day) were derived for the FFQ.To estimate portion size, we used the total number of servings (of standard portion sizes) per month of certain energy dense products that are frequently consumed in the Netherlands: sliced meat, meat, beer and wine. To illustrate small adaptations, the number of sugar cubes in cups of coffee and tea, and milk added to a cup of coffee were evaluated.Subjects reporting extreme differences between baseline and 12 months follow-up (60% increase or decrease in energy intake (MJ/day)) were excluded from the analyses (n = 6).We hypothesised that waist circumference in the control group would increase by 0.5 cm (standard deviation of difference = 1.3 cm) per year and that it would remain stable in the intervention group . Based oproc mixed; SAS for Windows, SAS Institute Inc. Cary, NC, USA; version 9.1). Models were constructed with the follow-up measurements as dependent variable and the baseline measurement as covariate. The estimate for treatment effect reflects the between-group-difference at follow-up, corrected for the value at baseline.The effect estimates of the intervention included all participants who had provided at least one follow-up measurement. Data were analysed using mixed models with a random cluster effect allowing each cluster to have its own intercept. Analyses were performed using SAS (d) were interpreted according to the Cohen's guidelines and indicate the size of the effect of the programme. Cut off points for small effects are d < 0.32, medium effects as 0.33 <d < 0.55 and large as d > 0.56 [Additionally, we calculated effect sizes, a frequently used measure to demonstrate the magnitude of the effect of an intervention programme. The standardised effect size is calculated as the difference between the mean changes between the intervention and control group divided by the pooled standard deviation . Effect d > 0.56 . We also2 and a waist circumference ≥ 102 cm [Secondary analyses were performed for waist circumference and body weight and fat intake and energy intake at 12 months follow-up in pre-defined subgroups of participants having low educational level , physically active former job, a BMI ≥ 30 kg/m≥ 102 cm . Also anAll statistical analyses were performed for men only, because age related changes in body composition differ between sexes and the number of women was too small to have sufficient power to draw conclusions. Statistical significance was set at p < 0.05 for all tests performed.2  and body weight . Although the declines were greater in the intervention group, the between-group-differences were not significant  .At 12-months follow-up, there was a significant decline (mean change) in waist circumference , sum of household activities , and total physical activity ((PASE) INT: 22.9; CON: 17.6) increased significantly. However, the between-group-differences were not significant  (Table Among men in both groups daily activities (y) Table . Men in y) Table .Waist circumference in men in the intervention and control group remained lower compared to baseline, though during the second year of follow-up an increase was observed. Body weight stabilised in both groups. Again the between-group-differences for waist circumference and body weight were not statistically significant Table .INT: 0.9; CON: 1.2; p = 0.03) in favour of the control group. For other lifestyle behaviours mentioned in Table Change in sport and recreational activities was higher after two year in the intervention group (74.5 min/week) compared to the control group . The sum of household activities increased in both groups  revealed a significant between-group-difference in waist circumference of -1.56 cm  at 12 month follow-up in favour of the intervention group. In this subgroup the reduction in body weight was also larger in the intervention group compared to the control group. However, the between-group-difference of -0.96 kg (95%CI: -2.40 to 0.47) was not significant. There were no significant differences in changes in waist circumference and body weight between the intervention and control group observed in any other predefined subgroup.Secondary analyses among men with low educational level   in the intervention group, while an increase was observed in the control group . The between-group-difference was -3.2 en% (p = 0.01).The per protocol analyses to test the influence of utilisation of the key modules did not reveal any differences between those that had actually utilised the modules once or more versus the randomly selected sex-matched control group at 12 and 24-months follow-up (data not shown).Retired subjects participating in a one- year low intensity energy balance programme decreased their waist circumference, body weight, BMI, blood pressure and most other body composition indices and improved their physical activity and dietary behaviour. Although the changes were more consistent and more pronounced among subjects of the intervention group, the between-group-differences were small and mostly not statistically significant. Additional analyses among low educated men indicate that the programme may be effective in men with a low educational level: for waist circumference and fat intake the between-group-differences were significantly different. After the follow-up period the between-group-differences more or less remained the same, though the magnitude of the differences diminished.We hypothesised that the intervention group would maintain their waist circumference and body weight in the two years following transition to retirement as opposed to the control group. Within the control group, the waist circumference would on average increase by 0.5 cm per year. Remarkably, in men, both groups reduced their body weight and weight circumference. And although the difference in change was -0.48, we could not demonstrate a significant effect. Possibly our study lacked statistical power. The sample size was calculated based on observational data on change in waist circumference in a middle-aged population. Such data were not available for the specific group of retirees we studied. Apparently, the variance that was used for the power calculation was too low. Further, despite the randomisation, the control group had on average higher, though non significant, scores for the outcome measurements at baseline, which may have caused regression to the mean. However, we included baseline values in the models and thus have allowed for these apparent differences.The lack of effect may also be due to our recruitment strategy resulting in a relatively healthy and health conscious group of subjects. The study participants were selected from pre-retirement workshops, often attended by higher socio-economic groups, who in general are more motivated to change physical activity and diet, which might have reduced the added value of the prevention programme. Earlier studies have described that individuals willing to participate in health promoting intervention studies are already interested in diet and physical activity and are health conscious ,31.Further, study participation itself may have led to increased awareness and motivation to change physical activity and/or diet in the control group and intervention group (Hawthorne effect), which also reduced the added value of the programme. The influence of the researchers or others involved in measurements is supposed to be very low, since information associated with the content of the intervention was not discussed at the physical examinations or during other contacts.et al, showed that in transition to retirement subjects decrease work-related activity and increase household activities as well as doing odd jobs [And last but not least, transition to occupational retirement per se may have induced the changes in (lifestyle) behaviours. The study by Nooyens odd jobs . Maybe tA limitation of the study is the small number of females. Although the percentage of women that participated is representative for the percentage of women that worked in this age group, the number was too small to draw conclusions on the effectiveness of the intervention. And although the PASE questionnaire was originally designed for older adults (65+ years) it was chosen because it distinguishes activities (household -and leisure activities) that are relevant for retired people. Moreover, the recall period was only one week which also enabled us to pick up changes over a short period of time.et al showed that determinants of weight gain among older populations do not really differ from determinants in adult populations [The programme of our study was developed according to the Intervention Mapping Protocol . This syulations .Our programme aimed to induce relatively small and possibly sustainable changes in physical activity and diet to prevent weight gain ,10.Moreover, the programme was developed in a way that it could be implemented nationwide, thus it was of low intensity, easily accessible and home-based. As a result, participants could voluntarily use the modules of the programme in accordance with their personal preferences. As a consequence commitment and adherence of the target group may have been too weak to result in a behaviour change.Although the use of personal computers and internet in the middle-aged has increased rapidly in recent years , it is uThe results of this study can by used by the Netherlands Heart Foundation and others to further improve the intervention modules. At present it is not clear if or how the results of this study will lead to further development or implementation of this intervention.The individually tailored one year energy balance programme did not have a significant effect on any of the outcomes in recent retirees though it showed a pattern of small, non- significant effects on changes in body composition, physical activity and dietary behaviour. Lack of power may partly account for these findings. Apparently transition to occupational retirement and/or participation in research had a greater impact than the intervention programme itself.The authors declare that they have no competing interests.AW, AJS, FJK and EGS were the principal investigators of the study and developed the concept and the design of the study. PJMH contributed to the body composition assessment, AS and SK contributed to the behavioural parts of the intervention and to the assessment of behaviour. AW performed the analyses and AW and JS drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/110/prepub


Mother's diet during pregnancy is important, since plant lignans and their metabolites, converted by the intestinal microflora to enterolignans, are proposed to possess multiple health benefits. Aim of our study was to investigate whether a dietary intervention affects lignan concentrations in the serum of pregnant women.A controlled dietary intervention trial including 105 first-time pregnant women was conducted in three intervention and three control maternity health clinics. The intervention included individual counseling on diet and on physical activity, while the controls received conventional care. Blood samples were collected on gestation weeks 8-9 (baseline) and 36-37 (end of intervention). The serum levels of the plant lignans 7-hydroxymatairesinol, secoisolariciresinol, matairesinol, lariciresinol, cyclolariciresinol, and pinoresinol, and of the enterolignans 7-hydroxyenterolactone, enterodiol, and enterolactone, were measured using a validated method.The baseline levels of enterolactone, enterodiol and the sum of lignans were higher in the control group, whereas at the end of the trial their levels were higher in the intervention group. The adjusted mean differences between the baseline and end of the intervention for enterolactone and the total lignan intake were 1.6 ng/ml  and 1.4 ng/mg  higher in the intervention group than in the controls. Further adjustment for dietary components did not change these associations.The dietary intervention was successful in increasing the intake of lignan-rich food products, the fiber consumption and consequently the plasma levels of lignans in pregnant women.http://www.isrctn.orgISRCTN21512277,  During pregnancy, the fetus is exposed to multiple biologically active compounds that originate from the maternal diet. Some of these may affect offspring's later health. Dietary phytoestrogens are examples of such compounds, as they are found in the amniotic fluid and the umbilical cord blood . In the Dietary lignans have been portrayed as health-promoting agents in many epidemiological studies, which show an inverse association between plant lignan intake or serum/urine enterolignan concentrations and chronic Western life-style diseases, including breast and colon cancer, and cardiovascular diseases . FurtherSeveral studies indicate that supplementation of a habitual diet with lignan-rich foods can affect circulating enterolignan concentrations in women . HoweverEach municipality in Finland is responsible for arranging maternity health-care services for its residents, and these are covered by public tax revenue. Almost all (99.7%) pregnant women attend public maternity clinics . The preIn the Finnish maternity health-care system, pregnant women are recommended to visit 11-15 times a nurse and three times to a physician. This study was implemented during two of these routine visits to nurses at gestation weeks 8-9 (baseline) and 36-37 (end of intervention).The participants were pregnant women with no earlier deliveries. Women who were younger than 18 years of age, or suffered from type I or type II diabetes mellitus, twin pregnancy, physical disability that prevented exercising or had otherwise problematic pregnancy, substance abuse, treatment or clinical history of any psychiatric illness, were unable to speak Finnish, or intended to change residence within three months, were excluded from the study. The nurses recruited the participants when they enrolled for their first clinic visit at the beginning of their pregnancy, usually by phone. Forty-nine women in the intervention clinics and 56 women in the control clinics gave informed consent for participation. Recruitment took place between August 2004 and January 2005.The participants visiting the control clinics received the standard maternity care. The intervention group received recommendations for gestational weight gain and physical activity counseling, the details of which are presented elsewhere ,13.For the dietary counseling, the following dietary objectives were set for each participant to achieve or maintain: 1) to follow a regular meal pattern, emphasizing the importance of breakfast and > = 1 hot meal every day, 2) to eat at least five portions (400 g) per day, in total, of different kinds of vegetables, fruits and berries, 3) to consume preferentially high-fibre bread (> = 5 g fibre/100 g), and 4) to restrict the intake of high-sugar snacks to < = 1 portion per day . The dietary counselling consisted of one primary counselling session  at the visit during gestation weeks 16-18, and three booster sessions  until gestation week 37.The pre-pregnancy weight and height were self-reported, whereas weight development during the pregnancy was based on measurement by nurses in maternity centers. The baseline questionnaire, including questions on background, lifestyle and dietary intake (a 57-item food frequency questionnaire), was completed before the first visit (at gestation week 8 or 9). The second follow-up questionnaire was completed at the end of the study, on gestation week 37. Similar FFQ was filled by both groups. The baseline dietary information was based on the diet during the month before the pregnancy and the follow-up information on the diet during the month before the 26 to 28 pregnancy week's visit.m/z 151, and deuterated matairesinol was used as internal standard.The plant lignans 7-hydroxymatairesinol, secoisolariciresinol, matairesinol, lariciresinol, cyclolariciresinol, and pinoresinol, and the enterolignans 7-hydroxyenterolactone, enterodiol, and enterolactone were quantified in the serum using a previously developed and validated high-performance liquid chromatography-tandem mass spectrometric (HPLC-MS/MS) method . BrieflyBaseline information on age, pre-pregnancy BMI, weight gain during pregnancy, education level and smoking status before and during pregnancy were reported by both in the intervention and the control groups. Education was self-reported and categorized as basic or secondary education, polytechnic or university training. Smoking was inquired both before  and during pregnancy . These variables were later included, when necessary, as confounding factors in the multivariable analyses. In all statistical analyses, p < 0.05 was used as the level of statistical significance.The group differences of lignans at the end point of both follow-ups adjusted for the baseline level of lignans and other possible confounders were examined by the linear regression model. The original lignan values were skewed, and were transformed by using the logarithm to enable statistical analysis requiring normally distributed variables. The results at the end point of each follow-up are illustrated as a group difference calculated using antilogs of mean differences of log-transformed variables, and presented with 95% CI.In the regression model, the analyses included baseline level of lignans, age, BMI, education, smoking and change in consumption of vegetables and fruits. Further adjustment was performed for dietary components that affect lignan intake or are thought to intervene with lignan metabolism. These were coffee, tea, other drinks, butter, potato, peas, milk products, pork, beef, and sugar. Since these dietary variables were not significant, they were dropped out from the backward stepwise regression model.Women in the intervention group were younger, less educated, and were more often smokers, and they had a higher pre-pregnancy weight and BMI on average than the women in the control group Table .Enterolactone was detectable in almost all the samples Table . Other lGroup differences were analyzed taking into account baseline lignans, age, BMI, education and smoking. The adjusted mean difference for enterolactone at the end of the intervention when compared to the baseline was 1.6 ng/ml higher in the intervention group than in the controls . Similar results were found for enterolignan . The mean adjusted difference between baseline and end for the sum of lignans was 1.4 ng/ml  higher in intervention group than in the controls .The intervention group was less educated than the control group. Education is widely known to be associated with diet and BMI  and may The small sample size was also a limitation of this study. Due to the small number of clinics, the clinic-level variation could not be taken into account by using multilevel analysis. Furthermore, there were more drop-outs in the intervention group than in the control group. Although the drop-out reasons were only partly related to the study, the drop-outs might have been less motivated to change their health behavior. In this pilot study, information on diet was obtained by questionnaires, which have not been validated for pregnant women. Additionally, use of food frequency questionnaire may be a limitation since the groups are not directly comparable. Weight before the pregnancy was self-reported, which may induce some bias. However, weight development during the pregnancy was measured by the nurses, and thus more reliably collected.The pregnant women in this study were healthy primiparas, who had relatively healthy dietary and physical activity habits. Therefore, there may not have been much room to further improve their diet. However, changes were noticed on diet and serum lignan levels among the women in the intervention group, indicating that the dietary intervention was successful.It is essential to determine whether this pregnancy intervention has any impact on the offspring's health. In our previous study, none of the newborns in the intervention group had a high birthweight  - an indWe have shown earlier by using animal models that changes in maternal diet during pregnancy alter mammary cancer risk among female offspring ,21. OtheThe authors declare that they have no competing interests.RL is principal investigator in the clinical trial study. EK, JR and NS were responsible for data management. AIS is responsible for all chemical analyses. EK, MF and JR conducted statistical analyses. LHC contributed to the article on expertise on nutrition and animal models, and all authors contributed in writing of the paper.Flow chart of the trial. Flow chart of the cluster-randomized trial showing participating clinics, number of women eligible, randomized and drop-outs.Click here for file