Sherina Mohd Sidik1 & Rozali Ahmad2
1 Department of Community Health, Faculty of Medicine and Health Science, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia
2 Ministry of Defence, Malaysia
ABSTRACT
Childhood obesity has been growing at an alarming rate and is the most common nutritional problem among children in developed as well as in developing countries. It is associated with significant morbidity and mortality, including cardiovascular, respiratory, gastrointestinal, endocrine and psychosocial morbidities. This unhealthy trend will progress to adulthood and is expected to lead to huge economic costs in health and social security systems. Among the many factors which contribute to the increasing prevalence of childhood obesity include environment and genetic factors. This paper discusses the aetiology, consequences and necessary interventions for this problem.

On behalf of the Organising Committee, I would like to extend our warmest invitation to you to our Primary Care Conference which will be held on the 6-7th July 2012. This conference is organised by the Department of Primary Care Medicine, University Malaya in conjunction with our 25th Anniversary Celebration.
The Department of Primary Care Medicine has been in existence since 1987. As the first Department to offer postgraduate training in Family Medicine, we have produced many graduates in Family Medicine.
The theme of the conference is “Consolidating the foundation and preparing for the future: Celebrating 25 years of Experience”. As the theme of the Conference indicates, the scientific programme will address important topics in primary care including management of cardiovascular diseases, prevention, men’s health, mental health and patient centred care. We have invited renowned local speakers to share their knowledge with you. The highlight of the conference will be our 25th anniversary Gala Dinner celebrating our 25 years of teaching, research and service.
We are looking forward to welcome you to the conference.

With best wishes,
Dr Adina Abdullah
Organising Chairperson

For any enquires please contact:
Pn Norlia Abdul Rahman
Tel: 03 7949 2802
Email: norlia@ummc.edu.my
at Department of Primary Care Medicine,
University Malaya
or
Secretariat Ms Nalini or Ms Puva,
Pfizer Sdn Bhd
Tel: 03 5568 6688

Craig J. Currie et al.

Corresponding author: Craig J. Currie, currie@cardiff.ac.uk.

http://care.diabetesjournals.org/content/early/2012/04/15/dc11-1277.abstract?papetoc

Abstract

OBJECTIVE To assess the association of compliance with treatment (medication and clinic appointments) and all-cause mortality in people with insulin-treated type 2 diabetes.

RESEARCH DESIGN AND METHODS Data were extracted from U.K. general practice records and included patients (N = 15,984) who had diagnostic codes indicative of type 2 diabetes or who had received a prescription for an oral antidiabetic agent and were treated with insulin. Records in the 30 months before the index date were inspected for clinical codes (recorded at consultation) indicating medication noncompliance or medical appointment nonattendance. Noncompliance was defined as missing more than one scheduled visit or having at least one provider code for not taking medications as prescribed. Relative survival postindex date was compared by determining progression to all-cause mortality using Cox proportional hazards models.

RESULTS Those identified as clinic nonattenders were more likely to be smokers, younger, have higher HbA1c, and have more prior primary care contacts and greater morbidity (P < 0.001). Those identified as medication noncompliers were more likely to be women (P = 0.001), smokers (P = 0.014), and have higher HbA1c, more prior primary care contacts, and greater morbidity (all P < 0.001). After adjustment for confounding factors, medication noncompliance (hazard ratio 1.579 [95% CI 1.167–2.135]), clinic nonattendance of one or two missed appointments (1.163 [1.042–1.299]), and clinic nonattendance of greater than two missed appointments (1.605 [1.356–1.900]) were independent risk factors for all-cause mortality.

CONCLUSIONS Medication noncompliance and clinic nonattendance, assessed during routine care by primary care physicians or their staff, were independently associated with increased all-cause mortality in patients with type 2 diabetes receiving insulin.

Received July 5, 2011.
Accepted February 19, 2012.

© 2012 by the American Diabetes Association.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

A B S T R A C T

Background
Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic
diseases, general health, development and well-being. The international evidence base for strategies that governments, communities
and families can implement to prevent obesity, and promote health, has been accumulating but remains unclear.
Objectives
This review primarily aims to update the previous Cochrane review of childhood obesity prevention research and determine the
effectiveness of evaluated interventions intended to prevent obesity in children, assessed by change in BodyMass Index (BMI). Secondary
aims were to examine the characteristics of the programs and strategies to answer the questions “What works for whom, why and for what cost?”

Search methods

The searches were re-run in CENTRAL, MEDLINE, EMBASE, PsychINFO and CINAHL in March 2010 and searched relevant
websites. Non-English language papers were included and experts were contacted.

Selection criteria

The reviewincludes data fromchildhood obesity prevention studies that used a controlled study design (with orwithout randomisation).
Studies were included if they evaluated interventions, policies or programs in place for twelve weeks or more. If studies were randomised at a cluster level, 6 clusters were required.

Interventions for preventing obesity in children (Review)
Copyright © 2011 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

Data collection and analysis

Two review authors independently extracted data and assessed the risk of bias of included studies. Data was extracted on intervention
implementation, cost, equity and outcomes. Outcome measures were grouped according to whether they measured adiposity, physical
activity (PA)-related behaviours or diet-related behaviours. Adverse outcomes were recorded. A meta-analysis was conducted using
available BMI or standardised BMI (zBMI) score data with subgroup analysis by age group (0-5, 6-12, 13-18 years, corresponding to
stages of developmental and childhood settings).

Main results

This review includes 55 studies (an additional 36 studies found for this update). The majority of studies targeted children aged 6-
12 years. The meta-analysis included 37 studies of 27,946 children and demonstrated that programmes were effective at reducing
adiposity, although not all individual interventions were effective, and there was a high level of observed heterogeneity (I2=82%).
Overall, children in the intervention group had a standardised mean difference in adiposity (measured as BMI or zBMI) of -0.15kg/m
2 (95% confidence interval (CI): -0.21 to -0.09). Intervention effects by age subgroups were -0.26kg/m2 (95% CI:-0.53 to 0.00) (0-
5 years), -0.15kg/m2 (95% CI -0.23 to -0.08) (6-12 years), and -0.09kg/m2 (95% CI -0.20 to 0.03) (13-18 years). Heterogeneity was
apparent in all three age groups and could not explained by randomisation status or the type, duration or setting of the intervention.
Only eight studies reported on adverse effects and no evidence of adverse outcomes such as unhealthy dieting practices, increased
prevalence of underweight or body image sensitivities was found. Interventions did not appear to increase health inequalities although this was examined in fewer studies.

Authors’ conclusions

We found strong evidence to support beneficial effects of child obesity prevention programmes on BMI, particularly for programmes
targeted to children aged six to 12 years. However, given the unexplained heterogeneity and the likelihood of small study bias, these
findings must be interpreted cautiously. A broad range of programme components were used in these studies and whilst it is not possible to distinguish which of these components contributed most to the beneficial effects observed, our synthesis indicates the following to be promising policies and strategies:
· school curriculum that includes healthy eating, physical activity and body image
· increased sessions for physical activity and the development of fundamental movement skills throughout the school week
· improvements in nutritional quality of the food supply in schools
· environments and cultural practices that support children eating healthier foods and being active throughout each day
· support for teachers and other staff to implement health promotion strategies and activities (e.g. professional development,
capacity building activities)
· parent support and home activities that encourage children to be more active, eat more nutritious foods and spend less time in
screen based activities
However, study and evaluation designs need to be strengthened, and reporting extended to capture process and implementation factors, outcomes in relation to measures of equity, longer term outcomes, potential harms and costs.
Childhood obesity prevention research must now move towards identifying how effective intervention components can be embedded
within health, education and care systems and achieve long term sustainable impacts.

Referrence: http://mpaweb.org.my/article.php?aid=23

Hepatitis B vaccine was first made available in 1982. The initial plasma derived vaccine was improved over the years and the current hepatitis B vaccines are manufactured using recombinant DNA technology and contains a portion of non-infectious hepatitis B virus gene coding for the HbsAg. Malaysia started routine Hepatitis B immunization for infants in 1989 using the three-dose regime with the first dose given shortly after birth, thereafter at 1 month and then at 5 months old to coincide with the third dose of DTP/OPV. Anti-HBs immunoglobulin is also given together with the first dose of hepatitis B vaccine (active-passive immunization) at different sites if the mother is found to be a carrier of Hepatitis B virus. Hepatitis B immunization prevents both vertical and horizontal transmission.

The immunogenicity and efficacy of current hepatitis B vaccines in preventing newborn babies from becoming infected and subsequently becoming chronic carriers of the hepatitis B virus (HBV) had long been established through many studies. This is important because a chronic carrier state is associated with the development of hepatocellular carcinoma. Studies conducted by the Malaysian Liver Foundation have found that 80% of the adults diagnosed to have hepatocellular carcinoma are chronic HBV carriers. Indeed, the hepatitis B vaccine is credited as being the first anti-cancer vaccine to be developed.

Medical practitioners often face a dilemma over three practical issues, which this short article will try to address. The emphasis is to give a perspective of what is already known about the current hepatitis B vaccine and its use in protection against HBV infection so that practitioners can make an informed decision on advising their patients. Knowledge on immunization against hepatitis B and its duration of protection is still ongoing. Hence, the practice of hepatitis B immunization may change in the near future as new knowledge emerges. Medical practitioners therefore will need to keep abreast of such knowledge so that their practice can be current.

Pre-vaccination serologic testing

The need to have blood tested to document the presence of protective anti-HBs antibody is to identify those who do not need to be vaccinated unnecessarily and hence save cost on purchasing the vaccine. In the majority of cases in healthy infants, children and adults this is unnecessary and should be guided by the likelihood that the individual had been exposed to HBV and/or another family member had been found to be infected or a carrier of the HBV. The administration of the vaccine in an immune or infected individual will not result in any adverse outcome. In the event that pre-serologic testing is deemed necessary, a combination of tests for HBsAg, anti-HBsAb and anti-HBcAb will differentiate those who are currently infected or had past infection (detectable anti-HBc antibody) from a carrier state (HBsAg positive) who can then be followed up and treated.

Post-vaccination serologic testing

The current hepatitis B vaccines are highly immunogenic with > 95% of children and adolescents developing protective antibody following the recommended three doses of vaccines. Thus, routine post-immunisation serologic testing is not recommended except in the following situations:

• Infants whose mothers are HbsAg carriers
• Immunodeficient states
• Patients undergoing dialysis
• Medical and dental students
• Paramedical staff

Post-vaccination serologic testing is usually carried out 1-3 months following the last dose of the vaccine. Anti-HBs antibody levels of = 10 mIU/L are considered protective against infection. Since low birth weight babies (< 2000 gm) respond poorly to the vaccine 1-3, one might even consider extending post-immunisation serologic testing in such situation. In a recent publication by WHO 4 it is recommended that this group of babies be given four doses of the vaccine, with the first dose given shortly after birth not considered as part of the primary series.

To boost or not to boost ?

Following the recommended three doses of vaccines the duration of immunity lasts at least 13-15 years 5 and seems to be longer in those with a higher post-immunisation antibody titre. The decline in the antibody titre is most rapid in the first year, after which the rate of decline slows down considerably. However, a low or undetectable anti-HBs Ab does not mean that there is loss of protective antibody 6.

Nevertheless, this observation of waning antibody level to < 10mIU/mL has generated some anxiety among practitioners and unwittingly brought about the controversial subject of whether a booster (fourth) dose of the vaccine is needed in 5-10 years after the last dose of the vaccine. In those subjects who have responded (anti-HBs antibody titre equal to or more than 10 mIU/mL) the duration of immunity is at least 15 years. Since the current hepatitis B vaccines are highly immunogenic in over 95% of immunocompetent vaccinees the large majority of children will retain long-term protection, unless there are reasons to believe otherwise. Protection against HBV is conferred by memory T-cells and B-cells, in those successfully vaccinated regardless of persistence of detectable antibody. This anamnestic response occurs on exposure to the HBV either naturally or by booster immunization. 7-12 Based on these observations regular booster doses of hepatitis B vaccine are not indicated for immunocompetent vaccinees. Indeed, currently none of the advisory bodies (Advisory Committee for Immunization Practices (ACIP) in the United States nor the European Consensus Group 13 on Hepatitis B Immunity) recommend a routine booster dose of hepatitis B vaccine following the primary series of three doses, regardless of whether or not the first dose was administered shortly after birth.

Summary :

1. Susceptibility testing is not indicated before immunization in immunocompetent children
2. Routine post-immunisation testing for anti-HBs level is not necessary
3. Antibody testing is recommended 1-3 months after the third dose of active immunization in the following small group of individuals :
   1. Infants born to HBsAg positive mothers
   2. Patients undergoing haemodialysis
   3. Immunocompromised patients including HIV-infected individuals
   4. Adults at occupational risk from sharps injuries eg. health care workers
   5. Spouses or sexual contacts of HBsAg positive persons

References

• Blondheim O, Bader D, Abend M, et al. Immunogenicity of hepatitis B vaccine in preterm infants. Archives of Disease in Childhood: Fetal & Neonatal Edition 1998;79: F206-8.
• Golebiowska M, Kardas-Sobantka D, Chlebna-Sokol D, Sabanty W. Hepatitis B vaccination in preterm infants. European Journal of Pediatrics 1999;158:293-7.
• Belloni C, Chirico G, Pistorio A, et al. Immunogenicity of hepatitis B vaccine in term and preterm infants. Acta Paediatrica 1998;87:336-8.
• Weekly epidemiological record No. 28, 2004.
• Watson B, West DJ, Chilkatowsky A et al. Persistence of immunologic memory for 13 years in recipients of a recombinant hepatitis B vaccine. Vaccine. 2001;19:3164-68.
• Banatvala J, Van Damme P, Oehen S. Lifelong protection against hepatitis B – the role of vaccine immunogenicity in immune memory.; Vaccine 2001;19:877-85.
• European Consensus Group on Hepatitis B Immunity. Are booster immunisations needed for lifelong hepatitis B immunity? Lancet 2000;355:561-5.
• Williams JL, Christensen CJ, McMahon BJ, et al. Evaluation of the response to a booster dose of hepatitis B vaccine in previously immunized healthcare workers. Vaccine 2001;19:4081-5.
• Greub G, Zysset F, Genton B, et al. Absence of anti-hepatitis B surface antibody after vaccination does not necessarily mean absence of immune response. Medical Microbiology & Immunology 2001;189:165-8.
• Moyes CD, Milne A, Waldon J. 1990. Very low dose hepatitis B vaccination in the newborn: anamnestic response to vaccine at four years. J Med Virol 30: 216–8.
• West DJ, Calandra GB. 1996. Vaccine induced immunologic memory for hepatitis B surface antigen: implications for policy on booster vaccination. Vaccine 14: 1019–27.
• Mahoney FJ, Kane M. 1999. Hepatitis B vaccine. In: SA Plotkin, WA Orenstein (eds) Vaccines (3rd edition). Philadelphia: WB Saunders Company.
• European Consensus Group on Hepatitis B Immunity. Are booster immunizations needed for lifelong hepatitis B immunity? Lancet. 2000; 355:561–565.

Prepared by Dr MT Koh 5 Dec 2004
Modified and corrected : April 2005