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A pragmatic randomised controlled trialin primary care of the Camden WeightLoss (CAMWEL) programmeKiran Nanchahal,1Tom Power,1Elizabeth Holdsworth,1Michelle Hession,1Annik Sorhaindo,1Ulla Griffiths,1Joy Townsend,1Nicki Thorogood,1David Haslam,2Anthony Kessel,1,3Shah Ebrahim,1Mike Kenward,1Andrew Haines1ABSTRACTObjectives: To evaluate effectiveness of a structuredone-to-one behaviour change programme on weightloss in obese and overweight individuals.Design: Randomised controlled trial.Setting: 23 general practices in Camden, London.Participants: 381 adults with body mass index$25 kg/m2randomly assigned to intervention(n¼191) or control (n¼190) group.Interventions: A structured one-to-one programme,delivered over 14 visits during 12 months by trainedadvisors in three primary care centres compared withusual care in general practice.Outcome measures: Changes in weight, per centbody fat, waist circumference, blood pressureand heart rate between baseline and 12 months.Results: 217/381 (57.0%) participants wereassessed at 12 months: missing values wereimputed. The difference in mean weight changebetween the intervention and control groups was notstatistically significant (0.70 kg (0.67 to 2.17,p¼0.35)), although a higher proportion of theintervention group (32.7%) than the control group(20.4%) lost 5% or more of their baseline weight(OR: 1.80 (1.02 to 3.18, p¼0.04)). The interventiongroup achieved a lower mean heart rate (meandifference 3.68 beats per minute (0.31 to 7.04,p¼0.03)) than the control group. Participants in theintervention group reported higher satisfaction andmore positive experiences of their care comparedwith the control group.Conclusions: Although there is no significantdifference in mean weight loss between theintervention and control groups, trained non-specialistadvisors can deliver a structured programmeand achieve clinically beneficial weight loss in somepatients in primary care. The intervention groupalso reported a higher level of satisfaction with thesupport received. Primary care interventions areunlikely to be sufficient to tackle the obesity epidemicand effective population-wide measures are alsonecessary.Clinical trial registration number: TrialregistrationClincaltrials.gov NCT00891943.INTRODUCTIONOverweight and obesity are major publichealth problems,1representing the fifthleading cause of death in the world2and anincreasing global challenge.3severe impacts on health, increasing the riskoftype2diabetes,cancers, heart and liver disease.1 4 5TheForesight Report6estimated the NationalHealth Service costs attributable to obesity in2007 as £4.2 billion. In 2010, 68% of men and58% of women in England were overweight orobese (body mass index (BMI) $25 kg/m2).7Obesity is a chronic condition requiringlifelong management as weight loss is oftenregained.8 9Achieving changes in behaviour ischallenging,10largely due to an inability toObesity hashypertension, someTo cite: Nanchahal K, PowerT, Holdsworth E, et al. Apragmatic randomisedcontrolled trial in primarycare of the Camden weightloss (CAMWEL) programme.BMJ Open 2012;2:e000793.doi:10.1136/bmjopen-2011-000793<Prepublication history forthis paper is available online.To view these files pleasevisit the journal online (http://dx.doi.org/10.1136/bmjopen-2011-000793).All authors, external andinternal, had full access to allthe data (including statisticalreports and tables) in thestudy and can takeresponsibility for the integrityof the data and the accuracyof the data analysis.Received 20 December 2011Accepted 30 March 2012This final article is availablefor use under the terms ofthe Creative CommonsAttribution Non-Commercial2.0 Licence; seehttp://bmjopen.bmj.com1London School of Hygiene &Tropical Medicine, London,UK2Watton Place Clinic,Watton-At-Stone, UK3Health Protection Agency,London, UKCorrespondence toKiran Nanchahal; email@example.com SUMMARYArticle focus- Evaluated structured one-to-one weight manage-ment programme.- Delivery by trained non-specialists.- Primary care setting.Key messages- Clinically important level of weight loss achievedby higher proportion of participants in theintervention (33%) compared with the controlgroup (20%).- Intervention group reported higher level ofsatisfaction with support received.- Primary care interventions are unlikely to besufficient to tackle the obesity epidemic.Strengths and limitations of this study- Relatively low threshold of body mass index $25for inclusion, with few exclusions, so wideapplicability of findings.- High loss to follow-up (43%), although similar toother studies in the area; used multiple imputa-tion to counter any biases.Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-0007931Open AccessResearch group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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maintain healthy eating and physical activity behaviours.11Modest weight loss (3%e9%) can prevent type 2 diabetes,improve fasting plasma glucose, blood pressure andlipids, and reduce antihypertensive medication.12e16Mostoverweight patients would like help with weight manage-ment from their general practices,17weight loss is feasiblein the short term (3e12 months)18 19and estimated to becost saving to the NHS,20although few recall receivingweight control advice from a health professional.21The aim of this study was to develop and evaluate theefficacy of an intervention programme with 12-monthfollow-up, for an ethnically diverse overweight/obesepopulation recruited from general practices in a prag-matic randomised controlled trial (RCT) following theMedical Research Council framework for complexinterventions.22To our knowledge, there are currentlyno other published RCTs of one-to-one lifestyle inter-ventions delivered in UK general practice to overweight/obese patients without comorbidities.METHODSAimsThe aims of the study were to assess, by means ofa pragmatic parallel group RCT, the effects on anthro-pometric measures, health-related parameters and thesense of well-being of offering individualised weightmanagement advice in primary care to overweight/obesepeople who wished to lose weight and to identify the keyfactors influencing the outcome of the intervention.The primary outcome was the difference between thecontrol and intervention groups in changes in bodyweight, and the secondary outcomes were differences inwaist circumference, per cent body fat, blood pressureand heart rate from baseline to 12 months.InterventionsThe intervention combined evidence-based componentsrecognised as essential for behaviour change andsuccessful weight loss23dhealthier eating, increasedphysical activity incorporated into patients' everydaylifestyles, tailored goal setting, keeping food and activitydiaries, self-monitoring, positive reinforcement, copingwith lapses and high-risk situations and long-termsupportdderived from theoretical frameworks under-pinning health promotion that have an emphasis onlong-term changes in habits. This includes, for example,social cognitive theory,24which addresses diet andactivity-related social support, outcome expectations,self-efficacy and self-regulation as well as diet and phys-ical activity monitoring to assess changes over time andgoal setting.25It also emphasised SMART (Specific,Measurable, Attainable, Relevant, Timely) goal setting,the relationship between goals and satisfaction and theachievement of goalsandthinking,26which focuses on environmental changes andstresses long-term changes in routines. The programmealso incorporated NICE guidance on management ofoverweight and obesity27as well as evidence-based prin-rewards,and systemsciples of behaviour modification,23adherence to treat-ment28and results from our pilot study (figure 1).18SixCAMWEL advisors were recruited from various occupa-tional backgrounds including healthcare, in line withthe NHS health trainers initiative.35received initial training over 2 days and further meetingswith the research team every 3e4 months. Training ofadvisors included briefing on the obesity epidemic; foodand physical activity behaviours associated with excessweight; principles of best practice and behaviour changestrategies; evidence for what has been shown to work inweight loss management programmes; the use of moti-vational interviewing methods, counselling techniquesand cognitiveebehavioural therapy methods to providetailored support for behaviour change; together withdetails of the study design and role play. All advisors weregiven a copy of the National Obesity Forum CD-Rom'Managing Obesity in Primary Care'. Participants wereinvited to attend 30 min sessions with the advisor everyfortnight for the first 12 weeks, every 3 weeks for12 weeks and finally monthly for the next 12 weeks,making a total of 14 sessions. A script and schedule oftopics for discussion were provided to the advisors foreach session. The topics included personally agreedweight loss goals, eating and physical activity goals,exploration of motivations for losing weight, personalcues to reduce unhealthy eating and sedentary behav-iour, support from family and friends, triggers associatedwith habits and routines, long-term benefits of smallchanges and the importance of scheduling and timemanagement. A commercially available weight manage-ment software package (http://www.perfect-diet-tracker.com) was used to record and monitor participant prog-ress and keep notes of each session by the advisors. Theadvisors were provided with access to a book giving thecalorie content of foods available in the UK,33a kitincluding 100-calorie portions of various food items andAdams Food and Alcohol Portion Pots (http://www.adamsportionpot.com). The intervention participantswere given pedometers and handouts associated witheach session, including a tailored motivational bookletto encourage increased levels of physical activity anda book of walks in the local area specially prepared forthe study (appendix 1). Further details are availablefrom the corresponding author (KN).There is no current comparator 'gold standard' treat-ment programme available for weight management ingeneral practice. In this pragmatic trial of a complexintervention, we assess the benefit of the interventioncompared with routine clinical practice. We provideda copy of the Quick reference NICE clinical guideline onObesity to all participating general practitioners (GPs)27and asked control participants to contact their generalpractice to receive usual weight management careprovided by the practice, which could include referral toa dietitian(http://www.camden.nhs.uk/adult-weight-management-service.htm), exercise on referral, the'Shape-Up' programme (http://camden.gov.uk/ccm/The advisors2Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-000793Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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navigation/leisure/sport-and-physical-activity/get-active-and-healthy/lose-weight/), prescription of weight lossmedication, weight loss surgery or no further treatment.All participants were given the British Heart Founda-tion booklet: "So you want to lose weight . for good."36RecruitmentAll general practices in Camden were visited and invitedto participate in the trial. Participants were recruitedbetween July 2009 and January 2010 from 23 of 39 NHSCamden general practices. The London Borough ofCamden has areas of relative affluence alongside areas ofrelative deprivation, with approximately 35% of thepopulation living in areas classified as some of the mostdeprived in England.37Education levels are also dispa-rate, with 47% of people in employment being educatedto degree level or above, while 17% of working agepeople have no qualifications.38Camden has an ethni-cally diverse population, with 27% belonging to minorityethnic groups.38Figure 1framework.CAMWEL interventionNanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-0007933Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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Several recruitment approaches were used. Primarily,participating practices wrote to a sample of patients withBMI $25 kg/m2; GPs and practice nurses were providedwith referral 'prescription' pads with a tear-off slip to begiven to the patient with contact details of the trialoffice; and posters and flyers were placed in practicewaiting areas and local pharmacies. During the final6 weeks of the recruitment period, three practicessupplemented recruitment by sending text messages topotentially eligible patients using their electronic record(EMIS) and messaging (iPLATO) systems. All practiceswere reimbursed for time spent on recruitment.Baseline measurementsPotential participants were screened by telephone foreligibility (MH, EH, TP). Inclusion criteria were: age18 years andabove, BMIa participating practice and willing to attend visits witha CAMWEL advisor over 12 months. Exclusion criteriawere pregnancy or lactation, diagnosis of renal failure,use of a pacemaker, recent diagnosis of cancer orparticipation in another weight management study.Following GP consent, participants were scheduled forscreening appointments with a researcher (MH) at oneof three practices. The study was explained and theparticipant invited to give informed written consent andto complete the baseline questionnaire. Height (withoutshoes) was measured to the nearest 0.1 cm usinga stadiometer. Weight (in light clothing) was measuredusing the Tanita (BC 420 MA) scales. The scales alsoreported per cent body fat, basal metabolic rate andmetabolic age (age expected for a given value of basalmetabolic rate). Waist was measured midway betweenthe iliac crest and the costal margin to the nearest0.1 cm. Blood pressure and heart rate were measuredusing a digital automatic monitor (Omron ModelM10-IT), with the average of three readings recordedwhere possible. The printout from the Tanita scales,including weight, BMI and metabolic age, was given toall participants.$25 kg/m2,attendingOutcomesAll participants were invited for follow-up at 6 and12 months. A letter was sent 3 weeks prior to the duedate, followed by a telephone call to arrange theappointment. Three attempts were made to contact eachparticipant. Measurements takenrepeated and participants were asked to completea questionnaire. A £30 voucher was provided for theirtime to all participants who completed each follow-upappointment.Theself-completedquestionnairesfollowing validated measures: EuroQol Visual AnalogueScale, ObesityandWeightHospital Anxiety and Depression Scale,40Rosenbergmeasure of self-esteem,41Duke-UNC Functional SocialSupport Questionnaire,42Three-Factor Eating Ques-tionnaire-1843and physical activity (RPAQ),44as well associo-demographic information. Deprivation was ascer-at baseline wereincluded theLossQuality-of-Life,39tained using the Index of Multiple Deprivation based onthe participant's home address postcode.45In addition, at follow-up, we used the Patient Assess-ment of Care for Chronic Conditions46 47to assess theparticipants' views on the care they received from theadvisors and the GP practice on helping them loseweight. A brief series of statements was used to assessparticipants' confidence in their ability to manage theirweight on a scale of 1 (disagree strongly) to 4 (agreestrongly). Further questions asked about the type of helpreceived from the GP practice regarding weight loss,changes made in behaviours related to weight manage-ment and experience of study participation. Participantsin the intervention group also completed an additionalsection to ascertain how helpful they found the sessionsand materials provided as part of the CAMWELprogramme.RandomisationParticipants were randomly allocated (allocation ratio1:1) to the control or intervention group (TP, EH, AS),using a computer-generated randomisation applicationwritten in VBA for MS Access (TP). The Taves method ofminimisation48was used to ensure the groups werebalanced for general practice, gender, age group (#50/>50 years), BMI category (#30/>30 kg/m2), diagnosisof diabetes (yes/no) and taking antipsychotic medicationor not.BlindingThe study was single blinded with members of the studyteam assessing baseline and follow-up measurementsblinded to group assignment.Sample sizeIn our pilot study, participants had a mean weight of98.1 kg (SD 17.3 kg) at baseline.18Since a loss of 5%e10% of body weight in obese adults is associated withsignificant reductions in the risk of obesity comorbid-ities, we considered a difference in weight betweengroups of 7% at 12-month follow-up to be clinicallyimportant. For the sample size calculation, we wished todetect a mean weight difference of 6.9 kg at 12 monthsbetween the two groups with two-sided statistical signifi-cance of 1%, power at 90% and the correlation coeffi-cientbetween baselineconservatively set at 0.7. We thus calculated a totalsample size of 228 (114 per group). Assuming a loss tofollow-up at 12 months of 40%,49it was estimated that380 participants would be required.and follow-upvaluesStatistical methodsComparisons between groups for continuous variableswere performed using two-sample t tests and regressionmethods, adjusting for the baseline value of the vari-able. c2tests and logistic regression were used forcategorical variables. Changes were calculated as valueat follow-up minus baseline value. Primary analyses wereconducted on an intention-to-treat basis, using multiple4Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-000793Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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imputation (MI) to account for missing data at follow-up. Exclusion of subjects with missing data is inefficientand can lead to biased results if those dropped areatypical in some respect50and MI can both increaseefficiency and reduce bias in such settings.51 52Miss-ingness in this study is dominated by attrition, but thereare also some intermediate missing outcome values andmissing baseline values (although not for weight) so the'Fully Conditional Specification' form of MI has beenused.53For each outcome, the full set of imputationvariables comprised the outcomes at each of the threeoccasions, together with a set of baseline variablesselected for their non-negligible association with miss-ingness or weight loss. For all outcomes, the followingbaseline variables were included: age, weight, per centbody fat, BMI, fat mass, metabolic age, deprivationstatus and employment status as well as totals from theObesity and Weight Loss Quality-of-Life, EuroQol VisualAnalogue Scale, Hospital Anxiety and Depression Scaleanxiety, Three-Factor Eating Questionnaire emotionaleating and RPAQ scales. The imputation procedure wascarried out separately for the two groups (interventionand control), and the resulting multiply imputed datasets were combined for the final MI analysis. A total of200 imputations were used to stabilise the results and toensure negligible loss of power.50Analyses using onlydata on participants who completed 12-month follow-upwere also conducted.Exploratory analyses (not using MI) were conductedexcluding subjects who had bariatric surgery or wereprescribed weight loss medication during the course ofthe trial. We also examined whether the degree of weightloss was associated with baseline characteristics or withchanges in health or quality-of-life measures. Analyseswere performed using STATA V.11.Ethical approvalThe study was approved by the London School ofHygiene & Tropical Medicine Ethics Committee, theCamden and Islington Community Research EthicsCommittee (reference number 09/H0722/22) and theNorth Central London Research Consortium.Figure 2through the trial.Flow of participantsRandomisedFollow-upNanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-0007935Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.com Downloaded from
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RESULTSParticipants were followed up at 6 months betweenJanuary 2010 and July 2010 and at 12 months betweenJuly 2010 and January 2011. Participant flow through thetrial is shown in figure 2.Baseline characteristicsWe recruited 381 participants with a median age of 48.5(IQR 37.5e60.4), weighing 60.1e152.2 kg, with waistcircumference of 76e147 cm. The majority (72%) werewomen, 12% (47/381) had diagnosed diabetes, 1.3%(5/381) were on antipsychotic medication, 60% were inemployment, 47% were university graduates and 73%described their ethnicity as Caucasian (table 1). Partici-pants wanted to lose an average of 18 kg (SD ¼12.4),representing 16.7% of their baseline weight. There wereno significant differences between groups for any ofthese variables.Response ratesMeasurements were obtained for 69% (n¼263) of thesample at 6 months and 57% (n¼217) at 12 months.There were no significant differences in follow-up rate at12 months by randomisation group (60.0% control,53.9% intervention, p¼0.23), but those followed uptended to be older, have lower BMI, fat mass and percent body fat, and were less likely to be from a deprivedarea than those not followed up (table 2).Table 1programme (intervention)Baseline characteristics of participants wishing to lose weight allocated to usual care (control) or to the CAMWELCharacteristicsControl group (n[190)Intervention group (n[191) All (n[381)Age (years), % (n)Age group (years), % (n)18e<3535e<5050e<60$60Body weight (kg)Waist circumference (cm)Per cent body fatFat mass (kg)Muscle mass (kg)BMI (kg/m2)BMI 25e<30, % (n)BMI $30, % (n)Systolic blood pressure (mm Hg)Diastolic blood pressure (mm Hg)Heart rate (beats per minute)Demographic details, % (n)Gender: FemaleEthnicity: whiteEducationNo qualificationsO/A-level or equivalentUniversity degreeEmploymentEmployed fulltimeEmployed half-timeUnemployedArea deprivation (IMD)Lowest quartile (deprived)2nd quartile3rd quartileHighest quartile (affluent)Family member overweightQol (range of values for each scale)EQ-VAS (0, 100)Self-esteem (1, 30)Social support (1, 5)Depression (0, 19)Anxiety (0, 19)Obesity-related Qol (0, 102)49.35 (15.45)48.17 (14.09)48.76 (14.77)20.53 (39)32.63 (62)19.47 (37)27.37 (52)90.95 (18.12)105.83 (13.01)38.90 (7.83)35.83 (12.82)52.18 (10.05)33.02 (5.40)31.05 (59)68.95 (131)126.42 (20.44)82.15 (12.36)76.68 (12.05)20.94 (40)31.41 (60)24.08 (46)23.56 (45)93.70 (18.40)107.56 (12.78)39.45 (8.06)37.28 (12.70)53.39 (10.55)33.92 (5.64)25.65 (49)74.35 (142)127.43 (20.17)83.40 (12.83)75.94 (12.03)20.73 (79)32.02 (122)21.78 (83)25.46 (97)92.33 (18.29)106.70 (12.91)39.18 (7.93)36.52 (12.76)52.76 (10.30)33.47 (5.53)28.35 (108)71.65 (273)126.92 (20.28)82.77 (12.59)76.32 (12.03)72.63 (138)70.63 (101)71.73 (137)74.25 (124)72.18 (275)72.58 (225)14.19 (21)27.71 (41)48.65 (72)8.82 (15)38.23 (65)44.71 (76)11.32 (36)33.33 (106)46.54 (148)37.50 (57)19.08 (29)43.42 (66)49.12 (84)14.04 (24)36.84 (63)43.65 (141)16.41 (53)39.94 (129)26.06 (49)25.00 (48)25.53 (47)23.40 (44)78.67 (118)23.94 (45)23.40 (44)25.00 (47)27.66 (52)77.33 (133)25.00 (94)24.20 (91)25.27 (95)25.53 (96)77.95 (251)48.22 (30.18)18.51 (6.01)3.84 (1.03)6.07 (4.20)7.81 (4.32)51.29 (26.71)47.42 (30.68)18.95 (5.89)3.91 (1.02)6.34 (4.31)8.66 (4.83)48.55 (25.47)47.80 (30.40)18.74 (5.94)3.87 (1.03)6.21 (4.25)8.25 (4.60)49.85 (26.06)Values are means (SDs) unless stated otherwise (number of subjects may differ for each variable).BMI, body mass index; EQ-VAS, EuroQol Visual Analogue Scale; IMD, Index of Multiple Deprivation; Qol, quality of life.6Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-000793Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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Primary outcomeBased on the intention-to-treat analysis using imputedmissing values (table 3), at 12-month follow-up, struc-tured support resulted in a mean difference in weightloss between the two groups of ?0.70 (?2.71 to 0.76) kg.A higher proportion of participants lost 5% or more oftheir baseline weight in the intervention (32.7%, 95% CI24.9% to 40.5%) when compared with the usual care(20.4%, 95% CI 13.3% to 27.5%) group (OR 1.80 (1.02to 3.18, p¼0.04).Secondary outcomesThe intervention programme was also associated withweak evidence of beneficial trends in waist circumfer-ence, per cent body fat and per cent weight change.Heart rate was reduced by 3.7 (0.3 to 7.0, p¼0.03) beatsper minute in the intervention group compared with thecontrol group.Based on data for participants who completed the 12-month follow-up (table 3), a higher proportion (one inthree compared to one in five) in the intervention grouphad lost at least 5% of their initial weight (difference14.7% (3.0 to 26.4, p¼0.01)) and experienced a greateraverage reduction in waist circumference (difference1.88 cm (0.01 to 3.76, p¼0.05)) compared with those inthe control group. Weak evidence of reductions in weight,per cent body fat, BMI, blood pressure and heart ratewere observed in the intervention group compared withthe control group. The absolute risk reduction for losing5% baseline weight was 14.7% (3.0 to 26.4), and thenumber needed to treat was 6.8 (3.8 to 33.2). A higherproportion of those in the intervention group (84%, 21/25) who had lost $5% at 6 months had managed to keepthis level of weight loss at 12 months compared with thosein the control group (61.5%, 8/13). We were unable toidentify characteristics of the subgroup of participantsmore likely to lose 5% of their baseline weight.No evidence of differences was found between the twogroups on any of the psychological or quality-of-lifemeasures.Trial participationParticipants in the intervention group were more satis-fied than those in the control group with the level ofweight loss achieved and they found participation in thetrial and feedback of physical measurements helpful(table4).Theinterventionreceiving more patient-centred care than those in thecontrol group as measured by the Patient Assessment ofCare for Chronic Conditions scales (table 5). Detailedanalysis of the interviews and focus groups with a subsetof the participants will be reported elsewhere.groupalsoreportedThe intervention programmeThe majority of participants (38/56, 67.9%) reportedthat a regular meeting with the advisor was the mosthelpful aspect of the programme and the least helpfulwas the use of handouts in improving eating habits (17/56, 30.3%). The majority (84%) said they would chooseto continue to meet an advisor beyond the 12 months ofTable 2(SE) unless otherwise stated)Comparison of baseline characteristics of participants followed up at 12 months and those lost to follow-up (meanFollowed up Lost to follow-upDifference (lost to follow-up L followed up)Mean (95% CI)Number (%)Age (years)Weight (kg)Waist (cm)Per cent body fatBMI (kg/m2)Metabolic age (years)Fat mass (kg)Muscle mass (kg)Basal metabolic rate (kcal)Female, % (n)Married/cohabiting, % (n)White ethnicity, % (n)No qualifications, % (n)Employed, % (n)Deprived area, % (n)Self-esteemSocial supportAnxietyDepressionEQ-VASObesity and weight-related quality of life217 (57.0)51.22 (1.01)90.86 (1.19)106.50 (0.89)38.47 (0.55)32.92 (0.37)60.70 (0.98)35.26 (0.93)52.49 (0.76)1682 (23.17)70.97 (154)45.36 (83)73.02 (138)13.16 (25)81.68 (107)19.16 (41)19.14 (0.44)3.86 (0.08)4.73 (0.14)3.51 (0.13)62.44 (1.53)47.31 (1.89)164 (43.0)45.50 (1.10)94.26 (1.48)106.96 (0.99)40.10 (0.60)34.18 (0.44)56.50 (1.08)38.14 (1.07)53.10 (0.86)1721 (27.23)73.78 (121)48.00 (60)71.90 (87)8.59 (11)71.90 (87)32.72 (53)18.15 (0.55)3.91 (0.09)5.13 (0.16)3.68 (0.17)54.92 (2.31)53.56 (2.37)?5.72 (?8.68 to ?2.77)3.39 (?0.31 to 7.10)?0.46 (?2.18 to 3.10)1.63 (0.02 to 3.24)1.26 (0.14 to 2.37)?4.20 (?7.06 to ?1.28)2.88 (0.10 to 5.67)0.61 (?1.65 to 2.87)39.0 (?31.0 to 109.0)2.81 (?6.23 to 11.86)2.64 (?8.70 to 13.99)?0.11 (?11.32 to 9.10)?4.56 (?11.40 to 2.27)?9.78 (?20.17 to 0.61)13.55 (4.61 to 22.50)?0.99 (?2.38 to 0.40)0.05 (?0.18 to 0.29)0.40 (?0.01 to 0.82)0.17 (?0.23 to 0.59)?7.52 (?2.05 to?12.98)6.25 (0.33 to 12.18)BMI, body mass index; EQ-VAS, EuroQol Visual Analogue Scale.Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-0007937Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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Table 3Changes in outcomes at 6 and 12 months and treatment differences between participants wishing to lose weight allocated to a structured one-to-one weight lossprogramme (intervention) or to usual care (control)VariablesUnadjusted change from baseline (95% CI)Average differencebetween groups(intervention L control)t Test/c2Difference between groups(x OR) based on multipleimputation* (95% CI)p ValueControl groupIntervention groupNumberMean (95% CI)NumberMean (95% CI)Mean (95% CI)p ValueWeight (kg)6 months129?0.95 (?1.74 to ?0.16)134?1.73 (?2.47 to ?0.99)?0.78 (?1.85 to 0.30)0.16?0.69 (?1.80 to 0.41)0.2212 months114?1.31 (?2.23 to ?0.37)103?2.39 (?3.46 to ?1.31)?1.08 (?2.49 to 0.32)0.13?0.70 (?2.17 to 0.76)0.35Waist circumference (cm)6 months125?2.19 (?3.12 to ?1.26)129?3.36 (?4.42 to ?2.29)?1.17 (?2.58 to 0.24)0.10?0.90 (?2.35 to 0.55)0.2212 months112?1.49 (?2.59 to ?0.40)100?3.37 (?4.91 to ?1.82)?1.88 (?3.76 to ?0.01)0.05?1.22 (?3.10 to 0.66)0.20Per cent body fat6 months125?0.12 (?0.66 to 0.42)131?0.89 (?1.36 to ?0.43)?0.77 (?1.48 to ?0.06)0.03?0.77 (?1.51 to ?0.04)0.0412 months111?0.23 (?1.02 to 0.57)101?0.72 (?1.27 to ?0.15)?0.49 (?1.47 to 0.49)0.32?0.71 (?1.71 to 0.28)0.16Per cent weight loss6 months129?1.04 (?1.88 to ?0.20)134?1.78 (?2.51 to ?1.05)?0.74 (?1.85 to 0.36)0.19?0.73 (?1.91 to 0.44)0.2212 months114?1.38 (?2.39 to ?0.37)103?2.59 (?3.65 to ?1.54)?1.21 (?2.66 to 0.23)0.10?0.79 (?2.37 to 0.79)0.33Per cent lost $5% baseline weight6 months12913.18 (7.34 to 19.02)13423.88 (16.66 to 31.10)10.70 (1.41 to 19.98)0.031.77 (0.96 to 3.23)yx0.0612 months11419.30 (12.05 to 26.54)10333.98 (24.83 to 43.13)14.68 (3.01 to 26.35)0.011.80 (1.02 to 3.18)zx0.04BMI (kg/m2)6 months129?0.36 (?0.65 to ?0.07)134?0.60 (?0.86 to ?0.34)?0.24 (?0.63 to 0.14)0.220.20 (?0.18 to 0.59)0.3012 months114?0.48 (?0.82 to ?0.13)103?0.83 (?1.22 to ?0.44)?0.35 (?0.87 to 0.16)0.180.34 (?0.18 to 0.85)0.20Systolic blood pressure (mm Hg)6 months121?2.92 (?6.56 to 0.73)1280.29 (?3.54 to 4.12)3.20 (?2.07 to 8.45)0.233.33 (?1.34 to 8.00)0.1612 months103?0.97 (?5.02 to 3.07)90?0.71 (?3.97 to 2.54)0.25 (?5.01 to 5.50)0.92?0.01 (?4.65 to 4.64)0.99Diastolic blood pressure (mm Hg)6 months121?2.29 (?4.70 to 0.12)128?1.52 (?3.98 to 0.95)0.77 (?2.66 to 4.21)0.661.87 (?1.12 to 4.87)0.2212 months1030.83 (?1.89 to 3.56)90?0.68 (?2.83 to 1.46)?1.51 (?4.96 to 1.93)0.39?1.59 (?4.77 to 1.60)0.33Heart rate (beats per minute)6 months1202.38 (0.21 to 4.55)127?0.47 (?2.79 to 1.85)?2.86 (?6.02 to 0.31)0.08?2.42 (?5.47 to 0.62)0.1212 months104?0.23 (?2.82 to 2.36)90?2.68 (?5.33 to 0.02)?2.44 (?6.14 to 1.25)0.19?3.68 (?7.04 to ?0.31)0.03*For all outcomes the following baseline variables were included: age, weight, per cent body fat, body mass index (BMI), fat mass, metabolic age, deprivation status and employment status as well astotals from the Obesity and Weight Loss Quality-of-Life, EuroQol Visual Analogue Scale, Hospital Anxiety and Depression Scale (anxiety), Three-Factor Eating Questionnaire (emotional eating) andphysical activity (RPAQ) scales.yPer cent lost $5% baseline weight control: 16.0 (9.7 to 22.3)%, intervention: 25.2 (18.0 to 32.3)%.zPer cent lost $5% baseline weight control: 20.4 (13.3 to 27.5)%, intervention: 32.7 (24.9 to 40.5)%.xValues represent OR.8Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-000793Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.com Downloaded from
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the current study, with most (73%) preferring to see theadvisor at least every 4 weeks.Behaviours associated with losing 5% or more of baselineweightParticipants who lost 5% or more of their baselineweight were more likely to state that they had reducedtheir fat and sugar intake in the previous 6 months thanthose who did not; there was no evidence of increasinglevels of physical activity between the groups (table 6).They also reported that attending regular meetings witha non-judgemental advisor, discussion on portion sizesand use of the pedometer were particularly useful andthat they would continue to monitor food intake tomaintain their weight.Exploratory analysisThirty-eight participants were known to have beenprescribed drugs for weight loss or to have undergoneweight loss surgery during the trial period. Of these, 27were followed up at 12 months (12 control: mean weightchange ?2.44 kg (?7.15 to 2.27); 15 intervention: meanweight change ?3.51 kg (?6.95 to ?0.08)). The differencebetween groups was 1.07 kg (?4.32 to 6.46, p¼0.69). Inanalysis excluding these participants, those in the inter-vention group showed significantly greater reductions inweight (1.72 kg (0.29 to 3.14, p¼0.02)), waist circumfer-ence (2.52 cm (0.32 to 4.72, p¼0.03)), BMI (0.63 kg/m2(0.11 to 1.14, p¼0.02)) and per cent baseline weight loss(1.94% (0.32 to 3.56, p¼0.02)) when compared with thecontrol group at 12 months. In addition, a higherTable 4 Participant satisfaction with care received by allocation group at 12 monthsInterventionControlDifference between groups(intervention L control)n/N% (SE)n/N% (SE)% (95% CI)p ValueSatisfied with level of weightloss achievedFound participating inCAMWEL helpful in meetinggoalsFound getting feedback onphysical measurements atbaseline and 6 months helpfulFound British HeartFoundation booklet31helpful37/6061.7 (6.3)14/61 23.0 (5.4)38.7 (22.5 to 54.9)<0.000151/59 86.4 (4.4)27/60 45.0 (6.4)41.4 (26.1 to 56.8)<0.000139/5867.2 (6.3)20/57 35.1 (6.3) 32.2 (14.9 to 49.5)<0.000150/58 86.2 (4.5) 38/5371.7 (6.2)14.5 (0.0 to 29.5)0.06Table 5Participant assessment of care received by allocation group at 12 monthsIntervention ControlDifference between groups(intervention L control)nMean (SE)nMean (SE)Mean (95% CI) p ValuePACIC*Patient activationAsked for my ideasGiven choicesAsked about any problemsDelivery system design/decision supportWritten list of things to doCare well organisedHow what I do influences weightGoal settingAsked to talk about my goalsHelped to set specific goalsGiven copy of my weight loss planEncouraged to attend sessionsAsked questions about health habitsProblem solving/contextual counsellingThought about my beliefs andtraditions when making recommendationsHelped to make plan for my daily lifePlan ahead even for difficult circumstancesAsked how weight affected me*Patient Assessment of Care for Chronic Conditions (PACIC) score.46 4758 3.29 (0.17)56 1.46 (0.13)1.83 (1.40 to 2.26)<0.000158 3.79 (0.14)55 1.70 (0.16)2.09 (1.68 to 2.50)<0.000158 3.35 (0.13)54 1.64 (0.14) 1.71 (1.32 to 2.09)<0.000158 3.34 (0.16)561.66 (0.15)1.69 (1.26 to 2.12)<0.0001Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-0007939Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.com Downloaded from
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proportion of participants in the advisor group lost $5%of their baseline weight when compared with the controlgroup (OR 2.68 (1.13 to 5.70, p¼0.03)).The number of sessions attended was available for 87participants of whom 40 (46%) attended more than 70%(10/14) of the available sessions. Half (50%) of theparticipants attendingmoreprogramme lost 5% or more of their baseline weightcompared with a quarter (23%) who attended fewersessions (difference 26.5%, 95% CI 6.9 to 46.3, p¼0.01).than70% of theDISCUSSIONPrincipal findingsThe structured one-to-one weight loss programme deliv-ered by non-specialists in general practice did not achievethe pre-specified difference in average weight loss of 7%.However, it did result in a higher proportion of theparticipants losing 5% or more of their baseline weightcompared with those randomised to usual care, which isconsidered a clinically important outcome in similartrials. This suggests that people likely to benefit fromsuch a programme are a subset of the total study popu-lation but we were unable to identify particular charac-teristics that would permit identification of a receptivegroup in advance. There was some evidence that theintervention group experienced greater reductions inmean weight, waist circumference and % body weightthan the control group. While the overall effects onweight loss are modest, they are not unimportant.Strengths and weaknesses of the studyThe key strengths of the CAMWEL programme are itswide applicability to overweight and obese people fromdiverse backgrounds as there were few exclusions, feasi-bility of its delivery in primary care by non-specialisttrained advisors and a patient-centred approach tomaking sustainable changes to diet and physical activityeasily incorporated into peoples' daily lives.Limitations include the slow initial recruitment,although this improved over time, particularly withmobile phone text message use.54Loss to follow-up washigh (43%), although similar to that of other weight lossstudies in the UK.55e58The response rate in theDESMOND diabetes management trial19was substan-tially higher (91%), perhaps because participants wererecently diagnosed diabetics and therefore highly moti-vated. High attrition in RCTs of weight loss is wellrecognised,59with a recent review reporting losses tofollow-up of 30%e60%.49We used MI for missing values to counter any biasesdue to loss to follow-up as high level of attrition involvesconsiderable uncertainty about outcomes for partici-pants lost to follow-up. We included patients with BMI$25 as NICE recommends treatment at this level,although this relatively low threshold and broad inclu-sion criteria may have diluted the results in terms ofaverage weight loss thus needing a larger sample todetect significant differences.Participants in the control group were advised tocontact their general practice to receive the usual careprovided for weight loss. We provided all GPs with NICEguidelines on obesity and participants with the BritishHeart Foundation booklet on weight loss as well as feed-back on the measurements taken at 6 months. Thisprovision of support could be one reason why participantsin the control group also lost weight over the period ofTable 6those who did notReported changes* in eating and activity habits by participants who lost 5% or more of baseline weight compared withLost 5% or more ofbaseline weightDifference betweengroups (yes L no)Yes(N[41)No(N[111)n%n% Percent (95% CI)p ValueWhat changes have you made to your diet during the last 12 months? (Tick all that apply)Reduced my fat intakeReduced my sugar intakeReduced my portion sizesWhat changes have you made to your activity levels in the last 12 months? (Tick all that apply)Used the stairs instead of taking the liftJoined a gym specifically to lose weightGet off one stop earlier when travelling by bus or tubeWalk rather than take car for journeys that are lessthan one mileHow will you continue to manage your weight; will youMonitor your food intake?Control your portions?Use a pedometer?Monitor your activity patterns?35242885.458.568.366435859.538.752.325.9 (11.7 to 40.1)19.8 (22.0 to 37.4)16.0 (?0.97 to 33.0)0.0030.0290.077171341.531.719.551.23120164427.918.014.439.613.6 (?3.7 to 30.8)13.7 (?2.2 to 29.6)5.1 (?8.7 to 8.9)11.6 (?6.2 to 29.4)0.1110.0690.4440.2008213226132378.163.431.756.15959204452.752.717.939.325.4 (9.69 to 41.1)10.7 (?6.67 to 28.1)13.8 (?2.1 to 29.8)16.8 (?0.86 to 34.4)0.0050.2370.0650.063*Data are missing for 75 participants who did not complete this section of the questionnaire.10Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-000793Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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Table 7Studies on weight loss conducted in general practice in the UK with 12-month follow-upStudyDesignInterventionEligibilitycriteriaWeight (kg)at baseline,mean (SD)Per cent (n/N)followed up at12 monthsMean weight change (kg) at 12 monthsLost ‡5%baseline weightin the interventiongroup, % (95% CI)InterventionControlDifference(95% CI)p ValueMoore et al,BMJ (2003)62Cluster RCTTrainedGPs, nursesBMI $30e67.7 (565/834)?0.6?0.91.0*0.5eMcConnon et al,BMC (2007)55RCTAccess towebsiteBMI $30; accessto internet98.4 (17.4)59.3 (131/221)?1.3?1.90.6 (1.4 to 2.5)0.5622Davies et al,DESMOND, BMJ(2007)19RCTGroupsessionsNewly diagnosedtype 2 diabetese90.9 (729/824)?3.0?1.9?1.0 (?1.9to ?0.12)0.03eRoss et al,Counterweight,BJGP (2008)56AuditTrainedpractice nursesBMI $30;BMI $28 withcomorbiditiese45.2 (642/1419)?3.0eee31 (27 to 34)Ahern et al, WeightWatchers, BMC(2011)63AuditWeightWatchersmeetingsBMI $30; NHSreferral scheme94.3 (IQR 83.7e107.7)53Median ¼?2.8eee33Jebb et al, WeightWatchers, Lancet(2011)57RCTWeightWatchersmeetingsBMI 27e35 +1 risk factor86.757.5 (444/772)?5.1?2.2?3.2 (?4.2to ?2.1)<0.000147yJolly et al, BMJ(2011)58RCTVariouszWhite BMI $30/$28 + comorbidity;S AsianBMI $25/$23 +comorbidity91.7 (17.9)70.5 (522/740)?3.5?1.1?2.5 (?4.2to ?0.8)0.0231 (22 to 41)CAMWELRCTOne-to-onesessionsBMI $2592.3 (18.3)57 (217/381)?2.4?1.3?1.1 (?2.5to 0.3)0.1334 (25 to 43)*Difference between groups at 12 months.yBased on graph in table 3.zRange of commercial or primary care-led programmes, intervention results given for Weight Watchers.BMI, body mass index; GP, general practitioners; RCT, randomised controlled trial.Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-00079311Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.com Downloaded from
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the trial resulting in greater similarity of changes in thetwo groups, which would represent bias if the GPs alteredtheir usual care by virtue of trial participation. Outcomesof RCTs may be influenced by participants' treatmentpreference60and research assessment procedures61trig-gering behaviour change and contributing to the weightloss seen in the control group.Behaviour change interventions tend to be complexwith multiple components and it is difficult to assess theeffectiveness of different components. This was a prag-matic trial reflecting the likely performance of theprogramme as delivered in practice. While the fidelity ofthe delivery of the intervention could be examined inmore detail, we have shown that patient assessment ofthe structured support by trained advisors is significantlybetter than usual care.Cost-effectiveness analyses are required to informdecision making about the value of attaining theseoutcomes and will be reported in a separate paper.Putting the study in contextSeven studies of weight change conducted in UK generalpractice have been published (see table 7). With theexception of a trial in newly diagnosed diabetics,RCTs provided no strong evidence of differences in weightloss between the intervention and control groups, exceptfor those using a commercial provider (Weight Watchers).Our trial achieved results at least comparable with themore targeted interventions based in general practice.ImplicationsWe have demonstrated that one-to-one structured supportby a trained advisor in general practice can help peoplewishing to lose weight change their behaviour sufficientlyleading to a clinically important loss in weight. While1 year may be too short a time to see all the benefits ofa weight management intervention, the majority ofparticipants found the Camwel programme helpfulsuggesting that they will continue to accrue benefit as theyimplement the behaviour change techniques learnedduring the study. Understanding how the interventionworked and why it worked just for some participants aswell as its cost-effectiveness are important and we willexplore these in our subsequent research. The impor-tance of our results lies in their generalisability. Ourresults, together with those from other researchers,suggest that individual approaches in general practice canachieve modest benefits for the National Health Service.However, primary care interventions are unlikely to besufficient to address the obesity epidemic and effectivepopulation-wide policy measures are needed as well,including increasing energy expenditure through activetravel64and reducing dietary intake.Acknowledgements We thank the study participants; the GPs and practicemanagers at the participating practices (Abbey Medical Centre, AmpthillSquare Medical Centre, Belsize Priory Medical Practice, The BloomsburySurgery, Brondesbury Medical Centre, Brunswick Medical Centre, CamdenRoad Surgery, Chomley Gardens Surgery, Fortune Green Road Surgery,Gower Place Practice, Gower Street Practice, Grays Inn Medical Centre,Hampstead Group Practice, James Wigg Group Practice, Kings Cross RoadPractice, Museum Practice, Park End Surgery, Parliament Hill Surgery,Prince of Wales Group Practice, Swiss Cottage Surgery, Regents ParkPractice); members of the advisory board (Chris Bonell, Phil Edwards, SusanJebb, David Simpson and Paul Wilkinson); the advisors (Rosalind Bose,Gloria Ferenando, Gillian Lampert, Tim Whelan, Gina Williams, DianaVillamil); as well as Nick Cavill for helping to write the motivational physicalactivity handbook, Jim McCambridge for help with training advisors andcommenting on the manuscript, Kate Lees for help with dietary aspects,Katie Williams (NHS Camden), Suzanne Taylor for data entry, David Taylorfor assistance with database management, Ray Bird for audio-visualassistance, Laura Doubleday and Sarah Milton for helping with follow-up ofparticipants, and Adams Portion Pots (Adams Insight Consulting, http://www.adamsportionpot.com) and NHS Camden for their support of thisstudy.Contributors KN, JLT, NT, DH, AK, SE and AH contributed to conception anddesign. MH, JLT, KN, EH, AS and UG contributed to acquisition of data, KN,TP, EH, MK and AH contributed to analysis and interpretation of data, and KNdrafted the article. KN, JLT and AH revised it critically for important intellectualcontent. All authors contributed to the final approval of the version to bepublished.Funding This work was supported by Camden Primary Care Trust (NHSCamden). The funding source had no role in the design or conduct of thestudy; collection, management, analysis or interpretation of the data andpreparation, review or approval of the manuscript.Competing interests All authors have completed the Unified CompetingInterest form at http://www.icmje.org/coi_disclosure.pdf (available on requestfrom the corresponding author) and declare that KN, TP, EH, MH, AS, UG andJLT had salary support from NHS Camden for the submitted work. AK wasDirector of Public Health at Camden Primary Care Trust between 2004 and2009. The views expressed here are personal, and no financial support wasreceived for the other authors' involvement in the CAMWEL Trial. No authorshave had a relationship with companies that might have an interest in thesubmitted work in the previous 3 years nor do their spouses, partners orchildren have financial relationships that may be relevant to the submittedwork. DH is on the scientific advisory board for LighterLife and no otherauthors have non-financial interests that may be relevant to the submittedwork.Ethics approval Ethics approval was provided by the London School ofHygiene & Tropical Medicine Ethics Committee, the Camden and IslingtonCommunity Research Ethics Committee (reference number 09/H0722/22) andthe North Central London Research Consortium.Provenance and peer review Not commissioned; externally peer reviewed.Data sharing statement No additional data available.REFERENCES1.Whitlock G, Lewington S, Sherliker P, et al; Prospective StudiesCollaboration. 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9.Perri MG, Sears SF Jr, Clark JE. Strategies for improvingmaintenance of weight loss. Toward a continuous care model ofobesity management. Diabetes Care 1993;16:200e9.Kinmonth AL, Wareham NJ, Hardeman W, et al. Efficacy of a theory-based behavioural intervention to increase physical activity in anat-risk group in primary care (ProActive UK): a randomised trial.Lancet 2008;371:41e8.Wing RR, Phelan S. Long-term weight loss maintenance. Am J ClinNutr 2005;82(Suppl 1):222Se5.Aucott L, Poobalan A, Smith WC, et al. Weight loss in obese diabeticand non-diabetic individuals and long-term diabetes outcomeseasystematic review. Diabetes Obes Metab 2004;6:85e94.Poobalan A, Aucott L, Smith WC, Avenell A, et al. Effects of weightloss in overweight/obese individuals and long-term lipid outcomeseasystematic review. Obes Rev 2004;5:43e50.Avenell A, Broom J, Brown TJ, et al. Systematic review of the long-term effects and economic consequences of treatments for obesityand implications for health improvement. Health Technol Assess2004;8:1e182.Norris SL, Zhang X, Avenell A, et al. Long-term effectiveness ofweight-loss interventions in adults with pre-diabetes: a review. Am JPrev Med 2005;28:126e39.Norris SL, Zhang X, Avenell A, et al. Long-term effectiveness oflifestyle and behavioral weight loss interventions in adults with type 2diabetes: a meta-analysis. Am J Med 2004;117:762e74.Potter MB, Vu JD, Croughan-Minhane M. Weight management: whatpatients want from their primary care physicians. J Fam Pract2001;50:513e18.Nanchahal K, Townsend J, Letley L, et al. Weight-managementinterventions in primary care: a pilot randomised controlled trial. Br JGen Pract 2009;59:e157e66.Davies MJ, Heller S, Skinner TC, et al; Diabetes Education and SelfManagement for Ongoing and Newly Diagnosed Collaborative.Effectiveness of the diabetes education and self management forongoing and newly diagnosed (DESMOND) programme for peoplewith newly diagnosed type 2 diabetes: cluster randomised controlledtrial. BMJ 2008;336:491e5.Trueman P, Haynes SM, Felicity Lyons G, et al. Long-term cost-effectiveness of weight management in primary care. Int J Clin Pract2010;64:775e83.Wardle J, Johnson F. Weight and dieting: examining levels of weightconcern in British adults. Int J Obes Relat Metab Disord2002;26:1144e9.Campbell M, Fitzpatrick R, Haines A, et al. Framework for design andevaluation of complex interventions to improve health. BMJ2000;321:694e6.Jones LR, Wadden RA. State of the science: behavioural treatment ofobesity. Asia Pac J Clin Nutr 2006;15(Suppl 1):30e9.Bandura A. Health promotion by social cognitive means. Health EducBehav 2004;31:143e64.Locke EA, Latham GP. Building a practically useful theory of goalsetting and task motivation: a 35-year odyssey. Am Psychol2002;57:705e17.Alemi F, Neuhauser D, Ardito S, et al. Continuous self-improvement:systems thinking in a personal context. Jt Comm J Qual Improv2000;26:74e86.NICE Clinical Guidance 43 Obesity: Quick Reference Guide 2 for theNHS. London: National Institute for Health and Clinical Excellence,2006.Koenigsberg MR, Bartlett D, Cramer JS. Facilitating treatmentadherence with lifestyle changes in diabetes. Am Fam Physician2004;69:309e16.Abraham C, Michie S. A taxonomy of behavior change techniquesused in interventions. Health Psychol 2008;27:379e87.Miller WR, Rose GS. Toward a theory of motivational interviewing.Am Psychol 2009;64:527e37.Foreyt JP, Poston WS. What is the role of cognitive-behavior therapyin patient management? Obes Res 1998;6(Suppl 1):18Se22.Managing Obesity in Primary Care CD-ROM. National obesity Forum,2004. nationalobesityforum.org.ukKellow J, Costain L, Walton R. The Calorie, Carb and Fat Bible.Peterborough: weight loss Resources, 2009.Byoni Ltd. Perfect Diet Tracker Software. http://www.perfect-diet-tracker.com/Michie S, Rumsey N, Fussell A, et al. Improving Health: ChangingBehaviour NHS Health Trainer Handbook. London: Department ofHealth, 2008.British Heart Foundation. So You Want to Lose Weight. For Good.London: British Heart Foundation, 2005.NHS Camden. Annual Report & Accounts 2009/10. Camden PrimaryCare Trust, 2010. http://www.camden.nhs.uk/downloads/012522A1_CNHS_Annual%20Report_LR.pdf10.11.12.13.126.96.36.199.18.104.22.168.188.8.131.52.188.8.131.52.220.127.116.11.188.8.131.52.38. Forward Planning Service London Borough of Camden Camden Profile2010. London Borough of camden Forward Planning service. http://www.camdendata.info/AddDocuments1/Forms/DispForm.aspx?ID¼131Patrick DL, Bushnell DM, Rothman M. Performance of two self-reportmeasures for evaluating obesity and weight loss. Obes Res2004;12:48e57.Olssøn I, Mykletun A, Dahl AA. The Hospital Anxiety andDepression Rating Scale: a cross-sectional study of psychometrics andcase finding abilities in general practice. BMC Psychiatry 2005;5:46.Rosenberg M. Society and the Adolescent Self Image. Princeton, NJ:Princeton University Press, 1965.Broadhead WE, Gehlbach SH, de Gruy FV, et al. The Duke-UNCFunctional Social Support Questionnaire: measurement of socialsupport in family medicine patients. Med Care 1988;26:709e23.Karlsson J, Persson LO, Sjo ¨stro ¨m L, et al. Psychometric propertiesand factor structure of the three-factor eating questionnaire (TFEQ) inobese men and women. Results from the Swedish obese subjects(SOS) study. Int J Obes Relat Metab Disord 2000;24:1715e25.Besson H, Brage S, Jakes RW, et al. Estimating physical activityenergy expenditure, sedentary time, and physical activity intensity byself-report in adults. Am J Clin Nutr 2010;91:106e14.Department for Communities and Local Government. The EnglishIndices of Deprivation 2010. London. 2010. http://www.communities.gov.uk/documents/statistics/pdf/1871208.pdfGlasgow RE, Wagner EH, Schaefer J, et al. Development andvalidation of the patient assessment of chronic illness care (PACIC).Med Care 2005;43:436e44.Schmittdiel J, Mosen DM, Glasgow RE, et al. Patient Assessment ofChronic Illness Care (PACIC) and improved patient-centeredoutcomes for chronic conditions. J Gen Intern Med 2008;23:77e80.Scott NW, McPherson GC, Ramsay CR, et al. The method ofminimization for allocation to clinical trials: a review. Control ClinTrials 2002;23:662e74.Douketis JD, Macie C, Thabane L, et al. Systematic review of long-term weight loss studies in obese adults: clinical significance andapplicability to clinical practice. Int J Obes (Lond) 2005;29:1153e67.Carpenter JR, Kenward MG. Missing Data in Clinical TrialsdAPractical Guide. National Health Service Coordinating Centre forResearch Methodology. Birmingham. 2008. http://www.haps.bham.ac.uk/publichealth/methodology/docs/invitations/Final_Report_RM04_JH17_mk.pdfRubin DB. Multiple Imputation for Nonresponse in Surveys. NewYork: Wiley, 1987.Kenward MG, Carpenter J. Multiple imputation: current perspectives.Stat Methods Med Res 2007;16:199e218.Royston P. Multiple imputation of missing values. STATA Journal2004;4:227e41.Nanchahal K, Hession M, Power T, et al. Challenges in recruitment toclinical trials and lessons learned from a randomized controlled trial ofa weight management intervention in general practice. Obes Rev2010;11(Suppl S1):P214.McConnon A, Kirk SF, Cockroft JE, et al. The Internet for weightcontrol in an obese sample: results of a randomised controlled trial.BMC Health Serv Res 2007;7:206.Counterweight Project Team. Evaluation of the CounterweightProgramme for obesity management in primary care: a starting pointfor continuous improvement. Br J Gen Pract 2008;58:548e54.Jebb SA, Ahern AL, Olson AD, et al. Primary care referral toa commercial provider for weight loss treatment versus standardcare: a randomised controlled trial. Lancet 2011;378:1485e92.Jolly K, Lewis A, Beach J, et al. Comparison of range of commercialor primary care led weight reduction programmes with minimalintervention control for weight loss in obesity: Lighten Up randomisedcontrolled trial. BMJ 2011;343:d6500.Inelmen EM, Toffanello ED, Enzi G, et al. Predictors of drop-out inoverweight and obese outpatients. Int J Obes (Lond) 2005;29:122e8.Thomas E, Croft PR, Paterson SM, et al. What influencesparticipants' treatment preference and can it influence outcome?Results from a primary care based randomised trial for shoulder pain.Br J Gen Pract 2004;54:93e6.McCambridge J, Kypri K. Can simply answering research questionschange behaviour? Systematic review and meta analyses of briefalcohol intervention trials. PLoS One 2011;6:e23748.Moore H, Summerbell CD, Greenwood DC, et al. Improvingmanagement of obesity in primary care: cluster randomised trial. BMJ2003;327:1085.Ahern AL, Olson AD, Aston LM, et al. Weight Watchers on prescription:an observational study of weight change among adults referred toWeight Watchers by the NHS. BMC Public Health 2011;11:434.Woodcock J, Edwards P, Tonne C, et al. Public health benefits ofstrategies to reduce greenhouse-gas emissions: urban land transport.Lancet 2009;374:1930e184.108.40.206.22.214.171.124.184.108.40.206.126.96.36.199.126.96.36.199.126.96.36.199.62.63.64.Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-00079313Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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APPENDIX 1The structure of the CAMWEL intervention programmeSessionnumberWeek Topic materialsHandouts10Getting started: establishworking relationship and goodrapport with participant; elicitpersonal reasons for losingweight, build commitment toprogram and introducelifestyle changes approach.BHF 'So you want to loseweight' bookletChanging habits: reviewprogress, explain importanceof changing habitspermanently and introducethe five steps to solvingproblems.Healthy eating: reviewprogress, explain importanceof regular meals, portionsizes, keeping a record anddiscuss making easy foodswaps. (Adam portion pots;100 kcal portion size foodbox)Let's get active: reviewprogress, explain importanceof activity guidelines anddiscuss ways of incorporatingphysical activity intoparticipant's lifestyle.Taking charge of yourenvironment: reviewprogress, explain importanceof cues and discuss ways ofchanging the environment tomake losing weight the 'easy'option.Eating when out and about:review progress, explain keysto making healthy choiceswhen out and about anddiscuss alcohol if appropriate.Tip the calorie balance:review progress at 3-monthstage of programme; explainenergy balance equation,importance of healthy eating,being active, social supportand action planning.Positive thinking: reviewprogress and introduce waysto stop negative thoughts and'talk back' with positive ones.Sequence of topicsAppointment cardBenefits of healthy habitsRecording your routinesDeciding to changeBehaviour change diaryFood diaryActivity diary22Problem solvingBuild a better recipeJust one more step(Behaviour change diary)(Food diary)(Activity diary)34FSA Eat Well bookletRate your plateEasy food swapsHealthy drinksFood labels card(Activity diary)46Being activeYour guide to walking inCamdenCut the fat and sugarCamden outdoor gymsSteps chartPrinted weight graph(Rate your plate)58Your environmentGoals and rewardsEat well on the cheap(Rate your plate)(Steps chart)Printed weight graph6 10Healthy choicesAlcohol and your dietEating when out and about(Rate your plate)(Steps chart)7 12Tipping the calorie balanceIndividual printed weightgraph(Steps chart)(Rate your plate)8 15Positive thinkingCamden Walk4Life maps(Food diary)(Activity diary)(Steps chart)(Rate your plate)(Behaviour change diary)Continued14Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-000793Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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ContinuedSessionnumberWeekTopic materialsHandouts9 18Getting off the slippery slope:review progress, identifyreasons for slips and ways ofgetting back on course.Slippery slopeCamden Walk4Life mapsBHF 'Healthy meals, HealthyHeart' or 'Food should be funand healthy' menusIndividual printed weightgraphSocial eatingIndividual printed weightgraph1021Social eating: reviewprogress, discuss socialsettings where it may bedifficult to stay in control ofeating healthily and ways toovercome this and enjoyhealthy social eating.Staying on course: reviewprogress, identify successfulchanges made and identifysituations where participantnot in control and discussways of overcoming barriers.11 27Staying on courseHealthy snacking100 Calorie portionsMeal plansdIndian/minimumcookingIndividual printed weightgraphStaying activeIndividual printed weightgraph(Rate your plate)(Food diary)(Steps chart)(Activity diary)1231 Staying active: reviewprogress; discuss additionalchanges made and howfurther activity can be addedinto lifestyle.Managing stress: reviewprogress; discuss how stressaffects weight and ways tomanage stress.(Activity diary)(Steps chart)1335Day-to-day stressIndividual printed weightgraph(Activity diary)(Steps chart)(Rate your plate)(Food diary)(Rate your plate)(Food diary)14 47Reshaping habits: reviewprogress since start ofprogramme; discuss ways ofcontinuing to lose/maintainchanges in the long term.Reshaping habitsCancer Research UK's Tentop tipsCamden architecture &walking guideTravel Camden: Camdenwalking mapBelsize walk; Jubilee WalkIndividual printed weightgraphCertificate of achievement(Steps chart)(Activity diary)PAGE fraction trail=15Nanchahal K, Power T, Holdsworth E, et al. BMJ Open 2012;2:e000793. doi:10.1136/bmjopen-2011-00079315Randomised controlled trial of the Camden Weight Loss (CAMWEL) programme group.bmj.com on May 8, 2012 - Published by bmjopen.bmj.comDownloaded from
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- Ambler Audi
- Anaktuvuk Pass Audi
- Anchor Point Audi
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- Aniak Audi
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ATLANTA — David West led Indiana on a 16-4 run to end the game, extending the season for the top-seeded Pacers with a 95-88 victory over the Atlanta Hawks on Thursday night.
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Union, CenturyLink continue talks on new labor accord
Published October 10, 2012 8:57 am
This is an archived article that was published on sltrib.com in 2012, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.
The union that represents some 13,000 CenturyLink employees, including 820 in Utah, said it is still negotiating with the company even though its contract with the giant telecommunications company expired last week.
Al Kogler, a spokesman for the Communications Workers of America, said union members remain on the job under a "day-to-day" extension of the contract.
CWA members last week authorized their union leadership to call a strike against the company if they deemed it necessary. However, Kogler pointed out that the vote didn't mean that a strike would be called.
Kogler said the union opposes a proposed increase in health care premiums and wants to bring more jobs back to the U.S.
Reader comments on sltrib.com are the opinions of the writer, not The Salt Lake Tribune. We will delete comments containing obscenities, personal attacks and inappropriate or offensive remarks. Flagrant or repeat violators will be banned. If you see an objectionable comment, please alert us by clicking the arrow on the upper right side of the comment and selecting "Flag comment as inappropriate". If you've recently registered with Disqus or aren't seeing your comments immediately, you may need to verify your email address. To do so, visit disqus.com/account.comments powered by Disqus
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Curious for guys that follow a little closer. The Buckeyes whiffed pretty big the last couple of weeks, do they have some extra schollies open or did they pilfer some kids from Ball St. to fill out their class. They were in on so many guys it seems that they had to go 1 way or another yesterday.
"He makes it really easy on you as a coach because he has tremendous football instincts," Michigan tight ends coach Jay Harbaugh said. "Things come really naturally to him. He doesn't have to see things too many times. He has a good sense for how things should look and feel, and he's a tough, physical guy."


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- 259Promote
Framed Art Print
Axis Mundiby Trudy Creen
Choose from a variety of frame styles, colors and sizes to compliment your favorite Society6 gallery, or fine art print - made ready to hang. Fine-crafted from solid woods, premium shatterproof acrylic protects the face of the art print, while an acid free dust cover on the back provides a custom finish. All framed art prints include wall hanging hardware.
glorious colours!
very nice!
nice placement on the iPhone too.
☆ ☆ ☆ ☆ ☆! ;-)
Wow Trudy. It's so pleasing!
Great piece, so colourful!
Thanks very much everyone. The original painting is going in an exhibition tomorrow!
wow! so wonderful! I love it!
the colours are amazing and the design stunning Trudy! xx
Wonderful piece, Trudy! I'm sure it's going to be a hit at your exhibit :-) Good luck with the show! So exciting!
this is so amazing ~ truly beautiful
great patterns :)
soo very cool!
nice colours!
beautiful work! :)
This turned out beautiful!! Congrats!
I really enjoy all the great colors you incorporated. Great piece! I want to buy this one day :).
Thanks everyone- I really I appreciate it so much. I have another big blank canvas the same size just waiting for something similar to paint!
Thanks Hugo and redboink~ :):)
Nice work Trudy!
Stunning Trudy, magical work! :o)
totaly amazing colors trudy!
thanks Gwenola, Anna and Noblackcolor :)))
Thank you cardboardcities :)
So Beautiful!!! :-)
Thanks Ingrid and María :)
Thanks very much Sandra :)
Fabulous painting!!
thank you Angelo :)
Trudy_your work is so invigorating!
that's a lovely thing to say Manu, thanks xx
Amazingly beautiful
thanks very much Christy :)
very nice!
Thank you Sensitive :)
magnificent coloring!
Thanks very much Captive Images :)
great art!
Thanks so much Diego :)
lovely colours and patterns
Thank you catspaws :)
very cool, love it!
thanks for the comment Tsuki- glad you like it :)
lush! :-D x
hey Clare :) Thanks very much :) x
I really love your style and color!
Thank you very much Vikki- likewise :)
glorious colors! love it!
Thank you armine , glad you like it :)
beautiful !
Thanks very much catspaws :)
So beautiful! Bold, vibrant colors :)
Thanks so much EbiEmporium :)
Gorgeous colors! So lively, it adds energy to the piece.
Wonderful! Love it!
really love this! Colors are awesome
Thanks very much everyone for the lovely comments :)))
Thank you Crystal :)
Thank you Ylak :)
Wow! The phones look so cool!!
Thanks Pegeen :)
Very beautiful!
Thank you Betty :)
Beautiful! Love the design and colors! :)
Thanks very much PeriwinklePeacoat :)
Love it.
thank you MOF :)
Gorgeous colors!
Thank you Amy :)
soo cool!!!**
thank you COUCOU :)
Beautiful work, Trudy!
Thank you Cheryl :)
So rad!!!
Nice work!
Very nice!
Thanks very much Tyler and Tex
Great colors!!
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Overcast Kids
A place for Overcast Kids to share their photos, videos...more»
Copy and paste this code below, to add an Overcast Kids badge to your other webpages! Let all your friends know that you are an Overcast Kid on Buzznet and that they can check out your photos, journals, and videos here!
Make sure that you check out Friendsorenemies.com ... almost every single day there is a new feature or exclusive video from Fall Out Boy or Fall Out Boy fans!!!!
- Guyliner poll
- ME WITH FALL OUT BOY pic
- they've always been good to me. pic
- dude what the fuck are you doing? pic
- ..and would anyone dare say i have a 'problem'... pic
- peteyyyyy pic
- FOB show in Cologne / Germany blog
- I wish I was that pen... pic
- Pete Wentz pic
- Pete on his unborn baby(ies?) pic
- Fall Out Boy for DoSomething.org/Maximum Ride Gree vid
- Rare photo.....Unique! pic
- N*E*W FOB shows in Europe: Do you have tickets? poll
- Patrick Stump on ZM Radio vid
- Nationalities of FOB-fans poll
Sunwear in Maryland heights by Overland Optical Family Eyecare
Sunwear & Eyeglasses are now a must-have fashion accessory. With new looks, colors, shapes and fashionable options these days eyeglasses can enhance just about any
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Discounts 50% off Second Pair Of Eyeglasses
50% off second pair of eyeglasses when using insurance on your pair or when purchasing a year supply of contacts. Some restrictions may apply. Offer
The Evolution of Patrick Stump
In honor of our favorite Soul Punk's 27th birthday, here's a gallery of his best looks. He's a little man, also evil, also into hats
back when i was a ock
when i won backstage passes at the Nintendo fusion tour '07
Dance, Dance
Memories Credit goes to FallOutBoyVEVO on youtube
Patrick's changing!!
Patrick Stump now has twitter and a solo album coming out!! YAY!!!! :D (plus how cute is this pic! its like '10 years younger'!)
Believers Never Die Slideshow
I made a slideshow of the Toronto Concert on May 5, 2009 of the FOB show. It was a great night for me to go
Fall Out Boy on Switch!! (so funny!!!)
i have this on tape its that great!! this is from..october? or maybe march....(i think its october). Switch is a UK teens music show on


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Ghostbuster LEGO Set Official (video)
Ghostbusters fans have won a small victory with LEGO. The 30th Anniversary Ghostbuster set designed by LEGO fan Brent Waller will be an official LEGO product signed off by the LEGO's headquarters in Billund, Denmark…but only the Ecto-1 and the minifigs of the characters. The infamous Ghostbuster building won't be included. But if the car sells like crazy, lets all hope that they'll finally come to their senses and give customers the whole set that they've been wanting. But Waller wasn't the only Ghostbusters fan that created his own LEGO rendition. A while back, LEGO builder Alex Jones, (aka Orion Pax within the LEGO world) created his own Ghostbusters headquarters that featured intricate detail that perfectly captured everything that you see in the movies. The video also announces other new LEGO sets that will hit shelves shortly.
Kristie Bertucci
Kristie Bertucci is an L.A.-based writer, who can't live without her MacBook Pro. When she's not writing, she's either reading or shopping (online, of course) and loves lazy days so she can catch up on her DVR-recorded shows and movies. She's definitely a Mac girl, she loves music and is currently on a mission to to have an insane and enviable iTunes library.


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search for a card
Result of the search for the collectible card:
The following 5 users match with the requested search. Click on their names to contact them.
For some advice on how to trade cards click here.
- isccatm LV11 (Mexico-San Luis de Potosi)
- german_lopez_31 LV4 (Chile-Santiago)
- diiego LV10 (Chile-Santiago)
- paulo25 LV5 (Chile-Valparaíso)
- jaspar_17 LV2 (Chile-Santiago)
When you register you will be able to search for all your cards in one go, and we will send you any new results of the search every day by email.


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Eddie Macaluso
Iona College baseball senior Eddie Macaluso was named the Buffalo Wild Wings Student-Athlete of the Week after a solid outing against Canisius.
Macaluso picked up his fourth victory of the season, as the southpaw hurler allowed just one-earned run on five hits and struck out three Golden Griffs before barely touching the 100-pitch plateau.
Macaluso surrendered an unearned run in the opening inning after a runner scored on a hit from third base after he advanced on a passed ball from second base. The only other blemish to the starters line came in the sixth-inning when he allowed a double and then an RBI triple.
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Peabody Candy Cane Martini
The Peabody has taken the candy cane from stocking stuffer to festive holiday cocktail with this unique and refreshing drink.
Level: Easy
Advertisement - Continue Reading Below
- 1½ oz. vodka
- 1 tsp. Peppermint Schnapps
- Crushed candy canes
- candy canes
- Mix all ingredients with ice in a shaker. Strain into a chilled cocktail glass. Garnish with a small candy cane or create a candy cane "rimmer" with crushed candy canes.
More recipes like this
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Insanely Easy Weeknight Dinners To Try This Week
These impressively easy, no-brainer ideas will get you to the weekend.
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Legislative committee studies Bauer proposal for collecting DNA from felony suspects
For immediate release:
Aug. 18, 2015
INDIANAPOLIS - The Interim Study Committee on Corrections & Criminal Code today listened to testimony about State Rep. Pat Bauer's (D-South Bend) legislative proposal to collect DNA samples from people arrested on felony charges.
Bauer and Jayann Sepich, a mother whose 22-year-old daughter, Katie, was brutally raped and murdered in New Mexico in 2003, testified that the collection of DNA from felony suspects has proven instrumental in solving crimes and of exonerating innocent people wrongly convicted of crimes in the 28 states that have enacted similar legislation.
"We know this (DNA collection) has the power to prevent unbearable pain that can be visited on so many families," Sepich told committee members. "And I am very intimately acquainted with that pain, because I still live through it."
Bauer initially proposed the idea in House Bill 1551, a measure that did not advance in the 2015 session. However, legislative leaders found the idea behind the bill compelling enough to ask for additional study.
"All states participate in the national DNA database called Combined DNA Index System or CODIS," explained Bauer. "However, 28 states have expanded their efforts by enabling police officers to collect a DNA sample when a felony suspect is booked. That information is then entered into the state's CODIS database.
"The database of people previously arrested or convicted of felonies is checked to see if there are matches," continued Bauer. "If one is found, the information is forwarded to investigators to determine whether additional charges should be filed. If there are no matches and the person is acquitted of the felony charges or they are dropped, then the DNA sample will be expunged from the database."
Sepich told study committee members that the real power of the DNA samples goes beyond the capturing of criminals.
"DNA helps us identify criminals," Sepich said. "It helps us solve crimes. But the power in DNA, especially taking it upon arrest, is not just in solving crimes, but preventing them."
Sepich then went on to give examples of how DNA collection could have prevented crimes. She said a study in Chicago tracked the history of eight convicted felons. She contends that if DNA had been taken during the first arrest of each of those men that 53 rapes and murders would have been prevented.
A 2013 U.S. Supreme Court ruling determined that requiring a forensic DNA sample upon felony arrest preserves constitutional rights and is a reasonable and legitimate police booking procedure, much like fingerprinting or photographing someone who has been arrested.
"The collection of forensic DNA has proven to be a highly useful tool in identifying individuals who have committed multiple crimes," Bauer said.
"The DNA data has also helped clear people who have been falsely accused of crimes. A study by an economist at the University of Virginia determined that a savings of more than $21 billion was realized in the United States, in one year alone, by expanding U.S. databases to include more offender profiles."
Breaking that figure down, Sepich told committee members that the same study showed that for every $30 invested in DNA collection, states saved $27,000 in taxpayer money.
Once the Interim Study Committee on Corrections & Criminal Code completes its examination of various issues, the members will determine whether or not to recommend legislation for the upcoming 2016 session of the Indiana General Assembly.


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joes_crystal's Mom Answers Activity
joes_crystal is a star in these topics:
Pregnancy > Baby Showers (4 helpful answers)
Recent Activity | Asked | Answered
baby showers for 2nd babies?
Most recent answer (02/15/2011):
i say of course, you wanna celebrate every baby. just because your having a baby shower doesnt mean people have to buy tons of baby thing...posted by joes_crystal
Should I throw my own baby shower?
Most recent answer (09/25/2015):
My mom passed away when I was around 14 weeks pregnant, and I felt that I wouldn't be able to handle a baby shower. My husband really...posted by cbk2001


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What do you guys think of this stuff? I know it's relabeled by FL and manufactured by a UK company. It's supposed to be pretty good. Now what my criteria is:
1. I have fairly limited access to an outdoor water supply.
2. Ride in the mud, gets thickly caked on in the winter.
3. Will this remove the crud and sand stuck to the grease on the pivot seals so I can safely open them up?
4. Ano and PC finishes
I figured bringing this to the Turner board would be best, since you guys know what works on the Turner finishes.
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As our Summer has been a combination of Rivieria sunshine & a scene from Noah's Ark I think we should all just embrace the season change as at least we will know what to wear in the morning, plus Desserts are so much better when it is colder…..welcome back to "The Crumble", we have missed you. Possibly not quite as much as Mr Keith Stott!!!!
We are also really excited to be introducing lots of other new dishes to our menu, and as always our team of Chefs have worked really hard to source some excellent locally sourced seasonal produce.
Stand out dishes for us when we tried them all (I know it is a hard job but somebody had to quality control them on your behalf!) were the Madras Spiced Salmon and the Wild Mushroom & Tarragon Strudel with not a vegetarian between us it really is lovely. The Featherblade of Beef is also a delicious dish and goes perfectly with a bottle of Cabernet Sauvignon (Bin 31) and if you want to hang on to a little bit of summer our Wild Boar Rose (Bin 37) is an excellent half way house.
Final News…we will now be opening in the evening from 5.30pm instead of 6 by popular demand. So for those of you who work at a normal time you don't have to wait for us anymore we will be here and open!
So Big Jumpers means we can all start eating Desserts again!!!
Happy Nearly Autumn,
Ellie, Ben, Vinny, Michael, Jenna, Magda, Gemma, Kirstin, Joanna, Adis, Lotte, Felix, Hamish, Avdyl, Darek, Woj, Andrew & Jan
PS. Christmas Menu is ready and the organised brigade are already booking tables – but we won't talk about that yet!!!


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Princess Maker 2
Published by
Developed by
3DO, DOS, FM Towns, GP32, Macintosh, PC-98, SEGA Saturn, TurboGrafx CD
[add review | score detail | rate game]
Related Web Sites
- Awful Anime review (A humorous review on Something Awful)
- Nuriko's Princess Maker 2 Page (Contains a brief description of the game as well as a fairly extensive game guide along with maps of the different areas.)
- Press Release (Entitled "Adventions Licenses Princess Maker 2 from Anime Prioneers Gainax.")
- Princess Maker 2 (This official story explaining what happened to the English language release of PM2.)
Searches and Links
Amazon ; an online store selling new and used computer and video games.
Google ; search engine that ranks by popularity
eBay ; Many older games listed on MobyGames are out of print. Auction sites like eBay are the best place to find them.
*Designated trademarks and brands are the property of their respective owners.


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December 03, 2013
The financially troubled parent company to several fleets, YRC Worldwide, is looking to investors to help it pay off some debt, according to the Journal of Commerce.
It hopes to raise nearly $29 million by selling 3 million shares of stock to help repay part of more than $69 million that is due in mid-February.
The move comes as the company is working to hammer out a new long-term labor contract with Teamster Union employees, in order to get other financing.
More details are available from the Journal of Commerce.
We offer e-newsletters that deliver targeted news and information for the entire fleet industry.
The expert, Mark Betner from CITGO, will answer your questions
The expert, Rence Oliphant from Hendrickson, will answer your questions
Relay Bypass Kit Monitors Amperage Draw
Set of Tools Cleans Male Pins on Terminals
SecureFuel Provides Transparent Fuel Payments
McLeod Offers 'Branded' Driver App for Fleets


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Jul 21
7573273456 for tickets
Nov 4
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Performing & debuting 3 hit singles with Greedy Boy Ent (Miami Based) recording artist Yung Key. Songs include "Shake Dat Ass" strip club banger & "Look At Me Boy" raggae type track. You Don't Want To Miss This...
Label: Black Entertiainer (C) 2013
P.K.A. "Rio Rose" was Born in Norfolk, Virginia & raised in Virginia Beach, Virginia, Rio Rose has
Developed a Unique style sound like no other artist out. Rio Rose is blessed with a brilliant charisma in his flow, astounding production prowess & gripping lyricism. This sensuous rapper has an al...See Full Bio


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Ramee Group of HotelsOpen
Ramee Group of Hotels India6 hotels | Sorted by Popularity
Ramee Guestline Hotel, Tirupati
2000 onwards
Rank 20Ranked 20 of 170 hotels in Tirupati
Average rating81 Ratings & 53 Reviews
"Hotel located bit far way from the Bus Stop and A/c is the room was good. Washroom was very good..."Pawan kumar , Kurnool, 2 months ago
Ramee Guestline Hotel, Bangalore
3000 onwards
Rank 137Ranked 137 of 1635 hotels in Bangalore
Average rating65 Ratings & 46 Reviews
"Ramee Guestline Hotel was good. For activities it was great as we were 14 people and we had lots..."Purushothan , Delhi, 2 months ago
Ramee Grand Hotel, Pune
4200 onwards
Rank 76Ranked 76 of 701 hotels in Pune
Average rating39 Ratings & 20 Reviews
"Pune city is one of the cool and happening place of West. Ramee Grand has good ambience and it..."Amaresh , Delhi, 2 months ago
Ramee Guestline Hotel - Juhu, Mumbai
5000 onwards
Rank 104Ranked 104 of 1060 hotels in Mumbai
Average rating36 Ratings & 19 Reviews
"Once you enter the huge premises of this place, you feel you have been transported elsewhere...."Pramod , Mumbai, Oct 21, 2014
Ramee Guestline- Dadar, Mumbai
6000 onwards
Rank 62Ranked 62 of 1060 hotels in Mumbai
Average rating33 Ratings & 14 Reviews
"Ramee Guestline is very famous in Dadar. It has many facilities. It has nice parking. It is on..."Dinesh patel , Delhi, 1 month ago
Ramee Guestline Hotel Khar, Mumbai
5000 onwards
Rank 148Ranked 148 of 1060 hotels in Mumbai
Average rating13 Ratings & 8 Reviews
"It's a good place to stay in the heart of the city. All transports are available from the door..."Sujay , Bangalore, Nov 25, 2014


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patch antenna definition
A patch antenna is a wafer-like directional antenna suitable for covering single-floor small offices, small stores and other indoor locations where access points cannot be placed centrally. Patch antennas produce hemispherical coverage, spreading away from the mount point at a width of 30 to 180 degrees.
Making Networks Virtual: The Latest on SDN Technologies
An exploration of Software-Defined Networking (SDN) technologies, network virtualization fundamentals, and the latest developments for both – helping IT pros adapt them to a modern hybrid network architecture.
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Patch antennas are also known as panel, flat panel or microstrip antennas. They are formed by overlaying two metallic plates, one larger than the other, with a dielectric sheet in the middle. This type of antenna is usually encased in white or black plastic, not only to protect the antenna, but also to make it easy to mount. Because they are flat, thin and lightweight, patch antennas are often hung on walls or ceilings where they remain visually unobtrusive and blend easily into the background.
Read more:
Understanding wireless antennas
Dig Deeper on Wireless LAN Implementation
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Photo Galleries
< MyNorthwest
Humane Society fetes actor James Cromwell at gala
Humane Society fetes actor James Cromwell at gala
4 of 4
FILE - This July 16, 2004, file photo shows a gray wolf at the Wildlife Science Center in Forest Lake, Minn. The Humane Society of the United States and other animal welfare groups filed a lawsuit Feb. 12, 2013 in federal court in the District of Columbia to restore federal protections for gray wolves in the western Great Lakes region that were lifted last year. Turning 60 in 2014, the Humane Society of the United States has millions of supporters, about 630 employees, a budget of $170 million and a long list of successes that has improved life for millions of animals. (AP Photo/Dawn Villella, file)
Photo by Associated Press
Photo by Associated Press
4 of 4
Original article: Humane Society fetes actor James Cromwell at gala
More Photo Galleries
Week in photos
Photos taken by the Associated Press Sept. 28 to Oct. 2.
Stargazers treated to supermoon eclipse
Stargazers were treated to a rare astronomical phenomenon with a total lunar eclipse combined with a so-called supermoon.
Week in photos
Photos from the Associated Press taken from around the world.
Four killed in Aurora Avenue Bridge crash in Seattle
The four people killed when a charter bus and Ride the Ducks vehicle collided were students from North Seattle College, The Seattle Times reports.
Big-name business leaders meet China's president in Seattle
Business leaders from Apple, Honeywell, Disney, Microsoft, Starbucks, Dow Chemical, Amazon, IBM, and many more attended a Wednesday morning meeting with the president of China.
Week in photos
Photos taken from around the world during Sept. 14-18.
Week in photos
Check out the week in photos from all over the world.


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A bit of a hike (about 1-2km) but well worth it! We went early in the day (8ish) in October (green season) and had the place to ourselves! The only fee that was associated with this was for parking.
Great hike! You have to do a little scramble to get to the upper falls. We did a zipline and ended up at the upper falls and pool
If you start at the bridge before entering the town be aware. My husband and I were greeted by a tico. His name to me is "Golom" from the "Lord of the rings" movies. He said he would show us the "way". He scooted around on the slippery rocks like nothing. HE HAD CROCS ON. Get CROCS with bottom soles that look like something to clean dirty dishes with. He never slipped and actually took them off and had me step on them in very odd angle spots. My expensive Keen sandels slipped badly. The" way", was insane. Major slippery rocks, at different inclines, crossing the river, scaling rocks. If you are not fit take a different path to see the falls. We made it to the 80 ft. fall. My husband dived off a cliff he had to climb up, but said it was insane and could barely catch his breath when he was done. It was beautiful. No Monkeys. They always say " you'll see monkeys" Wrong. We were there for ten days, we saw them twice. Although, you did hear them around. Obviously, you then had to reverse your course and go back the same way.
there are 3 Waterfalls, and they are awesome. On the first one you can go for a swim. If you hike up to the third one, you can jump into the second one and also there is a tarzan swing to have a lot of fun. don´t go in flip flops its a pretty steep hike.
Coming from the USA I have seen a lot of water falls, but this one was warm! I couldnt believe it!We started our walk from our hotel room in Montezuma, it was a fast easy walk to the trail. On the way there and back we purchased a drink from a guy on.the street..coconut water mm so drink some colons with you ;)The hike was very mellow, not steep at all. we only had time for the first fall. If you have time I would check this out and go for a swim!
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Common image questions in regards to developing WP7 applications which are all related to the same issue of Build Action.
- Why won't my images show in my WP7 app?
- Why aren't the Application Icon buttons showing in my WP7 app?
- Why aren't the images showing up in my CONTROL-NAME control?
- Which path do I use to show my images, in examples I see two different ways?
- What is the difference between Content and Resource in Build Action property?
- What is "Build Action"?
Side Note I've been seeing these questions (or question) over, and over again. When you start seeing it every 4 or 5 questions, I think there's something wrong. Perhaps someone could turn this into a Community Wiki so we can keep future WP7 questions relevant and more unique?


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Khushi and Arnav
Khushi and Arnav
Courtesy: Iss Pyaar Ko Kya Naam Doon
Popular Search Terms: arnav, khushi arnav photos, khushi and arnav pics, www.kushi and arnav.com, khushi and arnav image, photo arnav khushi
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View: 105240 Comments: 298
Celebrity : Sanaya Irani , Barun Sobti
TV Show : Iss Pyaar Ko Kya Naam Doon? [ Iss Pyaar Ko Kya Naam Doon? Forum ]
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Love u Barun
Proud to b a Sobtian.
!!!!! Miss you Sanaya Irani lots and lots !!!!!!
Sanaya Irani
Waiting for for you to back on TV !!!!
Edited on:23 May 2015 at 7:30pm
Love Arshi...& Miss them
Sanaya Irani...boring without you, hurry back
Barun sobti keep rocking and no one can be like you in everything
Tha King of expressions
Love you a lot Barun
Missing you so much.!!!!!!
Sanaya Irani you are the best love you
Love you loads Barun !!!!
Stay Blessed !!
Missing you so badly Sanaya irani
Come back to our screens soon
Arnav/Barun had such a lovely, warm aura around him!


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ENGLEWOOD, Colo., Nov. 13 /PRNewswire/ -- On November 10, 2009, Judge David R. Herndon, the federal judge presiding over the Yasmin and Yaz (Drospirenone) Marketing Sales Practices and Product Liability Multidistrict Litigation MDL #2100 in the Southern District of Illinois, appointed Michael S. Burg as one of three Co-Lead Counsel to serve on the Plaintiffs' Steering Committee. The PSC reports directly to Judge Herndon, and is responsible for conducting pre-trial proceedings on behalf of all plaintiffs who have cases in the MDL. Mr. Burg has also served as a member of the Plaintiff Steering Committee for the Zyprexa Multidistrict Litigation in the Eastern District of New York, as a member of the State-Federal Liaison Committee for the Vioxx Multidistrict Litigation in the Eastern District of Louisiana, and as Co-Lead Counsel for the Ortho Evra Products Liability Multidistrict Litigation in the Northern District of Ohio.
Burg Simpson Eldredge Hersh & Jardine, P.C. ("Burg Simpson") is an Englewood, Colorado based law firm with a national practice and national reputation. In addition to handling extremely complex cases in Colorado, Burg Simpson is a leader in complex Multidistrict Litigation and has been appointed as Lead or Liaison counsel in several MDLs in the last five years. These leadership appointments demonstrate Burg Simpson's ability to handle complex litigation on a mass scale and are demonstrative of various Courts' recognition of Burg Simpson's ability to handle such complex and large-scale litigation.
When asked to comment, Michael Burg said, "My leadership role in this proceeding is testament to the reputation Burg Simpson has achieved in the mass torts arena as a result of its excellent work in previous MDL proceedings."
Yaz and Yasmin are birth control pills manufactured by Bayer, which contain a progestin known as Drospirenone. The claims being asserted are that Yaz and Yasmin cause clotting injurie
|SOURCE Burg Simpson Eldredge Hersh & Jardine, P.C.
Copyright©2009 PR Newswire.
All rights reserved


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You are always welcome here at our free ringtones website, where you can easily download hot ringtones for your mobile phone. Today we have a ringtone of "Fur Elise" by Richard Clayderman as well as 998 other ringtones by Richard Clayderman. "Fur Elise" is a top-rated song from the "Concerto" album that was composed by Richard Clayderman at their recording studio together with other 11 tracks. You can listen to all 5 Richard Clayderman – "Fur Elise" ringtone variations available here and download it for free directly to your smart phone. You can also listen to other 16 albums produced by Richard Clayderman for all time. "Fur Elise" is referred to PIANO, and Audiko offer a huge amount of PIANO melodies absolutely for free. And finally, we have collected lyrics for this track and you can view it here as well. So feel free to browse, listen, download ringtones at Audiko.net. Make your phone sound cool!
Richard Clayderman Fur Elise Ringtone
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Updated: September 11, 2008, 5:00 PM ETBy EXPN.com | Volcom
Over the course of the month of May, the Volcom skate team posted up in an apartment in Brooklyn, NY with the sole purpose of skating epic New York spots. While we were out there we did a ton of filming, and since we had such a great crew and some amazing filmerswe decided to team up with the boys over at Fuel TV to bring you a 30-minute show on our trip.
The show is called, "All The Days Roll Into One" and will premiere on Fuel TV on October 20th at 8 pmuntil then we will be ...
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