Biomedical subjects

P R Croft

Publications and source records attributed to P R Croft.

At least 19 recordsLinked to original sources

PubMed1997

Psychosocial factors in the workplace--do they predict new episodes of low back pain? Evidence from the South Manchester Back Pain Study.

STUDY DESIGN: A prospective, population-based cohort study of working adults. OBJECTIVES: To determine whether work-related psychosocial factors and social status predict the occurrence of new episodes of low back pain and influence consultation behavior. SUMMARY AND BACKGROUND DATA: Dissatisfaction with work and social status has been associated with low back pain in several studies; few of these studies have been prospective or population based. METHODS: An initial postal survey was returned by 4,501 (59%) adults (18-75 years old) registered with two primary care practices. From this, a cohort of 1,412 people currently in employment and free of low back pain was identified, and baseline information on work-related psychosocial factors and psychologic distress was obtained. Social class was derived from current occupation using a standardized classification. New episodes of low back pain occurring in the next 12 months were identified by continuous monitoring of primary care consulters and by mailing a second questionnaire a year later to identify occurrences of low back pain for which no consultation was sought. RESULTS: The baseline cross-sectional survey showed modest but significant associations between low back pain and perceived inadequacy of income (risk ratio 1.3), dissatisfaction with work (risk ratio 1.4) and social class IV/V (risk ratio 1.2). In the follow-up year, the risk of reporting low back pain for which no consultation was sought doubled in those dissatisfied with their work. Both perceived inadequacy of income (odds ratio 3.6) and social class IV/V (odds ratio 4.8) were strongly associated with consulting with a new episode of low back pain during the follow-up year, an association more marked in women. The associations with work dissatisfaction and perceived adequacy of income were not explained by general psychologic distress or social status. CONCLUSION: People dissatisfied with work are more likely to report low back pain for which they do not consult a physician, whereas lower social status and perceived inadequacy of income are independent risks for working people to seek consultation because of low back pain.

Adult↗

PubMed1997

Employment and physical work activities as predictors of future low back pain.

STUDY DESIGN: A population-based longitudinal study conducted in northwest England for a 12-month period involving adults aged 18-75 years. OBJECTIVES: To determine physical factors related to employment that predict a new episode of low back pain. SUMMARY OF BACKGROUND DATA: Most epidemiologic studies that have examined the relation between occupation and back pain have been cross-sectional or retrospective in design. Because workers who have experienced low back pain may have changed jobs or work activities, it is important to use longitudinal studies that define "exposures" before the onset of symptoms. METHODS: From adults registered with two general practices in northwest England, 1412 people who were currently in employment and free of low back pain were identified. A lifetime occupational history was recorded for all participants, with details of activities performed in each occupation. Data on consultations for low back pain during the follow-up year were collected through computerized medical records, whereas those who had not consulted with low back pain were sent another questionnaire at the end of the 1-year follow-up. RESULTS: An increased risk of a new episode of low back pain was found in those whose jobs involved lifting/pulling/pushing objects of at least 25 lbs, or whose jobs involved prolonged periods of standing or walking. Risks were, in general, greater in women, for a first ever episode of back pain and for back pain that led to a general practice consultation. No clear relation between years of exposure to such factors and magnitude of risk was evident. CONCLUSIONS: Occupational activities, particularly in women, such as working with heavy weights or lengthy periods of standing or walking, were associated with the occurrence of low back pain. Short-term influences may be more important in the occurrence of new episodes rather than cumulative lifetime exposure, and emphasize that such morbidity may be avoidable.

Adult↗

PubMed1997

Prevalence of shoulder pain in the community: the influence of case definition.

OBJECTIVE: To compare estimates of the occurrence of shoulder pain according to (a) different approaches to defining 'shoulder' and (b) restricting the definition to only include those with associated disability. METHODS: A postal questionnaire survey was sent to a sample of 500 patients registered with a general practice in south Manchester. After additional mailings to non-responders, 312 questionnaires were returned (66% adjusted response rate). Four definitions of shoulder pain were used to estimate the occurrence of symptoms derived from answers to the questionnaire. Two were based on questions asking directly about pain in the shoulder and the upper trunk and neck region respectively and two were based on markings on a pain drawing in the shoulder complex and the upper trunk respectively. To determine the occurrence of disabling shoulder pain responders were subsequently approached for interview. Of the responders, 232 (74%) were successfully interviewed. Those indicating that they were suffering from 'current' shoulder symptoms, pain on the day of interview, were asked to complete a short, 23 item, questionnaire enquiring about disability in daily living associated with such symptoms. RESULTS: In total 160 (51%) people reported shoulder pain according to at least one definition. This one month period prevalence ranged from 31% to 48% across the four definitions with the lowest estimate being for the question asking directly about shoulder symptoms. In total 84 people (27% of all respondents) answered positively to all four definitions. Only seven people who answered positively when asked directly about shoulder pain did not indicate symptoms on the pain drawing in the shoulder complex. By contrast 65 (30%) of those answering negatively to the direct question about shoulder pain indicated symptoms on the pain drawing in the upper trunk region or answered positively to the direct question about pain in the upper trunk or neck region. However only 19 (9%) of those answering negatively to the direct question indicated symptoms in the shoulder complex on the pain drawing, compared with 38 (18%) indicating symptoms in the upper trunk region and 59 (27%) symptoms in the upper trunk and neck region. Limiting the definition to only include current symptoms with some associated disability (at least one item on the disability questionnaire being answered positively) restricted the point prevalence to 20% (n = 46). CONCLUSIONS: Using a pain drawing based definition with case ascertainment restricted to an area in and around the shoulder complex is recommended for surveys assessing the occurrence of shoulder symptoms in the general population. To solve the problem of the poor specificity associated with symptom based definitions it is useful to incorporate an additional classification to restrict the definition to more disabling problems.

Adolescent↗

PubMed1997

Occupational factors related to shoulder pain and disability.

OBJECTIVES: To determine, in a population based study, the influence of occupational factors on the occurrence of shoulder pain and disability. METHODS: A random sample of patients was selected from the register of a general practice in the Greater Manchester area of the United Kingdom. Information was collected by a posted questionnaire with specific enquiries about symptoms in the shoulder region and related disability. A lifetime occupational history was obtained including physical exposures, working conditions, and psychosocial aspects of each workplace. Analysis has been conducted as a case-control study, comparing occupational exposures at the time of onset of symptoms in those with shoulder pain and disability with corresponding occupational exposures in those without shoulder pain and disability. RESULTS: An increased risk of shoulder pain and disability in men was associated with carrying weights on one shoulder (relative risk (RR) 5.5, 95% confidence interval (95% CI) 1.8 to 17), whereas those who reported working with hands above shoulder level, using wrists or arms in a repetitive way, or stretching down to reach below knee level had about twice the risk of shoulder pain and disability. Men working frequently in very cold or damp conditions had a fourfold and sixfold risk respectively of shoulder pain and disability. Reporting of shoulder pain and disability was also more common among men and women who reported that their work caused a lot of stress (RR 1.9, 95% CI 0.9 to 4.1) or was very monotonous (RR 2.7, 95% CI 1.3 to 5.4). The relations between physical exposures, working conditions, and psychosocial factors were independent. CONCLUSIONS: This population based study has shown that physical activities carried out at work, the physical conditions under which the work is conducted, psychosocial aspects of work, or the working environment are all independently related to the occurrence of shoulder symptoms and disability, emphasising the multifactorial nature of this condition.

Activities of Daily Living↗

PubMed1996

Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study.

BACKGROUND: A pathological cause cannot be identified for most new episodes of low back pain (LBP) presenting to the general practitioner. One important potential influence on susceptibility is previous pain experience. To accurately investigate the contribution of this phenomenon to the onset of new episodes of LBP a prospective population study is required. AIMS: To determine the relationship of prior pain in the back and other musculoskeletal sites to risk of subsequent new episodes of LBP. METHODS: The population studied included all 2715 adults from the South Manchester Back Pain Study who were free of LBP during the month prior to the baseline survey. At baseline a detailed musculoskeletal pain history was obtained. New episodes of LBP over the subsequent 12 months were ascertained by: (i) prospectively monitoring all primary care consultations in the study cohort (consulting episodes) and (ii) a follow-up survey after 1 year to determine new episodes during that 12-month period not leading to consultation (non-consulting episodes). RESULTS: The 12-month cumulative incidence of new consulting episodes was 3% in males and 5% in females, and for new non-consulting episodes 31% in males and 32% in females. Those with a history of previous LBP had twice the rate of new episodes, both consulting and non-consulting, compared to those with no LBP in the past. Neck pain or pain in other musculoskeletal sites at baseline also doubled the risk of a subsequent new episode of LBP. Adjusting for psychological distress and the other pain variables had little influence on the findings. CONCLUSION: In those currently free of LBP a previous history of the symptom substantially increases the risk of a further episode, with pain in other sites an equally strong independent predictor of subsequent LBP.

Adolescent↗

PubMed1996

The frequency of restricted range of movement in individuals with self-reported shoulder pain: results from a population-based survey.

Prevalence studies suggest that shoulder pain is very common (7-20%) in the adult population, though little is known about the severity and impact of such pain. Disability results, in part, from the restriction of movement and we therefore determined the frequency of restricted shoulder movement in individuals in a general population sample reporting shoulder pain and associated disability. In all, 232 individuals were interviewed about shoulder pain and related disability, and their range of shoulder movement in the following planes was measured: elevation, forward flexion, backward flexion, external rotation and internal rotation, together with the minimum difference achieved between the tip of a thumb and the spinous process of C7. In total, 48 (21%) subjects reported current pain and disability in one or both shoulders. Using receiver operating characteristic (ROC) analysis, cut-offs for restricted movements were selected at the point of maximal discrimination between painful and pain-free shoulders. There was considerable overlap in the distribution of range of movement, at all six sites, between these two groups. The highest positive predictive value for pain was observed in restriction of the thumb to cervical spine movement (53%), but this also had the lowest negative predictive value. By contrast, the highest negative predictive value was observed for restriction of external rotation (96%). Restriction in any plane was observed in 77% of those individuals with pain, but was also present in half of those without pain. In summary, most people with self-reported shoulder pain in the community do not have widespread restriction of movement. Reduction in external rotation was the most discriminatory, but it is necessary to examine movement in multiple planes to assess the true burden of shoulder pain in the community.

Adolescent↗

PubMed1996

Interobserver reliability in measuring flexion, internal rotation, and external rotation of the hip using a plurimeter.

OBJECTIVE: To determine reliability of the measurement of hip movements (flexion, internal rotation, and external rotation) between medical practitioners. METHODS: Six clinicians carried out measurements of hip movements on each of six patients with osteoarthritis of one hip, using a specifically designed plurimeter. RESULTS: There was no evidence of any systematic difference between medical practitioners in the measurement of hip flexion, internal rotation, or external rotation. The degree of agreement was greatest for hip flexion. CONCLUSIONS: This study has shown that measurement of range of movement at the hip is repeatable between practitioners using a simple plurimeter and may represent an examination that is suitable for monitoring progress and treatment.

Evaluation Studies as Topic↗

PubMed1996

Osteoarthritis of the hip and acetabular dysplasia in Nigerian men.

OBJECTIVE: To determine the prevalence of osteoarthritis (OA) of the hip and of acetabular dysplasia and the association between these conditions in 63 male patients (126 hips) aged 60 to 75 years who had undergone intravenous urography for nonarthritic indications at the University of Maiduguri Teaching Hospital, Nigeria. METHODS: Two definitions of radiographic OA were employed: the first based on joint space measurement and the second on global assessment of features of OA. Acetabular dysplasia was defined as a center-edge angle of <25 degrees or an acetabular depth of <9 mm. Results were compared with a British study that used similar methods. RESULTS: The prevalence of a minimal joint space < or = 2.5 mm was 7.0% in the hips of Nigerian men compared with 13.2% in the British study. The prevalence of acetabular dysplasia in the Nigerian population based on center-edge angle and acetabular depth was 3.3 and 2.9%, respectively. No dysplastic hip in the Nigerian population, defined by either measurement, showed osteoarthritic change. CONCLUSION: Our study shows a lower prevalence of hip OA in elderly Nigerian men compared with similar aged men in Britain. The prevalence of dysplasia in the 2 populations was similar, and so cannot account for the difference in OA prevalence. Furthermore, shallow acetabula were not associated with OA of the hip in the Nigerian men.

Acetabulum↗

PubMed1996

The natural history of chronic pain in the community: a better prognosis than in the clinic?

OBJECTIVE: To evaluate the predictors of improvement at 2 years in subjects with chronic widespread pain ascertained from a community survey. METHODS: As part of a community based epidemiological survey on the occurrence of pain, 141 subjects (age range 24-74 years; 44 men, 97 women) were selected for more detailed assessment. Followup information on pain experience was collected at a median of 27 months (range 15-35). Subjects were categorized according to whether they had no pain, chronic widespread pain (according to the American College of Rheumatology criteria), or regional pain, both at initial assessment and followup. In addition, subjects were examined at both time periods for tender points. RESULTS: Of those with chronic widespread pain at initial assessment, 35% still had chronic widespread pain at followup, 50% regional pain, and 15% no pain. Of those originally with regional pain, 65% still had regional pain, 19% chronic widespread pain, and 16% no pain at followup. Logistic regression analysis was conducted to examine factors among those with chronic widespread pain associated with still having these symptoms at followup. Female sex, older age, leaving school at a young age, high tender point count, high levels of fatigue, or additional physical or psychological symptoms were all associated with symptoms being less likely to resolve. CONCLUSION: Chronic widespread pain in the community has a generally good prognosis. However, those with additional symptoms associated with the fibromyalgia syndrome were more likely still to have chronic widespread pain 2 years later.

Adult↗

PubMed1996

Widespread pain: is an improved classification possible?

OBJECTIVE: The classification of widespread pain, proposed by the American College of Rheumatology (ACR) for use in the clinic as a screen for fibromyalgia, as described, does not require truly widespread pain. Studies considering the epidemiology of widespread pain per se may therefore require a definition with greater face validity, which might also show enhanced associations with other physical and psychological measures. We aimed to develop a more coherent definition of widespread pain for use in epidemiological studies and to compare performance in identifying individuals with significant morbidity. METHODS: A group of 172 subjects who had participated in a community based study on the occurrence of pain were identified and categorized by their pain experience as indicated on line drawings of the body according to ACR definition and to a new, more stringent definition that required the presence of more diffuse limb pain. A number of other clinical and psychological measures were recorded for these individuals and the association between their pain status measures and these other variables was assessed and compared. RESULTS: Persons satisfying the newly proposed definition for chronic widespread pain, in comparison with those who satisfied only the present ACR definition, had a significantly higher score on the General Health Questionnaire [median difference (MD) 7.95% CI 1.13], a higher score on the Health and Fatigue Questionnaire (MD 10.95% CI 0.15), and greater problems with sleep (sleep problem score MD 4.95% CI 0.9). Those satisfying the new definition also had a greater number of tender points on examination (MD 3.95% CI -1.7). The morbidity of those satisfying only the present ACR definition was closer to persons who had regional pain. CONCLUSION: A redefinition of widespread pain has produced a group of subjects whose pain is (a) likely to be more "widespread" and (b) is associated more strongly with factors such as psychological disturbance, fatigue, sleep problems, and tender points, and may be more appropriate in epidemiological studies.

Adolescent↗

PubMed1995

Psychologic distress and low back pain. Evidence from a prospective study in the general population.

STUDY DESIGN: The present is a prospective population-based cohort study. OBJECTIVES: To determine whether psychologic distress in patients free of low back pain predicts future new episodes of such pain. SUMMARY OF BACKGROUND DATA: An associating between symptoms of depression and anxiety and low back pain has been described in cross-sectional studies. It is unclear whether this represents cause or effect or whether it is found only in chronic pain sufferers attending specialist clinics. There is a need to investigate this prospectively in the general population. METHODS: The study population was 4501 adults aged 18-75 years who responded to a questionnaire survey mailed to all those registered with two family practices in the United Kingdom. The survey inquired about low back pain during the previous month and included the 12-item General Health Questionnaire, a validated schedule for measuring psychologic distress in the general population. New episodes of low back pain during the 12 months after the survey were identified by two methods--continuous monitoring of all primary care consulters and a second postal survey at the end of the 12-month period to determine occurrences for which consultation had not been sought. RESULTS: Among 1638 subjects free of current low back pain in the baseline survey, the likelihood of developing a new episode of nonconsulting low back pain was higher among those with General Health Questionnaire scores in the upper third of the range compared with the lower third (adjusted odds ratio, 1.8 [1.4, 2.4]). This could not be explained either by age and gender differences or by general physical health. The increased risk persisted when analysis was restricted to those who at baseline could not recall ever having had low back pain in the past and to those with full-time employment. CONCLUSION: Symptoms of psychologic distress in individuals without back pain predict the subsequent onset of new episodes of low back pain. We calculate from these data that the proportion of new episodes of low back pain that might be attributable to such psychologic factors in the general population is 16%.

Adolescent↗

PubMed1995

Estimating the prevalence of low back pain in the general population. Evidence from the South Manchester Back Pain Survey.

STUDY DESIGN: This report gives the results of a population-based cross-sectional mailed questionnaire, with prospective follow-up of survey responders and nonresponders. OBJECTIVE: To determine the 1-month period prevalence of low back pain in an adult population in the United Kingdom and to estimate the effect of nonresponse bias. SUMMARY OF BACKGROUND DATA: Previous United Kingdom population studies have reported a 1-year period prevalence of low back pain of 37%. However, the definitions of low back pain have varied, and the influence of nonresponse rarely has been reported. METHODS: The study population was made up of all 7669 adults (18 to 75 years old) registered with two family practices in a sociodemographically mixed suburban area. The questionnaire, including a pain drawing to identify the site of any pain, was mailed to the entire study population. Two repeat mailings were sent to nonresponders. Family practice consultations about low back pain by individuals from the study population were monitored over the following 12 months using computerized records of all surgery contacts. RESULTS: Of the study population, 4501 (59%) responded. The 1-month period prevalence of low back pain was 39% (35% in males, 42% in females). The age distribution was unimodal, with peak prevalence in those aged 45 to 59 years old. Responders to the first mailing had a small but nonsignificant increase in prevalence compared with those who responded to the second or third mailing. Nonresponders had a subsequent consultation rate for low back pain that was 22% lower than that for the survey responders. CONCLUSIONS: After considering potential differences in nonresponders, the estimated 1-month prevalence of low back pain was between 35% and 37%. Prevalence figures in survey responders may overestimate the true population prevalence by a modest amount.

Adolescent↗

PubMed1995

Number of children as a risk factor for low back pain in men and women.

OBJECTIVE: To estimate the influence of the number of liveborn children on the risk of low back pain. METHODS: The study design was a cross-sectional population-based survey. The 4,501 respondents to a postal survey were asked to provide data on the occurrence of low back pain and on any children they had. Data on some potential confounding variables were also obtained. RESULTS: There was an increased risk of low back pain in those who were married compared with those who were unmarried, among both men (odds ratio 1.7) and women (odds ratio 1.6). Among married individuals, there was a linear trend of increasing risk with increasing numbers of children. CONCLUSION: The risk of low back pain is related more to childrearing than to childbearing, although this effect might be partially mediated by unknown confounders associated with increasing family size.

Adolescent↗

PubMed1994

Socioeconomic influences on back problems in the community in Britain.

OBJECTIVE: To determine the association between measures of socioeconomic status and reported back pain in a national sample survey of the adult population of Britain. DESIGN: Secondary analysis of a cross sectional interview survey (the Health and Lifestyle Survey). SETTING: Households in England, Wales, and Scotland. SUBJECTS: Those 9003 adults aged 18 years and above who agreed to an interview, from a study base of 12,254 private households that had been identified in a three stage sampling procedure based on electoral registers. Subjects who reported back pain in the month before interview were compared with all those who stated they had not experienced this symptom. MEASURES AND RESULTS: Women whose households were in the lowest income category were more likely to report back pain than those in the highest income group (odds ratio 1.6, 95% confidence interval (CI) 1.2, 2.1). In addition, women with no formal educational qualification were more likely to report back pain than women who had a qualification (odds ratio 1.5, 95% CI 1.0, 2.1). These associations were not explained by smoking, obesity, and coexistent depressive symptoms. In men the only socioeconomic link with back pain seemed to be manual occupation. CONCLUSIONS: These findings confirm the higher burden of back pain in the socially disadvantaged, but suggest that this cannot yet be explained by known risk factors for back trouble.

Adult↗

PubMed1994

Oral contraception and stroke. Evidence from the Royal College of General Practitioners' Oral Contraception Study.

BACKGROUND AND PURPOSE: A nested case-control analysis of data collected during the prospective Royal College of General Practitioners' Oral Contraception Study was performed to examine the relation between use of oral contraception and risk of stroke. METHODS: The 253 women who had a first-ever stroke (International Classification of Diseases, eighth revision, codes 4300 to 4389) or amaurosis fugax (code 3791) between 1968 and 1990 (case subjects) were compared with 759 women who did not have this diagnosis (control subjects). RESULTS: Smoking, social class, and history of hypertension were found to be important risk factors for stroke. Women who had ever used oral contraceptives had an increased risk of all stroke (odds ratio, 1.5; 95% confidence interval, 1.1 to 2.0, adjusted for smoking and social class) and of a fatal event (adjusted odds ratio, 2.3; 95% confidence interval, 1.2 to 4.4). A significant doubling of all stroke risk was observed among current users, an effect that was apparent in both smokers and nonsmokers. Former users had a small nonsignificant elevation in risk of all stroke but a stronger risk of a fatal event. The effects in former users appeared to be restricted to women who smoked. CONCLUSIONS: Current users of oral contraceptives appeared to be at increased risk of stroke. There is some evidence that former users may also have a persisting effect, although further research is needed to confirm these observations.

Adult↗

PubMed1990

Blood pressure measurement in adults: large cuffs for all?

STUDY OBJECTIVE: The aim of the study was to determine whether a single size of cuff for adult blood pressure measurements is appropriate for general clinical practice. DESIGN: The study was a prospective survey of a sample of adult blood pressure measurements using two cuffs with different bladder sizes (12 X 23 cm and 15 X 33 cm) in a randomised design using a random zero sphygmomanometer. SETTING: Blood pressures were measured in a general practice and in a hospital outpatient clinic. PARTICIPANTS: The participants were 35-60 year old men and women invited to attend a blood pressure screening programme in the general practice (n = 170), and 35-74 year old patients attending a general medical outpatients (n = 72). MEASUREMENTS AND MAIN RESULTS: The small cuff gave higher readings of systolic blood pressure than the large cuff (mean difference 4.4 mm Hg). The difference increased as systolic pressure increased but did not show a clear association with arm circumference. The small cuff also gave higher diastolic pressure readings (mean difference 3.0 mm Hg), but only when arm circumference exceeded 30 cm. The variability of the differences between readings from the two cuffs was wide, little affected by arm circumference, and was similar to the variability between measurements using the same cuff size. CONCLUSIONS: In terms of precision there is no basis for using two different cuff sizes unless it is physically difficult to obtain a reading with one or the other. Since readings with large cuffs are closer to intraarterial pressures in large arms, and the large cuff used here did not underestimate diastolic pressure in small arms, the large cuff alone could be recommended for general use.

Adult↗

PubMed1988

Incidence of acute otitis media in infants in a general practice.

A 12-month study of the incidence of acute otitis media in children under three years of age in an urban practice of 10 000 patients showed that acute otitis media accounted for one in 10 of all episodes of illness presented. In contrast to findings in Scandinavia and the USA the incidence of acute otitis media in the first year of life (11.5%) was lower than in the second year (28.6%). The study included a number of children in their third year and the incidence in this group was higher still (30.8%).The problems of defining acceptable diagnostic criteria for acute otitis media, and the relation of these diagnostic criteria to the differences in our results compared with previous studies are discussed.

Acute Disease↗

PubMed1986

How useful is weight reduction in the management of hypertension?

A group of previously untreated obese hypertensive patients were started on a weight reduction programme supervised by two dietitians working in a general practice surgery. It was stressed from the beginning of the programme that reducing blood pressure was the purpose of the diet. The results of follow-up after six months are presented together with results for a control group of obese hypertensive patients not receiving dietary advice or drug therapy, but being followed by the general practitioner. The weight, systolic blood pressure and diastolic blood pressure of the dieting hypertensive group were significantly lower than those of the non-dieting group after six months. However, the drop-out rate was significantly higher for the dieting group than for the non-dieting group.The results of a separate comparison between a control group of obese normotensive patients following the same dietary programme and the group of dieting obese hypertensive patients are also presented. Attendance rates and weight loss achieved were significantly better for the hypertensive group than for the normotensive group after 12 months.Weight reduction appears to be an effective first-line therapy for approximately 50% of obese patients with mild to moderate hypertension, and raised blood pressure appears to provide motivation for such patients to attend a dietitian's clinic and to lose weight.

Adult↗