Plant Lectin on Blood Agglutination

Lectin is a protein that is commonly found in certain plants such as grains   (wheat), legumes (soybeans and peanuts), and also can be found in potato, tomato, eggplant and pepper. It is found to be toxic, especially if the food containing it is undercooked. It causes damage to the gut wall in the stomach. Lectin’s toxicity may even cause rapid death. Lectin is a glycoprotein. As a glycoprotein, it is capable of binding to carbohydrate. It tends to bind to carbohydrates in specific and reversible manner. It is a protein that has binding site specific to carbohydrate. Because of this ability of lectin, it can cause agglutination of red blood cells. It does so by interaction with the sugar moieties of the cell wall leading to the clumping together of the cells. In blood agglutination by lectin, its active sites are the ones that bind to the sugar moieties present in the cell wall of the red blood cells These active sites are consists of certain amino acid residues. It was suggested that there are two or more amino acid residues that are present in the active site of lectin (cited in Sharon, 2007). Some of these amino acid forms hydrogen bonds with the hydroxyl group of the sugar or carbohydrate moiety. The other amino acids interact hydrophobically. Aside from these interactions, other kinds of interactions such as coordination with the metal, like interaction with the iron compound of the hemoglobin in the red blood cells, and electrostatic interaction might occur as well.   Further interaction of these active sites to other carbohydrate part of the blood cells results to large mass, then the clumping of cells occurs. Specificity of lectin towards carbohydrates depends on the kind of amino acid present in its active site. This made plant lectin found its usefulness in the field of medicine. One application of plant lectin is in determining blood group. Lectin can agglutinate specific types of erythrocytes. Different sources of lectin may have different active sites, therefore may dictate the kind of carbohydrate it binds with. Plant lectins, despite of the danger it may pose in our health, can be still useful in our life. As the study and research on lectin progresses, more benefits that we can derive from these compounds are revealed. Reference Sharon, N. (2007). Lectins: Carbohydrate-specific Reagents and Biological Recognition Molecules. Journal of Biological Chemistry, 282, 5, 2753-2764. Retrieved December 9,   2007 from, http://www.jbc.org/cgi/content/full/282/5/2753   

How the Bill of Rights Affects My Life

In 1791, the first ten amendments to the Constitution of the United States, also known as the Bill of Rights, become ratified. The Bill of Rights contained freedoms that Americans held to be their inalienable rights, and were so important that before ratifying the Constitution many states insisted on a promise of amendments guaranteeing individual rights. It was created to set limitations on the power of the United States government, protecting the natural rights of liberty and property. The Bill of Rights affects every Americans life, in many different ways: it sets standards for people to live by, it gives us the right to be citizens, and it also gives us freedom of speech. The Bill of Rights gives citizens freedom, but it also crosses the line between right and wrong. It punishes those that have done wrong, and rewards those that deserve it. It basically sets boundaries, not just for the lower or middle class, but for everyone. It reminds me of the Ten Commandments; rules are set for the people of the land, and when those rules are broken, justice is served. The Bill of Rights also gives us the right to be citizens of the United States. Not just anyone can become an actual citizens, most aliens in the U. S. are illegal. Why? Because the Bill of Rights put a stop to them becoming legal; and while that has its positives and negatives, I believe that it’s a good thing that not everyone can become a citizen of our great nation. The culture, the history, the population, all of it would be different if just anyone was allowed in. I wouldn’t be the person that I am today. Lastly, the Bill of Rights grants us the freedom of speech. The liberty to speak our minds and say what we need to say. In so many countries freedom of speech is banned, and here, sometimes even I take it for granted. Freedom of Speech is saying what you believe needs to be said, whether good or bad, without being punished for it. So, as one can see the Bill of Rights not only affects my life, but it also affects the lives of others around me. We the people are so blessed to be citizens of this nation, and to think that our ancestors (somewhere way down the line) were the great minds that created the Bill of Rights. The Bill of Rights sets standards for people to abide by, it grants select people to become citizens, and it gives us the freedom of speech; but, those are just the highlights and there’s more to that book than just its cover.

Oscar Wilde’s Essay

The following essay will examine British Literature in two fold: the first being that of Oscar Wilde’s contribution to British Literature and the second being feminism in British Literature in the 1800’s and on. It is hoped that focusing on two separate but entangled subjects will make the paper more accessible and therefore broader in scope and understanding of the reader to British Literature. Peacocks and Sunflowers:Oscar Wilde’s â€Å"Immoral Aestheticism† as an Escape from Reality into the Realm of Beauty Gilbert, the author’s alter ego in Oscar Wilde’s essay â€Å"The Critic as Artist† (originally published in 1888) declared that â€Å"[a]ll art is immoral† (274), and that phrase turned into a manifesto for the â€Å"immoral aestheticism† doctrine of the famous dandy who decorated rooms with peacock feathers and showed in public with a sunflower in the buttonhole. The writer was condemned by contemporaries as a breacher of Victorian ‘moral’ style of living but justified by successors. As Ellmann explains, â€Å"[s]in is more useful to society than martyrdom, since it is self-expressive not self-repressive† and thus contributes more significantly to the acute goal of â€Å"the liberation of the personality† (Ellmann 310). The man who used to be convicted of the offence of â€Å"gross indecency† is praised now as an icon of decadent and modernist style, a revolutionary in aesthetics and ethics, and a prophet of beauty which is above and outside any boundaries. The concept of art and beauty as abstract notions being unrelated to the narrowly dichotomous morals takes a key position in Wilde’s oeuvre. Today’s critics are never tired in their coining of appropriate definitions for the writer’s aesthetic programme. Gillespie, one of the most important researchers of Wilde’s legacy, viewed it as consisting of â€Å"paradoxical gestures† which â€Å"delineate an aesthetic that celebrates the impulse to integrate, amalgamate, and conjoin rather than separate, dissipate, or disperse† (37). Although the writer was aware of â€Å"the grave spiritual dangers involved in a life of immoral action and experiment† (Pearce 164), he underlined the right of an artist to be immoral for the sake of eternal beauty. In his aestheticism, Wilde was an admirer and disciple of essayist and art critic Walter Horatio Pater with the latter’s emphasis on the esthete as a novel kind of being (Murphy 1992; Wood 2002). He was also immersed into the late 19th century cultural milieu as being involved into a polylogue on the topics of art, artist, ethics, and beauty which resulted in the emergence of Decadence and Modernism (Bell 1997). Altogether with the English fin de siecle men of art such as A. C. Swinburne, Walter Pater, Lionel Johnson, Ernest Christopher Dowson, George Moore Symons, and D. G. Rossetti, Wilde researched the concept of aesthetics as being constructed by a person who was proud of â€Å"[his] non-participation †¦ in ethical controversy† (Woodcock 53) and thus freed from the restrictions imposed by society and common law. Oscar Wilde’s â€Å"immoral aestheticism† as an integral part of the decadent and early modernist styles is what the present proposal attempts to look at. It will research Wilde’s critical and fictional legacy in regard to ideas and concepts as pertinent to the new understanding of relationship between art and morals. This proposal attempts to re-examine Oscar Wilde as a theorist of the novel aesthetics, establishing a link between the writer and other theorists and critics to prove that the call for immoral aestheticism was a brilliant attempt to overcome the boredom of reality and enter the world of absolute beauty. Modern Women’s Voices: Sexual Subjectivity in the texts of Victorian and contemporary British women writers Feminism is still one of the most popular critical lenses to zoom into details of history of literature and social life (Brennan 2002; Jackson 1998; Kemp 1997; Scott 1996), and it is proven to be useful within the framework of the given proposal aimed at tracing the common and differentiating points of the two critical periods of British literature. I am especially interested in the late Victorian epoch with its rise of independent women’s suffragist voices and the latest period with its diversity of tones and melodies composed by women writers amidst the turmoil of free speech and re-thinking of common gender values such as career, family, child-rearing, and gender relationships. The novels chosen are The Story of a Modern Woman by Ella Hepworth Dixon (1894), Anna Lombard by Victoria Cross (the pseudonym of Annie Sophie Cory1901), Foreign Parts by Janice Galloway (1994) and Olivia Joules and the Overactive Imagination by Helen Fielding (2004). The earlier and later books are divided by almost a century but despite a temporal distance there are common motives and aspirations which approximate the Victorian ‘New Woman’ and a modern British female as depicted in fiction. The feminist movement of the late Victorian period was pre-conditioned by many factors which made the trend not accidental but seriously grounded in the wider social context being permeated by patriarchal ascendance and rigidness of social structure (Bernstein 1997; Lewis and Ardis 2003). The ‘New Women’ movement that acquired much power during the period from the late 1890s to roughly 1915 featured a range of opinions concerning the heightened role of a female in a modern society (Walls 2002; Mitchell 1999). As Ardis (1990) observed, Dixon went farther than her colleagues in asserting the preciousness and independency of a woman as a self-sustaining creature (see also Fehlbaum 2005), whereas Cross’s Anna Lombard represents another type of the late Victorian womanhood as sacrificing her desires and aspirations for the sake of the traditional familial institution. The most recent books by Galloway and Fielding cannot be straight-forwardly labeled as ‘feminist’ writing, although they utilise some stylistic elements of feminist narration (Greene 1991). Whereas Galloway vividly portrays contemporary women as being able to function outside the patriarchic framework but provides no answer to the question about the appropriateness of such life style, Fielding is often criticised for the attempts to find consensus with a men’s world and, therefore, to abandon the programme of modern Amazons (Marsh 2004). Anyhow, both contemporary British women of letters share specific ideas concerning authorship and the interplay between feminist and non-feminist traditions to the extent that they can be seen as spiritual sisters of their Victorian predecessors. Being equipped with solid theoretical instruments from gender studies and psychology (e. g. Lacanian psychoanalytic theory) to conceptualise the evolution of womanhood and gendered selves in Great Britain throughout a century, I hope to establish a link between late Victorian and recent women’s writings with a special emphasis on the literary features of the female novel. The freshness of the proposal is in the choice of research objects (all the four novels are not enough extensively discussed by academic critics) and the carrying of analysis within the theoretical framework concerning authorship that was proposed by a Russian scholar Michael Bakhtin.

Pain and the Role of the Nurse in Helping Patients Manage Factors Assignment - 1

Pain and the Role of the Nurse in Helping Patients Manage Factors affecting it - Assignment Example Pain is difficult phenomenon to define. This is because of it is a personal and subjective experience and no tow people will experience pain in exactly the same way. It has been defined in many ways. The International Association of Pain (IASP) defines it as â€Å"an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.† A second definition defines pain as â€Å"†whatever the experiencing person says it is, and existing whenever the person says it does.† Al these explain to us that acrually there is no standard definition of pain but it can be seen as something that makes a person uncomfortable and therefore necessitates the individual to seek medical attention because they are unable to stand the its effects. There exist behavioural and emotional factors that contribute to pain. The behavioural factors include any habit or action of an individual that contributes to the pain syndrome. The factors can be contorlled by the individual, they are modifiable and thus can respond to behaviour modification programs. These may include factors such as improper jaw opening, continuous application of pressure on body parts, gum chewing etc. on the other hand emotional factors are the psychological factors that contribute to pain and these include stress, depression and anxiety among others. These factors result in pain in many ways and it is important to deal with the root cause of each facotr if the pain is to be managed effectively .

Frida Kahlo Essay Example | Topics and Well Written Essays - 1000 words

Frida Kahlo - Essay Example The paper "Frida Kahlo" analyzes the life and art of Frida Kahlo. Her father was German, however, his true nationality was Jewish. While his life he was a photographer. Her mother used to be an America originated Spaniard. At the age of six years old, the artist used to suffer from polio. This determined the reason why since then the right leg became shorter and thinner than the left one. At the age of eighteen, Kahlo survived in a car accident: a broken iron rod collector tram stuck in the stomach and left groin, shattering the hipbone. The still painful months of inactivity began. It was that time when Kahlo asked her father for a brush and paint. There was a special frame made for Frida in order to allow her to paint lying. 1929 was an important year for the artist. She enters the National Institute of Mexico. For the year, held in almost total immobility, Kahlo obtained a serious passion for painting. Again, start walking, she attended art school and in 1928 joined the Communist Party. Her work has been praised by the time by the famous artist Diego Rivera of Communist era. When Frida was twenty-two years old, she married him. Their family life is seething passions. They could not always be together, but never – apart. They tied relationship which could be characterized as passionate, obsessive, and sometimes painful. In 1953, Mexico City is hosting the first solo exhibition of Frida Kahlo. None of self-portrait of Frida Kahlo smiles: serious, even mournful face, bushy eyebrows grown together.

Art paper Research Example | Topics and Well Written Essays - 1000 words

Art - Research Paper Example Some of the objects are unidentifiable and there is little color. In this painting, color is minimal, which is different from many of Picassos other works. The main coloring is black, white and greyscale, with some green and a burnt reddish-brown color. The use of minimal color makes the one area that is in green stand out which says the paintings name, Ma Jolie. This brings emphasis and attention to the artwork. Black and white is found throughout the entire canvas with just touches of the color which indicates that the artist may have only wanted to emphasize certain areas of the artwork while others blended in and surrounded it. What I see is a conglomeration of objects scattered across a canvas. It is difficult to determine what all objects are contained in this scattering of images as they are all somewhat unidentifiable. One object looks like a column, one looks like an old-time prescription bottle, one looks like it could be a flask or maybe even a camera. One object that is brown could be a flute of some sort as it has multiple black holes that look like an instrument. It also looks like a mound of papers underneath or even on a place mat. As I previously stated, it looks like a still life in a way but in a way that is not realistic but instead more modernized and abstract in nature. I think what the artist is trying to say in this art work is simply describing things around him during the time frame in which this was painted. I think that it is none other than a grouping on a table of things that are of interest to him or describe his era. That is what I think the collection of objects are is just that: a few objects that perhaps inspired him. I think his lack of color exemplifies that he only wants certain things to stand out such as what appears to be a paper or program that says Ma Jolie. The black and white and large amount of white space helps to create that emphasis. Picasso also uses a lot of basic lines within the painting

Call of Submissions for Coalition Government's Review of Essay

Call of Submissions for Coalition Government's Review of Counter-Terrorism & Security Powers in the UK - Essay Example Its main drawback being the restrictions of liberty it imposes on individuals. Some of its limitations are travel restrictions, curfews and restrictions on individuals someone can associate with. An alternative proposed to it is use of intelligence and captured evidence in easing prosecutions. The stop and search policy has faced pertinent objections concerning fundamental human rights particularly on profiling based on religion or race. The commission argues that the powers to stop and search should be founded on rational suspicion of an individual. It should only be arbitrarily employed in exceptional circumstances like addressing an immediate terrorist threat. Another key area raising concern is the length of period of detention before formal charges. The current extended pre-charge detention period contravenes human rights and British constitutional principles and history. Thus a review of the 28 days to 14 days pre-trial detention period is ideal (Equality and Human Rights Commi ssion, 2010). ... The use of community service providers in complex counter-terrorism operations, a Prevent strategy, has raised serious concerns. This is because intelligence gathering has been delegated to service providers like teachers. This is in inconsistent with their foremost professional duty and responsibilities. Prevent’s approach to countering terrorism is described as too broad and too narrow. By focusing on particular communities while ignoring threats of extremism not related to Islam, Prevent effectively fuels intolerance against the Muslim residents. Due to its sinister operational transparency, Prevent has lost the faith and confidence of local communities. The secrecy on intentions of its projects such as funding free IT facilities at a youth center targeting Muslims at a town, North of England has further exposed its unpopular strategy. Consequently, Prevent’s dependence on surveillance and intelligence collecting has made it infringe on peoples personal space creatin g fertile grounds for unequal treatment and human rights abuse (Liberty, 2010). With similar areas of submissions as Equality and Human Rights Commission, Amnesty Internationals select submissions included diplomatic assurances and national security deportations. The diplomatic assurances fronted by the UK government have been consistently challenged since it does not guarantee that an individual deported will not be ill-treated or tortured. International human rights laws forbid governments from deporting individuals likely to be subjected to such abuses. The negotiated bilateral diplomatic agreements entered with countries like Ethiopia, Lebanon and Libya have been observed as an attempt to elude

Technologies for Treating Hazardous Waste Essay Example | Topics and Well Written Essays - 250 words

Technologies for Treating Hazardous Waste - Essay Example Sanitary landfill is the used of an area as an isolation place of the solid waste until the danger of the waste is reduced. This kind of treating solid waste can be successful if the area is large and the isolation is good (â€Å"Solid Waste,† n.d.). Gasification on the other hand is the exposure to high temperature/extreme heat with the use of oxygen to decompose the waste. It has the advantages of lessening the size of waste and makes the transportation of waste easier. This is a type of incineration that has no contribution to air pollution. Composting is one of the oldest ways to treat solid waste. It is used specifically to solid wastes that decompose. It makes the area of decomposition very appropriate to the waste, so that decomposition occurs faster (â€Å"Solid Waste Management† n.d.). From the said technologies, gasification is the best. It can be observed that it has more advantages. It lessens the volume of waste in a shorter time because it reduces the waste on the spot. It also does not contribute pollution to nature especially to air unlike other thermal treatment. It brings back energy. And lastly it demands less space compared to sanitary

Personal Property for Person Suffering from Alzheimers Disease Assignment

Personal Property for Person Suffering from Alzheimers Disease - Assignment Example The appellee used the parking garage for purposes of parking his automobile since the public was invited to use it. The parking garage in which the appellee parked his car was owned by the appellant, and before parking his automobile, the appellee received a receipt to allow for the same. The nature of the relationship between the appellee and the appellant, therefore, qualifies for express bailment. The express bailment, in this case, is written as is proven by the receipt, a written confirmation. The bailment at will would depend on the amount of time that the bailor, Mr Allen, would need to use the parking garage, and would be terminated once he submitted the receipt to the attendant at the single exit of the parking garage. The bailee would act as a warehouse because there would be a compensation for the period of time used to store the automobile.The bailment, in this case, was for the mutual benefit of both the bailor who is the appellee in this case and the bailee who is the a ppellant (Twomey and Jennings). While the bailor would have his automobile parked in a safe environment, the bailee would receive a payment that is in relation to the amount of the time that the parking garage was used. When bailment is for the mutual benefit of both bailor and bailee, the bailee is liable to the bailor for ordinary negligence, and the bailee bears the duty of ordinary care to his property (Twomey and Jennings).Though the appellee and the appellant have a bailor-bailee kind of relationship, there is no liability to be borne by the bailee. Any liability that would have been shouldered by the appellant was disqualified by the receipt purchased by the appellee. The ticket bore clear instructions that it only served the purpose of gauging the time an automobile has been in the parking garage and not for identification of the vehicle. Though there was an attendant present at the exit of the parking garage, the attendant had no means of identifying whether persons left wi th the right cars. The ticket also made it clear that the appellant would not be held responsible for losses incurred by theft,  collision or otherwise; and that automobiles were parked at owner’s risk.

Scholarship application Essay Example | Topics and Well Written Essays - 500 words - 1

Scholarship application - Essay Example I was brought up in a small village in Kenya where I was inspired by my grandmother’s ability to offer herbal medicines to many villagers who could not afford or access medical services. Having moved to Kenya’s capital, Nairobi, where I pursued a degree in mass communication, I witnessed how difficult it is for people to access basic services, including healthcare and sanitation. I also worked as a relief worker with Kenya Red Cross and Red Crescent at the Kakuma Refugee Camp where I learnt the basics of nursing and report writing. These experiences while in Kenya made me realize the importance of having nurses in our societies, and this fueled my desire to become one. I hold an excellent academic record that makes me best suited for this scholarship. Currently, I hold a masters degree in Public Health from Michigan State University. I graduated with a GPA of 3.76 from the Michigan State University. While at this university, I actively participated in workshops on gender, women and sexuality. I also hold a Bachelors Degree in Nursing from the York University in Toronto, Canada. I not only graduated as a Deans Honor Roll member but also took extra classes in culture and gender. Among these extra classes were Ghanaian percussion, and intermediate, North Africa and Middle East Dance. Finally, have a degree in Mass Communication from the Kenya Institute of Mass Communication, Nairobi, Kenya. While studying in Kenya, I was involved in a number of projects, including environmental health projects, girl child education and women empowerment. My academic background has helped me interact with people from various backgrounds and enhanced my understanding o f the various issues affecting humanity, including healthcare services. I have also been involved in various volunteer activities that have further helped enhance my practical knowledge and experiences. I currently volunteer at the Suburu

Connection between language,culture and identity Essay

Connection between language,culture and identity - Essay Example d accent, be the words written or in an electronic form, however in Hall’s view â€Å"Language is one of the ‘media’ through which thoughts, ideas and feelings are represented in a Culture† (Hall, 1968, p. 1), which is true since language is the only mode of transportation in a culture and for these thoughts and ideas to be transported from one person to another it is necessary that the individuals or people between whom thoughts have to be transported speak and understand the same language thus enabling them to decipher each other’s thoughts, feelings and ideas. When we discuss language as the only means of transportation of thoughts and feelings from one person to another we not only speak of words spoken or written but also of symbols and signs and any other means which we classify into one word ‘language’ to simplify things a bit. Hence language is a mode of representation; this representation may be in any form, including symbols, w ords, sounds, musical notes, body language or facial expressions. As Stuart Hall explains about the relation between language and representation; insisting that languages ‘utilise’ representation and are in fact methods of representation which, not only in written form or through dialogue, help in expressing ourselves be it an idea or a feeling. Hall further debates that all of the languages function on similar elements feeding their own creation by the need of people to express and communicate. Therefore all our actions or gestures represent something and ‘language’ is what delivers that representation though the case may be that a particular language delivers the representation of a particular culture. Moreover Hall points out that apart from us people, industries such as fashion industries also use representation through clothing and hence a language to express their ideas, but what factor it is that gives ‘meaning’ to these ideas and though ts and even to people and language? Hall clarifies that;

Prospectus of bsrm steels limited Essay Example for Free

Prospectus of bsrm steels limited Essay Declarations and due diligence certificates Declaration about the responsibility of the Directors including the CEO of the Company in respect of the prospectus Consent of the Directors to Serve Declaration about filing of prospectus with the Registrar of Joint Stock Companies Firms Due Diligence Certificate of Manger to the Issue Due Diligence Certificate of the Underwriter(s) Risk factors management perceptions about the risks Capital structure Use of IPO proceeds Description of business Back ground of the project Important date Nature of business Principal products and services The Rolling Process Market for the BSRMS Products Relative contribution to income Associate subsidiary/related holding company Distribution of products/services Sources and availability of raw materials and principal suppliers Competitive condition of business Sources of and requirement for power, gas and water or any other utilities Customer providing 10% or more revenues Contract with principal customers and suppliers Material patents, trademarks, license or royalty agreements Number of employees (as per audited accounts) Capacity and current utilization of facility Description of property Financial Condition and Plan of Operation Internal and external sources of fund (as per audited accounts) Material commitment for capital expenditure Causes for material changes Seasonal aspect of the Company’s business Known trends, events or uncertainties Change in the assets of the Company used to pay off any liabilities Loan taken from holding/parent company or subsidiary company Loan given to holding/parent company or subsidiary company Future contractual liabilities Future capital expenditure VAT, income tax, customs duty or other tax liability Operating lease agreement Financial lease and other financial commitment Personnel related scheme Revaluation of assets Breakdown of issue expenses Auditors certificate regarding any allotment of shares to promoters or Sponsor shareholders for consideration other than in cash -5- Page No 7 7 10 11 11 11 11 12 12 13 15 15 15 15 15 15 16 16 17 17 17 17 17 18 18 18 18 19 19 19 19 20 20 20 20 20 20 21 21 21 21 21 21 21 21 21 21 22 22 Issuer Issue Managers  ¦  ¦  ¦ Alliance Financial Services Limited BSRM Steels Limited South Asia Capital Limited Item Transactions with subsidiary/holding company or associate companies Material information which is likely to have an impact Directors and officers Information regarding directorship Directors involvement in other organization Family relationship among directors and top five officers Short bio-data of the directors Credit information Bureau (CIB) report Description of senior executive and departmental heads Involvement of Directors and officers in certain legal proceedings Certain Relationships and Related Transactions Transaction with related parties Directors facilities Executive compensation Remuneration paid to top five salaried officers Aggregate amount of remuneration paid to directors and officers (as audited accounts) Remuneration paid to Director who was not an officer Future compensation to Director or officers Pay increase intention Options granted to Directors, officers and employees Transaction with the Directors and subscribers to the Memorandum Tangible assets per share Ownership of the Company’s securities Composition of Shareholders Share hold by Directors Shareholding structure 5% or more as on 30 April 2008 Securities owned by the officers Determination of offering price Market for the securities being offered Declaration about listing of shares with Stock Exchange Trading and settlement Description of Securities outstanding or being offered Dividend, voting, pre-emption rights Conversion and liquidation rights Dividend policy Other rights of shareholders Debt securities Lock-in on sponsors share Refund of subscription money Subscription by and refund to non-resident Bangladeshi (NRB) Availability of securities Offer Application for subscription Allotment Underwriting of shares Principal terms and conditions of underwriting agreement Underwriter’s right to represent in the Board of Directors of the Company Auditors report to the shareholders Audited Financial Statements Auditors report under section 135(1), Para 24(1) of part II of schedule III to Companies Act, 1994 Ratio Analysis Additional disclosures as required by Securities and Exchange Commission Credit rating report of BSRMS Application forms -6- Page No 23 23 23 23 24 25 26 26 27 27 27 27 28 28 28 28 28 28 28 29 29 29 29 29 29 30 30 30 30 31 31 31 31 31 31 32 32 32 36 36 36 36 37 38 38 38 38 39 40 54 55 57 59 76 Issuer Issue Managers  ¦  ¦  ¦ Alliance Financial Services Limited BSRM Steels Limited South Asia Capital Limited Disclosure in respect of issuance of security in Demat Form As per provision of the Depository Act, 1999 and regulations made there under, shares will only be issued in dematerialized condition. All transfer/transmission/splitting will take place in the Central Depository Bangladesh Ltd. (CDBL) system and any further issuance of shares (right/bonus) will be issued in dematerialized form only. Conditions under Section 2CC of the Securities and Exchange Ordinance, 1969 Part A 1. The company shall go for Initial Public Offer (IPO) for 20,00,000 ordinary shares of Taka 100 (taka one hundred) each at par worth Taka 20,00,00,000 (Taka twenty crore) only following the Securities and Exchange Commission (Public Issue) Rules, 2006, the Depository Act, 1999 and regulations made there under. 2. The abridged version of the prospectus, as approved by the Commission, shall be published by the issuer in four national daily newspapers (in two Bangla and two English), within 03 (three) working days of issuance of this letter. The issuer shall post the full prospectus vetted by the Securities and Exchange Commission in the issuer’s website and shall also put on the websites of the Commission, stock exchanges, and the issue managers within 03 (three) working days from the date of issuance of this letter which shall remain posted till the closure of the subscription list. The issuer shall submit to SEC, the stock exchanges and the issue managers a diskette containing the text of the vetted prospectus in â€Å"MS -Word† format. 3. Sufficient copies of prospectus shall be made available by the issuer so that any person requesting a copy may receive one. A notice shall be placed on the front of the application form distributed in connection with the offering, informing that interested persons are entitled to a prospectus, if they so desire, and that copies of prospectus may be obtained from the issuer and the issue managers. The subscription application shall indicate in bold type that no sale of securities shall be made, nor shall any money be taken from any person, in connection with such sale until twenty five days after the prospectus has been published. 4. The company shall submit 40 (forty) copies of the printed prospectus to the Securities and Exchange Commission for official record within 5 (Five) working days from the date of publication of the abridged version of the prospectus in the newspaper. 5. The issuer company and the issue managers shall ensure transmission of the prospectus, abridged version of the prospectus and relevant application forms for NRBs through e-mail, simultaneously with publication of the abridged version of the prospectus, to the Bangladesh Embassies and Missions abroad and shall also ensure sending of the printed copies of abridged version of the prospectus and application forms to the said Embassies and Missions within five working days of the publication date by express mail service (EMS) of the postal department. A compliance report shall be submitted in this respect to the SEC jointly by the issuer and the issue managers within two working days from the date of said dispatch of the prospectus the forms. 6. The paper clipping of the published abridged version of the prospectus, as mentioned at condition 2 above, shall be submitted to the Commission within 24 hours of the publication thereof. 7. The company shall maintain separate bank account(s) for collecting proceeds of the Initial Public Offering and shall also open FC account(s) to deposit the application money of the Non-Resident Bangladeshis (NRBs) for IPO purpose, and shall incorporate full particulars of said FC account(s) in the prospectus. The company shall open the abovementioned accounts for IPO purpose; and close these accounts after refund of over-subscription. Non- Resident Bangladeshi (NRB) means Bangladeshi citizens staying abroad including all those who have dual citizenship (provided they have a valid Bangladeshi passport) or those, whose foreign passport bear a stamp from the concerned Bangladesh Embassy to the effect that no visa is required to travel to Bangladesh. 8. The issuer company shall apply to all the stock exchanges in Bangladesh for listing within 07(seven) working days from the date of issuance of this letter and shall simultaneously submit the vetted prospectus with all exhibits, as submitted to SEC, to the stock exchanges. 9. The following declaration shall be made by the company in the prospectus, namely: â€Å"Declaration about Listing of Shares with the Stock Exchange(s): None of the stock exchange(s), if for any reason, grants listing within 75 days from the closure of subscription, any allotment in terms of this prospectus shall be void and the company shall refund the subscription money within fifteen days from the date of refusal for listing by the stock exchanges, or from the date of expiry of the said 75 (seventy five) days, as the case may be. In case of non -refund of the subscription money within the aforesaid fifteen days, the company directors, in addition to the issuer company, shall be collectively and severally liable for refund of the subscription money, with interest at the rate of 2% (two percent) per month above the bank rate, to the subscribers concerned. -7- Issuer Issue Managers  ¦  ¦  ¦ Alliance Financial Services Limited BSRM Steels Limited South Asia Capital Limited The issue managers, in addition to the issuer company, shall ensure due compliance of the above mentioned conditions and shall submit compliance report thereon to the Commission within seven days of expiry of the aforesaid fifteen days time period allowed for refund of the subscription money. † 10. The subscription list shall be opened and the sale of securities commenced after 25 (twenty five) days of the publication of the abridged version of the prospectus and shall remain open for 5 (Five) consecutive banking days. 11. A non-resident Bangladeshi shall apply either directly by enclosing a foreign demand draft drawn on a bank payable at Dhaka, or through a nominee by paying out of foreign currency deposit account maintained in Bangladesh or in Taka, supported by foreign currency encashment certificate issued by the concerned bank, for the value of securities applied for through crossed bank cheque marking â€Å"Account Payee only†. The NRB applicants shall send applications to the issuer company within the closing date of the subscription so as to reach the same to the company by the closing date plus nine days. Applications received by the company after the above time period will not be considered for allotment purpose. 12. The company shall apply the spot buying rate (TT clean) in US Dollar, UK Pound Sterling and Euro of Sonali Bank, which shall be mentioned in the Prospectus, as prevailed on the date of opening of the subscription for the purpose of application of the NRBs and other non-Bangladeshi persons, where applicable. 13. The company and the issue managers shall ensure prompt collection/clearance of the foreign remittances of NRBs and other non-Bangladeshis, if applicable, for allotment of shares. 14. Upon completion of the period of subscription for securities the issuer and the issue managers shall jointly provide the Commission and the stock exchanges with the preliminary status of the subscription within 05 (five) working days, in respect of the following matters, namely: (a) Total number of securities for which subscription has been received; (b) Amount received from the subscription; and (c) Amount of commission paid to the banker to the issue. 15. The issuer and the issue managers shall jointly provide the Commission and the stock exchanges the list of valid and invalid applicants in 2 (two) CDs and final status of subscription to the Commission within 3 (three) weeks after the closure of the subscription along with bank statement (original), branch-wise subscription statement. The list of valid and invalid applicants shall be finalized after examination with the CDBL in respect of BO accounts and particulars thereof. 16. The IPO shall stand cancelled and the application money shall be refunded immediately (but not later than 5 (Five) weeks from the date of the subscription closure) if any of the following events occur: (a) Upon closing of the subscription list it is found that the total number of valid applications (in case of under subscription including the number of the underwriter) is less than the minimum requirement as specified in the listing regulations of the stock exchange(s) concerned; or (b) At least 50% of the IPO is not subscribed. 17. 10% of total public offering shall be reserved for non-resident Bangladeshi (NRB) and 10% for mutual funds and collective investment schemes registered with the Commission, and the remaining 80% shall be open for subscription by the general public. In case of under subscription under any of the 10% categories mentioned above, the unsubscribed portion shall be added to the general public category and, if after such addition, there is over subscription in the general public category, the issuer and the issue managers shall jointly conduct an open lottery of all the applicants added together. 18. All the applicants shall first be treated as applied for one minimum market lot of 50 shares worth Tk. 5000/-. If, on this basis, there is over subscription, then lottery shall be held amongst the applicants allocating one identification number for each application, irrespective of the application money. In case of over-subscription under any of the categories mentioned hereinabove, the issuer and the issue managers shall jointly conduct an open lottery of all the applications received under each category separately in presence of representatives from the issuer, the stock exchanges and the applicants, if there be any. 19. An applicant cannot submit more than two applications, one in his/her own name and another jointly with another person. In case an applicant makes more than two applications, all applications will be treated as invalid and will not be considered for allotment purpose. In addition, whole or part of application money may be forfeited by the Commission. -8- Issuer Issue Managers  ¦  ¦  ¦ Alliance Financial Services Limited BSRM Steels Limited South Asia Capital Limited 20. The primary shares allotted to an applicant through IPO may be forfeited by SEC, if the BO account of the said applicant is found closed at the time of allotment of shares. All IPO applicants are required to keep their BO accounts operational till allotment of IPO shares. 21. Lottery (if applicable) shall be held within 4 (four) weeks from closure of the subscription date. 22. The company shall issue share allotment letters to all successful applicants within 5 (five) weeks from the date of the subscription closing date. Within the same time, Refund to the unsuccessful applicants shall be made in the currency in which the value of securities was paid for by the applicants without any interest through Account Payee Cheque/ refund warrants with bank account number, bank’s name and Branch as indicated in the securities application forms payable at Dhaka/ Chittagong/ Khulna/ Rajshahi/ Barisal/ Sylhet/ Bogra, as the case may be subject to condition 19 above. Refund money of the unsuccessful applicants shall be credited directly to their respective bank accounts with in 5 (five) weeks from the date of the subscription closing, who have mentioned in the IPO application forms, bank account numbers with the bankers to the issue and other banks as disclosed in the prospectus. A compliance report in this regard shall be submitted to the Commission within 6(six) weeks from the date of closure of subscription. 23. The company shall furnish the List of Allotees to the Commission and the stock exchange(s) simultaneously in which the shares will be listed, within 24 (twenty four) hours of allotment. 24. In the event of under-subscription of the public offering, the unsubscribed portion of securities shall be taken up by the underwriter(s) (subject to para -16 above). The issuer must notify the underwriter to take up the underwritten shares within 10 (ten) days of the subscription closing date on full payment of the share money within 15(fifteen) days of the issuer’s notice. The underwriter shall not share any underwriting fee with the issue managers, other underwriters, issuer or the sponsor group. 25. All issued shares of the issuer at the time of according this consent shall be subject to a lock in period of three years from the date of issuance of prospectus or commercial operation, whichever comes later: Provided that the persons, other than directors and those who hold 5% or more, who have subscribed to the shares of the company within immediately preceding two years of according consent, shall be subject to a lock -in period of one year from the date of issuance of prospectus or commercial operation, whichever comes later. 26. Either a Jumbo Share (one for each of the existing Sponsors/ Directors/ Shareholders) in respect of the shares already issued shall be issued covering together respective total holding, which shall contain the expiry date of lock-in period or Sponsors/Directors/Promoters/Shareholders’ shareholding shall be converted into demat form but shall be locked-in as per the condition at para-25 above. 27. In case of Jumbo Share Certificate issued to the existing Sponsors/ Directors/Shareholders, the said share certificates shall be kept under custody of a security custodian bank registered with SEC during the lock-in period. The name and branch of the bank shall be furnished to the Commission jointly by the issuer and the issue managers, along with a confirmation thereof from the custodian bank, within one week of listing of the shares with the stock exchange(s). 28. In case of dematerialization of shares held by the existing Sponsors/ Directors/Shareholders, the copy of dematerialization confirmation report generated by CDBL and attested by the managing director of the company along with lock-in confirmation shall be submitted to SEC within one week of listing of the shares with the stock exchange(s). 29. The company shall apply to the stock exchanges for listing within 7(seven) working days of issuance of this letter and shall simultaneously submit to the Commission attested copies of the application filed with the stock exchanges. 30. The company shall not declare any benefit other than cash dividend based on the financial statement for the period ended December 31, 2007. Part-B 1. The issue managers (i. e. , Alliance Financial Services Limited and South Asia Capital Limited) shall ensure that the abridged version of the prospectus and the full prospectus is published correctly and in strict conformity without any error/omission, as vetted by the Securities and Exchange Commission. 2. The issue managers shall carefully examine and compare the published abridged version of prospectus on the date of publication with the copy vetted by SEC. If any discrepancy/inconsistency is found, both the issuer and the issue managers shall jointly publish a corrigendum immediately in the same newspapers concerned, simultaneously endorsing copies thereof to SEC and the stock exchange(s) concerned, correcting the discrepancy/inconsistency as required under ‘Due Diligence Certificates’ provided with SEC. -9- Issuer Issue Managers  ¦  ¦  ¦ Alliance Financial Services Limited BSRM Steels Limited South Asia Capital Limited 3. Both the issuer company and the issue managers shall, immediately after publication of the prospectus and its abridged version, jointly inform the Commission in writing that the published prospectus and its abridged version are verbatim copies of the same as vetted by the Commission. 4. The fund collected through IPO shall not be utilized prior to listing with stock exchange and that utilization of the said fund shall be effected through banking channel, i. e. through account payee cheque, pay order or bank drafts etc. 5. The company shall furnish report to the Commission on utilization of IPO proceeds within 15 days of the closing of each quarter until such fund is fully utilized, as mentioned in the schedule contained in the prospectus, and in the event of any irregularity or inconsistency, the Commission may employ or engage any person, at issuer’s cost, to examine whether the issuer has utilized the proceeds for the purpose disclosed in the prospectus. 6. All transactions, excluding petty cash expenses, shall be effected through the company’s bank account(s). 7. Proceeds of the IPO shall not be used for any purpose other than those specified in the prospectus. Any deviation in this respect must have prior approval of the shareholders in the General Meeting under intimation to SEC and stock exchange(s). 8. The company shall remove the restrictive clauses regarding issuance transfer of shares and grouping of shares from its Articles of Association. Part C 1. All the above conditions imposed under section 2CC of the Securities and Exchange Ordinance, 1969 shall be incorporated in the prospectus immediately after the page of the table of contents, with a reference in the table of contents, prior to its publication. 2. The Commission may impose further conditions/restrictions etc. from time to time as and when considered necessary, which shall also be binding upon the issuer company. Part D 1. As per provision of the Depository Act, 1999 and regulations made there under, shares will only be issued in dematerialized condition. All transfer/transmission/splitting will take place in the Central Depository Bangladesh Ltd. (CDBL) system and any further issuance of shares (including right/bonus) will be made in dematerialized form only. An applicant (including NRB) shall not be able to apply for allotment of shares without beneficial owner account (BO account). 2. The issue managers shall also ensure due compliance of all above. GENERAL INFORMATION Alliance Financial Services Limited (AFSL) and South Asia Capital Limited (SACL) have prepared the prospectus from information supplied by BSRM Steels Limited (the Issuer Company) and also after several discussions with the Chairman, Managing Director, Directors and concerned executives of the company. BSRM Steels Limited, Alliance Financial Services Limited and South Asia Capital Limited collectively and individually, having made all reasonable inquiries, confirm that to the best of their knowledge and belief, the information contained herein is true and correct in all material aspects and that there are no other material facts, the omission of which, would make any statement herein misleading. No person is authorized to give any information or to make any representation not contained in this Prospectus and if given or made, any such information and representation must not be relied upon as having been authorized by the company or Alliance Financial Services Limited and South Asia Capital Limited. The Issue as contemplated in this prospectus is made in Bangladesh and is subject to the exclusive jurisdiction of the Courts of Bangladesh. Forwarding this prospectus to any person resident outside Bangladesh in no way implies that the issue is made in accordance with the laws of that country or is subject to the jurisdiction of the laws of that country. A copy of this prospectus may be obtained from the Corporate Head Office of BSRM Steels Limited, Alliance Financial Services Limited, South Asia Capital Limited, the Underwriters and the Stock Exchanges where the securities will be traded. 10 Issuer Issue Managers  ¦  ¦  ¦ Alliance Financial Services Limited BSRM Steels Limited South Asia Capital Limited Declarations and Due Diligence Certificates Declaration about the Responsibility of the Directors, including the CEO of the Company â€Å"BSRM Steels Limited† in Respect of the Prospectus This prospectus has been prepared, seen and approved by us, and we, individually and collectively, accept full responsibility for the authenticity and accuracy of the statements made, information given in the prospectus, documents, financial statements, exhibits, annexes, papers submitted to the Commission in support thereof, and confirm, after making all reasonable inquiries that all conditions concerning this public issue and prospectus have been met and that there are no other information or documents the omission of which make any information or statements therein misleading for which the Commission may take any civil, criminal or administrative action against any or all of us as it may deem fit. We also confirm that full and fair disclosure has been made in this prospectus to enable the investors to make a well-informed decision f or investment. Sd/ Alihussain Akberali Chairman Sd/Zohair Taherali Director Sd/Aameir Alihussain Managing Director* Sd/Tehseen Zohair Taherali Director Sd/Sabeen Aameir Director Consent of the Directors to Serve We hereby agree that we have been serving as Directors of â€Å"BSRM Steels Limited and confirm to continue to act as Directors of the Company. Sd/ Alihussain Akberali Chairman Sd/Zohair Taherali Director Sd/Aameir Alihussain Managing Director* Sd/Tehseen Zohair Taherali Director Sd/Sabeen Aameir Director * Mr. Aameir Alihussain is also a shareholder Director of the company. Declaration about filing of Prospectus with the Registrar of Joint Stock Companies Firms A dated and signed copy of the Prospectus has been filed for registration with the Registrar of J

Effect of School Based Obesity Interventions

Effect of School Based Obesity Interventions ABSTRACT Introduction Background Obesity in both adult and children is fast becoming one of the most serious public health problems of the 21st century in developed and developing countries alike. It is estimated that approximately 10% of school age children. The prevalence of childhood overweight and obesity is ever on the increase in the UK as in the rest of the world. It is estimated that the prevalence of overweight and obesity among 2 10 year old children in the UK rose from 22.7%-27.7% and 9.9%-13.7% respectively between 1995 and 2003; these figures are set to increase unless something is done. School-based interventions offer a possible solution in halting obesity prevalence, because the school setting provides an avenue for reaching out to a high percentage of children (especially in the western world), opportunity for constant monitoring of children and the resources for anti-obesity interventions. Objectives To systematically review the evidence of the impact of school-based interventions to prevent childhood obesity on: Adiposity (primary objective) Knowledge, physical activity levels and diet (secondary objectives) Methods The review was done following the Cochrane collaboration guidelines. In addition to searching electronic databases, first authors of all included studies were contacted. A recognised critical appraisal tool was used to assess the quality of included studies. Results Three RCTs and one CCT met the inclusion criteria for the review. All four studies had a control and intervention group; with various study limitations. While none of the studies found statistically significant BMI changes in intervention groups when compared with control group post-intervention, all of them recorded either a significant change in diet, or an increase in physical activity levels. INTRODUCTION BACKGROUND Obesity is generally understood as abnormal accumulation of fat to the extent that presents health risk (Kiess, Marcus et al. 2004), and was added to the international classification of diseases for the first time in 1948 (Kipping, Jago et al. 2008). The worldwide clinical definition of adult obesity by the WHO is body mass index (BMI) ≠¥ 30kg/m2 (WHO 2006). In children however, because of the significant changes in their BMI with age (Cole, Bellizzi et al. 2000), there is no universally accepted definition of obesity (Parizkova and Hills 2004; Bessesen 2008) and it therefore varies from country-to-country. The most commonly used definition of childhood obesity is the US definition which measures overweight and obesity in a reference population using the cut off points of 85th and 95th centiles of BMI for age (Ogden, Yanovski et al. 2007). In the UK, overweight and obesity are diagnosed using a national reference data from a 1990 BMI survey of British children (Stamatakis, Prima testa et al. 2005). Children whose weights are above the 85th centile are classed as overweight and over the 95th centile are considered obese (Reilly, Wilson et al. 2002). Recent estimates suggest that obesity has reached epidemic proportions globally with about 400 million adults being clinically obese, a figure projected to rise to about 700 million by 2015 (WHO 2006). In children, the current WHO estimates are that about 22 million children globally under age 5 are overweight (WHO 2008). In the UK, evidence suggests that obesity is set to be the number one preventable cause of disease in a matter of time (Simon, Everitt et al. 2005). In the last three decades, the scale as well as the prevalence of obesity have grown rapidly amongst all age, social and ethnic groups in the UK, as well as globally (Table 1)(Kipping, Jago et al. 2008). Estimates suggest that in the UK, between 1984 and 2002/2003, the prevalence of obesity in boys aged 5-10 rose by 4.16%, and by 4.8% in girls (Stamatakis, Primatesta et al. 2005). There is therefore there is an urgent need for the development and implementation of effective intervention strategies to halt the ever increasing obesity prevalence (Summerbell Carolyn, Waters et al. 2005). OBESITY CAUSATION The primary risk factors associated with the increase in prevalence of childhood obesity are ever increasing involvement in sedentary lifestyles and an increase also in the consumption of high energy dense food and drink (Ebbeling, Pawlak et al. 2002; Sekine, Yamagami et al. 2002; Speiser, Rudolf et al. 2005; Topp, Jacks et al. 2009). The underlying mechanism of obesity formation is an imbalance between energy input and expenditure (Moran 1999; Kipping, Jago et al. 2008) Genetic and environmental factors greatly influence the bodys energy balance. Nevertheless, genetic conditions which either cause production of excessive fat in the body or reduce the rate at which it is broken down, of which Prader-Willi syndrome is an example account for less than 5% of obese individuals (Speiser, Rudolf et al. 2005), with environmental factors accounting for a very high percentage (French, Story et al. 2001). The major cause of the rising obesity problem is arguably changes in physical and social environments (French, Story et al. 2001). In recent times, there has been a remarkable shift towards activities that do not promote energy expenditure, for example, most children would travel to school in cars rather walk, in contrast to what obtained in the 1970s (Popkin, Duffey et al. 2005; Anderson and Butcher 2006). There is evidence to suggest that obese children are less active than their non-obese counterparts, hence promoting physical activity such as walking or exercising will help prevent obesity in children (Hughes, Henderson et al. 2006). Media time (television viewing, playing video games and using the computer) has been identified as one of the significant environmental changes responsible for the surge in childhood obesity. Besides promoting physical inactivity, it encourages energy input via excessive snacking and inappropriate food choices as a result of television advertisements (Ebbeling, Pawlak et al. 2002; Speiser, Rudolf et al. 2005). Robinson in his study reveals that â€Å"between ages 2 and 17, children spend an average of 3 years of their waking lifetime watching television alone† (Robinson 1998). Parents play a significant role in where, what and how much their children eat and to an extent, how physically active their children are. In most homes, children make their food choices based on the options they are presented with by their parents, and they characteristically would go for wrong option, more so if they have an obese parent (Strauss and Knight 1999). Other changes within the family such as physical inactivity and working patterns of parents have contributed somewhat to the obesity epidemic. In a family where the parents work full-time, there tends to be very little time for them to prepare wholesome home-made meals and this could possibly explain the increasing demand for eating out (Anderson and Butcher 2006) thereby increasing intake of high energy dense food. Childrens attitude to and participation in physical activities depends largely on how physically active their parents are. Thus children of sporty parents embrace exercise heartily and are therefore less prone to becoming obese.(Sallis, Prochaska et al. 2000). In addition to these family factors, societal factors such as high crime rate, access to safe sports/recreational facilities, transportation and fewer physical education programs in schools significantly impact on energy balance (Koplan, Liverman et al. 2005; Popkin, Duffey et al. 2005; Topp, Jacks et al. 2009). French summarizes the environmental influence on obesity by opining that â€Å"The current epidemic of obesity is caused largely by an environment that promotes excessive food intake and discourages physical activity† (French, Story et al. 2001) CONSEQUENCES OF OBESITY Evidence suggests that childhood obesity and/or overweight has a great impact on both physical and psychological health; causing effects such as behavioral problems and low self esteem, with a higher risk in girls than in boys (Reilly, Methven et al. 2003). Although most of the serious consequences do not become evident until adulthood, research has shown childhood obesity to be linked to metabolic disorders such as insulin resistance and type 2 diabetes, stroke and heart attacks, sleep apnea, nonalchoholic fatty liver disease, higher incidence of cancers, depression, dyslipidaemia, increased blood clotting tendency, etc (Ebbeling, Pawlak et al. 2002; Reilly, Methven et al. 2003; Kiess, Marcus et al. 2004; D. A. Lawlor, C. J. Riddoch et al. 2005; Daniels 2006; WHO 2006). One of the long-term serious consequences of childhood obesity is that obese children are twice more likely to grow into obese adults than their non-obese counterparts (Moran 1999); however, this largely depends on factors such as age of onset, severity of the disease and the presence of the disease in one parent (Moran 1999; Campbell, Waters et al. 2001; Kiess, Marcus et al. 2004; WHO 2006). Other long term consequences include early death and adverse socio-economic consequences such as poor educational attainment and low/no income in adulthood (Reilly, Methven et al. 2003; Fowler-Brown and Kahwati 2004; Kiess, Marcus et al. 2004). Obesity-related morbidity places a huge and growing financial demand on governments. In the UK alone, the Department of Health has reported that obesity costs the NHS and the UK economy as a whole about  £1b and between  £2.3b  £2.6b annually respectively, with the cost to the NHS projected to rise to  £3.6b by 2010 (DH 2007). TREATMENT AND PREVENTION The treatment of obesity requires a multidisciplinary approach due to the multi-faceted nature of the condition (Parizkova and Hills 2004). This is aimed at reducing caloric intake and increasing energy expenditure through physical activity (Ebbeling, Pawlak et al. 2002). These interventions are more likely to be successful if the patients family is involved and the treatment tailored to individual needs and circumstances (Fowler-Brown and Kahwati 2004). In extreme cases, options such as surgical and pharmacological treatments could be exploited. These options are very unpopular and usually not recommended because the associated health risks outweigh the benefits by far (Epstein, Myers et al. 1998; Ebbeling, Pawlak et al. 2002). Considering the huge costs and high levels of treatment failure associated with obesity treatment (Stewart, Chapple et al. 2008), the axiom by Benjamin Franklin cannot describe any other condition better than it describes obesity management. â€Å"An ounce of prevention is worth a pound of cure† Dietz et al confirm this by saying that prevention remains the best and most effective management of obesity (Dietz and Gortmaker 2001). Obesity prevention interventions are usually set either in the home or at school with an objective of eliminating peer pressure and, by so doing effect behavioral change (Ebbeling, Pawlak et al. 2002). Literature suggests that the school has so far remained the choice setting for these preventive interventions despite the very limited evidence on its effectiveness (Birch and Ventura 2009). Why is the school setting a good focus of intervention? Approximately 90% of children are enrolled in schools in developed countries (Baranowsk, Cullen et al. 2002) Children spend a substantial amount of time in school and therefore consume a considerable proportion of their daily calories at school (Katz, OConnell et al. 2005) School related activities present an opportunity to educate children on the concept of energy balance, healthy living and how to make appropriate food choices (Ebbeling, Pawlak et al. 2002; Koplan, Liverman et al. 2005) It offers opportunity for continuity and constant monitoring via frequent contact (Baranowski T 2002) Schools have an availability of existing manpower and facilities needed for anti-obesity interventions (Kropski, Keckley et al. 2008) In a nut shell, â€Å"Schools offer many other opportunities for learning and practicing healthful eating and physical activity behaviors. Coordinated changes in the curriculum, the in-school advertising environment, school health services, and after-school programs all offer the potential to advance obesity prevention† (Koplan, Liverman et al. 2005). PREVIOUS SYSTEMATIC REVIEWS Systematic reviews have been conducted on the effectiveness of school-based interventions in the prevention of childhood obesity. Campbell et al (2001), conducted a systematic review of 7 randomised control trials (RCTs) (6 were school-based, varying in length of time, target population, quality of study and intervention approach). The review found that dietary and physical education interventions have an effect on childhood obesity prevalence. However, success varied with different interventions amongst different age groups. Two of the three long term studies that focused on a combination of dietary education and physical activity, and dietary education respectively reported an effect on obesity prevalence reduction. Similarly, 1 out of the 3 school based short-term interventions that focused only on reducing sedentary activity also found an effect on obesity prevalence. While this review shows that dietary and physical activity interventions based at school are effective against th e risk factors of obesity, the question of generalisability and reproducibility arises as the review reports the majority of the included primary studies were carried out in the US. Most of the studies used BMI as a measure of adiposity, and BMI as has been documented varies across ethnic and racial groups (Rush, Goedecke et al. 2007), thus, it will be inappropriate to apply the findings of US-based obesity prevention interventions to children in middle and low income countries where conditions are different. There are also concerns about the methodology and study design. For example the school-based study by Gotmaker et al (1999) had limitations such as low participation rate (65%) and the researchers were unable to adjust for maturity in boys and there was also poor assessment of dietary intake. All these limitations could have been responsible for a high percentage of the reported intervention effect thus affecting the validity of the results of the study (Gortmaker, Peterson et al. 1999). The authors of the review however concluded that there is currently very limited high quality evidence on which to draw conclusions on the effectiveness of anti-obesity programmes. A Cochrane review which is an update of the Campbell et al (2001) study by Summerbell et al (2005) has examined the impact of diet, physical activity and/or lifestyle and social support on childhood obesity prevention. Their review examined the effectiveness of childhood obesity prevention interventions which included school based interventions. Their study included 10 long-term (a minimum duration of 12 months) and 12 short-term (12weeks 12 months) clinical trials (randomised and controlled). 19 out of the 22 studies that met their inclusion criteria were school/pre-school based. The study chose the appropriate study type; more than one reviewer was involved in the entire process of data collection, extraction and selection of included studies. In general, the study found that most of the school-based interventions (dietary and/or physical activity) reported some positive changes in targeted behaviours, but however had very little or no statistically significant impact on BMI. The reviewers stated that none of the 22 studies fulfilled the quality criteria because of some form of methodological weakness which includes measurement errors. For instance, the study by Jenner et al (1989) had no valid method of measuring food intake. The studies by Crawford et al (1994), Lannotti et al (1994) and Sallis et al (2000) had similar measurement errors. Reporting error was identified in studies by Little et al (1999) and Macdiarmid et al (1998). There were also reliability concerns about the secondary outcomes measurement in some of the included studies. The reviewers therefore expressed the need for further high quality research on effectiveness. Kropski et al (2008) reviewed 14 school-based studies that were designed to effect a life style change, a change in BMI, decrease overweight prevalence through a change in nutrition, physical activity or a combination of both. Of the 14 studies, three were done in the UK, one in Germany and 10 in the US. The right type of studies were chosen for this review and the whole process was done by more than one reviewer, however they were unable to draw strong conclusions on the efficacy of school-based interventions because of the limited number of primary studies available and methodological or design concerns which include: small sample size (Luepker, Perry et al. 1996; Mo-suwan, Pongprapai et al. 1998; Nader, Stone et al. 1999; Warren, Henry et al. 2003), no intention-to treat analysis (Danielzik, Pust et al.; Sallis, McKenzie et al. 1993; Sahota, Rudolf et al. 2001; Warren, Henry et al. 2003), possibility of type I (Coleman, Tiller et al. 2005) and type II errors (Warren, Henry et al. 2003), unit of analysis errors (Sallis, McKenzie et al. 1993) and inconsistent results (Mo-suwan, Pongprapai et al. 1998; Caballero, Clay et al. 2003; Coleman, Tiller et al. 2005). Despite their inability to draw a conclusion on effectiveness, overall, the review found that a combination of nutritional and physical activity interventions had the most effect on BMI and prevalence of overweight, with the result largely varying from community-to-community. The nutrition only and physical activity only interventions appeared to have had a change on lifestyles of participants but either had no significant effect on the measures of overweight or no BMI outcomes were measured. Another systematic review on the effectiveness of school-based interventions among Chinese school children was carried out by M.Li et al (2008). The authors included 22 primary studies in their review. The review reported that the primary studies showed that there are some beneficial effects of school-based interventions for obesity prevention; the reviewers however expressed their concerns that most of the studies included in the review had what they considered to be serious to moderate methodological weaknesses. Sixteen of the 22 studies included studies were cluster control trials, and there was no mention by any of the researchers that cluster analysis was applied to any of the 16 studies. In addition to lack of cluster analysis, no process evaluation was conducted in any of the studies. Only one study performed an intention to treat analysis. Twelve studies experienced dropouts, but there was incomplete information on the study population at the end of the trial and the reason f or the dropouts. Additionally, none of the studies explained the theory upon which they based their intervention. There was also potential recruitment and selection bias in all the primary studies as identified by the reviewers. They stated that none of the studies reported the number of subjects that were approached for recruitment into the study. As none of the RCTs included described the method they used in randomization, neither did they state if the studies were blinded or not. The methodological flaws in a high percentage of the included primary studies could impact on the validity of the findings of the review. Again, the authors failed to reach a conclusion on the effectiveness of the interventions because of the intrinsic weaknesses found in the primary studies, and as a result state the need for more primary studies that would address the methodological weaknesses that is highly present in nearly all existing primary studies conducted on this topic so far. The study of the efficacy of school-based interventions aimed at preventing childhood obesity or reducing the risk factors is a rather complex one. Pertinent issues on effectiveness of school-based interventions to prevent the risk factors of obesity remain that there is very limited/weak evidence on which to base policies on. Heterogeneity of primary research (in terms if age of study population, duration of intervention, measurement of outcomes and outcomes measured) makes further statistical analysis nearly impossible. BMI is currently the most widely used measure of overweight and obesity in children. However, BMI has no way of distinguishing between fat mass and muscle mass in the body and might therefore misdiagnose children with bigger muscles as obese. Another disadvantage of using BMI in overweight measurement is its inability of depicting the body fat composition (Committee on Nutrition 2003), other surrogate indicators of adiposity may be needed. Most authors that have carried out a review on this topic so far have expressed the need for further research on this topic to add to the existing body of evidence. RATIONALE FOR THIS STUDY All the systematic reviews on this subject so far have focused mainly on the United States. Lifestyle differences such as eating habits between American and British children possibly affect generalisability and reproducibility of US findings to the UK. For example, in the US, research has shown that 0.5% of all television advertisements promote food, and that about 72% of these food advertisements promote unhealthy food such as candy and fast food (Darwin 2009). In the UK paradoxically, the government in 2007 enforced regulations banning television advertisement of unhealthy foods (foods with high fat, salt, and sugar content) during television programmes aimed at children below 16 years of age (Darwin 2009). Thus US children are at a higher risk of becoming obese than their UK counterparts as a result of higher rate of exposure to TV junk food advertisements. Another lifestyle difference between American and British children is physical activity. In the UK, a high percentage of children aged 2 to 15 achieve at least 60 minutes of physical activity daily (about 70% of males and 60% of females) (DoH 2004), as opposed to the US where only about 34% of school pupils achieve the daily recommended levels of physical activity daily (CDC 2008). These differences highlight the importance of public health policies being based on the local population characteristics rather than on imported overseas figures. There is therefore need to review the evidence of UK school-based obesity interventions to inform policy relevant to the UK population. To the best of my knowledge following an extensive literature search, no systematic review has been conducted on the effectiveness of school-based intervention in preventing childhood obesity in the UK, despite the high prevalence of the condition and its public health significance in this country. This research aims to bridge this gap in knowledge by focusing on UK based studies to evaluate the efficacy of school-based interventions in the UK population. This study therefore stands out insofar as it will be assessing the effectiveness of school-based interventions in the reducing the risk factors of obesity in the UK, with a hope of providing specific local recommendations based on UK evidence. This type of review is long overdue in the UK, considering that the governments target to reduce childhood obesity to its pre-2000 levels by the year 2020 (DoH 2007) will require local evidence of effective interventions to succeed. The next stage of this review will describe in detail the research methodology to be used to conduct the proposed systematic review. Also included will be research strategy details to be adopted, study selection criteria, data collection and analysis. AIMS AND OBJECTIVES The aim of this research is to: Systematically review school-based intervention studies in the UK aimed at reducing the risk factors of childhood obesity among school children. Objectives are: To assess the efficacy of school-based anti-obesity interventions in the UK. To identify the most effective form of school-based interventions in the prevention of childhood obesity amongst school children in the UK. CRITERIA FOR INCLUDING STUDIES IN THIS REVIEW METHODS This review was performed as a Cochrane review. The Cochrane guidance on systematic reviews and reporting format were as far as possible adhered to by the author (Green, Higgins et al. 2008). The entire review process was guided by a tool for assessing the quality of systematic reviews, alongside the accompanying guidance (health-evidence.ca 2007a; health-evidence.ca 2007b). TYPES OF STUDY In the search for the effectiveness of an intervention, well conducted randomised control trials (which are the best and most credible sources of evidence) will be the preferred source of studies for this review. However, because of the limited number of RCTs conducted on this topic so far, this study will include controlled clinical trials if there is insufficient availability of RCTs. TYPES OF PARTICIPANTS School children under 18 years of age TYPES OF INTERVENTIONS Interventions being evaluated are those that aim to: Reduce sedentary lifestyle Effect nutritional change Combine the two outcomes above Reduce obesity prevalence Effect an attitude change towards physical activity and diet Studies that present a baseline and post intervention measure of primary outcome. Interventions not included in this study are: Those with no specified weight-related outcomes Those that involved school-age children but were delivered outside of the school setting, as our focus is based on school-based interventions aimed at obesity prevention. Studies done outside the UK Studies with no specified interventions Non-RCTs or CCTs For each intervention, the control group will be school children not receiving the intervention(s). TYPES OF OUTCOMES MEASURED Primary outcomes Change in adiposity measured as BMI and/or skin fold thickness Secondary outcomes Knowledge Physical activity levels Diet SEARCH METHODS FOR IDENTIFICATION OF STUDIES Electronic searches The electronic databases OVID MEDLINE ® (1950-2009), PsycINFO (1982-2009), EMBASE (1980-2009) and the British Nursing Index (1994-2009) were all searched using the OVID SP interface. The Wiley Interscience interface was used to search the following databases: Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects. There was also a general search of internet using Google search engine, in an attempt to identify any ongoing studies or unpublished reports before proceeding to search grey literature sources. Grey literature For references to childhood obesity prevention in schools, the following grey literature sources were searched: British Library Integrated Catalogue (http://catalogue.bl.uk/F/?func=filefile_name=login-bl-list) ISI index of Conference Proceedings (http://wok.mimas.ac.uk/) SCIRUS (http://www.scirus.com/) System for Information on Grey Literature (http://opensigle.inist.fr/) ZETOC (http://zetoc.mimas.ac.uk) Additionally, current control trials database at http://www.controlled-trials.com/ was searched for any ongoing research. The UK national research register was also searched at https://portal.nihr.ac.uk/Pages/NRRArchive.aspx. All the links to the grey literature databases were tested at the time of this review and found to be working. Hand searches It was not possible to conduct a hand search of journals due to pragmatic reasons. Reference lists Reference lists of retrieved studies were searched for other potential relevant studies that might have been omitted in the earlier search. Correspondence First author of all included studies were contacted with a view to seeking more references. DATA COLLECTION AND ANALYSIS Selection of studies The abstracts and titles of the hits from the electronic databases searched were screened for relevance by a single assessor. Those that were thought to be potentially relevant were retrieved and downloaded unto EndnoteTM to make the results manageable and also avoid loss of data. At the end of the search, all databases were merged into one single database and duplicated records of the same study were removed. Subsequently, the assessor then sought and obtained the full text of, and reviewed the relevant studies that were considered eligible for inclusion. Multiple reports of same study were linked together. No further data were sought for studies not included in the review. Data extraction Data extraction from included studies was done by a single reviewer and the data recorded on a data extraction form. A summary of each included study was described according to these characteristics: Participants (age, ethnicity etc.), study design, description of school-based interventions, study quality and details such as follow-ups and date, location, outcomes measured, theoretical framework, baseline comparability and results Assessment of methodological quality of included studies A number of researchers (Jackson, Waters et al. 2005) and the Cochrane guidelines for systematic reviews of health promotion and public health interventions (Rebecca Armstrong, Waters et al. 2007) strongly advise using the Quality Assessment Tool for Quantitative Studies (2008a) developed by the Effective Public Health Practice Project in Canada and the accompanying dictionary (to act as a guideline) (2008b) in assessing methodological quality. Based on criteria such as selection bias, study design, blinding, cofounders, data collection methods, withdrawals and drop-outs and intervention integrity, the tool which is designed to cover any quantitative study employs the use of a scale (strong, moderate or weak) to assess the quality of each study included in the review. Analysis Considering the small number of studies included in the review and heterogeneity in terms of interventions, delivery methods, intensity of interventions, age of participants, duration of intervention and outcomes measured, it was not statistically appropriate to undertake a Meta analysis, which admittedly would have been the preferred method of analysing and summarising the results of the studies. A narrative synthesis of the results was done instead. RESULT DESCRIPTION OF STUDIES Results of the search The search of electronic sources identified 811 citations out of which 97 potential studies were retrieved. A reference management software EndnoteTM was used to search for and remove duplicate citations. Further screening of title and abstract reduced the number of citations to 17 potential studies. Full texts of the 17 studies were sought, 13 were excluded, and four met the inclusion criteria and were therefore included in the review. Authors of the four studies were then conta Effect of School Based Obesity Interventions Effect of School Based Obesity Interventions ABSTRACT Introduction Background Obesity in both adult and children is fast becoming one of the most serious public health problems of the 21st century in developed and developing countries alike. It is estimated that approximately 10% of school age children. The prevalence of childhood overweight and obesity is ever on the increase in the UK as in the rest of the world. It is estimated that the prevalence of overweight and obesity among 2 10 year old children in the UK rose from 22.7%-27.7% and 9.9%-13.7% respectively between 1995 and 2003; these figures are set to increase unless something is done. School-based interventions offer a possible solution in halting obesity prevalence, because the school setting provides an avenue for reaching out to a high percentage of children (especially in the western world), opportunity for constant monitoring of children and the resources for anti-obesity interventions. Objectives To systematically review the evidence of the impact of school-based interventions to prevent childhood obesity on: Adiposity (primary objective) Knowledge, physical activity levels and diet (secondary objectives) Methods The review was done following the Cochrane collaboration guidelines. In addition to searching electronic databases, first authors of all included studies were contacted. A recognised critical appraisal tool was used to assess the quality of included studies. Results Three RCTs and one CCT met the inclusion criteria for the review. All four studies had a control and intervention group; with various study limitations. While none of the studies found statistically significant BMI changes in intervention groups when compared with control group post-intervention, all of them recorded either a significant change in diet, or an increase in physical activity levels. INTRODUCTION BACKGROUND Obesity is generally understood as abnormal accumulation of fat to the extent that presents health risk (Kiess, Marcus et al. 2004), and was added to the international classification of diseases for the first time in 1948 (Kipping, Jago et al. 2008). The worldwide clinical definition of adult obesity by the WHO is body mass index (BMI) ≠¥ 30kg/m2 (WHO 2006). In children however, because of the significant changes in their BMI with age (Cole, Bellizzi et al. 2000), there is no universally accepted definition of obesity (Parizkova and Hills 2004; Bessesen 2008) and it therefore varies from country-to-country. The most commonly used definition of childhood obesity is the US definition which measures overweight and obesity in a reference population using the cut off points of 85th and 95th centiles of BMI for age (Ogden, Yanovski et al. 2007). In the UK, overweight and obesity are diagnosed using a national reference data from a 1990 BMI survey of British children (Stamatakis, Prima testa et al. 2005). Children whose weights are above the 85th centile are classed as overweight and over the 95th centile are considered obese (Reilly, Wilson et al. 2002). Recent estimates suggest that obesity has reached epidemic proportions globally with about 400 million adults being clinically obese, a figure projected to rise to about 700 million by 2015 (WHO 2006). In children, the current WHO estimates are that about 22 million children globally under age 5 are overweight (WHO 2008). In the UK, evidence suggests that obesity is set to be the number one preventable cause of disease in a matter of time (Simon, Everitt et al. 2005). In the last three decades, the scale as well as the prevalence of obesity have grown rapidly amongst all age, social and ethnic groups in the UK, as well as globally (Table 1)(Kipping, Jago et al. 2008). Estimates suggest that in the UK, between 1984 and 2002/2003, the prevalence of obesity in boys aged 5-10 rose by 4.16%, and by 4.8% in girls (Stamatakis, Primatesta et al. 2005). There is therefore there is an urgent need for the development and implementation of effective intervention strategies to halt the ever increasing obesity prevalence (Summerbell Carolyn, Waters et al. 2005). OBESITY CAUSATION The primary risk factors associated with the increase in prevalence of childhood obesity are ever increasing involvement in sedentary lifestyles and an increase also in the consumption of high energy dense food and drink (Ebbeling, Pawlak et al. 2002; Sekine, Yamagami et al. 2002; Speiser, Rudolf et al. 2005; Topp, Jacks et al. 2009). The underlying mechanism of obesity formation is an imbalance between energy input and expenditure (Moran 1999; Kipping, Jago et al. 2008) Genetic and environmental factors greatly influence the bodys energy balance. Nevertheless, genetic conditions which either cause production of excessive fat in the body or reduce the rate at which it is broken down, of which Prader-Willi syndrome is an example account for less than 5% of obese individuals (Speiser, Rudolf et al. 2005), with environmental factors accounting for a very high percentage (French, Story et al. 2001). The major cause of the rising obesity problem is arguably changes in physical and social environments (French, Story et al. 2001). In recent times, there has been a remarkable shift towards activities that do not promote energy expenditure, for example, most children would travel to school in cars rather walk, in contrast to what obtained in the 1970s (Popkin, Duffey et al. 2005; Anderson and Butcher 2006). There is evidence to suggest that obese children are less active than their non-obese counterparts, hence promoting physical activity such as walking or exercising will help prevent obesity in children (Hughes, Henderson et al. 2006). Media time (television viewing, playing video games and using the computer) has been identified as one of the significant environmental changes responsible for the surge in childhood obesity. Besides promoting physical inactivity, it encourages energy input via excessive snacking and inappropriate food choices as a result of television advertisements (Ebbeling, Pawlak et al. 2002; Speiser, Rudolf et al. 2005). Robinson in his study reveals that â€Å"between ages 2 and 17, children spend an average of 3 years of their waking lifetime watching television alone† (Robinson 1998). Parents play a significant role in where, what and how much their children eat and to an extent, how physically active their children are. In most homes, children make their food choices based on the options they are presented with by their parents, and they characteristically would go for wrong option, more so if they have an obese parent (Strauss and Knight 1999). Other changes within the family such as physical inactivity and working patterns of parents have contributed somewhat to the obesity epidemic. In a family where the parents work full-time, there tends to be very little time for them to prepare wholesome home-made meals and this could possibly explain the increasing demand for eating out (Anderson and Butcher 2006) thereby increasing intake of high energy dense food. Childrens attitude to and participation in physical activities depends largely on how physically active their parents are. Thus children of sporty parents embrace exercise heartily and are therefore less prone to becoming obese.(Sallis, Prochaska et al. 2000). In addition to these family factors, societal factors such as high crime rate, access to safe sports/recreational facilities, transportation and fewer physical education programs in schools significantly impact on energy balance (Koplan, Liverman et al. 2005; Popkin, Duffey et al. 2005; Topp, Jacks et al. 2009). French summarizes the environmental influence on obesity by opining that â€Å"The current epidemic of obesity is caused largely by an environment that promotes excessive food intake and discourages physical activity† (French, Story et al. 2001) CONSEQUENCES OF OBESITY Evidence suggests that childhood obesity and/or overweight has a great impact on both physical and psychological health; causing effects such as behavioral problems and low self esteem, with a higher risk in girls than in boys (Reilly, Methven et al. 2003). Although most of the serious consequences do not become evident until adulthood, research has shown childhood obesity to be linked to metabolic disorders such as insulin resistance and type 2 diabetes, stroke and heart attacks, sleep apnea, nonalchoholic fatty liver disease, higher incidence of cancers, depression, dyslipidaemia, increased blood clotting tendency, etc (Ebbeling, Pawlak et al. 2002; Reilly, Methven et al. 2003; Kiess, Marcus et al. 2004; D. A. Lawlor, C. J. Riddoch et al. 2005; Daniels 2006; WHO 2006). One of the long-term serious consequences of childhood obesity is that obese children are twice more likely to grow into obese adults than their non-obese counterparts (Moran 1999); however, this largely depends on factors such as age of onset, severity of the disease and the presence of the disease in one parent (Moran 1999; Campbell, Waters et al. 2001; Kiess, Marcus et al. 2004; WHO 2006). Other long term consequences include early death and adverse socio-economic consequences such as poor educational attainment and low/no income in adulthood (Reilly, Methven et al. 2003; Fowler-Brown and Kahwati 2004; Kiess, Marcus et al. 2004). Obesity-related morbidity places a huge and growing financial demand on governments. In the UK alone, the Department of Health has reported that obesity costs the NHS and the UK economy as a whole about  £1b and between  £2.3b  £2.6b annually respectively, with the cost to the NHS projected to rise to  £3.6b by 2010 (DH 2007). TREATMENT AND PREVENTION The treatment of obesity requires a multidisciplinary approach due to the multi-faceted nature of the condition (Parizkova and Hills 2004). This is aimed at reducing caloric intake and increasing energy expenditure through physical activity (Ebbeling, Pawlak et al. 2002). These interventions are more likely to be successful if the patients family is involved and the treatment tailored to individual needs and circumstances (Fowler-Brown and Kahwati 2004). In extreme cases, options such as surgical and pharmacological treatments could be exploited. These options are very unpopular and usually not recommended because the associated health risks outweigh the benefits by far (Epstein, Myers et al. 1998; Ebbeling, Pawlak et al. 2002). Considering the huge costs and high levels of treatment failure associated with obesity treatment (Stewart, Chapple et al. 2008), the axiom by Benjamin Franklin cannot describe any other condition better than it describes obesity management. â€Å"An ounce of prevention is worth a pound of cure† Dietz et al confirm this by saying that prevention remains the best and most effective management of obesity (Dietz and Gortmaker 2001). Obesity prevention interventions are usually set either in the home or at school with an objective of eliminating peer pressure and, by so doing effect behavioral change (Ebbeling, Pawlak et al. 2002). Literature suggests that the school has so far remained the choice setting for these preventive interventions despite the very limited evidence on its effectiveness (Birch and Ventura 2009). Why is the school setting a good focus of intervention? Approximately 90% of children are enrolled in schools in developed countries (Baranowsk, Cullen et al. 2002) Children spend a substantial amount of time in school and therefore consume a considerable proportion of their daily calories at school (Katz, OConnell et al. 2005) School related activities present an opportunity to educate children on the concept of energy balance, healthy living and how to make appropriate food choices (Ebbeling, Pawlak et al. 2002; Koplan, Liverman et al. 2005) It offers opportunity for continuity and constant monitoring via frequent contact (Baranowski T 2002) Schools have an availability of existing manpower and facilities needed for anti-obesity interventions (Kropski, Keckley et al. 2008) In a nut shell, â€Å"Schools offer many other opportunities for learning and practicing healthful eating and physical activity behaviors. Coordinated changes in the curriculum, the in-school advertising environment, school health services, and after-school programs all offer the potential to advance obesity prevention† (Koplan, Liverman et al. 2005). PREVIOUS SYSTEMATIC REVIEWS Systematic reviews have been conducted on the effectiveness of school-based interventions in the prevention of childhood obesity. Campbell et al (2001), conducted a systematic review of 7 randomised control trials (RCTs) (6 were school-based, varying in length of time, target population, quality of study and intervention approach). The review found that dietary and physical education interventions have an effect on childhood obesity prevalence. However, success varied with different interventions amongst different age groups. Two of the three long term studies that focused on a combination of dietary education and physical activity, and dietary education respectively reported an effect on obesity prevalence reduction. Similarly, 1 out of the 3 school based short-term interventions that focused only on reducing sedentary activity also found an effect on obesity prevalence. While this review shows that dietary and physical activity interventions based at school are effective against th e risk factors of obesity, the question of generalisability and reproducibility arises as the review reports the majority of the included primary studies were carried out in the US. Most of the studies used BMI as a measure of adiposity, and BMI as has been documented varies across ethnic and racial groups (Rush, Goedecke et al. 2007), thus, it will be inappropriate to apply the findings of US-based obesity prevention interventions to children in middle and low income countries where conditions are different. There are also concerns about the methodology and study design. For example the school-based study by Gotmaker et al (1999) had limitations such as low participation rate (65%) and the researchers were unable to adjust for maturity in boys and there was also poor assessment of dietary intake. All these limitations could have been responsible for a high percentage of the reported intervention effect thus affecting the validity of the results of the study (Gortmaker, Peterson et al. 1999). The authors of the review however concluded that there is currently very limited high quality evidence on which to draw conclusions on the effectiveness of anti-obesity programmes. A Cochrane review which is an update of the Campbell et al (2001) study by Summerbell et al (2005) has examined the impact of diet, physical activity and/or lifestyle and social support on childhood obesity prevention. Their review examined the effectiveness of childhood obesity prevention interventions which included school based interventions. Their study included 10 long-term (a minimum duration of 12 months) and 12 short-term (12weeks 12 months) clinical trials (randomised and controlled). 19 out of the 22 studies that met their inclusion criteria were school/pre-school based. The study chose the appropriate study type; more than one reviewer was involved in the entire process of data collection, extraction and selection of included studies. In general, the study found that most of the school-based interventions (dietary and/or physical activity) reported some positive changes in targeted behaviours, but however had very little or no statistically significant impact on BMI. The reviewers stated that none of the 22 studies fulfilled the quality criteria because of some form of methodological weakness which includes measurement errors. For instance, the study by Jenner et al (1989) had no valid method of measuring food intake. The studies by Crawford et al (1994), Lannotti et al (1994) and Sallis et al (2000) had similar measurement errors. Reporting error was identified in studies by Little et al (1999) and Macdiarmid et al (1998). There were also reliability concerns about the secondary outcomes measurement in some of the included studies. The reviewers therefore expressed the need for further high quality research on effectiveness. Kropski et al (2008) reviewed 14 school-based studies that were designed to effect a life style change, a change in BMI, decrease overweight prevalence through a change in nutrition, physical activity or a combination of both. Of the 14 studies, three were done in the UK, one in Germany and 10 in the US. The right type of studies were chosen for this review and the whole process was done by more than one reviewer, however they were unable to draw strong conclusions on the efficacy of school-based interventions because of the limited number of primary studies available and methodological or design concerns which include: small sample size (Luepker, Perry et al. 1996; Mo-suwan, Pongprapai et al. 1998; Nader, Stone et al. 1999; Warren, Henry et al. 2003), no intention-to treat analysis (Danielzik, Pust et al.; Sallis, McKenzie et al. 1993; Sahota, Rudolf et al. 2001; Warren, Henry et al. 2003), possibility of type I (Coleman, Tiller et al. 2005) and type II errors (Warren, Henry et al. 2003), unit of analysis errors (Sallis, McKenzie et al. 1993) and inconsistent results (Mo-suwan, Pongprapai et al. 1998; Caballero, Clay et al. 2003; Coleman, Tiller et al. 2005). Despite their inability to draw a conclusion on effectiveness, overall, the review found that a combination of nutritional and physical activity interventions had the most effect on BMI and prevalence of overweight, with the result largely varying from community-to-community. The nutrition only and physical activity only interventions appeared to have had a change on lifestyles of participants but either had no significant effect on the measures of overweight or no BMI outcomes were measured. Another systematic review on the effectiveness of school-based interventions among Chinese school children was carried out by M.Li et al (2008). The authors included 22 primary studies in their review. The review reported that the primary studies showed that there are some beneficial effects of school-based interventions for obesity prevention; the reviewers however expressed their concerns that most of the studies included in the review had what they considered to be serious to moderate methodological weaknesses. Sixteen of the 22 studies included studies were cluster control trials, and there was no mention by any of the researchers that cluster analysis was applied to any of the 16 studies. In addition to lack of cluster analysis, no process evaluation was conducted in any of the studies. Only one study performed an intention to treat analysis. Twelve studies experienced dropouts, but there was incomplete information on the study population at the end of the trial and the reason f or the dropouts. Additionally, none of the studies explained the theory upon which they based their intervention. There was also potential recruitment and selection bias in all the primary studies as identified by the reviewers. They stated that none of the studies reported the number of subjects that were approached for recruitment into the study. As none of the RCTs included described the method they used in randomization, neither did they state if the studies were blinded or not. The methodological flaws in a high percentage of the included primary studies could impact on the validity of the findings of the review. Again, the authors failed to reach a conclusion on the effectiveness of the interventions because of the intrinsic weaknesses found in the primary studies, and as a result state the need for more primary studies that would address the methodological weaknesses that is highly present in nearly all existing primary studies conducted on this topic so far. The study of the efficacy of school-based interventions aimed at preventing childhood obesity or reducing the risk factors is a rather complex one. Pertinent issues on effectiveness of school-based interventions to prevent the risk factors of obesity remain that there is very limited/weak evidence on which to base policies on. Heterogeneity of primary research (in terms if age of study population, duration of intervention, measurement of outcomes and outcomes measured) makes further statistical analysis nearly impossible. BMI is currently the most widely used measure of overweight and obesity in children. However, BMI has no way of distinguishing between fat mass and muscle mass in the body and might therefore misdiagnose children with bigger muscles as obese. Another disadvantage of using BMI in overweight measurement is its inability of depicting the body fat composition (Committee on Nutrition 2003), other surrogate indicators of adiposity may be needed. Most authors that have carried out a review on this topic so far have expressed the need for further research on this topic to add to the existing body of evidence. RATIONALE FOR THIS STUDY All the systematic reviews on this subject so far have focused mainly on the United States. Lifestyle differences such as eating habits between American and British children possibly affect generalisability and reproducibility of US findings to the UK. For example, in the US, research has shown that 0.5% of all television advertisements promote food, and that about 72% of these food advertisements promote unhealthy food such as candy and fast food (Darwin 2009). In the UK paradoxically, the government in 2007 enforced regulations banning television advertisement of unhealthy foods (foods with high fat, salt, and sugar content) during television programmes aimed at children below 16 years of age (Darwin 2009). Thus US children are at a higher risk of becoming obese than their UK counterparts as a result of higher rate of exposure to TV junk food advertisements. Another lifestyle difference between American and British children is physical activity. In the UK, a high percentage of children aged 2 to 15 achieve at least 60 minutes of physical activity daily (about 70% of males and 60% of females) (DoH 2004), as opposed to the US where only about 34% of school pupils achieve the daily recommended levels of physical activity daily (CDC 2008). These differences highlight the importance of public health policies being based on the local population characteristics rather than on imported overseas figures. There is therefore need to review the evidence of UK school-based obesity interventions to inform policy relevant to the UK population. To the best of my knowledge following an extensive literature search, no systematic review has been conducted on the effectiveness of school-based intervention in preventing childhood obesity in the UK, despite the high prevalence of the condition and its public health significance in this country. This research aims to bridge this gap in knowledge by focusing on UK based studies to evaluate the efficacy of school-based interventions in the UK population. This study therefore stands out insofar as it will be assessing the effectiveness of school-based interventions in the reducing the risk factors of obesity in the UK, with a hope of providing specific local recommendations based on UK evidence. This type of review is long overdue in the UK, considering that the governments target to reduce childhood obesity to its pre-2000 levels by the year 2020 (DoH 2007) will require local evidence of effective interventions to succeed. The next stage of this review will describe in detail the research methodology to be used to conduct the proposed systematic review. Also included will be research strategy details to be adopted, study selection criteria, data collection and analysis. AIMS AND OBJECTIVES The aim of this research is to: Systematically review school-based intervention studies in the UK aimed at reducing the risk factors of childhood obesity among school children. Objectives are: To assess the efficacy of school-based anti-obesity interventions in the UK. To identify the most effective form of school-based interventions in the prevention of childhood obesity amongst school children in the UK. CRITERIA FOR INCLUDING STUDIES IN THIS REVIEW METHODS This review was performed as a Cochrane review. The Cochrane guidance on systematic reviews and reporting format were as far as possible adhered to by the author (Green, Higgins et al. 2008). The entire review process was guided by a tool for assessing the quality of systematic reviews, alongside the accompanying guidance (health-evidence.ca 2007a; health-evidence.ca 2007b). TYPES OF STUDY In the search for the effectiveness of an intervention, well conducted randomised control trials (which are the best and most credible sources of evidence) will be the preferred source of studies for this review. However, because of the limited number of RCTs conducted on this topic so far, this study will include controlled clinical trials if there is insufficient availability of RCTs. TYPES OF PARTICIPANTS School children under 18 years of age TYPES OF INTERVENTIONS Interventions being evaluated are those that aim to: Reduce sedentary lifestyle Effect nutritional change Combine the two outcomes above Reduce obesity prevalence Effect an attitude change towards physical activity and diet Studies that present a baseline and post intervention measure of primary outcome. Interventions not included in this study are: Those with no specified weight-related outcomes Those that involved school-age children but were delivered outside of the school setting, as our focus is based on school-based interventions aimed at obesity prevention. Studies done outside the UK Studies with no specified interventions Non-RCTs or CCTs For each intervention, the control group will be school children not receiving the intervention(s). TYPES OF OUTCOMES MEASURED Primary outcomes Change in adiposity measured as BMI and/or skin fold thickness Secondary outcomes Knowledge Physical activity levels Diet SEARCH METHODS FOR IDENTIFICATION OF STUDIES Electronic searches The electronic databases OVID MEDLINE ® (1950-2009), PsycINFO (1982-2009), EMBASE (1980-2009) and the British Nursing Index (1994-2009) were all searched using the OVID SP interface. The Wiley Interscience interface was used to search the following databases: Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effects. There was also a general search of internet using Google search engine, in an attempt to identify any ongoing studies or unpublished reports before proceeding to search grey literature sources. Grey literature For references to childhood obesity prevention in schools, the following grey literature sources were searched: British Library Integrated Catalogue (http://catalogue.bl.uk/F/?func=filefile_name=login-bl-list) ISI index of Conference Proceedings (http://wok.mimas.ac.uk/) SCIRUS (http://www.scirus.com/) System for Information on Grey Literature (http://opensigle.inist.fr/) ZETOC (http://zetoc.mimas.ac.uk) Additionally, current control trials database at http://www.controlled-trials.com/ was searched for any ongoing research. The UK national research register was also searched at https://portal.nihr.ac.uk/Pages/NRRArchive.aspx. All the links to the grey literature databases were tested at the time of this review and found to be working. Hand searches It was not possible to conduct a hand search of journals due to pragmatic reasons. Reference lists Reference lists of retrieved studies were searched for other potential relevant studies that might have been omitted in the earlier search. Correspondence First author of all included studies were contacted with a view to seeking more references. DATA COLLECTION AND ANALYSIS Selection of studies The abstracts and titles of the hits from the electronic databases searched were screened for relevance by a single assessor. Those that were thought to be potentially relevant were retrieved and downloaded unto EndnoteTM to make the results manageable and also avoid loss of data. At the end of the search, all databases were merged into one single database and duplicated records of the same study were removed. Subsequently, the assessor then sought and obtained the full text of, and reviewed the relevant studies that were considered eligible for inclusion. Multiple reports of same study were linked together. No further data were sought for studies not included in the review. Data extraction Data extraction from included studies was done by a single reviewer and the data recorded on a data extraction form. A summary of each included study was described according to these characteristics: Participants (age, ethnicity etc.), study design, description of school-based interventions, study quality and details such as follow-ups and date, location, outcomes measured, theoretical framework, baseline comparability and results Assessment of methodological quality of included studies A number of researchers (Jackson, Waters et al. 2005) and the Cochrane guidelines for systematic reviews of health promotion and public health interventions (Rebecca Armstrong, Waters et al. 2007) strongly advise using the Quality Assessment Tool for Quantitative Studies (2008a) developed by the Effective Public Health Practice Project in Canada and the accompanying dictionary (to act as a guideline) (2008b) in assessing methodological quality. Based on criteria such as selection bias, study design, blinding, cofounders, data collection methods, withdrawals and drop-outs and intervention integrity, the tool which is designed to cover any quantitative study employs the use of a scale (strong, moderate or weak) to assess the quality of each study included in the review. Analysis Considering the small number of studies included in the review and heterogeneity in terms of interventions, delivery methods, intensity of interventions, age of participants, duration of intervention and outcomes measured, it was not statistically appropriate to undertake a Meta analysis, which admittedly would have been the preferred method of analysing and summarising the results of the studies. A narrative synthesis of the results was done instead. RESULT DESCRIPTION OF STUDIES Results of the search The search of electronic sources identified 811 citations out of which 97 potential studies were retrieved. A reference management software EndnoteTM was used to search for and remove duplicate citations. Further screening of title and abstract reduced the number of citations to 17 potential studies. Full texts of the 17 studies were sought, 13 were excluded, and four met the inclusion criteria and were therefore included in the review. Authors of the four studies were then conta