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Effect of Positive Airway Pressure on Endothelial Function

Effect of Positive Airway Pressure on Endothelial Function. Effect of continuous positive airway pressure on endothelial function in patients with obstructive sleep apnea: a meta-regression analysis Abstract Objective: Obstructive sleep apnea (OSA) is related to the occurrence of endothelial dysfunction. Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA. Previous studies assessing the effect of CPAP on endothelial function in OSA have yielded conflicting results. Therefore, our aim is to perform a meta-analysis and evaluate the effect of CPAP on endothelial function in OSA and explore potential moderating factors. Methods: We systematically collected data from available electronic databases between January 1989 and May 2014 and performed a meta-analysis with regression models. The overall effects were measured by the weighted mean difference (WMD), together with the 95% confidence interval (CI). A fixed or random effects model was used according to heterogeneity as appropriate. Meta-regression analysis was used to explore the source of heterogeneity. Results: Eleven eligible studies of 199 subjects were finally included. Meta-analysis using a random-effects model revealed that treatment with CPAP significantly improved endothelial function as assessed peripherally by Flow-mediated dilation (FMD) (WMD 2.92, 95% CI: 2.21 to 3.63, p < 0.001). However, the endothelial function assessed peripherally by nitroglycerine-mediated dilatation (NMD) was not significantly improved using a random-effects model (WMD 0.90, 95% CI: −1.63 to 3.43, p=0.48). None of the significant effects of tested moderators (mean age, percentage of males, information of CPAP usage and sleep-related variables pre- and post-CPAP) and publication bias were found. Conclusions: CPAP significantly improved brachial artery FMD in OSA patients. Despite the significant heterogeneity, we did not identify any significant moderating factors. Keywords: Endothelial function; Meta-analysis; Continuous positive airway pressure; Obstructive sleep apnea Introduction Obstructive sleep apnea (OSA) is a clinical sleep-breathing disorder disease that is characterised by repeated episodes of complete or partial upper airway obstruction during sleep [1]. The ensuing activation of oxidative stress and systemic inflammation are key factors in the pathogenesis of OSA-related cardiovascular complications [2]. Endothelial dysfunction is an early stage of atherosclerosis and is an independent predictor of cardiovascular morbidity and mortality [3-4]. A positive association exists between endothelial dysfunction and the risk of subsequent cardiovascular events in OSA [5]. This relationship has promoted the use of ultrasound in pathophysiological studies and clinical trials, in which the perception of flow-mediated dilation (FMD) is a biomarker of vascular function and serves as a surrogate of risk of cardiovascular event [6]. Currently, continuous positive airway pressure (CPAP) is recommended as the main treatment in the management of OSA [7]. CPAP is effective in decreasing mean diastolic blood pressure (DBP) and reducing the risk of serious cardiovascular outcomes [8]. CPAP has a positive effect on decreasing inflammation, decreasing oxidative stress, and increasing endothelial nitric oxide (NO) production [9]. All these factors play an important role in endothelial dysfunction in patients with OSA. Numerous studies have also explored the effects of CPAP treatment on the surrogate vascular outcome of FMD [10-20]. However, the conclusions were lack of consistency. In addition, moderating factors such as, the presence of obesity, insulin resistance and metabolic syndrome affecting the change in endothelial function should be also taken into account. Thus, the aim of our meta-analysis is to summarize available evidence and explore possible moderating factors. Materials and Methods We strictly followed the preferred reporting items for systemic reviews and meta-analyses (PRISMA) guidelines during the procession of design, implementation, and reporting of this meta-analysis [21]. Search strategy and selection criteria Electronic databases, including PubMed, EMBASE and the Cochrane Library, were searched using a combination of computerised and manual methods. The search terms used were as follows: (CPAP or continuous positive airway pressure) combined with (obstructive sleep apnea hypopnea syndrome or OSAHS or obstructive sleep apnea syndrome or OSAS or obstructive sleep apnea or OSA or sleep apnea) and paired with (flow-mediated or flow mediated or FMD or endothelial function or endothelial dysfunction or endothelium-dependent or blood flow or arterial stiffness or vascular resistance). Two investigators (Drs. Xu and Wang) independently performed this search process. No restrictions, including language or study object, were applied. The scientific papers included in our meta-analysis ranged from April 1989 to May 2014. The following inclusion criteria were used: 1) studies involving patients with OSA; 2) CPAP treatment was used as the intervention, and the duration of CPAP used should be at least 2 weeks as we did not evaluate the acute effect of CPAP on endothelial function; 3) FMD or nitroglycerine-mediated dilatation (NMD) should be reported or could be estimated before and after the CPAP intervention; 4) participants were adults (≥18 years) or above. In addition, to avoid double-counting study participants, only the most-recent article was included if data from duplicate publications or the same trials were identified. The exclusion criteria were as follows: 1) reviews, abstracts, and non-human studies; 2) studies with other interventions that might influence endothelial function; 3) OSA patients in studies did not use CPAP on a daily basis; and 4) unpublished studies for which we could not obtain the data from authors through email. Data collection Data were extracted from the included studies by two reviewers (Drs. Xu and Wang). Concrete information was collected onto a collection worksheet in the form of standardised data. These data included 1) first author, year of publication, number of enrolled and compliant cases, adherence and duration of CPAP usage, percentage of males and mean age in patients; 2) the variables of apnea-hypopnea index (AHI) and body mass index (BMI) pre- and post-treatment of CPAP; and 3) endothelial dysfunction-related variables, such as systolic blood pressure (SBP), DBP, FMD and NMD before and after CPAP usage. Any inconsistencies were resolved by discussion and the final dataset was verified by all the authors. Statistical analysis Review Manager software (ver. 5.2; Cochrane Collaboration, Oxford, United Kingdom) and Stata software (version 10.0; Stata Corporation, College Station, TX, USA) were used for statistical analyses in this meta-analysis. The pooled estimate of weighted mean difference (WMD) and 95% confidence interval (CI) for continuous data were calculated to determine the statistical result. A Mantel-Haenszel fixed-effect model or DerSimonian and Laird random-effect model was chosen according to non-heterogeneity or heterogeneity as appropriate [22]. Heterogeneity across the eligible studies was examined using the Q-test and I2 statistic (if p value <0.1, a significant heterogeneity existed) [23]. Potential publication bias was assessed by funnel plots and Egger’s linear regression test [24]. To explore the possible origin of heterogeneity across these studies, meta-regression was performed according to previous meta-analysis [25]. Results Search results A flow diagram showing the searching procedure we performed is presented in Fig. 1. A total of 414 citations were identified from initial search. After reading titles and abstracts, 397 records were excluded for different reasons (Fig. 1). As a result, 17 potentially eligible candidate studies were obtained. After carefully assessing the content of these articles, 6 articles were further excluded for the following reasons: 2 studies [26-27] had an overlapping population; 2 studies [28-29] were missing data on FMD or NMD; 1 study [30] lacked data on pre-and post-CPAP; and 1 study [31] involved using CPAP for only one day. Finally, 11 studies [10-20] (11 studies evaluating FMD and 5 studies evaluating NMD) with a total of 199 OSA patients met all the inclusion criteria and were included in this meta-analysis (controls in the study were not included) (Fig. 1). Study characteristics The basic characteristics of eligible studies are shown in Table 1. The publication year ranged from 2004 to 2013. Most participants were men (67%~ 100%) with an age range from 38 to 58.4 years old. CPAP usage adherence ranged from 2.84~ 7.1 hours per night, and the duration of CPAP usage ranged from 1~6 months. Details on mean age, percentage of males, information concerning CPAP usage, and the variables of AHI, BMI, SBP, and DBP, as well as measures of endothelial function (FMD and NMD) pre- and post-CPAP are also represented in Table 1. Effect of CPAP on FMD or NMD A significant improvement was found in FMD after CPAP treatment (WMD 2.92, 95% CI: 2.21 to 3.63, p < 0.001), and a significant heterogeneity for this outcome was found (I2= 76%, p < 0.001) (Fig. 2). CPAP treatment did not significantly improve NMD (WMD 0.90, 95% CI: −1.63 to 3.43, p=0.48), and heterogeneity for this outcome also existed (I2= 63%, p = 0.03) (Fig. 3). Meta-regression analyses were performed to explore the origin of heterogeneity (Table 2). No significant effects were found for all the examined covariates, namely proportion of males, mean age, adherence of CPAP, duration of CPAP, and change in BMI, SBP, DBP, and AHI associated with CPAP usage, indicating that changes in endothelial function were independent of changes in the aforementioned factors (Table 2). Sensitivity analysis A sensitivity analysis was used to examine the influence of each included study on the pooled result. This analysis was performed by omitting one study each time. For FMD, the pooled WMD (95%CI) ranged from 2.68 (1.94~ 3.43) to 3.16 (2.46~ 3.86). For NMD, the pooled WMD (95%CI) ranged from -0.08 (-2.23~2.07) to 1.82 (-0.75~4.39). No changes were found in the statistical significance of the pooled estimate. Publication bias Funnel plots revealed there was no significant asymmetry in the meta-analyses of FMD and NMD (Figures were not shown). Egger’s linear regression test also suggested no presence of publication bias for FMD and NMD (p=0.602 and p=0.553, respectively). Discussion Based on this systemic review and meta-analysis, we summarised the published evidence of CPAP on endothelial function as measured by FMD or NMD. The pooled data revealed that CPAP therapy substantially enhanced FMD (WMD 2.92, 95% CI: 2.21 to 3.63, p < 0.001) resulting in a positive effect of CPAP on endothelial-dependent vasodilation. However, treatment of CPAP did not significantly improve NMD (WMD 0.90, 95% CI: −1.63 to 3.43, p=0.48), suggesting that no effect of CPAP on endothelium-independent vasorelaxation was found. Furthermore, although significant between-study heterogeneity was existed, none of the potential factors significantly modified the main effect. OSA is associated with numerous cardiovascular conditions (i.e., atherosclerosis, systemic/resistant hypertension, cardiac arrhythmias, stroke and pulmonary hypertension) [3-4, 32]. Importantly, endothelial dysfunction, as assessed by brachial artery FMD and NMD, is an independent risk factor for the development of conventional cardiovascular diseases (CVDs) [6, 33]. Circulating endothelial cell (CEC) and endothelial progenitor cell (EPC) values, which served as surrogate markers of endothelial damage and repair, were also elevated in OSA and its complications, including CVDs [34]. The mechanisms of OSA-induced endothelial dysfunction are not yet been completely understood. However, several pathways linking OSA and endothelial dysfunction have been discussed briefly. Intermittent hypoxia (IH), sleep fragmentation and sleep deprivation mainly contribute to the occurrence of endothelial dysfunction in OSA patients. Reactive oxygen species (ROS) induced by IH can damage endothelial cells through promoting superoxide production, suppressing phosphorylation of endothelial nitric oxide synthase (NOS) and reducing its activity [35], and reducing endothelial nitric oxide (NO) bioavailability [36]. In addition, IH can also activate proinflammatory pathways, which finally leads to low-grade systemic inflammation. The inflammatory cytokines (i.e., C-reactive protein, tumour necrosis factor alpha and interleukin-8) play an important role in mediating endothelial dysfunction [37]. A clinical study revealed that endothelial function is strongly associated with circulating T-regulatory lymphocytes and appears to correlate with sleep fragmentation [38]. Sleep deprivation induces a reduction in endothelial-dependent vasodilation that is associated with NOS and cyclooxygenase pathway alterations [39]. The beneficial effect of CPAP on improving endothelial dysfunction is partially from reducing oxidative and inflammatory activity and impaired endothelial repair capacity of OSA patients, as well as improving NO bioavailability [10-20]. The duration of CPAP usage and CPAP compliance are important issues as endothelial function is attainable with short CPAP usage; however, when referring to patients who had poor CPAP compliance, the results were contradictory. CPAP significantly changed FMD from 3.3±0.3% to 5.8±0.4% at 1 week in OSA patients [19]. This effectiveness was even validated after one night of CPAP usage [31]. In OSA patients who used CPAP for 1 month and then withdrew usage for 1 week, FMD after CPAP withdrawal was significantly lower than that at 4 weeks of CPAP treatment (5.0±0.7% versus 8.9 ±1.9%) and was similar to baseline [20]. These studies indicate that CPAP might have an acute effect on endothelial function, and this influence might be reversible. The treatment effect of CPAP was significantly higher in patients using CPAP less than 4 hours/night compared with controls, and the treatment effect displays a dose-dependency correlation [10], whereas in another study, there were no FMD changes in patients who used CPAP ≤4 hours daily or declined CPAP use (5.0±2.38% versus 4.30±2.60%)[18]. Our meta-analysis revealed the significant increasing of endothelial function in OSA after CPAP treatment. The increasing brachial artery FMD may represent an attenuation of mechanisms of underlying OSAS-related cardiovascular morbidity. In addition, we observed large heterogeneity across the included studies, it is essential to explore factors which influence this relationship. That’s to say, potential moderating factors in our meta-analysis did not reveal any significant results. To the best of our knowledge, this is the first meta-analysis to investigate the effects of CPAP treatment on the endothelial function of patients with OSA. This statistical analysis adds validity to the positive effect of CPAP in patients with OSA; however, some limitations in this meta-analysis should be addressed. First, most of the included studies are observational; thus, the pooling data may be less precise and reliable than the pooled results of random control trials (RCTs). Second, the enrolled participants of the included studies are older (range from 38~58.4 years old), more obese (27.7~35.5 Kg/m2) and have more severe OSA (25~64.9 events/hr) than the general population. Thus, whether younger, less obese and milder OSA patients will obtain a beneficial effect from CPAP is unknown. As a result, special designed studies focusing on these participants are needed to confirm this positive effect of CPAP. Third, the duration of CPAP therapy ranges from 1 to 6 months, and this duration is relatively short. The long-term effect of CPAP should be further explored. Fourth, the heterogeneity across the studies of our meta-analysis makes the comparison vulnerable to bias. In addition, meta-regression analyses did not reveal any potential modifiers upon the effect of CPAP on endothelial function. Lastly, the total sample size in this meta-analysis was relatively small (199 OSA patients). Thus, long-term RCTs with larger sample size are warranted to confirm the positive effect of CPAP on the endothelial function of patients with OSA. In conclusion, our meta-analysis supports that CPAP improves endothelial function in patients with OSA. Although between-study heterogeneity was existed, none of significant moderating factors was found. Further RCTs with larger sample sizes and longer CPAP usage periods are essential to obtain more precise results to confirm these findings. Effect of Positive Airway Pressure on Endothelial Function
Table of Contents Introduction Definition Prescription Benefits EEN in the Case Consequences Conclusion Reference List Introduction The digestive system performs a vital role in the human body. It provides the body with the elements needed for its survival and further development. Digesting products that a person consumes, the system preserves the balance crucial for its functioning. Therefore, the gastrointestinal tract is one of the elements of this system that is responsible for nutrition as traditional food enters the stomach via the tract. However, there are several cases when this method of nutrition turns out to be inefficient because of a disease or a patients temporary or permanent inability to feed. Under these conditions, the delivery of nutritional substances to the body should be organized in another way to support a patient during his/her recovery. In such cases, enteral nutrition becomes one of the most efficient approaches to performing this task and avoiding undernourishment. Definition In general, enteral nutrition could be defined as a way to provide food through a special tube that could be placed in the patients nose, stomach, or the small intestine (Adler 2013). Regarding the method chosen for the insertion, the percutaneous endoscopic gastrostomy or percutaneous endoscopic jejunostomy could be applied (Adler 2013). The first one suggests placing the tube through the skin into the stomach or gastrostomy (Adler 2013). The second approach presupposes that a tube is inserted into the small intestine (Klingensmith

Public Policy: Obesity and Aging Society Research Paper

Introduction In the aging societies of the United States, obesity has undergone a dramatic increase in recent years. People attribute this to many factors ranging from the excessive intake of energy food through lack of proper physical exercises to genetic susceptibility. They further estimate that approximately one-third of adults in the United States are obese, 15 million of which comprise of the older adults aged 51 years and above (Fontaine, Cutler and Allison 189). Obesity is a “medical condition characterized by excess accumulation of body fats to the level that the affected individual experiences diverse health effects resulting to a number of health problems and other chronic conditions” (Flegal, Carroll and Curtin 237). Professional doctors determine obesity based on the ’Body-mass index (MBI), a measurement that compares body weight with body height. Therefore, a person can be overweight and not obese. An obese person has increased likelihood of acquiring various diseases, which include heart diseases, diabetes type 2, specific types of osteoarthritis and cancer, sleep apnea. The prevalence of obesity in an aging society is on an upward trend. For instance, According to Fontaine, Cutler and Allison , between 1999 and 2002,the percentage of obese adults aged from 65 to 74 years increased from 18% to approximately 36%(187). Obesity in the aging society has become an epidemic due to diverse detrimental effects related to it. This follows because a big proportion of obese older people have obesity-related chronic illnesses or detrimental degenerative conditions like cardiovascular diseases, arthritis, and cancer. This paper addresses the issues surrounding obesity epidemic. It, further, shows its respective influence on the human population as people age. Implications of obesity in an aging society on entitlement programs Obesity among older or senior citizens in the United States has far-reaching implications on various entitlement programs specifically social security, and Medicare. The fiscal malaise experienced by the entitlements programs mainly result from increased rates of obesity amongst senior citizens. Policy makers often debate on the mitigation measures to reduce entitlements costs, as they have profound effects on the nation’s economic growth. The United States’ Social security, the world’s largest program in social insurance program, faces diverse challenges as the number of beneficiaries increase. The social security has diverse programs such as unemployment benefits, Medicare- a health insurance for the disabled and old, programs in medical assistance known as Medicaid program, disability insurance, assistance for poor families, patient protection programs, and affordable care programs. Get your 100% original paper on any topic done in as little as 3 hours Learn More These programs require a lot of money to implement. However, it benefits millions of citizens. The number of senior citizens requiring health insurance from social security has increased resulting to increased expenditure. From recent studies, it is evident that the increase of obese people in the aging society is tantamount to increased expenditure in social security. Disability pensions that are attributable to increased obesity cost the US economy billions of dollars every year. In the realm of the United States’ health care, the aging society is drawing much attention based on the evident increase of obesity prevalence among older citizens that has resulted to an increase in many chronic conditions. This has escalated the cost of drugs and services in the healthcare sector. Therefore, the aging society is among the leading contributors of ballooning costs of healthcare, which result to an increase in government budgets. Medicare costs have increased because of the increase in medical bills based on the myriad diseases related to the aging obesity. According to Andereveva, Robert, and Ringel , “Medicare is a unique entitlement program which avails health insurance to citizens aged from 65 years and above or to citizens with disabilities without any regard to their income” (1938). The US government enacted this program in 1965. It provides the aging and disabled citizens with coverage for health insurance similar to the one offered to fit the non-elderly citizens in private sectors. Medicare includes part A that is the hospital insurance; Part B, which is the supplementary insurance that covers outpatients, home care services and physician visits; and part D that is coverage for prescription drugs. According to recent statistics, Medicare covers approximately 44 million citizens who include both disabled and senior citizens in the United States (Andereveva, Robert, and Ringel 1939). This program receives funds from revenues accrued from general taxes, beneficiary premiums as well as taxes from the federal payroll. With the high number of people under Medicare program, increase in chronic conditions related to obesity poses a great challenge to the program. Finkelstein and Fiebelkorn noted how substantial proportions of excess costs in health care amongst obese adults in the United States occur from the age of 65 years…hence covered by Medicare, which translates into direct charges to all working citizens through government’s taxation (224). Consequently, Medicare expenditure has to rise because of the high increase in health complications related to obesity among older citizens in the United States. These illnesses require special and long-term health care management by highly skilled and specialized caregivers. We will write a custom Research Paper on Public Policy: Obesity and Aging Society specifically for you! Get your first paper with 15% OFF Learn More According to various researches conducted on this issue, people spend billions of dollars on various entitlement programs in healthcare alone. For instance, “it is estimated that, in 2008 only, the United States spent approximately $600 billion on Medicaid and Medicare programs” (James 67). This resulted from the fact that a considerable proportion of America’s citizens are aging. As a result, they use greater services in healthcare. The impacts of obesity on life expectancy, health costs, and quality of care Increase in prevalence of obesity in the aging society has increased health costs at a tremendous rate. This contribution emerges from the fact that obesity in the aging citizens has resulted to an increase in chronic conditions that are expensive to treat. One pivotal metric to summarize the huge burden obesity has on the systems of healthcare and the whole society is to perform an assessment of the diverse economic costs associated with obesity. The metric encompasses various financial consequences obtained from medical resources used to treat obesity-related illnesses, both nonfatal and fatal health conditions. Through studying of diverse economic consequences associated with obesity using monetary terms, there is a clear analysis of the impacts of obesity in senior citizens on health cost. The affected people and other stakeholders make hefty payments on cases related to obesity. Health costs attributable to increase in obesity in an aging society include both direct and indirect costs. It consist of various resources used in hospitals, which include distinct costs incurred by excessive utilization of pharmacotherapy, ambulatory care, laboratory costs, hospitalization, radiological costs, and long-term care in nursing homes because of the various diseases attributed to obesity. Unsurprisingly, huge burdens of diseases lead to various devastating consequences occurring from increased risks of cancer, diabetes, cardiovascular diseases, and nonfatal but costly health conditions like osteoarthritis. These conditions have increased health costs largely. Hser et al. examines the relationship between the increase in health costs in the United States and trends in obesity. The authors found that , between year 1987 and year 2000, a combination of increased obesity prevalence and rise in spending among obese citizens accounted for 27% of the total growth in expenditure in the United States’ healthcare”(Hser et al. 34). This signifies tremendous changes that have occurred on the standard care accorded to obesity-related diseases and conditions such as hypertension, hyperlipidemia, heart diseases, and diabetes. Escalating health costs pose a great challenge to the health sector and patients. The annual heath costs of treating obesity-related conditions and diseases in the United States amount to billions of dollars. They are responsible for approximately 4% to 7% of total expenditure in healthcare (Fontaine, Cutler and Allison 191). Many researchers have noted how majority of healthcare costs increase when obesity levels increase. Moreover, indirect costs that are obesity-related exist. They include decrease in years of life that is disability-free, early retirement, reduced productivity, and absenteeism in work, disability pensions, and the increase in mortality. Thus, it is imperative to implement effective measures to reduce health costs in the country. This is achievable through various preventive measures that will curb the increasing obesity in the aging society. For instance, providing counseling services to citizens on how to practice proper eating habits, as well as exercising their bodies, is significant to reducing the number of people who are becoming obese. Not sure if you can write a paper on Public Policy: Obesity and Aging Society by yourself? We can help you for only $16.05 $11/page Learn More On the other hand, obesity in the aging society has reduced the quality of care given to patients due to overwhelming increases in cases requiring high medical attention. Many obese adults in the United States seeking medical care often lack enough obesity screening, counseling, and diagnosis. Even with detailed anthropometric data on patients, the care providers fail to offer high quality services. The aging society in America presents a big proportion of the total population. With the increasing obesity prevalence among them, medical facilities are becoming overwhelmed by high demand for distinct services. Quality of healthcare for acute and chronic conditions, often related to obesity in an aging society, has decreased over the years. If the past trends in obesity in an aging society continue unchecked, the quality of care will continue to diminish. In addition, the health costs will rise, as many older and obese people will be prone to many infections. Therefore, effective behavioral and health interventions are paramount in curtailing the witnessed rise of obesity cases by addressing its roots, which include poor preparation of food, widespread proximity to food with high proportions of calories, and sedentary lifestyles. Obesity in the aging society has profound effects on life expectancy. The negative effects that obesity has on life expectancy manifest themselves in various chronic diseases such as diabetes and cancer, which have increased their prevalence over the years. According to Susan, Cutler, and Rosen, estimates gathered by experts reveal how obesity is responsible for 5% to 15% of annual deaths that occur in the United States (2253). Obesity leads to diverse diseases such as diabetes, cardiovascular diseases, and other health problems, which result to a reduced life expectancy, as many obese people die prematurely. Utilizing data obtained from three decades ago, Susan and her colleagues point out how the increasing rate of obesity among senior citizens in the United States is posing an immense challenge to the country, as it is causing early deaths among the citizens, which translate into reduced life expectancy (Susan, Cutler, and Rosen 2257). This follows because people with high BMI have reduced life expectancy, as obesity exacerbates diverse chronic conditions such as osteoarthritis, hypertension, and increased blood cholesterol, amongst others. The reduction in life expectancy poses a huge threat to the country’s economy. Many productive citizens will lose their lives before attaining their full potential, thus, dwindling economic progress in the respective areas they were working. In addition, Fontaine and colleagues reckon that obesity reduces life expectancy for the US citizens. They estimate how life expectancy can reduce with up to 18% for citizens aged 60 years (Fontaine et. al 194). Efforts to increase life expectancy and reduced detrimental effects associated with obesity should focus on stabilizing or reversing upwards trends in obesity. The baby boom generation Baby boom generation refers to people born after the Second World War mainly from 1946 to 1964. Baby boomers present a considerable proportion of the United States’ population totaling to approximately 76 million people (Strauss and Howe 54). Therefore, with the increase in obesity in the aging population, baby boomers are a big concern. As Charles, Reynolds, and Gatz reckon, the first baby boomers will reach 65 years in the year 2011, which is the standard age of retirement in the United States (143). Thus, tomorrow’s America faces a big challenge, as it will be a queer aging society mainly contributed by the fact that, over the coming decade, enormous percentage of the baby boom generation will have reached retirement age. As the generation of baby boomers reach retirement age, it becomes eligible to the benefits of social security. Unfortunately, as majority baby boomers approach retirement, social security funds are reducing because of the big number of people requiring various benefits from these funds. Baby boomers are, not only aging, but also living longer. This means that they will need more Medicare entitlement programs for greater periods. Medicare costs are increasing due to increase in treatment costs in systems of healthcare in the United States. These costs include high costs of doctors’ reimbursement, high price for stays in hospitals, and increases in the prices of prescription drugs. Thus, the increasing obesity in senior citizens who will comprise of baby boomers has diverse long-term implications. First, there will be detrimental implications on the health sector due to the increase in health problems related to obesity, as health insurance costs will escalate at an alarming rate. Moreover, entitlement programs will experience financial whammy since the number of people requiring various benefits will be overwhelming. Obesity in the aging society will increase expenditure in medical insurance programs such as Medicare and Medicaid. This will lead to financial challenges to various entitlement programs. Overall diagnosis of the epidemic, and recommendations Obesity has become a crisis in public health because the increasing rates are presenting a huge pandemic that require urgent attention in the United States if potential mortality, economic, morbidity tolls are to be mitigated. Concomitant improvements are vital in ensuring that obesity does not diminish longevity and life quality of the aging. As James posits, due to the increase in obesity for the past thirty years, health status of the US’ population have experienced adverse effects (58). Today’s older citizens in America, more so the generation of baby boomers, have caused unprecedented demands for cosmetic surgery, knee replacements and other requirements. Many people have embarked on measures on how to remain young via non-medical solutions like exercise, taking multivitamins, having more sleep. Due to many researches on the effects of obesity in an aging society, the negative effects of obesity seem pronounced making the adoption of mitigation measures a paramount endeavor. Practices and policies to prevent people from gaining excess weighty will reduce huge burden experienced from obesity. Although there are many ongoing debates about effects of obesity in an aging society, people need to take effective measures to address this epidemic. As James posits, negative effects of obesity on life expectancy, heath costs, entitlement programs, and economic growth will increase if the rate of obesity increase persists every year (56). Without proper measures, the aging generation in the United States will require excess healthcare and other amenities mainly contributed by obesity-related health complications. The mainstays of curbing obesity are physical exercises and dieting. In addition, it is imperative to improve the quality of the diet one consumes by reducing the amount of high-energy foods especially those rich in sugars and fats. Efficient preventive measures such as counseling service and early screening are also significant in reducing obesity epidemic Conclusion As the prevalence of obesity in an aging society continues to increase, more pressing challenges of extensively quantifying distinct impacts posed by this epidemic to inform health services and public policies emerge. Failure to mitigate the increasing rate of obesity will eventually erode the tremendous gains in life expectancy and health observed since the beginning of 20th century. Works Cited Andereveva, Harold, Robert, Sturm and Ringel, Samuel. Moderate and severe obesity have large differences in health care costs. Obes Res 12.12 (2004): 1936-1943. Charles, Timothy, Reynolds, Samuel, and Gatz, Mike. “Age-related differences and change in positive and negative affect over 23 years”. Journal of Personality and Social Psychology 80.1 (2001): 136–151 Finkelstein, Einstein and Fiebelkorn, Mophat. National medical spending attributable to overweight and obesity: how much, and who’s paying? Health Aff (Millwood) 3.1 (2003): 219-226. Flegal, Morgan, Carroll, Moan, and Curtin, Roberts. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 303.3 (2010): 235-241. Fontaine, Knight, Cutler, Wang, and Allison, Douglas. Years of life lost due to Obesity. JAMA 289.2 (2003):187-193. Hser, Young, et al. Effects of program and patient characteristics on retention of drug Treatment patients. Evaluation and Program Planning 24.2 (2001): 331–341. James, William. The epidemiology of obesity: the size of the problem. J Intern Med 263.5 (2008): 52-336. Strauss, William and Howe, Neil. Generations: The history of America’s future. Harper Perennial.454.6 (1992):.43-324. Susan, Stewart, Cutler, David, and Rosen, Allison. Forecasting the effects of obesity and smoking on U.S. life expectancy. N Engl J Med 361.23 (2009): 2252-2260.

Week 9 Assignment – Problem-Solving Essay: Part 2 Overview The 18th-century French writer known as Voltaire has been quoted

essay help online free Week 9 Assignment – Problem-Solving Essay: Part 2 Overview The 18th-century French writer known as Voltaire has been quoted as having said, “No problem can withstand the assault of sustained thinking.” When faced with a problem, what do you do to solve it? This assignment asks you to apply a six-step problem-solving process to a specific problem scenario. Instructions You will write a paper that presents a synthesis of your ideas about solving the problem using this systematic approach. Review the six-step problem-solving process outlined in the webtext. Read the article, The Problem-Solving Process. Write a 4–5 page paper in which you: Define the problem in the scenario that you chose in the Week 7 assignment, Problem-Solving: Part 1. Analyze the problem in the scenario. Generate options for solving the problem in the scenario. Evaluate the options for solving the problem. Decide on the best option for solving the problem. Explain how you will implement the chosen solution and reflect on whether this option was the most effective. The paper should follow guidelines for clear and organized writing: Include an introductory paragraph and concluding paragraph. Address the main ideas in body paragraphs with a topic sentence and supporting sentences. Adhere to standard rules of English grammar, punctuation, mechanics, and spelling. Use the Strayer Library to find at least five academic resources. Use four sources to support your writing. Choose sources that are credible, relevant, and appropriate. Cite each source listed on your source page at least one time within your assignment. For help with research, writing, and citation, access the library or review library guides.

The UAE Pearl Company in England vs. Sweden Research Paper

Introduction The UAE Pearl Company is an established date processing and exporting business in the United Arab Emirates. The company’s objective is to become the largest date and dates products exporter in the world. The business aims at processing, packaging, and exporting more than 150, 000 tons annually to over 50 countries globally. So far, the company exports dates and dates products to 15 African countries, most parts of Asia, and Arab countries. The company offers more than 20 different dates varieties, including the Local UAE Dates and Zahidi Dates. Most of the exported dates products are whole dates and sweets made from the product. The company’s quest to expand the export of its date products follows the fact that most of the global markets have been exploited while Europe has not been fully tapped. Europe, specifically the European Union (EU), is a significant market for the exporters of dates and its products. The EU accounts for not less than 30 percent of dates imports in value, even though this figure represents only 10 percent of the total world imports (Al-Shreed et al., 2012). This finding implies that import prices in the EU are favorably higher compared to the general world market. On the other hand, the EU has experienced stagnant dates import value for more than a decade now. Besides, the prices of dates imports have deteriorated since 1996. Therefore, it is imperatively viable for the new date products that the company is making to be exported to improve the business export value in the EU market. The decision for selecting the countries to export the products was reached by using a Gravity Two-Phase decision model (Anderson, 2010). The first phase involved screening and eliminating countries that had the least likelihood of market opportunities on the first entry. This process involved five steps: Eliminating unpromising countries Developing a list of promising countries’ market exports and obtaining sufficient data concerning them for applying the screen criteria Actualizing the screening criteria for promising markets to narrow down to a shorter list for further investigation Doing a secondary data analysis Rationalizing on the chosen and eliminated countries by adjusting judgments on screening for the second phase analysis The second phase involved also four steps. While the first step was to simulate a list grading criteria, the second one involved doing research on the countries that had been shortlisted in the first phase. The third one included applying the grading criteria to the shortlisted countries while the last one included coming up with a list of the most preferable countries. After this thorough analysis, England and Sweden were arrived at based on the results from the applied criteria. Economic-Geographic Features of England As obtained from Marsh (2013), England has one of the largest economies globally. The country is a mixed economy that receives contributions from the government and private sectors. Its economy’s main sectors include agriculture and the services sector. The formal currency is the sterling pound while the main commercial activities are finance, banking, and insurance. The country is one of the world’s most industrialized. Its main products are aircraft and ships, machine tools, electronics, motor vehicles, petroleum, textiles, food processing, and coal among others. In terms of trade, England is among the leading nations globally. Its main exports include manufactured goods, chemicals, food, and fuels. Its chief imports include food products, machinery, and fuels. Its main trading partners are the US. The larger EU Labor is distributed in a manner where services take more than 70 percent, agriculture less than 2 percent, while the industry has a share of 25 percent of its workforce. In terms of castes and class, social class is more pronounced compared to ethnicity. People classify themselves as wither middle class, upper class, or the working class. England’s main imports are arms, aerospace, and software manufacturing. The services sector contributes close to 75% GDP, followed by industry, and then agriculture. Tourism brings more than one million people every year. Geographically, England is part of the countries that form the United Kingdom. It borders Wales and Scotland, the Irish Sea to the North West, Celtic Sea to the South East, and the North Sea to the East. It has more than 100 islands. Get your 100% original paper on any topic done in as little as 3 hours Learn More England’s land cover is roughly 13, 395 square km. According to the 2008 consensus, it has a population of approximately 5.5 million people. Its terrain alternates between low hills and plains. In addition, it boasts of a rich cover of natural resources such as petroleum, coal, natural gas, limestone, tin, gypsum, and iron ore among others (Broadberry

Questions and summaries about paintings and readings, 6 pages, double spaced

Questions and summaries about paintings and readings, 6 pages, double spaced.

For the most part I have sent everything except for one file (sermon 28), I will try and attach when beginning the assignment, otherwise I will send the last set of reading directly into the drop box so that you can still use it for reference if it is needed. This assignment is 6 pages, double spaced, and no outside sources are to be used whatsoever. Everything should be cited from the readings. -Explain the message presented in the 5th century triumphal arch in the SMM Church-It is a visual sermon about the significance of Christ’s first coming (Incarnation) for mankind’s salvation at the second coming-Compare the imagery not only to the account of Christ’s early life in the Gospels but also to the apocryphal new testament-The arrangement of the narrative suggests an overall message similar to that of the Apse mosaic at Santa PrudenzianaQuestions to Answer-Identify the sequence of events depicted left to right in each of the rows of images, beginning with the top row-How does the clothing of the Virgin Mary differ from what you would expect, given her social status described in the Gospels?-According to the Apocryphal accounts of the annunciation, what is she weaving?-What is the significance of the scarlet thread that she holds?-Relate it to the “veil of flesh,” that she contributed to the incarnation mentioned in Leo’s sermon-What does the priest Simon say when he sees Christ and how is this significant to the meaning of the top row?-Consider how the use of clothing and setting in the second row helps not only to identify the figures but also to make a statement about Christ’s divinity -In the two narratives of the second row, what nations recognize Christ as the Messiah?-How are those nations different from those who recognize Christ in the top row?-Relate those who recognize Christ (top row vs. second row) to the female personifications in the mosaic at Santa Prudenziana -How is power visually depicted in the third row? What does the pairing of the two scenes in the third row say about earthly power?-How do the two cities at the bottom of the Arch relate to the overall theme of the First and Second comings of Christ?-How are they similar to the building depicted at Santa Prudenziana?-In what other works discussed in class have you seen the symbols in the center
Questions and summaries about paintings and readings, 6 pages, double spaced