Accuracy of self-reported body weight compared to measured body weight. A population survey

In 1977, in the evaluation of the prevention programme for cardiovascular diseases, 11,880 persons in Eastern Finland were asked to report their own weight on a questionnaire. Each participant was weighted during the following clinical examination. The data of the self-reported body weight were analysed according to sex, age, measured weight and body-mass index (BMI). The results showed that older people underestimated their weight to a greater extent than did younger people of both sexes. The error between measured and self-reported weight was greater in heavier subjects than in thinner individuals. In both sexes weight estimate error (measured weight minus self-reported weight) correlated more strongly with high BMI than with measured weight. Associations between weight estimate error and other variables were studied using a multiple regression model. Men whose annual family income was low were more likely to underestimate their weight than the men with a high annual income. In general, women reported their weight more correctly than men did. Older women were more likely to report their weight less than younger women, whereas women who visited their doctor frequently or who had higher annual family incomes were more aware of their actual body weight than those who had few doctor's consultations or whose family income was low. In men 5.2% and in women 8.3% of the variation in the weight estimate error was explained by the regression model.(ABSTRACT TRUNCATED AT 250 WORDS)     

Building aging level indices based on ability to perform personal care and household management activities]

Defining aging as deterioration of the ability required for the activities of daily living with increasing age, we developed a formula for estimating the age of aging. In 1994 and 1995, a questionnaire survey was conducted for 11,592 individuals (4,885 men, mean age 61.6, standard deviation 14.6; and 6,677 women, mean age 63.2, standard deviation 14.8) who were members of 7 cohorts (5 community-based cohorts and 2 cohorts of examiners at a health-promotion center). The questionnaire included three groups of questions related to medical treatment, aging-related symptoms, and personal care (ADL; Activities of Daily Living) and household management (IADL: Instrumental ADL). Multiple regression analysis was made by sex and age group (over 65 years old, under 65 years old) using age as a dependent variable and the three question categories as explanatory variables. Using multiple regression analysis by question category, five items were abstracted from each of the three groups, so that a total of 15 items were abstracted from all questions. Five items were then abstracted from the 15 by multiple regression analysis, and the predicted aging age for an individual is estimated using this statistical model from the results of the questionnaire survey. The predicted aging age is significantly associated with age (r = 0.40-0.49, p = 0.0001). The difference between the predicted aging age and age is greater among the older or younger people. The expected predicted aging age is estimated using regression analysis of the predicted aging age on age. Aging level indices by sex and age groups were determined by the difference between the expected predicted aging age and age. We are planning to carry out an epidemiological study on the risk factor for aging using the aging level indices in seven cohorts.     

A mathematical model for determining age-specific diabetes incidence and prevalence using body mass index

PurposeFew models have been developed specifically for the epidemiology of diabetes. Diabetes incidence is critical in predicting diabetes prevalence. However, reliable estimates of disease incidence rates are difficult to obtain. The aim of this study was to propose a mathematical framework for predicting diabetes prevalence using incidence rates estimated within the model using body mass index (BMI) data.MethodsA generic mechanistic model was proposed considering birth, death, migration, aging, and diabetes incidence dynamics. Diabetes incidence rates were determined within the model using their relationships with BMI represented by the Hill equation. The Hill equation parameters were estimated by fitting the model to National Health and Nutrition Examination Survey (NHANES) 1999–2010 data and used to predict diabetes prevalence pertaining to each NHANES survey year. The prevalences were also predicted using diabetes incidence rates calculated from the NHANES data themselves. The model was used to estimate death rate parameters and to quantify sensitivities of prevalence to each population dynamic.ResultsThe model using incidence rate estimates from the Hill equations successfully predicted diabetes prevalence of younger, middle-aged, and older adults (prediction error, 20.0%, 9.64%, and 7.58% respectively). Diabetes prevalence was positively associated with diabetes incidence in every age group, but the associations among younger adults were stronger. In contrast, diabetes prevalence was more sensitive to death rates in older adults than younger adults. Both diabetes incidence and prevalence were strongly sensitive to BMI at younger ages, but sensitivity gradually declined as age progressed. Younger and middle aged adults diagnosed with diabetes had at least a two-fold greater risk of death than their nondiabetic counterparts. Nondiabetic older adults were found to be under slightly higher death risk (0.079) than those diagnosed with diabetes (0.073).ConclusionsThe proposed model predicts diagnosed diabetes incidence and prevalence reasonably well using the link between BMI and diabetes development risk. Ethnic group and gender-specific model parameter estimates could further improve predictions. Model prediction accuracy and applicability need to be comprehensively evaluated with independent data sets.     

Dimensions of health and their importance for morale in old age: A multivariate examination

Numerous researchers have pointed to the centrality of health in personal adaptation in the later years. This investigation examines morale in regard to 16 health indicators. Probability techniques were used to draw a sample of 104 noninstitutionalized people, 65 years of age and older. Productmoment correlations indicated a substantial relatedness among the health indicators. A principal components factor analysis generated five health dimensions: Assessing and Promoting Own Health, Health Behavior and Facilities, Disease and Its Control, Sensory Abilities, and Source of Care. Morale was bivariately related most to the individual measures of fatigue, comparative health level, visual acuity, and general self-rated health. A multiple regression analysis indicated that morale was reported to be higher among those who felt more rested upon wakening in the morning, who had better visual abilities, and who saw their health level as being at least as good as in the past.Dr. Mancini is Assistant Professor of Family Development at Virginia Polytechnic Institute and State University, 202 Wallace Annex, Blacksburg, Virginia 24061. Dr. Quinn is Assistant Professor of Family Life at Texas Tech University, Lubbock, Texas 79406. This study was supported in part by a Biomedical Research Support Grant from the National Institutes of Health. It was presented at the annual meeting of the Gerontological Society, San Diego, November 1980.     

Regulation of alcohol intake with advancing age.

Previous surveys of alcohol use in the general population have not gathered sufficient data to allow for estimations of the blood alcohol levels (BACs) routinely achieved in survey participants. Our goal was to assess the influence of age on the estimated peak BAC achieved on typical drinking occasions in a representative sample (n=2,626) of the U.S. adult population. Variables related to the quantity and duration of alcohol consumption on typical drinking occasions were assessed by computer-assisted telephone interview. In addition, the height, weight, age, and gender of subjects were ascertained to be used in equations to predict the volume of distribution of ethanol (total body water). Prediction equations were used to estimate the probable peak BACs achieved during the typical drinking occasion. The survey identified 1,833 subjects ("current drinkers") of 18-89 years, who reported alcohol consumption within the past 12 months. Linear regression analyses performed on data from these "current drinkers" revealed that, for both men and women, there was an age-related decrease in the predicted peak BAC achieved on typical drinking occasions. The approaches used to modify the BAC with advancing age differed slightly for men and women, but both relied heavily upon a reduction in the quantity of consumption.     

Measuring the projected public health impact of lung cancer through lifetime and age-conditional risk estimates

PURPOSE: Lifetime and age-conditional probability (risk) estimates of developing lung cancer in the United States are presented by age, race, and gender. Effects on the risk estimates of an aging population and changing tobacco use are identified. METHODS: Risk estimates were derived by applying cross-sectional, population-based incidence rates of malignant lung cancer and mortality rates from other causes to a hypothetical cohort. The cohort was aged through a double-decrement life table to determine the expected proportion of the population that would develop the disease across age intervals. Incidence and mortality data were obtained from the Surveillance, Epidemiology, and End Results (SEER) Program and the National Centers for Health Statistics, respectively. RESULTS: Among all cancers, risk estimates of developing lung cancer within 10 years, conditioned on being free of the disease at age 50, 60, or 70, ranked second to prostate cancer for men and second to breast cancer for women. For men, despite higher incidence rates of lung cancer for blacks than whites across most age groups, the risk of developing this disease over the life-span becomes similar, because white men are more likely to live to older ages where lung cancer is common. For women, lung cancer incidence rates are similar between Whites and Blacks, but an older age distribution among white women explains their greater lifetime risk of being diagnosed with the disease. Changes in the age distribution between the mid 1970s and the mid 1990s had little impact on the short-term risk estimates of developing lung cancer for younger ages but had a large influence on long-term risk estimates, particularly for the older age groups. CONCLUSIONS: Declining lung cancer among younger age groups may be attributed to declining tobacco use among the cohorts, but several more years may be required before the trends begin to fall in older age groups, particularly in women. In the meantime, an aging population is contributing to more people being diagnosed with lung cancer. Consequently, the projected risk of developing lung cancer will remain high for several years to come.     

The significance and consequences of having painful and disabled joints in older age: co-existing accounts of normal and disrupted biographies

Abstract This paper examines the meanings of symptoms for people with osteoarthritis. The study comprised 27 in‐depth interviews with men and women aged between 51 and 91 years (median age = 76) and draws on previous sociological work about experiences of chronic illness, disability and ageing. In particular, the distinction proposed by Bury between ‘meaning as significance’ (the significance and connotations associated with illness) and ‘meaning as consequence’ (problems created for the individual by activity restriction and social disadvantage), provides a useful framework to examine the biographical aspects of symptoms. We found that older respondents portrayed their symptoms as a normal and integral part of their biography, but they also talked about the highly disruptive impact of symptoms on their daily lives. We consider how these co‐existing accounts of meaning make sense in the context of cultural connotations of ageing and the implications for meeting health care needs of older people with osteoarthritis.     

Sexual Activity and Aging

Sexuality is an important component of emotional and physical intimacy that men and women experience throughout their lives. Research suggesting that a high proportion of men and women remain sexually active well into later life refutes the prevailing myth that aging and sexual dysfunction are inexorably linked. Age-related physiological changes do not render a meaningful sexual relationship impossible or even necessarily difficult. Many of these physiological changes are modifiable. There are various therapeutic options available to patients to achieve maximum sexual capacity in old age.This article reviews the prevalence of sexual activity among older adults, the problems these adults encounter with sexual activity, and the role of the health care professional in addressing these problems. The physiological sex-related changes that occur as part of the normal aging process in men and women are reviewed, as well as the effect of age-related physical and psychological illness on sexual function. The attitudes and perceptions of the media and general public toward sexual activity and aging are summarized. An understanding of the sexual changes that accompany the aging process may help general practitioners and other doctors to give practical and useful advice on sexuality as well as refute the misconception that aging equates to celibacy. A thorough awareness of this aspect of older people’s quality of life can raise meaningful expectations for aging patients.     

Comparison of visual estimates of children's portion sizes under both shared-plate and individual-plate conditions

OBJECTIVE: This paper compares the accuracy of visual estimations of children's food intake in settings where several children eat together off 1 plate vs individual-plate eating scenarios. DESIGN: Eight trained observers were tested in their ability to estimate food portions consumed by children enacting common eating scenarios. Foods were categorized by food group and according to their presentation by individual-plate and shared-plate. Observed food weight estimates were compared to actual weights. SUBJECTS/SETTING: The 8 observers visually estimated 69 food portions of children eating alone and 26 portions where children were eating from a shared plate. This study was carried out in Sarlahi District, a rural, central lowland region of Nepal. STATISTICAL ANALYSES: Pearson's correlation coefficients were calculated to examine associations between estimated and actual weights. A fixed effects model was constructed to compare observers. RESULTS: Analyses revealed that observer estimates of food weights under field conditions were well correlated with actual weights for individual-plate (r = 0.89) and for shared-plate (r = 0.84) scenarios. Observers estimated food weights when children ate together on a shared plate less accurately than they did in settings where children ate alone. With the exception of 1 observer, observers did not differ significantly in their ability to estimate food weights. Accuracy of estimations was influenced by food weight with greater error associated with food quantities of less than 70 g. CONCLUSIONS: Visual estimation is a relatively accurate, valid method of assessing child food intake under rural field conditions, and the only method to obtain accurate information on dietary intake in regions where shared-plate eating is frequent.     

The Relationship of Perceived Age and Sales of Tobacco and Alcohol to Underage Customers

The ability of store clerks to estimate the age of their customers is critical in preventing illegal sales of tobacco and alcohol to underage individuals. To avoid illegal sales of tobacco products to minors, the Food and Drug Administration created a policy in 1997 requiring store clerks to request identification of anyone perceived to be under age 27. A similar age standard has not been implemented for alcohol. The purpose of this article is to assess whether age 27 is adequate for minimizing tobacco sales to those under age 18 and whether this age is also a useful standard for minimizing illegal alcohol sales to those under age 21. The analysis is based on age estimates from 49 gas station and convenience store clerks. Each clerk estimated ages of 45 people filmed on video whose actual ages ranged from 15 to 29. T-tests, analysis of variance, contingency tables and logistic regression were used to analyze the data. Store clerks found it more difficult to estimate ages of female customers than male customers. In addition, the store clerks significantly underestimated age of male customers under 18 and of female customers under 21. In contrast, the clerks significantly overestimated age of customers 21 years and older. Among underage customers, the store clerks' age, gender, work experience, education, and training in requesting identification had no influence on ability to judge age, nor did it have a strong influence on whether an underage customer was considered 18 or older or 21 or older. The results suggest that age 27 is adequate for minimizing illegal tobacco sales. Adoption of a similar or slightly older age may be appropriate for minimizing illegal alcohol sales.     

Socioeconomic factors associated with the onset of disability in older age: a longitudinal study of people aged 75 years and over

Although the association between socioeconomic status and mortality is well documented, there is less work focusing on the association with morbidity in older people. This is partly due to the difficulties of measuring socioeconomic status at older ages. The work that does exist tends to use cross-sectional data and objective measures of socioeconomic status such as education, social class or income. However, these standard measures may be less relevant for older people. In this study, we explore the association between socioeconomic status and disability in older people using a range of individual, household and area level indicators of socioeconomic status, including a subjective measure of adequacy of income. We use cross-sectional data of 1470 participants aged 75 years or over on 31/12/1987 and registered with a UK primary care practice. Of these 719 participants with no disability at baseline were followed up until 2003 with measurements at up to seven time points to determine onset of disability. Disability was defined as difficulty with any one of five activities of daily living. In cross-sectional multivariate analysis, age, housing tenure, living status and a subjective measure of income adequacy were associated with prevalence of disability. In longitudinal analyses, self-perceived adequacy of income showed the strongest association with onset of disability; with those reporting difficulties managing having a median age of onset 80.5 years, 7 years younger than those who felt their income was adequate (median age 87.8 years). The prospective association between self-perceived adequacy of income and onset of disability decreased with age. This subjective measure of income adequacy may signify difficulties in budgeting, but could also capture differences in objective indicators of status not recorded in this study, such as wealth. Further work is needed to explore what causes older people to experience difficulty in managing their money and to understand the mechanisms behind its impact on their physical health.     

Probabilities of transition among health states for older adults

Goal: To estimate the probabilities of transition among self-rated health states for older adults, and examine how they vary by age and sex. Methods: We used self-rated health (excellent, very good, good, fair, poor, dead) collected in two longitudinal studies of older adults (mean age 75) to estimate the probability of transition in 2 years. We used the estimates to project future health for selected cohorts. Findings: These older adults were most likely to be in the same health state 2 years later, but a substantial proportion changed in both directions. Transition probabilities varied by initial health state, age and sex. Men were more likely than women to transition to excellent or dead. Women were more likely than men to transition to good or fair health. Although women aged 70 will have more years of life and more years of healthy life than men, they also have more years of unhealthy life, and the proportion of remaining life that is healthy is slightly higher for men. When observed and predicted years of healthy life (YHL) were compared in various subgroups, the YHL of persons with less favorable baseline characteristics was lower than predicted, and vice-versa. Differences, however, were small (about 5%). Conclusions: These transition probability estimates can be used to predict the future health of individuals or groups as a function of current age, sex, and self-rated health. This revised version was published online in June 2006 with corrections to the Cover Date.     

The cost of fall-related injuries among older people in NSW, 2006-07

This study aimed to establish comprehensive estimates of the cost of fall-related injury among older people in NSW. A health service utilisation approach was used to estimate the cost of hospital treatment, residential care and ambulance transport. Other costs were estimated by deriving ratios of inpatient costs to other services from the literature. In the 2006-07 financial year, 251,000 (27%) of older people fell at least once and suffered, in total, an estimated 507,000 falls. An estimated 143000 medically treated fall-related injuries among older people resulted in lifetime treatment costs of $558.5 million. Although only 18% of these injuries resulted in hospital admission, the cost of care associated with these cases accounted for 84.5% of the total cost. The cost of fall-related injury among older people in NSW in 2006-07 is a significant increase over earlier estimates and underscores the urgent need for effective preventive efforts across the state.     

基于机器学习的宁夏地区老年人生物学年龄研究

目的 生物学年龄(Biological age, BA)可以更有效的判断个体真正的衰老状态，精准预测BA有助于为老年个体早期制定有针对性的预防措施，目前关于老年人分亚群对生物学年龄与生化指标相关性研究较少。利用机器学习算法计算宁夏地区老年人的生物学年龄，并识别相关生物化学指标分亚群进行分析。方法 纳入2020年宁夏地区老年人健康体检者共4 060名作为研究对象，采集空腹静脉血、尿液检测生物化学指标，利用随机森林(Random Forest, RF)算法筛选与BA相关的生物学指标，计算生物学年龄，并对RF算法的预测精度进行评估。结果 在老年人的不同亚群(低龄、中龄、高龄)中，各年龄段生物学指标在生物学年龄的重要性各有不。研究采用平均绝对误差(Mean Absolute Error,MAE)、均方根误差(Root Mean Square Error,RMSE)、相关系数(Coefficient of association,R²)进行模型的效能评估。结论 利用随机森林计算老年人生物学年龄并分析相关指标，可以更加精准定位老年人中高危人群及对健康老龄化有一定的指导。     

Life tables adjusted for comorbidity more accurately estimate noncancer survival for recently diagnosed cancer patients

ObjectivesTo provide cancer patients and clinicians with more accurate estimates of a patient's life expectancy with respect to noncancer mortality, we estimated comorbidity-adjusted life tables and health-adjusted age.Study Design and SettingUsing data from the Surveillance Epidemiology and End Results–Medicare database, we estimated comorbidity scores that reflect the health status of people who are 66 years of age and older in the year before cancer diagnosis. Noncancer survival by comorbidity score was estimated for each age, race, and sex. Health-adjusted age was estimated by systematically comparing the noncancer survival models with US life tables.ResultsComorbidity, cancer status, sex, and race are all important predictors of noncancer survival; however, their relative impact on noncancer survival decreases as age increases. Survival models by comorbidity better predicted noncancer survival than the US life tables. The health-adjusted age and national life tables can be consulted to provide an approximate estimate of a person's life expectancy, for example, the health-adjusted age of a black man aged 75 years with no comorbidities is 67 years, giving him a life expectancy of 13 years.ConclusionThe health-adjusted age and the life tables adjusted by age, race, sex, and comorbidity can provide important information to facilitate decision making about treatment for cancer and other conditions.     

Effects of age on validity of self-reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988-1994

OBJECTIVE: To compare self-reported to measured heights and weights of adults examined in the Third National Health and Nutrition Examination Survey (NHANES III), and to determine to what extent body mass index (BMI) calculated from self-reported heights and weights affects estimates of overweight prevalence compared with BMI calculated from measured values. DESIGN: A complex sample design was used in NHANES III to obtain a nationally representative sample of the US civilian, noninstitutionalized population. During household interviews, survey respondents were asked their height and weight. Trained health technicians subsequently measured height and weight using standardized procedures and equipment. SUBJECTS: The analytical sample consisted of 7,772 men and 8,801 women 20 years old and older. STATISTICAL ANALYSES PERFORMED: Only persons with measured and self-reported heights and weights were included in the analysis, and statistical sampling weights were applied. t Tests, Pearson product moment correlation coefficients, sensitivity, and specificity analyses were used to determine the validity of self-reported measurements and prevalence estimates of overweight, defined as BMI of 25 or greater. RESULTS: Age is an important factor in classifying weight, height, BMI, and overweight from self-reports. Statistically significant differences were found for the mean error (measured-self-reported values) for height and BMI that were notably larger for older age groups. For example, the mean error for height ranged from 2.92 to 4.50 cm for women and from 3.06 to 4.29 cm for men, 70 years and older. Despite the high correlation between measured and self-reported data, the prevalence of overweight calculated from measured values was higher than that calculated from self-reported values among older adults. When calculated with self-reported height, BMI was one unit lower than when calculated from measured height for persons > or = 70 years. Specificity was high but sensitivity decreased with increasing age cohorts. Regression equations are provided to determine actual height from self-reported values for older adults. CONCLUSION/APPLICATIONS: Self-reported heights and weights can be used with younger adults, but they have limitations for older adults, ages > or = 60 years. In research studies and in clinical settings involving older adults, failure to measure height and weight can result in subsequent misclassification of overweight status. Therefore, registered dietitians are encouraged to obtained a measured weight and height using a calibrated scale and stadiometer.     

Self-reported stress: findings from the 1985 National Health Interview Survey

The National Health Interview Survey's 1985 Health Promotion and Disease Prevention Questionnaire included questions on the amount of stress experienced in the past 2 weeks, the effect of stress on health, thoughts about seeking help for personal or emotional problems, and actual help-seeking behaviors. This report examines responses to these questions and analyzes self-reported levels of stress by sex and other respondent characteristics. In 1985, an estimated 34 million people aged 18 years and older experienced "a lot" of stress in the 2-week period preceding the interview. Women were more likely than men to report a lot of stress (23 percent versus 18 percent), and respondents 65 years of age or older were more likely than younger respondents to report "almost no" stress. An estimated 21 million people (13 percent) believed that, over the past year, stress had "a lot" of effect on their health. Seventeen percent of the population considered seeking help in the past year for personal or emotional problems from family, friends, helping professionals, or self-help groups. Sixty-nine percent of those who thought about seeking help reported that they actually did seek help. In terms of health practices, men and women who reported higher levels of stress than others of their sex also were more likely to report that they rarely or never ate breakfast, slept 6 or fewer hours per night, were physically less active than their peers, or drank more alcoholic beverages than usual in the 2 weeks prior to the survey.     

The welfare implications of disability for older people in Ireland

Recent data analysed for Ireland suggest a strong link between disability status and household poverty, while there exists substantial evidence to suggest that disability is highly prevalent among persons of older age. Within this context, this paper estimates the welfare implications of disability for older people in Ireland. We define and estimate models of the private costs borne by households with older persons who have a disability in Ireland, both in general and by severity of illness or condition. Our modelling framework is based on the standard of living approach to estimating the cost of disability. The model quantifies the extra costs of living associated with disability and is estimated by comparing the standard of living of households with and without disabled members at a given income, controlling for other sources of variation. The analysis suggests that the estimated economic cost of disability for older people in Ireland is significant and varies by severity of disability, as well as by household type. The results also suggest that the cost of disability increases in proportionate terms as the number of people in the household decreases. Our results are important when considering the effectiveness of policies that aim to address the economic problems associated with disability for older people, suggesting that current policy in Ireland does not go far enough. They indicate that older people face a double jeopardy through age and disability, which is not reflected in official poverty rates and support the case for the introduction of disability-adjusted poverty payments.     

Prediction of Discharge of Inpatients

This paper describes a survey in which 273 surgical patients at St. Thomas' Hospital, London, were studied to ascertain the extent to which their discharge could be predicted. Initial length-of-stay estimates were recorded for 57 percent of the cases; the excess of actual over predicted length of stay had a mean of 2.71 and a standard deviation of 10.2 days. The length of stay of the other 43 percent had greater variability. Continuous predictions of discharge were made, in which discharge dates were regularly estimated and assigned degrees of certainty, which were also recorded. The information obtained represented a 31.5 percent reduction in the squared prediction error of the number of discharges within three days over an estimate employing only a count of patients under review. The implications of the findings are discussed.     

Cholesterol and heart disease in older persons and women. Review of an NHLBI workshop.

The value of serum total cholesterol measurement in predicting coronary heart disease (CHD) is well established in middle-aged men, but has been questioned in middle-aged women and older people of both sexes. To address this, the most recent follow-up data from 25 populations in 22 US and international cohort studies were presented and analyzed at a recent National Heart, Lung, and Blood Institute (NHLBI) workshop. Crude relative and absolute excess risks of fatal CHD were determined for individual studies and pooled across studies to determine pooled risk estimates. Serum total cholesterol and low-density-lipoprotein (LDL) cholesterol levels predicted fatal CHD in middle-aged (< 65 years) and older (> or = 65 years) men and women, though the strength and consistency of these relationships in older women were diminished. High-density-lipoprotein (HDL) cholesterol levels inversely predicted CHD in middle-aged men and women and in older women, but not in older men. Data for minority groups and for overseas populations were similar to those for white people in the United States. Relative risk estimates were generally lower for older than for middle-aged subjects, but absolute excess risk was greater. Older people and middle-aged women with elevated cholesterol levels are clearly at increased risk of coronary disease; whether this risk can be modified by dietary or drug therapy, and at what level intervention is appropriate, must not be determined.