Andrew Lee, M.D.

• Department of Ophthalmology
• Baylor College of Medicine
• Houston, TX

Biopsychosocial mechanisms of chronic itch in patients with skin diseases: a review hair loss cure yahoo order 0.5mg dutasteride overnight delivery. Prevalence of symptoms experienced by patients with different clinical types of psoriasis hair loss cure sold on imus in the morning buy 0.5 mg dutasteride overnight delivery. Better medication adherence results in greater improvement in severity of psoriasis hair loss medication causes cheap dutasteride 0.5mg with visa. Beyond attentional strategies: cognitive-perceptual model of somatic interpretation hair loss growth products order 0.5mg dutasteride with amex. Hypochondriasis and symptom reporting ­ the effect of attention versus distraction hair loss cure xanthoma 0.5mg dutasteride with mastercard. Ernst J hair loss 19 years old order 0.5mg dutasteride with visa, Bцker H, Hдttenschwiler J, Schьpbach D, Northoff G, Seifritz E, Grimm S, et al. The association of interoceptive awareness and alexithymia with neurotransmitter concentrations in insula and anterior cingulate. On the relationship between interoceptive awareness and alexithymia: is interoceptive awareness related to emotional awareness? Effectiveness of relaxation and visualization techniques as an adjunct to phototherapy and photochemotherapy of psoriasis. Self-reported interoceptive awareness in primary care patients with past or current low back pain. Assessment of mindfulness by self-report: the Kentucky inventory of mindfulness skills. The benefits of being present: mindfulness and its role in psychological well-being. Disease severity measures in a population of psoriasis patients: the symptoms of psoriasis correlate with selfadministered psoriasis area severity index scores. Beyond unfavorable thinking: the illness cognition questionnaire for chronic diseases. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. Alexithymia as related to sex, age, and educational level: results of the Toronto Alexithymia Scale in 417 normal subjects. National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening. Mindfulness meditation for the treatment of chronic low back pain in older adults: a randomized controlled pilot study. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Body Awareness: a phenomenological inquiry into the common ground of mind-body therapies. While stigmatization is known to be disabling and stressful for patients, little is known about its correlates and effective interventions are lacking. Methods: Questionnaires were administered to 514 patients with psoriasis in a crosssectional study. Zero-order correlation and multiple regression analyses were conducted including sociodemographic, disease-related, personality, illness cognitions, and social support predictor variables. Results: Stigmatization was experienced by 73% of patients to some degree, and correlated with all five categories of predictor variables. In multiple regression analyses, stigmatization was associated with higher impact on daily life; lower education; higher disease visibility, severity, and duration; higher levels of social inhibition; having a type D personality; and not having a partner. Conclusions: Results indicate that perceived stigmatization is common in psoriasis, and can be predicted by sociodemographic, disease-related, and personality variables. These predictor variables provide indications on which patients are especially vulnerable regarding perceived stigmatization, which might be used in treatment. Social relationships are important for health and wellbeing, and social rejection can lead to physical, behavioral, and emotional problems [1]. Social rejection is central to the experience of stigmatization, which can be defined as an awareness of social disapproval, discrediting, or devaluation based on an attribute or physical mark [2­3]. In psoriasis, a chronic skin condition characterized by red plaques on the skin [4], the experience of stigmatization is commonly mentioned as one of its more troubling characteristics [5­9]. Stigmatization contributes considerably to disability, depression, and reduced quality of life in psoriasis [12­14], and can be considered a stressor. As distress can be a trigger for psoriasis exacerbation, this can become a vicious self-perpetuating cycle [15­17]. Despite these detrimental consequences, relatively few studies have studied interventions targeting stigmatization-related problems, and thus far no compelling evidence has been found for any type of intervention [18­19]. Firstly, it is important to recognize that stigmatization is a societal problem, and therefore societal educational interventions including contact between patients and the general population are called for to alter the public view [20]. In order to aid intervention development, a broad understanding of associated risk factors is needed, to be able to identify risk populations and focus points for interventions. The literature suggests several potential sociodemographic predictors of perceived stigmatization in psoriasis, such as lower age [7], being female [5], and lower education [7]. Secondly, disease-related variables such as higher disease severity, longer disease duration, greater cosmetic involvement, and greater impact of the condition on daily life may be relevant [7­9, 13, 21, 22]. General ways in which patients deal with a chronic condition, such as heightened helplessness regarding the disease and its consequences, and lower disease acceptance have also been found to be predictive [7]. Additionally, social support and a large social network may serve a protective function against experiences of stigmatization [7]. While several studies have examined the abovementioned variables as predictors, the role of personality has hardly been studied [7, 9]. Type D personality has been associated with increased risk of cardiovascular morbidity and mortality [24] and impaired health behavior [25], which are both frequently reported in psoriasis [26, 27]. Being socially inhibited implies being sensitive to negative reactions of others, which may cause stigmatization experiences to be especially detrimental. Additionally, having a stable tendency to experience negative affect may worsen psychological distress, which in turn may increase disease severity and resultantly visibility [15­17], and thereby vulnerability to stigmatization experiences. This study aims to examine the relative contributions of a broad range of concepts, including never examined variables such as type D personality, to perceived stigmatization in a large sample of patients with psoriasis. It was hypothesized that perceived stigmatization would be related to the sociodemographic variables age, educational level, and being single; the disease-related variables severity, duration, visibility, and impact; type D personality; the illness cognitions acceptance and helplessness; and social support. This broad approach may provide indications for screening and interventions for reducing stigmatization-related problems. Inclusion criteria were a minimum age of 18 years and a dermatologist-confirmed psoriasis diagnosis. Exclusion criteria were illiteracy, pregnancy, and severe physical and mental comorbid conditions. This study made use of questionnaires that were administered between 2010 and 2013 to determine participant eligibility for a study on the effectiveness of internet-based cognitive behavioral treatment for psoriasis [36]. The study was approved by Predictors of stigmatization 51 the regional medical ethics committee and carried out in accordance with the declaration of Helsinki [38]. This assesses to what extent the patient feels stigmatized as a result of the skin condition. Items are assessed on a four-point Likert scale, with higher scores reflecting higher levels of perceived stigmatization (theoretical range 6-24). Example items are "others feel uncomfortable touching me due to my skin disease" or "other people sometimes make annoying comments about my skin disease". Disease duration was assessed by asking how old the patient was when diagnosed, and subtracting this number from their current age (range 0-64 years). Illness cognitions the Illness Cognition Questionnaire [44] was used to measure two illness cognitions: acceptance, assessing the extent of positive adaptation to chronic illness with emphasis on decreasing its negative aspects (six items, =. Statistical analysis All variables were checked for outliers, normality and normal distribution of residuals, and logarithmic transformations were successfully applied in case of non-normal distribution of variables. Only study variables showing significant zero-order correlations with perceived stigmatization were entered in regression analyses. To study the relative contribution of five categories of variables (sociodemographic, disease-related, personality, illness cognitions, and social support), each category was entered in a consecutive step with perceived stigmatization as the dependent variable. The mean values of perceived stigmatization, impact on daily life, social support and illness cognitions were similar to those found in previous research in psoriasis [39], and scores on type D personality were comparable with those found in the general population [33, 47]. Perceived stigmatization Seventy-three percent of our sample perceived at least some stigmatization, as indicated by a positive score on at least one of the six items, as reported in previous studies [7, 8]. Individual associations with perceived stigmatization Zero-order correlations of study variables are reported in Table 3. Furthermore, higher perceived stigmatization scores were associated with a smaller social network (p = 0. Predictors of stigmatization 55 Relative impact on perceived stigmatization Table 4 presents the results of multiple regression analyses that were performed to examine the relative impact of predictors on perceived stigmatization. In blocks 4 and 5, illness cognitions of helplessness and acceptance, and perceived and actual social support did not significantly add to the model. For all other variables included in the model, mean scores were used to calculate the regression outcome. The final model, including only the significant predictors, explained a total of 49. A model excluding multivariate outliers (n = 16; critical Mahalanobis Distance value = 32. Predictors of stigmatization: final model Predictors Sociodemographic Age Married / With partner Education (primary) disease-related Disease severity Disease visibility Disease duration Impact on daily life Personality Negative affectivity Social inhibition Type D F-change R2. The vast majority of our sample experienced perceived stigmatization to some degree, corresponding with previous studies [7, 8]. Higher levels of perceived stigmatization were found to be correlated with sociodemographic and disease-related variables, personality, illness cognitions and social support. Greater severity and visibility and longer disease duration were predictive of perceived stigmatization, underlining the importance of early dermatological treatment; patients whose psoriasis is not adequately controlled may be more affected by stigmatization. However, the impact of the condition was a much stronger predictor, corresponding with the notion that the subjective experience of impact is generally more important than disease severity [48, 49]. In contrast with an earlier study [7], the impact of the 58 Chapter 3 condition was also a stronger predictor than the illness cognition of helplessness. The relative and different contribution of both variables may be explained by the high correlation between these variables in the current study and in previous research [48]. It seems likely that patients with psoriasis who are prone to feelings of helplessness regarding the disease may also experience a larger impact of psoriasis and magnify negative reactions of others. This corresponds with studies suggesting that type D is associated with social impairments [50, 51]. These results extend preliminary evidence indicating that type D may be a risk factor for worse outcomes in psoriasis [34, 35], by showing for the first time that it is associated with increased perceived stigmatization. However, these results should be replicated in further research, as the effect of type D became marginally significant when excluding multivariate outliers. Regarding sociodemographic variables, the significant predictors lower age, lower educational level and being single were in line with previous research indicating that the negative psychosocial influence of psoriasis is particularly strong in younger patients [7, 52]. To develop a comprehensive model of factors influencing perceived stigmatization, both potential risk factors. While the current study provides evidence for the former, results of the latter (social support) were inconsistent with previous research [7], possibly due to the inclusion of predictor variables not previously studied. Furthermore, while the current study examined self-perceived support, a more objective measure may lead to different results. Future research should further explore the role of protective factors in perceived stigmatization. Strengths of the current study include the large sample size, simultaneous assessment of relevant variables to control for shared variance, including personality variables never before studied, and inclusion of patients from a variety of settings. Limitations include Predictors of stigmatization 59 the cross-sectional design, precluding conclusions about cause and effect, and the relatively mild disease severity of our sample, which may limit generalizability. Lastly, some predictor variables showed high intercorrelations, but none of them were above the multicollinearity cutoff point of. In conclusion, perceived stigmatization was found to be common in patients with psoriasis and was predicted by specific sociodemographic, disease-related, and personality variables. This provides several possible focus points for individual screening and interventions, in addition to the societal interventions that are needed to target the overarching problem. Firstly, the predictors found in this study provide clinicians with an understanding of which patients may be especially vulnerable to stigmatizationrelated problems, which may warrant special attention during consultations. Type D and especially its social inhibition component may be screened for, when further evidence confirms our preliminary results indicating that individuals with this personality subtype are especially vulnerable to stigmatization-related problems. Stigmatization-related problems may be screened using validated instruments [39], followed by targeted interventions that may focus on the impact of the condition on daily life, considering that this was the largest predictor. Cognitive behavioral treatment, including social skills training, seems promising as an intervention framework. Previous research indicates that it can decrease perceived stigmatization in skin conditions [57], improve psychological and disease-related outcomes in psoriasis [58, 59], and decrease helplessness, which shows high correlations with disease impact [60­62]. In order to target the social inhibition aspect of type D personality, social skills training and evidence-based interventions for social fears, such as cognitive behavioral therapy and/or exposure therapy, may be an additional treatment approach [63, 64]. The current study provides a framework of characteristics of patients who are at greater risk to perceive stigmatization, which has been shown to have detrimental psychological consequences in psoriasis. Future research should expand upon these findings in order to examine interplays between predictors in prospective studies. Further development of screening and intervention procedures are needed in order to facilitate implementation of tailored evidence-based treatment to reduce the psychosocial burden of chronic skin conditions. The need to belong: desire for interpersonal attachments as a fundamental human motivation. Helplessness as predictor of perceived stigmatization in patients with psoriasis and atopic dermatitis. Re-framing stigma: felt and enacted stigma and challenges to the sociology of chronic and disabling conditions.

Ein GroЯteil der Variation zwischen Individuen in der Kohlenhydratzufuhr ist demnach auf Unterschiede in der Gesamtenergiezufuhr zurьckzufьhren hair loss ulcerative colitis generic dutasteride 0.5mg line. Von Interesse ist aber hдufig nicht hair loss in men 4 women buy 0.5mg dutasteride mastercard, ob Personen viel oder wenig Energie (und damit auch viel oder wenig Kohlenhydrate) aufnehmen hair loss vitamin d buy dutasteride 0.5 mg without prescription, ob sie unterschiedlichen Geschlechts hair loss in menopause order 0.5 mg dutasteride, Gewichts oder unterschiedlich kцrperlich aktiv sind hair loss patterns order dutasteride 0.5mg amex, sondern ob sie relativ zu дhnlichen Personen viel oder wenig Kohlenhydrate aufnehmen hair loss in men xosbextliyi discount 0.5mg dutasteride fast delivery. In Beobachtungsstudien kann mittels statistischer Adjustierung eine Angleichung in den Risikofaktoren zwischen den untersuchten Gruppen vorgenommen werden. Zum Beispiel simuliert eine Adjustierung hinsichtlich der Energiezufuhr eine isokalorische Interventionsstudie, in welcher eine Variation in der Kohlenhydratzufuhr nur durch den Austausch mit anderen Energietrдgern realisiert werden kann. Unterschiede in der Interpretation solcher Modelle ergeben sich auch aus der Art, wie die Nдhrstoffzufuhr als Expositionsvariable modelliert wird. Eine ьbliche Form der Energieadjustierung von Nдhrstoffvariablen ist die Verwendung von Nдhrstoffdichten, z. Wird in einem Modell auch fьr die Gesamtenergiezufuhr kontrolliert, entspricht die Risikoschдtzung der Wirkung einer Substitution von Kohlenhydraten fьr eine vergleichbare Menge an Nahrungsenergie aus einem oder mehreren anderen energieliefernden Nдhrstoffen. Eine alternative Methode der Energieadjustierung stellt die Berechnung der Abweichung in der Nдhrstoff25 Kapitel 2: Methodische Vorgehensweise zufuhr (z. Ballaststoffe) vom mittleren Wert fьr eine gegebene Energiezufuhr (Nдhrstoffresiduen) dar. Zwar lassen sich so Personen mit relativ hoher Zufuhr und Personen mit relativ niedriger Zufuhr (relativ zu ihrer Energiezufuhr) vergleichen, eine Interpretation energieadjustierter Nдhrstoffwerte als absolute Zufuhr ist aber nicht sinnvoll. Die Beurteilung der Kohlenhydratzufuhr ist deshalb bei Beobachtungsstudien immer auch in Abhдngigkeit von den statistischen Modellen zur Ableitung des Erkrankungsrisikos zu sehen. Weitere Probleme, die mit der Erhebung und Analyse von Ernдhrungsdaten verbunden sind, wie Messfehler und selektive Untererfassung bestimmter Komponenten, sind eher allgemeiner Natur (Bingham et al. Daher wurden Studien, in denen kohlenhydrathaltige Lebensmittel wie Brot, Nudeln oder Kartoffeln als Expositionsfaktoren betrachtet wurden, nicht in die Auswertung eingeschlossen. Der Energiegehalt dieser Getrдnke wird fast ausschlieЯlich durch den Gehalt an Mono- bzw. Daher werden die Ergebnisse dieser Studien unter dem Gliederungspunkt Mono- und Disaccharide in den entsprechenden Kapiteln aufgefьhrt. Als weitere Ausnahme wurde nach Studien zum Aspekt Vollkornprodukte (Suchbegriff whole grain[s]) bzw. Getreideprodukte aus Mehl mit niedrigem Ausmahlungsgrad (Suchbegriff refined grain[s]) recherchiert, da mit der Betrachtung dieser Lebensmittelgruppen als Expositionsfaktoren indirekt eine Aussage ьber den Einfluss von Getreideballaststoffen ermцglicht wird und zu diesem Aspekt zahlreiche Studien existieren. Neben den qualitativen und quantitativen Aspekten der Kohlenhydratzufuhr bestьnde auch die Mцglichkeit, Ernдhrungsmuster und ihren Zusammenhang mit der Kohlenhydratzufuhr und chronischen Krankheiten zu betrachten. Da bei dieser Art der Betrachtungsweise jedoch nicht direkt auf die Wirkung der Kohlenhydratzufuhr geschlossen werden kann, wurden Ernдhrungsmuster im Rahmen dieser Leitlinie nur sehr eingeschrдnkt bearbeitet. Bei der Literatursuche wurden mцglichst wenige Begriffe von vornherein ausgeschlossen. Unter der,grauen Literatur" werden Verцffentlichungen wissenschaftlicher Natur verstanden, die in den gдngigen Literaturdatenbanken nicht zu finden sind, wie z. Diese Art von Literatur ist oft schwer zugдnglich und kann nur unter erheblichem personellem und finanziellem Aufwand zusammengetragen werden. Fьr die vorliegende Leitlinie musste aus diesen Grьnden auf die Suche nach grauer Literatur verzichtet werden. Es ist nicht davon auszugehen, dass durch fehlende graue Literatur entscheidende Literaturquellen ьbersehen wurden. Insbesondere Erkenntnisse mit hochrangiger Evidenzbewertung, wie Interventionsstudien oder 26 Kapitel 2: Methodische Vorgehensweise Kohortenstudien bzw. Anders verhдlt es sich allerdings mit nicht in Fachzeitschriften publizierten Studienergebnissen, die z. Auch im Bereich der Ernдhrungsepidemiologie ist von der Tendenz auszugehen, dass Studienergebnisse, die keinen Zusammenhang zwischen einer Exposition und einer Krankheit aufzeigen konnten, seltener publiziert wurden als positive oder negative Effektschдtzungen. Eine empirische Erhebung ьber das AusmaЯ dieses Problems fьr den hier betrachteten Themenbereich gibt es nicht. Bei zugesetztem Zucker handelt es sich um Zucker als Zutat zu verarbeiteten Lebensmitteln sowie um Zucker, der bei der Lebensmittelzubereitung im Haushalt oder wдhrend der Mahlzeit hinzugefьgt wird. Nicht gemeint sind natьrlich vorkommende Mono- und Disaccharide in Milch, Obst und Sдften. Als zuckergesьЯte Getrдnke werden kohlensдurehaltige Erfrischungsgetrдnke wie ColaGetrдnke und Limonaden sowie solche ohne Kohlensдure wie Fruchtsaftgetrдnke, -nektare und Eistee bezeichnet, denen Zucker zugesetzt wurde. ZuckergesьЯte Getrдnke haben zum Teil einen hohen Gehalt an zugesetzten Zuckern und liefern Energie (Kalorien) aber essenzielle Nдhrstoffe nur in unbedeutenden Mengen. Ein Zusammenhang zwischen dem Konsum dieser Getrдnke und dem Risiko fьr Adipositas und Diabetes mellitus Typ 2 wird цffentlich diskutiert. Deswegen und aufgrund des groЯen Interesses an diesen Getrдnken hat die Leitlinienkommission entschieden, diese Lebensmittelgruppe neben den Kohlenhydratfraktionen als einziges Lebensmittel zu betrachten. Ballaststoffe, Vollkorn(produkte) und Getreideprodukte aus niedrig ausgemahlenem Mehl (z. Type 405): Neben der Betrachtung des Einflussfaktors,gesamte Ballaststoffzufuhr" erfolgte hдufig auch eine Analyse hinsichtlich der Herkunft der Ballaststoffe (aus Getreide, Gemьse, Obst bzw. Lag der Vollkornanteil darunter, erfolgte eine Zuordnung zu Getreideprodukten aus Mehl mit niedrigem Ausmahlungsgrad. In anderen Studien wurde der Verzehr bestimmter vollkornhaltiger Lebensmittel gesondert abgefragt und unter Heranziehung der genannten Verzehrshдufigkeit und PortionsgrцЯe eine tдgliche Zufuhrmenge geschдtzt. Es kam auch vor, dass der Gehalt an Vollkorn, Kleie und Keimling in allen von den Studienteilnehmern verzehrten Lebensmitteln berechnet und danach summiert wurde, so dass sehr genaue Angaben zur Zufuhr von Vollkorn(bestandteilen) vorlagen (Koh-Banerjee et al. Cummings und Stephen (2007) wiesen darauf hin, dass auch die Struktur des Vollkornbestandteils eines Lebensmittels (intakt versus vermahlen) eine Rolle spielt, dies aber in Studien bislang kaum berьcksichtigt wurde. Unter dem in der Leitlinie verwendeten Begriff Getreideprodukte, werden Getreideflocken und Getreidemehlprodukte verstanden. Falls eine zu hohe Trefferzahl eine weitere Begrenzung erforderlich machte, erfolgte dies durch Eingabe der folgenden Begriffe: intake, uptake, ingestion, consumption, prevention, nutrition(al), diet, dietary. Eur J Clin Nutr 2007; 61: S5­S18 Deutsche Adipositas-Gesellschaft, Deutsche Diabetes-Gesellschaft, Deutsche Gesellschaft fьr Ernдhrung, Deutsche Gesellschaft fьr Ernдhrungsmedizin. Evidenzbasierte Leitlinie: Fettkonsum und Prдvention ausgewдhlter ernдhrungsmitbedingter Krankheiten. Glykдmischer Index und glykдmische Last ­ ein fьr die Ernдhrungspraxis des Gesunden relevantes Konzept? Teil 1: Einflussfaktoren auf den glykдmischen Index sowie Relevanz fьr die Prдvention ernдhrungsmitbedingter Erkrankungen. Dietary sweeteners containing fructose: overview of a workshop on the state of the science. Am J Epidemiol 2003; 158: 14-21; discussion 22-6 Koh-Banerjee P, Franz M, Sampson L, et al. Could exposure assessment problems give us wrong answers to nutrition and cancer questions? In: Vom Umgang mit Zahlen und Daten: eine praxisnahe Einfьhrung in die Statistik und Ernдhrungsepidemiologie. Besonders in der Altersgruppe der jungen Erwachsenen ist die Zahl der Adipцsen und Ьbergewichtigen im letzten Jahrzehnt weiter angestiegen (Benecke und Vogel 2003). Da adipцse Kinder und Jugendliche ein erhцhtes Risiko haben, auch im Erwachsenalter ein hohes Kцrpergewicht zu haben (Reilly et al. Diese Zusammenhдnge mit den Komponenten des Metabolischen Syndroms scheinen bereits im Kindes- und Jugendalter zu gelten (Arbeitsgemeinschaft Adipositas im Kindesalter 2008). Adipositas geht zudem mit einer erhцhten Gesamtmortalitдt einher (Prospective Studies Collaboration 2009, Pischon et al. Umfassende Informationen zu Entstehung, klinischen Folgen, Prдvention und Therapie der Adipositas im Kindes-, Jugend- und Erwachsenenalter kцnnen den Leitlinien der Deutschen Adipositas-Gesellschaft entnommen werden (Deutsche Adipositas-Gesellschaft et al. Ьberernдhrung einerseits und Bewegungsmangel anderseits die zentralen Ansatzpunkte fьr die Prдvention und Therapie von Adipositas dar. Da die Therapie von bereits bestehender Adipositas insgesamt bislang wenig erfolgreich ist, ist die Identifikation von Faktoren, die eine lдngerfristige positive Energiebilanz begьnstigen, fьr die Prдvention von besonderer Bedeutung. Allerdings kann die gegenwдrtige rasche Zunahme der Adipositasprдvalenz nicht auf Verдnderungen in der genetischen Veranlagung zurьckgefьhrt werden. In den letzten Jahren mehren sich die Hinweise, dass auch Stimuli in Schwangerschaft und frьher Kindheit die spдtere Entwicklung einer Adipositas nachhaltig,prдgen" kцnnten (Oken et al. Zu den besonderen Situationen, die der Entstehung einer Adipositas hдufig Vorschub leisten, zдhlt Nikotinverzicht nach jahrelanger Gewцhnung an seine appetitzьgelnde Wirkung. Fьr Frauen gilt eine Schwangerschaft als Faktor, der das Risiko einer Gewichtszunahme erhцht. Glucokortikoide, Beta-Blocker, atypische Neuroleptika und blutzuckersenkende Medikamente wie Insulin, Sulfonylharnstoffe und Glitazone) eine Gewichtszunahme (Deutsche Adipositas-Gesellschaft et al. Da Verдnderungen in der Energiedichte meist nur unvollstдndig kompensiert werden (Stubbs et al. Andererseits kцnnten Mechanismen, die einen Gewichtsverlust unter einer kohlenhydratarmen Kost begьnstigen [Sдttigung durch Ketonkцrperbildung bzw. Hinsichtlich der Rolle der Getrдnke mit zugesetztem Zucker in der Adipositasentstehung wird vor allem eine erhцhte Energiezufuhr diskutiert. So fьhrte der Konsum von zuckergesьЯten Getrдnken im isoenergetischen Vergleich mit Kohlenhydraten aus festen Lebensmitteln zu einer hцheren Energiezufuhr und einer Zunahme im Kцrpergewicht (DiMeglio und Mattes 2000). Energieliefernde Getrдnke zeichnen sich vermutlich durch eine geringere Sдttigungswirkung als vergleichbare feste Lebensmittel aus (Mourao et al. Eine solche unzureichende Energiekompensation scheint besonders dann aufzutreten, wenn zuckergesьЯte 33 Kapitel 3: Kohlenhydratzufuhr und Prдvention der Adipositas Getrдnke zwischen den Mahlzeiten verzehrt werden (Almiron-Roig et al. Nach Verzehr von fructosereichen Lebensmitteln werden in der Leber vermehrt Triglyceride synthetisiert, welche dann zur Speicherung ins periphere Fettgewebe transportiert werden (Stanhope et al. AuЯerdem wurde postuliert, dass Fructose aufgrund der fehlenden Ausschьttung von Insulin im Vergleich zu Glucose weniger sдttigend wirke (Bray et al. Eine Expertenrunde konnte kьrzlich keine tatsдchliche Evidenz fьr eine gewichtsfцrdernde Wirkung der Fructose ьber ihren Energiegehalt hinaus feststellen (Jones 2009). Gьnstige prдventive Wirkungen einer hohen Ballaststoffzufuhr kцnnten aus ihrer erhцhten Sдttigungswirkung oder einer Begьnstigung der Fettoxidation resultieren (Pereira und Ludwig 2001). Fьr die erhцhte Sдttigungswirkung wird zum einen eine verringerte Energiedichte der Kost diskutiert. Zum anderen fьhrt eine hцhere Ballaststoffzufuhr zu einer verzцgerten Magenentleerung und Absorption der energieliefernden Nдhrstoffe. Diese resultiere in einer verlangsamten Blutzuckerantwort und einer verminderten Insulinsekretion, die ihrerseits eine verminderte Speicherung von Fett begьnstige (Burton-Freeman 2000, Pereira und Ludwig 2001). Vergleichbare Mechanismen werden fьr die Assoziation zwischen der Zufuhr von Vollkornprodukten und der Kцrpergewichtsregulation postuliert (Koh-Banerjee und Rimm 2003). Diese Konstellation begьnstigt die Aufnahme von Glucose in Muskel-, Fett- und Leberzellen. Bei Andauern dieser anabolen Stoffwechsellage ohne neue Nahrungszufuhr kann es in der spдteren postprandialen Phase aufgrund des Abfalls der Blutglucosekonzentration bis unter das Ausgangsniveau zu einem Anstieg der gegenregulatorischen Hormone kommen (Ludwig et al. Es wird postuliert, dass solche milden Hypoglykдmien eine vermehrte Energiezufuhr und somit die Entstehung einer Adipositas begьnstigen (Ludwig 2002). Die Kohortenstudien fьr Kinder und Jugendliche sind zudem nach dem Alter des untersuchten Kollektivs geordnet zusammengefasst. Des Weiteren war eine Zunahme der Kohlenhydratzufuhr auch bei 288 gesunden niederlдndischen Mдnnern im Verlauf von 5 Jahren nicht mit der gleichzeitigen Verдnderung ihres Kцrpergewichtes oder ihres Taillenumfangs assoziiert (Nooyens et al. Allerdings wurde prospektiv kein Zusammenhang mit dem Taille-Hьft-Quotienten beobachtet (Ludwig et al. Da die Erniedrigung der Fettzufuhr in der Regel mit einer Erhцhung der Kohlenhydrat- und Ballaststoffzufuhr einhergeht, kцnnen Interventionsstudien zur Erniedrigung der Fettzufuhr jedoch indirekte Hinweise liefern. Trotz Rebound war das Kцrpergewicht in der Interventionsgruppe auch nach 9 Jahren noch geringer als in der Kontrollgruppe (-0,5 kg, p = 0,001). Nach initialem Gewichtsverlust stieg das Gewicht der Interventionsgruppe vergleichbar zur Kontrollgruppe stetig an, d. Die beobachteten gьnstigen Effekte kцnnten wesentlich auf eine gleichzeitige Erhцhung der Ballaststoffzufuhr zurьckzufьhren sein. Tatsдchlich hing die Gewichtsreduktion laut einer multivariaten Sekundдranalyse mit der Reduktion der Fettzufuhr und der Erhцhung der Ballaststoffzufuhr zusammen (Howard et al. Allerdings war der Gewichtsabfall nach 1 Jahr nicht mehr signifikant (Lee-Han et al. Die gepoolte Analyse der Daten aus der Nachuntersuchung nach 2 Jahren ergab, dass eine hцhere Kohlenhydratzufuhr (gemittelt aus 5 Erhebungen in 2 Jahren) mit einer Erhцhung des Kцrpergewichts und des Kцrperfettanteils nach 2 Jahren assoziiert war (Korrelationskoeffizienten r = 0,33 bzw. Die Evidenz fьr den fehlenden langfristigen Einfluss einer Verдnderung der Kohlenhydratzufuhr auf die Entstehung der Adipositas wird als wahrscheinlich eingestuft. In einer weiteren Auswertung dieser Kohorte fand sich zudem kein Zusammenhang zwischen der Kohlenhydratzufuhr und dem Taillenumfang 15 Jahre spдter. Bei 2 Kinderkohorten mit 41 australischen 8- bis 9-Jдhrigen, die nach 1 Jahr nachuntersucht wurden (Bogaert et al. In 3 weiteren Kohorten wurde die Kohlenhydratzufuhr im Alter ab 2 Jahren auf ihre prospektive Bedeutung fьr die Kцrperzusammensetzung untersucht. In einer australischen Kohorte fand sich bei 243 Kindern eine inverse Assoziation der Kohlenhydratzufuhr zwischen dem 2. Die Zufuhr von gesдttigten Fettsдuren und Gesamtfett war im Studienverlauf in der Interventionsgruppe signifikant niedriger als in der Kontrollgruppe, die Kohlenhydratzufuhr hingegen signifikant hцher. Lebensjahr keinen Zusammenhang zwischen Verдnderungen in der Hцhe der Fettzufuhr (und damit einhergehenden Verдnderungen der Kohlenhydratzufuhr) und der gleichzeitigen Gewichtszunahme (Lagstrцm et al. Die vorliegenden Studien legen fьr Kinder und Jugendliche ьberwiegend nahe, dass die Kohlenhydratzufuhr bzw. Beide Gruppen nahmen im vergleichbaren MaЯe an Kцrpergewicht zu, allerdings erhцhte sich die abdominale Gesamtfettmasse (p < 0,05) sowie die viszerale abdominale Fettmasse (p < 0,01) nur in der Gruppe der Teilnehmer, die fructosegesьЯte Getrдnke verzehrt hatten (Stanhope et al. Weitere prospektive Kohortenstudien oder gut durchgefьhrte Interventionsstudien von ausreichender Zeitdauer zu Zusammenhдngen zwischen dem Verzehr von Monosacchariden und der Entwicklung des Kцrpergewichts liegen nicht vor. Die Evidenz zur Relevanz der Monosaccharide fьr das Adipositasrisiko ist unzureichend.

Removing or mitigating local direct drivers of degradation can be achieved through changing land management practices on a specific parcel of land {4 hair loss cure forum order dutasteride 0.5 mg on-line. There is an urgent need to find monitoring methods that can reliably and repeatedly distinguish impacts of climate variability from anthropogenic degradation {4 hair loss prevention shampoo purchase 0.5mg dutasteride mastercard. Degradation can take place in both natural and transformed land hair loss cure bbc 0.5 mg dutasteride overnight delivery, such as crop fields {4 hair loss in menopause prevention cheap dutasteride 0.5mg with amex. Natural baselines may be meaningful when hair loss in men masquerade safe 0.5 mg dutasteride, for instance hair loss cure news 2013 discount dutasteride 0.5 mg amex, biodiversity impacts are being considered. However, recent baselines such as the present, 10 or 20 years in the past may be far more relevant when considering zero net land degradation targets, assessing the impact of policy interventions or devising sustainable land management interventions. Restoration and mitigation of degradation without changes in current land use is likely to be more common than attempts to restore landscapes to their natural state. Changes in soil and soil functions occur in almost all forms of degradation with profound but slow impacts on crop production (well established). These functions require maintenance of soil physical structure, a wide range of soil organisms and the prevention of pollution that can result from applications of chemicals. Generally, erosion is insidious, unrecognizable on an annual basis, but can lead to a total collapse of the cropping and rangeland systems over decades; thus, long-term monitoring is needed. Soil acidification ­ due to the over-application of fertilizers and atmospheric pollutants ­ is affecting soils in North America, Central and Northern Europe and Southern China {4. An estimated 76 million ha of mostly irrigated land has been lost to salinization {4. An estimated 55 Pg C has been lost from soil organic carbon predominantly from croplands since 1800s (established but incomplete) {4. Rangeland degradation, due to a multitude of factors, is occurring (with some exceptions) on all continents with rangelands (established but incomplete). More contemporary changes to rangelands include a multitude of other degradation processes, such as invasion by alien plant species {4. Erosion and the leaching of agricultural chemicals due to poor land management has profound off-site impacts on wetland, river systems, coastal waters and groundwater (well established). In the coming decades, it is likely that fire in many regions of the world will increase as a result of greater human occupation of natural ecosystems and the effects of climate changes {4. In addition to their local impacts, urban centres have off-site impacts including: increases in pollution of the atmosphere, land surface and waterways; increases of surface temperature; changes in the water cycle; and changes in species composition and biodiversity {4. Biodiversity loss ­ as a consequence of land transformation ­ is reasonably well understood. By 2005, land use and related pressures had reduced species richness by about 15% compared with what they would have been in the absence of human impacts. However, few accurate measurements of species numbers exist for many groups of organisms, owing to difficulties in detection. Hence, many global estimates are based on a few, easilyobserved groups such as higher plants and large animals that are unlikely to be representative of actual numbers, although they do allow for processes to be tested. The distribution of declines is not geographically uniform and losses are greater in some land-cover and land-use types than in others: mines, industrial areas, urban areas, croplands and improved pastures have the greatest decreases compared with primary ecosystems and secondary growth. The biodiversity of ecosystems undergoing recovery has been found to average half the natural levels {4. Converting forest or rangeland to cropland can result in huge increases in food, but at the cost of biodiversity and regulating services. National, regional and global land degradation and restoration monitoring networks should be strengthened or established where absent. These are essential to determine the locations, extent and severity of degradation as a prelude to restoration and prevention. On-the-ground monitoring needs to complement remote sensing techniques and, in both cases, appropriate indicators need to be refined or established. The conditions in which permanent degradation occurs (and its frequency) are critical since their ecosystem services are also lost. The resulting anthropogenic impacts on land have been so profound that a new geologic era has been recognized, the Anthropocene (Ellis et al. The concept of "planetary boundaries" has emerged to attempt to forestall irreversible, adverse impacts on the Earth (Steffen et al. However, there has been, and continues to be, confusion over the meaning of the term "degradation". There is a distinction between, on the one hand, the human causes, motivations and consequences of land degradation and, on the other, the biophysically imposed constraints. It is important to recognize that environmental processes alone can result in conditions that take the form of anthropogenic degradation (such as natural hillslope erosion), but are not anthropogenic drivers of "degradation", unless the natural process is initiated or exacerbated by humans (such as erosion following removal of vegetation). Degradation results from a multitude of drivers (see Chapter 3) and can be manifested in many forms (see Section 4. It can be driven by changes in land cover caused by, for example, pollution, pests and diseases spreading as a result of climate change and through biodiversity loss. The multitude of drivers has differing impacts on different environmental systems and the drivers from Chapter 3 are mapped to impacts in Section 4. Nevertheless, the exact biophysical processes and degradation outcomes are, in many cases, insufficiently known. Many believe they can recognize it when they see it (in the field or with satellite imagery), yet the confusion in the literature belies this view. The definition of the term has led to interminable reviews (see review by Vogt et al. In curve 2 to 3 (blue) the degree of anthropogenic stress determines the level of ecosystem service over the full range, until point 3 when the stress is so high that it has no further effect. The second curve (5 to 6) reaches a threshold (5) at which the response to stress is non-linear and the ecosystem changes to a new state that cannot return to the upper level, no matter how much the stress is alleviated. On the other hand, there are conditions in which stress drives down the provision of the service, as illustrated by curve 5 to 6, until it reaches a threshold (point 5) (Turnbull et al. The analogy of response curves is helpful only when one anthropogenic stress is involved, but normally there are many that affect ecosystem services, such as soil type, pollution, soil compaction, loss of palatable species for livestock, and reduced productivity ­ all in one location. The first is those that are caused by the physical environment with no human involvement, and the second, those that are brought about by human action alone (anthropogenic stresses). A further increase in environmental stress drives the site over the cusp and into the zone of permanent degradation, from which no return is possible without drastic, expensive and lengthy artificial remediation. These concepts lead to recognition of six types of "degradation" shown in Table 4. Recognition of this distinction can be difficult, but it is critical when assessing the status and planning for restoration ­ the initial failure to recognize these two states and their difference from true degradation has caused much confusion, for example understanding of Sahelian "desertification" (see Chapter 1 and Section 4. The ecosystem service(s) is represented by the vertical dimension and the ecosystem dynamics by movement over the surface. The higher up on the surface in the vertical dimension, the higher the ecosystem service. The top two edges represent stress from the natural environmental (left) and anthropogenic stress (right). The fold or cusp in the surface (5) represents the threshold of a zone of permanent degradation. Sites that move over the threshold of resilience on any trajectory cannot return to the upper zone of resilience. A second surface shown below (7) represents a site that naturally provides lower environmental services, but is not initially degraded: it has all the features of the upper surface including resilience and the possibility of permanent degradation (see Section 4. Types v and vi are the only states that are correctly termed "degradation" (Adeel et al. Type iv is of greatest interest since, if the stress is alleviated, it has the capacity to recover naturally ­ although recovery may be accelerated by human intervention; the alternative being unremitting, further degradation to Type v or vi. Recovery from Types v and vi is actually possible, but only with significant efforts and expenses, or over exceptionally long-time periods, generally exceeding a human life-span. Comments · Land with low resource availability in its natural state often appears superficially similar to degraded land. However, the recovery of the original, pre-degradation ecosystem is at best extremely slow. In the ecological literature, this state is referred to as a deflected succession, a subclimax, or plagioclimax. Qualitative data (including indigenous and local knowledge) can also have error metrics and can be combined with quantitative data and statistical methods in joint analyses known as "mixed methods" (Creswell, 2007). Data are collected at a wide range of spatial and temporal scales: from single points or small areas of a few hectares, all the way up to global, and for one point in time to monitoring long-term trends. Global measurements are almost entirely made using remote sensing since they can have global coverage, spatial resolutions of a few meters and daily, monthly or annual repeat measurements. In the case of remote sensing of vegetation, the remarkable characteristics of vegetation indices. For example, in forested areas, there is extensive mapping of transformation to other land cover types, but less recognition of the extent of degradation within untransformed forest. Developing indicators and monitoring them are essential to any understanding of land degradation. A single, largearea map has been developed based on the development of functions for upscaling point data to a full spatial extent using correlated environmental covariates, for which spatial data are available, such as Global Soil Information System (Brus et al. Other information, such as plant diversity, generally cannot be measured directly, although some interspecific differences can be detected by seasonal phenological changes in the indices. More direct detection of species has been achieved in some cases using many spectral bands with imaging spectrometry (hyperspectral), but the "spectral diversity" often consists of more than one, not single taxonomic species (Gholizadeh et al. An important aspect of data use, by which degradation can be detected and monitored, is improved access. Another difficulty in the use of data is the gap between research products and adoption for routine monitoring. Furthermore, access generally assumes broadband, high speed internet which may not be available in less-developed countries, limiting local interpretation and dissemination of local data to the broader community. Both processes are relevant to degradation, but in quite distinct ways related to their scale of action (Wiegand et al. Furthermore, many areas of current degradation, degraded prior to current satellite-based trend data, may appear as stable land in these data sets (Gibbs & Salmon, 2015). The same occurs over space ­ for example, deposition of wind- blown products of surface erosion can takes place over hundreds of square kilometres, and hundreds of kilometres from the source, yet cattle hoofs that compact the soil are limited to paddocks measuring hectares. Multi-metric indices, however, are not ideal since they can give a false impression of being founded on well-accepted knowledge of ecosystem processes when, in many cases, they are or contain, highly subjective components. In addition, just because an index is numeric does not make it ecologically sound. Specific indices have strengths and weaknesses, but all are subject to certain flaws: they are subject to loss of information in the condensation of multidimensional variability into a one-dimensional index (so the condition in need of remediation often cannot be identified from the index alone); they are subject to systematic bias if raw data are converted into categorical scores; they are subject to weighting, as combination of multiple data types, either implicitly or explicitly, weights the measurements of the properties by different amounts, thus emphasizing some aspects more than others (Cai et al. Weightings can only be justified if the processes are understood well enough to select appropriate ones to which assign greater weight. Model results can be very accurate when the biophysical processes are known and adequate data are available. The demand for data and parameters can be prohibitive, and oftentimes default values have to be used with consequent reduction of accuracy. Multiple types of reference states are in use to furnish a start, baseline or reference condition for comparison with the current conditions (Table 4. A salutary warning of the danger of a lack of baseline was given by Alexander von Humboldt in 1848, as reported by Gritzner (1981), that travellers unfamiliar with arid lands are "easily led to adopt the erroneous inference that absence of trees is a characteristic of hot climates" where in reality, the area had long been degraded by the enormous caravans that crossed the Sahara. Clearly Humboldt recognized the difference between Types i and vi degradation (Table 4. A target condition is based on a deliberate choice and is therefore context-dependent. For example, in the case of long-standing cropland agriculture, sustained and healthy crop production, rather than the natural land cover, is the target. The concept shares some features of models since a set of a priori definitions based on socioeconomic and biophysical factors are selected and then used to classify types of degradation. Syndromes have been used in relation to degradation and its socioeconomic effects (Ibбсez et al. Although land transformation can, in itself, be considered as a form of degradation, transformed land may also enhance provisioning of specific ecosystem services, such as agricultural commodities. Evaluation of land degradation and restoration requires answers to the questions, "degraded relative to what? This provides an objective assessment, as opposed to the selection of a target condition which is an aspiration (or a natural baseline, see 4. A historical trend can indicate undesirable changes in an ecosystem and also point to the processes of degradation that have led to the current state and restoration efforts. While highly desirable, unfortunately there are few, detailed, time-series of observations of ecosystem properties that are more than 50 years old. Adequate data to match with key characteristics of; "Current", "Ecological Integrity" or "Target" definitions Long time-series of records allow more accurate specification of trends Measurement techniques used must be known and repeated in all subsequent data collections Davis & Shaw (2001); Graumlich (1993) Gammage (2011) Storkey et al. Specify measurement techniques Land managers, farmers, foresters, biodiversity experts, environmentally-aware public and so on. Historical baselines have been used extensively for assessment of the status and trends of species and ecosystems. Furthermore, sites may have suffered degradation before the historical baseline. These can sometimes be dated or otherwise assigned to the pre-human period, but they are often too generalized to specify the state of the environment in adequate detail for comparison with existing conditions. Data availability for the last 100 years is obviously greater in number, type and accuracy. However, even for an Anthropocene baseline, a significant amount of qualitative judgement is needed. Increasing greenhouse gas emissions that lead to high greenhouse gas concentrations over time.

Over half of the studies were performed in Sweden by the same authors hair loss uk cheap 0.5mg dutasteride free shipping, but post-hoc analyses did not find differences in outcomes between the Swedish and other studies (data not shown) hair loss in male cats generic 0.5mg dutasteride otc. Women constituted a large proportion of most study populations hair loss cure latisse discount 0.5mg dutasteride otc, reflecting the often unequal Meta-analytic review of internet-based treatment 103 gender distribution of different chronic somatic conditions hair loss eating disorder purchase dutasteride 0.5 mg otc. Second hair loss rogaine order dutasteride 0.5 mg with mastercard, studies were found to be of variable methodological quality hair loss 7 year old boy cheap dutasteride 0.5 mg on line, which may influence both individual study results and overall outcomes in meta-analysis. Although all studies had unclear or high risk of blinding bias, this is often unfeasible or very difficult to achieve in non-pharmacological behavioral interventions and thus may not be a valid indicator of study quality [71]. The current review included a relatively diverse range of chronic somatic conditions, and outcomes were often assessed with various different questionnaires. However, similar effects and low heterogeneity were found for most outcomes, supporting the idea that the included studies were comparable regarding their outcomes. As more trials become available in the future, meta-analyses should be performed for separate chronic somatic conditions. Fourth, long-term between-group follow-up measurements were often lacking, precluding a reliable long-term estimate. Fifth, there was substantial variation in description of treatment content, therapist contact, and dropout. For instance, not all therapist contact was with a trained therapist but could also include "expert" patients, nurses, physicians, occupational therapists, or research assistants. Dropout rates were not always adequately described and generally high, which is a common problem with internet interventions [75]. The current review was limited to published studies, as it was unfeasible to obtain a complete and unbiased overview of all unpublished grey literature on this subject. This may have led to an overestimation of effectiveness, as published studies are generally more likely to include statistically significant results [76]. However, several studies that did not find an effect were included in the current review, indicating that not only studies with significant results are published on this topic. Finally, we used the pooled standard deviation based on pre- and post-intervention measurements in our meta-analysis. When using change scores in meta-analysis, the most appropriate measure would have been the standard deviation of changes. However, the included studies did not report sufficient information to calculate these standard deviations [29], which has been recognised as a common problem when using change scores. Our approach can, however, be considered as a conservative approach since the calculated standard deviations will be slightly larger than the standard deviations of changes would have been. Another alternative would have been to perform the meta-analysis based on post-intervention measurements, but such an approach does not take into account possible differences in baseline measurements. Nevertheless, we 5 104 Chapter 5 also performed a meta-analysis based on post-intervention measurements results. The results of this meta-analysis were very similar to the change score results reported in our study (data not shown), and would have led to similar conclusions. More studies with adequate sample sizes focusing on a wider range of chronic somatic conditions with between-group long-term follow-up are needed. Only one study involved older patients [38], yet older patients are often affected by chronic conditions. Preliminary research suggests that tailoring interventions may be an effective strategy to promote engagement and adherence [77­79]. Strategies found to be predictive for adherence include increased therapist contact, more frequent website updates, and more frequent intended usage [80]. Last, the "active ingredients" of interventions need to be identified, in order to develop effective interventions for specific problems. Analyses on computer-generated data about how subjects access the website may also be a worthwhile approach to examine engagement, usability, and active ingredients [82]. Larger improvements are occasionally found for diseasespecific outcomes related to daily-life impact of the illness, which underlines the importance of tailoring interventions to specific (patient) groups. Our results also indicate that interventions of longer duration may be more effective for psychological outcomes such as depression, which implies that tailoring the duration of interventions to specific problems may be appropriate. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. A systematic review of the effectiveness of problem solving approaches towards symptom management in cancer care. Cognitive-behavioural therapy as an adjunctive treatment in chronic physical illness. Cost-effectiveness of internet-based cognitive behavior therapy for irritable bowel syndrome: results from a randomized controlled trial. E-health in caring for patients with atopic dermatitis: a randomized controlled cost-effectiveness study of internet-guided monitoring and online self-management training. A Comprehensive Review and a Meta-Analysis of the Effectiveness of Internet-Based Psychotherapeutic Interventions. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Internet-administered cognitive behavior therapy for health problems: a systematic review. Eland-de Kok P, van Os-Medendorp H, Vergouwe-Meijer A, Bruijnzeel-Koomen C, Ros W. A systematic review of internet-based self-management interventions for youth with health conditions. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. Online randomized controlled trial of brief and full cognitive behaviour therapy for depression. Chronic care: making the case for ongoing care [internet] 2010 [cited 13 december 2016] Available from. Evaluating depression severity and remission with a modified Beck Depression Inventory. A cluster randomised trial of an internet-based intervention program for tinnitus distress in an industrial setting. Randomized controlled trial of internet-based cognitive behavior therapy for distress associated with tinnitus. The effectiveness of an online mind-body intervention for older adults with chronic pain. Internet-based rehabilitation for individuals with chronic pain and burnout: a randomized trial. Controlled trial of Internet-based treatment with telephone support for chronic back pain. Guided internet-based cognitive behavioural treatment for chronic back pain reduces pain catastrophizing: a randomized controlled trial. Online counseling via e-mail for breast cancer patients on the German internet: preliminary results of a psychoeducational intervention. A randomized controlled trial of an internet-based treatment for chronic headache. Effectiveness of an online fatigue self-management programme for people with chronic neurological conditions: a randomized controlled trial. Multimodal behavioral treatment of migraine: an Internet-administered, randomized, controlled trial. A randomized controlled trial of Internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus. Internet versus group cognitive-behavioral treatment of distress associated with tinnitus: a randomized controlled trial. Acceptability, effectiveness, and cost-effectiveness of internet-based exposure treatment for irritable bowel syndrome in a clinical sample: a randomized controlled trial. Long-term follow-up of internet-delivered exposure and mindfulness based treatment for irritable bowel syndrome. The internet-based arthritis self-management program: a one-year randomized trial for patients with arthritis or fibromyalgia. A controlled trial of self-help treatment of recurrent headache conducted via the Internet. Web-based depression treatment for type 1 and type 2 diabetic patients: a randomized, controlled trial. Generic and disease-specific measures in assessing health status and quality of life. Individually-tailored, Internet-based treatment for anxiety disorders: A randomized controlled trial. Computer-tailored health interventions delivered over the Web: review and analysis of key components. Cognitive-behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials. A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress. Blinding was judged more difficult to achieve and maintain in nonpharmacologic than pharmacologic trials. Incorporating variations in the quality of individual randomized trials into meta-analysis. Two cheers for meta-analysis: problems and opportunities in aggregating results of clinical trials. Does the inclusion of grey literature influence estimates of intervention effectiveness reported in meta-analyses? Engagement and retention: measuring breadth and depth of participant use of an online intervention. Chronic health conditions and internet behavioral interventions: a review of factors to enhance user engagement. Persuasive system design does matter: a systematic review of adherence to web-based interventions. Participants filled out standardized self-report questionnaires assessing physical and psychological functioning and impact on daily activities at baseline, posttreatment assessment, and 6-month follow-up. Patients frequently experience problems with mood, distress, and social impairments in addition to the burden of physical symptoms [3­6]. These problems may also negatively impact upon skin status, disease course, adherence, and dermatological treatment success [7­11]. Possible predictors and correlates of treatment outcomes, including the therapeutic relationship [37, 38] and adherence [39], also remain unexplored in this group. In addition, sociodemographic, disease-related, and treatment-related predictors and correlates of treatment effects were explored. Inclusion criteria were a diagnosis of psoriasis, age 18 years, 126 Chapter 6 and a positive psychological risk profile. An independent person randomized the participants (allocation ratio: 1:1) using a computerized program that minimized on age, gender, educational level, recruitment site, self-assessed disease severity, and medication use. A member of the research team informed the participants by phone and letter about treatment assignment. The intervention consisted of five flexible treatment modules containing a broad variety of cognitive and behavioral techniques focused on themes that patients often experience problems with: itch, pain, fatigue, negative mood, and social relationships. The participants started with two face-to-face intake sessions with their therapist (a psychologist), in which individual treatment goals were discussed. Next, patients received a telephone-based instruction of the intervention website by a researcher to ensure that they were capable of working with the program from home. The patients received personalized written feedback on their assignments from their therapist approximately once a week. Intervention duration and content varied between participants, depending on treatment goals, with a mean duration of 25 ± 12 weeks (range 1­57 weeks). Further measurement details of all study variables can be found in the supplementary methods and results. Primary analyses were conducted using linear mixed-effects modeling, which has superior qualities with regard to missing values [56] and makes use of all available data, making this a full intention-totreat analysis. Between-group effects at post-treatment assessment and follow-up were analyzed with baseline scores of dependent variables as covariates. Time was operationalized as a continuous variable, and post-treatment assessment varied across participants as a result of different intervention lengths. Fixed linear effects of time and condition were included as well as random effects of intercept. Primary analyses were conducted including all variables included in the randomization (age, sex, educational level, recruitment site, systemic medication use, etanercept use, and disease severity) as covariates [57]. A power analysis with 80% power indicated that a sample size of two groups of 65 patients was needed, assuming the effect size d = 0. In explorative analyses examining correlates of treatment effects, tendencies towards significant effects (p < 0. Untransformed scores are displayed in this table, bNumber of patients reporting use of systemic treatment, cn = 2-12 missings. Primary outcomes Results on primary outcomes and their subcomponents, including effect sizes, are presented in Table 2 and Figure 2. Similar results were obtained in secondary analysis including no other covariates than baseline values of the dependent variable (p. These outcomes were stable across post-treatment assessment and 6-month follow-up, with the exception of fatigue, which tended to be lower at post-treatment assessment than at 6-month follow-up (p =. The improvements in role limitations due to emotional problems at post-treatment assessment were further enlarged at follow-up (p =. In secondary analysis including no other covariates than baseline values of the dependent variable, no between-group differences were found (p.

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