Parents' experiences of participating in health-promoting activities at a family centre for preschool children in Sweden.

In Sweden, the family centre is a meeting place for families in a neighbourhood. It is a place for families to meet and exchange experiences and is a confidence-filled place for preschool children to play and develop. The staff at the family centre collaborate on early prevention strategies to promote health. Since 2014, the Public Dental Health Service in Södra Ryd, Skövde, has been a collaborative partner with the family centre. OBJECTIVES: To explore and describe the parents' experiences of participating in health-promoting activities at the family centre. BASIC RESEARCH DESIGN: A qualitative design based on interviews, analysed using a phenomenograpic approach. PARTICIPANTS: Six focus groups with two to six participants in each group. RESULTS: Three themes, all describing parents' experiences of visiting the family centre, emerged in the analysis. The themes were as follows; "Social fellowship", "A secure place" and "A learning environment". Each theme contained three categories, which represent the parents' different conceptions. CONCLUSIONS: The present study showed that the parents who visit the family centre found that the collaboration is perceived as positive and has many benefits. The participants found that the family centre is an institution that increases social interaction. Furthermore, meeting dental professionals in an arena outside the clinic creates confidence and makes people feel secure. Parents also learn both from the staff and from each other. According to these findings, the family centre is a suitable arena to work on health-promotion activities.

Experience of collaboration at a family centre for preschool children in Sweden.

In 2014, the Public Dental Health Service in Södra Ryd, Skövde, started a collaboration at the local family centre with the aim of performing health-promoting activities. Personnel at the family centre can play an important role in promoting children's health, including oral health, by testing preventive guidance. OBJECTIVES: To describe the personnel's experience of collaboration. BASIC RESEARCH DESIGN: Qualitative interviews with transcripts analysed using the phenomenographic approach. PARTICIPANTS: Seven staff with experience of collaboration. All were female, aged 34-62 and were dental nurses, child health-care nurses, preschool teacher or family centre co-ordinators. RESULTS: Three themes describing personnel's experience of collaboration at the family centre emerged: Collaboration produces an holistic approach, Co-location creates added value and Working methods result in development. Each theme was represented by three to four categories that represent different conceptions of collaboration at a family centre. CONCLUSIONS: The staff had found that the way of working was positive, mainly because it gave an increased overall view and that the co-location created added value. It also created development through mutual learning and new methods. However, it took time to establish collaboration and required permissive leadership.

Caries and costs: an evaluation of a school-based fluoride varnish programme for adolescents in a Swedish region.

UNLABELLED: In 2003, 19 public dental clinics in Västra Götaland Region implemented a population-based programme with fluoride varnish applications at school every six months, for all 12 to 15 year olds. In 2008, the programme was extended to include all 112 clinics in the region. OBJECTIVE: To evaluate caries increment and to perform a cost analysis of the programme. BASIC RESEARCH DESIGN: A retrospective design with caries data for two birth cohorts extracted from dental records. Three groups of adolescents were compared. For Group 1 (n = 3,132), born in 1993, the fluoride varnish programme started in 2003 and Group 2 (n = 13,490), also born in 1993, had no fluoride varnish programme at school. These groups were compared with Group 3 (n = 11,321), born in 1998, when the programme was implemented for all individuals. The total cost of the four-year programme was estimated at 400SEK (≈ 44€) per adolescent. RESULTS: Caries prevalence and caries increment in 15 year olds were significantly lower after the implementation of the programme. Group 2, without a programme, had the highest caries increment. The cost analysis showed that it was a break-even between costs and gains due to prevented fillings at the age of 15. CONCLUSIONS: This school-based fluoride varnish programme, implemented on a broad scale for all 12 to 15 year olds, contributed to a low caries increment at a low cost for the adolescents in the Västra Götaland Region in Sweden.

The contribution of VEGF signalling to fostamatinib-induced blood pressure elevation.

BACKGROUND AND PURPOSE: Fostamatinib is an inhibitor of spleen tyrosine kinase (TK). In patients, fostamatinib treatment was associated with increased BP. Some TK inhibitors cause BP elevation, by inhibiting the VEGF receptor 2 (VEGFR2). Here, we have assessed the mechanistic link between fostamatinib-induced BP elevation and inhibition of VEGF signalling. EXPERIMENTAL APPROACH: We used conscious rats with automated blood sampling and radio telemetry and anaesthetized rats to measure cardiovascular changes. Rat isolated aorta and isolated hearts, and human resistance vessels in vitro were also used. NO production by human microvascular endothelial cells was measured with the NO-dependent probe, DAF-FM and VEGFR2 phosphorylation was determined in mouse lung, ex vivo. KEY RESULTS: In conscious rats, fostamatinib dose-dependently increased BP. The time course of the BP effect correlated closely with the plasma concentrations of R406 (the active metabolite of fostamatinib). In anaesthetized rats, infusion of R406 increased BP and decreased femoral arterial conductance. Endothelial function was unaffected, as infusion of R406 did not inhibit hyperaemia- or ACh-induced vasodilatation in rats. R406 did not affect contraction of isolated blood vessels. R406 inhibited VEGF-stimulated NO production from human endothelial cells in vitro, and treatment with R406 inhibited VEGFR2 phosphorylation in vivo. R406 inhibited VEGF-induced hypotension in anaesthetized rats. CONCLUSIONS AND IMPLICATIONS: Increased vascular resistance, secondary to reduced VEGF-induced NO release from endothelium, may contribute to BP increases observed with fostamatanib. This is consistent with the elevated BP induced by other drugs inhibiting VEGF signalling, although the contribution of other mechanisms cannot be excluded.

A new grading for easy and concise description of functional status after spinal cord lesions.

BACKGROUND: Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN: Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE: To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING: Multi-center study at 13 spinal units in 6 countries. METHODS: Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS: Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS: A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

STUDY DESIGN: Multicenter international cohort study. OBJECTIVE: The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels. SETTING: In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken. METHODS: Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation. RESULTS: Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001). CONCLUSIONS: Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions.

STUDY DESIGN: A multi-center international cohort study. OBJECTIVE: To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs). SETTING: A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East. METHODS: SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity. RESULTS: In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearson's coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ≥ 0.95. Cronbach's α values for the entire SCIM III scale were 0.833-0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02). CONCLUSION: The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.

PURPOSE: To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. METHOD: Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. RESULTS: Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbach's alpha was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P<0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. CONCLUSIONS: The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

Inter-rater reliability of motor and sensory examinations performed according to American Spinal Injury Association standards.

STUDY DESIGN: Prospective observational. AIM: To examine inter-rater reliability of motor and sensory examinations performed according to American Spinal Injury Association (ASIA) standards. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, UK. MATERIAL AND METHOD: Results of ASIA motor and sensory examinations performed by two experienced examiners on 45 patients with spinal cord injury (SCI) were compared. RESULTS: Total ASIA scores showed very strong correlation between the two examiners, with Pearson correlation coefficients and intraclass correlation coefficients exceeding 0.96, P<0.01 for total motor, light touch and pin prick scores. The agreement for individual muscle testing of the 10 ASIA key muscles showed substantial agreement for majority of muscles, with the weighted Kappa coefficient range 0.649-0.993, P<0.05. The overall agreement in assignment of manual muscle testing grades (0-5) was 82% on the right and 84% on the left, with the strongest agreement for grade '0' and the weakest for grade '3'. The unweighted Kappa coefficient for agreement in motor and sensory levels ranged from 0.68 to 0.78 (P<0.01). There was no difference in ASIA impairment grades derived from the two examiners' results. CONCLUSIONS: Our study results showed very good levels of agreement in ASIA clinical examinations between two experienced examiners. The established degree of variability due to inter-rater differences should be taken into account in study design of clinical trials with more than one assessor..

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation.

BACKGROUND: A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version. OBJECTIVE: To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis. DESIGN: Multicenter cohort study. SETTING: Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East. SUBJECTS: 425 patients with spinal cord lesions (SCL). INTERVENTIONS: SCIM III assessments by professional staff members. Rasch analysis of admission scores. MAIN OUTCOME MEASURES: SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries. RESULTS: Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found. CONCLUSIONS: The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Obesity in 4-year-old children more prevalent in girls and in municipalities with a low socioeconomic level.

AIM: To provide updated prevalence data of BMI and obesity in 4-year-old Swedish children, also exploring socioeconomic differences. SUBJECTS: A total of 4407 children born 1998-1999 (2231 boys and 2176 girls) in the county of Västerbotten, Sweden. METHODS: Overweight and obesity was estimated using the International Obesity Task Force cutoff values (ISO BMI). Information about socioeconomic level of the municipalities was collected from a health survey of the adult population. RESULTS: Of the boys, 16.7% were classified as overweight and 3.1% of these as obese. Corresponding figures for girls were 22.1% and 6%. [corrected] The P50 and P95 values for BMI were 16.2 and 18.8 for boys and 16.1 and 19.3 for girls, respectively. P50 was at the same level as in previous Swedish studies, while P95 was higher in this study. Obesity, in girls, was more prevalent in municipalities with a low socioeconomic level. CONCLUSION: Overweight and obesity in pre-school children in Sweden is more prevalent in girls than in boys, and the prevalence is as high as in school age children. A low socioeconomic level of living area seems to be related to a higher prevalence of obesity. Increased preventive efforts, both on the individual and the societal level, must be undertaken to reduce future health risks in obese children.

Perceptual threshold to cutaneous electrical stimulation in patients with spinal cord injury.

STUDY DESIGN: Prospective experimental. OBJECTIVES: The aim of this study was to develop a quantitative sensory test (QST) that could be used for assessing the level and the density (degree of impairment) of spinal cord injury (SCI) and for monitoring neurological changes in patients with SCI. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust, UK. METHODS: Perceptual threshold to 3 Hz cutaneous electrical stimulation was measured in 30 control subjects and in 45 patients with SCI at American Spinal Injuries Association (ASIA) sensory key points for selected dermatomes between C3 and S2 bilaterally. Electrical perceptual threshold (EPT) was recorded as the lowest ascending stimulus intensity out of three tests at which the subject reported sensation. The level of SCI according to EPT results was established for right and left sides as the most caudal spinal segment at which patient's EPT was within the control range (mean +/- 2 standard deviation (SD)). The level of SCI, according to EPT, was then compared with clinical sensory level derived according to ASIA classification. RESULTS: In the control group, EPT depended on the dermatome tested and was lowest for T1 (1.01 +/- 0.23 mA, mean +/- SD) and highest for L5 (3.32 +/- 1.14 mA). There was strong correlation between corresponding right and left dermatomes and between repeated assessments. In the SCI group, the level of lesion according to EPT and clinical testing was the same in 43 of the 90 tests (48%). In 37 cases (41%), the EPT level was higher than the clinical level, and in 10 cases (11%), it was lower. Below the level of lesion in incomplete SCI and in the zone of partial preservation in complete SCI, the EPT values in most dermatomes were raised compared with the control group. CONCLUSIONS: EPT is a simple, reproducible QST that can assess both the level and the density of SCI. It seems to add sensitivity and resolution to the standard clinical testing and could be a useful adjunct in longitudinal monitoring of patients with SCI for research purposes during natural recovery and therapeutic interventions. SPONSORSHIP: International Spinal Research Trust (ISRT), UK, Grant CLI001.

Towards improved clinical and physiological assessments of recovery in spinal cord injury: a clinical initiative.

Clinical practice and scientific research may soon lead to treatments designed to repair spinal cord injury. Repair is likely to be partial in the first trials, extending only one or two segments below the original injury. Furthermore, treatments that are becoming available are likely to be applied to the thoracic spinal cord to minimise loss of function resulting from damage to surviving connections. These provisos have prompted research into the improvement of clinical and physiological tests designed (1) to determine the level and density of a spinal cord injury, (2) to provide reliable monitoring of recovery over one or two spinal cord segments, and (3) to provide indices of function provided by thoracic spinal root innervation, presently largely ignored in assessment of spinal cord injury. This article reviews progress of the Clinical Initiative, sponsored by the International Spinal Research Trust, to advance the clinical and physiological tests of sensory, motor and autonomic function needed to achieve these aims.

Mobility of the spine after spinal surgery in acute spinal cord injury.

STUDY DESIGN: Retrospective study of mobility of the spine. OBJECTIVES: To study the relation between mobility of the spine, operation and length of surgical stabilisation. SETTING: The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK. METHOD: Questionnaires were sent to 99 consecutive acute traumatic spinal cord-injured patients (UK residents) admitted in 1990-1994. All had acute spinal surgery. A total of 68 responded. Their replies, medical records and radiographs were reviewed. RESULTS: (1) In all, 63 patients had surgery in the cervical, thoracolumbar or lumbar spine; 11 of them had more than two functional spinal units (FSUs) stabilised, 10 of these 11 (91%) had less than satisfactory results in terms of metal failure, improper placement of the implant or functional restriction of spinal mobility (FROSM). A total of 35 had 1-2 FSUs stabilised. None of them had metal failure or improper placement of implant, but 14 (40%) had less than satisfactory result due to FROSM; 17 had laminectomy alone, four of these had FROSM. (2) Five patients had surgery in the thoracic spine. Three of these who had 5-7 FSUs stabilised had no FROSM. Two had laminectomy alone, one of whom had FROSM. CONCLUSION: (1) Long surgical stabilisation in the cervical, thoracolumbar and lumbar spines was likely to result in either metal failure or FROSM. (2) Long surgical stabilisation of the thoracic spine was not associated with either metal failure or FROSM. (3) A small proportion of patients had laminectomy alone. One of them who had multiple injuries had FROSM.

Increasing prevalence of overweight in young schoolchildren in Umeå, Sweden, from 1986 to 2001.

AIM: To investigate the current prevalence and trend of overweight in young schoolchildren in Umeå, Sweden. METHODS: Two cross-sectional samples of children were studied: 1115 randomly selected children from preschool class to grade 6 (aged 6-13 y) attending school in 2001 and a matched sample of 507 schoolchildren from grades 0, 1 and 4 (aged 6-11 y) attending school in 1986. Overweight was defined according to age- and gender-specific body mass index (BMI) cut-off values, corresponding to BMI values of 25 kg/m2 (level 1) and 30 kg/m2 (level 2) at late adolescence. RESULTS: In the population from 2001, the prevalence of overweight was 23% (18% at level 1, 5% at level 2). The prevalence differed with age, with a higher prevalence at the ages of 6 and 13 y. Comparing children from grades 0, 1 and 4, attending school in 1986 and 2001, respectively, the total prevalence of overweight was twice as high in 2001 as in 1986. Regarding severe overweight (level 2), the difference was even larger (five times). In the 1986 sample, the prevalence of overweight did not differ between girls and boys, while significantly more girls than boys were overweight in 2001. CONCLUSION: In this sample of young children from Sweden, the prevalence of overweight doubled over the past 15 y and severe overweight increased even more, suggesting a need for intensified preventive efforts in young schoolchildren.

Predicting normal lung function in patients with childhood spinal cord injury.

STUDY DESIGN: A prospective observational study. OBJECTIVES: To compare the height and arm span measurements in childhood spinal cord injured (SCI) people and examine the subsequent effect on calculating the predicted lung function using standard formulae and to discuss which of the two measurements is the most appropriate to use in these formulae. SETTING: National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK. METHOD: A total of 12 children had lung function tests performed and at the same time had height and armspan measured. The predicted lung function was calculated twice; once using height and then using arm span and compared. The actual lung function test results were expressed as percentage of the two predicted values, respectively, and compared. RESULTS: The difference between the mean height (1499 mm) and arm span (1649 mm) measurements was significant (P<0.001). In all cases, the arm span measurement was greater than the height. The two predicted lung function values (one calculated using height and the other armspan) were significantly different (P<0.001). When lung function test results were expressed as percentage of the two predicted values they gave a very different interpretation of the results. The actual performance was much lower than the predicted values if arm span, rather than height, was used in prediction equations. CONCLUSION: In childhood SCI, the difference in height and arm span is significant. This affects the predicted lung function values significantly and thus changes the interpretation of the lung function test results. The most appropriate measurement to use in prediction equations (height or arm span) in these subjects is yet to be decided.

Consumption of added fats and oils in the European Prospective Investigation into Cancer and Nutrition (EPIC) centres across 10 European countries as assessed by 24-hour dietary recalls.

OBJECTIVE: To evaluate the consumption of added fats and oils across the European centres and countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). DESIGN AND SETTING: 24-Hour dietary recalls were collected by means of standardised computer-guided interviews in 27 redefined EPIC centres across 10 European countries. SUBJECTS: From an initial number of 36 900 subjects, single dietary recalls from 22 924 women and 13 031 men in the age range of 35-74 years were included. RESULTS: Mean daily intake of added fats and oils varied between 16.2 g (Varese, Italy) and 41.1 g (Malmö, Sweden) in women and between 24.7 g (Ragusa, Italy) and 66.0 g (Potsdam, Germany) in men. Total mean lipid intake by consumption of added fats and oils, including those used for sauce preparation, ranged between 18.3 (Norway) and 37.2 g day-1 (Greece) in women and 28.4 (Heidelberg, Germany) and 51.2 g day-1 (Greece) in men. The Mediterranean EPIC centres with high olive oil consumption combined with low animal fat intake contrasted with the central and northern European centres where fewer vegetable oils, more animal fats and a high proportion of margarine were consumed. The consumption of added fats and oils of animal origin was highest in the German EPIC centres, followed by the French. The contribution of added fats and oils to total energy intake ranged from 8% in Norway to 22% in Greece. CONCLUSIONS: The results demonstrate a high variation in dietary intake of added fats and oils in EPIC, providing a good opportunity to elucidate the role of dietary fats in cancer aetiology.

Diversity of dietary patterns observed in the European Prospective Investigation into Cancer and Nutrition (EPIC) project.

OBJECTIVE: To describe the diversity in dietary patterns existing across centres/regions participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). DESIGN AND SETTING: Single 24-hour dietary recall measurements were obtained by means of standardised face-to-face interviews using the EPIC-SOFT software. These have been used to present a graphic multi-dimensional comparison of the adjusted mean consumption of 22 food groups. SUBJECTS: In total, 35 955 men and women, aged 35-74 years, participating in the EPIC nested calibration study. RESULTS: Although wide differences were observed across centres, the countries participating in EPIC are characterised by specific dietary patterns. Overall, Italy and Greece have a dietary pattern characterised by plant foods (except potatoes) and a lower consumption of animal and processed foods, compared with the other EPIC countries. France and particularly Spain have more heterogeneous dietary patterns, with a relatively high consumption of both plant foods and animal products. Apart from characteristics specific to vegetarian groups, the UK 'health-conscious' group shares with the UK general population a relatively high consumption of tea, sauces, cakes, soft drinks (women), margarine and butter. In contrast, the diet in the Nordic countries, The Netherlands, Germany and the UK general population is relatively high in potatoes and animal, processed and sweetened/refined foods, with proportions varying across countries/centres. In these countries, consumption of vegetables and fruit is similar to, or below, the overall EPIC means, and is low for legumes and vegetable oils. Overall, dietary patterns were similar for men and women, although there were large gender differences for certain food groups. CONCLUSIONS: There are considerable differences in food group consumption and dietary patterns among the EPIC study populations. This large heterogeneity should be an advantage when investigating the relationship between diet and cancer and formulating new aetiological hypotheses related to dietary patterns and disease.