| 1. |
- Ericson Jogsten, Ingrid, 1980-
(författare)
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Assessment of human exposure to per- and polyfluorinated compounds (PFCs) : exposure through food, drinking water, house dust and indoor air
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Per- and polyfluorinated compounds (PFCs) are detected in humans worldwide but all sources of human exposure have not been fully characterized. The aim of this thesis was to evaluate the contributions from food, water, air and dust as sources for human PFC exposure in the general population. Per- and polyfluorinated compounds (PFCs) are detected in humans worldwide but all sources of Up to 27 PFCs were determined at trace levels in blood (ng/mL), water (ng/L), foods (ng/g), dust (ng/g) and air (pg/m3) in a selected Catalan population and PFC intake was estimated from the measured PFC concentrations of the different sources of exposure. The major compounds detected in human blood of the studied population were perfluorooctane sulfonate (PFOS; 7.6 ng/mL), perfluorohexane sulfonate (PFHxS; 3.6 ng/mL) and perfluorooctanoic acid (PFOA; 1.8 ng/mL). In general, PFOS was also the major compound detected in most sources of exposure. Food was found to be the dominant pathway for human PFC exposure accounting for more than 70 % of the total intake of both PFOS and PFOA. In the most populated area (the Barcelona Province) where the highest levels were measured, tap water can contribute to the total exposure substantially with more than 50 % for adults. Indoor sources were negligible in the selected area for most PFCs when compared to food and water intake, except for toddlers under a worst case scenario where contribution from dust and food intake were equal (19 %). Pharmacokinetic (PK) modelling resulted in exposure of 103 ng PFOS/day and 33 ng PFOA/day of adults from the internal PFC blood concentrations. This agrees well with the intake estimated from external exposure through food, drinking water, house dust and indoor air of 80 ng PFOS/day and 32 ng PFOA/day and evidently all major exposure sources for the general population were included (in this study).
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| 2. |
- Eriksson, Ulrika, 1972-
(författare)
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Contribution of polyfluoroalkyl phosphate esters (PAPs) and other precursor compounds to perfluoroalkyl carboxylates (PFCAs) in humans and the environment
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Per-and polyfluoroalkyl substances (PFAS) are anthropogenic compounds that have been spread all over the world. The use of fluorotelomer compounds, short-chained homologues, and other PFASs with perfluorinated moieties has emerged recent years. One of these emerging compound classes is polyfluoroalkyl phosphate esters (PAPs), which have the ability to degrade into persistent PFCAs.The aim of this thesis was to assess the contribution of PAPs and other precursors to the exposure of PFCAs to humans and the environment. The main objective was to analyze a wide range of PFAS in human serum, wild bird eggs, indoor dust, waste water, and sludge. There was a significant contribution from selected precursors to the total amount of PFASs in the abiotic compartments indoor dust, waste water, and sludge. Levels of PAPs found in house dust exceeded those of PFCAs and perfluorosulfonic acids (PFSAs), revealing PAPs as a world-wide important exposure source.A net increase was during waste water treatment was observed for several PFASs in Swedish waste water treatment plants. Together with presence of precursor compounds and intermediates in the influent water and the sludge, this suggest that degradation of PFCA precursors contributed to the increase of PFCAs. Detection of precursors in human serum, together with slow declining trends of PFCAs, revealed an ongoing exposure of PFCAs to the general population of Australia. The diPAPs and the FTSAs were also detected in raptor bird eggs from Sweden from both the terrestrial and the freshwater environment. The precursors concentrations and patterns observed reveal that current regulatory measures are insufficient for the purpose of protecting humans and the environment from PFASs exposure.
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| 3. |
- Kärrman, Anna
(författare)
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Analysis and human levels of persistent perfluorinated chemicals
- 2006
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- An extensive use of perfluorinated chemicals (PFCs) in the last 50 years has resulted in a worldwide spread of these persistent chemicals. Human populations are subjected to a large number of PFCs in ways that are not yet fully explained. The aims of this thesis are to develop and assure the quality of analytical methods in order to collect information on human levels and to facilitate the assessment of human exposure of PFCs. Solid-phase extraction (SPE) methods for human blood and milk using two sorbents, octadecyl (C18) and a weak anion exchange polymer (WAX), were developed. Perfluorinated alkyl sulfonates (PFSAs) and perfluorinated alkyl carboxylic acids (PFCAs) with carbon chain lengths between four and fourteen together with perfluorooctane sulfonamide (PFOSA) could be extracted from human matrices. These extraction procedures enable selective and sensitive analysis of PFCs in human matrices using single quadrupole mass spectrometry (SQMS). The accuracy and reliability of the methods are discussed in the context of intralaboratory as well as interlaboratory quality assurance. Further improvements of the analysis are discussed including the evaluation of ultra performance liquid chromatography (UPLC). Human whole blood, plasma and serum from Sweden, Australia and the United Kingdom have been analysed. The blood matrix selection in the assessment and comparisons of human exposure to PFCs is crucial. Human plasma contains a high percentage of PFSAs and PFCAs. On the contrary, only about 20% of the total PFOSA content is present in plasma after removal of the red blood cells. Up to eleven persistent PFCs are detected in human blood, with detection levels between 0.1-0.5 ng/mL. A gender difference with higher serum levels for males is apparent. An age trend was observed for perfluorooctane sulfonate (PFOS) levels in serum from Australia. The levels found in Australian serum indicate that emissions from the PFC production facilities are of less importance for human exposure. Matched human milk and serum samples from Sweden show that milk levels of PFCs are about 1% of the maternal serum level. Up to five persistent PFCs are found in human milk from Sweden, with detection limits between 0.005-0.1 ng/mL, and the levels in Swedish pooled milk samples have remained constant between 1996 and 2004. A linear relationship between the maternal serum level and milk level was seen for PFOS and its shorter homologue perfluorohexane sulfonate (PFHxS). The daily intake of PFOS for a nursing infant in Sweden is estimated to be 121 ng/day if the maternal serum level is 20 ng/mL. Lactation is therefore a major exposure source for breast-fed infants. Monomethyl- and dimethyl-branched isomers of PFOS could be separated in human blood using high performance liquid chromatography (HPLC). Human plasma contains a smaller percentage of the linear PFOS compared to commercially available PFOS standard materials, which indicate isomer specific uptake and/or elimination. A difference in the isomer composition is also seen between the countries studied. Human blood from the UK and Australia have significantly lower amount of linear PFOS (59-60%) compared to Swedish blood (68%). This geographical variation suggests different human exposure sources and pathways.
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| 4. |
- Wide, Peter, 1972-
(författare)
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Neurogenic bladder and bowel dysfunction : Clinical aspects in children with spinal dysraphism
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Spinal dysraphism (SD) is a congenital malformation that to a varying extent, often severely, affects the life of the child and the family. Most individuals with SD suffer from neurogenic bladder and bowel dysfunction—with the risk of urinary tract infections, renal deterioration, urinary and fecal incontinence—that affects social participation and quality of life negatively. In newborns with SD, early detection of neurogenic bladder dysfunction and determination of post-void residual urine are required to determine the need of clean intermittent catheterization (CIC) and follow-up.The non-invasive method of four-hour voiding observation with provocation test (VOP) was used to evaluate bladder function in 50 newborn children with SD. Voiding patterns for the children were described and compared with those of 50 healthy newborns evaluated with VOP in an earlier study. Comparison revealed significant differences among several variables. In particular, leakage at provocation test and not voiding with a stream were common in newborns with SD but did not occur in healthy newborns. VOP is a non-invasive standardized method to determine residual urine in newborns with SD. It also adds information on voiding pattern, frequency, voiding with a stream and leakage at provocation.Findings in neonatal VOP of the same cohort of newborns with SD were then related to radiology, presence of urinary tract infections during the first year, and urodynamic findings and use of CIC at the age of one year. It was found that, in children with SD, not voiding with a stream may have a predictive value for the need of CIC at the age of one year, followed probably by lifelong CIC. Despite this, the presence of an open SD per se has stronger predictive value, and each child needs to be evaluated individually while considering a number of factors. The main value of VOP may be as a structured non-invasive screening method to uncover neurogenic bladder-sphincter dysfunction in the newborn. Studies with a larger number of subjects than the present are needed to evaluate the potential of VOP in newborns with closed spinal dysraphism in whom the neurological consequences vary.A retrospective analysis detected renal damage on DMSA scintigraphy in 5 of 41 children with SD who were followed according to a proactive national program with minimal use of surgery. Median follow-up time was 10 years. High baseline pressure was confirmed as a risk factor for renal damage. Compliance with treatment and follow-up is likely to be an important factor for renal health. Therefore, efforts to support children and their families are crucial. A questionnaire-based study of 107 children with SD (age 6–16y) in Sweden and Norway examined aspects of treatment for neurogenic bowel dysfunction focusing on incontinence, independence, general satisfaction and quality of life. It was found that transanal irrigation (TAI) and antegrade colonic enemas (ACE) are effective treatments, but are time-consuming and difficult to perform independently. The majority of children using TAI (72%) and ACE (63%) never went to the toilet alone to empty their bowels. As children achieving independence on the toilet reported higher quality of life, efforts to support independence are beneficial.Continent, self-managing children with healthy kidneys enjoy high quality of life and contribute more fully to society. Therefore, further research is required to investigate and develop existing and new technologies and methods that mitigate the problems related to SD, and to make them accessible to all children with spinal dysraphism.
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| 5. |
- Andersson, Lena, 1965-
(författare)
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Quartz in Swedish iron foundries : exposure and cancer risk
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aims of the studies underlying this thesis were to assess the exposure to quartz in Swedish iron foundries and to determine the cancer morbidity for Swedish foundry workers. A cohort of 3,045 foundry workers and a final measurement database of 2,333 number of samples was established.The exposure measurements showed high levels of respirable quartz, in particular for fettlers and furnace and ladle repair workers with individual 8 hr TWA (GM=0.041 and 0.052 mg/m3; range 0.004-2.1 and 0.0098-0.83 mg/m3). In our database, the quartz concentrations as 8hr TWAs of current and historical data varied between 0.0018 and 4.9 mg/m3, averaging 0.083 mg/m3, with the highest exposures for fettlers (0.087 mg/m3) and furnace and ladle repair workers (0.42 mg/m3). The exposure for workers using respirators assuming full effect when used were assessed quantitatively, revealing workers with actual exposure exceeding the occupational exposure limits.Overall cancer morbidity was not increased, but the incidence of lung cancer was significantly elevated (SIR 1.61; 95 % CI 1.20-2.12). In the cohort study, significant associations between lung cancer and cumulative quartz exposure were detected for quartz doses of 1-2 mg/m3 * year (SIR 2.88; 95 % CI 1.44-5.16) and >2 mg/m3 * year (SIR 1.68; 95 % CI 1.07- 2.52). These findings were not confirmed in the case-control analysis.The agreement between the estimated exposure in our early historical model and the development model showed a regression coefficient of 2.42, implying an underestimation of the historical exposure when using the development model data. The corresponding comparison between the development and the validation model based on our survey data showed a B of 0.31, implying an overestimation of present exposures when using data from the validation model.The main conclusions of the thesis are that certain foundry workers are still exposed to high levels of quartz, and the overall excess lung cancer could not be confirmed in the exposure-response analysis.
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| 6. |
- Holmgren, Eva, 1972-
(författare)
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Getting up when falling down : reducing fall risk factors after stroke through an exercise program
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The purpose of this thesis was to identify fall risk individuals (+55) after stroke by validating a fall risk index and in post-stroke individuals with high risk of falls evaluate the impact of an intervention program on fall risk factors.A previously developed fall risk index was validated, modified and re-validated. The validation showed a sensitivity of 97% and a specificity of 26%. This result was not considered sufficiently accurate. Therefore a modified index was created in the Validation sample and re-validated back in the Model fit sample. The modified index was reduced to three items and included postural stability + visuospatial hemi-inattention + male sex.The randomized controlled trial contained an intervention program (IP) with High-Intensity Functional Exercises as well as implementation these exercises in to real life situations together with educational group discussions. The participants were enrolled and randomized three to six months after their stroke. The assessments were performed at the Clinical Research Center at Norrlands University Hospital. The Intervention Group (IG) received a program of 35 sessions (exercise and group discussions) and the Control Group (CG) received five group discussions.Performing daily activities at 6 months follow-up and falls-efficacy post-intervention and at the 3 months follow-up showed significant improvement in the IG compared with the CG (p<0.05). The IP did not have a statistically significant impact on Balance or Lifestyle activities. When evaluating gait, step time variability for the paretic leg and the variability in Cycle Time for the paretic and non-paretic leg were improved for the IG. The time spent on the non –paretic leg in the gait cycles’ most stable phase, Double Support, was reduced by almost half (0.9 sec to 0.4 sec) since baseline for the IG after the intervention and remained reduced to the three month follow-up. Quality of Life showed an improvement in the CG compared with the IG for the mental scales, Mental Component Scale and Mental Health subscale at the 3 month follow-up (p=.02).In conclusion, this intervention program significantly improved performance of everyday life activities, falls-efficacy and the variability in gait. These are three major fall risk factors and might in the long run have an impact on decreasing falls in persons that had a stroke.
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| 7. |
- Holstein, Jane, 1970-
(författare)
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Cultural Competence for Health Professionals : Instrument Development
- 2019
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Licentiatavhandling (övrigt vetenskapligt/konstnärligt)abstract
- In recent decades, both global migration in general and specifically migration to Sweden have increased. This development compels the need for delivering healthcare to the increasingly diverse populations in Sweden. To support health professionals, for instance occupational therapists, in developing their professional knowledge in encounters with foreign-born clients a self-rating instrument measuring cultural competence is developed. This may contribute to the development of suitable services for foreignborn clients and improve person-centered interventions for these clients.The general aim of this thesis was to develop an instrument for health professionals by examining psychometric properties and utility of the Swedish version of the Cultural Competence Assessment Instrument (CCAI-S) among occupational therapists. The specific aim of study I was to evaluate the content validity and utility of the Swedish version of the Cultural Competence Assessment Instrument (CCAI-S) among occupational therapists. The study had a descriptive and explorative design. Nineteen occupational therapists participated, divided into four focus groups. Qualitative content analysis was used to examine the content validity and utility of the CCAI-S. The specific aim of study II was to examine the clinical relevance, construct validity and reliability of the Swedish version of the Cultural Competence Assessment Instrument (CCAI-S) among Swedish occupational therapists. The study had a cross-sectional design. A web-based questionnaire was e-mailed to a randomised sample of 428 occupational therapists to investigate the construct validity, reliability and utility of the CCAI-S. Factor analysis was performed as well as descriptive statistics.The findings from study I revealed high content validity for all 24 items. However, six items needed reformulations and exemplifications. Regarding utility, the results showed strong support for CCAI-S. The category ‘Interactions with clients’ showed that the CCAI-S could be utilised individually for the health professional and create a higher awareness of cultural questions in practice. The category ‘Workplace and its organisational support’ displayed potential for use in different workplaces regarding CCAI-S and indicated the importance of organisational support for health professionals in the development of cultural competence. The findings from study II regarding construct validity generated a three-factor model with the labels ‘Openness and awareness’, ‘Workplace support’ and ‘Interaction skills’. All three factors showed high factor loadings and contained 12 of the 24 original items. The Cronbach’s Alpha showed high support for the three-factor model. Concerning utility, the participants reported that all 24 items had high clinical relevance.In conclusion, the findings from the two studies indicated good measurement properties and high clinical relevance for the CCAI-S. This may sup-port the utilisation of CCAI-S in the Swedish context for health professionals, for instance occupational therapists. The results of the instrument development show that the upcoming published version of the CCAI-S can be a valuable self-assessment tool for health professionals who strive to improve in person-centred communication in encounters with foreign-born clients. CCAI-S can also be of support for the organisation to serve as a guide for what to focus on to develop cultural competence within the staff. Altogether this presumably influence the effectiveness of the healthcare and enhance the evidence of interventions for foreign-born clients. To develop an instrument is an iterative process requiring several evaluations and tests in various settings and populations. Therefore further psychometric testing and utility studies on the CCAI-S is crucial.
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| 8. |
- Joelsson, Tove
(författare)
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The influence of Pulp Type and Hot-pressing Conditions on Paper Strength Development
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The hot-pressing technology has proven to have the potential for manufacturing of strong, wet stable materials based on eco-friendly renewable and recyclable lignocellulose. The purpose of this work was to study how the pulp characteristics and the hot-pressing conditions affect the dry and wet strength properties of paper. Two different devices for hot-pressing were used. One using felted nip and a heated cylinder with a temperature limit at 200°C and one new design using a hard nip and an IR-heated steel belt with a temperature limit of 300°C.The results showed that dry strength can increase up to 150% for high yield pulp (HYP) based sheets at pressing temperatures well above the softening temperature of lignin. The maximum dry tensile strength obtained was 70 kNm/kg at 200°C pressing temperature and the corresponding value for a lignin-rich kraft pulp was about 130 kNm/kg, an increase of 30%. For all lignin-rich pulps the dry strength increased linearly with density up to 200°C whereafter it levelled off and was reduced.The wet tensile strength for paper based on HYP increase from 2 to 28 kNm/kg and for paper based on unbleached kraft pulp from 5 up to 60 kNm/kg in the temperature interval 20-270°C. The increase in wet strength independently of pulp grade seemed to be exponential to the pressing temperature with the steepest slope above 150°C. For unbleached kraft pulp a lignin content of minimum 7% seemed to be necessary for improved wet strength but 12% gave the highest value within the studied interval. In HYPs the lignin content is 25-28% depending on the pulping process but the level of wet strength was lower which is probably related to the lower density and lower dry strength compared to unbleached kraft pulps.Dry strength of lignin-rich paper is enhanced by improved fibre-fibre contact that can be improved by compression at high temperature, well above softening temperature (Tg) of moist lignin, native or chemically modified. It is known that sulfonation of lignin lowers the Tg in moist conditions. It was observed that at 150°C temperature the dry strength increased by 15% to a level of 71 kNm/kg for the high sulfonated pulp compared to the lower sulfonated pulp that had a dry strength of 60 kNm/kg at the same density. The level of wet strength was however not found to be affected by the sulfonation.Paper strength is to a large extent related to pulp fibre morphology and fines content. In this work studied these aspects where briefly studied with respect to hot-pressing and the results indicate that the relative influence of fibre morphology seems to be reduced with increasing pressing temperature. Hot-pressed sheets based on a coarse fines free fibre fraction showed 100% dry strength increase and wet strength increase up to 20 kNm/kg. The dry and wet strength were however also shown to be favoured by the presence of fines fraction.Wet strength development as a function of temperature was fitted to an Arrhenius type of equation and activation energies were found to be similar for very different pulp grades provided that the lignin content is above 7%. This could indicate that the process(es) giving wet strength were similar.It was found that the ratio wet:dry strength was about 35-60% for all lignin containing pulp grades. A rule of thumb for an efficient wet strength resin is that the wet: dry strength ratios are 15%. This means that it should be possible to manufacture wet-strong paper from lignin-rich pulps by means of hot-pressing without using wet strength chemicals. The concern regarding repulpability of such material led to an initial test to disintegrate this paper showing that re-pulping under vigorous mixing at room temperature is possible.The connection between dry and wet strength, high pressing temperature, and lignin content of pulp fibres is suggested to be related to some redistribution mechanisms of surface lignin between adjacent fibres. The improved wet strength and water resistance could be due to intermixing of lignin polymers across the interface between contacting fibre surfaces, or it could be lignin sufficient to cover the fibre-fibre bonds and/or chemical modifications, but these remain open questions.
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| 9. |
- Näsström, Gunilla, 1968-
(författare)
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Measurement of alignment between standards and assessment
- 2008
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Many educational systems of today are standards-based and aim at for alignment, i.e. consistency, among the components of the educational system: standards, teaching and assessment. To conclude whether the alignment is sufficiently high, analyses with a useful model are needed. This thesis investigates the usefulness of models for analyzing alignment between standards and assessments, with emphasis on one method: Bloom’s revised taxonomy. The thesis comprises an introduction and five articles that empirically investigate the usefulness of methods for alignment analyses.In the first article, the usefulness of different models for analyzing alignment between standards and assessment is theoretically and empirically compared based on a number of criteria. The results show that Bloom’s revised taxonomy is the most useful model. The second article investigates the usefulness of Bloom’s revised taxonomy for interpretation of standards in mathematics with two differently composed panels of judges. One panel consisted of teachers and the other panel of assessment experts. The results show that Bloom’s revised taxonomy is useful for interpretation of standards, but that many standards are multi-categorized (placed in more than one category). The results also show higher levels of intra- and inter-judge consistency for assessment experts than for teachers. The third article further investigates the usefulness of Bloom’s revised taxonomy for analyses of alignment between standards and assessment. The results show that Bloom’s revised taxonomy is useful for analyses of both standards and assessments. The fourth article studies whether vague and general standards can explain the large proportion of multi-categorized standards in mathematics. The strategy was to divide a set of standards into smaller substandards and then compare the usefulness and inter-judge consistency for categorization with Bloom’s revised taxonomy for undivided and divided standards. The results show that vague and general standards do not explain the large proportion of multi-categorized standards. Another explanation is related to the nature of mathematics that often intertwines conceptual and procedural knowledge. This was also studied in the article and the results indicate that this is a probable explanation. The fifth article focuses on another aspect of alignment between standards and assessment, namely the alignment between performance standards and cut-scores for a specific assessment. The validity of two standard-setting methods, the Angoff method and the borderline-group method, was investigated. The results show that both methods derived reasonable and trustworthy cut-scores, but also that there are potential problems with these methods.In the introductory part of the thesis, the empirical studies are summarized, contextualized and discussed. The discussion relates alignment to validity issues for assessments and relates the obtained empirical results to theoretical assumptions and applied implications. One conclusion of the thesis is that Bloom’s revised taxonomy is useful for analyses of alignment between standards and assessments. Another conclusion is that the two standard setting methods derive reasonable and trustworthy results. It is preferable if an alignment model can be used both for alignment analyses and in ongoing practice for increasing alignment. Bloom’s revised taxonomy has the potential for being such an alignment model. This thesis has found this taxonomy useful for alignment analyses, but its’ usefulness for increasing alignment in ongoing practice has to be investigated.
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| 10. |
- Ernersson, Åsa
(författare)
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Hyper-alimentation - effects on health and well-being.
- 2010
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The general aim of this thesis was to prospectively examine the effects on health and well-being when healthy normal weight individuals increase their energy intake, mainly from fast food and simultaneously adopt a sedentary lifestyle.This thesis is based upon a prospective experimental study design where 18 healthy normal weight individuals, 12 men and 6 women, aged 26 (6.6) years, increased their energy intake with in average 70 % during four weeks. Simultaneously their physical activity was limited to a maximum of 5000 steps per day. An age and gender matched control group (n=18), was recruited and asked not to change their eatingand physical activity habits for four weeks. Long-term follow-up measurements were performed after 6 and 12 months and 2.5 years after the intervention.During the intervention body weight increased with 6.4 (2.8) kg and measurements of body composition showed an increase of both fat mass and fat free mass after the intervention. Lower physical and mental health scores on SF-36 as well as depressive symptoms were found compared to baseline. They were temporary and when followed up 6 and 12 months after the intervention, physical and mental health had returned to baseline values, despite a somewhat increased body weight. The main essence of adopting an obesity provoking behaviour was lack of energy emerging from five structures: influenced self-confidence, commitment to oneself and others, managing eating, feelings of tiredness and physical impact. Laboratory measurements showed an increase of ALT above reference limits in 14 of the 18 participants during the intervention and HTGC increased, although this was not related to the increase in ALT levels. Twelve months after the intervention an increase of body weight with 1.5 (2.4) kg was found compared to baseline (p=0.018), fat free mass was unchanged compared to baseline while fat mass had increased, + 1.4 (1.9) kg (p=0.01). Two and a half years after the intervention an increase of body weight with 3.1 (4.0) kg was found compared to baseline (p=0.01), while there was no change in controls compared to baseline, + 0.1 (2.5) kg (p=0.88).Hyper-alimentation and limited physical activity during a short-term period of 4 weeks is sufficient to temporarily induce worsened HRQoL, cause depressive symptoms and lack of energy in healthy normal weight individuals. There were also temporary but clear effects on biochemical markers, suggesting that hyperalimentation per se can induce profound ALT elevations in less than 4 weeks. During the intervention both fat mass and fat-free mass increased while after 12 months there was only an increase of fat mass which was greater than expected from epidemiological studies. The marked difference between the increase in body weight in the intervention- and control group at 2.5 years also raises the question whether there is a long-term effect of increasing fat mass after a short period of hyperalimentation.
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