Inactivation of the von Hippel-Lindau tumor suppressor leads to selective expression of a human endogenous retrovirus in kidney cancer.

A human endogenous retrovirus type E (HERV-E) was recently found to be selectively expressed in most renal cell carcinomas (RCCs). Importantly, antigens derived from this provirus are immunogenic, stimulating cytotoxic T cells that kill RCC cells in vitro and in vivo. Here, we show HERV-E expression is restricted to the clear cell subtype of RCC (ccRCC) characterized by an inactivation of the von Hippel-Lindau (VHL) tumor-suppressor gene with subsequent stabilization of hypoxia-inducible transcription factors (HIFs)-1α and -2α. HERV-E expression in ccRCC linearly correlated with HIF-2α levels and could be silenced in tumor cells by either transfection of normal VHL or small interfering RNA inhibition of HIF-2α. Using chromatin immunoprecipitation, we demonstrated that HIF-2α can serve as transcriptional factor for HERV-E by binding with HIF response element (HRE) localized in the proviral 5' long terminal repeat (LTR). Remarkably, the LTR was found to be hypomethylated only in HERV-E-expressing ccRCC while other tumors and normal tissues possessed a hypermethylated LTR preventing proviral expression. Taken altogether, these findings provide the first evidence that inactivation of a tumor suppressor gene can result in aberrant proviral expression in a human tumor and give insights needed for translational research aimed at boosting human immunity against antigenic components of this HERV-E.

Early diagnosis improves survival in kidney cancer

Kidney cancers account for 2-3% of all adult malignancies in the UK. Men are predominantly affected by renal cancer with an average age at diagnosis of 64 years. Renal (or clear) cell carcinoma (RCC) accounts for 90% of kidney cancers. Early diagnosis improves survival with five-year survival rates for renal cancer of 70-94% for localised tumours in the UK. RCC should be suspected in the presence of localising symptoms such as flank pain, a loin mass or haematuria; constitutional upset including weight loss, pyrexia and/or night sweats; or with unexplained laboratory tests. Smoking, obesity and hypertension are the most important and most common risk factors. Environmental exposure to asbestos, cadmium and trichloroethylene are less common risk factors. Patients on chronic dialysis and renal transplant recipients are at increased risk of RCC in their native kidneys. If kidney cancer is suspected on history, physical examination or initial screening tests then a red flag ultrasound examination of the renal tracts should be requested. Dipstick urinalysis is of great value as asymptomatic haematuria may be the only abnormal test in the presence of non-specific symptoms such as weight loss or loin pain. Visible or non-visible haematuria, in the absence of proteinuria, suggests an underlying structural abnormality is present in the kidneys, ureters or bladder. Surgical removal of RCCs, where feasible, may result in cure in up to 40-60% of cases. Individuals too frail for major surgery may benefit from thermal ablation and cryotherapy. Agents that target the VEGF and mTOR pathways are considered first line in the treatment of metastatic RCC. Sunitinib, recommended by NICE, is administered orally and acts by inhibiting the VEGF receptor.

Genetically Engineered Oncolytic Adenoviruses for the Treatment of Kidney and Breast Cancer

Metastatic kidney and breast cancer are devastating diseases currently lacking efficient treatment options. One promising developmental approach in cancer treatment are oncolytic adenoviruses, which have demonstrated excellent safety in many clinical trials. However, antitumor efficacy needs to be improved in order to make oncolytic viruses a viable treatment alternative. To be able to follow oncolytic virus replication in vivo, we set up a non-invasive imaging system based on coinjection of a replication deficient luciferase expressing virus and a replication competent virus. The system was validated in vitro and in vivo and used in other projects of the thesis. In another study we showed that capsid modifications on adenoviruses result in enhanced gene transfer and increased oncolytic effect on renal cancer cells in vitro. Moreover, capsid modified oncolytic adenoviruses demonstrated significantly improved antitumor efficacy in murine kidney cancer models. To transcriptionally target kidney cancer tissue we evaluated two hypoxia response elements for their usability as tissue specific promoters using a novel dual luciferase imaging system. Based on the results of the promoter evaluation and the studies on capsid modifications, we constructed a transcriptionally and transductionally targeted oncolytic adenovirus armed with an antiangiogenic transgene for enhanced renal cell cancer specificity and improved antitumor efficacy. This virus exhibited kidney cancer specific replication and significantly improved antitumor effect in a murine model of intraperitoneal disseminated renal cell cancer. Cancer stem cells are thought to be resistant to conventional cancer drugs and might play an important role in breast cancer relapse and the formation of metastasis. Therefore, we examined if capsid modified oncolytic adenoviruses are able to kill these cells proposed to be breast cancer initiating. Efficient oncolytic effect and significant antitumor efficacy on tumors established with breast cancer initiating cells was observed, suggesting that oncolytic adenoviruses might be able to prevent breast cancer relapse and could be used in the treatment of metastatic disease. In conclusion, the results presented in this thesis suggest that genetically engineered oncolytic adenoviruses have great potential in the treatment of metastatic kidney and breast cancer.

Cancer mortality in IBM endicott plant workers, 1969-2001: An update on a NY production plant

BACKGROUND: In response to concerns expressed by workers at a public meeting, we analyzed the mortality experience of workers who were employed at the IBM plant in Endicott, New York and died between 1969-2001. An epidemiologic feasibility assessment indicated potential worker exposure to several known and suspected carcinogens at this plant. METHODS: We used the mortality and work history files produced under a court order and used in a previous mortality analysis. Using publicly available data for the state of New York as a standard of comparison, we conducted proportional cancer mortality (PCMR) analysis. RESULTS: The results showed significantly increased mortality due to melanoma (PCMR = 367; 95% CI: 119, 856) and lymphoma (PCMR = 220; 95% CI: 101, 419) in males and modestly increased mortality due to kidney cancer (PCMR = 165; 95% CI: 45, 421) and brain cancer (PCMR = 190; 95% CI: 52, 485) in males and breast cancer (PCMR = 126; 95% CI: 34, 321) in females. CONCLUSION: These results are similar to results from a previous IBM mortality study and support the need for a full cohort mortality analysis such as the one being planned by the National Institute for Occupational Safety and Health.

Concomitant and antecedent deep venous thrombosis and cancer survival in male US veterans

Survival is reportedly worse in patients with cancer concurrently diagnosed with deep venous thrombosis. However, information on specific malignancies is limited. From a cohort study of male US veterans we identified incident cancer cases (n aEuroS== aEuroS412 008) and compared survival patterns among those with versus without a history of deep venous thrombosis. Using Cox proportional hazard models, we estimated hazard ratios (HRs) and 95%% confidence intervals as measures of the relative risk of dying. Individuals with (versus without) a concomitant deep venous thrombosis and cancer diagnosis had a higher risk of dying (HR aEuroS== aEuroS1.38; 1.28--1.49). The most prominent excess mortality (HR aEuroS== aEuroS1.29--2.55) was observed among patients diagnosed with deep venous thrombosis at the time of diagnosis of lung, gastric, prostate, bladder, or kidney cancer. Increased risk of dying was also found among cancer patients diagnosed with deep venous thrombosis 1 year (HR aEuroS== aEuroS1.14; 1.07--1.22), 1--5 years (HR aEuroS== aEuroS1.14; 1.10--1.19), and > 5 years (HR aEuroS== aEuroS1.27; 1.23--1.31) before cancer; this was true for most cancer sites (HR aEuroS== aEuroS1.17--1.64). In summary, antecedent deep venous thrombosis confers a worse prognosis upon cancer patients. Advanced stage at diagnosis, treatment effects, lifestyle factors, and comorbidity could explain differences by cancer site and time frame between a prior deep venous thrombosis diagnosis and cancer outcome.

Renal cell cancer:Nurses' role in prevention and management

In both the UK and throughout Europe, more patients are presenting with renal cell cancer (RCC), also known as renal cell carcinoma or kidney cancer. The overall survival rate varies depending on tumour grade, nodal involvement and metastasis. For those with metastasis survival drops to 10%. This article explores the risk factors associated with RCC diagnosis and staging, treatments including drugs and procedures and the role of the nurse in diagnosis and accurate assessment. Nurses are ideally suited to consider the physical, functional, social, and emotional status of their patients In addition, it is essential that the nurse has an understanding of new pharmaceutical therapies, which have been licensed to treat RCC, and a sound knowledge of the possible side effects and nursing management associated with these drugs.

Caractérisation de DKK1 comme antigène tumoral et manipulation des lymphocytes T CD8 : utilisation de la voie de Wnt en immunothérapie du cancer

L’immunothérapie tumorale à médiation cellulaire est un traitement qui utilise le système immunitaire des patients afin d’induire une réponse des lymphocytes T CD8+ (T CD8+) contre la tumeur. Cette réponse est produite suite à la reconnaissance des antigènes par les T CD8+. Ces cibles sont appelées antigènes tumoraux (TAA) et définies comme des protéines exprimées par les cellules cancéreuses mais absentes des tissus normaux. Par une approche bio-informatique, notre laboratoire a identifié Dickkopf-1 (DKK1), une protéine inhibitrice de la voie de Wnt, comme un TAA potentiel. Une immunothérapie à médiation cellulaire efficace requiert l’identification de TAA candidats pertinents. Le traitement de patients par immunothérapie pourrait également être améliorées par l’augmentation de la puissance d’action anti-tumorale ainsi que la persistante des T CD8+ spécifiques aux TAA. Ce projet de doctorat se divise en deux parties : 1- La caractérisation de l’expression de DKK1 dans les cancers communs et la détermination de son immunogénicité afin de valider sa candidature comme TAA. 2- La reprogrammation des T CD8+, de patients atteints d’un cancer commun, vers un phénotype moins différentié afin d’augmenter leur potentiel anti-tumoral et leur persistance. Dans le premier objectif, nous avons caractérisé l’expression de DKK1 dans le cancer du sein et dans d’autres cancers communs. Le profil d’expression de DKK1 a été étudié par RT-PCR et par ELISA dans plusieurs lignées cellulaires de cancer et dans les tissus normaux. L’expression de DKK1 a aussi été étudiée dans des échantillons cliniques provenant de cancers du sein, du poumon et du rein. Trente pourcents (30%) des tumeurs provenant d’un cancer du sein exprimaient DKK1. La moitié des tumeurs DKK1(+) était triple négative, donc pas de récepteurs d’œstrogène et de progestérone et était Her-2/neu(-) (ces patientes ont des possibilités de traitements très restreintes). De plus, 50% des échantillons cliniques de tumeurs du poumon et 30% des tumeurs de rein exprimaient DKK1. Les observations effectuées dans le cancer du poumon ont été, par la suite, corroborées par d'autres groupes qui ont montré une corrélation entre l'expression de DKK1 et un mauvais pronostic. Après avoir confirmée l’expression de DKK1 dans les cancers communs, justifiant ainsi sa candidature comme TAA, nous avons évalué l’immunogénicité de DKK1. Pour ce faire, nous avons effectué des stimulations in vitro de cellules mononucléées du sang périphérique (PBMC) de patient(e)s atteint(e)s d’un cancer du sein ou du poumon avec des peptides dérivés de DKK1 pouvant être présentés par les complexes majeurs d’histocompatibilité (CMH) HLA-A*0201. Des clones de T CD8+ reconnaissant un peptide de DKK1 ont été identifiés et isolés. Par essai multiplex et cytométrie de flux intracellulaire, la polyfonctionnalité d’un ces clones T CD8+ spécifiques à DKK1 a été étudiée et a révélée un profil effecteur, renforçant ainsi la candidature de DKK1 comme TAA. Dans l’ensemble, les résultats obtenus dans cette première partie de thèse suggèrent une possible utilisation de DKK1 en immunothérapie contre les cancers communs, attribuable à son expression dans ces cancers et la possibilité de faire proliférer des T CD8+ effecteurs spécifiques à DKK1 à partir de sang de patients. Dans la seconde partie de cette thèse, je décrirai la manipulation in vitro des T CD8+ de patients atteints d’un cancer commun, afin d’augmenter la force et la durée de leurs fonctions anti-tumorales. Il a été démontré que des lymphocytes moins différentiés sont capables d’une réponse immunologique plus efficace et durable. Nous avons basé ce projet sur l’utilisation d’un inhibiteur pharmacologique de la GSK-3, pour activer de la voie de Wnt chez les T CD8+ et ainsi leur conférer un phénotype moins différentié, partageant des caractéristiques de la cellule naïve et de la cellule mémoire. Des cultures de T CD8+, spécifiques à des antigènes viraux, en présence de l’inhibiteur ont permis d’augmenter la sécrétion d’interféron (IFN)- et leur activité cytotoxique. Ces résultats indiquent un effet de l’activation de la voie de Wnt sur la fonction des T CD8+. Ces observations sont rapportées pour la première fois chez les T CD8+ humains et suggèrent une nouvelle stratégie, applicables à l’immunothérapie du cancer, afin de prolonger la persistance des cellules ainsi que leur activité anti-tumorale. En conclusion, ces travaux de recherche ont mené à la réalisation d’une étape très importante dans la validation de la candidature de DKK1 comme TAA pour les cancers communs, soit la démonstration de son expression dans ces cancers et son absence dans les tissus normaux dérivés d’organes importants. Ces travaux ont également mené à la démonstration de l’immunogénicité de DKK1, par l’identification d’un peptide de DKK1 reconnu par les T CD8+. De plus, l’étude de la polyfonctionnalité des T CD8+ spécifiques à DKK1 a révélée un profil effecteur favorable pour l’obtention d’une réponse anti-tumorale efficace. Ces découvertes pourraient servir à l’élaboration d’une stratégie d’immunothérapie à médiation cellulaire pour les cancers communs. Pour sa part, l’étude phénotypique et fonctionnelle de la modulation de la voie de Wnt dans les T CD8+ a donné lieu à l’observation d’un phénotype encore jamais rapporté chez l’humain, conférant aux T CD8+ un aspect moins différentié avec des caractéristiques propre à un phénotype mémoire. Ces résultats sont pertinents dans l’amélioration de l’immunothérapie du cancer, passant par l’augmentation de la persistance des lymphocytes. En résumé, les résultats présentés dans cette thèse de doctorat fournissent des évidences indéniables quant à la validation de DKK1 comme TAA pour une immunothérapie à médiation cellulaire des cancers communs. Ces résultats fournissent également des preuves quant à la pertinence de la reprogrammation des T CD8+ par l’activation de la voie de la voie de Wnt, afin de générer des lymphocytes médiateurs plus efficaces pour ce type de thérapie.

Bioorganometallic fulvene-derived titanocene anti-cancer drugs

A review. 6-Substituted fulvenes are interesting and easily accessible starting materials for the synthesis of novel substituted titanocenes via reductive dimerization, carbolithiation or hydridolithiation reactions, which are followed by a transmetallation reaction with titanium tetrachloride in the latter two cases. Depending on the substitution pattern, these titanocenes prove to be bioorganometallic anticancer drugs, which have significant potential against advanced or metastatic renal-cell cancer. Patients bearing these stages of kidney cancer have a poor prognosis so far and therefore real progress in the area of metal-based anticancer drugs may come from this simple and effective synthetic approach. This tutorial review provides an insight into the synthesis of fulvene-derived titanocenes and their activity in preclin. expts.

Inherited susceptibility to uterine leiomyomas and renal cell cancer

Herein we report the clinical, histopathological, and molecular features of a cancer syndrome with predisposition to uterine leiomyomas and papillary renal cell carcinoma. The studied kindred included 11 family members with uterine leiomyomas and two with uterine leiomyosarcoma. Seven individuals had a history of cutaneous nodules, two of which were confirmed to be cutaneous leiomyomatosis. The four kidney cancer cases occurred in young (33- to 48-year-old) females and displayed a unique natural history. All these kidney cancers displayed a distinct papillary histology and presented as unilateral solitary lesions that had metastasized at the time of diagnosis. Genetic-marker analysis mapped the predisposition gene to chromosome 1q. Losses of the normal chromosome 1q were observed in tumors that had occurred in the kindred, including a uterine leiomyoma. Moreover, the observed histological features were used as a tool to diagnose a second kindred displaying the phenotype. We have shown that predisposition to uterine leiomyomas and papillary renal cell cancer can be inherited dominantly through the hereditary leiomyomatosis and renal cell cancer (HLRCC) gene. The HLRCC gene maps to chromosome 1q and is likely to be a tumor suppressor. Clinical, histopathological, and molecular tools are now available for accurate detection and diagnosis of this cancer syndrome.

Protein kinase C activation and its role in kidney disease

Protein kinase C (PKC) comprises a superfamily of isoenzymes, many of which are activated by cofactors such as diacylglycerol and phosphatidylserine. In order to be capable of activation, PKC must first undergo a series of phosphorylations. In turn, activated PKC phosphorylates a wide variety of intracellular target proteins and has multiple functions in signal transduced cellular regulation. A role for PKC activation had been noted in several renal diseases, but two that have had most investigation are diabetic nephropathy and kidney cancer. In diabetic nephropathy, an elevation in diacylglycerol and/or other cofactor stimulants leads to an increase in activity of certain PKC isoforms, changes that are linked to the development of dysfunctional vasculature. The ability of isoform-specific PKC inhibitors to antagonize diabetes-induced vascular disease is a new avenue for treatment of this disorder. In the development and progressive invasiveness of kidney cancer, increased activity of several specific isoforms of PKC has been noted. It is thought that this may promote the kidney cancer's inherent resistance to apoptosis, in natural regression or after treatments, or it may promote the invasiveness of renal cancers via cellular differentiation pathways. In general, however, a more complete understanding of the functions of individual PKC isoforms in the kidney, and development or recognition of specific inhibitors or promoters of their activation, will be necessary to apply this knowledge for treatment of cellular dysregulation in renal disease.

Increasing BMI was associated with increasing risk for overall cancer incidence and mortality in middle-aged women

Question: In middle-aged women, what is the association between body mass index (BMI) and cancer incidence and mortality?METHODSDesign: Prospective cohort study with mean follow-up of 5.4 years for cancer incidence and 7.0 years for cancer mortality.Setting: Population-based study in England and Scotland, United Kingdom.Patients: 1 222 630 women 55 to 64 years of age (mean 56 y) who had no history of cancer at baseline.Risk factors: BMI at baseline, divided into 5 categories (< 22.5, 22.5 to 24.9, 25.0 to 27.4, 27.5 to 29.9, and ≥ 30 kg/m2).Outcomes: Cancer incidence and mortality, overall and for 17 specific types of cancer, identified through linkage with the National Health Service central registers.Main results: Increasing BMI was associated with increasing risks for all cancers, endometrial cancer, esophageal adenocarcinoma, kidney cancer, leukemia, postmenopausal breast cancer, multiple myeloma, pancreatic cancer, non-Hodgkin lymphoma, and ovarian cancer; and with decreasing risks for esophageal squamous cell carcinoma, lung cancer, and premenopausal breast cancer (Table). Risks for stomach, colorectal, cervical, bladder, and brain cancer and malignant melanoma did not vary by BMI. Patterns for cancer mortality were similar to those for cancer incidence: Relative risk for death from any type of cancer was 1.06 (95% CI 1.02 to 1.10) per 10-unit increase in BMI. In postmenopausal women, the estimated proportion of cancer attributable to being overweight or obese (BMI ≥ 25 kg/m2) was 5% for all cancers and about 50% for endometrial cancer and esophageal adenocarcinoma.Conclusions: In middle-aged women, increasing body mass index was associated with increasing risk for cancer incidence and mortality overall. High body mass index increased risk for some types of cancer but reduced risk for other types.

Histone deacetylase inhibitors target diabetes via chromatin remodeling or as chemical chaperones?

Globally, obesity and diabetes (particularly type 2 diabetes) represents a major challenge to world health. Despite decades of intense research efforts, the genetic basis involved in diabetes pathogenesis & conditions associated with obesity are still poorly understood. Recent advances have led to exciting new developments implicating epigenetics as an important mechanism underpinning diabetes and obesity related disease. One epigenetic mechanism known as the "histone code" describes the idea that specific patterns of post-translational modifications to histones act like a molecular "code" recognised and used by non-histone proteins to regulate specific chromatin functions. One modification which has received significant attention is that of histone acetylation. The enzymes which regulate this modification are described as lysine acetyltransferases or KATs and histone deacetylases or HDACs. Due to their conserved catalytic domain HDACs have been actively targeted as a therapeutic target. Some of the known inhibitors of HDACs (HDACi) have also been shown to act as "chemical chaperones" to alleviate diabetic symptoms. In this review, we discuss the available evidence concerning the roles of HDACs in regulating chaperone function and how this may have implications in the management of diabetes. © 2009 Bentham Science Publishers Ltd.

Nephrotoxicity and nephrocarcinogenicity of dinitrotoluene : new aspects to be considered

Technical dinitrotoluene (DNT) is a mixture of 2,4- and 2,6-DNT. In humans, industrial or environmental exposure can occur orally, by inhalation, or by skin contact. The classification of DNT as an 'animal carcinogen' is based on the formation of malignant tumors in kidneys, liver, and mammary glands of rats and mice. Clear signs of toxic nephropathy were found in rats dosed with DNT, and the concept was derived of an interrelation between renal toxicity and carcinogenicity. Recent data point to the carcinogenicity of DNT on the urinary tract of exposed humans. Between 1984 and 1997, 6 cases of urothelial cancer and 14 cases of renal cell cancer were diagnosed in a group of 500 underground mining workers in the copper mining industry of the former GDR and having high exposures to explosives containing technical DNT. The incidences of both urothelial and renal cell tumors in this group were 4.5 and 14.3 times higher, respectively, than anticipated on the basis of the cancer registers of the GDR. The genotyping of all identified tumor patients for the polymorphic enzymes NAT2, GSTM1, and GSTT1 identified the urothelial tumor cases as exclusively 'slow acetylates'. A group of 161 miners highly exposed to DNT was investigated for signs of subclinical renal damage. The exposures were categorized semi-quantitatively into 'low', 'medium', 'high', and 'very high'. A straight dose-dependence of the excretion of urinary biomarker proteins with the ranking of exposure was seen. Biomarker excretion (alpha1-microglobulin, glutathione S-transferases alpha and pi) indicated that DNT-induced damage was directed toward the tubular system. New data on DNT-exposed humans appear consistent with the concept of cancer initiation by DNT isomers and the subsequent promotion of renal carcinogenesis by selective damage to the proximal tubule. The differential pathways of metabolic activation of DNT appear to apply to the proximal tubule of the kidney and to the urothelium of the renal pelvis and lower urinary tract as target tissues of carcinogenicity.

Genetic susceptibility to environmental toxicants : the interface between human and experimental studies in the development of new toxicological concepts

The growing knowledge of the genetic polymorphisms of enzymes metabolising xenobiotics in humans and their connections with individual susceptibility towards toxicants has created new and important interfaces between human epidemiology and experimental toxicology. The results of molecular epidemiological studies may provide new hypotheses and concepts, which call for experimental verification, and experimental concepts may obtain further proof by molecular epidemiological studies. If applied diligently, these possibilities may be combined to lead to new strategies of human-oriented toxicological research. This overview will present some outstanding examples for such strategies taken from the practically very important field of occupational toxicology. The main focus is placed on the effects of enzyme polymorphisms of the xenobiotic metabolism in association with the induction of bladder cancer and renal cell cancer after exposure to occupational chemicals. Also, smoking and induction of head and neck squamous cell cancer are considered.

Estimating the burden of disease attributable to excess body weight in South Africa in 2000

Objective. To estimate the burden of disease attributable to excess body weight using the body mass index (BMI), by age and sex, in South Africa in 2000. Design. World Health Organization comparative risk assessment (CRA) methodology was followed. Re-analysis of the 1998 South Africa Demographic and Health Survey data provided mean BMI estimates by age and sex. Populationattributable fractions were calculated and applied to revised burden of disease estimates. Monte Carlo simulation-modelling techniques were used for the uncertainty analysis. Setting. South Africa. Subjects. Adults 30 years of age. Outcome measures. Deaths and disability-adjusted life years (DALYs) from ischaemic heart disease, ischaemic stroke, hypertensive disease, osteoarthritis, type 2 diabetes mellitus, and selected cancers. Results. Overall, 87% of type 2 diabetes, 68% of hypertensive disease, 61% of endometrial cancer, 45% of ischaemic stroke, 38% of ischaemic heart disease, 31% of kidney cancer, 24% of osteoarthritis, 17% of colon cancer, and 13% of postmenopausal breast cancer were attributable to a BMI 21 kg/m2. Excess body weight is estimated to have caused 36 504 deaths (95% uncertainty interval 31 018 - 38 637) or 7% (95% uncertainty interval 6.0 - 7.4%) of all deaths in 2000, and 462 338 DALYs (95% uncertainty interval 396 512 - 478 847) or 2.9% of all DALYs (95% uncertainty interval 2.4 - 3.0%). The burden in females was approximately double that in males. Conclusions. This study shows the importance of recognising excess body weight as a major risk to health, particularly among females, highlighting the need to develop, implement and evaluate comprehensive interventions to achieve lasting change in the determinants and impact of excess body weight.