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Physician practices related to use of BMI-for-age and counseling for childhood obesity prevention: A cross-sectional study
Holly R Wethington1,
Bettylou Sherry1 &
Barbara Polhamus1
Screening for obesity and providing appropriate obesity-related counseling in the clinical setting are important strategies to prevent and control childhood obesity. The purpose of this study is to document pediatricians (PEDs) and general practitioners (GPs) with pediatric patients use of BMI-for-age to screen for obesity, confidence in explaining BMI, access to referral clinics, and characteristics associated with screening and counseling to children and their caregivers.
The authors used 2008 DocStyles survey data to examine these practices at every well child visit for children aged two years and older. Counseling topics included: physical activity, TV viewing time, energy dense foods, fruits and vegetables, and sugar-sweetened beverages. Chi-square tests were used to examine differences in proportions and logistic regression to identify characteristics associated with screening and counseling.
The final analytic sample included 250 PEDs and 621 GPs. Prevalence of using BMI-for-age to screen for obesity at every well child visit was higher for PEDs than GPs (50% vs. 22%, χ2 = 67.0, p ≤ 0.01); more PEDs reported being very/somewhat confident in explaining BMI (94% vs. GPs, 87%, p < 0.01); more PEDs reported access to a pediatric obesity specialty clinic for referral (PEDs = 65% vs. GPs = 42%, χ2 = 37.5, p ≤ 0.0001).
In general, PEDs reported higher counseling prevalence than GPs. There were significant differences in the following topics: TV viewing (PEDs, 79% vs. GPs, 61%, χ2 = 19.1, p ≤ 0.0001); fruit and vegetable consumption (PEDs, 87% vs. GPs, 78%, χ2 = 6.4, p ≤ 0.01). The only characteristics associated with use of BMI for GPs were being female (OR = 2.3, 95% CI = 1.5-3.5) and serving mostly non-white patients (OR = 1.8, 95% CI = 1.1-2.9); there were no significant associations for PEDs.
The findings for use of BMI-for-age, counseling habits, and access to a pediatric obesity specialty clinic leave room for improvement. More research is needed to better understand why BMI-for-age is not being used to screen at every well child visit, which may increase the likelihood overweight and obese patients receive counseling and referrals for additional services. The authors also suggest more communication between PEDs and GPs through professional organizations to increase awareness of existing resources, and to enhance access and referral to pediatric obesity specialty clinics.
Obesity in youth is a significant public health problem; almost 17% of children and adolescents 2-19 years are obese based on 2007-08 estimates [1]. To address overweight and obesity, the American Academy of Pediatrics (AAP), the US Preventive Services Task Force, and the Expert Committee on Childhood Obesity, comprised of representatives from professional organizations, experienced scientists and clinicians, recommend using BMI-for-age to screen for overweight and obesity in children ages two years and over, and also counseling on behaviors such as nutrition and physical activity [2–5]. Primary care providers with pediatric patients are well suited to screen for overweight and obesity and counsel on health-related behaviors; however, previous research has shown primary care providers are not routinely screening for overweight and obesity using BMI-for-age [6, 7].
Using BMI-for-age increases the likelihood that pediatricians will identify overweight or obesity status in youth [6, 8]. Furthermore, of all overweight or obese youth, those identified as overweight or obese were more likely to receive nutrition and physical activity counseling [6, 9, 10] and appropriate treatment [11, 12]. Identifying overweight or obese children and adolescents is important because they are at an increased risk for several cardiovascular disease risk factors and type II diabetes compared to normal weight children and adolescents [13, 14]. Furthermore, childhood obesity can increase the likelihood of adult obesity [15, 16].
The purpose of the study was to determine the proportion of pediatricians (PEDs) and general practitioners (GPs) with pediatric patients who 1) screen for obesity using BMI-for-age at every well child visit; 2) are confident in explaining BMI-for-age results to children and their parents, 3) have access to a pediatric obesity specialty clinic; and 4) counsel on physical activity, TV viewing time, intake of energy dense foods (i.e., the amount of energy (kilocalories or kcal) in a gram (g) of food [17]; foods with lower energy density such as raw carrots have fewer kilocalories per gram than those with higher energy density, such as French fries), fruits and vegetables, and sugar-sweetened beverages. The investigators tested for differences in use of BMI-for-age and counseling habits between PEDs and GPs. It was hypothesized that PEDs would screen and counsel more than GPs, thus differences may indicate a need for general or family practice residency programs or continuing medical education to address this issue. The investigators also examined whether there were differences in the use of BMI-for-age as a screening tool and counseling habits by child's weight status because physicians may be more inclined to counsel children who appear to be overweight or obese. In addition, an exploratory analysis was conducted to examine predictors potentially associated with physicians' likelihood of screening for obesity using BMI-for-age and providing counseling in order to identify those who are following recommended protocol.
This study is based on data from the DocStyles 2008 web-based survey. DocStyles is a web-based panel survey developed by Porter Novelli, with input from federal public agencies as well as other profit and non-profit organizations. The survey instrument was designed to provide insights into physicians' attitudes and counseling behaviors regarding a variety of health issues relevant to adult or pediatric patients that included but were not limited to pregnancy health, cancer screenings, nutrition, physical activity, and weight status. The CDC Human Subjects Review determined these analyses were exempt from Human Subjects Review because this is a secondary data analysis using data without identifiers.
This study is based on PEDs and GPs, who comprise part of the DocStyles 2008 data. The sample originated from the Epocrates Honor Panel (http://www.epocrates.com), which consists of 135,000 verified physicians from multiple specialties invited to participate in surveys [18]. The goal for DocStyles was 250 PEDs and 1,000 GPs respondents. In order to reach this goal, Porter Novelli employed a probability sampling method to randomly select a sample of 14,346 physicians from the Epocrates Honors Panel database to match the American Medical Association (AMA) files in terms of name, age, sex, and region [19]. Of these 14,346, 2,207 are PEDs and 7,205 are GPs. A total of 1,785 PEDs and 5,671 GPs did not respond to the invitation or tried to respond after the survey closed; 146 PEDs and 457 GPs logged in to take the survey but were eliminated due to filled quotas for their specialty; one PED and 11 GPs did not complete the entire survey; and 22 PEDs and 72 GPs were eliminated based on the screener questions. Potential participants were screened at the beginning of the survey to assure they met the following criteria: 1) currently practicing in the US; 2) working in an individual, group, or hospital practice; and 3) have been practicing medicine for at least three years. Response rates, 19% for PEDs and 21% for GPs, were calculated by weighting respondents who were terminated due to filled quotas as a factor of the overall sample pool as opposed to classifying them as standard incompletes [19]. The different physician specialties were included because they were of particular interest to the data collectors and the total sample by itself is not intended to be representative of a national population of physicians or physician specialties. There are no weights in the sample, rendering it impossible to control for type of physician. Participating physicians received an honorarium of $50-$75 for their time and were not required to participate in the survey and could opt out at anytime. The study was limited to include all PEDs (n = 250) and GPs with pediatric patients (n = 621).
Porter Novelli compared the overall DocStyles sample, by physician specialty, to the AMA master file for gender, age, and region of the country. For GPs, a slightly higher percentage of males were included in the overall DocStyles sample compared to the AMA master file. For PEDs, 61% of DocStyles respondents were male while the AMA master file shows 44% of PEDs are male. The authors were unable to assess the comparability of this analytic sample of GPs to the AMA master file because sample was restricted to only those who see pediatric patients. The sample protocol for DocStyles is complex and although there are substantial efforts to assure representativeness it is possible that volunteer selection bias is present.
Analysis I. Prevalence of Screening, Confidence, Referral, and Counseling
The first analysis examined these on the basis of the following questions:
"How often do you use BMI-for-age to screen for obesity for children 2 years of age or older? (Never, Rarely, At some visits, At most visits, or At every well child visit)."
Because it is recommended physicians use BMI-for-age to screen for obesity at every well child visit, the responses were dichotomized to reflect physicians who do and do not use BMI-for-age to screen for obesity at every well child visit.
"How confident are you in explaining BMI-for-age results to children and their parents? (Not at all confident, Slightly confident, Somewhat confident, very confident)."
Responses were collapsed into two categories: Somewhat or Very confident and Not at all or Slightly confident.
"For your obese patients with complications or co-morbidities, do you have access to a pediatric obesity specialty clinic (typically a tertiary care center) for referral? (Yes or No)."
for each of the following topics: being physically active, amount of TV time, consumption of energy dense foods, eating fruits and vegetables daily, and consumption of sugar-sweetened beverages respondents needed to indicate whether they or a staff member discussed the topic with all patients, with both those overweight (BMI 85th -94th percentile) and those obese (BMI > 95th percentile), only with those overweight (BMI 85th-94th percentile), only those obese (BMI > 95th percentile), or they generally did not discuss it. The question was presented in tabular form. The responses were collapsed into the following categories: All patients and Only with overweight or obese.
Analysis 2: Predictors of Screening and Counseling
To predict use of BMI-for-age to screen for obesity and physicians' counseling habits on prevention the authors used the same predictor variables for both types of physicians: physicians' gender; physicians' race/ethnicity (non-Hispanic white or Other); number of years practiced (< 10 years or ≥ 10 years); physicians' type of practice (individual or group/hospital/clinic); patients' race/ethnicity (mostly white or mostly minority); and patients' income category (low or middle/upper).
Analyses were conducted with SAS version 9.2 [20]. For Analysis 1, the authors used chi-square tests to determine differences in screening, confidence, and referral between the two physician groups. Next, the authors determined the prevalence among physicians who responded that they had "generally discussed" that topic with all patients, "only discuss that topic with overweight or obese patients", or they "generally do not discuss that topic with any patient" overall and for each topic area individually; prevalences are reported for each physician type and the corresponding differences in proportions based on chi-square test using a 0.05 level of significance. For Analysis 2, adjusted logistic regression to determine predictors of using BMI-for-age at every well child visit versus not using BMI-for-age at every well child visit was conducted. Adjusted logistic regression was conducted to determine predictors of counseling all patients versus only overweight/obese patients for each counseling topic to investigate if physicians were more likely to report increased counseling for overweight/obese patients. Analyses were run separately for each physician type.
Demographic characteristics of the study participants are presented in Table 1. For PEDs and GPs, more respondents were male (63% and 76%, respectively). The majority of respondents were non-Hispanic white (66% PEDs, 75% GPs) and had been practicing for 10 years or more (60% PEDs, 61% GPs). Further, the majority of PEDs (60%) and GPs (66%) were in a group practice compared to an individual practice or hospital/clinic-based practice.
Table 1 Demographics of Pediatricians and General Practitioners, DocStyles, 2008
Overall, 30% of physicians reported screening for obesity using BMI-for-age at every well child visit (data not shown). Rates were higher for PEDs than GPs (50% vs. 22%, p ≤ 0.01) (Table 2). Similarly, PEDs were more likely to respond that they were somewhat or very confident in explaining BMI-for-age results compared to GPs (PEDs, 94% vs. GPs, 87%, p ≤ 0.01). Although there were differences, 87% or more reported having "confidence explaining BMI-for-age to patients and their parents". Access to a pediatric obesity specialty clinic for referral was reported by 65% of PEDs, compared to 42% of GPs (p ≤ 0.0001).
Table 2 Obesity Screening, Confidence, and Referral to Pediatric Obesity Specialty Clinic by Physician Type, DocStyles, 2008
Overall, it was found that 52% of PEDs and 45% of GPs reported counseling all patients on all topic areas and 6% of PEDs and 11% of GPs reported counseling only overweight or obese patients on all topic areas (Table 3). In general, for each topic area, most PEDs and GPs reported counseling all patients, while a smaller proportion of PEDs and GPs reported counseling only overweight or obese patients. Only a few physicians reported that they generally do not discuss one or more counseling issues Counseling all patients was highest for fruit and vegetable consumption and physical activity and lowest for consumption of energy dense foods. Excluding those who did not discuss, PEDs had a significantly higher prevalence of counseling all patients than GPs for TV viewing time (PEDs, 79% vs. GPs, 61%, χ2 = 19.1, p ≤ 0.0001) and for consumption of fruits and vegetables PEDs, 87% vs. GPs, 78%, χ2 = 6.4, p ≤ 0.01) (data not shown).
Table 3 Physician Self-reported Counseling Practices by Physician Type, DocStyles, 2008
Table 4 reports predictors for using BMI-for-age to screen for obesity. Only two predictors were found among GPs: female GPs were more likely to report screening children at every well child visit compared to male GPs (OR = 2.3, 95% CI = 1.5, 3.5) and GPs with a patient population that is mostly non-white were more likely to report screening children at every well child visit compared to GPs with a mostly white patient population (OR = 1.8, 95% CI = 1.1, 2.9). No predictors were significantly associated with BMI screening among PEDs.
Table 4 Adjusted Odds Ratios for BMI-for-Age at Every Well-Child Visit by Physician Type, DocStyles, 2008*
Predictors varied by topic and generally were not significantly associated with counseling with three exceptions (data not shown). PEDs with a race/ethnicity of "Other" were more likely to counsel all patients on energy dense foods compared to non-Hispanic white PEDs (OR = 1.9, 95% CI = 1.1, 3.5). Female GPs were more likely to counsel all patients on TV viewing time (OR = 1.9, 95% CI = 1.2, 2.9) and fruit and vegetable consumption (OR = 2.0, 95% CI = 1.2, 3.4) compared to male GPs.
This study documented that only 50% of PEDs and 22% of GPs who treated pediatric patients reported routinely using BMI-for-age to screen for weight status in all patients at each well child visit as recommended by the AAP [3]. While the authors' hypothesis that PEDs would use BMI-for-age more than GPs was supported, these findings suggest that increased efforts are needed to attain the AAP goal among both specialties.
The literature documents fairly similar levels of use of BMI by PEDs compared to GPs. This study's finding that 50% PEDs reported using BMI-for-age at every well child visit is slightly higher than previous findings, which ranged from 11% to 35% for reporting always or generally using BMI [6, 21–24]. However, these results are very similar to a 2010 AAP study that found 52% of PEDs compute or plot BMI at most or every well child visit [25]. This study's finding of 22% of GPs reporting use of BMI-for-age to screen for obesity at every well child visit, although disconcerting, is consistent with previous studies. Woolford and colleagues (2008) reported 17% of family physicians' used BMI charts [21] and Kolagotla and Adams' (2004) found that 22% of family physicians routinely used BMI on pre-adolescents [22]. Interestingly, Kolagotla and Adams, who reported results by patient age, found that 5% of family practitioners routinely used BMI for children ages 3-7 years, and 49% routinely used BMI for adolescents. The authors were unable to examine whether GPs had different levels of BMI-for-age usage for different age groups. This is an area in need of further investigation.
Both PEDs and GPs reported high levels of confidence in explaining BMI-for-age results, although a significantly higher proportion of PEDs reported a high level of confidence. For both specialties, these findings suggest that factors other than lack of confidence may be responsible for the low levels of using BMI-for-age, such as time [26, 27].
A significantly lower proportion of GPs with pediatric patients reported access to a pediatric obesity specialty clinic than PEDs. This highlights a potential disparity for GPs with pediatric patients and could be one explanation as to why a smaller proportion of GPs screen with BMI-for-age at every visit compared to PEDs: GPs do not have a sufficient protocol for their obese pediatric patients. GPs should be encouraged to access AAP resources in their states and communities to help them find referral clinics for their obese patients. Further, organizations such as AAP could include outreach efforts to GPs with pediatric patients.
The five counseling topics were examined separately because they are five of the six priority target behaviors to prevent and control obesity for the Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention (http://www.cdc.gov/nccdphp/DNPAO/aboutus/index.html). The counseling topics were also included in the recommendations for healthcare providers' counseling for pediatric patients and their families by the Expert Committee on Childhood Obesity [4].
This study assessed if PEDs and GPs were counseling on a topic area in general, not if PEDs' and GPs' were educating patients and their parents on specific recommendations. Recommendations exist for children on three of the five counseling topics: physical activity, TV viewing time, and fruit and vegetable consumption. Regarding physical activity, the 2008 Physical Activity Guidelines for Americans recommend children and adolescents (ages 6-17 years) engage in 60 minutes or more of physical activity daily, where most of the 60 minutes or more per day be either moderate- or vigorous-intensity and include vigorous-intensity physical activity at least three days per week [28]. Furthermore, children and adolescents should engage in muscle-strengthening and bone-strengthening exercises as part of daily physical activity, or at least three days of the week [28]. Regarding TV viewing, the AAP currently recommends youth ages two years and over engage in no more than two hours of television viewing, or screen time (television plus other forms of media for entertainment purposes) per day [29]. Lastly, recommendations for fruit and vegetable exist, yet recommended consumption amounts vary depending on a child's age, sex, and activity level, where for example children aged 2 years require daily about 1 cup each of vegetables and fruit and 18 year olds require daily about 3 cups of vegetables and 2 cups of fruit [30, 31].
Interestingly, this study found among PEDs that the three topic areas with recommendations have the highest prevalence of counseling: physical activity (83%), TV time (79%), and fruit and vegetable consumption (87%) compared to energy dense foods (59%) and sugar-sweetened beverages (65%). These findings are very similar to an AAP study that found 86% of PEDs reported counseling all patients on physical activity, 76% counseled on TV viewing time, 89% on fruits and vegetables, 44% on energy dense foods, and 65% on sugar-sweetened beverages [25]. The lower counseling prevalence of energy density and sugar-sweetened beverages suggests that if there were recommendations for these topic areas, physicians might counsel their patients in these areas more frequently. Consumption of energy dense foods was the least counseled topic by both PEDs and GPs. This is an important issue because of the frequent consumption of high energy dense foods, such as fast food [32, 33]. Somewhat similar to PEDs, GPs with pediatric patients reported a higher prevalence of counseling all patients on physical activity and fruit and vegetable consumption compared to the other three topics examined.
It is unknown why PEDs and GPs with pediatric patients do not report higher rates of using BMI-for-age and counseling, and why a discrepancy exists between the two specialties. One barrier may be the lack of time because evidence shows that the time needed for recommended screening and counseling exceeds the available time for primary care visits [26, 27]. Future research could discover other barriers that PEDs and GPs with pediatric patients confront and determine if different steps are necessary to overcome such barriers for the two different specialties.
The analyses to identify predictors associated with use of BMI-for-age and counseling habits documented that race/ethnicity of PEDs and gender of physician among GPs as significant predictors. Interestingly, "Other" PEDs were more likely to counsel all patients on energy dense foods compared to non-Hispanic white PEDs. GPs with a patient population that is mostly non-white were also more likely to use BMI-for-age. To the best of the authors' knowledge, these findings have not been previously reported. Additionally, among GPs, females were more likely to use BMI-for-age, counsel all patients on TV viewing time, and counsel all patients on fruit and vegetable consumption compared to male GPs. This is consistent with previous research showing female physicians were more likely to offer preventive services and counseling compared to male physicians [22, 34, 35]. These findings need to be further explored so that education and training can be targeted to those most in need of changing their screening and counseling practices.
There were two strengths to this study. First is the attempt to match the convenience sample of physicians included in the Epocrates Honors Panel to the AMA master file for age, gender, and region, for each specialty area to make the findings more generalizable. A second strength is the inquiry about a quality of care issue, the use of BMI-for-age to screen for childhood obesity, given this is the AAP recommended method for screening. Previous research has shown that substantial proportions of PEDs and family practitioners reported not using the recommended BMI-for-age to screen for obesity, but they relied on height and weight growth charts, visual assessment, evaluating trends overtime, or only calculating BMI if concerned [22, 27]. With increased attention on obesity, it is important to demonstrate whether screening practices, based on the recommended tool are improving.
This study has limitations. First, there may be sampling bias. While attempts were made to match the sample to the AMA master file for age, gender, and region, there were differences in the sample for gender compared to the AMA master file. This sample included a higher percentage of male physician respondents for both PEDs and GPs compared to the AMA master file. Additionally, the sample may not be representative of all PEDs and GPs because of potential for volunteer bias due to quota sampling and the original database being an opt-in database. Generalizing results to all PEDs and GPs is not possible because of the low response rates for PEDs and GPs. A second limitation is a possible reporting bias from physicians' self-reported use of BMI-for-age to screen for obesity resulting in an overestimated BMI-for-age use. A third limitation is that the authors were not able to assess methods other than BMI-for-age for obesity screening. It is possible practitioners in this sample are using other methods to assess weight status although not the recommended protocol. Using methods other than BMI-for-age has different implications than not screening at all. For example, obese children who are not screened at all may be less likely to receive appropriate referral compared to obese children who receive appropriate referral after being diagnosed using a different method. Unfortunately, the data did not allow for more exploration for use of other methods. A fourth limitation is the authors did not specify which type of specialty clinic when asking about referral to a pediatric obesity specialty clinic. Physician respondents may have interpreted this question differently (e.g., bariatric surgery clinic, endocrinologist, lipidologist). However, those who responded affirmatively have a system in place to refer obese patients regardless of clinic type. A fifth limitation, the responses to the question about counseling activities could have been biased or incomplete because the physician respondent might not know whether or not his/her staff is counseling on overweight prevention topics that were listed in the question. Finally, the number of calculations necessary to examine counseling habits by six physician characteristics (i.e., gender of physician, years practiced, race of physician, type of practice, SES of patients, and race of patient population), five counseling topic (physical activity, TV viewing, energy dense food consumption, fruit and vegetable consumption, and sugar-sweetened beverage consumption), and two physician types (PEDs and GPs) resulted in 60 odds ratios (6*5*2). With a significance level of 0.05, this increased the possibility of a type I error.
These findings suggest a great need for some important next steps to increase adherence to the AAP and Institute of Medicine (IOM) obesity screening recommendations [2, 3, 36], counseling recommendations on nutrition and age-appropriate physical activity, as well as establish a system for referral to a pediatric obesity specialty clinic. Strategies for improving screening include changes in the protocol for staff to screen for obesity [35] and having a nurse or assistant calculate BMI for the physician have been identified as facilitators to use of BMI [27]. Another strategy is the use of electronic medical record systems that automatically calculate BMI-for-age once height and weight data are entered [37]. This would allow the graphs to be readily available to the physician to review and draw attention to necessary counseling. Another strategy is continuing medical education (CME) for PEDs and GPs with pediatric patients which may increase self-efficacy and knowledge of obesity screening and counseling, which may in turn increase the level of confidence when discussing the topic with parents [25]. There are existing resources to increase physician screening and counseling expertise. The Maine Youth Overweight Collaborative (MYOC) and the Washington state model provide examples for improving physicians' ability to screen for obesity and offer appropriate management of obesity [38, 39]. The MYOC intervention provides tools for clinical decision support and counseling and self-management support for families and patients, [38] while the Washington state model integrates obesity prevention and management into the clinic setting that emphasizes small, consistent behavior changes, and self-regulation of eating/feeding practices with children, teenagers, and families; building local community partnerships; and encouraging broader advocacy and policy change [39].
In addition, as of January 2010, the American Board of Pediatrics requires ongoing practice improvements for maintenance of certification [40]. These ongoing practice improvements ensure that board certified PEDs understand the importance of BMI-for-age to identify obesity and provide obese patients with appropriate medical assessment. In the future, the 2009 Healthcare Effectiveness Data and Information Set (HEDIS) measure, "Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents," will provide useful information on whether or not healthcare providers are screening for obesity with BMI and offering appropriate counseling for children and adolescents and their parents [41].
Only 50% of PEDs and 22% of GPs with pediatric patients reported using BMI-for-age, about half of PEDs and GPs reported counseling all patients on the five weight-related topics included in this survey, and only 65% of PEDs and 42% of GPs reported access to a pediatric obesity specialty clinic. More research is needed to better understand why BMI-for-age is not being used to screen at every well child visit and how frequently other screening tools are being used. This is important because previous research has shown that plotting BMI leads to greater recognition of a weight problem [23], and a higher likelihood of receiving counseling [6, 9, 10] and treatment [12, 42]. While the findings that physicians reported counseling all patients and not just those who were overweight or obese presented here are reassuring, the overall counseling prevalence is somewhat low. Further, it remains crucial to identify overweight or obese status and ensure these patients receive appropriate counseling and physicians make referrals for additional services. The authors also suggest more communication between PEDs and GPs through professional organizations to increase awareness of existing resources, and to enhance access and referral to pediatric obesity specialty clinics. Physician practices have an important role in overcoming the epidemic of pediatric obesity.
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Paeratakul S, Ferdinand DP, Champagne CM, Ryan DH, Bray GA: Fast-food consumption among US adults and children: Dietary and nutrient intake profile. J Am Diet Assoc. 2003, 103: 1332-1338. 10.1016/S0002-8223(03)01086-1.
French SA, Story M, Neumark-Sztainer D, Fulkerson JA, Hannan P: Fast food restaurant use among adolescents: Associations with nutrient intake, food choices and behavioral and psychosocial variables. International Journal of Obesity. 2001, 25: 1823-1833. 10.1038/sj.ijo.0801820.
Rattay KT, Fulton JE, Galuska DA: Weight counseling patterns of U. S. Pediatricians. Obes Res. 2004, 12: 161-169. 10.1038/oby.2004.21.
Dunlop AL, Leroy Z, Trowbridge FL, Kibbe DL: Improving providers' assessment and management of childhood overweight: results of an intervention. Ambul Pediatr. 2007, 7: 453-457. 10.1016/j.ambp.2007.07.006.
Institute of Medicine: Preventing Childhood Obesity: Health in the Balance. 2005, Washington, DC: The National Academies Press
Sesselberg TS, Klein JD, O'Connor KG, Johnson MS: Screening and counseling for childhood obesity: Results from a national survey. Journal of American Board of Family Medicine. 2010, 23: 334-342. 10.3122/jabfm.2010.03.090070.
Polacsek M, Orr J, Letourneau L, Rogers V, Holmberg R, O'Rourke K, Hannon C, Lombard KA, Gortmaker SL: Impact of a primary care intervention on physician practice and patient and family behavior: Keep ME Healthy-The Maine Youth Overweight Collaborative. Pediatrics. 2008, 123: S258-S266.
Pomietto M, Dixon Docter A, Van Borkulo N, Alfonsi L, Krieger J, Liu LL: Small steps to health: Building sustainable partnerships in pediatric obesity care. Pediatrics. 2008, 123: S308-S316.
American Board of Pediatrics. General Pediatrics: Maintenance of Certificate Examination: 2009, Chapel Hill, NC, American Board of Pediatrics, September 1, 2009 - June 30, 2010.
National Committee for Quality Assurance: HEDIS 2009 Summary Table of Measures, Product Lines and Changes. 2. 2009. 7-20-2009., [http://www.ncqa.org]
The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/12/80/prepub
Acknowledgements and Funding
There are no additional persons to acknowledge.
The DocStyles 2008 items analyzed in this article were supported by the Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention.
The authors are employees of this funding body, thus this funding body participated in writing the items; analyzing and interpreting the data; writing the manuscript; and deciding to submit the manuscript for publication.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention
Division of Nutrition, Physical Activity, & Obesity, Centers for Disease Control & Prevention, 4770 Buford Hwy, NE Mail Stop K-25, Atlanta, GA, 30341, USA
Holly R Wethington
, Bettylou Sherry
& Barbara Polhamus
Search for Holly R Wethington in:
Search for Bettylou Sherry in:
Search for Barbara Polhamus in:
Correspondence to Holly R Wethington.
HRW participated in the design of the study, conducted data analysis and interpretation of data, and drafted the manuscript. BS participated in the design of the study, acquisition of data, interpretation of data, and revising the manuscript critically for important intellectual content. BP participated in the acquisition of data, interpretation of data, and revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.
https://doi.org/10.1186/1471-2296-12-80
Vegetable Consumption
Counseling Prevalence
Energy Dense Food


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Brent Metschan
Brent Metschan got involved with Wonders & Worries after a conversation with his friend – and former Board President, Richard Paddock. Brent wanted to volunteer for a nonprofit that focused on children, and Richard invited him to sit in on a few strategic meetings. It was a perfect match. After seven years of advocating for Wonders & Worries, Brent decided to increase his involvement by joining the Board of Directors.
Brent currently chairs the Urban Scavenger Hunt on April 8 , an event that appeals because it's for every type of person. In his words, "If you are looking for a family oriented event, the Scavenger Hunt is for you!" If you prefer black-tie parties with great stories, prizes, and dancing, then Unmasked Gala checks all the boxes. If you enjoy some good ole Texas fun for yourself, your friends, your co-workers or your clients, look no further than the No Worries Classic. If you have a taste for all three, you can do that too!
"Each event is unique," he says, "but all have the common tie of helping Wonders & Worries provide the level of care needed for so many kids and teens."
What makes Wonders & Worries stand out to Brent is that it is the only organization of its kind in the nation. Brent has friends and relatives who have dealt with cancer and, "I am so thankful there is an organization that I could tell them about to help with their children." He has been asked by friends in multiple states if there was a Wonders & Worries in their city, and hopes the organization can expand to meet the demand: "We can only grow nationally through the generosity of our donors," he says, and
"I know it is not a matter of if, but when, we'll expand."
Brent's favorite memories with Wonders & Worries the moments he has introduced his friends to the organization. "It was one thing for me to tell them about the work being done," he says, "but it was another for them to truly understand what Wonders & Worries is accomplishing." He loves that his friends are often inspired to get involved as well.
The services Wonders & Worries provides are free of charge to the clients. Wonders & Worries receives no government funding and rely solely on the generosity of companies and individuals. Brent says he wants the organization to continue to provide the same level of service it has always been able to provide. "We have never turned a family away and do not want to ever do that. The best way to ensure this never happens is for the incredibly gracious people and companies here in Austin and Georgetown to continue to help us through donations and grants."
The Johnson Family
The Heise Family
The Steele Family

redpajama_set_name: RedPajamaCommonCrawl


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America's Voice En Español »
Reform is Urgent
tags: AVEF, Immigration in the Courts, Pili Tobar, TPS, AVEF, Press Releases
Children & TPS Holder-Plaintiffs Fight to Stay Together at Hearing While Admin's Racism on Full Display
by AV Press Releases on August 14, 2019
Immigrants and Their Families Bravely Stand up to Pres. Trump & His Anti-Immigrant Agenda
At a hearing today in Pasadena for the lawsuit Ramos v. Nielsen, the government tried to justify its racist and unconstitutional termination of Temporary Protected Status (TPS) that will strip over 400,000 immigrants of their legal status, lead to mass deportations and ultimately separate many of them from their U.S. citizen children and families here in the U.S.
In response to these extensive measures the Trump administration is taking to separate families, Pili Tobar, Deputy Director of America's Voice, said:
Today, the Trump administration's racism was on full display as the government actively argued to strip immigrants of their legal status in order to deport and separate them from their families.
The plaintiffs in Ramos v. Nielsen represent the hundreds of thousands of TPS holders across the country and their families who are integral members of American communities. They extensively contribute to our economy and are deeply rooted in our neighborhoods, cities, and states.
Many TPS holders have been here for decades, and are unable to return to their home country because of extreme violence and instability acknowledged by the Administration. We are proud to stand with the plaintiffs and their families who are courageously fighting against hate and bigotry. Their bravery represents the broader determination and fearlessness of countless immigrant communities across the nation who will not let the tyrant in the White House or his depraved minions terrorize them or their loved ones and strip them of their homes and livelihoods.
We urge the court to keep the preliminary injunction in place, so that the Senate can take the necessary steps to fix this problem once and for all and pass the Dream and Promise Act, which has already been approved by the House. TPS holders and undocumented youth deserve more than a temporary fix- they deserve permanent protections that only the U.S. Congress can grant. Republican Senators need to stop playing politics with the lives of human beings and stand up to President Trump instead of cowering in fear. They must act now.
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The goal of America's Voice Education Fund is to create the public momentum for reforms that will transform a dysfunctional immigration system into a regulatory system that works. To achieve this, we conduct cutting edge public opinion research, perform rapid response communications in English and Spanish, and support courageous leaders who are standing up for real immigration reform.
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Septic Repairs and Septic Upgrades Even If It Is Wet Out!
https://septicpreservation.com/wp-content/uploads/2018/03/030918S.png 1280 1920 Holly Walker http://septicpreservation.com/wp-content/uploads/2018/04/sps_logo_number.png Holly Walker2018-03-09 08:02:362018-03-04 10:06:30Septic Repairs and Septic Upgrades Even If It Is Wet Out!
In this instance our client has added bedrooms to their property and therefore require a septic inspection.


Jahahara Alkebulan-Ma'at, an Oakland resident and activist, lived in the same small rental home on a property near Lake Merritt in Oakland for 22 years until a new owner changed the locks, shut off water and power to the house, and threatened his physical safety. He finally came home one day in March 2017 to find half of his home demolished. Working with the Eviction Defense Center and the Oakland City Attorney, Mr. Alkebulan-Ma'at courageously fought to vindicate his rights, resulting in an extraordinary settlement.
The Bay Area's historic and ongoing housing crisis has created an epidemic of eviction, displacement, and violations of tenants' basic rights with devastating ripple effects on community health and economic opportunity.
To address this crisis, the Oakland City Attorney's Office has leveraged minimal staff resources to successfully fight for housing preservation and the human rights of tenants in Oakland. Cases have successfully prevented displacement of Oakland families and have resulted in millions of dollars in settlements.
In the midst of this crisis, the Oakland City Attorney is partnering with nonprofit legal advocates to file housing lawsuits and pursue justice for tenants subject to severe misconduct.
Learn why Oakland City Attorney is in a unique position to protect tenants at imminent risk of displacement and enforce state and local laws.
Hear directly from a tenant about enduring severe harassment and fighting for his rights.
Learn how nonprofits both defend against evictions and go on the offensive against abusive landlords.
Discuss an innovative government-nonprofit partnership advancing a 'protection-first' approach at this critical moment in the Bay Area housing crisis, buying time for longer term solutions.
Discuss how targeted philanthropy can prevent the displacement of vulnerable populations.
Jahahara Amen-RA Alkebulan-Ma'at is a Baba (Father, CommUNITY Elder) and "free-tired" grassroots neighborhood, labor union, environmental and justice organizer. For nearly half a century, he has helped build and directed organizations and campaigns, including campaigns for tenants rights and building more affordable housing in Chicago, Kansas City, New York, Oakland-San Francisco Bay Area and around the African Diaspora. Since the early 1970s, he has been a leader in the movements for African independence, liberation, reparations and healing; and, a major supporter of women and girls' rights, reparations and full equality. He is also the author of several books, hundreds of articles, songs, poems and art works.
Chief Assistant City Attorney Maria Bee is a member of the City Attorney's Executive Team. In 2016, she was assigned to head the newly established Affirmative Litigation, Innovation & Enforcement Division, which focuses on social, economic and environmental justice for Oakland residents. Ms. Bee received her Bachelor of Arts from the University of California, Berkeley. She graduated from UC Berkeley School of Law and has 25 years of experience in the legal community, both as a practicing attorney and as a fighter for justice for the most vulnerable populations.
Demitrius is the Program Officer for the Anchoring Communities, or PLACE, pathway at the San Francisco Foundation. There, he is advancing social change and community liberation through grant-making, strategic collaborations, and civic leadership and engagement to prevent the displacement of low-income families and communities of color from the Bay Area. With his team, Demitrius works to ensure these diverse neighborhoods are places where all residents can live, work, worship, create and thrive.
Scott Hugo is an attorney in the Neighborhood Law Corps (NLC), an award-winning program that partners with community organizations, connects residents with resources, and brings impact litigation on behalf of the City to combat some of the most challenging problems facing Oakland neighborhoods such as slumlords and human trafficking. After graduating from UCLA with a BA in Political Science and History, Mr. Hugo attended Oxford University on a Rhodes Scholarship and earned a MPhil in International Relations. He then completed the joint Juris Doctor/Master of Public Policy program at Harvard Law School and the Kennedy School of Government.
As Litigation Director for Centro Legal, Jesse supervises the organization's individual, impact, and class action lawsuits in state and federal court, to protect the rights of low-income and immigrant workers, tenants, and other clients and communities, and improve conditions more broadly. Jesse first worked at Centro as a Skadden fellow from 2007 to 2009, teaching an introductory law class and running a site-based legal clinic at Melrose Leadership Academy, a public junior high school in East Oakland. Since then, Jesse has been Centro Legal's Interim Legal Services Director and Executive Director, and has practiced law in the areas of workers' rights, tenants' rights, immigration, and consumer protection. After graduating from Harvard Law School in 2006, Jesse completed both federal district and appellate court clerkships on the Ninth Circuit, for Judges Dean D. Pregerson and Richard A. Paez. Jesse also worked as a Neighborhood Law Attorney for the City of Oakland, bringing lawsuits on behalf of tenants living in substandard housing and immigrant victims of fraud. Jesse's commitment to the rights of low-income and immigrant communities stems from his work before law school as a teacher, social worker, and factory worker in Oakland and Fremont, California, and his hometown of Tucson, Arizona.
Anne Tamiko Omura is the Executive Director of the Eviction Defense Center. She has dedicated 23 years to serving low income tenants.
This event is open to NCG members and non-member funders.


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Octenole sind chemische Verbindungen, aus der Gruppe der Kohlenwasserstoffe, die eine Doppelbindung und eine Hydroxygruppe enthalten:
 1-Octen-3-ol
 2-Octen-1-ol

 3-Octen-1-ol

redpajama_set_name: RedPajamaWikipedia


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Home / Teas/Herbal & Other / Yogi Tulsi Spiced Berry Immune Support (16 Tea Bags)Purchase this product now and earn 10 Points!
Yogi Tulsi Spiced Berry Immune Support (16 Tea Bags)
YOGI Tulsi Spiced Berry Immune Support (16 Tea Bags) Supports Immune Function
Our Tulsi Spiced Berry Immune Support tea combines Tulsi Leaf and Elderberry to supply antioxidants and naturally support your immune function. We add warming herbs traditionally used in Ayurveda along with Blueberries for a delicious and comforting tea to support your overall health and well-being.*
*These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.
Brewing Suggestions:
Bring water to boiling and steep 5 to 10 minutes. Enjoy 1 to 3 cups a day. For a stronger tea, use 2 tea bags.
Tulsi Leaf
Tulsi Leaf, also referred to as Basil Leaf or Holy Basil, is a delicious and well-known culinary herb that is rich in antioxidants. Tulsi is considered a warming herb and has been traditionally used to support the immune system and overall health.
Cinnamon Bark
Cinnamon Bark comes from a small evergreen tree that is native to Sri Lanka. Cinnamon is a pungent, sweet and hot spice that can warm and invigorates the body and support function of the respiratory and digestive systems. It can also help to promote circulation to the joints and support immune function.
Native to Europe, elderberry has been used in European folk medicine since antiquity. Elderberries supplyanthocyanidins – powerful purple pigment compounds that act as antioxidants. Elderberry can also help support respiratory function, and is used by herbalists to soothe the throat.
Cardamom is a uniquely flavored culinary herb in the ginger family. But cardamom is more than its delicious flavor. This herb is warming and has been traditionally used to support healthy stomach and digestive function as well as the respiratory system.
Licorice root is a flavorful, sweet herb that has been used for thousands of years and is still one of the most widely used herbs in all herbal systems. Licorice has been used traditionally to support the skin and the liver. It also is thought by herbalists to help soothe indigestion and the throat.
Nutmeg is an evergreen tree native to Indonesia and is the only plant that is the source of two different spices. Nutmeg is actually the seed of the tree, while the dried lacy reddish covering or aril of the seed gives us mace. Nutmeg has a sweet, nutty aroma and slightly sweet taste.
Ginger Root, the underground stem, or rhizome, of the plant Zingiber officinale, has been used in many herbal traditions since ancient times. In Ayurveda, Ginger is known as the wonder herb, and it's no wonder, since Ayurveda employs Ginger for a wide variety of health applications, including digestive support. Historically, Ginger Root was also one of the most respected herbs for supporting joint health. Additionally, Ginger Root has been traditionally used to support healthy peripheral circulation; and can aid in warming up cold hands and feet, and will also promote sweating when needed.
Lemongrass is a tropical herb that is popular in Thai cooking. Traditionally, is has been used to support normal respiratory function. Lemongrass tastes great and is a warming herb that can support digestion.
Clove Bud
Clove Buds are the aromatic dried flower buds of a tree in the Myrtle family. The English name clove derives from Latin clavus (nail), as the shape of the buds resembles small nails. Clove bud is widely used as a spice in ancient Asian herbal traditions. With a warming quality, clove supports circulation and digestion.
Not only is Black Pepper one of the most widely used culinary spices in the world, it also has a long history of use in traditional herbal medicine. A spicy herb that can help support digestion, it also supplies antioxidants, which can help to reduce free radicals. As a diuretic, black pepper can support water balance in the body.
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Hilde Hemmes Eyebright Herb 50g
Hilde Hemmes Stinging Nettle – 30 Teabags
Hilde Hemmes Bloat-Rid 30 Teabags


text:
Drosophila bromelioides este o specie de muște din genul Drosophila, familia Drosophilidae, descrisă de Pavan și Cunha în anul 1947. Conform Catalogue of Life specia Drosophila bromelioides nu are subspecii cunoscute.

Referințe

Drosophila


What do the Meigs County village of Middleport, the city of St. Paul, Minn., a U.S. Navy warship, and the date Dec. 7 have in common? They are all oddly connected and intertwined by the 1941 Japanese Attack on Pearl Harbor – the event that thrust the United States into World War II.
History has a way of making strange twists and turns, coincidence is often the norm rather than the exception, and seemingly unrelated people, places, and dates find a bizarre way to connect and interlock through time.
First the person: Rear Admiral William W. Outerbridge (1906-1986).
Although called a Middleport native, Outerbridge was born in Victoria, Hong Kong. He was raised in Middleport and attended Middleport High School, later graduating from Marion Military Institute in Alabama, and in 1927 from the U.S. Naval Academy (according to a popular, free, web-based encyclopedia).
The warship: the USS Ward (DD-139/APD-16).
As one of 111 members of the Wickes-class of destroyers built by the Navy in 1917-1919, the USS Ward was commissioned in 1918 in the closing days of World War I after being constructed in just 17-and-a-half days at the Mare Island Navy Yard in California.
The USS Ward was a little over a football field in length at 314 feet, 30 feet wide and displaced 1,247 tons with a full load. Its two steam turbines could propel it up to speeds of 40 miles per hour. Armament included four four-inch deck guns, a three-inch anti-aircraft gun, four torpedo tubes and depth charges.
For Americans, the date Sunday, Dec. 7, 1941, will always live in infamy, as President Franklin Roosevelt declared. Three December 7ths play into this story.
That morning in 1941 found the USS Ward patrolling off the entrance of Pearl Harbor, Hawaii, with a crew largely comprised of Naval Reservists hailing from St. Paul, Minn. At the helm was Lieutenant Commander William W. Outerbridge, who had been given command of the warship just two days earlier.
The USS Ward was looking for a submarine, having been alerted to the presence of a submarine by a Coast Guard minesweeper earlier that morning.
At 6:30 a.m. the crew of the cargo ship USS Antares alerted the USS Ward to the presence of a submarine apparently attempting to follow it into the harbor. Seven minutes later, the crew of the USS Ward spotted the submarine and attacked. The first shot missed the submarine but the second shot reportedly went straight into the base of the submarine's conning tower. For good measure, the USS Ward dropped depth charges on the sub after it slipped beneath the waves.
Outerbridge immediately notified Naval Command at Pearl Harbor of the incident, but was largely ignored, and an hour later 353 aircraft of the Japanese Imperial Navy descended on the island, relegating the USS Ward to a mere footnote in the Japanese Attack on Pearl Harbor.
The attack of the USS Ward on the Japanese midget submarine has been called the first U.S. shots of World War II, although in actuality American destroyers pulling convoy duty in the Atlantic Ocean were already at war against German u-boats. In any event, it was the first shots in the war versus Japan.
Fast forward three years to Dec. 7, 1944.
After Pearl Harbor, the USS Ward was converted into a troop transport and redesignated APD-16. It had participated in several amphibious assaults until, during efforts to retake the Philippine Islands, it was struck and heavily damaged by a Japanese kamikaze aircraft. When the resulting fires could not be put out, the crew was ordered to abandon ship, and a nearby destroyer was summoned to sink her.
That destroyer was the USS O'Brien, commanded by Commander William W. Outerbridge, who proceeded to send his old ship, the ship that fired America's first shots of the Pacific Theater three years earlier to the day, to the bottom of the ocean. According to some sources, Outerbridge didn't dwell on the significance of that action, but just did his job. Amazingly, no crew members of the USS Ward were lost.
The war went on until Sept. 2, 1945, and Outerbridge went on to bigger assignments. Many of the USS Ward's sister ships saw service in World War II serving in several allied navies. A dozen of them were destroyed during the war, and the remainder were scrapped immediately afterwards.
Although Outerbridge had earned the Navy Cross for his action on Dec. 7, 1941, some academics doubted that the USS Ward had actually sunk a Japanese midget submarine. However those doubts were put to rest in 2002 when searchers from the University of Hawaii found a Japanese mini-sub a few miles off the coast laying in 1,200 feet of water – complete with a shell hole through the base of the conning tower, and right where the USS Ward reported.
This past Thursday, Dec. 7 (76 years after the attack on Pearl Harbor), an expedition team led by Microsoft co-founder Paul Allen announced that it had found the wreckage of the USS Ward near Ponson Island in the Philippines. For the first time in 73 years, human eyes could again behold the USS Ward – on a video screen, probably made in Japan.
Today a historical marker in Middleport commemorates its son Rear Admiral William W. Outerbridge, and in St. Paul, the gun that fired the "first shot" is on display at the Minnesota State Capitol, honoring the "First Shot" Minnesotans of the USS Ward, all of whom are gone now.
Time will tell if this is the end of the story, however history rarely works in that manner.


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AFL Beat 2019 Round 8
*Not A* Sponsored Post
AFL Beat
Fuck You America
Insane Shit
Offseason Events
ballsofsteelandfury - May 14, 2019 May 13, 2019
This week,
The Blues have The Blues (AGAIN!)
A Showdown in the Dark
And this is how you handball!
Welcome to Balls of Steel's AFL Beat!
Round 8 Recaps and Highlights
We are again back to a normal schedule with no Australian Thursday Night games for the foreseeable future. That means one Australian Friday Night game (North American Thursday night), five Australian Saturday games (North American Friday night/Saturday morning), and three Australian Sunday games (North American Saturday night/Sunday morning).
This week, the first game had the struggling Sydney Swans facing the surging Essendon Bombers in Sydney, which is usually a problem.
It seems the Swans got a little bit of good old-fashioned home-cooking this week as a potential game-deciding penalty was not called at the end.
The controversy arose after the game as it was shown that one of the Swans players tried to climb the post to stop the shot. The referee, instead of giving a direct penalty, told him to get down, which he did. In my view, it's probably ok to not call a penalty as he did not exactly "shake" the post, which is what the rule explicitly says. Here are the full game highlights:
Sydney Swans 77 Essendon Bombers 72
The proper Friday Night game had the classic Carlton v Collingwood rivalry match. Even though Carlton is at the bottom of the ladder, after the expected loss to the Pies, they played hard for about three quarters. Almost there.
Here are the full-game highlights:
Carlton Blues 87 Collingwood Magpies 106
Later, the Western Bulldogs hosted the Brisbane Lions in a battle of teams trying to prove they are good.
For this week, the Doggies proved to be better than the Lions, although I'm not sure how much each side has for the rest of the competition.
Western Bulldogs 92 Brisbane Lions 76
Even later on Friday night, the Gold Coast Suns and Melbourne Demons met in an epic clash of mediocrity. Neither team is really that good, but that made for a good and close game.
The game went down to the final two minutes:
If the Gold Coast player marks that ball, the game is over. And they say the NFL is a game of inches… Here are the highlights:
Gold Coast Suns 60 Melbourne Demons 61
The next game had the sinking St. Kilda Saints hosting the West Coast Eagles, which, if you're going to play the Eagles, is probably the best place to play them.
Unfortunately, the Saints did not take advantage of the home field and have now sunk to their more familiar spot mid-table.
St. Kilda Saints 70 West Coast Eagles 88
The last game of the night featured another edition of The Showdown, otherwise known as the Adelaide Derby.
The Power were the "host" team this time and it turned out to be a good game, as most Showdowns tend to be.
In the end, the Crows took this one and are now firmly in the top four after a rough start to the year.
Port Adelaide Power 68 Adelaide Crows 88
The first game of North American Saturday night (Australian Mother's Day) had the twin coaches (Chris Scott of the Geelong Cats and Brad Scott of the North Melbourne Kangaroos facing each other in the battle for Mom's affection.
Chris now holds the edge in matchups after a tight contest in which the difference in the game was accuracy in front of goal. The Cats had it and the Roos didn't.
North Melbourne Kangaroos 80 Geelong Cats 104
The second of the Saturday night games had the Hawthorn Hawks hosting the GWS Giants and I'll just let Giants fan BFC tell you how it went:
I previously thought the whole Giants can't win at the MCG narrative was bullshit but I may stand corrected.
The first quarter, the Giants played like they were point shaving. The rest of the game, the Giants played like they needed to be relegated. Very little tackling, horrible kicking, and I don't think Mumford being out was a difference maker, but it didn't help.
This is a different team without Callan Ward and Lachie Whitfield
The only people still looking good in the fourth quarter were Coniglio and Toby Greene
When Jeremy Cameron misses four from point blank range, you're not going to win.
It was ugly. Here are the full-game highlights:
Hawthorn Hawks 71 GWS Giants 38
The last game of the Round had the Fremantle Dockers hosting the Richmond Tigers after last week's embarrassing defeat for the Tigers.
Talk about a regroup! The Tigers went into Perth and kicked the Dockers' collective ass.
Fremantle Dockers 86 Richmond Tigers 111
Let's take a look at the ladder, shall we?
P TEAM W L T PTS %
1 Geelong Cats 7 1 0 28 145.6
2 Collingwood Magpies 6 2 0 24 126.1
3 Adelaide Crows 5 3 0 20 118.1
4 GWS Giants 5 3 0 20 116.3
5 Brisbane Lions 5 3 0 20 103.8
6 Richmond Tigers 5 3 0 20 98.5
7 West Coast Eagles 5 3 0 20 97.4
8 Fremantle Dockers 4 4 0 16 112.7
9 Hawthorn Hawks 4 4 0 16 105.4
10 Western Bulldogs 4 4 0 16 102.7
11 Port Adelaide Power 4 4 0 16 102.6
12 St. Kilda Saints 4 4 0 16 93.9
13 Essendon Bombers 3 5 0 12 99.8
14 Gold Coast Suns 3 5 0 12 78.6
15 Melbourne Demons 3 5 0 12 75.6
16 Sydney Swans 2 6 0 8 82.7
17 North Melbourne Kangaroos 2 6 0 8 80.9
18 Carlton Blues 1 7 0 4 84.9
Here is the Balls Graph:
The Cats are still a game on top of the competition, but the win against the Roos shows that anyone can beat anyone this year. There are still a lot of games left to play.
One thing is for sure: Carlton is bad.
Footy Tipping Contest
Here is where we are after Round Eight:
P TIPPER Round
Tips Round
Margin Total Tips Total Margin
1 Litre_cola 5 11 46 214
2 Son Of Spam 6 20 42 233
3 BC Dick 4 38 41 293
4 BFC 5 18 39 276
5 BALLS 3 17 38 241
6 Yeah Right 4 49 38 327
7 Why Eagles Why 6 5 37 224
8 Joliet Jake Delhomme 6 15 35 273
9 Game Time Decision 4 20 35 301
10 Dolph Ucker 4 22 34 251
11 Sharkbait 4 105 33 354
12 Blax 5 5 32 211
It was a tough week for everyone, but specially me. BFC has now leapfrogged me into 4th place. Everyone else is pretty close, so one bad week for Litre and we're all right back into this thing!
Litre remains our leader but Son Of Spam has taken over second place and is threatening to pull off the AFL Tipping Double! (He won the AFLW competition). Well done to everyone for putting in their tips!
DONT FORGET TO PUT THE FOOTY TIPS IN!
Here is the schedule for this week (all times Pacific):
3:10 AM (Late Thursday Night!) – West Coast Eagles v Melbourne Demons at Optus Stadium
It looks like the Eagles will get back on a winning streak. I don't think the Demons win in Perth.
8:45 PM – Collingwood Magpies v St. Kilda Saints at the MCG
The poor Saints are in 12th place. Insert Moe "Hello, old friend" jpg.
9:10 PM – Brisbane Lions v Adelaide Crows at the Gabba
The Lions are still in good shape, but must win this game at home in order to get taken seriously.
11:35 PM – Geelong Cats v Western Bulldogs at GMHBA Stadium
The Cats need to show their class against the Jeckyl and Hyde Doggies. Which Western team will show up in Geelong?
2:25 AM – Essendon Bombers v Fremantle Dockers at Marvel Stadium
This one shapes up as an intriguing matchup. Neither team has convinced me that they are any good.
2:25 AM – North Melbourne Kangaroos v Sydney Swans at Blundstone Arena
The Roos played well against the Cats and always play well in Tasmania.
8:10 PM – Port Adelaide Power v Gold Coast Suns at Adelaide Oval
The Suns are continuing their downward slide after a hot start. Same as last year and the year before that and….
10:20 PM – Richmond Tigers v Hawthorn Hawks at the MCG
This time, the Hawks are the "visitors" at the MCG. The Tigers seem to be back, so this shapes up as the Match of The Round.
11:40 PM – GWS Giants v Carlton Blues at Giants Stadium
After a tough loss at the MCG, a game at home against the lowly Blues is just what the doctor ordered for the Giants.
That's all for this week! Sorry about the late post. Hey, maybe I can be Canadian!
See you next week!
International Member of the Geelong Cats and recovering Steelers fan. Likes Butts. And Balls. And Boobs. Pretty much anything that starts with the letter B. Preferably together.
Latest posts by ballsofsteelandfury (see all)
Primer Sexy Sábado de Fútbol de 2020 – January 18, 2020
Dok Zymm – International Woman of Mystery – Chapter 1 – January 7, 2020
Balls on…The College Football Playoff – December 31, 2019
Tagged AFL anti-pants Balls of Steel Rated S for Sexy Roger Goodell is a National Disgrace things to do when you drink
Your "Making Do With What I Found" Monday Evening Open Thread
Your "Put Out To Pasture" Tuesday Evening Open Thread
My Dockers are going to be exactly like my EPL team, Bournemouth. They start out the year on fire sitting up in 2nd, 3rd place and I start thinking they've figured it out. It's going to be their year.
Four games later and they've lost to a bunch of teams they should be able to beat and at the end of the year they're in 14th fucking place and wallowing in mediocrity.
As a Vikings fan I specialize in mediocrity.
Whoa there. I still plan for the Saints to finish tenth as then all would be right in the world.
Geelong is kicking ass so far, which makes me happy.
Ironically, Australia has begun systematically hunting and culling stray cats. Big problem down there.
https://www.cnn.com/2019/04/26/asia/feral-cats-australia-intl/index.html
nomonkeyfun
Australia is really looking to slay that pussy. Up top Bruce-bro.
Also, their record is worse than the Vikings in championship games.
https://en.wikipedia.org/wiki/Emu_War
Geelong is most definitely kicking ass.
Yes, Great excuse for this.
I want to superimpose the Bombers' graph line over the Murderhorn.
Any sort of research I do has obviously got me nowhere. Time to just pick at random. Except for Carlton.
Dawwwww, c'mon Giants, do better!
And be healthier


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Promotion runs from 00:08:01 am on Monday 4th March 2019 and ends at midnight on Wednesday 31st July 2019. 500 jerseys available in total.
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Buy Love Canvas Wall Art from $29.99 at Bed Bath & Beyond. Enliven your little girl's décor and send a beautiful message with the Love Canvas Wall Art. Vibrant and colorful with pink and blue striped top and bottom borders and pretty pink and blue patterns in each block letter, this canvas is utterly charming.Enliven your little girl's décor and send a beautiful message with the Love Canvas Wall Art. Vibrant and colorful with pink and blue striped top and bottom borders and pretty pink and blue patterns in each block letter, this canvas is utterly charming.


As the Chairman of the Federal Spending Oversight Subcommittee of the Senate Homeland Security and author of 'The Waste Report,' Senator Rand Paul yesterday sent a letter to the Chairman of the Budget Committee Mike Enzi (R-WY) and Ranking Member Bernie Sanders (I-VT) seeking to include and consider his findings of $1.12 billion of wasteful spending from 'The Waste Report' in the FY2017 budget.
U.S. Sen. Sherrod Brown (D-OH) this week urged the U.S. Treasury Department to reject proposed cuts to the Central States Pension Plan that could devastate Ohio families.
Senator James Lankford (R-OK) today sent a letter to the Acting Secretary of the Department of Education, John King, to question their use of guidance documents that attempt to inappropriately establish regulatory-type policy changes for colleges and universities without going through the rule-making process.
Today U.S. Senator Lisa Murkowski (R-AK) pressed Assistant Secretary of the Army for Civil Works, Jo-Ellen Darcy, on the need for a deep water port in the Arctic region.
We request that the Department of Health and Human Services (HHS) Office of the Inspector General (OIG) conduct an audit of all fetal tissue research supported by HHS, specifically examining the Department's oversight of contractor and grantee compliance with the laws governing fetal tissue research.
U.S. Senators Lisa Murkowski and Dan Sullivan, and Congressman Don Young recently sent a letter (attached) to U.S. Fish and Wildlife Service (FWS) Director Dan Ashe expressing serious concern over the agency's upcoming subsistence harvest quota limits.
Senate Democratic Leaders sent a letter to President Obama today urging him to consider taking unilateral action to protect America's economy in the face of continued intransigence and obstruction from Republicans.


text:
Paul de Calkere (tweede helft dertiende eeuw) was een burgemeester van Brugge.

Levensloop
Paul de Calkere behoorde tot een familie van makelaars, ook al behoorde hij zelf niet tot de nering van de makelaars.

Hij behoorde tot het stadsbestuur. Hij was:
 schepen in 1273, 1275, 1283, 1285, 1287, 1289, 1291, 1293, 1298 en 1299;
 burgemeester van de schepenen in 1282, 1286, 1291, 1292, 1293, 1294 en 1295.

De Calkere trad in 1293 namens de stad op bij de aankoop door de stad van de tolrechten die tot dan aan de heren van Gistel behoorden.

In 1300 (tenzij het een zoon van hem was) was hij mede-organisator van een toernooi georganiseerd door het gezelschap van de Witte Beer.

Hij bezat grond in Aardenburg en in Vlissegem.

Bron
 Dirk VANDENAUWEELE, Schepenbank en schepenen te Brugge (1127-1384). Bijdrage tot de studie van een gewone stedelijke rechts- en bestuursinstelling, met lijst van Wetsvernieuwingen van 1211 tot 1357, doctoraatsverhandeling (onuitgegeven), Katholieke Universiteit Leuven, 1977.

Literatuur
 Albert SCHOUTEET, Regesten op de oorkonden 1089-1300, Brugge, 1973.
 Andries VAN DEN ABEELE, Het gezelschap van de Witte Beer, Brugge, 2000.
 Leen BERVOETS, De inwoners van Brugge in de twaalfde en dertiende eeuw: een prosopografische studie van de Bruggelingen tot 1280, masterthesis (onuitgegeven), Universiteit Gent, 2016.

DeCalkere
Persoon in de Nederlanden in de 13e eeuw
Zuid-Nederlands burgemeester (voor 1830)


With online casinos and real-money online gaming growing in popularity, making money online is more fun than ever… When you win. Making money off of gaming can be a notoriously difficult, but addictive process that people are falling into every day. While we're not telling you to look into financial betting odds or the ins-and-outs of house betting odds, a little research and a few of the tips below can help making money in online gaming a more successful and fruitful process.
By this, we don't necessarily mean stop playing casino games. A lot of games, online or in-house are mostly or entirely down to luck, but you can still be smart about your bets and gambles. Don't join a poker table with players of a higher skill level than you, don't bet on roulette squares if you're short on money and are notoriously unlucky against the wheel, and don't join a game that you don't know how to play. Stick to what you know and what you find fun.
This is extremely important if you know you're the type to over-gamble. If you only have £20 to spend, then only take £20. Leave your card and any cash you can't afford to spend at home, and once you're out of money, leave. If you start to bring in wins, be realistic. You can lose what you've won faster than you can win it, and it's important to keep track of what you're spending and what you're winning. If you've been sitting at a poker table and haven't won or broken even since you started twenty minutes ago, then stand up and walk away. As thrilling as risk-taking can be, it can also be your downfall.
Once you stop having fun, it's time to stop playing. Losing money is a horrible feeling if you aren't winning anything back and as tempting as it might be to spend the last of your money on that last, final game, stepping back will be more beneficial to you. Gaming is supposed to be fun, and as soon as it reaches a point in which it's not, it's definitely time to stop.
Most, if not all, online gaming sites will offer you some kind of welcome bonus. Take full advantage of this as much as you can, and use it to enjoy yourself. If using £10 worth of bets or gambles will get you another £50 in bonus, it can be worth joining and betting just for the extra money. Most sites will make it so that you can only use that money on their site, but that £50 can bring you in even more if you play the right games and place the right bets.
All in all, knowing when to quit will be your best skill when it comes to making and keeping money while you're gaming online. If you aren't winning, step back, and if you are winning, also step back when you reach a certain point. Set yourself a goal – if you reach that goal, then stop and enjoy your winnings, and if you don't, make sure you don't spend any more than you can afford to, or intended to spend.


1978 CA Deeper Near Shore Miscellaneous $45,000	 09/24/2018 - New listing.
2009 California Dive - Sea Cucumber Dive $23,500	 02/11/2019 - Price Reduction. 1-09-19New price. 12-21-18 New listing.
2013 California Dive-Sea Cucumber Dive $25,000	 02/05/2019 - New price. 1-7-19 New listing.
1488 California Dungeness - 34.5'/250 Pot Shellfish $125,000	 $75,000	 04/05/2016 - New offer. 8-19-15 New listing. Good to 34' 6".
1836 California Dungeness - 35.5' 175 Pot Shellfish $65,000	 10/13/2017 - New listing.
1927 California Dungeness - 38.6/250 Pot Shellfish $90,000	 04/28/2018 - New listing.
1703 California Dungeness 52'/400 Pot Shellfish Wanted $300,000	- or part trade a 47'/250 pot permit and cash 02/03/2017 - New listing. Permit wanted. Buy 52'/400 or have 47'/250 pot permit to trade w/cash.
957 California Lobster Shellfish $108,000	 05/31/2018 - New listing.
1890 California Lobster Shellfish $130,000	 02/28/2018 - New listing.
1721 California Lobster Shellfish $120,000	 02/28/2017 - New listing.
1822 California Near Shore North Miscellaneous $30,000	 02/09/2018 - Deep water, North Central Region Wanted.
1979 California Nearshore South Central Hook and Line Miscellaneous $95,000	 09/24/2018 - New listing.
1967 California Nearshore South Non-Trap Miscellaneous $95,000	 08/15/2018 - New listing.
1933 Oregon Blue/Black Near Shore Endorsed 28' Miscellaneous Wanted $25,000	 04/05/2019 - New offer. Permit wanted. Good to 28' minimum.
1693 Oregon Columbia River Youngs Bay and Willipa Bay Permits Salmon $12,000	 01/05/2017 - New listing. Both permits together. 2 net included.
1953 Oregon Dive - Sea Urchin Wanted $30,000	 07/24/2018 - New offer. Permit wanted.
1997 Oregon Dive - Sea Urchin Dive $32,000	 11/13/2018 - New listing.
1983 Oregon Dungeness 26' 300 Pot Shellfish $50,000	 09/28/2018 - New listing. Good to 26' max.
1999 Oregon Dungeness 52' 200 Pot Shellfish Wanted $80,000	 11/16/2018 - New offer. Permit good to 52' wanted.
1817 Oregon Dungeness 52' 300 Pot Lease Shellfish Wanted $15,000	 09/08/2017 - Lease wanted with gear.
2041 Oregon Dungeness 58' 500 Pot Shellfish Trade 03/07/2019 - New listing. Looking for Coastal longline permit and/or California crab permit.
1938 Oregon Southern Clam Dive Dive $16,000	 05/30/2018 - New listing.
1453 Oregon Troll 30' Salmon $9,000	 05/22/2015 - New listing. Good to 30'.
1449 Oregon Troll 30' Salmon $11,000	 05/08/2015 - New listing. Good to 30'.
1510 Oregon Troll 30' Salmon $8,000	 $5,000	 08/08/2017 - New offer. 10-21-15 New listing. Good to 30' max.
1535 Oregon Troll 42.9' Salmon $16,500	 12/31/2015 - New listing. Good to 42.9 max.
1446 Oregon Troll Unlimited Salmon $28,500	 04/14/2017 - New listing.
1837 Oregon Troll Unlimited Salmon Trade for Washington Troll 10/13/2017 - New listing. Wants to trade for Washington Troll permit.
1475 Oregon Troll Unlimited w/Gear Salmon $25,000	 04/16/2016 - New price. 2-12-16 New listing. Permit and 3 spool Kolstrand gurdies, leads, floats, drags, etc.
1991 Puget Sound Crab $178,000	 12/30/2018 - New Listing.
1951 Puget Sound Crab Shellfish Wanted $150,000	 06/21/2018 - New offer.
2014 Puget Sound Crab Shellfish $170,000	 01/08/2019 - New Listing.
1949 Puget Sound Crab Shellfish $172,000	 06/15/2018 - New listing.
2038 Puget Sound Crab Lease $30,000	 03/01/2019 - Looking to lease two Puget Sound crab for 2019 season. $30k for two.
2026 Puget Sound Crab Lease Shellfish Wanted $15,000	 04/19/2019 - Lease wanted. New offer for 19/20 season.
1143 Puget Sound Gillnet Salmon $22,000	 01/25/2017 - New price. 9-2-15 Includes fall net. 8-19-15 New price. 8-4-14 New listing. Gear available w/permit.
1424 Puget Sound Gillnet Salmon $18,000	 $15,000	 12/23/2018 - SOLD. 12-15-18 Sale pending. 12-13-18 New offer. 11-28-17 New listing.
1758 Puget Sound Gillnet Salmon $18,000	 03/18/2018 - New listing.
1845 Puget Sound Gillnet w/gear Salmon $30,000	 11/12/2018 - New listing. 2 king nets, Skagit net, sockeye net and fall chum included.
2056 Puget Sound salmon gillnet Salmon $15,000	 04/11/2019 - New listing.
2020 Puget Sound Seine Salmon $140,000	 $140,000	 03/27/2019 - SOLD. 2-6-19 New listing.
1655 Puget Sound Shrimp Pot Shellfish Wanted $290,000	 11/06/2017 - New Offer. Permit wanted.
1994 Washington Charter 10 pole Salmon $60,000	 11/07/2018 - New listing.
2002 Washington Coast Dungeness 55'/500 Pot Lease Shellfish 10% up to $25k 11/20/2018 - New listing. For lease at 10% up to max of $25k. Good to 55' max.
1974 Washington Coast Dungeness 58'/500 Pot Shellfish $410,000	 09/12/2018 - New listing. Good to 58' max.
1851 Washington Coast Dungeness 58'/500 Pot Shellfish $400,000	 12/06/2018 - New listing. Good to 66'.
1985 Washington Coast Dungeness 58'/500 Pot Lease Shellfish $20,000	 11/20/2018 - New listing. $20k flat fee.
1770 Washington Coast Dungeness 58'/500 Pot w/gear Shellfish $575,000	 05/20/2017 - New listing. Good to 68'. Includes 500 pots.
1973 Washington Coast Dungeness 77'/500 Pot Shellfish Trade 09/11/2018 - New listing. Permit is good to 77'. Want trade to 52' permit, either 300 or 500 pot and cash.
2040 Washington Coast Spot Prawn Pot 78' Shellfish $290,000	 03/01/2019 - New listing. Includes some gear.
1889 Washington Columbia River/Grays Harbor Lease Salmon $2,100	 02/28/2018 - New listing.
1659 Washington Columbia River/Greys Harbor Salmon $6,500	 04/11/2019 - New listing.
1439 Washington Columbia River/Willapa and Youngs Bay permits Salmon $12,000	 01/05/2017 - New listing. Both permits together. 2 nets included.
1888 Washington Columbia River/Willapa Lease Salmon $2,100	 02/28/2018 - New listing.
1184 Washington Dive - Urchin Dive Wanted $50,000	 08/02/2018 - New offer. Permit wanted.
1352 Washington Sardine Seine Miscellaneous Make Offer 05/21/2017 - New listing. Make offer.
1470 Washington Troll Salmon $22,500	 $19,500	 03/10/2019 - SOLD. 3-7-19 New offer. Sale pending. 1-17-19 New listing.
1729 Washington Troll Lease Salmon $4,000	 04/16/2019 - New listing.
2022 Washington Troll with gear Salmon $25,000	 01/25/2019 - New listing. Permit and aluminum poles and hayrack and gurdies.