Pub Date : 2023-12-01Epub Date: 2023-08-24DOI: 10.1136/bmjnph-2022-000600
Meghan O'Hearn, Julia Reedy, Ella Robinson, Christina Economos, John B Wong, Gary Sacks, Dariush Mozaffarian
Introduction: The private sector plays a critical role in influencing food choices and health outcomes of consumers. Among private sector actors, investors are a powerful yet underutilised stakeholder for driving scalable public health impact. There are systems to facilitate investors' involvement, notably environmental, social and governance (ESG) investing, which is well placed to include an assessment of business risks to social well-being. However, nutrition efforts within the ESG agenda (ESG-Nutrition) are nascent. We aimed to critically assess the strength of existing ESG-Nutrition metrics to advance the science of measuring business impacts on consumer nutrition and health.
Methods: ESG-Nutrition metrics were extracted from eight ESG frameworks and categorised across four domains: product portfolio healthfulness; product distribution and equity; product marketing and labelling; and nutrition-related governance. The strength of each metric was evaluated and scored 1-3 (best), independently by two researchers, based on six attributes: materiality, objectivity, alignment, activity, resolution and verifiability. The total score (range 6-18) and intercorrelation for each attribute was calculated.
Results: Across 529 metrics, most related to product marketing and labelling (n=230, 43.5%), followed by product healthfulness (n=126, 23.8%), nutrition-related governance (n=108, 20.4%) and product distribution and equity (n=65, 12.3%). Across all metrics, average total score was 10.94 (1.58), with average attribute scoring highest for verifiability (mean: 2.36 (SD: 0.57)), objectivity (2.11 (0.61)) and materiality (2.01 (0.68)) and lowest for activity (1.83 (0.74)), alignment (1.37 (0.67)) and resolution (1.26 (0.65)). Most intercorrelations were null, suggesting attributes were measuring distinct characteristics of each metric. Significant heterogeneity across domains and frameworks was also observed.
Conclusions: This research identifies a range of nutrition-related metrics used in ESG frameworks with respect to food companies, but with substantial heterogeneity in relevant nutrition domains covered and strength of each metric. Efforts are required to improve the quality of metrics across frameworks, establish standardised reporting and align these with investor priorities.
{"title":"Landscape analysis of environmental, social and governance (ESG) investing metrics for consumer nutrition and health in the food and beverage sector.","authors":"Meghan O'Hearn, Julia Reedy, Ella Robinson, Christina Economos, John B Wong, Gary Sacks, Dariush Mozaffarian","doi":"10.1136/bmjnph-2022-000600","DOIUrl":"10.1136/bmjnph-2022-000600","url":null,"abstract":"<p><strong>Introduction: </strong>The private sector plays a critical role in influencing food choices and health outcomes of consumers. Among private sector actors, investors are a powerful yet underutilised stakeholder for driving scalable public health impact. There are systems to facilitate investors' involvement, notably environmental, social and governance (ESG) investing, which is well placed to include an assessment of business risks to social well-being. However, nutrition efforts within the ESG agenda (ESG-Nutrition) are nascent. We aimed to critically assess the strength of existing ESG-Nutrition metrics to advance the science of measuring business impacts on consumer nutrition and health.</p><p><strong>Methods: </strong>ESG-Nutrition metrics were extracted from eight ESG frameworks and categorised across four domains: product portfolio healthfulness; product distribution and equity; product marketing and labelling; and nutrition-related governance. The strength of each metric was evaluated and scored 1-3 (best), independently by two researchers, based on six attributes: materiality, objectivity, alignment, activity, resolution and verifiability. The total score (range 6-18) and intercorrelation for each attribute was calculated.</p><p><strong>Results: </strong>Across 529 metrics, most related to product marketing and labelling (n=230, 43.5%), followed by product healthfulness (n=126, 23.8%), nutrition-related governance (n=108, 20.4%) and product distribution and equity (n=65, 12.3%). Across all metrics, average total score was 10.94 (1.58), with average attribute scoring highest for verifiability (mean: 2.36 (SD: 0.57)), objectivity (2.11 (0.61)) and materiality (2.01 (0.68)) and lowest for activity (1.83 (0.74)), alignment (1.37 (0.67)) and resolution (1.26 (0.65)). Most intercorrelations were null, suggesting attributes were measuring distinct characteristics of each metric. Significant heterogeneity across domains and frameworks was also observed.</p><p><strong>Conclusions: </strong>This research identifies a range of nutrition-related metrics used in ESG frameworks with respect to food companies, but with substantial heterogeneity in relevant nutrition domains covered and strength of each metric. Efforts are required to improve the quality of metrics across frameworks, establish standardised reporting and align these with investor priorities.</p>","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10800242/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44171687","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-14DOI: 10.1136/bmjnph-2023-000758
Karen M O'Callaghan, Huma Qamar, Alison D Gernand, AK Onoyovwi, Stanley Zlotkin, Abdullah A Mahmud, Tahmeed Ahmed, Farhana K Keya, Daniel E Roth
Background Vitamin D may modify iron status through regulation of hepcidin and inflammatory pathways. This study aimed to investigate effects of maternal vitamin D supplementation on iron status in pregnancy and early infancy. Methods In a trial in Dhaka, Bangladesh, women (n=1300) were randomised to one of five vitamin D 3 regimens from 17 to 24 weeks’ gestation until 26 weeks postpartum (prenatal; postpartum doses): 0;0, 4200;0, 16 800;0, 28 000;0 or 28 000;28 000 IU/week. All participants received standard iron-folic acid supplementation. In this secondary analysis (n=998), we examined effects of prenatal;postpartum vitamin D on serum ferritin and other biomarkers of maternal iron status (transferrin saturation, total iron binding capacity, soluble transferrin receptor and hepcidin) at delivery, and infant ferritin and haemoglobin at 6 months of age. Using linear regression, we estimated per cent mean differences between each intervention group and placebo with 95% CIs, with and without adjustment for baseline ferritin or inflammatory biomarkers (C reactive protein and α-1-acid glycoprotein (AGP)). Results At delivery, ferritin concentrations were similar between each intervention group and placebo in unadjusted (n=998) and baseline ferritin-adjusted analyses (n=992; p>0.05). Compared with placebo, AGP was lower in each intervention group (per cent difference (95% CI) = −11% (−21 to –1.0), −14% (−23 to –3.5) and −11% (−19 to –2.0) in the 4200 IU/week, 16 800 IU/week and 28 000 IU/week groups, respectively; n=779). In the subgroup of women with baseline 25-hydroxyvitamin D < 30 nmol/L, ferritin was lower in each intervention group versus placebo (−23% (−37 to –5.0), −20% (−35 to –1.9) and −20% (−33 to –4.1) in the 4200 IU/week, 16 800 IU/week and 28 000 IU/week groups, respectively; n=645); effects were slightly attenuated after adjustment for inflammation (n=510). There were no effects of vitamin D on other iron biomarkers among women at delivery or infants aged 6 months. Conclusion These findings do not support improvement of iron status by vitamin D. The effect of prenatal vitamin D supplementation on ferritin may reflect an anti-inflammatory mechanism.
{"title":"Maternal prenatal, with or without postpartum, vitamin D3 supplementation does not improve maternal iron status at delivery or infant iron status at 6 months of age: secondary analysis of a randomised controlled trial","authors":"Karen M O'Callaghan, Huma Qamar, Alison D Gernand, AK Onoyovwi, Stanley Zlotkin, Abdullah A Mahmud, Tahmeed Ahmed, Farhana K Keya, Daniel E Roth","doi":"10.1136/bmjnph-2023-000758","DOIUrl":"https://doi.org/10.1136/bmjnph-2023-000758","url":null,"abstract":"Background Vitamin D may modify iron status through regulation of hepcidin and inflammatory pathways. This study aimed to investigate effects of maternal vitamin D supplementation on iron status in pregnancy and early infancy. Methods In a trial in Dhaka, Bangladesh, women (n=1300) were randomised to one of five vitamin D 3 regimens from 17 to 24 weeks’ gestation until 26 weeks postpartum (prenatal; postpartum doses): 0;0, 4200;0, 16 800;0, 28 000;0 or 28 000;28 000 IU/week. All participants received standard iron-folic acid supplementation. In this secondary analysis (n=998), we examined effects of prenatal;postpartum vitamin D on serum ferritin and other biomarkers of maternal iron status (transferrin saturation, total iron binding capacity, soluble transferrin receptor and hepcidin) at delivery, and infant ferritin and haemoglobin at 6 months of age. Using linear regression, we estimated per cent mean differences between each intervention group and placebo with 95% CIs, with and without adjustment for baseline ferritin or inflammatory biomarkers (C reactive protein and α-1-acid glycoprotein (AGP)). Results At delivery, ferritin concentrations were similar between each intervention group and placebo in unadjusted (n=998) and baseline ferritin-adjusted analyses (n=992; p>0.05). Compared with placebo, AGP was lower in each intervention group (per cent difference (95% CI) = −11% (−21 to –1.0), −14% (−23 to –3.5) and −11% (−19 to –2.0) in the 4200 IU/week, 16 800 IU/week and 28 000 IU/week groups, respectively; n=779). In the subgroup of women with baseline 25-hydroxyvitamin D < 30 nmol/L, ferritin was lower in each intervention group versus placebo (−23% (−37 to –5.0), −20% (−35 to –1.9) and −20% (−33 to –4.1) in the 4200 IU/week, 16 800 IU/week and 28 000 IU/week groups, respectively; n=645); effects were slightly attenuated after adjustment for inflammation (n=510). There were no effects of vitamin D on other iron biomarkers among women at delivery or infants aged 6 months. Conclusion These findings do not support improvement of iron status by vitamin D. The effect of prenatal vitamin D supplementation on ferritin may reflect an anti-inflammatory mechanism.","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134900622","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background Research on menstrual hygiene management practices (MHMP) has yet to be conducted among adolescent girls in Bangladesh who have gained services from the Urban Primary Health Care Project (UPHCP). This study aimed to assess the effects of behavioural change communication activities on MHMP among urban school adolescent girls. Methods A convenience sample of 270 adolescent girls (aged 10–19) who had no chronic diseases from 5 schools in Dhaka city was selected using a descriptive cross-sectional design from February to May 2018. A semistructured (interviewer-administered) questionnaire was used. Frequencies were calculated for descriptive analysis. Results About 17% of girls had irregular menstrual cycles, 57% felt uneasy and 27% had >7 days of menstrual flow. Fifty-five per cent of the girls used sanitary napkins. Most (95%) and 26% of the girls did not change their pads during school and at night, respectively. Sixty-five per cent of girls disposed of the used pads at the public dustbin, and 83% bathed during menstrual. Only 4% of girls were aware of the iron folic acid tablets. Conclusions Despite the availability of services from UPHCP, the acceptance and adherence to MHMP among adolescent girls still need to be improved.
{"title":"Effects of behavioural change communication (BCC) on menstrual hygiene practices among urban school adolescent girls: a pilot study","authors":"Farzana Saleh, Kazi Rumana Ahmed, Taslima Khatun, Nandini Roy, Sadia Uddin, Md Rowshan Kabir","doi":"10.1136/bmjnph-2023-000754","DOIUrl":"https://doi.org/10.1136/bmjnph-2023-000754","url":null,"abstract":"Background Research on menstrual hygiene management practices (MHMP) has yet to be conducted among adolescent girls in Bangladesh who have gained services from the Urban Primary Health Care Project (UPHCP). This study aimed to assess the effects of behavioural change communication activities on MHMP among urban school adolescent girls. Methods A convenience sample of 270 adolescent girls (aged 10–19) who had no chronic diseases from 5 schools in Dhaka city was selected using a descriptive cross-sectional design from February to May 2018. A semistructured (interviewer-administered) questionnaire was used. Frequencies were calculated for descriptive analysis. Results About 17% of girls had irregular menstrual cycles, 57% felt uneasy and 27% had >7 days of menstrual flow. Fifty-five per cent of the girls used sanitary napkins. Most (95%) and 26% of the girls did not change their pads during school and at night, respectively. Sixty-five per cent of girls disposed of the used pads at the public dustbin, and 83% bathed during menstrual. Only 4% of girls were aware of the iron folic acid tablets. Conclusions Despite the availability of services from UPHCP, the acceptance and adherence to MHMP among adolescent girls still need to be improved.","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134900752","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-14DOI: 10.1136/bmjnph-2023-000764
Valentine Bordier, Fabienne Teysseire, Jürgen Drewe, Philipp Madörin, Oliver Bieri, Arno Schmidt-Trucksäss, Henner Hanssen, Christoph Beglinger, Anne Christin Meyer-Gerspach, Bettina K Wölnerhanssen
Introduction Previous studies in humans and rats suggest that erythritol might positively affect vascular function, xylitol decrease visceral fat mass and both substances improve glycaemic control. The objective of this study was to investigate the impact of a 5-week intake of erythritol and xylitol on vascular function, abdominal fat and blood lipids, glucose tolerance, uric acid, hepatic enzymes, creatinine, gastrointestinal tolerance and dietary patterns in humans with obesity. Methods Forty-two participants were randomised to consume either 36 g erythritol, 24 g xylitol, or no substance daily for 5 weeks. Before and after the intervention, arterial stiffness (pulse wave velocity, arteriolar-to-venular diameter ratio), abdominal fat (liver volume, liver fat percentage, visceral and subcutaneous adipose tissue, blood lipids), glucose tolerance (glucose and insulin concentrations), uric acid, hepatic enzymes, creatinine, gastrointestinal tolerance and dietary patterns were assessed. Data were analysed by linear mixed effect model. Results The 5-week intake of erythritol and xylitol showed no statistically significant effect on vascular function. Neither the time nor the treatment effects were significantly different for pulse wave velocity (time effect: p=0.079, Cohen’s D (95% CI) −0.14 (−0.54–0.25); treatment effect: p=0.792, Cohen’s D (95% CI) control versus xylitol: −0.11 (–0.61–0.35), control versus erythritol: 0.05 (0.44–0.54), erythritol versus xylitol: 0.07 (–0.41–0.54)). There was no statistically significant effect on abdominal fat, glucose tolerance, uric acid, hepatic enzymes and creatinine. Gastrointestinal tolerance was good except for a few diarrhoea-related symptoms. Participants of all groups reduced their consumption of sweetened beverages and sweets compared with preintervention. Conclusions The 5-week intake of erythritol and xylitol showed no statistically significant effects on vascular function, abdominal fat, or glucose tolerance in people with obesity. Clinical trial registration NCT02821923 .
先前对人类和大鼠的研究表明赤藓糖醇可能对血管功能有积极影响，木糖醇可以减少内脏脂肪量，两种物质都可以改善血糖控制。本研究的目的是调查5周摄入赤藓糖醇和木糖醇对肥胖人群血管功能、腹部脂肪和血脂、葡萄糖耐量、尿酸、肝酶、肌酐、胃肠耐量和饮食模式的影响。方法将42名受试者随机分为每天服用36 g赤藓糖醇、24 g木糖醇和不服用任何药物组，持续5周。在干预前后，评估动脉硬度(脉搏波速度、小动脉与静脉直径比)、腹部脂肪(肝脏体积、肝脏脂肪百分比、内脏和皮下脂肪组织、血脂)、葡萄糖耐量(葡萄糖和胰岛素浓度)、尿酸、肝酶、肌酐、胃肠耐量和饮食模式。数据采用线性混合效应模型进行分析。结果5周摄入赤藓糖醇和木糖醇对血管功能无显著影响。脉冲波速在时间和治疗效果上均无显著差异(时间效应:p=0.079, Cohen 's D (95% CI) - 0.14 (- 0.54-0.25);治疗效果:p=0.792, Cohen 's D (95% CI)对照与木糖醇:- 0.11(-0.61-0.35)，对照与赤糖醇:0.05(0.44-0.54)，赤糖醇与木糖醇:0.07(-0.41-0.54))。对腹部脂肪、葡萄糖耐量、尿酸、肝酶和肌酐的影响无统计学意义。除少数腹泻相关症状外，胃肠道耐受性良好。与干预前相比，所有组的参与者都减少了含糖饮料和糖果的摄入量。结论:5周摄入赤藓糖醇和木糖醇对肥胖患者的血管功能、腹部脂肪或葡萄糖耐量无统计学意义的影响。临床试验注册编号NCT02821923。
{"title":"Effects of a 5-week intake of erythritol and xylitol on vascular function, abdominal fat and glucose tolerance in humans with obesity: a pilot trial","authors":"Valentine Bordier, Fabienne Teysseire, Jürgen Drewe, Philipp Madörin, Oliver Bieri, Arno Schmidt-Trucksäss, Henner Hanssen, Christoph Beglinger, Anne Christin Meyer-Gerspach, Bettina K Wölnerhanssen","doi":"10.1136/bmjnph-2023-000764","DOIUrl":"https://doi.org/10.1136/bmjnph-2023-000764","url":null,"abstract":"Introduction Previous studies in humans and rats suggest that erythritol might positively affect vascular function, xylitol decrease visceral fat mass and both substances improve glycaemic control. The objective of this study was to investigate the impact of a 5-week intake of erythritol and xylitol on vascular function, abdominal fat and blood lipids, glucose tolerance, uric acid, hepatic enzymes, creatinine, gastrointestinal tolerance and dietary patterns in humans with obesity. Methods Forty-two participants were randomised to consume either 36 g erythritol, 24 g xylitol, or no substance daily for 5 weeks. Before and after the intervention, arterial stiffness (pulse wave velocity, arteriolar-to-venular diameter ratio), abdominal fat (liver volume, liver fat percentage, visceral and subcutaneous adipose tissue, blood lipids), glucose tolerance (glucose and insulin concentrations), uric acid, hepatic enzymes, creatinine, gastrointestinal tolerance and dietary patterns were assessed. Data were analysed by linear mixed effect model. Results The 5-week intake of erythritol and xylitol showed no statistically significant effect on vascular function. Neither the time nor the treatment effects were significantly different for pulse wave velocity (time effect: p=0.079, Cohen’s D (95% CI) −0.14 (−0.54–0.25); treatment effect: p=0.792, Cohen’s D (95% CI) control versus xylitol: −0.11 (–0.61–0.35), control versus erythritol: 0.05 (0.44–0.54), erythritol versus xylitol: 0.07 (–0.41–0.54)). There was no statistically significant effect on abdominal fat, glucose tolerance, uric acid, hepatic enzymes and creatinine. Gastrointestinal tolerance was good except for a few diarrhoea-related symptoms. Participants of all groups reduced their consumption of sweetened beverages and sweets compared with preintervention. Conclusions The 5-week intake of erythritol and xylitol showed no statistically significant effects on vascular function, abdominal fat, or glucose tolerance in people with obesity. Clinical trial registration NCT02821923 .","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134992180","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-14DOI: 10.1136/bmjnph-2023-000714
Nina Trivedy Rogers, David I Conway, Oliver Mytton, Chrissy H Roberts, Harry Rutter, Andrea Sherriff, Martin White, Jean Adams
Introduction Tooth extraction due to dental caries is associated with socioeconomic deprivation and is a major reason for elective childhood hospital admissions in England. Consumption of sugar-sweetened beverages is a risk factor for dental caries. We examined whether the soft drinks industry levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in incidence rates of hospital admissions for carious tooth extraction in children, 22 months post-SDIL implementation. Methods Changes in incidence rates of monthly National Health Service hospital admissions for extraction of teeth due to a primary diagnosis of dental caries (International Classification of Diseases; ICD-10 code: K02) in England, between January 2012 and February 2020, were estimated using interrupted time series and compared with a counterfactual scenario where SDIL was not announced or implemented. Periodical changes in admissions, autocorrelation and population structure were accounted for. Estimates were calculated overall, by Index of Multiple Deprivation (IMD) fifths and by age group (0–4 years, 5–9 years, 10–14 years, 15–18 years). Results Compared with the counterfactual scenario, there was a relative reduction of 12.1% (95% CI 17.0% to 7.2%) in hospital admissions for carious tooth extractions in all children (0–18 years). Children aged 0–4 years and 5–9 years had relative reductions of 28.6% (95% CI 35.6% to 21.5%) and 5.5% (95% CI 10.5% to 0.5%), respectively; no change was observed for older children. Reductions were observed in children living in most IMD areas regardless of deprivation. Conclusion The UK SDIL was associated with reductions in incidence rates of childhood hospital admissions for carious tooth extractions, across most areas regardless of deprivation status and especially in younger children. Trial registration number ISRCTN18042742 .
由于龋齿而拔牙与社会经济贫困有关，是英国儿童选择性住院的主要原因。饮用含糖饮料是患龋齿的一个危险因素。我们研究了2016年3月宣布并于2018年4月实施的软饮料行业税(SDIL)是否与实施后22个月儿童龋齿住院率的变化有关。方法初步诊断为龋齿的每月国民保健院拔牙住院率的变化(国际疾病分类;使用中断时间序列对2012年1月至2020年2月期间英国的ICD-10代码:K02进行了估计，并与未宣布或实施SDIL的反事实情景进行了比较。考虑了招生、自相关和人口结构的周期性变化。根据多重剥夺指数(IMD)五分之一和年龄组(0-4岁、5-9岁、10-14岁、15-18岁)计算总体估计值。结果与反事实情景相比，所有儿童(0-18岁)因龋齿拔牙入院的相对减少了12.1% (95% CI 17.0%至7.2%)。0-4岁和5-9岁儿童的相对下降分别为28.6% (95% CI 35.6%至21.5%)和5.5% (95% CI 10.5%至0.5%);在年龄较大的儿童中没有观察到变化。生活在大多数贫困地区的儿童，不论是否贫困，都出现了减少。结论:英国SDIL与儿童龋齿住院率的降低有关，在大多数地区，无论贫困状况如何，尤其是在年幼的儿童中。试验注册号ISRCTN18042742。
{"title":"Estimated impact of the UK soft drinks industry levy on childhood hospital admissions for carious tooth extractions: interrupted time series analysis","authors":"Nina Trivedy Rogers, David I Conway, Oliver Mytton, Chrissy H Roberts, Harry Rutter, Andrea Sherriff, Martin White, Jean Adams","doi":"10.1136/bmjnph-2023-000714","DOIUrl":"https://doi.org/10.1136/bmjnph-2023-000714","url":null,"abstract":"Introduction Tooth extraction due to dental caries is associated with socioeconomic deprivation and is a major reason for elective childhood hospital admissions in England. Consumption of sugar-sweetened beverages is a risk factor for dental caries. We examined whether the soft drinks industry levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in incidence rates of hospital admissions for carious tooth extraction in children, 22 months post-SDIL implementation. Methods Changes in incidence rates of monthly National Health Service hospital admissions for extraction of teeth due to a primary diagnosis of dental caries (International Classification of Diseases; ICD-10 code: K02) in England, between January 2012 and February 2020, were estimated using interrupted time series and compared with a counterfactual scenario where SDIL was not announced or implemented. Periodical changes in admissions, autocorrelation and population structure were accounted for. Estimates were calculated overall, by Index of Multiple Deprivation (IMD) fifths and by age group (0–4 years, 5–9 years, 10–14 years, 15–18 years). Results Compared with the counterfactual scenario, there was a relative reduction of 12.1% (95% CI 17.0% to 7.2%) in hospital admissions for carious tooth extractions in all children (0–18 years). Children aged 0–4 years and 5–9 years had relative reductions of 28.6% (95% CI 35.6% to 21.5%) and 5.5% (95% CI 10.5% to 0.5%), respectively; no change was observed for older children. Reductions were observed in children living in most IMD areas regardless of deprivation. Conclusion The UK SDIL was associated with reductions in incidence rates of childhood hospital admissions for carious tooth extractions, across most areas regardless of deprivation status and especially in younger children. Trial registration number ISRCTN18042742 .","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134993577","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Introduction Deteriorating mobility and falls reduce independence and quality of life for older people receiving aged care services. This trial aims to establish effectiveness on the mobility of older people, and explore cost-effectiveness and implementation of a telehealth physiotherapy programme. Method and analysis This type 1 hybrid effectiveness-implementation randomised controlled trial will involve 240 people aged 65+ years receiving aged care services in community or residential settings. Participants will be randomised to either: (1) the Telehealth Physiotherapy for Older People (TOP UP) Program or (2) a wait-list control group. The 6-month intervention includes 10 physiotherapy sessions delivered by videocall (Zoom). The intervention will include the local support of an aged care worker and online exercise resources. Primary outcome is mobility at 6 months post randomisation measured by the Short Physical Performance Battery. Secondary outcomes include rate of falls, sit-to-stand, quality of life, and goal attainment at 6 months after randomisation. Regression models will assess the effect of group allocation on mobility and the other continuously scored secondary outcomes, adjusting for baseline scores. The number of falls per person over 6 months will be analysed using negative binomial regression models to estimate between-group differences. An economic analysis will explore the cost-effectiveness of the TOP UP programme compared with usual care. Implementation outcomes and determinants relating to the intervention’s reach, fidelity, exercise dose delivered, adoption, feasibility, acceptability, barriers and facilitators will be explored using mixed methods. Conclusion This is the first trial to investigate the effectiveness, cost-effectiveness and implementation of a physiotherapy intervention in aged care delivered solely by telehealth internationally. The study has strong aged care co-design and governance and is guided by steering and advisory committees that include staff from aged care service providers and end-users. Trial results will be disseminated via peer-reviewed articles, conference presentations and lay summaries. Trial registration number The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12621000734864).
{"title":"Physiotherapy-led telehealth and exercise intervention to improve mobility in older people receiving aged care services (TOP UP): protocol for a randomised controlled type 1 hybrid effectiveness-implementation trial","authors":"Rik Dawson, Marina Pinheiro, Vasikaran Nagathan, Morag Taylor, Kim Delbaere, Juliana Olivera, Abby Haynes, Jenny Rayner, Leanne Hassett, Catherine Sherrington","doi":"10.1136/bmjnph-2022-000606","DOIUrl":"https://doi.org/10.1136/bmjnph-2022-000606","url":null,"abstract":"Introduction Deteriorating mobility and falls reduce independence and quality of life for older people receiving aged care services. This trial aims to establish effectiveness on the mobility of older people, and explore cost-effectiveness and implementation of a telehealth physiotherapy programme. Method and analysis This type 1 hybrid effectiveness-implementation randomised controlled trial will involve 240 people aged 65+ years receiving aged care services in community or residential settings. Participants will be randomised to either: (1) the Telehealth Physiotherapy for Older People (TOP UP) Program or (2) a wait-list control group. The 6-month intervention includes 10 physiotherapy sessions delivered by videocall (Zoom). The intervention will include the local support of an aged care worker and online exercise resources. Primary outcome is mobility at 6 months post randomisation measured by the Short Physical Performance Battery. Secondary outcomes include rate of falls, sit-to-stand, quality of life, and goal attainment at 6 months after randomisation. Regression models will assess the effect of group allocation on mobility and the other continuously scored secondary outcomes, adjusting for baseline scores. The number of falls per person over 6 months will be analysed using negative binomial regression models to estimate between-group differences. An economic analysis will explore the cost-effectiveness of the TOP UP programme compared with usual care. Implementation outcomes and determinants relating to the intervention’s reach, fidelity, exercise dose delivered, adoption, feasibility, acceptability, barriers and facilitators will be explored using mixed methods. Conclusion This is the first trial to investigate the effectiveness, cost-effectiveness and implementation of a physiotherapy intervention in aged care delivered solely by telehealth internationally. The study has strong aged care co-design and governance and is guided by steering and advisory committees that include staff from aged care service providers and end-users. Trial results will be disseminated via peer-reviewed articles, conference presentations and lay summaries. Trial registration number The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12621000734864).","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134900753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-09DOI: 10.1136/bmjnph-2022-000522
Ryan E King, Claire Palermo, Alyce N Wilson
Objective To systematically map nutrition content in medical curricula across all 23 medical schools in Australia and New Zealand accredited by the Australian Medical Council (AMC). Methods A cross-sectional content analysis was conducted. Learning outcomes for 20 AMC-accredited medical curricula were extracted from online repositories and directly from universities in February to April 2021. Nutrition relevant learning outcomes or equivalent learning objectives/graduate attributes were identified. Nutrition learning outcomes were analysed according to Bloom’s revised taxonomy to determine whether outcomes met cognitive, psychomotor or affective domains and at what level. Results Of the total 23 AMC-accredited medical curricula, 20 medical schools had learning outcomes able to be sourced for analysis. A total of 186 nutrition learning outcomes were identified within 11 medical curricula. One medical school curriculum comprised 129 of 186 (69.4%) nutrition learning outcomes. The majority of outcomes (181, 97.3%) were in the cognitive domain of Bloom’s revised taxonomy, predominantly at level 3 ‘applying’ (90, 49.7%). The psychomotor domain contained five nutrition learning outcomes (5, 2.7%), while the affective domain contained none. New Zealand medical curricula (153, 82.3%) contained 4.6-fold more nutrition learning outcomes than Australian curricula (33, 17.7%). When comparing clinical and preclinical years across curricula, the proportion of learning outcomes in the psychomotor domain was 3.7-fold higher in clinical years (4.08%) versus preclinical years (1.15%). Conclusion There is wide variation across medical curricula regarding the number of nutrition learning outcomes. This may lead to varying competency of medical graduates to provide nutrition care in Australia and New Zealand.
{"title":"Mapping nutrition within medical curricula in Australia and New Zealand: a cross-sectional content analysis","authors":"Ryan E King, Claire Palermo, Alyce N Wilson","doi":"10.1136/bmjnph-2022-000522","DOIUrl":"https://doi.org/10.1136/bmjnph-2022-000522","url":null,"abstract":"Objective To systematically map nutrition content in medical curricula across all 23 medical schools in Australia and New Zealand accredited by the Australian Medical Council (AMC). Methods A cross-sectional content analysis was conducted. Learning outcomes for 20 AMC-accredited medical curricula were extracted from online repositories and directly from universities in February to April 2021. Nutrition relevant learning outcomes or equivalent learning objectives/graduate attributes were identified. Nutrition learning outcomes were analysed according to Bloom’s revised taxonomy to determine whether outcomes met cognitive, psychomotor or affective domains and at what level. Results Of the total 23 AMC-accredited medical curricula, 20 medical schools had learning outcomes able to be sourced for analysis. A total of 186 nutrition learning outcomes were identified within 11 medical curricula. One medical school curriculum comprised 129 of 186 (69.4%) nutrition learning outcomes. The majority of outcomes (181, 97.3%) were in the cognitive domain of Bloom’s revised taxonomy, predominantly at level 3 ‘applying’ (90, 49.7%). The psychomotor domain contained five nutrition learning outcomes (5, 2.7%), while the affective domain contained none. New Zealand medical curricula (153, 82.3%) contained 4.6-fold more nutrition learning outcomes than Australian curricula (33, 17.7%). When comparing clinical and preclinical years across curricula, the proportion of learning outcomes in the psychomotor domain was 3.7-fold higher in clinical years (4.08%) versus preclinical years (1.15%). Conclusion There is wide variation across medical curricula regarding the number of nutrition learning outcomes. This may lead to varying competency of medical graduates to provide nutrition care in Australia and New Zealand.","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135241681","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-07DOI: 10.1136/bmjnph-2023-000702
Pushpanjali Shakya, Archana Shrestha, Monish Bajracharya, Abha Shrestha, Bård Erik Kulseng, Biraj Man Karmacharya, Smriti Shrestha, Seema Das, Ishwori Byanju Shrestha, Krishnaa Barun, Nistha Shrestha, Eva Skovlund, Abhijit Sen
Background Although several lifestyle intervention studies have been conducted in low/middle-income countries, there were no such studies in Nepal. Therefore, a group-based culturally tailored Diabetes Prevention Education Program (DiPEP) was conducted recently. The study aimed to evaluate the effect of DiPEP in glycated haemoglobin (HbA1c), weight, waist circumference, physical activity and diet among population with pre-diabetes. Method A two-arm cluster randomised controlled trial was conducted in 12 clusters of two urban areas in Nepal. The DiPEP was a 6 month intervention (four 1-hour weekly educational sessions and 5 months of follow-up by community health workers/volunteers (CHW/Vs)). A postintervention assessment was done after 6 months. Linear mixed model was used to estimate the mean difference in primary outcome (HbA1c) and secondary outcomes (weight, waist circumference, physical activity and diet) between intervention and control arms, adjusted for baseline measure. Results In intention-to-treat analysis with a total of 291 participants, the estimated mean difference in HbA1c was found to be 0.015 percentage point (95% CI −0.074 to 0.104) between the intervention arm and the control arm, while it was −0.077 (95% CI −0.152 to −0.002) among those who attended at least 3 out of 4 educational sessions. The estimated mean difference in weight (in participants who attended ≥1 educational session) was −1.6 kg (95% CI −3.1 to −0.1). A significantly lower grain consumption was found in intervention arm (−39 g/day, 95% CI −65 to −14) compared with the control arm at postintervention assessment. Conclusion Although compliance was affected by COVID-19, individuals who participated in ≥3 educational sessions had significant reduction in HbA1c and those who attended ≥1 educational session had significant weight reduction. Grain intake was significantly reduced among the intervention arm than the control arm. Hence, group-based lifestyle intervention programmes involving CHW/vs is recommended for diabetes prevention. Trial registration number NCT04074148 .
背景:虽然在中低收入国家进行了一些生活方式干预研究，但在尼泊尔没有这样的研究。因此，最近开展了一项基于群体的文化定制糖尿病预防教育计划(DiPEP)。该研究旨在评估DiPEP对糖尿病前期人群糖化血红蛋白(HbA1c)、体重、腰围、身体活动和饮食的影响。方法采用两组随机对照试验，选取尼泊尔2个城市地区的12个聚类。DiPEP是一个为期6个月的干预(4次每周1小时的教育课程和5个月的社区卫生工作者/志愿者(CHW/Vs)的随访)。6个月后进行干预后评估。采用线性混合模型估计干预组和对照组之间主要结局(HbA1c)和次要结局(体重、腰围、体力活动和饮食)的平均差异，并根据基线测量进行调整。在总共291名参与者的意向治疗分析中，干预组和对照组的HbA1c估计平均差异为0.015个百分点(95% CI - 0.074至0.104)，而在至少参加了4次教育课程中的3次的患者中，HbA1c的估计平均差异为- 0.077 (95% CI - 0.152至- 0.002)。估计体重的平均差异(参加≥1次教育课程的参与者)为- 1.6 kg (95% CI为- 3.1至- 0.1)。在干预后评估中，与对照组相比，干预组的谷物消耗量显著降低(- 39 g/天，95% CI为- 65至- 14)。结论尽管依从性受到COVID-19的影响，但参加≥3次教育课程的个体HbA1c显著降低，参加≥1次教育课程的个体体重显著减轻。与对照组相比，干预组的谷物摄入量明显减少。因此，建议以群体为基础的生活方式干预方案，包括CHW/vs预防糖尿病。试验注册号NCT04074148。
{"title":"Effectiveness of a group-based Diabetes Prevention Education Program (DiPEP) in a population with pre-diabetes: a cluster randomised controlled trial in Nepal","authors":"Pushpanjali Shakya, Archana Shrestha, Monish Bajracharya, Abha Shrestha, Bård Erik Kulseng, Biraj Man Karmacharya, Smriti Shrestha, Seema Das, Ishwori Byanju Shrestha, Krishnaa Barun, Nistha Shrestha, Eva Skovlund, Abhijit Sen","doi":"10.1136/bmjnph-2023-000702","DOIUrl":"https://doi.org/10.1136/bmjnph-2023-000702","url":null,"abstract":"Background Although several lifestyle intervention studies have been conducted in low/middle-income countries, there were no such studies in Nepal. Therefore, a group-based culturally tailored Diabetes Prevention Education Program (DiPEP) was conducted recently. The study aimed to evaluate the effect of DiPEP in glycated haemoglobin (HbA1c), weight, waist circumference, physical activity and diet among population with pre-diabetes. Method A two-arm cluster randomised controlled trial was conducted in 12 clusters of two urban areas in Nepal. The DiPEP was a 6 month intervention (four 1-hour weekly educational sessions and 5 months of follow-up by community health workers/volunteers (CHW/Vs)). A postintervention assessment was done after 6 months. Linear mixed model was used to estimate the mean difference in primary outcome (HbA1c) and secondary outcomes (weight, waist circumference, physical activity and diet) between intervention and control arms, adjusted for baseline measure. Results In intention-to-treat analysis with a total of 291 participants, the estimated mean difference in HbA1c was found to be 0.015 percentage point (95% CI −0.074 to 0.104) between the intervention arm and the control arm, while it was −0.077 (95% CI −0.152 to −0.002) among those who attended at least 3 out of 4 educational sessions. The estimated mean difference in weight (in participants who attended ≥1 educational session) was −1.6 kg (95% CI −3.1 to −0.1). A significantly lower grain consumption was found in intervention arm (−39 g/day, 95% CI −65 to −14) compared with the control arm at postintervention assessment. Conclusion Although compliance was affected by COVID-19, individuals who participated in ≥3 educational sessions had significant reduction in HbA1c and those who attended ≥1 educational session had significant weight reduction. Grain intake was significantly reduced among the intervention arm than the control arm. Hence, group-based lifestyle intervention programmes involving CHW/vs is recommended for diabetes prevention. Trial registration number NCT04074148 .","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135475014","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-02DOI: 10.1136/bmjnph-2023-000661
Rebecca Fisher, Kathy Martyn, Vittoria Romano, Alison Smith, Rosemary Stennett, Sally Ayyad, Sumantra Ray
{"title":"Improving the assessment of older adult’s nutrition in primary care: recommendations for a proactive, patient-centred and aetiology approach","authors":"Rebecca Fisher, Kathy Martyn, Vittoria Romano, Alison Smith, Rosemary Stennett, Sally Ayyad, Sumantra Ray","doi":"10.1136/bmjnph-2023-000661","DOIUrl":"https://doi.org/10.1136/bmjnph-2023-000661","url":null,"abstract":"","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135932952","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-28DOI: 10.1136/bmjnph-2023-000757
Adam W Potter, David P Looney, William J Tharion, Lyndsey J Nindl, Angie Pazmino, Lara D Soto, Danielle M Arcidiacono, Karl E Friedl
Women’s roles in the US military have progressively changed over the past several decades. Previously women were barred from combat roles. Recent change in policy allow women into combat roles in the Marine Corps, and this has led to women being trained for combat specialties. Objectives This observational cross-sectional study describes body composition and performance values for modern Marine Corps women. Methods Volunteers were 736 Marine women who were assessed for body composition and physical performance; (age 29.5±7.3 (18–56) years; height 163.6±6.8 (131.0–186.1) cm; body mass 68.3±9.2 (42.0–105.3) kg; years in the military 8.9±6.8 (0.5–37) years-in-service). Body composition measures were obtained using dual-energy X-ray absorptiometry and single-frequency bioelectrical impedance analyses. Performance measures were obtained from official physical and combat fitness test scores (PFT; CFT) as well as from data on measured countermovement jumps (CMJ) on a calibrated force platform. Results Mean body composition metrics for Marine women were: 47.5±5.7 fat free mass (FFM) (kg), 30.1%±6.4% body fat (%BF), 2.6±0.3 bone mineral content (kg), and 25.5±2.8 body mass index (kg/m 2 ); performance metrics included 43.4±3.2 maximal oxygen uptake (VO2max; mL.kg.min), 22.4±7.1 CMJ height (cm) and 2575±565.2 CMJ peak power (W). Data showed strong correlations (r) (≥0.70) between PFT and VO2max scores (0.75), and moderate correlations (≥0.50) between CFT and VO2max scores (0.57), CFT and PFT scores (0.60), FFM and CMJ peak power (W) (0.68), and %BF to VO2max (−0.52), PFT (−0.54), CMJ-Ht (−0.52) and CMJ relative power (W/kg) (−0.54). Conclusion Modern Marine women are both lean and physically high performing. Body composition is a poor predictor of general physical performance.
{"title":"Physical performance and body composition reference values for modern US Marine Corps women","authors":"Adam W Potter, David P Looney, William J Tharion, Lyndsey J Nindl, Angie Pazmino, Lara D Soto, Danielle M Arcidiacono, Karl E Friedl","doi":"10.1136/bmjnph-2023-000757","DOIUrl":"https://doi.org/10.1136/bmjnph-2023-000757","url":null,"abstract":"Women’s roles in the US military have progressively changed over the past several decades. Previously women were barred from combat roles. Recent change in policy allow women into combat roles in the Marine Corps, and this has led to women being trained for combat specialties. Objectives This observational cross-sectional study describes body composition and performance values for modern Marine Corps women. Methods Volunteers were 736 Marine women who were assessed for body composition and physical performance; (age 29.5±7.3 (18–56) years; height 163.6±6.8 (131.0–186.1) cm; body mass 68.3±9.2 (42.0–105.3) kg; years in the military 8.9±6.8 (0.5–37) years-in-service). Body composition measures were obtained using dual-energy X-ray absorptiometry and single-frequency bioelectrical impedance analyses. Performance measures were obtained from official physical and combat fitness test scores (PFT; CFT) as well as from data on measured countermovement jumps (CMJ) on a calibrated force platform. Results Mean body composition metrics for Marine women were: 47.5±5.7 fat free mass (FFM) (kg), 30.1%±6.4% body fat (%BF), 2.6±0.3 bone mineral content (kg), and 25.5±2.8 body mass index (kg/m 2 ); performance metrics included 43.4±3.2 maximal oxygen uptake (VO2max; mL.kg.min), 22.4±7.1 CMJ height (cm) and 2575±565.2 CMJ peak power (W). Data showed strong correlations (r) (≥0.70) between PFT and VO2max scores (0.75), and moderate correlations (≥0.50) between CFT and VO2max scores (0.57), CFT and PFT scores (0.60), FFM and CMJ peak power (W) (0.68), and %BF to VO2max (−0.52), PFT (−0.54), CMJ-Ht (−0.52) and CMJ relative power (W/kg) (−0.54). Conclusion Modern Marine women are both lean and physically high performing. Body composition is a poor predictor of general physical performance.","PeriodicalId":36307,"journal":{"name":"BMJ Nutrition, Prevention and Health","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-10-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136233100","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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