| 1. |
- Bammann, Karin, et al.
(författare)
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Early Life Course Risk Factors for Childhood Obesity: The IDEFICS Case-Control Study
- 2014
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Ingår i: PLoS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 9:2
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Tidskriftsartikel (refereegranskat)abstract
- Background: The early life course is assumed to be a critical phase for childhood obesity; however the significance of single factors and their interplay is not well studied in childhood populations. Objectives: The investigation of pre-, peri- and postpartum risk factors on the risk of obesity at age 2 to 9. Methods: A case-control study with 1,024 1:1-matched case-control pairs was nested in the baseline survey (09/2007–05/ 2008) of the IDEFICS study, a population-based intervention study on childhood obesity carried out in 8 European countries in pre- and primary school settings. Conditional logistic regression was used for identification of risk factors. Results: For many of the investigated risk factors, we found a raw effect in our study. In multivariate models, we could establish an effect for gestational weight gain (adjusted OR = 1.02; 95%CI 1.00–1.04), smoking during pregnancy (adjusted OR = 1.48; 95%CI 1.08–2.01), Caesarian section (adjusted OR = 1.38; 95%CI 1.10–1.74), and breastfeeding 4 to 11 months (adjusted OR = 0.77; 95%CI 0.62–0.96). Birth weight was related to lean mass rather than to fat mass, the effect of smoking was found only in boys, but not in girls. After additional adjustment for parental BMI and parental educational status, only gestational weight gain remained statistically significant. Both, maternal as well as paternal BMI were the strongest risk factors in our study, and they confounded several of the investigated associations. Conclusions: Key risk factors of childhood obesity in our study are parental BMI and gestational weight gain; consequently prevention approaches should target not only children but also adults. The monitoring of gestational weight seems to be of particular importance for early prevention of childhood obesity.
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| 2. |
- Börnhorst, Claudia, et al.
(författare)
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Age-Specific Quantification of Overweight/Obesity Risk Factors From Infancy to Adolescence and Differences by Educational Level of Parents
- 2023
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Ingår i: International Journal of Public Health. - 1661-8564. ; 68
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: To explore the age-dependent associations between 26 risk factors and BMI in early life, and differences by parental educational level. Methods: Data of 10,310 children (24,155 measurements) aged 2–16years participating in a multi-centre European cohort from 2007 to 2014 were utilized. Trajectories of overweight/obesity risk factors and their age-specific associations with BMI were estimated using polynomial mixed-effects models. Results: Exposure to most unfavourable factors was higher in the low/medium compared to the high education group, e.g., for PC/TV time (12.6 vs. 10.6h/week). Trajectories of various risk factors markedly changed at an age of 9–11years. Having a family history of obesity, maternal BMI, pregnancy weight gain and birth weight were positively associated with BMI trajectories throughout childhood/adolescence in both education groups; associations of behavioural factors with BMI were small. Parental unemployment and migrant background were positively associated with BMI in the low/medium education group. Conclusion: Associations of risk factors with BMI trajectories did not essentially differ by parental education except for social vulnerabilities. The age period of 9–11years may be a sensitive period for adopting unfavourable behaviours.
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| 3. |
- Börnhorst, Claudia, et al.
(författare)
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Metabolic status in children and its transitions during childhood and adolescence-the IDEFICS/I.Family study.
- 2019
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Ingår i: International journal of epidemiology. - : Oxford University Press (OUP). - 1464-3685 .- 0300-5771. ; 48:5, s. 1673-1683
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Tidskriftsartikel (refereegranskat)abstract
- This study aimed to investigate metabolic status in children and its transitions into adolescence.The analysis was based on 6768 children who participated in the European IDEFICS/I.Family cohort (T0 2007/2008, T1 2009/2010 and/or T3 2013/2014; mean ages: 6.6, 8.4 and 12.0years, respectively) and provided at least two measurements of waist circumference, blood pressure, blood glucose and lipids over time. Latent transition analysis was used to identify groups with similar metabolic status and to estimate transition probabilities.The best-fitting model identified five latent groups: (i) metabolically healthy (61.5%; probability for group membership at T0); (ii) abdominal obesity (15.9%); (iii) hypertension (7.0%); (iv) dyslipidaemia (9.0%); and (v) several metabolic syndrome (MetS) components (6.6%). The probability of metabolically healthy children at T0 remaining healthy at T1 was 86.6%; when transitioning from T1 to T3, it was 90.1%. Metabolically healthy children further had a 6.7% probability of developing abdominal obesity at T1. Children with abdominal obesity at T0 had an 18.5% probability of developing several metabolic syndrome (MetS) components at T1. The subgroup with dyslipidaemia at T0 had the highest chances of becoming metabolically healthy at T1 (32.4%) or at T3 (35.1%). Only a minor proportion of children showing several MetS components at T0 were classified as healthy at follow-up; 99.8% and 88.3% remained in the group with several disorders at T1 and T3, respectively.Our study identified five distinct metabolic statuses in children and adolescents. Although lipid disturbances seem to be quite reversible, abdominal obesity is likely to be followed by further metabolic disturbances.
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| 4. |
- Börnhorst, Claudia, et al.
(författare)
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The role of lifestyle and non-modifiable risk factors in the development of metabolic disturbances from childhood to adolescence.
- 2020
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Ingår i: International journal of obesity. - : Springer Science and Business Media LLC. - 1476-5497 .- 0307-0565. ; 44, s. 2236-2245
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Tidskriftsartikel (refereegranskat)abstract
- The study aimed to identify the effects of lifestyle, C-reactive protein (CRP) and non-modifiable risk factors on metabolic disturbances in the transition from childhood to adolescence.In 3889 children of the IDEFICS/I.Family cohort, latent transition analysis was applied to estimate probabilities of metabolic disturbances based on waist circumference, blood pressure, blood glucose, and lipids assessed at baseline and at 2- and 6-year follow-ups. Multivariate mixed-effects models were used to assess the age-dependent associations of lifestyle, non-modifiable risk factors and CRP, with the transformed probabilities of showing abdominal obesity, hypertension, dyslipidemia, or several metabolic disturbances (reference: being metabolically healthy).Higher maternal body mass index, familial hypertension as well as higher CRP z-score increased the risk for all four metabolic outcomes while low/medium parental education increased the risk of abdominal obesity and of showing several metabolic disturbances. Out of the lifestyle factors, the number of media in the bedroom, membership in a sports club, and well-being were associated with some of the outcomes. For instance, having at least one media in the bedroom increased the risk for showing several metabolic disturbances where the odds ratio (OR) markedly increased with age (1.30 [95% confidence interval 1.18; 1.43] at age 8; 1.18 [1.14; 1.23] for interaction with age; i.e., resulting in an OR of 1.30×1.18=1.53 at age 9 and so forth). Further, entering puberty at an early age was strongly associated with the risk of abdominal obesity (2.43 [1.60; 3.69] at age 8; 0.75 [0.69; 0.81] for interaction with age) and the risk of showing several metabolic disturbances (2.46 [1.53; 3.96] at age 8; 0.71 [0.65; 0.77] for interaction with age).Various factors influence the metabolic risk of children revealing the need for multifactorial interventions. Specifically, removing media from children's bedroom as well as membership in a sports club seem to be promising targets for prevention.
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| 5. |
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| 6. |
- Do, Stefanie, et al.
(författare)
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The role of psychosocial well-being and emotion-driven impulsiveness in food choices of European adolescents
- 2024
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Ingår i: International Journal of Behavioral Nutrition and Physical Activity. - 1479-5868. ; 21:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: It is unclear whether a hypothetical intervention targeting either psychosocial well-being or emotion-driven impulsiveness is more effective in reducing unhealthy food choices. Therefore, we aimed to compare the (separate) causal effects of psychosocial well-being and emotion-driven impulsiveness on European adolescents’ sweet and fat propensity. Methods: We included 2,065 participants of the IDEFICS/I.Family cohort (mean age: 13.4) providing self-reported data on sweet propensity (score range: 0 to 68.4), fat propensity (range: 0 to 72.6), emotion-driven impulsiveness using the UPPS-P negative urgency subscale, and psychosocial well-being using the KINDLR Questionnaire. We estimated, separately, the average causal effects of psychosocial well-being and emotion-driven impulsiveness on sweet and fat propensity applying a semi-parametric doubly robust method (targeted maximum likelihood estimation). Further, we investigated a potential indirect effect of psychosocial well-being on sweet and fat propensity mediated via emotion-driven impulsiveness using a causal mediation analysis. Results: If all adolescents, hypothetically, had high levels of psychosocial well-being, compared to low levels, we estimated a decrease in average sweet propensity by 1.43 [95%-confidence interval: 0.25 to 2.61]. A smaller effect was estimated for fat propensity. Similarly, if all adolescents had high levels of emotion-driven impulsiveness, compared to low levels, average sweet propensity would be decreased by 2.07 [0.87 to 3.26] and average fat propensity by 1.85 [0.81 to 2.88]. The indirect effect of psychosocial well-being via emotion-driven impulsiveness was 0.61 [0.24 to 1.09] for average sweet propensity and 0.55 [0.13 to 0.86] for average fat propensity. Conclusions: An intervention targeting emotion-driven impulsiveness, compared to psychosocial well-being, would be marginally more effective in reducing sweet and fat propensity in adolescents.
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| 7. |
- Formisano, Annarita, et al.
(författare)
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Family structure and childhood obesity: results of the IDEFICS project
- 2014
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Ingår i: Public Health Nutrition. - 1368-9800. ; 17:10, s. 2307-2315
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To analyze the association between family structure and adiposity in children. Design: Cross-sectional and longitudinal analysis of the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study cohort. Setting: Primary schools and kindergartens. Subjects: Children (n 12 350; aged 7 to 9 (SD 1.8) years) for the cross-sectional analysis and children (n 5236; at baseline: normal weight, aged 5 to 9 (SD 1.8) years) for the longitudinal study underwent anthropometry. Family structure was analyzed as (i) number and type of cohabiting adults and (ii) number of siblings. Results: In the cross-sectional analysis, after controlling for covariates, children living with grandparents had significantly higher BMI Z-score than those living with both parents (0.63; 95% CI 0.33, 0.92 v. 0.19; 95% CI 0.17, 0.22; P,0.01); in addition, the higher the number of siblings, the lower the BMI Z-score (only child 50.31; 95% CI 0.24, 0.38; 1 sibling 50.19; 95% CI 0.16, 0.23; 2 siblings 50.15; 95% CI 0.09, 0.20; >2 siblings 50.07, 95% CI 0.04, 0.19;P,0.001). Over the 2-year follow-up, differences in weight gain were observed across family-structure categories. Further, the risk of incidence of overweight/ obesity was significantly lower the higher the number of siblings living in the household (v. only child: 1 sibling 50.74, 95% CI 0.57, 0.96; 2 siblings 50.63, 95% CI 0.45, 0.88; >2 siblings 50.40, 95% CI 0.21, 0.77), independently of confounders. Conclusions: The study suggests that an independent association between family structure and childhood obesity exists.
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| 8. |
- Gianfagna, Francesco, et al.
(författare)
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The role of neuromedin U in adiposity regulation. Haplotype analysis in European children from the IDEFICS Cohort.
- 2017
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Ingår i: PloS one. - : Public Library of Science (PLoS). - 1932-6203. ; 12:2
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Tidskriftsartikel (refereegranskat)abstract
- Neuromedin U (NMU) is a hypothalamic neuropeptide with important roles in several metabolic processes, recently suggested as potential therapeutic target for obesity. We analysed the associations between NMU gene variants and haplotypes and body mass index (BMI) in a large sample of European children.From a large European multi-center study on childhood obesity, 4,528 children (2.0-9.9 years, mean age 6.0±1.8 SD; boys 52.2%) were randomly selected, stratifying by age, sex and country, and genotyped for tag single nucleotide polymorphisms (SNPs; rs6827359, T:C; rs12500837, T:C; rs9999653,C:T) of NMU gene, then haplotypes were inferred. Regression models were applied to estimate the associations between SNPs or haplotypes and BMI as well as other anthropometric measures. BMI was associated with all NMU SNPs (p<0.05). Among five haplotypes inferred, the haplotype carrying the minor alleles (CCT, frequency = 22.3%) was the only associated with lower BMI values (beta = -0.16, 95%CI:-0.28,-0.04, p = 0.006; z-score, beta = -0.08, 95%CI:-0.14,-0.01, p = 0.019) and decreased risk of overweight/obesity (OR = 0.81, 95%CI:0.68,0.97, p = 0.020) when compared to the most prevalent haplotype (codominant model). Similar significant associations were also observed using the same variables collected after two years' time (BMI, beta = -0.25, 95%CI:-0.41,-0.08, p = 0.004; z-score, beta = -0.10, 95%CI:-0.18,-0.03, p = 0.009; overweight/obesity OR = 0.81, 95%CI:0.66,0.99, p = 0.036). The association was age-dependent in girls (interaction between CCT haplotypes and age, p = 0.008), more evident between 7 and 9 years of age. The CCT haplotype was consistently associated with lower levels of fat mass, skinfold thickness, hip and arm circumferences both at T0 and at T1, after adjustment for multiple testing (FDR-adjusted p<0.05).This study shows an association between a NMU haplotype and anthropometric indices, mainly linked to fat mass, which appears to be age- and sex-specific in children. Genetic variations within or in linkage with this haplotype should be investigated to identify functional variants responsible for the observed phenotypic variation.
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| 9. |
- González-Gil, Esther M, et al.
(författare)
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Food intake and inflammation in European children: the IDEFICS study.
- 2016
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Ingår i: European journal of nutrition. - : Springer Science and Business Media LLC. - 1436-6215 .- 1436-6207 .- 1435-1293. ; 55:8, s. 2459-2468
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Tidskriftsartikel (refereegranskat)abstract
- This cross-sectional study assesses the relationship between consumption frequencies of food items and high-sensitivity C-reactive protein (hs-CRP) in European children.
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| 10. |
- González-Gil, Esther M., et al.
(författare)
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Improving cardiorespiratory fitness protects against inflammation in children : the IDEFICS study
- 2022
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Ingår i: Pediatric Research. - : Springer Nature. - 0031-3998 .- 1530-0447. ; 91:3, s. 681-689
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Tidskriftsartikel (refereegranskat)abstract
- Background: Muscular and cardiorespiratory fitness (MF and CRF) have been related to inflammation. Thus, the aim of this study was to assess the relationship between fitness and high-sensitivity C-reactive protein (hs-CRP) in European children both in the cross-sectional and longitudinal analysis. Methods: Three hundred and fifty-seven children (46.2% males) aged 2–9 years with hs-CRP measured, data from MF and CRF, diet quality, objectively measured physical activity (PA) and screen time at baseline and follow-up after 2 years were included. Body mass index z-score (zBMI), waist circumference (WC) and fat mass index (FMI) were assessed. MF and CRF were also dichotomized as follows: low-medium quartiles (Q1–Q3) and highest quartile (Q4). Results: At follow-up, children with the highest CRF (Q4) showed a lower probability of having high hs-CRP. In the longitudinal analysis, children who improved their CRF over time showed a significantly lower probability (p < 0.05) of being in the highest hs-CRP category at follow-up, independently of the body composition index considered: odds ratio (OR) = 0.22 for zBMI, OR = 0.17 for WC, and OR = 0.21 for FMI. Conclusions: Improving CRF during childhood reduces the odds of an inflammatory profile, independently of body composition and lifestyle behaviours. These highlight the importance of enhancing fitness, especially CRF, to avoid an inflammatory state in children. Impact: Improvements in the cardiorespiratory profile during childhood could reverse an unfavourable inflammatory status.There is a longitudinal and inverse association between CRF and inflammation in children.This is the first longitudinal study assessing the relationship between fitness and inflammation during childhood that takes also into account the lifestyle behaviours.Results from the present study suggest a protective role of fitness already in childhood.Efforts to improve fitness in children should be aimed at as inflammation could trigger future cardiovascular disease.
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| 11. |
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| 12. |
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| 13. |
- Intemann, Timm, et al.
(författare)
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A Late Meal Timing Pattern Is Associated with Insulin Resistance in European Children and Adolescents
- 2024
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Ingår i: PEDIATRIC DIABETES. - 1399-543X .- 1399-5448. ; 2024
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Tidskriftsartikel (refereegranskat)abstract
- Meal timing has been associated with metabolic markers in adults, but not in children or adolescents. The aim of this study was to investigate associations of meal timing patterns (MTPs) with insulin resistance (IR) and triglyceride levels in children and adolescents. In this cross-sectional study, we included 2,195 participants aged 8-15 years from the European I.Family study (2013/14). Habitual diet exposures were derived using 24-hr dietary recalls and HOMA-IR, HbA1c, and triglycerides were used as metabolic outcome variables. We applied k-means cluster analysis on five dietary exposures (energy proportion in the morning and evening, eating window, pre-sleep fasting and eating frequency), which revealed the following three MTPs: "early-often", "late-long" and "late-infrequent-short". We used linear mixed models to estimate the associations between MTPs and the z-scores of the metabolic outcome variables. The association analysis revealed differences between MTPs in HOMA-IR but not in HbA1c or triglyceride z-scores. The "late-infrequent-short" pattern was associated with a 0.19 (95%-CI: (0.01, 0.36)) higher HOMA-IR z-score compared to the "early-often" pattern in the model adjusted for age, BMI z-score, education, sex, country, and family membership. These findings suggest that the timing of meals may influence IR already in childhood and adolescence. Therefore, the time of meals should be considered in future nutrition research and dietary advice for children and adolescents.
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| 14. |
- Intemann, Timm, et al.
(författare)
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Urinary sucrose and fructose to validate self-reported sugar intake in children and adolescents : results from the I.Family study
- 2019
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Ingår i: European Journal of Nutrition. - : Springer. - 1436-6207 .- 1436-6215. ; 58:3, s. 1247-1258
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Tidskriftsartikel (refereegranskat)abstract
- PURPOSE: Excessive consumption of free sugar increases the risk for non-communicable diseases where a proper assessment of this intake is necessary to correctly estimate its association with certain diseases. Urinary sugars have been suggested as objective biomarkers for total and free sugar intake in adults but less is known about this marker in children and adolescents. Therefore, the aim of this exploratory study is to evaluate the relative validity of self-reported intake using urinary sugars in children and adolescents.METHODS: The study was conducted in a convenience subsample of 228 participants aged 5-18 years of the I.Family study that investigates the determinants of food choices, lifestyle and health in European families. Total, free and intrinsic sugar intake (g/day) and sugar density (g/1000 kcal) were assessed using 24-h dietary recalls (24HDRs). Urinary sucrose (USUC) and urinary fructose (UFRU) were measured in morning urine samples and corrected for creatinine excretion (USUC/Cr, UFRU/Cr). Correlation coefficients, the method of triads and linear regression models were used to investigate the relationship between intake of different types of sugar and urinary sugars.RESULTS: The correlation between usual sugar density calculated from multiple 24HDRs and the sum of USUC/Cr and UFRU/Cr (USUC/Cr + UFRU/Cr) was 0.38 (p < 0.001). The method of triads revealed validity coefficients for the 24HDR from 0.64 to 0.87. Linear regression models showed statistically significant positive associations between USUC/Cr + UFRU/Cr and the intake of total and free sugar.CONCLUSIONS: These findings support the relative validity of total and free sugar intake assessed by self-reported 24HDRs in children and adolescents.
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| 15. |
- Mehlig, Kirsten, 1964, et al.
(författare)
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Children's propensity to consume sugar and fat predicts regular alcohol consumption in adolescence.
- 2018
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Ingår i: Public health nutrition. - 1475-2727. ; 21:17, s. 3202-3209
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Tidskriftsartikel (refereegranskat)abstract
- The present study investigated the association between sugar and fat intake in childhood in relation to alcohol use in adolescence. We hypothesized that early exposure to diets high in fat and sugar may affect ingestive behaviours later in life, including alcohol use.Design/Setting/SubjectsChildren from the European IDEFICS/I.Family cohort study were examined at ages 5-9 years and followed up at ages 11-16 years. FFQ were completed by parents on behalf of children, and later by adolescents themselves. Complete data were available in 2263 participants. Children's propensities to consume foods high in fat and sugar were calculated and dichotomized at median values. Adolescents' use of alcohol was classified as at least weekly v. less frequent use. Log-binomial regression linked sugar and fat consumption in childhood to risk of alcohol use in adolescence, adjusted for relevant covariates.Five per cent of adolescents reported weekly alcohol consumption. Children with high propensity to consume sugar and fat were at greater risk of later alcohol use, compared with children with low fat and low sugar propensity (relative risk=2·46; 95 % CI 1·47, 4·12), independent of age, sex and survey country. The association was not explained by parental income and education, strict parenting style or child's health-related quality of life and was only partly mediated by sustained consumption of sugar and fat into adolescence.Frequent consumption of foods high in fat and sugar in childhood predicted regular use of alcohol in adolescence.
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| 16. |
- Mehlig, Kirsten, 1964, et al.
(författare)
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Genetic associations vary across the spectrum of fasting serum insulin: results from the European IDEFICS/I.Family children's cohort.
- 2023
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Ingår i: Diabetologia. - 1432-0428. ; 66:10, s. 1914-24
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Tidskriftsartikel (refereegranskat)abstract
- There is increasing evidence for the existence of shared genetic predictors of metabolic traits and neurodegenerative disease. We previously observed a U-shaped association between fasting insulin in middle-aged women and dementia up to 34 years later. In the present study, we performed genome-wide association (GWA) analyses for fasting serum insulin in European children with a focus on variants associated with the tails of the insulin distribution.Genotyping was successful in 2825 children aged 2-14 years at the time of insulin measurement. Because insulin levels vary during childhood, GWA analyses were based on age- and sex-specific z scores. Five percentile ranks of z-insulin were selected and modelled using logistic regression, i.e. the 15th, 25th, 50th, 75th and 85th percentile ranks (P15-P85). Additive genetic models were adjusted for age, sex, BMI, survey year, survey country and principal components derived from genetic data to account for ethnic heterogeneity. Quantile regression was used to determine whether associations with variants identified by GWA analyses differed across quantiles of log-insulin.A variant in the SLC28A1 gene (rs2122859) was associated with the 85th percentile rank of the insulin z score (P85, p value=3×10-8). Two variants associated with low z-insulin (P15, p value <5×10-6) were located on the RBFOX1 and SH3RF3 genes. These genes have previously been associated with both metabolic traits and dementia phenotypes. While variants associated with P50 showed stable associations across the insulin spectrum, we found that associations with variants identified through GWA analyses of P15 and P85 varied across quantiles of log-insulin.The above results support the notion of a shared genetic architecture for dementia and metabolic traits. Our approach identified genetic variants that were associated with the tails of the insulin spectrum only. Because traditional heritability estimates assume that genetic effects are constant throughout the phenotype distribution, the new findings may have implications for understanding the discrepancy in heritability estimates from GWA and family studies and for the study of U-shaped biomarker-disease associations.
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| 17. |
- Mikkelsen, Andrea, et al.
(författare)
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Blood fatty acid composition in relation to allergy in children aged 2–9 years: results from the European IDEFICS study
- 2017
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Ingår i: European Journal of Clinical Nutrition. - : Springer Science and Business Media LLC. - 0954-3007 .- 1476-5640. ; 71, s. 39-44
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Tidskriftsartikel (refereegranskat)abstract
- Background/objectives: Blood polyunsaturated fatty acids (PUFA) are involved in allergy development, but the etiological role of n-6 and n-3 PUFA is still controversial. A European multicenter study of children (IDEFICS) provided the opportunity to explore the cross-sectional association between fatty acids (FA) and allergy. Subjects/methods: Blood FA levels were measured in 2600 children aged 2–9 years and were recorded as the percentage of weight of all FA detected. Logistic regression of allergy status on FA components was adjusted for age, sex, country, body mass index, family history of allergic disease, breast-feeding, and number of siblings. The results were given as odds ratios (OR) for current vs no allergy ever and an increase in FA by 1s.d. Results: Overall, higher proportions of n-6 PUFA were associated with higher odds of allergy (OR=1.21 (1.05, 1.40)). Monounsaturated FA (MUFA) were associated with reduced risk for allergy (OR=0.75 (0.65, 0.87)), whereas saturated FA did not differ by allergy status. The strongest associations were observed in children <4 years old, with ORs of allergy given as 1.62 (1.15, 2.29) for n-3 PUFA and 0.63 (0.42, 0.95) for MUFA. With regard to individual FA, these associations were independently observed for docosapentaenoic acid (22:5 n-3) and oleic acid (18:1 n-9). Conclusions: Both PUFA subtypes were positively associated with allergy in an age-dependent manner, whereas MUFA was associated with less allergy. The observation of high proportions of n-3 PUFA in allergic children younger than 4 years might help to understand the nature of early onset of atopic disease.
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| 18. |
- Murtas, Rossella, et al.
(författare)
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Does Providing Assistance to Children and Adolescents Increase Repeatability and Plausibility of Self-Reporting Using a Web-Based Dietary Recall Instrument?
- 2018
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Ingår i: Journal of the Academy of Nutrition and Dietetics. - : Elsevier. - 2212-2672 .- 2212-2680. ; 118:12, s. 2324-2330
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Tidskriftsartikel (refereegranskat)abstract
- Background It is important to find ways to minimize errors when children self-report food consumption. Objective The objective of this study was to investigate whether assistance given to children completing a self-administered 24-hour dietary recall instrument called SACANA (Self-Administered Child, Adolescent and Adult Nutrition Assessment) increased the repeatability and plausibility of energy intake (EI) estimates. Participants/setting The study was conducted between October 2013 and March 2016 in a convenience sample of 395 children, aged 8 to 17 years, from eight European countries participating in the I.Family study. Design SACANA was used to recall the previous day's food intake, twice in a day, once with and once without assistance. Main outcome measures The difference in EI between the first and second recalls was the main repeatability measure; the ratio of EI to basal metabolic rate was the plausibility measure. Statistical methods Generalized linear mixed models, adjusted for sex, age, and body mass index z-score, were used to assess whether assistance during the first vs second recall influenced repeatability and plausibility. Results The difference in estimated EI (EI from second recall minus EI from first recall) was significantly lower (P<0.001) in those assisted at first (median=-76 kcal) than those assisted at second recall (median=282 kcal). Modeling showed that EI at assisted first recall was 19% higher (95% CI 1.13 to 1.24) than in assisted second recall. Overall, 60% of recalls had a plausible EI. Modeling to estimate the simultaneous effects of second vs first recall and assistance vs no assistance on plausibility showed that those assisted at first recall had significantly higher odds of a plausible recall than those unassisted (odds ratio 3.64, 95% CI 2.20 to 6.01), with no significant difference in plausibility of second recall compared to the first (odds ratio 1.48, 95% CI 0.92 to 2.35). Conclusions When children are assisted at first recall, the plausibility and repeatability of the later unassisted recall improve. This improvement was evident for all ages. A future, adequately powered study is required to investigate the age range for which assistance is advisable.
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| 19. |
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| 20. |
- Santaliestra-Pasías, Alba M., et al.
(författare)
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Food and beverage intakes according to physical activity levels in European children : the IDEFICS (Identification and prevention of Dietary and lifestyle induced health EFfects In Children and infantS) study
- 2018
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Ingår i: Public Health Nutrition. - : Cambridge University Press. - 1368-9800 .- 1475-2727. ; 21:9, s. 1717-1725
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: Physical activity (PA) levels and dietary habits are considered some of the most important factors associated with obesity. The present study aimed to examine the association between PA level and food and beverage consumption in European children (2-10 years old).Design/Setting/SubjectsA sample of 7229 children (49·0 % girls) from eight European countries participating in the IDEFICS (Identification and prevention of Dietary and lifestyle induced health EFfects In Children and infantS) study was included. Moderate-to-vigorous PA (MVPA) was assessed objectively with accelerometers. FFQ was used to register dietary habits. ANCOVA and binary logistic regression were applied.RESULTS: Boys who spent less time in MVPA reported lower consumption of vegetables, fruits, cereals, yoghurt, milk, bread, pasta, candies and sugar-sweetened beverages (SSB) than boys who spent more time in MVPA (P<0·05). Moreover, boys who spent less time in MVPA were more likely to consume fast foods and water than those in the highest MVPA tertile (P<0·05). Girls who spent less time in MVPA reported lower consumption frequencies of vegetables, pasta, bread, yoghurt, candies, jam/honey and SSB than girls in the highest MVPA tertile (P<0·05). Also, girls in the lowest MVPA tertile were more likely to consume fast foods and water than those with high levels of MVPA (P<0·05).CONCLUSIONS: Food intake among European children varied with different levels of daily MVPA. Low time spent in MVPA was associated with lowest consumption of both high- and low-energy-dense foods and high fast-food consumption.
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| 21. |
- Schreuder, Anton, et al.
(författare)
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Population trajectories and age-dependent associations of obesity risk factors with body mass index from childhood to adolescence across European regions: A two-cohort study
- 2024
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Ingår i: Pediatric Obesity. - 2047-6302 .- 2047-6310. ; 19:2
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To investigate population trajectories of behavioural risk factors of obesity from childhood to adolescence and their associations with body mass index (BMI) in children across European regions. Methods: Data were harmonised between the European multi-centre IDEFICS/I.Family and the Amsterdam Born Children and their Development Cohort. Participants were aged 2.0–9.9 and 5.0–7.5 years at baseline, respectively, and were followed until age 18 years. Behavioural risk factors of interest included diet, physical activity, media use and sleep. Mixed effects models were used for statistical analyses to account for repeated measurements taken from the same child. Results: The study included a total of 14 328 individuals: 4114, 4582, 3220 and 2412 participants from Northern, Southern, Eastern Europe and Amsterdam, respectively. Risk factor means and prevalences changed with age, but the trajectories were mostly similar across regions. Almost no associations between behavioural factors and BMI were found at the age of 6 years. At 11 years, daily sugar-sweetened foods consumption, use of active transport, sports club membership and longer nocturnal sleep duration were negatively associated with BMI in most regions; positive associations were found with media use. Most associations at 11 years of age persisted to 15 years. Conclusions: Whilst population trajectories of media use and nocturnal sleep duration are similar across European regions, those of other behavioural risk factors like active transport and daily vegetable consumption differ. Also, associations between behavioural risk factors and BMI become stronger with age and show similar patterns across regions.
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| 22. |
- Sina, Elida, et al.
(författare)
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Association of infant feeding patterns with taste preferences in European children and adolescents : A retrospective latent profile analysis
- 2019
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Ingår i: Nutrients. - : MDPI. - 2072-6643. ; 11:5, s. 1-16
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Tidskriftsartikel (refereegranskat)abstract
- The aim was to investigate associations between the duration of infant feeding practices (FP) and taste preferences (TP) in European children and adolescents. A total of 5526 children (6-16 years old) of the I.Family study completed a Food and Beverage Preference Questionnaire to measure their preferences for sweet, fatty and bitter tastes. Mothers retrospectively reported the FPs duration in months: exclusive breastfeeding (EBF), exclusive formula milk feeding (EFMF), combined breastfeeding (BF&FMF) and the age at the introduction of complementary foods (CF). Using logistic regression analyses and latent class analysis (latent profiles of FP and CF were identified), we explored associations between profiles and TP, adjusting for various covariates, including the Healthy Diet Adherence Score (HDAS). A total of 48% of children had short durations of EBF (≤4 months) and BF&FMF (≤6 months) and were introduced to CF early (<6 months). No significant relationship was observed between the single FPs and TP, even when considering common profiles of FP. HDAS was inversely associated with sweet and fatty TP, but positively with bitter TP. Contrary to our hypotheses, we did not observe associations between FP and children’s TP later in life. Further studies with higher FP variation and longitudinal design are needed to investigate the causal associations between infant FP and taste preferences later in life. © 2019 by the authors. Licensee MDPI, Basel, Switzerland.
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| 23. |
- Sina, Elida, et al.
(författare)
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Digital media exposure and cognitive functioning in European children and adolescents of the I.Family study
- 2023
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Ingår i: Scientific Reports. - : Springer Nature. - 2045-2322. ; 13:1
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Tidskriftsartikel (refereegranskat)abstract
- The digital environment can pose health risks through exposure to unhealthy content. Yet, little is known about its relation to children’s cognitive functioning. This study investigates the association between digital media (DM) exposure and children’s cognitive functioning. This cross-sectional study is based on examinations of children aged 8–18 years (N = 8673) of the I.Family cohort (2013–2014). Exposure to television, computer, smartphone and internet was self-reported (hours/day). Media multitasking (MMT) was defined as simultaneous use of computers with other digital or non-screen-based activities. Standard instruments were used to assess cognitive inflexibility (score: 0–39), decision-making ability (− 100 to + 100) and impulsivity (12–48). Adjusted regression coefficients and 99.9%CIs were calculated by generalized linear mixed-effects models. In total, 3261 participants provided data for impulsivity, 3441 for cognitive inflexibility and 4046 for decision-making. Exposure to smartphones and media multitasking were positively associated with impulsivity (βsmartphone = 0.74; 99.9%CI = 0.42–1.07; βMMT = 0.73; 99.9%CI = 0.35–1.12) and cognitive inflexibility (βsmartphone = 0.32; 99.9%CI = -0.02–0.66; βMMT = 0.39; 99.9%CI = 0.01–0.77) while being inversely associated with decision-making ability. Extensive smartphone/internet exposure combined with low computer/medium TV exposure was associated with higher impulsivity and cognitive inflexibility scores, especially in girls. DM exposure is adversely associated with cognitive functioning in children and adolescents. Children require protection against the likely adverse impact of digital environment.
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| 24. |
- Sparano, Sonia, et al.
(författare)
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Being Macrosomic at Birth is an Independent Predictor of Overweight in Children: Results from the IDEFICS Study.
- 2013
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Ingår i: Maternal and child health journal. - : Springer Science and Business Media LLC. - 1573-6628 .- 1092-7875. ; 17:8, s. 1373-1381
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Tidskriftsartikel (refereegranskat)abstract
- Fetal macrosomia is a risk factor for the development of obesity late in childhood. We retrospectively evaluated the relationship between maternal conditions associated with fetal macrosomia and actual overweight/obesity in the European cohort of children participating in the IDEFICS study. Anthropometric variables, blood pressure and plasma lipids and glucose were measured. Socio-demographic data, medical history and perinatal factors, familiar and gestational history, maternal and/or gestational diabetes were assessed by a questionnaire. Variables of interest were reported for 10,468 children (M/F=5,294/5,174; age 6.0±1.8years, M±SD). The sample was divided in four groups according to child birth weight (BW) and maternal diabetes: (1) adequate for gestational age offspring (BW between the 10th and 90th percentiles for gestational age) of mothers without diabetes (AGA-ND); (2) adequate for gestational age offspring of mothers with diabetes (AGA-D); (3) macrosomic offspring (BW>90th percentile for gestational age) of mothers without diabetes (Macro-ND); (4) macrosomic offspring of mothers with diabetes (Macro-D). Children macrosomic at birth showed significantly higher actual values of body mass index, waist circumference, and sum of skinfold thickness. In both boys and girls, Macro-ND was an independent determinant of overweight/obesity, after the adjustment for confounders [Boys: OR=1.7 95% CI (1.3;2.2); Girls: OR=1.6 95% CI (1.3;2.0)], while Macro-D showed a significant association only in girls [OR=2.6 95% CI (1.1;6.4)]. Fetal macrosomia, also in the absence of maternal/gestational diabetes, is independently associated with the development of overweight/obesity during childhood. Improving the understanding of fetal programming will contribute to the early prevention of childhood overweight/obesity.
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| 25. |
- Sprengeler, Ole, et al.
(författare)
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Trajectories of objectively measured physical activity and childhood overweight : longitudinal analysis of the IDEFICS/I.Family cohort
- 2021
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Ingår i: International Journal of Behavioral Nutrition and Physical Activity. - : BioMed Central. - 1479-5868. ; 18:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: Since only few longitudinal studies with appropriate study designs investigated the relationship between objectively measured physical activity (PA) and overweight, the degree PA can prevent excess weight gain in children, remains unclear. Moreover, evidence is limited on how childhood overweight determines PA during childhood. Therefore, we analyzed longitudinal trajectories of objectively measured PA and their bi-directional association with weight trajectories of children at 2- and 6-year follow-ups. Methods: Longitudinal data of three subsequent measurements from the IDEFICS/I.Family cohort study were used to analyze the bi-directional association between moderate-to-vigorous PA (MVPA) and weight status by means of multilevel regression models. Analyses comprised 3393 (2-year follow-up) and 1899 (6-year follow-up) children aged 2–15.9 years from eight European countries with valid accelerometer data and body mass index (BMI) measurements. For categorized analyses, children’s weight status was categorized as normal weight or overweight (cutoff: 90th percentile of BMI) and children’s PA as (in-) sufficiently active (cutoffs: 30, 45 and 60 min of MVPA per day). Results: Children engaging in at least 60 min MVPA daily at baseline and follow-ups had a lower odds of becoming overweight (odds ratio [OR] at 2-year follow-up: 0.546, 95% CI: 0.378, 0.789 and 6-year follow-up: 0.393, 95% CI: 0.242, 0.638), compared to less active children. Similar associations were found for 45 min MVPA daily. On the other side, children who became overweight had the lowest odds to achieve 45 or 60 min MVPA daily (ORs: 0.459 to 0.634), compared to normal weight children. Conclusions: Bi-directional associations between MVPA and weight status were observed. In summary, at least 60 min MVPA are still recommended for the prevention of childhood overweight. To prevent excess weight gain, 45 min MVPA per day also showed preventive effects.
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| 26. |
- Stahlmann, Katharina, et al.
(författare)
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A cross-sectional study of obesogenic behaviours and family rules according to family structure in European children.
- 2020
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Ingår i: The international journal of behavioral nutrition and physical activity. - : Springer Science and Business Media LLC. - 1479-5868. ; 17:1
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Tidskriftsartikel (refereegranskat)abstract
- There has been an increase in children growing up in non-traditional families, such as single-parent and blended families. Children from such families have a higher prevalence of obesity and poorer health outcomes, but research onthe relationship with obesogenic behaviours is limited.Therefore, the aim of this study was to investigate whether there are associations between family structures and obesogenic behaviours and related family rules in European children and adolescents.The sample included 7664 children (mean age±SD: 10.9±2.9) from 4923 families who were participants of the multi-centre I.Family study (2013/2014) conducted in 8 European countries. Family structure was assessed by a detailed interview on kinship and household. Obesogenic behaviours (screen time, sleep duration, consumption of sugar-sweetened beverages (SSBs)) and family rules (rules for computer and television, bedtime routine, availability of SSBs during meals) were determined by standardized questionnaires. Multilevel mixed-effects linear and logistic regression models were used to model the associations of family structure with obesogenic behaviours and family rules. Sex, age, parental education level, number of children and adults in the household and BMI z-score were covariates in the models. Two-parent biological families were set as the reference category.Children from single-parent families were less likely to have family rules regarding screen time (OR: 0.62, 95% CI: 0.40-0.94, p=0.026) with higher reported hours of screen time per week (β=2.70h/week, 95% CI: 1.39-4.00, p<0.001). The frequency of weekly SSB consumption differed by family structure in a sex-specific manner: girls from single-parent (β=3.19 frequency/week, 95% CI: 0.91-5.47, p=0.006) and boys from blended/adoptive families (β=3.01 frequency/week, 95% CI: 0.99-5.03, p=0.004) consumed more SSBs. Sleep duration, bedtime routines and availability of SSBs during meals did not differ between children from these family structures. Parental education did not modify any of these associations.Parents in non-traditional family structures appear to experience more difficulties in restricting screen time and the intake of SSBs in their children than parents in traditional two-parent family structures. Our findings therefore suggest that additional support and effective strategies for parents in non-traditional families may help to reduce obesogenic behaviours in children from such family types.
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| 27. |
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| 28. |
- Thumann, Barbara F., et al.
(författare)
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Cross-Sectional and Longitudinal Associations Between Psychosocial Well-Being and Cardiometabolic Markers in European Children and Adolescents
- 2020
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Ingår i: PSYCHOSOMATIC MEDICINE. - 0033-3174 .- 1534-7796. ; 82:8, s. 764-773
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Research examining aspects of positive mental health as potential predictors of cardiometabolic health in young populations is scarce. We investigated the associations between psychosocial well-being and waist circumference (WAIST), blood pressure (BP), the homeostasis model assessment for insulin resistance, triglycerides, and high-density lipoprotein cholesterol considering life-style factors as mediators. Methods: Data of European children and adolescents participating in the baseline (2007/2008), first follow-up (FU1; 2009/2010) and second follow-up (FU2; 2013/2014) examinations of the IDEFICS/I.Family study were used (n(cross-sectional) = 6519;n(longitudinal) = 1393). A psychosocial well-being score was calculated from 16 items on emotional well-being, self-esteem, and social relationships (0-48 points). Cardiometabolic markers were transformed to age- and sex-specific and, in case of BP, also height-specificzscores. Life-style factors included diet, physical activity, sleep, and electronic media use. Applying path analysis, we obtained unstandardized estimates of direct and indirect effects of well-being on cardiometabolic markers. Results: Cross-sectionally, well-being score showed a negative direct and a negative indirect effect through life-style factors on WAISTzscore (estimate per 4-point increase, -0.051 [p = .001] and -0.014 [p < .001], respectively). Longitudinally, positive changes in well-being score between baseline and FU1 and between FU1 and FU2, respectively, demonstrated negative indirect effects through life-style factors(FU2) on WAIST z score(FU2). Both cross-sectionally and longitudinally, higher levels of well-being showed lowering indirect effects on homeostasis model assessment, BP, and triglyceridezscores and an increasing indirect effect on high-density lipoprotein cholesterolzscore through both life-style factors and WAISTzscore. Conclusions: These results supported our hypothesis that a healthier life-style may be one mechanism through which higher well-being is linked with lower abdominal obesity and fewer other cardiometabolic disorders in young populations.
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| 29. |
- Verbestel, Vera, et al.
(författare)
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Using the intervention mapping protocol to develop a community-based intervention for the prevention of childhood obesity in a multi-centre European project: the IDEFICS intervention.
- 2011
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Ingår i: The international journal of behavioral nutrition and physical activity. - : Springer Science and Business Media LLC. - 1479-5868. ; 8
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Tidskriftsartikel (refereegranskat)abstract
- ABSTRACT: Background: The prevalence of childhood obesity has increased during the past decades and is now considered an urgent public health problem. Although stabilizing trends in obesity prevalence have been identified in parts of Europe, preventive efforts in children are still needed. Using the socio-ecological approach as the underlying theoretical perspective, the IDEFICS project aimed to develop, implement and evaluate a community-based intervention for the prevention of childhood obesity in eight European countries. The aim of the present manuscript was to describe the content and developmental process of the IDEFICS intervention. Methods: The intervention mapping protocol (IMP) was used to develop the community-based intervention for the prevention of childhood obesity in 3 to 10 years old children. It is a theory- and evidence-based tool for the structured planning and development of health promotion programs that requires the completion of six different steps. These steps were elaborated by two coordinating centers and discussed with the other participating centers until agreement was reached. Focus group research was performed in all participating centers to provide an informed basis for intervention development. Results: The application of the IMP resulted in an overall intervention framework with ten intervention modules targeting environmental and personal factors through the family, the school and the community. The summary results of the focus group research were used to inform the development of the overall intervention. The cultural adaptation of the overall intervention was realised by using country specific focus group results. The need for cultural adaptation was considered during the entire process to improve program adoption and implementation. A plan was developed to evaluate program effectiveness and quality of implementation. Conclusions: The IDEFICS project developed a community-based intervention for the prevention of childhood obesity by using to the intervention mapping heuristic. The IDEFICS intervention consists of a general and standardized intervention framework that allows for cultural adaptation to make the intervention feasible and to enhance deliverability in all participating countries. The present manuscript demonstrates that the development of an intervention is a long process that needs to be done systematically. Time, human resources and finances need to be planned beforehand to make interventions evidence-based and culturally relevant.
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| 30. |
- Wolters, Maike, et al.
(författare)
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Association of desaturase activity and C-reactive protein in European children
- 2017
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Ingår i: Pediatric Research. - : Nature Publishing Group. - 0031-3998 .- 1530-0447. ; 81:1, s. 27-32
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Desaturase enzymes influence the fatty acid (FA) composition of body tissues and their activity affects the conversion rate of saturated to monounsaturated FA and of polyunsaturated FA (PUFA) to long-chain PUFA. Desaturase activity has further been shown to be associated with inflammation. We investigate the association between delta-9 (D9D), delta-6 (D6D) and delta-5 desaturase (D5D) activity and high sensitive C-reactive protein (CRP) in young children. METHODS: In the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) cohort study children were examined at baseline (TO) and after 2 y (T1). D9D, D6D, and D5D activities were estimated from TO product-precursor FA ratios. CRP was measured at TO and T1. In a subsample of 1,943 children with available information on FA, CRP, and covariates, the cross-sectional and longitudinal associations of desaturase activity and CRP were analyzed. RESULTS: Cross-sectionally, a D9D increase of 0.01 units was associated with a 11% higher risk of having a serum CRP Percentile 75 (P75) (OR, 99% CI: 1.11 (1.01; 1.22)) whereas D6D and D5D were not associated with CRP. No significant associations were observed between baseline desaturase activity and CRP 2 y later. CONCLUSION: Cross-sectionally, our results indicate a positive association of D9D and CRP independent of weight status. High D9D activity may increase the risk of subclinical inflammation which is associated with metabolic disorders. As D9D expression increases with higher intake of saturated FA and carbohydrates, dietary changes may influence D9D activity and thus CRP. However, it remains to be investigated whether there is a causal relationship between D9D activity and CRP.
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| 31. |
- Wolters, Maike, et al.
(författare)
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Associations of Whole Blood n-3 and n-6 Polyunsaturated Fatty Acids with Blood Pressure in Children and Adolescents ± Results from the IDEFICS/I.Family Cohort
- 2016
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Ingår i: PLoS ONE. - : Public Library of Science (PLoS). - 1932-6203. ; 11:11
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Tidskriftsartikel (refereegranskat)abstract
- Background Polyunsaturated n-3 and n-6 polyunsaturated fatty acids (PUFA) are precursors of biologically active metabolites that affect blood pressure (BP) regulation. This study investigated the association of n-3 and n-6 PUFA and BP in children and adolescents. Methods In a subsample of 1267 children aged 2±9 years at baseline of the European IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) cohort whole blood fatty acids were measured by a validated gas chromatographic method. Systolic and diastolic BP was measured at baseline and after two and six years. Mixed-effects models were used to assess the associations between fatty acids at baseline and BP z-scores over time adjusting for relevant covariables. Models were further estimated stratified by sex and weight status. Results The baseline level of arachidonic acid was positively associated with subsequent systolic BP (β = 0.08, P = 0.002) and diastolic BP (β = 0.07, P<0.001). In thin/normal weight children, baseline alpha-linolenic (β = -1.13, P = 0.003) and eicosapentaenoic acid (β = -0.85, P = 0.003) levels were inversely related to baseline and also to subsequent systolic BP and alpha-linolenic acid to subsequent diastolic BP. In overweight/obese children, baseline eicosapentaenoic acid level was positively associated with baseline diastolic BP (β = 0.54, P = 0.005). Conclusions Low blood arachidonic acid levels in the whole sample and high n-3 PUFA levels in thin/normal weight children are associated with lower and therefore healthier BP. The beneficial effects of high n-3 PUFA on BP were not observed in overweight/obese children, suggesting that they may have been overlaid by the unfavorable effects of excess weight.
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| 32. |
- Wolters, Maike, et al.
(författare)
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The role of a FADS1 polymorphism in the association of fatty acid blood levels, BMI and blood pressure in young children-Analyses based on path models.
- 2017
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Ingår i: PloS one. - : Public Library of Science (PLoS). - 1932-6203. ; 12:7
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Tidskriftsartikel (refereegranskat)abstract
- The recent obesity epidemic in children also showed an increase in the prevalence of hypertension. As blood pressure (BP) is associated with (long-chain) polyunsaturated fatty acids (LC PUFA), genetic variation in desaturase enzymes being involved in the synthesis of LC PUFA may be associated with BP. This study aimed to investigate the direct effects (independent of mediating variables) and indirect effects (mediated through intermediate variables) of a common variant in the FADS1 gene, rs174546, known to affect delta-5 desaturase (D5D) activity on PUFA level, body mass index (BMI) and BP.A subsample of the IDEFICS (Identification and prevention of dietary- and lifestyle-induced health effects in children and infants) baseline survey including 520 children aged 2 to <10 years from six European countries was included. The association between rs174546 (T
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| 33. |
- Zaqout, Mahmoud, et al.
(författare)
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Determinant factors of physical fitness in European children.
- 2016
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Ingår i: International journal of public health. - : Springer Science and Business Media LLC. - 1661-8564 .- 1661-8556. ; 61:5, s. 573-82
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Tidskriftsartikel (refereegranskat)abstract
- This study was designed to explore the determinants of physical fitness in European children aged 6-11years, cross-sectionally and longitudinally.
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