Diet Program Research Articles

Investigation of vitamin D, vitamin B12 and ferritin levels in children receiving Home Health Care Services in Southeastern Turkey

Objective: For proper nutrition of children followed by the Home Health Care (HHC) unit, a close follow-up is extremely important. Vitamin deficiencies are common in children in this group who need parental or caregiver-dependent nutrition. The purpose of this study conducted in Batman Province, was to investigate vitamin D, vitamin B12 and ferritin levels of individuals under 18 years of age who are followed by the HHC unit and continue their lives and treatments at home, except for emergencies. Materials and Methods: This study was derived from the files of 416 pediatric patients who were followed up in Batman Province HHC unit between January 1, 2022, and December 31, 2022. It was designed as a retrospective, single-center study evaluating 25-hydroxyvitamin D (OH) levels, vitamin B12 levels, ferritin levels, and demographic variables from individuals followed by HHC unit. The data were collected from the HHC unit’s files. IBM-SPSS version 24 was used for analysis. Results: The mean age of the 416 children receiving home health care services included in the study was 10.38±4.37 years. 234 (56.2%) of the participants were male and 182 (43.8%) were female. The 25(OH)D level was 18.47±5.41 ng/mL for all ages, and the ferritin level was 34.90 (33.08) ng/mL. The vitamin B12 level was 480.31±190.38 ng/L. The 25-OH-D vitamin levels of the children in the study was significantly low. Conclusion: Patients followed within the scope of home health care services are at risk for malnutrition and vitamin deficiencies, and annual follow-up of the patients in this regard and personalized diet programs should be created. Vitamin D insufficiency and deficiency are common in children in this group, who cannot leave the house except for compulsory situations and cannot benefit from sunlight sufficiently. We think that these children with chronic diseases should take vitamin D prophylaxis.

Screening blood glucose and blood pressure to prevent the risk of diabetes mellitus and hypertension

During the covid 19 pandemic, Gamping Lor did not hold activities that risk causing crowds in order to avoid the transmission of covid 19, thus they didn’t do any activity. This condition will worsen public health conditions, which are vulnerable to exposure to NCD (Non-Communicable Diseases). In Indonesia, the number of people with DM (Diabetes mellitus) is estimated to increase by 2 times in 2030. The purpose of this service is to conduct screening for early detection of diabetes and hypertension in vulnerable communities of Gamping Lor. The method used is counseling and examination practice. The results of the activity there were 68 participants consisting of women 89.7% men 11.3%. with a picture of the following conditions; Hypertension, 35.3% prehypertension 27.3%, Normal 29.4%, Low 7.3%; hyperglycemia 15.2%, hypoglycemia, 4.5%, normal 83.3%; BMI status; Thin 11.11%, ideal,22.22%, Overweight, 20.6% Obesity level 1 , 34.9%; obesity grade 2; 11.11%. Participants with high hypertension conditions, but more normal sugar levels. Participants overweight to obesity are higher than the ideal and thin. Conclusion : Service I I went well according to plan. More participants were affected by pre and hypertension, but normoglucose, on the other hand, experienced the most overweight and obesity. So it is important to do a diet and fat burning program according to age.

Exploring engagement with a web-based dietary intervention for adults with type 2 diabetes: A mixed methods evaluation of the T2Diet study.

Improved understanding of participant engagement in web-based dietary interventions is needed. Engagement is a complex construct that may be best explored through mixed methods to gain comprehensive insight. To our knowledge, no web-based dietary intervention in people with type 2 diabetes (T2D) has previously used a mixed methods approach. The aim of this study was to explore factors that may contribute to effective engagement in a web-based dietary program for people with T2D. This study employed a mixed methods intervention design, with a convergent design embedded for post-intervention evaluation. The convergent design collected and analyzed quantitative and qualitative data independent of each other, with the two datasets merged/compared during results/interpretation. Quantitative data collected from intervention group participants (n = 40) were self-administered questionnaires and usage data with average values summarized. Qualitative data were participant semi-structured interviews (n = 15) incorporating a deductive-inductive thematic analysis approach. The results from the quantitative and qualitative data indicated positive overall engagement with the web-based dietary program. Factors that contributed to effective engagement were sustained frequency and intensity of engagement; structured weekly program delivery; participants affective engagement prior to and during the intervention, with positive affective states enhancing cognitive and behavioral engagement; and participants experience of value and reward. In addition, the user-centered development process employed prior to intervention delivery played an important role in facilitating positive engagement outcomes. This study yielded novel findings by integrating qualitative and quantitative data to explore engagement with a web-based dietary program involving people with T2D. Effective engagement occurred in this intervention through a combination of factors related to usage and participants' affective, cognitive and behavioral states. The engagement outcomes that emerged will be useful to current and future researchers using digital technologies to deliver lifestyle interventions for T2D or other chronic health conditions.

The association between gut-health promoting diet and depression: A mediation analysis

BackgroundRecent research has highlighted the relevance of a gut-health promoting diet as a possible treatment and prevention for depression. A dietary pattern with consumption of fermented food and high consumption of dietary fiber can promote gut health, physical health, and might even improve mental health. This study aimed to investigate the interrelationship among diet, physical health, and depression. MethodsThis study used a nationally representative sample (N = 16,572) from the National Health and Nutrition Examination Survey (2011–2018). Dietary information was collected by dietary recall interviews. Depression was assessed by the 9-item Patient Health Questionnaire. Subjective physical health was indicated by self-reported Body Mass Index (BMI). Objective physical health was indicated by BMI measured by trained health technicians. Path analysis was used to test the association between diet and depression, and the mediating roles of self-reported BMI and BMI measured by technicians. ResultsConsumption of probiotic foods and higher intake of fiber were significantly associated with lower levels of depressive symptoms. Both subjective and objective physical health significantly mediated the relationship between variables of diet and mild depressive symptoms. Subjective physical health also significantly mediated the relationship between high intake of dietary fiber and lower likelihood of reporting severe depressive symptoms. ConclusionDespite being cross-sectional in nature, this study presented evidence that gut-health promoting diets may reduce depressive symptoms through improving physical health. These findings provide preliminary support to diet programs for preventing depression and diet programs as an alternative or supplementary treatment of depression.

Maternal Undernutrition Induces Cell Signalling and Metabolic Dysfunction in Undifferentiated Mouse Embryonic Stem Cells

Peri-conceptional environment can induce permanent changes in embryo phenotype which alter development and associate with later disease susceptibility. Thus, mouse maternal low protein diet (LPD) fed exclusively during preimplantation is sufficient to lead to cardiovascular, metabolic and neurological dysfunction in adult offspring. Embryonic stem cell (ESC) lines were generated from LPD and control NPD C57BL/6 blastocysts and characterised by transcriptomics, metabolomics, bioinformatics and molecular/cellular studies to assess early potential mechanisms in dietary environmental programming. Previously, we showed these lines retain cellular and epigenetic characteristics of LPD and NPD embryos after several passages. Here, three main changes were identified in LPD ESC lines. First, their derivation capacity was reduced but pluripotency marker expression was similar to controls. Second, LPD lines had impaired Mitogen-activated protein kinase (MAPK) pathway with altered gene expression of several regulators (e.g., Maff, Rassf1, JunD), reduced ERK1/2 signalling capacity and poorer cell survival characteristics which may contribute to reduced derivation. Third, LPD lines had impaired glucose metabolism comprising reduced upstream enzyme expression (e.g., Gpi, Mpi) and accumulation of metabolites (e.g., glucose-6-P, fructose-6-P) above the phosphofructokinase (PFK) gateway with PFK enzyme activity reduced. ESC lines may therefore permit investigation of peri-conceptional programming mechanisms with reduced need for animal experimentation.Graphical

Self-Efficiency and Quality of Life Coronary Heart Disease Patients: A descriptive study

Introduction: Coronary heart disease is a disease that requires treatment in the long term and even for life, a strict diet, and restriction of physical activity which directly affects the patient's quality of life. Self-efficacy is one factor that affects the patient 's quality of life with coronary heart disease. Methods: This study aimed to determine the relationship between self-efficacy and quality of life of patients with coronary heart disease at the Cardiology Polyclinic at Sanglah Hospital Denpasar. This study used a correlational analytic design with a cross-sectional approach, a cardiac self-efficacy questionnaire, and the WHOQOL BREF. The sample size was 164 respondents recruited by consecutive sampling technique. Result: Most respondents were in the moderate self-efficacy category of 80 respondents (48.8 %), and most had a moderate quality of life, namely 64 respondents (39.0 %). Conclusion: High self-efficacy will increase the ability of coronary heart disease patients to follow a programmed therapy regimen, adhere to the recommended diet program, and regulate physical activities optimally so that they will be able to maintain and improve their quality of life

Latihan Fisik Melalui Senam Low Impact terhadap Kadar HBA1C Penderita Diabetes Mellitus

This study aims to see the effect of physical exercise through low-impact gymnastics on Hba1c DMT2 levels at the Makrayu Health Center in Palembang City. This research design uses Quasi-experiments with Control. The results showed that of the 33 respondents, the most were 26 people (78.8%) of gender, with the highest level of education being low education, 15 (45.4%) with a good diet program, as many as 17 (51.5%) programs good treatment as many as 23 (69.7%). Furthermore, for genetic risk factor variables, 17 (51.5%). In conclusion, there is an average difference between HbA1c levels in the second measurement for the intervention group and the control group, and the intervention group in the first and second measurements. There was a mean difference between the HbA1c levels of the intervention group in the first and second measurements.
 
 Keywords: Diabetes Mellitus Type 2, HbA1c, Low Impact Exercise

Sociodemographic patterning of dietary profiles among Inuit youth and adults in Nunavik, Canada: a cross-sectional study

ObjectivesCountry (traditional) foods are integral to Inuit culture, but market food consumption is increasing. The Qanuilirpitaa? 2017 Nunavik Health Survey (Q2017) reported similar country food consumption frequency compared to that in 2004; however, examining food items individually does not account for diet patterns, food accessibility, and correlations between food items. Our objective was to identify underlying dietary profiles and compare them across sex, age, ecological region, and food insecurity markers, given the links among diet, health, and sociocultural determinants.MethodsFood frequency and sociodemographic data were derived from the Q2017 survey (N = 1176). Latent profile analysis identified dietary profiles using variables for the relative frequencies of country and market food consumption first, followed by an analysis with those for country food variables only. Multinomial logistic regression examined the associations among dietary profiles, sociodemographic factors, and food insecurity markers (to disassociate between food preferences and food access).ResultsFour overall dietary profiles and four country food dietary profiles were identified characterized by the relative frequency of country and market food in the diet. The patterns were stable across several sensitivity analyses and in line with our Inuit partners’ local knowledge. For the overall profiles, women and adults aged 30–49 years were more likely to have a market food–dominant profile, whereas men and individuals aged 16–29 and 50+ years more often consumed a country food–dominant profile. In the country food profiles, Inuit aged 16–29 years were more likely to have a moderate country food profile whereas Inuit aged 50+ were more likely to have a high country food–consumption profile. A low country and market food–consumption profile was linked to higher prevalence of food insecurity markers.ConclusionWe were able to identify distinct dietary profiles with strong social patterning. The profiles elucidated in this study are aligned with the impact of colonial influence on diet and subsequent country food promotion programs for Inuit youth. These profiles will be used for further study of nutritional status, contaminant exposure, and health to provide context for future public health programs.

Preventive Care: Improving Health of Medicare, Medicaid, and Children’s Health Insurance Program Patients Through Access to Fresh Fruit and Vegetables

Diet is the number one risk factor for deaths in the United States. Members of marginalized and impoverished communities particularly struggle to afford nutritious food. Poor diets result in health disparities along socio-economic, age, racial, ethnic, indigenous, rural, and urban lines. Despite the ever-growing social and financial burden of diet-related chronic diseases, the U.S. has failed to invest in health care-related dietary policy. This Article proposes produce prescriptions as a national dietary preventive medicine program through Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).Recently, nonprofits, governments, and health care providers have designed innovative produce prescription programs to combat diet-related chronic diseases. In these programs, clinical providers can prescribe subsidized fruit and vegetables to patients. Produce prescriptions empower patients by making dietary change affordable and by motivating patients to improve their health. Numerous studies, pilot projects, and local programs demonstrate that produce prescriptions can improve health care outcomes for individuals from diverse communities. Most at-risk members of our society receive health coverage through Medicare, Medicaid, or CHIP. This Article analyzes how to scale up produce prescriptions within these programs using law and policy.

Familial dietary intervention in children with excess body weight and its impact on eating habits, anthropometric and biochemical parameters.

Obesity is considered a civilisation disease which increases mortality and impairs quality of life, also among children and adolescents. The prevalence of overweight and obesity is steadily increasing in the developmental age population. Environmental factors are responsible for the main reason of excessive adipose tissue accumulation. Among these, poor eating habits and lack of exercise play the largest role. Familial prevalence of obesity and family dietary patterns also receive significant attention. Many specialists believe that the treatment of obesity should be multidirectional, effective and minimally invasive. Therefore, effective and safe methods are being investigated to effectively reduce body weight and improve eating habits. Dietary education programmes are an alternative to improve the health status of obese and overweight children and adolescents. To be fully effective, these programmes should involve the whole family. In the face of constantly increasing prevalence of overweight and obesity in the developmental age population and the lack of effective methods to combat its occurrence, it seems appropriate to try to assess the effectiveness of a one-year-long dietary education of children and adolescents with excess body weight on their eating habits and the eating habits of their mothers, as well as selected anthropometric and biochemical parameters in these children using a simple educational tool, the Healthy Food Pyramid. The study group consisted of 68 children with overweight and obesity, patients of the Department of Paediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age of the Pomeranian Medical University in Szczecin. The study used a proprietary questionnaire to assess dietary habits. Patients participated in six individual educational meetings over a twelve-month period. Eating habits were assessed in children and mothers before and after dietary intervention. Sixty-seven questionnaires before and after the dietary intervention were used for analysis. Sixty-eight children completed the study. Those who did not complete the study came from families living in rural areas and their mothers mostly had primary or vocational education. One-year dietary education resulted in significant improvements in body weight, waist and hip circumference, WHtR and selected measured carbohydrate and lipid metabolism parameters with the exception of total cholesterol. The one-year dietary intervention did not have the same effect on the change in dietary habits in children and in their mothers.

Assessing Consumer Willingness to Pay for Nutritional Information Using a Dietary App

A healthy society is the foundation of development in every country, and one way to achieve a healthy society is to promote healthy nutrition. An unbalanced diet is one of the leading causes of noncommunicable diseases globally. If food was correctly selected and correctly consumed, both the problems of overeating and lack of nutrition could be largely solved while also decreasing public health costs. Interventions such as presenting necessary information and warning labels would help consumers make better food choices. Hence, providing nutritional information to consumers becomes essential. The present study investigates the importance of nutrition information labels on consumers' preferences by estimating their willingness to pay for features and information provided by a dietary software program (app). An application can easily display the information to the consumers and help them make informed food choices. A discrete choice experiment investigated consumers' preferences and willingness to pay to receive nutritional information. Mixed multinomial logit and latent class analysis were applied. The results showed the existence of heterogeneity in consumer preferences for different nutritional information provided by the application. Consumers are willing to pay more for salt and fat alerts. The results of this study allow for the analysis of consumers' interest in nutritional information. Such results are essential for the industry for future investments in similar applications that potentially could help consumers make better informed choices.

Micronutrient intake of children in Ghana and Benin: Estimated contribution of diet and nutrition programs.

We estimated how micronutrient needs of young children, aged 6-24 months were covered by the standard (traditional) diets in Ghana and Benin, and the contributions of partial breastfeeding and national nutrition programs aimed at improving micronutrient status to overall micronutrient intakes. Estimates of micronutrient intake from standard diets were based on previous surveys, using the food composition table of West Africa (INFOOD). Recommended micronutrient intakes were based on World Health Organization recommendations. Children were grouped in threeage groups (6-8, 9-12, and 13-24 months) to capture the changing dynamics of the complementary feeding period. As expected, from 6 months of age onwards, breastmilk didn't cover the micronutrient needs. The standard diets contributed only minimal to micronutrient intakes of children ranging from 0% to 37% of recommended intakes for Ca, Fe, Zn, vitamin A, vitamin Dand iodine depending on the micronutrient considered. The contribution of mass (bio)-fortification programs to the coverage of micronutrient needs varied widely, depending on the staple food considered and the country, but overall did not allow to fill the gap in micronutrient needs of children except for vitamin A in some contexts. In contrast, consumption of voluntary fortified complementary food, especially formulated for the needs in this age groups, contributed substantially to overall micronutrient intake and could fill the gap for several micronutrients. The development of young child-targeted programs including micronutrient-dense foods, associated with interventions to increase the diet diversity and meal frequency, could significantly improve micronutrients intakes of children in both Ghana and Benin.

Evaluation under real-life conditions of a lifestyle intervention for diabetes prevention developed by the municipal health services of Madrid, Spain

The Diet, Physical Activity and Health (Alimentación, Actividad física y Salud, ALAS) program is an intervention implemented by the municipal health services of Madrid with the objective of reducing weight and preventing diabetes in high-risk population by improving diet and physical activity. The ALAS program combines individual visits with a 10-session group workshop that takes place over a 6-month period. This study evaluated the effectiveness of the ALAS intervention implemented under real-life conditions between 2016 and 2019. The intervention was evaluated with a pre- and post-intervention study with follow-up performed 6 and 12 months from the start of the program. The analyzed outcomes were a 5–10% reduction in the initial weight, body mass index (BMI), waist circumference and a change in glycemic status in prediabetic participants. Statistical models were adjusted by sociodemographic variables. The participants were recruited from municipal community health centers or referred by municipal occupational health services. Between 2016 and 2019, 1629 people participated in the program. At 6 months, 85% of the participants had lost weight; 43% had lost 5% or more of their initial weight, and 12% had lost 10% or more. Regarding BMI, 22.3% of participants who were initially obese were no longer obese, and 15.2% of the overweight participants achieved normal weight. A total of 35.1% of the prediabetic participants reverted to normoglycemic status. The intervention was found to be more effective for men, for those who completed the intervention and those who accessed the program through the occupational health route. Among the participants who accessed the intervention via the community, the intervention was more effective in those with a high educational level. The evaluation demonstrated the effectiveness of the ALAS program for reducing weight and the risk of developing Type 2 diabetes when applied under real-life conditions. The effectiveness of the intervention differed according to gender, access route and educational level of the participants.

Opportunities to advance implementation science and nutrition research: a commentary on the Strategic Plan for NIH Nutrition Research.

Despite population-wide recommendations by the U.S. Dietary Guidelines for Americans and others to encourage health-promoting dietary patterns, the proportion of Americans following dietary recommendations remains low. The gaps in the adoption and integration of evidence-based dietary interventions, practices, programs, and policies (EBIs) into community and clinical settings signal the need to strengthen efforts in implementation science (IS) in nutrition research to understand and alleviate barriers to adopting and sustaining healthy dietary behaviors and practices. Equally important is the translation of this research into practice in a variety of settings and across the diversity of populations. Recognizing this need, the U.S. National Institutes of Health (NIH) 2020-2030 Strategic Plan for NIH Nutrition Research calls for the expansion of IS as a key opportunity to advancing nutrition research. This commentary highlights three scientific opportunities to stimulate IS in nutrition research and provides examples for each opportunity. These include: (a) Advance consideration of implementation and dissemination early in the design of interventions to facilitate opportunities for equitable scale-up and sustainability of EBIs, (b) Develop and test strategies for equitable implementation of nutrition and diet EBIs in health care and community settings, and (c) Build and strengthen the infrastructure, capacity, and expertise needed to increase use of IS in clinical and community nutrition research to swiftly move the research into practice. By advancing the three opportunities identified in this commentary, the scientific community has the potential to advance the field of nutrition research and IS with the ultimate goal of improving public health.

Nurse Practitioner-Led Ketogenic Diet for Adults With Overweight/Obesity

A retrospective analysis was done of a nurse practitioner (NP)-led low-calorie ketogenic diet for adults with overweight and obesity study to determine whether results were comparable to physician-led low-calorie ketogenic diet programs. A statistically significant (P < .05) reduction was noted. NP results were compared with physician-led studies. The first study showed more weight loss in the physician group, whereas the NP had better outcomes compared with the second physician study. Results were statistically significant. The study concluded that a NP-led low-calorie ketogenic diet program is effective in primary care.

The obesity code: Book review

Dr. Jason Fung presents a novel, comprehensive model of obesity that delivers unexpected insights into healthy eating in this highly accessible and challenging book. Dr. Fung is a nephrologist (kidney doctor) who launched the Intensive Dietary Management program in Toronto. Dr. Jason Fung is regarded as a member of the foremost experts on intermittent fasting, a subject I knew very little about before going through his book. His intermittent fasting approach is his trademark prescription for obesity and type 2 diabetes individuals. Dr. Fung discusses utilizing intermittent fasting to end the cycle of insulin resistance and achieve a healthy weight.

Effect of aquatic resistance interval training and dietary education program on physical and psychological health in older women: Randomized controlled trial.

Due to demographic changes, the world's population is progressively aging. The physiological deterioration of the older adult may lead to reduced balance capacity and increased risk of falls, among others, due to the prevalence of degenerative diseases. Physical exercise can be effective in reducing the risk of disease and slowing functional decline in older people. The aim of the research is to test the effects of aquatic resistance training and dietary education on health indicators, strength, balance, functional autonomy, perception of satisfaction with life. Thirty-four participants aged 69 ± 4 years were randomly assigned into two groups: experimental (aquatic resistance interval training) and control group (no intervention). The intervention consisted of resistance training in an aquatic environment carried out for 14 weeks (three sessions per week: 60 min each). All variables were analyzed twice; pre - post intervention. Aquatic resistance training has positive effects on strength (p < 0.001), functional self-sufficiency (p < 0.001) and aerobic capacity (p < 0.001), however, no significant differences were observed in the perception of satisfaction with life and balance. Research results suggest that older women who engage in regular, scheduled aquatic resistance training have greater autonomy in performing activities of daily living, agility, gait control, and body composition variables (lower fat compartment and greater muscle mass).

Five-year follow-up of patients with knee osteoarthritis not eligible for total knee replacement: results from a randomised trial

ObjectivesThe main objective was to investigate 5-year outcomes in patients with knee osteoarthritis, randomised to one of two non-surgical treatments.SettingTwo outpatient clinics.ParticipantsAt baseline, 100 patients with radiographic and symptomatic knee...

Hypotensive and HbA1c reducing effect of novel dietary intervention program “COMB meal program”: Two randomized clinical trials

Both hypertension and diabetes are so-called “silent killers.” We previously demonstrated the effect of a novel diet intervention program using COMpletely Balanced meal (COMB meal) consisting of 33 nutrient types on improving multiple parameters, including blood pressure and hemoglobin A1c (HbA1c). The present study evaluated the antihypertensive and antidiabetic effects of the program in an open-label randomized control trial. Trial 1 enrolled 100 males with high blood pressure (systolic blood pressure [SBP] ≥ 130 mmHg, and/or diastolic blood pressure [DBP] ≥ 85 mmHg). Trial 2 enrolled 99 males with HbA1c levels ≥ 5.6 %. Participants assigned to the test group took COMB meals every weekday for 4 weeks, replacing two meals per day. Compared to the control group, the test group showed significantly decreased DBP (p = 0.047) and HbA1c (p = 0.039). These results indicate that the novel program based on COMB meal might improve blood pressure and glucose metabolism through both nutrient supplementation and weight loss.

Rationalisation of the UK Nutrient Databank for Incorporation in a Web-Based Dietary Recall for Implementation in the UK National Diet and Nutrition Survey Rolling Programme.

The UK National Diet and Nutrition Survey rolling programme (NDNS RP) commenced in 2008 and moved in 2019 from a traditional paper food diary to a web-based 24 h recall, Intake24. This paper describes the approach to update and downsize the underlying UK Nutrient Databank (NDB) for efficient data management and integration into Intake24. Consumption data from the first 10 years (2008/2009 to 2017/2018) of NDNS RP informed decisions on whether foods from the extensive UK NDB were to be retained, excluded, revised or added to for creation of a rationalised NDB. Overall, 5933 food codes in the extensive NDB were reduced to 2481 food codes in the rationalised NDB. Impact on assessment of nutrient intakes was evaluated by re-coding NDNS 2017 data using the rationalised NDB. Small differences were observed between estimated intakes (Cohen's d ≤ 0.1) for all nutrients and there was a good level of agreement (Cohen's κ ≥ 0.6) between the extensive and rationalised NDBs. The evaluation provides confidence in dietary intake estimates for ongoing nutritional surveillance in the UK and strengthens the evidence of a good agreement between concise food databases and large food databases incorporated into web-based 24 h recalls for estimating nutrient intakes at the population level.