Dietary Management Of Diabetes Research Articles

Blood glucose-lowering activity of protocatechuic acid is mediated by inhibiting α-glucosidase

α-Glucosidase inhibitors are effective in controlling postprandial hyperglycemia, which play crucial roles in the management of type 2 diabetes. Protocatechuic acid (PCA) is one of phenolic acids existing not only in various plant foods but also as a major microbial metabolite of dietary anthocyanins in the large colon. The present study investigated the inhibitory mechanism of PCA on α-glucosidase in vitro and examined its effect on postprandial blood glucose levels in vivo. Results from in vitro experiments demonstrated that PCA was a mix-type inhibitor of α-glucosidase. Driven by hydrogen bonds and van der Waals interactions, PCA reversibly bound with α-glucosidase to form a stable α-glucosidase-PCA complex in a spontaneous manner. The computational simulation found that PCA could insert into the active cavity of α-glucosidase and establish hydrogen bonds with catalytic amino acid residues. PCA binding aroused the steric hindrance for substrates to enter active sites and caused the structural changes of interacted catalytic amino acid residues. PCA also exhibited postprandial hypoglycemic capacity in diabetic mice. This study may provide the theoretical basis for the application of PCA as an active ingredient of functional foods in dietary management of diabetes.

Adaptations in the transformation of cassava (Manihot esculenta Crantz; Euphorbiaceae) for consumption in the dietary management of diabetes: the case of Palikur, or Parikwene People, from French Guiana.

In the French overseas department of French Guiana, in South America, nutrition therapy for the management of diabetes is based on French guidelines. However, this region is demographically diverse and includes several populations of Indigenous Peoples, Parikwene among others, also called Palikur. Due to socio-economical, cultural, and geographical differences, along with distinctions in the local food system, dietary recommendations, which many consider in the context of post-colonial power dynamics, are not well suited to local populations. In the absence of suitable recommendations, it is hypothesized that local populations will adapt their dietary practices considering diabetes as an emerging health problem. Seventy-five interviews were conducted with community members and Elders, as well as healthcare professionals and administrators providing services to the Parikwene population of Macouria and Saint-Georges de l'Oyapock communes. Data regarding the representation of cassava (Manihot esculenta Crantz) consumption and diabetes were collected via semi-structured interviews and participant observation (i.e., observation and participation in community activities), namely via participating in activities related to the transformation of cassava tubers at swidden and fallow fields. Parikwene have adapted the transformation of cassava tubers for their consumption in the management of diabetes.The importance of cassava tubers as a staple and core food to the Parikwene food system was established by identifying it as a cultural keystone species. Narratives illustrated conflicting perceptions regarding the implication of cassava consumption in the development of diabetes. Adaptations to the operational sequence involved in the transformation of cassava tubers led to the production of distinct cassava roasted semolina (i.e., couac), based on organoleptic properties (i.e., sweet, and acidic couac). Preferences for the consumption of acidic couac were grounded in the Parikwene knowledge system, as well as attention to diabetes related symptoms and glucometer readings. These results provide important insights related to knowledge, attitudes, and practices in developing locally and culturally adapted approaches to providing dietary recommendations in the treatment of diabetes.

NUTRITIONAL ASSESSMENT AND NUTRITION EDUCATION NEEDS OF RETIREES IN ABIA STATE, NIGERIA

Retirement is a transition from paid occupation to other life ventures and is associated with aging, which isa degenerative process and thus points at the need for a continuous nutritional assessment of this age groupin other to identify their nutrition educational needs. The study was a cross sectional design. A systematicrandom sampling technique was used to select 100 retirees for the study. Questionnaire and interview wasthe instruments for data collection. Height and weight measurement were also taken and used to obtain theirBMI. A 24 hours dietary recall was used to get their dietary diversity score. Blood pressure was measuredwith a mercury sphygmomanometer at least twice in each participant. Random Blood Glucose was checkedwith venous blood. Descriptive statistics (frequency and percent) was employed using SPSS version 21 whilesignificance was accepted at p<0.05. Result showed that 65% of the participants were female while 35%were males. The prevalence of overweight and obesity observed in this study was 30% and 46% respectively,39% were hypertensive, 8% had diabetes. Many (85%) of the retirees were at high risk of metabolicconditions while 6% and 9% of the retirees were at moderate and low risk respectively. Less than half (47%)of the retirees had medium dietary diversity, 39% had low dietary diversity while 14% had high dietarydiversity. Many 74%, 65% and 58% of them stated their need for education on dietary management ofdiabetes, hypertension and basic nutrition (foods) for the aged. The nutritional status and nutrition educationneed of the retirees needs to be checked most often which is aimed at reducing the risk factors of underand/or over nutrition for the retirees in Abia state as well manage those with health conditions such asdiabetes, hypertension and co-morbidities.

Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective.

Diabetes and obesity are both increasing at a fast pace and giving rise to a new epidemic called diabesity. Lifestyle interventions including diet play a major role in the treatment of diabetes, obesity and diabesity. There are many guidelines on dietary management of diabetes or obesity globally and also from South Asia. However, there are no global or South Asian guidelines on the non-pharmacological management of diabesity. South Asia differs from the rest of the world as South Asians have different phenotype, cooking practices, food resources and exposure, medical nutrition therapy (MNT) practices, and availability of trained specialists. Therefore, South Asia needs its own guidelines for non-pharmacological management of diabesity in adults. The aim of the Consensus on Medical Nutrition Therapy for Diabesity (CoMeND) in Adults: A South Asian Perspective is to recommend therapeutic and preventive MNT in the South-Asians with diabesity.

A comparative evaluation of in vitro antihyperglycemic potential of Bamboo seed rice (Bambusa arundinacea) and Garudan samba (Oryza sativa): An integrated metabolomics, enzymatic and molecular docking approach

The study reports the in vitro antihyperglycemic potential of Bamboo seed rice/BSR, a brown rice from Bambusa arundinacea species in comparison to a traditional Indian brown rice - Garudan samba/GS from Oryza sativa species using an integrated approach. Untargeted phenolic profiling using Q-TOF-LC-MS/MS confirmed sixty-three phenolic metabolites in BSR and thirty-nine in GS. The most abundant phenolics in BSR and GS were gallic acid, 4-hydroxybenzaldehyde, caffeic acid 4-O-glucoside and p-coumaric acid. Additionally, eriocitrin was abundant in BSR and cirsimaritin in GS. Predicted glycemic index determined using an in vitro starch digestibility technique indicated BSR to be a low GI variety and GS a moderate GI variety. In terms of antihyperglycemic enzyme inhibitory potential, BSR exhibited better α-amylase inhibition, whereas GS exhibited greater inhibition of dipeptidyl peptidase IV. This was further confirmed using molecular docking techniques which revealed that eriocitrin and cirsimaritin were strong inhibitors of α-amylase and DPP IV enzymes. The study thus revealed brown rice varieties from both Bambusa sp. and Oryza sp. as healthier options to white rice in the dietary management of diabetes and as good sources of several bioactive phenolic compounds.

In Vitro Glycemic Response of Indigenous Pigmented Rice Cultivars from South India and Influence of Different Carbohydrate Components

Staple diet patterns such as white rice consumption play an important part in the occurrence of chronic lifestyle-related disease like diabetes. This study intended to identify pigmented rice cultivars from India as an alternative to white rice. Nine carbohydrate components were quantified in six red and two black pigmented rice varieties. In vitro starch digestibility was also analyzed and the predicted glycemic index (pGI) was estimated. The relationship between the carbohydrate components and the pGI of the rice varieties was analyzed. The rice varieties, Kattuyanam and Chennangi exhibited high levels of insoluble dietary fibre, total dietary fibre and amylose. High soluble dietary fibre contents were observed in Poonghar and Aruvadam kuruvai. The levels of resistant starch and slowly digestible starch were found to be the highest in Karupakavuni. The results indicated Kattuyanam, Chennangi, Karungkuruvai, and Poonghar to be low pGI rice varieties (< 55). The three varieties, Kesari, Karupakavuni, and Aruvadam kuruvai were categorized under the medium pGI category (56-69). Mapillai samba had a high pGI of 70 which could be due to processing (partially milled and parboiled), but had significantly lower pGI than the white rice, Sona masuri (GI – 76). The dietary fibre components, resistant starch, slowly digestible starch, and the amylose content were negatively correlated with the pGI. Among these components, the insoluble dietary fibre, total dietary fibre, and resistant starch with significantly high (p ≤0.01) correlation were found to be the major determining factors of pGI in the studied pigmented rice cultivars. The inclusion of the identified pigmented rice varieties with low to medium glycemic response in the diet could become a key role in the dietary management of diabetes, especially among the rice-eating population.

A Moderated-Mediation Model of the Relationship between Dietary Satisfaction and Fatigue in Older Adults with Diabetes: The Role of Meal Planning and Depressive Symptoms.

Little research has examined the pathways between psychological factors and fatigue in older adults with diabetes. This study explored the pathways between diet-related quality of life and depressive symptoms in predicting fatigue using a moderated-mediation model. A convenience sample of adults ≥65 years (n = 127) with diabetes completed a cross-sectional survey including measures of fatigue severity, diet-related quality of life, and depressive symptoms, and a moderated-mediation analysis assessed the relationships between them. Diet satisfaction was negatively related to fatigue, which was mediated by depressive symptoms. In the moderated-mediation model, diet satisfaction had a conditional effect on fatigue through the mediating effect of depressive symptoms, moderated by meal planning difficulty. At higher levels of perceived meal planning difficulty, lower diet satisfaction was indirectly associated with higher fatigue through depressive symptoms, but this pathway was non-significant at lower levels. Findings suggest that supportive care for diet therapy might improve psychological outcomes in older adults with diabetes, especially for those having difficulties with daily dietary practice. Meal planning difficulties in the dietary management of diabetes accompanied by low diet satisfaction may lead to negative psychological outcomes. Monitoring satisfaction and burdens associated with dietary practices could improve fatigue in this population.

A Review on Green Revolution, Nutritional Transition, Diabetes and Millet Movement in India

<p>The advent of the green revolution in the early 1960s in India, when high yielding varieties<br />were introduced into the farm coupled with enhanced irrigation facilities and fertilizers resulted<br />in massive agricultural output. The over emphasis on high yielding crops such as wheat,<br />maize and rice not only improved the harvest index and per capita food availability, but also<br />showed a nutritional transition among people. The indigenous whole grains such as amaranth,<br />barley, sorghum and millets were commonly consumed by people prior to the green revolution.<br />Among these, millet found a dramatic decline in cultivation. Various reasons can be attributed<br />to this shift from millet to other crops. However today, the typical diet of an Indian is of high<br />carbohydrate and low protein since the majority of consumers prefer rice and wheat in their<br />diet. This transition in nutrition from complex carbohydrates of indigenous crops to high<br />glycemic index foods such as wheat and rice is correlated with the incidence of diabetes<br />mellitus. The incidence of diabetes in India is growing exponentially and to combat it, a<br />demand for food containing complex carbohydrates with a higher level of dietary fiber is<br />needed. This review deals with the idea of ‘The Millet Movement’ in India, a strategy through<br />which the dietary management of diabetes can be handled in a better way considering the<br />nutritive value of the millet.</p>

The dietary education trial in carbohydrate counting (DIET-CARB Study): study protocol for a randomised, parallel, open-label, intervention study comparing different approaches to dietary self-management in patients with type 1 diabetes

IntroductionClinical guidelines recommend that patients with type 1 diabetes (T1D) learn carbohydrate counting or similar methods to improve glycaemic control. Although systematic educating in carbohydrate counting is still not offered...

Dietary Management of Diabetes: Focus on Ketogenic Diet

AbstractIn an era of ever-increasing burden of obesity and diabetes, an out-of-the-box thinking is required to challenge the status quo. With dismal results of current nutritional and therapeutic armamentarium, ketogenic diet can provide this opportunity. Ketogenic diet has profound pathophysiological as well as evolutionary basis for it to be used as a tool in diabetes management. Despite progressively accumulating evidence for clinical efficacy and safety, widespread adoption of ketogenic diet remains low due to lack of expertise and standard guidelines.

Nutrition Therapy in Gestational Diabetes Mellitus: Time to Move Forward.

Nutrition therapy remains the conventional first-line approach to treatment of gestational diabetes mellitus (GDM). It will reach every woman with GDM across differing diagnostic criteria (1) and phenotypic heterogeneity (2). The goal of nutrition in pregnancy is to support maternal, placental, and fetal metabolic needs, and it may be the first introduction to a lifetime of healthy eating (3). In this way, nutrition therapy in GDM becomes an early-stage intervention in the vicious cycle of intergenerational obesity and diabetes (4). Importantly, because the prevalence of GDM has reached an alarming ≥20% of pregnancies (5), a cost-effective approach to management is urgently needed. While controlling fetal exposure to maternal hyperglycemia and overnutrition, effective nutrition can treat GDM in a way that is fiscally reasonable and culturally sensitive, ultimately reducing the need for medication and intensified health care resource use (1). The importance of nutrition therapy in GDM is a premise unlikely to be contested. Yet, the widely accepted approach rooted in carbohydrate restriction was challenged more than a decade ago based on concerns related to higher fat intake and exacerbation of maternal insulin resistance by free fatty acids (6,7). The dietary management of diabetes in pregnancy has remained in limbo ever since, with no specific guidelines for nutrition therapy in GDM, a travesty that has resulted in non–evidence-based, fragmented, and inconsistent approaches globally (8–12). Action is necessary not only because of the powerful influence of nutrition on fetal programming and development (13,14) but also because of the ability to positively impact the health of millions of mother-infant dyads. Currently, nutrition therapy appears to have become our Achilles heel, such that despite our strength, we have limped forward in generating clinical evidence to substantiate …

Characteristics of older adults with diabetes: What does the current aged care resident look like?

The prevalence of diabetes in older adults in residential aged care (RAC) is twice that of community dwelling older adults. Older adults with diabetes have been highlighted as being at high risk of frailty and malnutrition, particularly when managed on a therapeutic diet. However, assumptions may be based on clinical presentation of our oldest old which may be at conflict with the clinical presentation of younger older adults. The aim of this retrospective audit was to identify the characteristics of aged care residents with diabetes, their comorbidities and malnutrition risk. Residents' with diabetes paper-based records were audited for demographic data, diet code, medical and medication history, malnutrition risk screening scores and anthropometric data. A total of 295 residents with diabetes records were audited across 13 sites in South Australia. Younger older adults (65-74 years) were generally in a healthy weight range (23-30 kg/m2 ) or obese (>30 kg/m2 ) and had gained weight since admission to RAC; whereas the oldest old were more likely to have lost weight and had a lower body mass index range 22.6-28.9 kg/m2 . An unexpected finding was the variability between RAC sites in dietary management of diabetes and potential inappropriate dietary management of malnutrition, as indicated by their food service diet codes. Findings suggest that younger older adults in RAC are more likely to be overweight which is maintained over a typical length of stay. Study findings indicate that diabetes management is inconsistent and highlights the need for mandated RAC menu guidelines.

Dietary intake of boiled breadfruit (Treculia africana) seeds did not improve hyperglycemia in streptozotocin induced diabetic rats: Effect on the oral glucose tolerance of normoglycemic rats.

Although African breadfruit (Treculia africana) is said to be useful in the dietary management of diabetes, the effect of cooking on its glycemic index has not been reported. Hence this study has investi- gated the effect of a dietary intake of boiled breadfruit on the serum glucose, glucose tolerance, body weights and relative organ weights of streptozotocin (STZ) induced diabetic rats. Twenty albino rats were used and were divided into four groups of five rats. Groups 1 (normal control) and 2 (diabetic control) received standard rat pellets while groups 3 (diabetic-test group) and 4 (non-diabetic) rats received breadfruit. The blood glucose of the normoglycemic rats fed standard rat feeds peaked at 30 min (149.75 ±11.12 mg/dl) following oral glucose loading (3 g/kg) but reduced to 85.25 ±21.05 mg/dl after another 90 min, while the blood glucose of the normoglycemic rats fed breadfruit peaked at 30 min (146.25 ±15.22 mg/dl) follow- ing oral glucose loading, but elevated (130.75 ±36.69 mg/dl) after another 90 min. There was significant elevation (P < 0.05) of the serum glucose, relative liver weight (RLW) and relative kidney weight (RKW) but a significant decrease in the body weights of the diabetic control compared with the normal control; no sig- nificant difference (P > 0.05) in the serum glucose, body weights, RLW and RKW of the test group compared with the diabetic control, and no significant differences (P > 0.05) in the serum glucose, body weights, RLW and RKW of the normal rats fed the breadfruit diet compared to the normal control. The study showed that the traditional method of cooking African breadfruit negatively affects its hypoglycemic property.

Identifying Barriers and Enablers in the Dietary Management of Type 2 Diabetes in M'Bour, Senegal.

The purpose of this study was to identify cultural enablers and barriers to dietary management of type 2 diabetes in M'Bour, Senegal. This qualitative study used the PEN-3 cultural model to explore diabetes dietary management within a cultural framework. Content analysis identified emergent themes based on the PEN-3 model. Forty-one individuals completed interviews. Themes reflecting ways that culture affects adherence to the diabetic diet included (a) having a different diet or eating separately from the communal family plate creates feelings of social isolation; (b) forgoing the diabetic diet sometimes occurs so that family members have enough food; (c) reducing servings of traditional foods feels like abandoning culture; and (d) women being responsible for preparing food, while men typically manage money for purchasing food yet do not provide input on what food is purchased. Results suggest that educating family units on the dietary management of diabetes may be more effective than individual education.

Biochemical basis of the use of cocoyam (Colocassia esculenta L.) in the dietary management of diabetes and its complications in streptozotocin induced diabetes in rats

ObjectiveTo investigate the biochemical basis of the anti-diabetic action of cocoyam [Colocassia esculenta (C. esculenta)] in streptozotocin diabetic rats. MethodsBlood glucose of the rats was measured with a glucometer. The relative heart weight, relative pancreatic weight, serum proteins, urea, creatinine, albumin, amylase, lipase, serum and hepatic aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP) and chemical analysis of the test feed were determined using standard techniques. ResultsThe diabetic rats fed with cocoyam had significant elevation (P<0.05) of relative pancreatic weight, hepatic AST, ALT, ALP and serum proteins and albumin, but had significant reduction (P<0.05) of blood glucose, serum urea, creatinine, amylase, lipase, AST, ALT and ALP compared with the diabetic control rats while these parameters were significantly altered (P<0.05) in the diabetic control rats compared with the non-diabetic rats. There were no significant differences (P>0.05) in the relative heart weights of all the rats in the three groups. The test feed contained considerable amounts of phenolics, crude fiber, Ca, Fe, K, Na but low amounts of oxalate and phytate. ConclusionsC. esculenta may exert its anti-diabetic action by delaying/regulating the rate at which dietary starch is hydrolyzed to glucose or possibly through inhibition of acute pancreatitis. Finally, the study also shows the potentials of C. esculenta in the dietary management of obesity.

A Google Glass Application to Support Shoppers With Dietary Management of Diabetes

We read with great interest the article titled “New Wearable Computers Move Ahead: Google Glass and Smart Wigs” by Dr David C. Klonoff published in the January 2014 issue of the Journal of Diabetes Science and Technology.1 Wearable computers have enormous potential to assist in diabetes management. Here, we further discuss a Google Glass application with the potential to advise and track dietary choices. Maintaining an appropriate diet is an important part of diabetes care.2 Because purchased food items are likely to be consumed regardless of nutritional value, dietary control begins at the supermarket. On-the-spot decision support tools may help shoppers make smarter food choices. Current approaches include educational materials and smartphone applications designed to inform shoppers of nutritional value. However, the abundance of food options in US supermarkets makes memorizing all of the necessary information cumbersome. It may be possible to employ an application that displays caloric density (calories/oz) and glycemic index as the user shops by scanning the barcodes of products loaded into the cart; it may even be possible to provide healthier alternatives if a poorly scoring food is scanned. The ability to provide real-time information in a hands-free and private manner makes Google Glass an ideal platform on which to build a tool to promote healthy choices in the supermarket. As an example, imagine a shopper with diabetes standing in the produce section trying to decide on a vegetable side dish (see the video available at: https://www.youtube.com/watch?v=UoUx1aFNES8). The shopper picks up the sweet corn, asks Google Glass to determine its glycemic index, and notes a score of 60. Next, the shopper performs the same actions for a bunch of broccoli, with Google Glass indicating a score of 10. The ease of using the Google Glass device to obtain real-time decision support in a simple, private, and hands-free way may increase the willingness or ability of patients with diabetes or members of their household to follow important dietary recommendations. At present, the Google Glass technology is cost prohibitive, but prices are expected to fall as Google opens this technology to the consumer market later this year. Recent announcements regarding establishment of a partnership between Google and the Luxottica Group eyeglass company suggest this will happen in the near future.3 Regardless, the technology must be affordable for the average patient to warrant further development. In addition, older patients need to be considered in designing the user interface. A large number of patients with diabetes are older and may not be comfortable with newer technology. The Google Glass “Diabetes Shopping” application4 built at Marshfield Clinical Research Foundation is in proof-of-concept stages, but has considerable room for growth in the areas of tracking and cataloguing, establishing connections to social media and peer support, providing alerts for calories or food choices, capturing cumulative calorie intake, and health coaching. The Google Glass diabetes application has the potential to improve diabetes management by improving dietary choices while shopping and the potential to do much more.

Diet, delusion and diabetes

Diet is good for diabetes, as everyone agrees, but which diet? The word itself has acquired such negative associations that professionals now prefer to talk of medical nutrition therapy, abbreviated to MNT to avoid the negative connotations of the word ‘nutrition’. Shakespeare said that ‘a rose by any other name would smell as sweet’, but it will still have thorns, and we will continue to call a diet a diet. Three related health benefits might be expected from a diet for diabetes: improved metabolic control, weight loss, and reduced risk of vascular disease. From a patient’s point of view, you diet because you want to lose weight, a desire typically expressed in the future conditional, as in ‘I really must think about going on a diet’. Overweight cannot be divorced from emotion, and its consequences cannot be measured in kilograms, for its true costs to the individual must be paid in the currency of the soul. Let us therefore ask a much simpler question: weight loss apart, which diet is best for diabetes? The recent American Diabetes Association (ADA) guidelines, drafted in the light of 150 years of experience in the dietary management of diabetes, conclude that we lack the evidence needed to reach a conclusion [3]. Will we ever find the right answer? Or are we asking the wrong questions? From an historical perspective, it is easy to see that the investigators of diet have confused circular motion with progress. The very low carbohydrate diets of the pre-insulin era yielded to the high carbohydrate diets of the late 1920s and 1930s, and these gave way to the free diets of the 1930s through to the 1950s. The cycle then resumed with the low carbohydrate diet of the 1960s, the high carbohydrate/high fibre diet of the 1970s, the free diets of the latter part of the century and the reincarnation of the pre-insulin regimen in the form of the Atkins diet. The enthusiasts have come and gone, each claiming unique virtue and spectacular success for their own particular regimen, and it would be hard to imagine a diet that has not at some stage constituted an article of faith in diabetes management. Almost all these diets worked some of the time, but we may suspect that few were followed with any degree of rigour for most of the time. Diabetologia (2009) 52:1–7 DOI 10.1007/s00125-008-1203-9

Health improvement through dietary management of type 2 diabetes

Diabetes is found to be one of the fastest growing chronic diseases with a high incidence among older people, and in residential care homes the prevalence of diabetes can be as high as 25% percent. A range of complications can develop following the onset of the disease. The prevention of these complications is in line with the emphasis that is being placed on health promotion and the prevention of ill health in current health strategies. This article will discuss a district nurse's approach to health improvement through dietary management of diabetes for elderly residents with type 2 diabetes living in a care home. The PRECEDE-PROCEED health promotion model chosen to assess the learning needs of the residents and to structure the implementation and evaluation of the health promotion project was good guidance and will form the structure for this article.

Is Aspartame Really Safer in Reducing the Risk of Hypoglycemia During Exercise in Patients With Type 2 Diabetes?

In addition to physical activity and healthy food choices, low-calorie sweetening agents, such as aspartame, are a recommended alternative to sugar for patients with type 2 diabetes in order to obtain a better control of carbohydrate intake and blood glucose levels (1–3). The safety of aspartame has been a controversial issue for quite some time now. This noncarbohydrate sweetener is currently found in over 6,000 food products and beverages throughout the world. At present, its attractiveness as an artificial sweetener in the dietary management of diabetes is related to its ∼200-fold sweetening power and the lack of effect on plasma glucose levels compared with sucrose. We have recently investigated the effect of different …

Dietary guidelines for the management of diabetes

This article outlines contemporary guidelines for the dietary management of diabetes, with the aim of reducing inconsistencies in dietary recommendations.