Identifying the relative contributions of body size across life course to midlife and late-life cognitive function: a Bayesian analysis from the Guangzhou Biobank Cohort Study.

Overweight and obesity among children and adolescents are increasing globally, requiring effective treatment strategies to mitigate future health risks. This systematic review and meta-analysis with meta-regressions evaluated the impact of Mediterranean diet (MD)-based dietary interventions, with or without physical activity (PA), on anthropometric parameters and adherence to the MD in children and adolescents with overweight or obesity. Scopus, PubMed/Medline, ISI/Web of Science, Embase, and Cochrane Central Register of Controlled Trials were searched as data sources for intervention studies, either designed as randomized controlled trials (RCTs) or non-RCTs. Primary outcomes were changes in body weight and body mass index (BMI); secondary outcomes included body fat, waist circumference, and adherence to the MD. Eighteen studies involving 1539 participants aged 2-18 years were analyzed. Nine and 2 of the included studies were RCTs and randomized trials without a control group, respectively, whereas the others were non-RCT studies without a control group. Four exclusively presented an MD-based dietary intervention without a PA addition. Mediterranean diet-based interventions improved BMI (effect size [ES] = 0.34; 95% CI, 0.13-0.56) and body fat (ES = 0.64; 95% CI, 0.19-1.08). Waist circumference changes were smaller but significant (ES = 0.22; 95% CI, 0.06-0.38). Changes in body weight (ES = 0.22; 95% CI, -0.04 to 0.48) were not significant. Combining these outcomes, the overall ES was computed at 0.42 (95% CI, 0.14-0.70). Adherence to the MD significantly increased in all studies reporting it. Interventions combining an MD and PA showed stronger effects compared with an MD alone. Mediterranean diet-based interventions, particularly with PA, significantly improve BMI and body fat in children and adolescents with obesity, offering a promising strategy for early-life obesity management. However, high study heterogeneity and nonsignificant results in some outcomes underscore the need for more robust research. PROSPERO registration no. CRD42020179868.

Obesity is a growing public health issue, with comorbidities including metabolic syndrome and psychiatric disorders. Stress, an inherent factor in daily life, can influence mood and eating behavior and contribute to psychiatric diseases. This study investigated whether social-single prolonged stress (social-SPS) affects anxiety-like and eating patterns in male and female rats exposed to an early-life monosodium glutamate (MSG)-induced obesity model. We also evaluated changes in hypothalamic protein expression levels of leptin (Ob-R), ghrelin (GHS-R1), dopamine 1 (D1R), and dopamine 2 (D2R) receptors. Male and female Wistar rats were exposed to MSG (4 g/kg/day) from post-natal day (PND) 1 to 10, followed by social-SPS exposure at PND 60. Rats were euthanized on PND 69, and hypothalamic samples were analyzed. MSG increased the Lee Index in both sexes at PND 60. MSG-treated rats exhibited reduced cumulative water, as well as decreased body weight over time. Cumulative food intake decreased only in male MSG-treated rats. Both MSG and Social-SPS, when used independently and in combination, reduced food intake in both sexes. Additionally, MSG and Social-SPS individually induced anxiety-like behavior only in females, but did not affect locomotor parameters in both sexes. Male rats exhibited decreased hypothalamic GHS-R1/Ob-R/D2R receptor protein expression, while females showed decreased Ob-R/D1R. These molecular changes were positively correlated with behavioral outcomes. These findings indicate that social-SPS can affect anxiety-like phenotype, eating patterns, and molecular responses in a sex-dependent manner within an early-life obesity model induced by MSG.

Maternal obesity is a key determinant of infant health, increasing early-life obesity risk. Lipids are mechanistically linked to obesity and may mediate intergenerational transfer, by influencing foetal or infant lipids. Using the Barwon Infant Study, we investigated associations between maternal pre-pregnancy body mass index (pp-BMI), lipidomic profiles of mothers, human milk, and infants, and early life growth. Ether lipids were of particular interest due to their abundance in human milk, association with breastfeeding, and roles in metabolism and inflammation. Linear regression analyses assessed relationships between maternal pp-BMI and lipid profiles across biospecimens, and infant BMI. A composite plasmalogen score, reflecting ether lipid metabolism, was developed due to its strong associations with pp-BMI and breastfeeding. Mediation analysis assessed if cord lipids mediated the effect of pp-BMI on birth weight. Maternal pp-BMI was significantly associated with maternal and cord lipids, and obesity risk indicators. Six cord blood lipids mediated up to 18% of the effect of pp-BMI on birth weight. Maternal plasmalogen score was negatively associated with pp-BMI and positively associated with human milk and infant plasmalogen scores from birth to four years of age. Infant plasmalogen score at six months was inversely associated with BMI z-score at four years of age. These findings suggest that ether lipids may be modifiable biomarkers of metabolic programming and intervention targets to reduce obesity risk in early life.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-025-30081-7.

Abstract Introduction While obesity is a recognized contributor to erectile dysfunction (ED), the impact of early-life obesity on the long-term function of the corpus cavernosum (CC) and pudendal artery (PA) is not well defined. We hypothesized that nutritional overload in early development triggers cellular senescence and structural changes, impairing neurovascular components of erectile function in adulthood. Objective We hypothesized that nutritional overload in early development triggers cellular senescence and structural changes, impairing neurovascular components of erectile function in adulthood. To determine whether early-life overnutrition induces long-term structural and functional alterations in the corpus cavernosum and pudendal artery. We aimed to assess cavernous and vascular reactivity, along with molecular markers of senescence and tissue remodeling, using a rat model of postnatal nutritional overload. Methods Wistar rats were nursed in small litter (SL; 3 pups/dam) to induce postnatal overnutrition or in normal litter (NL; 10 pups/dam) as controls. After weaning on postnatal day (PND) 21, animals were maintained on standard chow until PND160. Body weight, fat pad mass, and systolic blood pressure (SBP) were recorded. Functional assays in CC and PA evaluated responses to phenylephrine (PE), acetylcholine (ACh), and electrical field stimulation (EFS). Transcriptomic profiling by RNA sequencing and gene validation via RT-qPCR were conducted to investigate markers of senescence and tissue remodeling. Results Final body mass did not differ between groups, but SL rats exhibited higher retroperitoneal and perigonadal fat mass, along with elevated SBP (SL: 120.5 ± 1.2 mmHg vs NL: 114.9 ± 0.58 mmHg). In the CC, EFS-induced relaxation was reduced in SL animals (16 Hz: SL 2.39 ± 0.53 mN vs NL 3.06 ± 0.28 mN), while PE- and EFS-induced contractions were increased and partially reversed by indomethacin, suggesting prostanoid involvement. In the PA, ACh-mediated relaxation was significantly impaired (Emax: SL 28 ± 6% vs NL 68 ± 5.5%), without changes in PE-induced tone. Transcriptomic analysis revealed 124 differentially expressed genes (DEGs) in the CC, 99 in male PA, and 252 in female PA. Enrichment mapping in male tissues highlighted pathways involved in extracellular matrix remodeling, metabolic control, and secretin-related GPCR signaling (e.g., Col1a1, Fstl3, Adamts6, Thbs6, PI3K-Akt-mTOR). In contrast, DEGs in female PA were enriched for innate immune and metabolic/hormonal response pathways. RT-qPCR in CC confirmed increased Bgn and Col1a2, along with altered expression of Calcrl, Vipr2, and Glp1/2r, consistent with senescence-associated remodeling. Cross-tissue comparison identified 11 shared genes, possibly involved in neurovascular tone, metabolic stress responses, and architectural remodeling. Conclusions Early-life obesity induces persistent structural and functional alterations in erectile and pudendal tissues, likely contributing to erectile dysfunction in adulthood. These changes appear to be mediated by pathways involving senescence, fibrosis, and secretin GPCR signaling. Additionally, the identification of shared molecular signatures across tissues highlights a potential neurovascular-metabolic axis disrupted by early metabolic stress. Ongoing studies aim to elucidate the specific roles of these candidate genes and pathways in the pathophysiology of obesity-induced sexual dysfunction. Disclosure No

Ovarian cancer (OC) remains a major cause of gynecologic cancer mortality worldwide, with incidence continuing to rise in low- and middle-SDI regions. Metabolic risk factors may be reshaping OC epidemiology. This study quantifies global OC burden from 1990 to 2023 and examines causal relationships between metabolic and behavioral factors and OC using Mendelian randomization (MR). Using GBD 2023 data, we assessed OC incidence, mortality, DALYs, and estimated annual percentage changes (EAPCs) across regions and SDI levels. A two-sample MR analysis was conducted to evaluate causal effects of multiple exposures, with sensitivity tests including MR-Egger, weighted median, and Cochran’s Q. From 1990 to 2023, global OC incidence increased by 111%, deaths by 100.7%, and DALYs by 97.4%. Age-standardized incidence and mortality rates declined until 2014 but have risen over the past decade, particularly in low- and middle-SDI settings. Women aged 30–49 years experienced the fastest growth in EAPC. MR results indicated significant associations between OC risk and HIP (OR = 1.29, 95% CI: 1.13–1.48), childhood BMI (OR = 1.22, 95% CI: 1.07–1.39), and waist circumference (OR = 1.28, 95% CI: 1.07–1.51), with consistent findings across sensitivity analyses and no evidence of pleiotropy. These results indicate a rising global OC burden and support a causal link between central adiposity, early-life obesity, and OC risk, emphasizing the need for targeted metabolic interventions and early detection strategies.

Emerging studies suggests a potential link between serum trimethylamine N-oxide (TMAO) and obesity in adults. However, data on this association in children remain scarce. The present study aimed to investigate the association of TMAO and its precursors with childhood obesity and to evaluate whether such associations would be modified by basic clinical characteristics. We conducted a case-control study involving 50 children with obesity and 50 children with normal weight aged 2–6 years. Serum TMAO and its precursors were quantified by ultra high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Multivariate logistic regression models and Pearson correlation analyses were performed after controlling several confounding factors. Serum choline was inversely associated with childhood obesity (OR (95% CI) for highest vs. lowest quartile: 0.16 (0.04, 0.61), p = 0.007), whereas serum creatinine and carnitine showed positive correlations (ORs: 30.03 and 5.31, p < 0.001 and p = 0.011 respectively). We also found that choline was negatively correlated with BMI (p = 0.038), whereas creatinine and carnitine were positively correlated with BMI (p < 0.001 and p = 0.002, respectively). in addition, subgroup analyses based on sex, age groups, and maternal gestational diabetes mellitus status showed generally consistent results, with no significant interactions. No significant associations of betaine, TMA and TMAO with childhood obesity were observed (all p > 0.05). Higher serum choline levels were associated with lower odds of childhood obesity, while elevated creatinine and carnitine levels were associated with higher odds. These findings provide hints regarding the potential significance of these metabolites, which can be influenced by gut microbiota activity, diet, and host metabolism, in early-life obesity. Not applicable.

Recent epidemiological evidence links early-life obesity and metabolic dysregulation to adult psychosis vulnerability, though a causal relationship remains unclear. Establishing causality in highly heritable psychotic disorders requires 1) demonstrating that early-life metabolic factors mediate between genetic vulnerability and psychosis trajectory, 2) dissecting mechanisms leading to early-life obesity in genetically vulnerable individuals, and 3) clarifying downstream neurodevelopmental pathways linking early-life obesity to psychosis symptoms. Here we investigated bidirectional pathways linking behavioral, body mass index (BMI), and neurodevelopmental trajectories in a unique longitudinal cohort of 184 individuals at high genetic risk for psychosis, due to 22q11.2 deletion syndrome (22q11DS), and 182 neurotypical control individuals, followed-up since childhood. We combined repeated BMI measurements with clinical/neurocognitive phenotyping and neuroimaging. We investigated the relationship between BMI trajectories with risk of psychosis and tested whether altered cortical or cerebellar development could underlie this association. Childhood behavioral impulsivity predicted early and progressive deviations in BMI trajectories, mediating the effects of 22q11DS vulnerability to early-life obesity. Chronic BMI increases manifesting during childhood predicted the subsequent emergence of psychosis during late adolescence/early adulthood, mediating the effects of behavioral impulsivity. A dose-effect relationship linked duration of increased BMI status to worsening of motor and cognitive disorganization, a key schizophrenia symptom domain, which was mediated by progressive gray matter volume reductions in posterior-inferior cerebellum. These findings suggest that metabolic dysregulation associated with obesity may link childhood behavioral impulsivity to psychosis vulnerability in 22q11DS by influencing cerebellar maturation. These findings might support preventive interventions targeting early-life metabolic trajectories in individuals at risk of psychosis.

Trends in the prevalence of early-onset cancer and associated early-life exposures among US adults: A serial cross-sectional study.

Activating nuclear receptor subfamily 2 group F member 2 in adipocyte stem cells rescues beige adipocyte metabolism impaired by excess early-life omega-6 fatty acids.

Obesity and pediatric fatty liver disease are increasingly prevalent, yet the underlying mechanisms linking these conditions to heightened inflammatory and immune responses remain poorly understood. Using a murine model reflecting early-life obesity and hepatic steatosis, we tested the hypothesis that obesity-driven hepatic inflammation intensifies systemic immune responses and exacerbates vascular dysfunction following innate immune activation. Newly weaned C57BL/6 mice were fed either a high-saturated-fat, high-cholesterol diet (HFD) or a control diet (CD) for four weeks, modeling adolescence in humans. HFD-fed mice exhibited hepatic and splenic enlargement, elevated plasma cholesterol levels, increased activity levels of liver enzymes (alanine and aspartate aminotransferases), and higher plasma serum amyloid A (SAA) concentrations. Following a sublethal dose of lipopolysaccharide (LPS), the expression of hepatic inflammatory genes (VCAM-1 and iNOS) was significantly elevated in HFD-fed mice, indicating an exaggerated local immune response. Mice fed an HFD also showed significant impairment in endothelium-dependent vasorelaxation compared to CD mice and saline-treated controls, while endothelium-independent responses remained intact. These vascular changes occurred in the context of hepatic inflammation, suggesting that early-life diet-induced steatosis sensitizes the vasculature to inflammatory insult. These findings suggest that obesity-driven hepatic inflammation primes exaggerated systemic immune responses to innate immune stimuli, potentially contributing to the vascular dysfunction and variable clinical morbidity observed in pediatric inflammatory conditions.

Barriers and Facilitators Influencing Parents' Willingness to Follow Healthcare Provider Guidance for Addressing Behaviors Linked to Early Childhood Obesity Risk: A Qualitative Descriptive Study.

Impact of high- and moderate-protein supplementation on early-life obesity and body composition: a randomized controlled trial in India.

Introduction/Objectives: – Obesity is recognized as a risk factor for erectile dysfunction (ED), yet it remains unclear whether childhood obesity contributes to the onset of ED in young adulthood. We hypothesize that early-life obesity leads to cell senescence, hence compromises cavernosal and pudendal function. Methods: – We compared the cavernosal and pudendal function of young adult male Wistar rats (5-month-old) from early-life obesity model to controls. At postnatal day (PND) 1, rats were assigned into small litter (SL, 2 male + 1 female pup/dam) or normal litter (NL, 5 male + 5 female pups/dam), with the SL inducing overfeeding during lactation. At PND 21, both groups were weaned, housed in equal-sized colonies (3 rats/cage), and fed standard chow to the end of the study. At PND 121, we confirmed the early-life obesity model from increased body mass of SL rats. The study concluded on PND 160, when the body mass, fat pad deposition, and mean arterial pressure (MAP) by tail-cuff were evaluated. Molecular studies and functional reactivity were conducted on the corpus cavernosum (CC) and pudendal artery (PA) samples collected from both groups. Concentration-response curves to phenylephrine (PE) and acetylcholine (ACh) were assessed. In the CC, contraction and relaxation to electrical field stimulation (EFS) were recorded. RNA sequencing (RNA-seq) and downstream analysis were conducted for differentially expressed genes (DEGs). Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was performed to assess the expression levels of Bgn (biglycan), Col1a2 (collagen type I alpha 2), P53 (tumor protein P53), and Glb1 (galactosidase beta 1). Non-linear regression analysis was used for concentration-response curves, and data were analyzed via Student’s t-test, expressed as mean ± S.E.M., with statistical significance set at p&lt;0.05. Results: – At PND 160, body mass showed no significant difference between SL group (594±14g) and NL group (559±13g). However, higher fat deposition was shown in SL rats (retroperitoneal fat: SL 11.25±1.23g vs NL 7.47±0.69g; perigonadal fat: SL 13.24±1.16g vs NL 10.05±0.55g). MAP was also elevated in SL group (120.5±1.20 mmHg) in comparison with NL group (114.9±0.58 mmHg). In the PA, ACh-induced relaxation was reduced in SL (Emax: SL 28±6% vs NL 68±5.5%), while PE-induced contraction remained unchanged. In the CC, EFS-induced relaxation was significantly lower in SL rats (16 Hz: SL 2.39 ± 0.53% vs NL 3.06 ± 0.28%). Both EFS- and PE- induced contractions were increased in SL group which was prevented by indomethacin. The RNA-seq analysis identified 135 downregulated and 158 upregulated genes in the PA, and 54 downregulated and 70 upregulated genes in the CC. And the RT-qPCR test revealed increased expression level of Bgn, Col1a2, P53, and Glb1 in the CC of SL rats. Conclusions: – Our findings suggest that early-life obesity is associated with long-term cavernosal and pudendal impairments, which may contribute to ED in young adulthood. These effects appear to involve mechanisms related to fibrosis and cell senescence. Further studies are needed to establish a direct causal link between early-life obesity and these vascular and functional alterations. NIDDK 132948 and NHLBI 149762 This abstract was presented at the American Physiology Summit 2025 and is only available in HTML format. There is no downloadable file or PDF version. The Physiology editorial board was not involved in the peer review process.

Dysfunction of the insulin-secreting β-cells is a key hallmark of Type 2 diabetes (T2D). In the natural history of the progression of T2D, factors such as genetics, early life exposures, lifestyle, and obesity dictate an individual's susceptibility risk to disease. Obesity is associated with insulin resistance and increased demand for insulin to maintain glucose homeostasis. Studies in both mouse and human islets have implicated the β-cell's ability to compensate through proliferation and survival (increasing functional β-cell mass) as a tipping point toward the development of disease. A growing body of evidence suggests the reduction of β-cell mass in T2D is driven majorly by loss of β-cell identity, rather than by apoptosis alone. The development and maintenance of pancreatic β-cell identity, function, and adaptation to stress is governed, in part, by the spatiotemporal expression of transcription factors (TFs), whose activity is regulated by signal-dependent post-translational modifications (PTM). In this review, we examine the role of these TFs in the developing pancreas and in the mature β-cell. We discuss functional implications of post-translational modifications on these transcription factors' activities and how an understanding of the pathways they regulate can inform therapies to promoteβ-cell regeneration, proliferation, and survival in diabetes.

Adult obesity increases the risk of kidney cancer (KIC), yet the link between early body size traits and KIC remains uncertain. This study aimed to investigate the causal relationship between early body size characteristics and KIC, including its subtypes, using Mendelian randomization (MR). We utilized data from public genome-wide association study (GWAS) databases on birth weight and body mass index (BMI) across childhood, adolescence, and adulthood as exposure variables, and KIC and its subtypes as outcome variables. A two-way two-sample MR analysis was performed to explore these associations, with the inverse variance weighted (IVW) method as the primary analytical approach and sensitivity analyses to assess result stability. IVW analysis revealed significant associations between childhood obesity [odds ratio (OR) =1.08, 95% confidence interval (CI): 1.04-1.14, P<0.001], childhood BMI (OR =1.23, 95% CI: 1.07-1.42, P=0.003), adolescent BMI (OR =1.22, 95% CI: 1.07-1.40, P=0.003), and adult BMI (OR =1.75, 95% CI: 1.41-2.17, P<0.001) with increased risk of KIC. Similar associations were observed for clear cell renal cell carcinoma (ccRCC), with childhood obesity (OR =1.09, 95% CI: 1.02-1.15, P=0.007), childhood BMI (OR =1.33, 95% CI: 1.14-1.55, P<0.001), adolescent BMI (OR =1.24, 95% CI: 1.04-1.47, P=0.01), and adult BMI (OR =1.97, 95% CI: 1.51-2.57, P<0.001) significantly linked to higher ccRCC risk. No evidence of reverse causation was found. This study provides MR evidence supporting a causal association between early-life obesity and KIC. Our findings suggest that reducing obesity in early life may have a potential positive impact on the prevention of KIC.

Abstract Obesity, defined as an excessive body fat content, has become increasingly common in children and adolescents. Obesity in early life is of concern due to its consequences on health in later life. The severity of these comorbidities typically increases with the severity of obesity. Currently, “overweight” is defined by a body mass index (BMI) for age of ≥85 th percentile but &lt;95 th percentile in children and adolescents, and “obesity” is defined as a BMI for age of ≥95 th percentile. Factors such as eating habits, genetics, environment, metabolism, and lifestyle play a vital role in the development of obesity. All available data suggest that 60%–80% of the observed variance in human body weight can be accounted for by inherited factors. Obesity can be countered through weight loss regimens with lifestyle interventions which generally include lower calorie consumption and increased physical activity. For children and adolescents with obesity, metformin is used in cases of insulin resistance and hyperinsulinemia. Octreotide is used for hypothalamic obesity. Bariatric surgery is performed for the treatment of severe childhood obesity. The causes, symptoms, prevention, and treatment of pediatric obesity are described in the present review.

While some parenting interventions designed for early-life obesity prevention have demonstrated short-term success, there is limited evidence of longer-term impacts and feasibility with underrepresented populations. The goal of this review was to examine existing general parenting programs for parents of children 0-5years that were not designed to target obesity but investigated long-term effects on parenting and/or were conducted with underrepresented populations to offer recommendations for the modification or development of parenting-focused obesity prevention programs. Most studies with sustained impacts on parenting in underrepresented populations were brief, group-based programs for parents of children 2-5years. Many effective interventions included guided practice of skills and cultural adaptations. Unique intervention approaches included remote or school-based delivery models and motivational interviewing. Brief, group-based programs for parents of young children may be a promising approach to achieving longer-term impacts of parenting interventions on obesity risk among underrepresented populations.

Background: Erectile dysfunction (ED) is largely associated with obesity, however, the consequences of early life obesity for ED in young adulthood are unknown. We hypothesize that obesity induced by preweaning overfeeding impairs vascular and erectile function and affects blood pressure in young adult male rats (5-month-old). Methods: At postnatal day (PND) 1, Wistar rats were divided into a normal litter (NL, 5 female + 5 male pups/dam) or small litter (SL, 2 male + 1 female pup/dam) during lactation. After weaning, SL pups had increased body weight. Next, rats from both groups returned to normal size colonies (4-5 rats per cage) and were fed standard chow. At PND160, we evaluated body weight and fat pad deposition, mean arterial pressure (MAP) by tail-cuff, and pudendal artery (PA) and corpus cavernosum (CC) reactivity. Concentration-response curves to phenylephrine (PE) or acetylcholine (ACh) were performed in both preparations. In the CC, contraction and relaxation to electrical field stimulation (EFS) were obtained. Concentration-response curves were analyzed using non-linear regression analysis. RNA sequencing (RNAseq) analyses were performed in both PA and CC. Data were analyzed by Student’s t-test and presented as mean ± S.E.M. Statistical significance was set at p&lt;0.05. Results: At PND160 no differences in body weight were observed in SL (594±14g) compared to NL (559±13g), however, there was an increase in fat deposition in SL (retroperitoneal fat: NL 7.47±0.69g vs SL 11.25±1.23g; perigonadal fat: NL 10.05±0.55g vs SL 13.24±1.16g). MAP was higher in SL (120.5±1.20 mmHg vs 114.9±0.58 NL). In the PA, ACh-induced relaxation was reduced in SL (Emax: 28±6%) vs NL (Emax: 68±5.5%), with no changes in the contraction to PE. In the CC, EFS-induced relaxation was significantly decreased in SL rats compared to NL rats (16 Hz: NL 3.06 ± 0.28% vs SL 2.39 ± 0.53%). RNAseq revealed that, in PA from SL rats, 289 and 224 genes were down and upregulated, respectively, while in the CC from SL rats, 115 genes were downregulated, and 110 genes were upregulated. Among them, hcn2 gene (which encodes HCN2, the hyperpolarization-activated cyclic nucleotide-gated potassium and sodium channel 2) was strongly downregulated in both PA and CC, and this may affect mechanotransduction. Conclusion: Our data shows that early-life obesity causes long-lasting vascular and cavernous damage that might be associated with endothelial and erectile dysfunction in young adulthood.

Mendelian randomization analysis separated the independent impact of childhood obesity and adult obesity on socioeconomic status, psychological status, and substance use