Obesogenic Risk Factors Research Articles

Evaluation of therapeutic effects of aqueous cinnamon extract against obesity associated dysregulation of pituitary-adrenal axis

Obesity is distinguished by unwanted and surplus accumulation of lipids in body principally in adipocytes. Inactive lifestyle and dietary irregularities are considered as premiers among a variety of obesogenic risk factors. Obesity is associated with variations in the concentration of trophic and tropic hormones from pituitary gland affecting different body parts and other endocrine glands including adrenal gland. Current study was design to explore the anti-obesity potential of cinnamon (Cinnamomum verum) against high sugar and high fat induced hyper-activity of pituitary-adrenal (PA) axis and obesity. Twenty-five healthy Wistar albino female rats were selected as model animal. Body weight, oral glucose tolerance test, serum cortisol, hematology and histopathological analysis were performed. The high sugar and high fat induced increase in body eight was decline by cinnamon administration. Hematological analysis revealed a significant decreased concentration of RBCs and hemoglobin and increased WBCs and platelet count following sub-acute exposure of high sugar and high fat changes were attenuated by cinnamon. High sugar and fat associated elevated serum cortisol was normalized after cinnamon exposure. Moreover, cinnamon protected the histopathological alterations following high sugar and fat administration, showed protective effects of Cinnamon against obesity associated dysregulation of PA axis and metabolic impairment.

Is Dog Owner Obesity a Risk Factor for Canine Obesity? A "One-Health" Study on Human-Animal Interaction in a Region with a High Prevalence of Obesity.

Obesity in humans is a growing global problem and is one of the greatest public health challenges we face today. Most researchers agree that, as in humans, the incidence in the companion animal population is also increasing. The aim of this study was to evaluate the risk factors contributing to canine obesity in a region with a high rate of human obesity (Canary Islands, Spain), co-occurrence of obesogenic risk factors, and a canine population with a high percentage of unneutered dogs. We have focused on owner risk factors that promote obesity in humans, such as weight, lifestyle, nutritional habits, and low physical activity, among others. Thus, the human–animal interaction relationship that contributes to human obesity and influences canine obesity has been studied. A multicentre cross-sectional analytical study of 198 pairs of dogs from urban households and their owners was used. A multivariable logistic regression study was completed to analyse owner characteristics variables associated with canine obesity. This transdisciplinary study was conducted with physicians and veterinarians using a “One Health” approach. Our results suggest that, in a region of high obesogenic risk, obese/overweight dogs are primarily female, older than 6 years, and neutered. Being an overweight dog owner was found to be the most important factor in the occurrence of obesity in dogs. Owners of overweight dogs were mainly females, older than 40 years, who did not engage in any physical activity. A strong correlation has been found between dog owners with low levels of education and obesity in their dogs. We suggest that veterinarians should develop and design strategies to encourage pet owners to engage in physical activity with their dogs for the benefit of both.

Competitive Food and Beverage Policies and Obesity among Middle School Students: Variability by Urbanicity in California.

Introduction: This study examined the association between California school nutrition policies and population-level trends in childhood overweight/obesity by levels of urbanicity.Methods: We used interrupted time series with Fitnessgram data on overweight/obesity from the period 2002 to 2010 pertaining to African American, Latino, Asian, and White students in seventh grades who attended California public schools. We used multilevel logistic regression models to examine the impact of the introduction of successive California school nutrition policies on overweight/obesity prevalence, stratified by gender and adjusted for school district-, school-, and student-level characteristics.Results: At the start of the study period, rural areas and second cities (i.e., population centers with lower population densities than urban areas) had relatively low prevalence, but experienced sharp increases in 2002–2004, leading to higher prevalence of overweight/obesity than suburban areas. There was evidence of beneficial policy influences on overweight/obesity in most areas, except for girls in urban areas and boys in second cities. The evidence of beneficial changes was strongest among children attending schools located in rural areas, and boys in suburban and urban areas. These results persisted even after we accounted for differences in racial/ethnic compositions, socioeconomic characteristics of the schools and school neighborhoods, and school sizes, as well as child-level race/ethnicity, age, and student fitness levels.Conclusion: Despite evidence of beneficial policy impact, childhood obesity prevalence remains high, especially in urban areas in California. Additional policies and environmental interventions are recommended to address obesogenic risk factors unique to each area.

Parent-based prevention after parental weight loss surgery: a pilot case-series trial.

Overeating and obesity are elevated in children of parents who have undergone weight loss surgery. Parents who have undergone weight loss surgery often report their personal history of obesity interferes with their knowledge, skills, and self-efficacy in developing their children's healthy habits, thus reducing the likelihood of addressing obesogenic environmental factors. This study examines whether a 6-session parent-based prevention after bariatric surgery online intervention is feasible and acceptable for parents. The study also explores the program's signal of efficacy in improving short-term outcomes related to decreased long-term risks for obesity by examining short-term impact on targeted parental cognitions, feeding practices, and child eating behaviors and physical activity habits. University Hospital, United States. Parents were recruited using flyers, clinician referrals, and social media. Measures assessed parental feeding practices, children's eating behaviors, daily hours of screen time, and outdoor play. Ten families enrolled and 7 completed the study. Parents found the intervention relevant and suitable for addressing their parenting concerns. Parental feeding behaviors, such as restriction and pressure to eat, reduced while tracking of sweets and high-fat snacks increased. Children reduced both emotional overeating and undereating. Children's daily hours of screen time reduced as well as their outdoor play time. Parent-based prevention after bariatric surgery aimed at helping parents who have undergone weight loss surgery engineer healthier family lifestyles is feasible, acceptable, and associated with reduced obesogenic risk factors.

Prevention of Childhood Obesity: A Position Paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN).

Global childhood obesity increased more than 8-fold over 40 years, inducing a very large personal, societal, and economic burden. Effects of available treatments are less than satisfactory; therefore, effective prevention is of high priority. In this narrative review, we explore preventive opportunities. The available evidence indicates large benefits of improving nutrition and lifestyle during early life, such as promoting breast-feeding and improving the quality of infant and early childhood feeding. Promoting healthy eating patterns and limiting sugar-containing beverage consumption from early childhood onwards are of great benefit. Regular physical activity and limited sedentary lifestyle and screen time alone have limited effects but are valuable elements in effective multicomponent strategies. The home environment is important, particularly for young children, and can be improved by educating and empowering families. School- and community-based interventions can be effective, such as installing water fountains, improving cafeteria menus, and facilitating regular physical activity. Reducing obesogenic risk factors through societal standards is essential for effective prevention and limiting socioeconomic disparity; these may comprise food, drink, and physical activity standards for day cares and schools, general food quality standards, front-of-pack food labeling, taxation of unhealthy foods, restriction of food advertisements to children, and others. Effective prevention of childhood obesity is not achieved by single interventions but by integrated multicomponent approaches involving multiple stakeholders that address children, families, and societal standards. Pediatricians and their organizations should be proactive in supporting and empowering families to support their children's health, and in promoting societal measures that protect children.

Cluster and simultaneity of modifiable risk factors for cardiovascular diseases in adolescents of Southeast Brazil

Abstract Aim: This study aimed to evaluate the cluster of the five major modifiable risk factors for cardiovascular diseases (CVD) and their associated factors and to identify patterns of concurrency of modifiable obesogenic risk factors associated with overweight in Brazilian adolescents. Methods: A survey was conducted (2015) with 1,055 (boys, n = 475; girls, n = 580) high school (public and private schools) adolescents (14-20 years old) in a medium-sized city in Southeast Brazil. The observed prevalence ratio (O) for the expected (E) risk factors (smoking, alcohol, insufficient physical activity, sedentary behavior, and poor diet) greater than one (O/E > 1) was considered as a cluster. We use multinomial and binary logistic regressions (stratified by sex) in the analyzes. Results: Almost 30% of adolescents had three or more risk factors (no factor = 5.4%). The five risk factors tended to cluster in boys (O/E = 2.5; 95% CI = 1.6-3.5). In both sexes, smoking and alcohol consumption persisted in O/E > 1 ratio. Conclusions: Boys showed a consistent pattern of association for risk factors. Overweight was associated with pairs of obesogenic risk factors in both sexes. The results indicate the need for health interventions that consider the cluster and the simultaneity of risk factors for CVD among Brazilian youth.

Peer Status Position within School-Based Hierarchies and Excessive Fat Accumulation in Adulthood-A 30 Year Follow up of a Stockholm Cohort.

Disadvantaged socioeconomic status is arguably the one exposure that has most consistently been linked to obesity, even more strongly so than diet and physical inactivity, which are the two main perceived root causes of weight gain. However, we still know very little about the relationship between having a disadvantaged social position and excessive fat accumulation, particularly when it comes to whether the relationship in question can also be seen as a long-term one, i.e., spanning from childhood to adulthood. By making use of the unique Stockholm Birth Cohort Multigenerational Study, the present study uses generalized ordered logistic regressions to examine the association between sociometrically assessed peer status position in school at age 13 and excessive fat accumulation at age 32. The results suggest that the odds of having excessive fat accumulation are about 0.5 times lower among popular and accepted children (ORs = 0.52 and 0.56, respectively), compared to those with a marginalized peer status position, independent of other obesogenic risk factors measured both prior and subsequent to peer status position. Our results give support to the notion that improved weight status may be another positive consequence of policies aiming to increase social inclusion within schools.

Lower Body Mass Index Z-Score Trajectory During Early Childhood After the Birth of a Younger Sibling

ObjectiveThe objectives of this study were to examine differences in body mass index z-score (BMIZ) trajectory during early childhood among children with a younger sibling compared with those without and to test potential mediators. MethodsThis longitudinal cohort study included 6050 participants of the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B). Focal children's weight, height, sibship status, screen time, active play time, family dinner frequency, and diet quality were assessed at 9 months, 24 months, preschool, and kindergarten when available. A piecewise linear regression model was used to examine the association between sibling birth and focal child's subsequent BMIZ trajectory to kindergarten. Mediation by screen time, active play time, family dinner frequency, and diet quality was tested. ResultsBMIZ trajectory was lower among children who had a new sibling join the family before kindergarten compared to children who did not have a new sibling join the family by kindergarten. The association was strongest when new sibship occurred when the focal child was 48 to 66 months (b = –0.026, P = .044). The association was not mediated by screen time, active play time, family dinner frequency, or diet quality. ConclusionAmong a nationally representative cohort of US children, new sibship before kindergarten was associated with a lower BMIZ trajectory. Several common obesogenic risk factors did not explain the association.

Edmonton obesity staging system among pediatric patients: a validation and obesogenic risk factor analysis.

The Edmonton Obesity Staging System for Pediatrics (EOSS-P) is a useful tool, delineating different obesity severity tiers associated with distinct treatment barriers. The aim of the study was to apply the EOSS-P on a Greek pediatric cohort and assess risk factors associated with each stage, compared to normal weight controls. A total of 361 children (2-14years old), outpatients of an Athenian hospital, participated in this case-control study by forming two groups: the obese (n=203) and the normoweight controls (n=158). Anthropometry, blood pressure, blood and biochemical markers, comorbidities and obesogenic lifestyle parameters were recorded and the EOSS-P was applied. Validation of EOSS-P stages was conducted by juxtaposing them with IOTF-defined weight status. Obesogenic risk factors' analysis was conducted by constructing gender-and-age-adjusted (GA) and multivariate logistic models. The majority of obese children were stratified at stage 1 (46.0%), 17.0% were on stage 0, and 37.0% on stage 2. The validation analysis revealed that EOSS-P stages greater than 0 were associated with diastolic blood pressure and levels of glucose, cholesterol, LDL and ALT. Reduced obesity odds were observed among children playing outdoors and increased odds for every screen time hour, both in the GA and in the multivariate analyses (all P<0.05). Although participation in sports>2 times/week was associated with reduced obesity odds in the GA analysis (OR=0.57, 95% CI=0.33-0.98, P linear=0.047), it lost its significance in the multivariate analysis (P linear=0.145). Analogous results were recorded in the analyses of the abovementioned physical activity risk factors for the EOSS-P stages. Linear relationships were observed for fast-food consumption and IOTF-defined obesity and higher than 0 EOSS-P stages. Parental obesity status was associated with all EOSS-P stages and IOTF-defined obesity status. Few outpatients were healthy obese (stage 0), while the majority exhibited several comorbidities. Since each obesity tier entails different impacts to disease management, the study herein highlights modifiable factors facilitating descend to lower stages, and provides insight for designing tailored approaches tackling the high national pediatric obesity rates.

Early rapid weight gain and subsequent overweight and obesity in middle childhood in Peru.

BackgroundRapid postnatal weight gain is associated with risk of overweight and obesity, but it’s unclear whether this holds in populations exposed to concurrent obesogenic risk factors and for children who have been extensively breastfed. This study investigates whether an increase in weight for age from birth to 1 year (infancy) and from 1 to 5 years (early childhood) predicts overweight and obesity, and waist circumference at 8 years, using data from a longitudinal cohort study in Peru.MethodsGeneralized estimating equations (GEE) models were constructed for overweight and obesity, obesity alone and waist circumference at 8 years versus rapid weight gain in infancy, and early childhood including adjusted models to account for confounders.ResultsRapid weight gain in both periods was associated with double the risk of overweight and obesity, obesity alone at 8 years and increased waist circumference even after controlling for maternal BMI and education level, sex of child, height-for-age at 8 years, consumption of “fast food” and number of days of active exercise. The association was significant, with some differences, for children in both rural and urban environments.ConclusionsRapid weight gain in infancy and in early childhood in Peru is associated with overweight and obesity at age 8 years even when considering other determinants of childhood obesity.Electronic supplementary materialThe online version of this article (doi:10.1186/s40608-016-0135-z) contains supplementary material, which is available to authorized users.

Depressive symptomatology, weight status and obesogenic risk among Australian adolescents: a prospective cohort study

ObjectivesAdolescence is a period of increased risk for mental health problems and development of associated lifestyle risk behaviours. This study examined cross-sectional and longitudinal associations between obesogenic risk factors, weight...

Environmental, Dietary, and Behavioral Factors Distinguish Chinese Adults with High Waist-to-Height Ratio with and without Inflammation1–3

Background: The environmental and behavioral risk factors associated with central obesity and/or inflammation in populations exposed to both obesogenic and pathogenic environments remain unclear.Objectives: We tested which of the characteristics distinguished 3 risk groups—high waist-to-height ratio (WHtR; >0.5) without inflammation [high-sensitivity C-reactive protein (hs-CRP) <3 mg/L], normal WHtR (≤0.5) with inflammation (hs-CRP: 3–10 mg/L), and high WHtR with inflammation—from the referent group with normal WHtR without inflammation and, secondarily, which factors differed between the groups with high WHtR with and without inflammation.Methods: The analytic sample included 8068 adults participating in the China Health and Nutrition Survey in 2009. Adjusted multinomial and logistic regression models were used to assess the risk of being in one of the “unhealthy” groups compared with the referent group.Results: Men with high WHtR with and without inflammation were more likely to live at higher urbanicity (57–63%) and have higher incomes (26–42%) and household sanitation (26–67%) and were >40% less likely to have high physical activity than the healthy referent group. Men with high WHtR with inflammation had higher odds of infectious symptoms than those with high WHtR without inflammation (OR: 1.73; 95% CI: 1.15, 2.61). Women with high WHtR without inflammation were less likely to have high household sanitation (44%) or perform high levels of physical activity (24%) and were 34% more likely to consume more fiber than the healthy referent group. Women with high WHtR and inflammation were more likely than those with high WHtR without inflammation to have infectious symptoms (OR: 1.45; 95% CI: 1.01, 2.07) and less likely to have higher fiber intake (OR: 0.77; 95% CI: 0.60,1.00) or physical activity (OR: 0.55; 95% CI: 0.41, 0.73).Conclusion: These results document different underlying pathogenic and obesogenic risk factors for visceral adiposity with and without inflammation in Chinese adults, suggesting that context-specific approaches may be needed to prevent and treat inflammation.

The clustering of diet, physical activity and sedentary behavior in children and adolescents: a review

Diet, physical activity (PA) and sedentary behavior are important, yet modifiable, determinants of obesity. Recent research into the clustering of these behaviors suggests that children and adolescents have multiple obesogenic risk factors. This paper reviews studies using empirical, data-driven methodologies, such as cluster analysis (CA) and latent class analysis (LCA), to identify clustering patterns of diet, PA and sedentary behavior among children or adolescents and their associations with socio-demographic indicators, and overweight and obesity. A literature search of electronic databases was undertaken to identify studies which have used data-driven methodologies to investigate the clustering of diet, PA and sedentary behavior among children and adolescents aged 5–18 years old. Eighteen studies (62% of potential studies) were identified that met the inclusion criteria, of which eight examined the clustering of PA and sedentary behavior and eight examined diet, PA and sedentary behavior. Studies were mostly cross-sectional and conducted in older children and adolescents (≥9 years). Findings from the review suggest that obesogenic cluster patterns are complex with a mixed PA/sedentary behavior cluster observed most frequently, but healthy and unhealthy patterning of all three behaviors was also reported. Cluster membership was found to differ according to age, gender and socio-economic status (SES). The tendency for older children/adolescents, particularly females, to comprise clusters defined by low PA was the most robust finding. Findings to support an association between obesogenic cluster patterns and overweight and obesity were inconclusive, with longitudinal research in this area limited. Diet, PA and sedentary behavior cluster together in complex ways that are not well understood. Further research, particularly in younger children, is needed to understand how cluster membership differs according to socio-demographic profile. Longitudinal research is also essential to establish how different cluster patterns track over time and their influence on the development of overweight and obesity.

FitKids360: design, conduct, and outcomes of a stage 2 pediatric obesity program.

This paper describes FitKids360, a stage 2 pediatric weight management program. FitKids360 is a physician-referred, multicomponent, low-cost healthy lifestyle program for overweight and obese youth 5–16 years of age and their families. FitKids360 provides an evidence-based approach to the treatment of pediatric overweight by targeting patients' physical activity, screen time, and dietary behaviors using a family-centered approach. The intervention begins with a two-hour orientation and assessment period followed by six weekly sessions. Assessments include lifestyle behaviors, anthropometry, and the Family Nutrition and Physical Activity (FNPA) survey, which screens for obesogenic risk factors in the home environment. Outcomes are presented from 258 patients who completed one of 33 FitKids360 classes. After completing FitKids360, patients increased moderate to vigorous physical activity by 14 minutes (P = 0.019), reduced screen time by 44 minutes (P < 0.001), and improved key dietary behaviors. Overall, FNPA scores increased by 9% (P < 0.001) and 69% of patients with “high risk” FNPA scores at baseline dropped below the “high risk” range by followup. Patients also lowered BMIs (P = 0.011) and age- and sex-adjusted BMI z-scores (P < 0.001) after completing the 7-week program. We hope this report will be useful to medical and public health professionals seeking to develop stage 2 pediatric obesity programs.

Child temperament and maternal predictors of preschool children’s eating and body mass index. A prospective study

Research has previously identified relationships between child temperament and BMI during childhood. However, few studies have addressed the broader implications of child temperament on the development of obesogenic risk factors, such as maternal feeding, child eating and body mass index (BMI) of pre-schoolers. Hence, the current study evaluated cross-sectional and prospective associations between child temperament, maternal feeding, maternal parenting styles, mother–child interaction, preschoolers’ eating behaviours and BMI. Child irritability, cooperation-manageability and easy–difficult temperaments, mother–child dysfunctional interaction, maternal pressure to eat and restriction were significantly cross-sectionally associated with child eating behaviours. Child enjoyment of food was significantly associated with child BMI. Child easy–difficult temperament and mother–child dysfunctional interaction predicted child eating behaviours longitudinally and baseline child BMI measures predicted child BMI longitudinally. Average maternal ratings of child temperament were relatively neutral, potentially explaining why most associations were not robust longitudinally. Future research should include a sample of greater socio-economic and BMI diversity as well as objective measures of child temperament, diet composition, maternal feeding practices, and mother–child interaction.

Associations between obesogenic risk factors and depression among adolescents: A systematic review

Adolescence is a transitional life phase that is associated with heightened risk for two major health conditions - obesity and mental health problems. Given the established comorbidity of obesity and depression, one avenue that warrants further exploration is the association between obesogenic risk and obesity in the expression and maintenance of depressive symptoms. The aim of the current systematic review was to identify and evaluate the empirical literature reporting the relationships between obesogenic risk factors (physical activity, sedentary behaviour, diet and weight status) and depression in adolescents. A search of five databases for studies published over the last decade found 24 studies eligible for review. Relationships were found between lack of physical exercise, heightened sedentary behaviour, poor diet quality, obese or overweight and depression in adolescence. However, the finding that obesogenic risk factors are associated with poor adolescent mental health should be interpreted with caution as data typically come from non-representative samples with less than optimal study design and methodology.

Associations between obesogenic risk factors and depression among adolescents: a systematic review

Adolescence is a transitional life phase that is associated with heightened risk for two major health conditions - obesity and mental health problems. Given the established comorbidity of obesity and depression, one avenue that warrants further exploration is the association between obesogenic risk and obesity in the expression and maintenance of depressive symptoms. The aim of the current systematic review was to identify and evaluate the empirical literature reporting the relationships between obesogenic risk factors (physical activity, sedentary behaviour, diet and weight status) and depression in adolescents. A search of five databases for studies published over the last decade found 24 studies eligible for review. Relationships were found between lack of physical exercise, heightened sedentary behaviour, poor diet quality, obese or overweight and depression in adolescence. However, the finding that obesogenic risk factors are associated with poor adolescent mental health should be interpreted with caution as data typically come from non-representative samples with less than optimal study design and methodology.

Associations between child temperament, maternal feeding practices and child body mass index during the preschool years: a systematic review of the literature

It is a research priority to identify modifiable risk factors to improve the effectiveness of childhood obesity prevention strategies. Research, however, has largely overlooked the role of child temperament and personality implicated in obesogenic risk factors such as maternal feeding and body mass index (BMI) of preschoolers. A systematic review of relevant literature was conducted to investigate the associations between child temperament, child personality, maternal feeding and BMI and/or weight gain in infants and preschoolers; 18 papers were included in the review. The findings revealed an association between the temperament traits of poor self-regulation, distress to limitations, low and high soothability, low negative affectivity and higher BMI in infants and preschool-aged children. Temperament traits difficult, distress to limitations, surgency/extraversion and emotionality were significantly associated with weight gain rates in infants. The results also suggested that child temperament was associated with maternal feeding behaviours that have been shown to influence childhood overweight and obesity, such as using restrictive feeding practices with children perceived as having poor self-regulation and feeding potentially obesogenic food and drinks to infants who are more externalizing. Interestingly, no studies to date have evaluated the association between child personality and BMI/weight gain in infants and preschoolers. There is a clear need for further research into the association of child temperament and obesogenic risk factors in preschool-aged children.

Systematic Review of School-based Obesity Interventions Targeting African American and Hispanic Children

Minority groups are disproportionally affected by the obesity epidemic. Schools represent an environment conducive to targeting obesogenic risk factors. The purpose of this review was to analyze systematically school-based interventions targeting African American and Hispanic children. Inclusion criteria were: completed experimental and quasi-experimental interventions targeting African American or Hispanic children in school settings located in the United States. A total of 10 articles met the specified inclusion criteria. Programs that affected body composition included physical activity and nutritional modalities and three of the programs modified school meals. Eight of the interventions incorporated behavioral theory as the framework for the intervention; however, only two programs explicitly operationalized the theories employed. Efficacy of school-based interventions targeting minorities can be enhanced through explicit operationalization of behavioral theories, incorporation of systematic process evaluation, long-term follow-up of intervention outcomes, and inclusion of the family and home environment.

Co-occurrence of Obesogenic Risk Factors Among Adolescents

The purpose of this study was to determine the prevalence, sociodemographic distribution, and co-occurrence of five potentially obesogenic behavioral risk factors (low physical activity, high screen time, low fruit and vegetable intake, high soft drink consumption, and high snack intake) among adolescents. Cross-sectional representative population survey (n = 1,568) of grade 6, 8, and 10 students (49% male) randomly selected from 70 primary and secondary schools in New South Wales, Australia, between February and May 2007. Co-occurrence was assessed using an observed-to-expected ratio (O/E) method. Only 5% of boys and 9% of girls had none of the five obesogenic behavioral risk factors studied. Overall, 51.4% of boys and 42.9% of girls had three or more risk factors. Prevalence of multiple risk factors (3+) was higher among boys and girls from lower income households and among girls whose mothers had less than grade 12 education. For both boys and girls, the occurrence of all five risk factors was 160% greater than expected (O/E ratio: 2.6). There was clear evidence of a co-occurrence of obesogenic risk factors among adolescents, especially among those from lower socioeconomic backgrounds, indicating this group would benefit from targeted prevention strategies.