In addition, Lebanese adolescents generally had low levels of dietary knowledge and 32.4% had low levels of dietary adherence. Their dietary adherence was significantly associated with their parents’ dietary adherence. The findings underline the significant role of the parents in shaping their children’s eating behaviours, in addition to the other determinants and factors affecting the diet of Lebanese adolescents. As the prevalence of paediatric overweight and obesity has reached alarming rates, the results of the current study have important implications for both public health policies and obesity prevention interventions in the Middle East and worldwide.Paediatric obesity is a severe public health problem accompanied by several physical and mental complications, mainly due to an imbalance between energy input and output. Dietary behaviours are influenced by many demographic factors and determinants, such as the place of residence and the level of dietary knowledge of the children and their parents. The aim of the current paper is to assess the levels of dietary knowledge, dietary adherence (in relation to recommendations), and the body mass index (BMI) of Lebanese adolescents in association with demographic variables, their parents’ dietary knowledge and adherence levels, and with other lifestyle behaviours. This cross-sectional study included 1535 Lebanese adolescents aged 15 to 18 years, from 16 public and private high schools located in urban and rural regions, and 317 of their parents. Our results showed that 30.2% of the adolescents were overweight or obese. Participants enrolled in private schools and those living in urban regions had a significantly higher BMI  Adolescence is a critical period for growth and development . Among tMany demographic factors affect eating behaviours, including the age, gender, degree of urbanisation, place of residence, and socio-economic status . StudiesIn Lebanon, studies have investigated neither the correlation between the dietary knowledge and dietary adherence of adolescents and children, nor the influence of the parents on their children’s dietary knowledge and adherence. In addition, very few studies have analysed the correlation between dietary habits and anthropometric outcomes of Lebanese adolescents. Moreover, there are no studies examining potential determinants related to the eating habits of Lebanese adolescents. Therefore, the aim of the current paper is to assess the levels of dietary knowledge, dietary adherence, and the BMI of Lebanese adolescents, as well as their association with demographic variables, parental dietary knowledge and adherence levels, and with clustered behaviours. This cross-sectional study included participants living in both urban and rural areas in Lebanon from different socio-economic backgrounds.The current cross-sectional study was conducted between October and December 2017, among 15- to 18-year-old adolescents attending public and private high schools in Beirut, Baalbeck, and Rayak in Lebanon, as well as their parents. Beirut, the capital of Lebanon, is an urban region, whereas Baalbeck and Rayak are rural regions. A total of 16 high schools were randomly selected from a list of high schools from the Ministry of Education, located in the selected locations: eight high schools from Beirut (six public and two private), six high schools from Baalbeck (three public and three private), and two high schools from Rayak (one public and one private). Participation was voluntary. Inclusion criteria for the participating adolescents included: (1) being Lebanese and enrolled in a Lebanese public or private high school located in one of the selected regions; (2) aged 15–18 years; (3) being fully capable  of communicating (as reported by parents or by school administration); (4) not having any chronic or genetic diseases (as reported by parents or by school administration).n) was directly proportional to the prevalence of overweight and obesity among Lebanese adolescents. As the adolescents participating in the previous pilot study [The required sample size  before administering the questionnaire. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Lebanese Ministry of Education and Higher Education  and the Institutional Review Board of the Lebanese International University . The final sample included 1535 adolescents and 317 parents (participation rate 19.4%). None of the approached adolescents refused to participate.Data collection at schools was performed by a dietitian (PI) and a trained research assistant. Quality control measures, such as training, pre-testing of the study questionnaires, and data collection and data entry monitoring , were applied. Data were collected using Arabic questionnaires (the native language of the participants). We describe the collected data in more detail below.The socio-demographic information included the following: (1) age of the participants and their date of birth; (2) their gender; (3) the school class; (4) the type of school (public or private); and (5) the address .N = 220) and parents (N = 108) [A Dietary Knowledge Questionnaire (DKQ) was administrated to adolescents and their parents. This questionnaire aims to assess the level of dietary knowledge of Lebanese adolescents and their parents. It was specifically designed for the current population and it was previously validated on a smaller similar sample of Lebanese adolescents (N = 108) . The DKQN = 108) . After fN = 108) .A Dietary Adherence Questionnaire (DAQ) was administrated to adolescents and their parents, aiming to assess their level of adherence to the dietary recommendations listed in the consensus statement from the American Heart Association  and the 2) [Weight and height were measured using standardised protocols and procedures  and cali2) .z-scores for consistency and comparability, compared to percentiles [z-scores, also known as BMI standard deviation (SD) scores, are measures of relative weight adjusted for age and gender [z-scores were calculated using the WHO AnthroPlus software [z-scores were classified as follows: ≤−3 indicating severe malnutrition; −2 to −2.9 indicating moderate malnutrition; −1 to −1.99 indicating mild malnutrition [BMI is recognised as the most appropriate measure to detect paediatric obesity  and it icentiles . BMI z-sd gender . In the software . As a frutrition ; −0.99 tutrition .Anthropometric measurements were obtained for 1418 out of 1535 (92.4%) adolescents. The rest of the participants were either absent during the measurement collection, refused to take their weight and/or height , or refused to follow the required procedure .z-score average, and the participants’ answers to the questionnaires. Independent t-tests were employed to determine significant differences between subgroup means . Pearson’s correlations were used to explore potential relations between knowledge, the adherence scores of adolescents and parents, and BMI z-scores. Effect sizes were categorised to three groups: small (r = 0.10–0.29), medium (r = 0.30–0.49), and large (r ≥ 0.50) [p value of less than 0.05 was considered statistically significant. The obtained scores are expressed as mean and standard deviation (SD).Data were entered and analysed using the Statistical Package for Social Sciences version 25.0 . We used descriptive statistics to analyse the participants’ characteristics, the average scores, the BMI  ≥ 0.50) . One-wayThe demographic characteristics of the participating adolescents and parents are shown in p < 0.001; see Adolescents scored an average of 26.91 (SD = 7.46) out of 56 on the DKQ, and 59.2% answered more than half of the questions incorrectly. In terms of demographic characteristics, there was no significant difference in the knowledge score between groups, except for the location: adolescents from rural schools scored higher than those from urban ones  out of 56 on the DKQ, and there were no significant differences between the groups based on demographics, except for the type of school, with the parents of students from private schools scoring significantly higher see . Detailep = 0.02), and adolescents living in rural regions scored higher than adolescents living in urban regions (p < 0.001).The mean total dietary adherence index score was 1.80 (SD = 1.57), and 32.4% of adolescents obtained a score below 1 . Girls scored significantly higher than boys  out of 37. There were significant differences between groups regarding gender, grade, and location. The mean unhealthy items score was 6.37 (SD = 3.19) out of 38, and there were significant differences between groups related to gender, type of school, and location see .p < 0.001 for both). Similarly, adolescents living in urban regions tended to participate more in physical activity classes compared to adolescents from rural regions (p < 0.001). As for the screen-viewing time of adolescents, girls and adolescents living in urban regions tended to spend more time watching television and looking at smartphones, tablets, and other screens, compared to boys and adolescents living in rural regions  at school more than adolescents from grade 11 and from private schools , and there were no significant differences between the groups based on demographics see .The mean healthy items score among parents was 10.21 (SD = 3.31), and there were no significant differences between groups in terms of demographics except for gender. The mean unhealthy items score among parents was 4.87 (SD = 2.59), and there were no significant differences between groups, except for location see . Detailez-score of the adolescents was 0.44 (SD ± 1.20), ranging from −3.78 to 4.11 (see z-score (−0.99 to 1.03). A total of 13.9% were overweight, 16.3% were obese, and 10.7% were underweight.The mean BMI 4.11 see . Overallp < 0.001). There were significant small positive correlations between the total knowledge score of the adolescents and their healthy items (p < 0.001), and their total dietary adherence index (p < 0.001). In addition, a significant small negative correlation was found between the total knowledge score of adolescents and their unhealthy items score (p < 0.001).p = 0.007), and negatively correlated with their unhealthy items score (p = 0.01). The healthy items score of the parents was significantly positively correlated with the healthy items score of their children (p < 0.001), and the same medium positive correlation was found between the unhealthy items score of the parents and their children. In addition, the total dietary adherence indexes of the parents and adolescents were significantly positively correlated (p = 0.007). Detailed correlations between the DAQ items of the parents and adolescents are shown in The total knowledge score of the parents was significantly positively correlated with their total dietary adherence index  and the total knowledge score of the parents (p = 0.029). By contrast, the BMI z-score was significantly negatively correlated with the healthy items and unhealthy items score of adolescents (p < 0.01), and the healthy items score of the parents , the intake of commercial fruit juices , the number of snacks , and the screen-viewing time .There was a significant negative correlation between the breakfast intake among adolescents and the intake of high-fat meats , physical activity practice outside school , and the weekly number of hours spent on physical activity . There was a significant negative correlation with the intake of high-fat dairy products , the intake of commercial juices , the number of snacks , and screen-viewing time . The interviewers of the current study insisted that if participants did not know the answer to a question, they should indicate “do not know” rather than provide random answers. As this eliminates filling in the correct answer by chance, this might have influenced the lower knowledge score. However, another cross-sectional study reported that 86% of the participating United Arab Emirati adolescents had a low level of dietary knowledge . With reThe average total adherence index among adolescents was above 1, meaning that, overall, the healthy items outweighed unhealthy ones, in line with a previous study . These fWith regard to the parents, the total dietary adherence index was well above 1, and the healthy items score was also higher than their children’s scores. It therefore seems that parents’ diets are healthier than those of their adolescent children. To our knowledge, there are no studies assessing the level of dietary adherence of parents specifically, but a study in Qatar among adults in general reported similar dietary adherence scores . Anotherz-scores. Furthermore, the BMI z-score was significantly higher among boys compared to girls in the current study, in line with other studies reporting that boys are at a higher risk for obesity [z-score was significantly higher in private high schools compared to public ones. Thus, adolescents with a higher socio-economic status . In particular, the percentage of obesity appeared high. This could be due to the nutrition transition affecting Lebanese children and adolescents who are adopting the Western lifestyle, characterised by long hours of screen-viewing time and the excessive consumption of fast food , althougion fees ), tend tion fees . Furtherd Jordan .However, underweight is another nutritional problem that this age category faces, with 10.7% of the current adolescents being undernourished. In a study in Tunisia, the prevalence of underweight among a similar sample of adolescents was lower (4.8%) . UnderweDespite mostly small effect sizes, the significant positive correlation between the dietary knowledge of adolescents and the total dietary adherence index shows that knowledge is one of the factors influencing the dietary habits of Lebanese adolescents. In other words, the more adolescents know about nutrition, the better they follow the dietary guidelines. These findings are in line with other studies reporting that university students with a higher nutrition knowledge score were more likely to follow the dietary guidelines . The curAs for the parents, we noticed a positive correlation between their total knowledge score and the adherence index, reflecting once again that knowledge is an important determinant of dietary habits . There wz-score of adolescents and their dietary knowledge score was found, which might indicate that overweight and obese children tend to be more interested in nutrition compared to other children. Similarly, parents of children with higher BMI z-scores tended to be more knowledgeable about nutrition as well. In line with this, Milosavljević, et al. [z-score, but rather only the BMI, failing to adjust for gender and age differences in BMI among adolescents [z-score of the current adolescents was further significantly negatively correlated with the intake of both the healthy items and the unhealthy items. Previous research has also shown that adolescents with higher BMIs tend to adopt less healthy behaviours [z-score and the healthy items score of the parents indicates that the healthy eating habits and PA practices of the parents influence the weight of their children. This is because parents following healthy habits may influence their children to adopt similar healthier choices , thereby leading to a decreased BMI z-score. To our knowledge, studies have not evaluated the association between the child’s BMI z-score and the healthy and unhealthy behaviours of the parents separately.A positive correlation between the BMI , et al.  reported, et al. . Other alescents . The BMIhaviours . Howeverz-score of Lebanese adolescents and the levels of dietary knowledge and dietary adherence of adolescents and their parents. The current study allows us to understand the dietary behaviour of Lebanese adolescents and the factors influencing it. In addition, all the questionnaires used were pre-tested and designed specifically to suit the Lebanese population [The main strength of the present study is its large and diverse sample covering both urban and rural regions and different types of high schools. Data collection was performed according to standardised and quality-controlled procedures. This is the first study in the region to investigate the correlation between the dietary knowledge and dietary adherence of adolescents and their parents. It is also the first study to examine the correlation between the BMI pulation . FurtherSome limitations should be also considered. First, the sample did not include participants from all the Lebanese regions, and it is therefore unclear whether the results can be generalised to the larger population. Second, the sample was not equally distributed over the different subgroups . These differences in the sample subgroups were expected based on previous studies conducted on a similar sample, with more girls than boys, as the percentage of girls enrolled in Lebanese high schools is higher compared to boys . Similarz-scores to prevent further weight loss among adolescents with undernutrition (10.7%). Health promoters should target the factors with the highest effect sizes with regard to BMI z-score and dietary adherence to make interventions more effective and more efficient, especially knowing that schools have limited time when it comes to extra-curricular activities. In addition, interventions should focus on individuals with the lowest dietary knowledge and adherence scores, e.g., adolescents from urban regions. Additionally, as some healthy behaviours co-occur with other healthy eating habits, future interventions must emphasise the importance of these specific behaviours  to enhance their effectiveness.Our findings are of interest to researchers, health promoters, educators, dietitians, and policy makers involved in improving the nutritional status and diet quality of adolescents worldwide. This study is the first step preceding the implementation of a dietary intervention to ameliorate the eating habits of Lebanese adolescents. Such interventions should be planned carefully to suit individuals with different BMI z-score, such as breakfast consumption, and focus on nutrition topics for which adolescents show the lowest knowledge and dietary adherence. National studies to investigate the change in obesity rates, as well modifications in the dietary knowledge and adherence levels in Lebanon, are recommended.This study indicates that the prevalence of overweight and obesity has reached alarming rates among Lebanese adolescents and it emphasises the importance of implementing interventions to prevent paediatric obesity among the youth population. Such interventions should target behaviours that are associated with a lower BMI


There is a growing body of research that demonstrates declines in subjective well-being and increases in mental health problems among children and young people in recent decades. However, there is little comparative research examining changes in adolescents’ life satisfaction (LS) across a large number of countries, and critically, how this differs across sociodemographic groups. This study addresses this question by investigating changes in the LS of 15-year-old students between 2015 and 2018, with particular attention given to differences by gender, socio-economic status, immigrant background and urbanity. Data for this study come from the Programme for International Student Assessment (PISA). Due to the skewed nature of LS scale variables, the current study includes both mean levels of LS in a 0 to 10 scale, and the proportion of students reporting low LS (5 points or less). Linear regression models were used. Results demonstrate a global decline in mean levels of LS in 39 out of the 46 countries. In most countries, mean LS declined more among girls than among boys. Mean LS declined more, and the proportion of students reporting low LS increased more, among non-immigrant students and those of higher SES in the majority of countries. Findings regarding rural or urban communities were mixed. We advise that heterogeneity across all sociodemographic groups needs to be accounted for in public policy efforts to increase LS among young people. SWB refers to a person’s cognitive and affective evaluations of his or her life . Since tInterest in measuring and evaluating children’s SWB has traditionally attracted less attention, probably due to the lack of political importance attributed to children’s perspectives . However1.1There is general academic consensus that child and adolescent well-being is a multidimensional concept that aims to measure the quality of children and adolescents’ lives . Measure1.2LS is a cognitive appraisal of one’s overall quality of life with a positive orientation . In reseDespite evidence of negative trends in children and young people’s well-being and mental ill-health as a whole, and mixed evidence on trends in LS across multiple countries, scarce research has examined trends in adolescents’ LS across sociodemographic groups, and no study has explored this in a large number of countries. Thus, to fill this research gap, this study investigates changes in adolescents’ LS across a large number of countries. In particular, we use data from PISA 2015 and 2018 to study changes in the LS of 15-year-old students in 46 countries.Did the life satisfaction of 15-year-old adolescents increase, decrease or remain stable in the period 2015–2018?Did changes in LS differ across gender, SES, immigrant background, rural/urban communities, or across countries?Are patterns of change in LS across these groups similar or different when comparing variation in mean LS and the proportion of students reporting low LS?To accomplish this, we asked the following research questions: 22.1n = 643,615; n (2015) = 312,028; n(2018) = 331,587). PISA is a worldwide study by the OECD, conducted in member and non-member countries and economies, carried out every 3 years and focused on 15-year-old students’ academic performance. PISA also collects a large amount of data on education policy and practice and, especially since 2015, on the broader well-being of students. More than 70 countries and economies participated in the 2015 and 2018 PISA editions, but data on LS was not collected in all countries. This study compares levels of students’ LS in the 46 countries and economies where LS data was collected and levels of missing data are low  or a boy (2).To investigate differences across SES, we created a categorical variable derived from PISA’s Economic, Social and Cultural Status (ESCS) index. First, we standardised this index with reference to each country such that 0 indicates the mean ESCS in each country and 1 the standard deviation. Then, from each country-specific continuous ESCS variable, we created the country-specific categorical SES variable, which indicates whether the student belongs to the bottom 25% in the country-specific ESCS scale (1), to the 50% in the middle (2) or to the top 25% (3).To study differences by immigrant background, we created a dichotomous variable  reporting whether the student has an immigrant background or not. Non-immigrant students are those born in the country and whose parents were born in the country. Immigrant students are those who have an immigrant background, this is those born out of the country or whose father or mother was born out of the country.To explore differences according to rural/urban location, we used PISA’s urbanity variable, which represents 5 levels on the rural-urban spectrum. In particular, this variable is derived from school principal’s responses to the following question: “Which of the following definitions best describes the community in which your school is located? A village, hamlet or rural area (fewer than 3000 people); A small town (3000 to about 15000 people); a town (15000 to about 100000 people); a city (100000 to about 1000000 people); a large city (with over 1000000 people)”.Finally, to study differences across the 46 countries, we included an additional country-level variable to identify participants from England, Wales, Northern Ireland and Scotland within the UK.2.3The aim of the current study was to compare 2015 and 2018 cohorts of 15-year-old students in 46 countries to explore differences in LS and how these differ by gender, SES, immigrant background, urbanity and across countries. Linear regression techniques were used to assess whether LS increased, decreased or remain stable in this period, and to identify patterns of change across different groups of students. Our outcome variables were LS  and the proportion of students reporting low LS (dichotomous variable). We used a single predictor variable –year, with a value of 0 for those who participated in 2015 and 1 for those who did it in 2018. We ran these models separately for each group of interest.First, we examined changes in LS for the general population of 15-year-old students. The focus was on mean levels of LS and the proportion of students reporting low LS . Then, we explored how mean levels of LS and the proportion of students reporting low LS had changed for girls and boys; for students of low, mid and high SES; for non-immigrant students and those with an immigrant background; and students attending schools located in more rural/ urban communities. Besides, we then explored differences across countries.Final student weights were applied in the analysis to account for PISA’s complex design. Levels of missing data in the variables studied are low, below 10% in most countries. For those categories where levels of missing data are high (above 20%), these are excluded from the analysis. To avoid problems associated with small sample size, categories with less than 50 observations were excluded from the analysis. The analysis was conducted using Stata 15 .33.1In addition, in many countries the results demonstrated much greater variation in mean levels of LS than in the proportion of students reporting low LS, and vice versa. This suggests that there are cross-country differences in patterns of variation in LS, as changes in LS were more concentrated around the tail of the 0 to 10 LS scale in some countries than in others.3.23.33.4Differences in changes in students’ LS between 2015 and 2018 by immigrant background are reported in Furthermore, 3.5Differences in changes to students’ LS between 2015 and 2018 across levels of urbanity are reported in 4The increasing policy interest in assessing children and young people’s well-being , 2014b sOverall, the study found strong evidence that mean levels of LS declined in the majority of countries, and similarly, that the proportion of students reporting low LS increased in this period in most countries. This finding conflicts previous research that found mixed patterns in changes to LS , howeverIn addition, this study found important heterogeneity between countries and across the sociodemographic groups. In terms of gender, overall changes in LS between 2015 and 2018 were more negative among girls than among boys. Specifically, the decline in mean levels of LS was greater among girls in approximately 67% of the countries. However, gender differences in the proportion of students with low LS was less pronounced, with approximately 41% of the countries demonstrating a greater decline among girls, and approximately 44% indicating greater changes among boys. This suggests that although girls overall seemed to fare worse in LS between 2015 and 2018, in a non-negligible portion of countries, more boys than girls experienced more negative changes in their satisfaction with life. Moreover, The study also found, overall, greater declines in LS among students of higher SES, than among those of lower SES. Similarly, the proportion of students who reported low LS increased more among students of higher SES than among those of lower SES in almost all countries. Although exceptions, such as the UK, were found, the study suggests counter-intuitive changes in LS related to SES. However, it is important to note that, in line with previous research e.g. , LS was Immigrant background influenced changes in LS such that greater decreases were found among non-immigrant students than among students with an immigrant background in most countries. In addition, non-immigrant students experienced a greater increase in the proportion of students reporting low LS compared to students with an immigrant background. Yet, similar to SES, LS was on average higher, and the proportion of students reporting low LS smaller, among non-immigrant students in the majority of countries. Thus, the study suggests that decreases in LS among non-immigrant students in recent years merits attention, yet these students still experience greater LS, on average, than students of an immigrant background.Lastly, the study found inconclusive evidence on the relationship between urban/rural locality and trends in LS. Though the results demonstrated that, overall, students’ LS was on average higher in more rural communities than urban localities, evidence for changes to LS, both average changes and proportion of students with low LS, was mixed. Given the great heterogeneity of results, the study suggests that the association between urban/rural setting and LS varies according to the country of interest.Previous research found some patterns across countries in correlates of adolescents’ LS . HoweverHeterogeneity across sociodemographic groups should also be considered in policy interventions intended to promote adolescents’ SWB and tackle these negative trends. For example, some interventions may need to be gender sensitive or target a particular group of students (e.g. immigrant students). Furthermore, the heterogeneity across countries, and in some countries, across rural/urban communities, suggests that policy efforts need to exercise caution when making generalisations across nations. Trends in LS observed in one society may well differ from those in a different one, or in a different region, state, or municipality. A policy response to deal with geographic heterogeneity in adolescents’ LS would be to promote the collection and analysis of data at the country level, but also, ideally, data which is representative of these different administrative levels and the rural/ urban population.Finally, the current study highlights important differences between trends in mean LS and low LS, which was substantial across some countries and sociodemographic groups. Changes in different places on the LS scale  imply different at-risk groups. Consequently, policy efforts must delineate if they aim to improve average LS, or target interventions to those with the lowest LS scores, as these groups of adolescents may differ. In addition, future research should explore what changes in LS taking place in different part of the scale may mean in terms of other important outcomes, such as mental health outcomes. A better understanding of the interconnections between changes to LS and changes in SWB or mental health could inform policy efforts intended to promote better well-being overall.5This study was affected by a series of limitations that are worth mentioning and which, ideally, should be addressed in future research. First, we focused on only one outcome variable  and the study of other SWB measures may well provide results which differ from those reported in this study. Second, we focus on 15–16-year-old adolescents mainly in high-income countries who were enrolled in formal education. This is a rather restrictive definition of adolescence and, ideally, future research should explore this question for other age groups, for adolescents in and out of school, and in a wider variety of countries. Moreover, exclusions rates in PISA can be high in some countries see  and, for6There is an increasing body of research demonstrating declines in levels of well-being and positive mental health among adolescents in multiple countries, but little research has explored changes in LS and how these differ between countries and across groups. This study investigated this question, finding a rather global decline in the LS of 15-year-old adolescents between 2015 and 2018. In addition, despite general trends in LS, differences across countries and groups were important. In most countries, LS worsened more among girls, among adolescents of higher SES, and those without an immigrant background. Changes to LS relative to urban/rural location were mixed. Moreover, in some cases, changes in LS was more concentrated in the lower part of the 0 to 10 LS scale than in others, revealing further differences across countries and groups. Overall, this research highlights the necessity of adopting more nuanced approaches to studying trajectories in adolescents SWB, which may help us improve our understanding of adolescents well-being and strategies to promote it.Appendix


The ideal cardiovascular health index (CVHI) is a measure to summarize cardiovascular (CV) health, and includes smoking, body-mass index, physical activity, blood pressure, glucose, total cholesterol, and diet.This study aimed to assess CV health using the CVHI and determinants on CV health in a rural African population, and correlate carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis, with CVHI.A cross-sectional analysis was performed on baseline data of the Ndlovu Cohort Study, located in rural South Africa. CVHI score (CVHIs) was calculated by the sum of favourable CVHI factors (range 0 to 7). Logistic regression was performed to examine the association of age, sex, HIV-status, education level, employment status, and income with good CV health . Mean CIMT was displayed by poor, intermediate and good CV health.The study included 1927 participants with a mean age of 38.7 years (SD ± 12.8). Of the factors contributing to the CVHI, glucose and total cholesterol scored best; diet least good. Average CVHIs for the population was 4.4 (SD ± 1.2) and 53% of the population had a good CV health. Determinants associated with good CV health were younger age, higher educational attainment, and HIV positivity. CVHIs showed good agreement with CIMT.CVHIs showed that more than half of the participants had a good CV health. Agreement between CVHIs and CIMT indicates potential use of CVHIs as a surrogate marker for CV risk. The study highlights the importance of education for health promotion; good CV health in HIV-positive participants may in part be attributed to more frequent health care contact and provision of chronic disease care.Good cardiovascular health (CVH) was observed in 53% of the study population.In global comparison, rural African study participants showed a good CVH score.HIV positivity was associated with a good CVH score.CVH score showed good agreement with carotid intima-media thickness. Cardiovascular disease (CVD) is the number one cause of death globally, causing 31% of all global deaths in 2016 [The Ideal Cardiovascular Health Index (CVHI) is used by the American Heart Association (AHA) as a tool to summarize cardiovascular health (CVH), and amalgamate traditional risk factors for CVD including smoking, overweight, high glucose, high total cholesterol, high blood pressure, unhealthy diet, and physical inactivity . Several56Socio-economic status (SES) has been associated with CVD 9. HoweveIn the absence of longitudinal data, the CVHI may be a marker for subclinical atherosclerosis. To assess the relation between CVHI and subclinical atherosclerosis, carotid intima-media thickness (CIMT), a well-established marker for subclinical atherosclerosis, can be used. CIMT is an ultrasound-based measurement of the thickness of the intima and media layer, referring to the common carotid artery as utilized in this paper. An increase in vessel wall thickness has been related to an increased risk of CVD . CVHI doThis study aims to assess the CVHI of a rural South African population and to investigate determinants of the CVHI. In addition, CVHI was assessed as a surrogate marker for CVH as compared to CIMT.Data was collected from the Ndlovu Cohort Study (NCS), a prospective cohort study in Elandsdoorn, a rural township in the Moutse area, Limpopo Province, South Africa. A total of 1927 participants were included between November 2014 and August 2017, with the intention to include 50% HIV positive participants. Participants were recruited from the community and the Ndlovu Medical Center, a large HIV treatment center contracted by the South African Department of Health to provide medical services. Inclusion criteria were: age ≥18 years, able to provide written informed consent, and committed to long-term follow-up. Ethical approval for this study was obtained from the Human Research Ethics Committee at the University of Pretoria, Pretoria, South Africa, and the Limpopo Department of Health Ethics Committee. The methods of the NCS have been described in detail by Vos, et al. .Data was collected on age, sex, demographics, general health, HIV status, and chronic medication use including medication for hypertension and diabetes.Information on cardiovascular (CV) risk factors and smoking was obtained with a modified version of the World Health Organization (WHO) STEPS instrument . PhysicaBlood pressure was measured after 5 minutes of rest in seated position with a sphygmomanometer device, and repeated on the side with the highest value. For systolic and diastolic blood pressure the average of the second and third measurement was used for analysis.Blood was collected in all participants for a non-fasting lipid profile and random glucose.Participants with a HIV-negative status or participants with an unknown HIV status were tested for HIV at time of enrolment. Testing was performed in accordance with the South African Department of Health guideline. For HIV-positive participants, documentation was needed of a positive HIV test, or proof of being on ART, if not available, the participant was retested.Ultrasound measurements were obtained for all participants. A total of six images were obtained including three angles of the right  and left  using a Meijer Arc. Images were read offline using the semi-automatically Artery Measurement System (AMS) software. The far and near wall were measured in each image at one cm distal to the tip flow divider. If this area was not clear, measurements were obtained until two cm distal of the tip flow divider. Ideally, each measurement covered a length of 10 mm; if this was not possible, a smaller segment was read. Mean CIMT was measured on each angle. For each participant the mean of all available CIMT scans was calculated.The scans were analysed by three readers, who were blinded for all participant characteristics. The intraclass correlation coefficient to assess inter reader variability was excellent, ranging between 0.92 and 0.93 .Table The criteria that we used to define good, intermediate and poor health for smoking, glucose, cholesterol, and diet differ slightly from the AHA criteria. The AHA defines a former smoker as someone who quit smoking more than 12 months ago but our data only allowed us to categorize former smoking in weeks, months or years. In addition, random glucose was measured in the study population, instead of fasting glucose. No cholesterol lowering medication was reported among participants, as expected from South African literature .The AHA definition of diet is based on five dietary components, consisting of; fruits and vegetables (≥4.5 cups/day), fish (≥ two 100 g servings/week), fiber rich whole grains (≥ three 30 g servings consisting 1.1 g of fiber per 10 g of carbohydrate/day), sodium (<1500 mg/day), and sugar sweetened beverages . As in the NCS only data on fruit and vegetable intake in servings/day was collected, the total servings of fruit and vegetables/day were used as a proxy for the dietary component. The cut-off for the number of servings to define CVH was based on the WHO recommendation of at least 400 grams of vegetables and/or fruits per day . Poor heIn total 43.3% of the participants had missing data for blood pressure measurement as the measurements in these participants were taken with a non-validated wrist device instead of the indicated arm device in the years 2016 and 2017. Besides, CIMT was missing for 7.9% of the participants due to unreadable or missing scans; data on income, and fruit and vegetables intake was missing for respectable 5.3% due to unreadable or missing scans, and for 2.1% of the participants due to incomplete questionnaires. All other variables had less than 2% missing values. Missing values were assumed to be missing at random.Multiple imputation was performed using the ‘mice’ package of R, generating 20 imputed datasets. All valid blood pressure measurements, age, gender, HIV positivity, smoking, BMI, total cholesterol levels, glucose levels, physical activity, fruit and vegetable intake, medication use, education, and employment were included in the imputation model. Passive imputation was used for variables which needed recoding, calculations or indices for analysis. Convergence plots confirmed that the MICE algorithm had converted. Each parameter of interest was estimated in each imputed dataset separately, and combined using Rubin’s rules for analysis. Data for summarization of study characteristics in graphs were obtained by computing the mean or selecting the most likely imputed value for those variables of interest . In addiFirst, study characteristics were reported by sex before performing multiple imputation. For continuous data mean with standard deviation (SD) were used for normally distributed data and median with minimum and maximum for skewed data. Categorical outcomes were presented as numbers with percentage. After multiple imputation a cross-sectional analysis was performed on the data. For all CVHI factors the frequency of good, intermediate and poor health was described by sex, using the definitions of Table Finally, the relation between CVHIs and CIMT was assessed. Mean CCA-CIMT was displayed per CHVIs category whilst accounting for age categories  and sex. For statistical analysis R version 3.6.1 was used . A two-sA total of 1927 participants were included in this study, of which 887 were HIV-positive (46.0%). The mean age of the study population was 38.7 years (SD ± 12.8)  out of six higher than those with blood pressure measurements (3.78 (SD ± 1.00)). Lower glucose levels and a healthier BMI contributed to this higher score; smoking had a negative contribution to this score.The average CVHIs was 4.4 SD ± 1.2). A total of 53% of the participants were classified as having good CVH according to the CVH categorization, with intermediate health (40%), followed by poor health (7%) , and, for those younger than 60 years, an estimated good CVH of 25.8% . The estNormal glucose and cholesterol measurements, followed by physical activity and blood pressure, contributed to a good CVHIs. This is not surprising as our population is still relatively young . Diet neThe higher proportion of good CVH might be explained by the slightly higher CVHIs, and larger proportion of HIV positivity as is observed in our analysis.Sex-dependent risk factors in this study were BMI and smoking. Men were far more likely to be a current smoker, and women were almost three-fold more likely to be overweight. These results are in line with patterns observed by van Nieuwenhuizen, et al. , in a stHIV-positive participants were observed to have a better CVH, results that are in line with the study by Martin, et al. undertaken in Uganda , and cou28In accordance with earlier studies, CIMT measurements related well with the CVHIs 30. This 31The individual risk factors composing the CVHIs, are not weighted based on their individual contribution to future CVD events, and are therefore not ideal for CVD risk prediction. Nonetheless, the use of CVHIs and individual factors of the CVHI are suitable for assessing current CV health status as undertaken in our study and for monitoring changes over time.There are some limitations that need mentioning. Adjustments were made to the CVHI definitions as proposed by the AHA, based on data availability. Fruit and vegetable intake were used as a proxy for five dietary components, in line with other studies using the AHA definition. Measurement of random glucose instead of fasting glucose might have led to a slight underestimation of good CVH.Around 15% of our participants were underweight. Underweight is acknowledged as a health risk by the AHA, but as it is a relatively rare condition in high-income countries, it was not integrated in the original CVHI recommendation . This miAlmost half of study participants had missing data on at least one variable; blood pressure was with 43.3% the largest contributor. Multiple imputation was conducted to avoid possible bias due to missing data. With missingness at random, population estimates are likely to be more precise and valid as opposed to complete case analysis. The proportion of participants with a desired blood pressure measurements was larger among those with missing data. This is most likely due to the higher percentage of HIV positivity in those with missing blood pressure data, being associated with lower blood pressure. No changes in the average CHVS is observed after imputation. Although multiple imputation strives towards the most likely values, complete data on all participants would have been most accurate.By design, half of the included participants in the Ndlovu Cohort Study (NCS) were HIV infected. This percentage is higher than the HIV prevalence of 16.8% among adults between 18 and 49 in South Africa in 2014 when NCS recruitment commenced . The oveFor the current cross-sectional analysis of NCS baseline data, CIMT was used as a marker of subclinical atherosclerosis and proxy for cardiovascular risk . The valIn this rural sub-Saharan setting, more than half of the population showed a good CVHIs. Remedial actions to further improve health include smoking reduction especially in men, better access and affordability of nutritious and healthy food, and continuing to encourage physical activity. Interventions should be adapted to local situations, informing about affordable and healthier options. The CVHIs was related with CIMT; indicating that CVHIs could be used as a surrogate marker for CVD.


Background: The prevalence of Helicobacter pylori infection (HPI) is still high around the world, which induces gastric diseases, such as gastric cancer (GC). The epidemiological investigation showed that there was an association between HPI and asthma (AST). Coptidis rhizoma (CR) has been reported as an herbal medicine with anti-inflammatory and anti-bacterial effects.Purpose: The present study was aimed to investigate the protective mechanism of HPI on AST and its adverse effects on the development of GC. Coptis chinensis was used to neutralize the damage of HPI in GC and to hopefully intensify certain protective pathways for AST.Method: The information about HPI was obtained from the public database Comparative Toxicogenomics Database (CTD). The related targets in AST and GC were obtained from the public database GeneCards. The ingredients of CR were obtained from the public database Traditional Chinese Medicine Systems Pharmacology (TCMSP). The network pharmacology including gene ontology (GO) enrichment analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis, and molecular docking were utilized. Protein–protein interaction was constructed to analyze the functional link of target genes. The molecular docking was employed to study the potential effects of active ingredients from CR on key target genes.Result: The top 10 key targets of HPI for AST were CXCL9, CX3CL1, CCL20, CCL4, PF4, CCL27, C5AR1, PPBP, KNG1, and ADORA1. The GO biological process involved mainly leukocyte migration, which responded to bacterium. The (R)-canadine and quercetin were selected from C. chinensis, which were employed to explore if they inhibited the HPI synchronously and protect against AST. The targets of (R)-canadine were SLC6A4 and OPRM1. For ingredient quercetin, the targets were AKR1B1 and VCAM1.Conclusion: CXCL9 and VCAM1 were the common targets of AST and HPI, which might be one of the imported targets of HPI for AST. Quercetin could be an effective ingredient to suppress HPI and help prevent AST. Helicobacter pylori (HP) is a Gram-negative, slightly aerobic bacterium, which attaches to the gastric epithelial cells and requires extremely harsh living conditions  with symptoms of nausea, vomiting, upper abdominal discomfort, and dull pain –10. EachAsthma (AST) is a heterogeneous disease with the characteristic of chronic airway inflammation involving a variety of cells and cellular components . The chrp = 0.021)  . Arnold I and GC . The HPI effects , 20. As  effects .C. chinensis, selected as a representative drug, was used to neutralize the damage of HPI for GC and to hopefully intensify certain protective pathways for AST. Thus, the creative points of this study are as follows: (1) HPI was assumed as one “drug,” which could damage the stomach and activate the protective pathway for AST. (2) C. chinensis, selected as one representative drug, was given hope to compromise the damage caused by HPI.In this research, the HPI was considered as a two-sided “drug,” which could cause the gastric discomfort/symptom of digestive tract on one side, such as GC, and on the other side, it could activate certain pathways, which appear protective for AST. Based on the abovementioned opinion, the network pharmacology theory was employed to investigate the relationship between GC, AST, and HPI. The flowchart of the entire paper is illustrated in http://ctdbase.org/) (https://www.genecards.org/) (The related targets about HPI were obtained from public database Comparative Toxicogenomics Database (se.org/) , where ids.org/) , which ivia the tool Draw Venn Diagrams (http://bioinformatics.psb.ugent.be/webtools/Venn/)  , which ihttps://cytoscape.org/). For interaction targets of GC and HP, it was performed with the same abovementioned operation, and its network was called GC–HPI network. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were operated on Metascape (https://metascape.org/gp/index.html#/main/step1). After intersection targets were imported into Metascape, H. sapiens and custom analysis were selected to calculate the GO cellular components, biological processes, molecular functions, and KEGG pathway.After the abovementioned processes, the network for AST and HPI was constructed successfully for the sake of distinction, and it was named as AST–HPI network in this paper. Then, AST–HPI network was input into the software Cytoscape for visualization  (https:/https://tcmspw.com/tcmsp.php), which can provide the related information, including ingredients name, oral bioavailability, drug-likeness, etc. In order to filter the main components, the drug-likeness and oral bioavailability were >0.18 and 30, respectively. Then, corresponding targets were collected in this database. The intersection dataset between HPI and CR was calculated via the Draw Venn Diagrams, and the PPI networks of CR and HP were established by String as described earlier. Here, the targets for the potential valid components of CR were discovered. AutoDock Vina (http://vina.scripps.edu/) was implemented to molecular docking to study the effects on key target genes.The ingredients of coptidis rhizoma (CR) were obtained from the public database Traditional Chinese Medicine Systems Pharmacology  and 308 edges according to the PPI network constructed in String, and the Protein–protein interaction network is shown in via Metascape are illustrated in Staphylococcus aureus infection, toll-like receptor signaling pathway, tuberculosis, and Rap1 signaling pathway were involved in this process.The results of GO enrichment analysis The top 10 key targets are presented in The results of the GO enrichment analysis are illustrated in via Draw Venn Diagrams contains 114 elements as shown in via String, there are 4 targets of ingredients of CR, which belongs to section A  was used to dehydrate the receptor (by using command: remove solvent), remove unwanted heteroatoms (by using command: remove organic), and save it as the receptor structure. The molecular docking was operated in AutoDock Vina after the relevant configuration, and the result is as shown in In order to test the probability of the combination of target and ingredient, molecular docking between quercetin and VCAM1, and also between quercetin and AKR1B1, was performed. Second structure of quercetin from PubChem was transformed to three-dimensional structure mization . Three-dmization . The molHelicobacter pylori infection could cause a variety of digestive diseases, such as chronic gastritis, gastric ulcer, duodenal ulcer, gastroesophageal reflux, atrophic gastritis, and GC  and were 14.8, 20.2, and 25.8% in 3–6, 7–11, and 12–17 years age group, respectively . Quercetin is a flavonoid commonly found in many edible and medicinal plants, such as onions, tea leaves, and C. chinensis. As mentioned in the literature reported, it has antioxidation, antitumor, hypoglycemia, blood lipids, and other pharmacological effects (The molecular docking has been widely used to predict the relationship between ingredients/drug and protein/targets , 51. In  effects . A recen effects . The exp effects . Thus, qThe limitation of study was that only GC was selected as one typical digestive disease influenced severely by HPI; in further studies, it will be investigated whether the mechanism of HPI leads to gastric disease synchronously, and how to activate the pathway which protects against AST. Another limitation was that it was predicted abstractly in this study and was not put into animal experimentation; however, the molecular docking could make up for this defect to some extent.CXCL9 and VCAM1 were the common targets of AST and HPI, which might be an imported target of HPI for AST. Quercetin could be an effective ingredient to suppress HPI and help prevent AST.All data involved in this study can be obtained from the public database.All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.FW was the guarantor of integrity of the entire study and designed the study. CC and FW dealt with study concepts. CC and FW defined the intellectual content of the manuscript. CC, FP, and FW involved in the literature research and revised and reviewed the manuscript. FP handled data acquisition. CC contributed to data analysis/interpretation, statistical analysis, and manuscript preparation. FW and FP edited the manuscript. All authors participated in this study and consent to publish this article in Frontiers in Oncology.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The intervention group performed an early physiotherapy program based on functional exercises, scar manual therapy, and educational tips. The control group received usual care. Shoulder range of motion (ROM), grip strength, upper limb pain and disability (SPADI), scar recovery (POSAS), myofascial adhesions (MAP-BC), quality of life (EORTCQLA-BR-23) and the presence of axillary web syndrome (AWS) and lymphoedema were assessed at baseline and immediately after intervention. A follow-up period of 6 months was performed for lymphoedema surveillance. Between groups significant differences in favor of the intervention were found for ROM (r = 0.43), grip strength (r = 0.32), SPADI (d = 0.45), POSAS (d = 1.28), MAP-BC (d = 1.82) and EORTCQLQ-BR 23 general function subscale (d = 0.37) . Our results suggest that an early physical therapy program seems to be more effective than usual care in women after SLNB. However, results should be interpreted with caution and future randomized trial with a larger sample size is needed.Selective sentinel lymph node biopsy (SLNB) represents a minimally invasive surgery in patients with breast cancer. The purpose of this study was to explore the possible effect of an early physiotherapy intervention for the recovery of the upper limb and the surgical scars after SLNB in comparison with usual care. A total of 40 patients were enrolled in either the control group ( Selective sentinel lymph node biopsy (SLNB) is considered a safe technique for axillary lymph node evaluation without the need for other more invasive techniques as, for example, axillary lymph node dissection ,2. At prHowever, although it is a less invasive surgical intervention, negative physical consequences may follow. The scientific literature proves that after SLNB, women are at risk of development of arm lymphedema, disability of shoulder function, pain, and decreased muscle strength, and quality of life ,6,7. In Another common condition observed after breast cancer surgery is the axillary web syndrome (AWS), which is a tense, non-erythematous painful band. It is palpable and visible under the skin and may appear from the armpit to the medial upper limb with extension to the antecubital fossa ,11. AlthSimilarly, lymphedema is still a problem in SLNB patients. A systematic review demonstrated that lymphedema is a nonnegligible complication in patients with SLNB-negative breast cancer, since the incidence of lymphedema in this population ranged from 0 to 63.4% . In a 4-Surgical scars have also a negative impact on the quality of life of patients operated on breast cancer. Recently, Gass et al.  reportedSeveral studies have indicated a negative physical impact on patients after SLNB and ALNB, and therefore, treatment to alleviate these symptoms in both types of surgery is suggested. Nevertheless, research investigating the impact of an early rehabilitation program after SLND is scarce . At presDue to the absence of previous research establishing whether, compared to usual care, an early physiotherapy intervention improves the recovery of upper limb and surgical scars after SLNB, the main purpose of this pilot study was to collect preliminary data on the effects of the aforementioned intervention  in orderThis is a quasi-experimental non-randomized controlled pilot trial. Randomization was not possible because the “Virgen del Rocio” hospital  offers early treatment of physiotherapy to all women who undergo SLNB, but the efficacy of this intervention has not been proven. It was therefore decided to select the control group of the nearby “De la Merced” hospital . The implemented study design was executed according to Consolidated Standards of Reporting Trials (CONSORT) statements . All resInformed consent was signed by all participants prior to surgical intervention, following the recommendations of the Declaration of Helsinki and the legal regulations in force in Spain regarding clinical research, especially Law 14/2007, of July 3, on biomedical research. The patients were also informed in a clear, precise, and sufficient way of all the aspects included in the study.During a period of eighteen months, participants were recruited in the two breast surgery units from the hospitals mentioned above. Inclusion criteria were as follows: (1) between 18 and 90 years old, (2) diagnosed with breast cancer, (3) intervened using the sentinel lymph node biopsy technique, (4) medical clearance of participation, (5) signed informed consent. The exclusion criteria were defined as follows: (1) history of ipsilateral cancer recurrence, (2) chronic disease or orthopaedic issues that would interfere with the ability to participate in this rehabilitation program, (3) existence of psychiatric disorders.The day before surgery, the researchers contacted in person with patients scheduled for SLNB in both hospitals, and all subjects who met the inclusion criteria were then evaluated (T0 or baseline). Subjects were then enrolled in the control group  or the experimental group . After surgery, patients were evaluated three times within 1 month: after hospital discharge (T1), after the stitches were taken out (T1 scar-related variables) and at the end of the intervention, or at 1 month after surgery in the case of the control group (T2). There was also a follow-up period of 6 months (T3). All evaluations were carried out by two experienced physical therapists . Equal mThe primary outcome measures were upper limb function  and scar recovery . Secondary outcomes were quality of life and the incidence of axillary web syndrome and lymphedema.To assess mobility, we used goniometry. The goniometer is the standard measure to assess the range of motion. Subjects were asked to move their arms in flexion, extension, abduction, and internal and external shoulder rotation. Maximum ROM was considered to be 180° for movements of flexion and abduction, 45° for extension, 100° for internal rotation, and 80° for external rotation. A single index was calculated as the percentage of the global movement .Grip strength was measured in kilograms using a calibrated hand dynamometer (JAMAR). The assessment was repeated three times with the hand of the affected side, and the average of the three tests was used for the main analysis .To assess the pain and disability of the upper limb, we used the Shoulder Pain and Disability Index (SPADI) scale . The SPAThe Patient and Observer Assessment Scale (POSAS) was used to assess the recovery of breast and axillary scars ,27. It iThe evaluation tool for Myofascial Adhesions in Patients after Breast Cancer  was used to assess the degree of adhesions that exist in the scar tissue and its surroundings. This scale was developed to quantitatively evaluate myofascial adhesions in patients with breast cancer ,29. The To measure the quality of life, a specific quality-of-life questionnaire was used, namely the Spanish version of the EORTCQLQ- BR-23 cancer-specific quality-of-life . It is cThe presence of axillary web syndrome (Yes/No) was evaluated by observation and palpation by the evaluators. Physical examination was performed as suggested in previous research: patient in a supine position with the elbow extended and the shoulder maximally abducted. The evaluator both visualizes and palpates for cords including the axilla, down the upper arm from the axilla to and across the antecubital space and down the forearm to the base of the thumb ,11.The presence of lymphedema (Yes/No) was evaluated via a telephone survey 6 months after the surgery. Women were classified as having self-reported lymphedema if they answered “yes” to the following question: ‘‘Since your breast cancer surgery, has a doctor ever told you that you have lymphoedema or arm edema?’’ .The intervention group received a supervised early physical therapy intervention based on functional recovery exercises and scar treatment with manual therapy in conjunction with educational tips on the management of the upper limb and the scar at home. The intervention consisted of four to six sessions within a month, depending on the evolution of the patient . This teThe objective of this stage was to normalize muscular tone, improve lymphatic drainage and restore the complete mobility of the upper limb, minimizing any residual limitation. It was performed as a program of exercises focusing on functional recovery and centered on lymphoedema prevention, as well as on postural hygiene and individualized exercises depending on the patient’s progress. These exercises consisted of respiratory movements, particularly diaphragmatic breathing, accompanied by upper limb movements, stretching, and progressive assisted active exercises. With these exercises, global functionality was treated, as well as muscular work, minimizing paresthesia symptoms in the upper limbs. A detailed description of these exercises is available online .At home, all exercises should be done three times a day and should not last more than 10 min in total. The first session took place at least 2 days after stitches removal. The women were taught how to clean the scar so that the poles could be gently removed . The patient was told that she should verify that the upper right underwear should be tight but not too tight because, in addition to discomfort, it could cause the accumulation of fluid in the sub axillary area. The surrounding areas of the scar were normalized by manual therapy and stretching in order to provide elasticity and prevent adhesions. The hardened areas were emphasized . At the At home, patients had to repeat scar treatment three times a day for a period of maximum 10 min. The educational intervention has been described in detail elsewhere . EducatiThe control group received usual care based on basic medical recommendations in written form before hospital discharge. Evaluation was implemented in the nurse and the surgeon office. Based on the recommendations for the design and analysis of pilot studies , we aimep < 0.05 as the statistical significance limit. Data analysis was carried out using the Statistical Package for the Social Sciences . The Shapiro-Wilk test was used to determine whether there was a normal distribution. Thus, categorical variables were assessed using the chi-square test. The continuous variables were compared using the t-test (for parametric variables) or the Wilcoxon and U Mann-Whitney test (for non-parametric variables) for non-paired samples analysis. Effect size was calculated using Cohen’s d statistic for parametric outcomes and by the statistic r  for non-parametric. We adopted a During the study period, 71 women were recruited in both hospitals. Of these, 25 women were recruited from the control group and 46 from the experimental group; 14 women were excluded for not meeting the inclusion criteria and 6 declined to participate. Finally, 20 women were allocated to the control group and no one was lost during the follow-up nor excluded from analysis. In total, 31 participants were allocated to intervention, and 11 women were lost during the follow-up period. Finally, 20 women were analyzed in the experimental group. Drop-out patients were not included in the analysis since no data were available after intervention. When they were contacted, the main reason for drop-out was the time they needed to travel to the hospital. The participants’ basic demographics and clinical-surgical characteristics are shown in p = 0.003), global SPADI (p = 0.001), state of scar (p = 0.000), myofascial adhesions (p = 0.000), and quality of life-subscale general function (p = 0.013). Contrary, no significant differences were found for grip strength (p = 0.113) or quality of life-subscale general symptoms (p = 0.072). In the experimental group, two women developed axillary web syndrome (10%), and none developed lymphedema 6 months after surgery. On the other hand, in the control group, significant differences were observed for the variables myofascial adhesions (p = 0.002) and general function (p = 0.000). However, it must be noted that the statistical significance in the case of myofascial adhesions was due to a worsening of these adhesions at T2. For the remaining variables of the control group, there were no statistically significant changes. No woman developed axillary web syndrome (0%) or lymphoedema 6 months after surgery.Intra-group differences before and after the intervention are shown in p = 0.006, r = 0.43)), grip strength , global SPADI , state of scar , myofascial adhesions  and quality of life-subscale general function ; no significant differences were found for quality of life-subscale general symptoms (p = 0.296), axillary web syndrome (p = 0.244) and lymphoedema development . There were no statistical differences between groups for quality of life  or the development of axillary web syndrome and lymphoedema.Our results are in accordance with Scaffidi et al. , who conSato et al.  comparedRegarding quality of life, our results could be explained by previous findings. For example, Peintinger et al. , in a loOn the other hand, there are, to date, no studies assessing the effect of an early physical therapy intervention on the recovery of surgical scars. Our results suggest that early scar mobilization could be an advisable strategy for scar recovery after SLNB. It has been shown that in the long term, scars after breast surgery affect women in their quality of life , and theOur study has, however, some limitations. First, it is a pilot study with a small sample size, although the role of pilot studies in health research, when used to plan a larger randomized controlled trial, has been pointed out . Second,In conclusion, our results suggest that an early physical therapy program seems to be more effective than usual care for the recovery of the upper limb and the surgical scars after SLNB. In contrast, our results do not seem to support the hypothesis that early physiotherapy intervention prevents the development of lymphoedema or axillary web syndrome. However, these results should be interpreted with caution, and future research considering a larger sample size in a single-blinded randomized controlled trial is needed. A cost-effectiveness study would also be desirable.


Malnutrition is caused either by cancer itself or by its treatment, and affects the clinical outcome, the quality of life (QOL), and the overall survival (OS) of the patient. However, malnutrition in children with cancer should not be accepted or tolerated as an inevitable procedure at any stage of the disease. A review of the international literature from 2014 to 2019 was performed. Despite the difficulty of accurately assessing the prevalence of malnutrition, poor nutritional status has adverse effects from diagnosis to subsequent survival. Nutritional status (NS) at diagnosis relates to undernutrition, while correlations with clinical outcome are still unclear. Malnutrition adversely affects health-related quality of life (HRQOL) in children with cancer and collective evidence constantly shows poor nutritional quality in childhood cancer survivors (CCSs). Nutritional assessment and early intervention in pediatric cancer patients could minimize the side effects of treatment, improve their survival, and reduce the risk of nutritional morbidity with a positive impact on QOL, in view of the potentially manageable nature of this risk factor. The importance of nutrition in children with cancer is indisputable . NutritiNS of pediatric cancer patients has been researched for a lengthy time and nutritional problems have long-been recognized ,5,6,7,8.The importance of NS in childhood cancer patients concerns its potential impact on disease progression and survival . The NS At the same time, the available data regarding the prevalence of poor nutritional status are derived at different phases of the disease and are highly variable among diagnostic groups, as well as between developed and developing countries ,13,14,15This review aims to identify NS alterations that occur during the management of childhood cancer. The purpose of the study is to investigate how neoplastic diseases affect the NS of children and adolescents, as well as how the nutritional profile affects treatment response, clinical outcome and long-term growth and health of survivors. By investigating the multifactorial components of nutrition in childhood cancer morbidity, this work aims to be the trigger to recognize the importance of nutrition in order to become an integral part of cancer treatment in children and adolescents in Greece.An electronic search of the international literature was performed, using the Cochrane Library, MEDLINE, SCOPUS, and PUBMED to identify systematic reviews, meta-analyses, randomized controlled trials and observational studies published during the period 2014–2019. The search strategy identified the following keywords and medical subject heading searches (MeSH): “childhood cancer”, “pediatric oncology”, “nutritional status”, and “malnutrition”. The reference list of all relevant articles was also examined, and possibly relevant corresponding articles were hand-searched. Particular attention has been paid to most recent articles, meta-analyses and systematic reviews conducted in countries with different socioeconomic status in order to identify possible influence. Studies involving adult patients were excluded.Many former and recent studies have investigated the issue of weight changes in children diagnosed with cancer. Pediatric cancer includes a heterogeneous group of diagnoses, while the repercussions, prognosis and the therapeutic planning differ according to tumor location, histological type, nature as well as biological behavior and age of incidence . Such diIn the cross-sectional observational study of Maia Lemos et al. , the autn = 495) of patients were severely nutritionally depleted, 19% (n = 207) were moderately depleted, and 34% (n = 358) were adequately nourished.Villanueva et al.  studied n = 56) or solid tumors (n = 18), were included in a prospective observational cohort study conducted in Istanbul [In total, 74 pediatric oncology patients newly diagnosed with hematological malignancies (Istanbul . Anthropp = 0.08). Similar trends are also observed in high-income countries (HICs) and can be attributed to disease burden.Pribnow et al.  conducten = 20), retinoblastoma (n = 3), bone and soft-tissue sarcoma (n = 15), Wilms’ tumor (n = 7) and others (n = 7). Yet, diseases were clustered in two groups—leukemia/lymphomas and solid tumors—for further analyses. According to their anthropometric measurements, patients were overall classified as 65.4% severely depleted, 13.5% moderately depleted, and 21.1% borderline/adequately nourished, that is considered at risk of developing undernutrition during treatment.In the same country, a cohort of 104 patients was screened for NS at diagnosis . The NS In the largest study so far from India, a total of 1693 new patients were enrolled, of whom 1187 had all anthropometric measurements performed . The prep = 0.8).Another study conducted in India, analyzed retrospectively weight records collected at diagnosis for patients with ALL, AML, solid tumors, and lymphomas . A totalNS at the time of cancer diagnosis is dependent on a cancer type, its localization and clinical stage of the disease . In addiIn the USA, a cohort of 2,008 children treated for high-risk ALL enrolled in Children’s Oncology Group study CCG–1961 (Children’s Cancer Group) . Weight In Italy, 126 newly diagnosed pediatric cancer patients were included in the study of Triarico et al. . For eacp = 0.002)—18.6% of them were overweight. However, children with MMT were less susceptible to overweight than the rest of the patients —only 5.4% of them were overweight. Girls with ALL were undernourished more often than other patients . There were no significant differences in the undernutrition/obesity frequency in other neoplasms groups.In Poland, the authors of  studied n = 15). There was no noteworthy difference in gender, age, or disease stage at diagnosis across children who were classified as underweight, normoweight or overweight.In Australia, Small et al.  retrospeIt is therefore understood that weight and height are important measurements for assessing a child′s NS. According to Brinksma et al. , the evap = 0.004).In the same country, Loeffen et al.  studied—According to published studies, the majority of data on NS of children with cancer at the time of diagnosis relates to undernutrition. Numerous studies include diverse measures and assessment methods, leading to a highly variable prevalence of undernutrition at diagnosis . Table 1The reported differences between studies are due to the fact that nutrition related problems—particularly the prevalence of undernutrition—depend on factors such as the timing of nutritional assessment. Nutritional assessment at diagnosis is often postponed in the context of many other procedures that may have a higher priority, some of which may even affect it . In addiNutritional assessment at the time of diagnosis, is probably the most appropriate time to prevent the deterioration of NS. Undernutrition worsens as the disease progresses, meaning that the longer the diagnosis is delayed, the higher the risk of undernutrition . TherefoNS at the time of diagnosis is an important factor which influences the response to the treatment, as well as the possibility of recovery . HoweverPrevious reports addressing the impact of weight on treatment-related toxicity (TRT) and event-free survival (EFS) in acute leukemia were limited by taking into account patient’s weight only at diagnosis ,45,46. APaciarotti et al.  performep < 0.001) and 0.05 SDS (p = 0.021) respectively. Increase continued during the following months and resulted in a doubling of the number of over-nourished patients. Fat-free mass (FFM)—which was already low at diagnosis—remained low. During the entire study period about 17% of the patients were undernourished on the basis of low FFM. The most important changes took place within three months after diagnosis. Particularly WFA and BMI decreased at first, in patients with hematological malignancies and solid tumors, while tended to increase in patients with brain tumors. In a three–month period both WFA and BMI increased in all diagnoses, compared to the time of diagnosis. Furthermore, HFA decreased in all diagnostic groups, whereas MUAC increased. TSFT, % FM, and FM were higher, especially for patients with BT. FFM was constant and values were lower in patients with brain tumors in comparison to children with hematological malignancies and solid tumors. Furthermore, stagnation of growth in terms of height contributed to increase in BMI. Consequently, it is imperative for clinicians to comprehend that in order to prevent increase in BMI during treatment, weight should remain stable until growth in height continues.There are several studies that present data on malnutrition in children with cancer, however little is known about the timing of under- and over-nutrition onset, as well as their respective causes. Brinksma et al.  intendedIniesta et al.  performeWith regard to solid tumors, NB is one of the most common solid tumors in children . Small ep = 0.0005). Even though undernutrition is a common problem in patients in resource-poor countries such as India, this study highlights that active nutritional intervention and education were able to significantly reduce the prevalence of undernutrition in patients at the end of treatment.In India, Radhakrishnan et al.  conducteNutritional support aims to reverse undernutrition seen at diagnosis, prevent undernutrition associated with treatment and promote weight and growth. There is no doubt that a poor nutritional state is a clear prognostic factor for treatment response and has an effect on the outcome of children with cancer .The presence of undernutrition correlates with a greater number of complications and relapses, as well as with decreased level of recovery ,52. UndeAccording to Barr et al. , two lann = 343,8%) compared to non-obese patients, but only in those aged 10 years and older. After these two landmark studies in pediatric leukemia, multiple analyses from international research centers have since described inconsistent associations between obesity and leukemia survival [Butturini et al. conducted the subsequent report, regarding >4000 children and adolescents with ALL. The CCG researchers focused on the effect of obesity, again as defined by BMI. The five-year EFS was poorer and the relapse rate higher in obese  and EFS . Overall a high BMI at diagnosis was associated with poor OS and EFS among pediatric acute leukemia patients [Amankwah et al.  performepatients .In contrast to the previous review , Orgel ep = 0.12) or mortality  either. A meta–analysis combining these findings with those of previous studies was also performed. Concerning ALL overweight/obese patients, the meta-analysis revealed an increased mortality and relapse risk  and  respectively. Similarly, an association between obesity and increased risk of mortality was observed for AML patients  [In the recent retrospective analysis, Saenz et al.  evaluate32–2.04) .n = 1,025) and found no statistically significant association between obesity and relapse. Two more studies in the US [Aldhafiri et al.  conducten the US ,65 also n the US  did not n the US  did not p = 0.022), osteosarcoma , and there was a trend toward poorer OS in rhabdomyosarcoma . High BMI in osteosarcoma was associated with increased nephrotoxicity and postoperative complications. Regarding other included disease categories, NS was not a significant predictor of outcomes.So far, data have been related to hematological malignancies, while studies evaluating the role of NS in pediatric solid tumors are lacking. Joffe et al.  conducteIniesta et al.  aimed ton = 13) and weight loss >5% of the initial body weight within the first three months after diagnosis, were strongly associated with FN episodes occurrence—(p = 0.010) and (p = 0.004) respectively. Regarding NS, survival was notably worse (p = 0.01) for undernourished children at diagnosis (n = 14) than for those who were adequately and over-nourished (n = 248).Moreover, the majority of research studies regarding the effect of malnutrition on infections and mortality have been conducted in homogenous populations including patients with one diagnosis. Loeffen et al.  investigp = 0.023). Another crucial finding in this study was the association between NS and severe infection, as infection is a major cause of mortality and was the second leading cause of death during the study period (22.9%). Particularly undernutrition was associated with severe infection (p = 0.033). In addition, undernourished patients had inferior median EFS (p = 0.049) and abandoned therapy more frequently (p = 0.015).Pribnow et al.  examinedWith regard to the increased risk of infections and their incidence, Triarico et al.  recentlyGiven the high prevalence of nutrition related problems during childhood cancer treatment and their impact on clinical outcomes, nutritional assessment should be mandatory from diagnosis and during treatment, in view of the possible manageable nature of this risk factor. Early adaptation of the NS screening for pediatric cancer patients could not only improve their survival, but also their QOL .Malnutrition during treatment for childhood cancer has not only substantial clinical implications, but may also adversely affect a child’s QOL . Until rTsiros et al.  conducteBrinksma et al. are the first to examine the association between NS and HRQOL across childhood cancer patients. Notably, they studied the association of undernutrition, over-nutrition, weight loss, weight gain with HRQOL in a heterogeneous group of children with cancer one year after diagnosis. In total, 104 patients (aged 2–18 years) diagnosed with hematological (43%), solid (33%), or brain malignancies (24%) participated in the study. Weight, height, and BMI were assessed and expressed as SDS. Furthermore, FFM and FM were calculated based on bioelectrical impedance analysis (BIA). The child- and parent-report versions of the PedsQL 4.0 Generic scale ,88 and tThese results have implications in clinical practice as they indicate the significance of adequate NS in children with cancer. Although the study could not demonstrate a causal relationship between nutrition related problems and HRQOL, undernourished and over-nourished patients experienced the lowest HRQOL across all cancer patients.Advances in treatment have resulted in considerable improvements in survival rates of pediatric cancer. This success translates into a growing population of long-term survivors . HoweverZhang et al.  performeAlthough many studies have focused on obesity and the consequences of being overweight, it was unclear at which time period survivors experienced excessive weight gain. Zhang et al.  performeZhang et al.  conducteCollins et al.  performeKarlage et al.  reportedAs regards to body composition, Marriott et al.  conducten = 79), three survivors (2.9%) had low BMD and 16 (15.8%) were classified as at risk for low BMD. Among survivors aged >20 years old, eight (7.9%) had osteopenia and none of them had osteoporosis. In comparison to the reference population most of the survivors had normal BMD values. However, the risk group—considered by the literature as with normal BMD—actually presented significantly lower bone mass values. Eventually, ALL survivors can regain lost bone mass during the post-treatment period. Yet, some of them will never achieve their higher BMD acquisition potential, presenting considerable bone deficit [Apart from body composition alterations, changes in bone metabolism constitute extensive adverse late effects of cancer treatment. They represent a major cause of morbidity in the CCSs population through pain, fractures, decrease of BMD and chronic deterioration of bone function ,108. Mol deficit .So far, most publications on the NS of CCSs focus on ALL. Wang et al.  systematWarner et al.  conductep = 0.004). None of them fit the strict criteria of MS, though 17 (9.6%) fit the lenient criteria which included overweight survivors as well as obese. As to CASs none participant fit the strict criteria for MS. However, 11 (2.4%) survivors had features of MS when the weight criteria were lenient. There was a higher prevalence of overweight/obesity between those diagnosed with ALL or BT  and the rest of survivors (13.6%). Overall the prevalence of obesity/overweight was lower in this cohort when compared to western literature. Yet, it is unclear whether these rates reflect the underlying undernutrition in developing countries such as India or the CCSs population of this study differ from their western counterparts. Despite the lower prevalence of overweight/obesity and MS in this cohort of survivors, CCSs remain at high risk for cardiometabolic complications.Even though overweight, obesity, and MS have been broadly reported in the Western literature, data from developing countries are lacking. Prasad et al.  conducteSome of the risk factors for overweight, obesity and MS are modifiable and in the hands of CCSs themselves. There are guidelines for promoting health in cancer survivors, including encouraging healthy nutrition, physical exercise and avoiding high-risk behaviors ,117. YetNevertheless, according to Brinkman et al.  healthy Unhealthy dietary behaviors have been associated with increased risk for health threatening conditions . In addiChildhood cancer is an illness related to severe morbidity and mortality. The malignancy itself remains the main cause of death among childhood cancer patients ,130. ConIt has been widely recognized in literature that the NS of children diagnosed with and treated for cancer is likely to be affected at some point during the disease trajectory. Actually, for many childhood cancer patients, the early progression of the disease and the commencement of antineoplastic therapies can affect the NS, leading to malnutrition with many adverse consequences ,74,131.One of the most important findings of this review—that focuses on NS alterations that occur during the management of childhood cancer—is that the reported prevalence of malnutrition—undernutrition, overweight and obesity—varies between different types of cancer, different stages of the disease, type of treatment, as well as among studies, highlighting the complexity and diversity of this population. Children diagnosed with specific cancer types develop nutrition related problems more often than others. For instance, at diagnosis prevalence of undernutrition is higher in patients with solid tumors—especially Wilms tumor or neuroblastoma—and much lower in children with ALL and HL ,11,14,21The majority of data that focus on NS of children with cancer at the time of diagnosis relates to undernutrition, the prevalence of which ranges from 10.8%  to 76% . These rClearly, the NS at the time of diagnosis is an important prognostic factor that affects treatment response as well as the possibility of recovery . HoweverCurrently, the most relevant research is retrospective or cross-sectional. The few prospectively designed studies that have been published principally concern children diagnosed with hematological malignancies while most of them do not refer to the NS at all stages of treatment . In addiStudies that investigate the association between NS at diagnosis and clinical outcome suggest that NS may affect cancer prognosis in children with cancer. Particularly, observed inferior survival was generally stable among studies . The preThe NS status of children with cancer has not only significant clinical implications, but also can adversely affect the long–term development and health of survivors, including children’s QOL which as shown by the review remains underestimated . There iThe lack of standard protocols and algorithms for assessment and treatment of nutritional problems, as well as limited in time dietary interventions are important factors that contribute to significant rates of malnutrition according to the literature. Meanwhile there is a lack of international specific dietary guidelines for children with cancer. Future scientific research should emphasize on proposing certain criteria that could assist the establishment of dietary instructions, such as cancer type, NS at diagnosis, treatment protocol, as well as children’s gender and age.Nutritional assessment should be mandatory from diagnosis and during treatment, in view of the possible manageable nature of this risk factor . TherefoNS of pediatric cancer patients plays a crucial role during the disease trajectory. The malignancy itself and the progression of the disease cause NS alterations, leading to malnutrition. In addition, the commencement of antineoplastic therapies affects energy balance with many negative consequences.Malnutrition—undernutrition, overweight, and obesity—is linked to adverse outcomes from diagnosis to long-term survivorship. NS at the time of diagnosis is an important prognostic factor that affects treatment response and the possibility of recovery. The impact of impaired NS on clinical outcome and cancer prognosis is related to treatment intolerance due to nutrient deficiency and immune incompetence. Increased risk of infection and alterations in drug metabolism lead to delays and treatment cessation that result in higher relapse rates and lower survival rates. In addition, undernutrition during treatment correlates to a greater number of complications, increasing TRM and decreasing EFS. Yet, correlations between NS alterations and clinical outcomes remain unclear. Nutrition related problems can also adversely affect the long-term health of survivors, including children’s HRQOL. The effects of NS that extend into survivorship put survivors at risk for numerous nutrition-related morbidities.Given the high prevalence of malnutrition during childhood cancer and as NS represents a modifiable risk factor, nutritional assessment should be mandatory from diagnosis, during treatment and subsequently. There are several methods for the clinical assessment of NS and each one of them has limitations and constraints. Among those performed in clinical practice MUAC, TSFT and BIA provide more information concerning body composition changes than BMI does. Nonetheless, the diversity among different indicators of NS prevents us from extracting safe results regarding the most suitable one. Ideally, the most appropriate indicator is the one that would not allow a malnourished child to remain underdiagnosed.As regards pediatric oncology, advances in treatment and follow-up care are significant. However, there is still a lack of international specific dietary guidelines for children with cancer. Hopefully, future scientific research should emphasize establishing cancer- and treatment-specific guidelines for nutrition. Early monitoring and adaptation of pediatric cancer patients’ NS as well as timely nutritional intervention could improve their treatment response, their clinical outcome, their survival, but also their QOL.


Mitochondrial DNA Part B: Resources, have retracted the following article:We, the Editor and Publisher of Mitochondrial DNA Part B: Resources, 3:1, 419–423 https://doi.org/10.1080/23802359.2018.1457988Sizhu Zheng, Yang Li, Xiaojun Yang, Jingyun Chen, Jing Hua & Yuan Gao (2018). DNA barcoding identification of Pseudococcidae (Hemiptera: Coccoidea) using the mitochondrial COI gene This article has been retracted due to concerns with the reliability of the data due to the methodology used, inaccurately described taxonomy, and discrepancies in the number and origin of the specimen sequences reported in the Methods and Table 1. We have not been able to resolve these concerns with the authors and therefore retract this article.We have been informed in our decision-making by our policy on publishing ethics and integrity and the COPE guidelines on retractions.The retracted article will remain online to maintain the scholarly record, but it will be digitally watermarked on each page as “Retracted”.