Background: Metabolic syndrome and co-morbid physical health conditions are highly prevalent in people with a mental illness. Modifiable lifestyle factors have been targeted to improve health outcomes. Healthy Body Healthy Mind (HBHM) program was developed to provide an integrated evidence-based program incorporating practical diet and exercise instruction; alongside meditation and mindfulness strategies, and comprehensive psychoeducation, to improve the physical and mental health of those with a mental illness.Methods: We report on two data points: (1) Qualitative data derived from the first HBHM program (version 1) exploring its utility and acceptance according to patient feedback; (2) Biometric and mental health data collected on the modified and enhanced 12-week HBHM program (version 2) involving a pilot of 10 participants. Mental and physical health outcomes, weight, abdominal circumference, fasting glucose, cholesterol, and triglycerides were measured at program entry and completion.Results: Qualitative data from HBHM version 1 provided valuable feedback to redevelop and enhance the program. At the end of the HBHM (version 2) 12-week program, a significant mean weight loss of 2 kg was achieved, p = 0.023. There was also a significant reduction in abdominal circumference (mean = 2.55 cm) and a decrease in BMI of almost one point (mean = 0.96 kg/m2), p = 0.046 and p = 0.019, respectively. There were no significant changes in mental health measures or on any other biometrics.Conclusion: Pilot data from the HBHM program found significant reductions in weight and abdominal obesity. The HBHM program could benefit from further modifications, and study replication is required using a controlled design in a larger sample. A highly complex relationship exists between physical and mental health. The rates of physical morbidity and mortality in people with mental illness is substantially higher than the general population , 2. EvenThe cluster of symptoms associated with these lifestyle diseases such as, excess visceral fat, along with hypertension, glucose intolerance/insulin resistance, and/or hyperlipidaemia has been labeled Metabolic Syndrome (MetS). In mental health populations, the rate of MetS is thought to be between 41 and 67% . A largeThere is potential to modify lifestyle factors that contribute to MetS  to improve the health and well-being of people with a mental illness. There are calls for an integrated response involving early diagnosis, treatment and management of physical and mental health via lifestyle modification . SeveralTo bridge the gap and provide an evidence-based integrated health approach, we developed the “Healthy Body, Healthy Mind Program (HBHM).” The aim was to assist people with a diagnosed mental illness and metabolic syndrome to improve mental and physical well-being. We presently report on: (1) Qualitative data derived from our first version of the HBHM program in 2011, exploring its utility and acceptance according to patient and clinician feedback; (2) Biometric data and mental health data collected on the modified and enhanced 12-week, second version of HBHM program involving a pilot of 10 participants.The Melbourne Clinic in Melbourne, Australia is a private psychiatric hospital with inpatient and outpatient services. The clinic had a longstanding weight management and lifestyle program, called Healthy Body Healthy Mind (HBHM), developed and facilitated by a general practitioner (GP), exercise physiologist and dietitian. HBHM program (version 1) provided weekly nutritional support from a dietitian, psychoeducation sessions on lifestyle modification and exercise practicals with an exercise physiologist. In late 2011, ethics approval was granted by The Melbourne Clinic Research Ethics Committee (HREC project number: 209) to collect qualitative data from participants to evaluate the perceived efficacy of the program's content, barriers in implementing the components, and feedback on how it could be improved. The qualitative data collected during 2011–2012 was used to redevelop and enhance the integrated lifestyle program which was pilot-tested at The Melbourne Clinic in 2016 (HREC project number: 249). This modified second program will henceforth be labeled as HBHM program (version 2).Patients attending The Melbourne Clinic outpatient services were invited to attend the program via a doctor's referral. Patients with a diagnosed mental illness  taking stable psychotropic medication (same dose for at least 4 weeks) with co-morbid diagnosed metabolic syndrome see  or obesiAt week 0, a range of medical and demographic information was collected including, age, gender, employment status, medication information, psychiatric diagnosis and medical co-morbidity. At week 0 and week 12, participants also had anthropometric measurements taken by an exercise physiologist  and completed self-report questionnaires on their mental health . In addition at week 0, participants were asked to state their goals for the program and what they hoped to achieve. They were also asked to rate their readiness to change in order to achieve their listed goals on a scale of 1–10 with 1 being “not ready” and 10 being “ready.” Participants were provided with a blood test request form to have fasting cholesterol, glucose and triglycerides measured at week 0 and week 12. The blood tests were conducted by Australian Clinical Labs.not at all to 3 = very much or most of the time). Higher scores on each scale are indicative of greater symptom severity. Scores above 11 (depression), 8 (anxiety), and 13 (stress) are considered severe, as indicated by the recommended cut-offs . All data was analyzed in SPSS 24. An alpha level of < 0.05 was used to determine significance.Qualitative data assessing the 2011 HBHM Program (version 1) was analyzed from written participant feedback forms. Comments were coded and grouped in categories by theme  and counted to obtain a frequency of mention by the 12 participants. For the quantitative data from the 2016 HBHM program (version 2), paired Written qualitative data from 12 participants  who participated in the first version of the HBHM program during 2011–2012 was thematically analyzed to aid the development of the 2016 HBHM program. n = 11; 91%). One participant commented that he/she needed “practical examples that can be implemented in day-to-day life” and less theory in order to engage with the program. However, many participants  commented that furthering their knowledge on how food effects the body and the harms of nutritionally poor food and no exercise on the body's functioning was useful as, “understanding aids motivation to change, oversimplification does not.” Poor motivation , fear of change  and difficulties engaging with the program due to low mood and anxiety  were common among participants. Additionally, many participants found cooking for one person and/or maintaining momentum on their own difficult . As one person stated, “[the] desire to try a new recipe is high at time of session but then lost when at home.” Participants requested more diagram-based notes of exercises/recipes and program content to be accessible at home due to poor recall . Injury and co-morbid physical health problems were some of the main barriers in adding exercise to their day-to-day lives . At home chair-based exercises and information on how and why to vary exercise was deemed helpful .The most beneficial/useful components of the program reported by the majority of participants were the cooking and exercise practicals  with a mean age of 51.8 years (SD = 12.9 years) . The most common primary DSM-IV psychiatric diagnosis as reported in the treating psychiatrist referral to the program was Major Depressive Disorder (MDD)  followed by Bipolar Affective Disorder , Generalized Anxiety Disorder (GAD)  and Alcohol Abuse . Psychiatric co-morbidity was common with diagnoses of Generalized Anxiety Disorder (GAD) , Binge Eating Disorder , Borderline Personality Disorder  and Major Depressive Disorder .Most of the sample was female (ars) see . Over han = 2; 25–50 mg/day), desvenlafaxine , fluvoxamine , paroxetine , venlafaxine ; escitalopram ; lamotrigine . On average participants were taking 2.4 (SD = 1.17) psychotropic medications ranging from 1 to 4 psychotropic medications. The most common psychotropic medication taken alongside a primary psychotropic medication were second generation antipsychotics  followed by mood stabilizers   see .n = 4; 40%), hypertension , arthritis , Type II Diabetes , sleep apnoea , and chronic pain/fibromyalgia . Other conditions such as, fatty liver disease , pancreatitis , ulcerative colitis , costochondritis , fructose malabsorption syndrome , endometriosis , restless leg syndrome  and hypothyroidism  wereself-reported.The most common chronic medical conditions self-reported by participants or as listed in the referral to the program were hyperlipidaemia  followed by eat healthier , reduce sugar intake  and lose weight . On average the participants rated their readiness to change as 7.75 (SD = 2.12) with ratings ranging from 3 to 10. Thus, as a whole the participants were very ready to make change.The most common goal was to increase exercise levels and fitness (t(9) = 2.75, p = 0.023. Weight change ranged from a +1.4 kg weight gain to a −6 kg weight loss. Along with weight loss, there was also a significant reduction in abdominal circumference (mean = 2.55 cm) and a drop in BMI of almost one point (mean = 0.96 kg/m2), t(9) = 2.32, p = 0.046 and t(9) = 0.96, p = 0.019. No significant changes in participant's blood levels or anthropometrics were found. Additionally, no significant changes in participant's mental health was found on the DASS when comparing week 0 to week 12 , and hence had less scope for improvement. Furthermore, when identifying goals of the program, not one participant mentioned they would like to improve their mental health. Rather the goals reported by participants were orientated toward improving their eating habits and losing weight. The incorporation of behavioral and psychological components  is deemed to benefit the delivery and engagement of the program contents and helped to adhere to recommendations in order to achieve the weight loss results.A major limitation to the current study was the small sample size and that it was uncontrolled. A larger sample with an appropriate control is required to assess the program effectiveness and allow for further feedback from participants to fine-tune the program. We also recognize that more work is needed to refine the delivery and format structure in respect to determining the best application of the program given costs and time constraints. In particular, the exercise component should aim to provide at least 90 min of moderate-to-vigorous exercise per week, as this intensity has been shown to improve psychiatric symptoms in patients with a serious mental illness . FurtherWhile the 12-week program was comprehensive, it also has its drawback in terms of time requirements, and a 6-h once per week delivery is quite intensive for people with a mental illness. A follow-up should also be employed to determine whether weight loss results are maintained, continued, or regained following the cessation of the program.There is the potential to restructure the program to have a blend of face-to-face delivery with online components, and even the use of a mobile phone app. This would provide flexibility, less demands on time, and less financial burden for the participants. Weight loss in this population is extremely challenging as many patients have co-morbid medical conditions, and limited social and economic resources. Thus, facilitating weight loss using strategies that can be implemented into everyday life is paramount to success. In addition, implementing and assessing strategies which prevent the all too frequent “weight regain” phenomena is crucial .As 60% of the sample were taking second generation antipsychotics, the results are encouraging for metabolically vulnerable patients. However, it is important to note, that the results cannot be generalized to participants with a serious mental illness as the current pilot did not include participants with schizophrenia who are at the most risk of developing MetS. It is unclear how this particular patient population would engage with this intervention. In conclusion, the pilot data of the HBHM program found significant benefits in reducing weight and abdominal obesity, with the potential to achieve substantial health benefits for patients with a mental illness and co-morbid metabolic syndrome. Study replication is required using a controlled design in a larger sample over a longer time period.This study was carried out in accordance with the recommendations of The National Statement on Ethical Conduct in Human Research 2007 and The Melbourne Clinic Ethics Committee. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The projects were approved by the Melbourne Clinic Ethics Committee (Project 209 and 249).All authors contributed to the drafting and editing of the manuscript. JAM and JS is responsible for the data analysis and manuscript preparation. JM, GO, CW, RO, and AB were involved in designing the program, running the program and collecting data. CN and JS contributed to the design of the program and provided oversight of the program.JS has no direct conflict of interest, however has received either presentation honoraria, travel support, clinical trial grants, book royalties, or independent consultancy payments from: Integria Healthcare & MediHerb, Pfizer, Scius Health, Key Pharmaceuticals, Taki Mai, FIT-BioCeuticals, Blackmores, Soho-Flordis, Healthworld, HealthEd, HealthMasters, SPRIM, Kantar Consulting, Research Reviews, Elsevier, Chaminade University, International Society for Affective Disorders, Complementary Medicines Australia, Grunbiotics SPRIM, Terry White Chemists, ANS, Society for Medicinal Plant and Natural Product Research, Sanofi-Aventis, Omega-3 Centre, the National Health and Medical Research Council, CR Roper Fellowship. The funders played no role in the study design, the collection, analysis or interpretation of data, the writing of this paper or the decision to submit it for publication. The remaining 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.


Sonic hedgehog (Shh) is a prototypical angiogenic agent with a crucial role in the regulation of angiogenesis. Experimental studies have shown that Shh is upregulated in response to ischemia. Also, Shh may be found on the surface of circulating microparticles (MPs) and MPs bearing Shh (Shh + MPs) have shown the ability to contribute to reparative neovascularization after ischemic injury in mice. The goal of this study was to test the hypothesis that, in humans with peripheral artery disease (PAD), there is increased number of circulating Shh + MPs. This was done by assessing the number of Shh + MPs in plasma of patients with PAD and control subjects without PAD. We found significantly higher number of Shh + MPs in plasma of subjects with PAD, compared to controls, while the global number of MPs—produced either by endothelial cells, platelets, leukocytes, and erythrocytes—was not different between PAD patients and controls. We also found a significant association between the number of Shh + MPs and the number of collateral vessels in the ischemic limbs of PAD patients. Interestingly, the concentration of Shh protein unbound to MPs—which was measured in MP-depleted plasma—was not different between subjects with PAD and the controls, indicating that, in the setting of PAD, the call for Shh recapitulation does not lead to secretion of protein into the blood but to binding of the protein to the membrane of MPs. These findings provide novel information on Shh signaling during ischemia in humans, with potentially important biological and clinical implications. Sonic hedgehog (Shh) is a morphogen belonging to the hedgehog (Hh) family of proteins and is crucial during embryonic development . In postMicroparticles (MPs) are small plasma membrane fragments shed by cells after blebbing due to cell activation and/or apoptosis. They play an important role in cell to cell communication because of their ability to act at distant site as well as locally, and to propagate the functional antigens of their parent cell . AngiogeThere is experimental evidence that MPs harboring Shh (Shh + MPs) may modulate the nitric oxide (NO) pathway, regulate the production of pro-angiogenic factors and the up-regulation of proteins involved in cell adhesion, and orchestrate several processes related to cell proliferation, differentiation and angiogenesis . HoweverThe experiments presented in this paper have tested the hypothesis that, in humans with peripheral artery disease (PAD)—a prototypical ischemic cardiovascular pathology —there isp = n.s.) and presence of diabetes , dyslipidemia , and hypertension . PAD patients were more frequently men  and smokers . History of myocardial infarction (MI) and stroke was reported more frequently by PAD patients than controls . Regarding pharmacological therapy, 84.0% of PAD patients were on single anti-platelet treatment (SAPT)  and 10.0% were on dual antiplatelet therapy (DAPT). On the other hand, 48.0% of controls were on SAPT and none was in DAPT. The use of statins, beta-blockers, and ACE inhibitors/ARB was not statistically different between patients and controls . Regarding disease severity, 15 PAD patients were in Leriche–Fontaine stage IIa (30.0%), 15 were in stage IIb (30.0%), 10 in stage III (20.0%), and 10 in stage IV (20.0%).The main demographic and clinical characteristics of the studied population are summarized in p = n.s.) (p = n.s.) (p = n.s.) (p = n.s.) , no significant difference was found between controls and PAD patients  a. Simila = n.s.) b, leucoc = n.s.) c, and er = n.s.) d.p < 0.001) (p < 0.001) (p < 0.001) (p < 0.001) (p < 0.001)  a. This i< 0.001) b, as wel< 0.001) c, leukoc< 0.001) d, and er< 0.001) e. A summary of the results of these studies is presented in Since in subjects with PAD the number of circulating Shh + MPs may be affected by the presence of other diseases—in particular coronary artery disease (CAD) and cerebrovascular disease—we separately analyzed PAD patients with and without history of MI, with and without history of ischemic stroke, and with and without history of either MI and/or stroke. We did not find significant differences between groups .We also looked at the number of Shh + MPs in PAD subjects at various stages of the disease, according to the Leriche–Fontaine classification . No significant differences were found between groups .In subjects with PAD, inflammation might be an additional driver for the production of Shh + MPs. Indeed, it is established that circulating levels of MPs are increased in pathologies associated with systemic or local inflammation  and, sinSince Shh is a potent prototypical angiogenic agent  we hypotp = n.s.)  plasma to assess the levels of Shh protein in subjects with PAD and controls. We found detectable levels of Shh protein in the MP-depleted plasma of all investigated individuals. However, there was no difference between subjects with PAD and controls  .This study was aimed to evaluate whether upregulation of Shh occurs in humans in the setting of ischemia. We decided to study patients with PAD, because this is a prototypical ischemic pathology and is characterized by the fact that important muscular masses are exposed to severe degrees of ischemia over a prolonged period of time. We found that the number of MPs bearing Shh is significantly increased in subjects with PAD compared to controls. Importantly, we did not find an increment in the global number of circulating MPs of endothelial, platelet, leukocyte, or erythrocyte origin, but only in those MPs that carry Shh, thus suggesting a specific role for this type of MPs in this pathological condition. Importantly, the number of Shh + MPs in our PAD cohort is not affected by the possible association with CAD and/or stroke, which indicates that these MPs are increased in PAD subjects independently on other ischemic cardiovascular diseases.We have not investigated the mechanisms responsible for the increased production of Shh + MPs in subjects with PAD. However, it is likely that hypoxia and ischemia are the main drivers of activation of the Shh pathway in these patients. Indeed, we have previously demonstrated, in a number of experimental animal models, that ischemia has the ability to reactivate the Hedgehog (Hh) signaling pathway. For instance, upon induction of hindlimb ischemia in mice, there is strong upregulation of Shh within the ischemic area . RecapitIn ischemic conditions, the reactivation of the Shh pathway is functionally important, since Shh is a potent angiogenic agent able to upregulate various families of angiogenic growth factors and is considered an important pathway for tissue repair and regeneration ,18,19,20We also determined the concentration of Shh protein in MP-depleted plasma of subjects with PAD and controls, finding no differences between the two groups. This is an interesting finding which suggests that, in the setting of ischemia, the call for Shh recapitulation does not lead to the secretion of protein into the blood, where it would be inactivated by inhibitory proteins, but to the binding of the protein to the membrane of MPs, in order to warrant its activity and the delivery of the message in a protected environment. This would be consistent with previous reports in the literature, that have clearly demonstrated that Shh carried by MPs is functionally active and has its main target in ECs. In particular, using in vitro assays, it has been shown that Shh + MPs are able to stimulate ECs to release NO, produce proangiogenic factors, and form capillary-like structures . Shh + MThis study has some potential limitations. First, it has been conducted on a relatively number of patients and thus deserves confirmation in larger samples. Also, it will be important to confirm these findings using an additional technique, i.e., Western blotting. We have not assessed the functional properties of Shh + MPs. In particular, it would be interesting to use in vitro and in vivo models of angiogenesis to determine whether MPs isolated from the plasma of subjects with PAD have different angiogenic capacities compared to MPs isolated from the plasma of subjects without PAD. Finally, it should be mentioned that previous data by other groups have found differences between PAD patients and controls in terms of number of circulating MPs of endothelial  or plateIn conclusion, this study shows that Shh bound to MPs is increased in subjects with PAD, while plasmatic Shh is not. Our findings provide novel information on Shh signaling in the course of ischemia in humans, with potentially important fundamental and clinical implications.n = 50) and controls (n = 50) were enrolled among patients consecutively admitted to the Vascular Medicine Outpatient Clinic of the A. Gemelli University Hospital of Rome, Italy and the Angiology Unit of the San Giacomo Hospital of Castelfranco Veneto, Italy, between 1 August 2015 and 30 September 2016. Inclusion criteria for patients were age >18 years, Caucasian race, and presence of clinically relevant PAD. Diagnosis of PAD was made in accordance with the criteria established by the Ad Hoc Committee on Reporting Standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery [PAD subjects ( Surgery . Severitn = 18), by the means of a validating scoring system, based on previous studies [Multidetector computed tomography (CT) angiography was used to assess size and number of collateral vessels in a subset of PAD patients  and then at 1500× g for 20 min to generate platelet-free plasma (PFP). Analysis were conducted using a FC500 Flow Cytometer  equipped with 2 laser lines (488 and 633 nm). The cytometer was preliminary calibrated by using the fluorescent Megamix beads  covering the MP (0.5 and 0.9 µm) and platelet size ranges (0.9 and 3 µm). The upper and the outer limits of MP gate were established just above the size of the 0.9 µm beads in a forward (FS) and side scatter (SS), the lower limit was the noise threshold of the instrument, and an absolute minimum threshold of 1 was set for the SS in order to reduce the background noise. MPs were identified as particles between 0.1 and 1 µm in size according to their light scattering. A total of 150,000 events were acquired for each sample. Selected samples were serially diluted in order to avoid coincidence and reduce artifacts. EMPs, PMPs, LMPs, and ErMPs were defined as vesicles positive for either CD144, CD42b, CD45, or CD235, respectively. Shh + MPs were identified as vesicles positive for Shh. Shh + EMPs were defined as vesicles double positive for CD144 and Shh . Blood was collected from PAD patients and controls into sodium citrate vacutainer tubes. Plasma was obtained by centrifugation of blood at 1570× nd coll. . In briep < 0.05. Calculations were performed with Prism 7  and IBM SPSS Statistics for windows, Version 20.0, released 2011 .Results are presented as mean ± SD. Since data were not always normally distributed, the non-parametric Mann-Whitney U test was used for comparison of two data sets. Correlation between the number of circulating MPs and clinical variables was evaluated by Pearson’s correlation test. Differences were considered statistically significant for


Energy drinks are very popular among teenagers but may cause health problems. Energy drink consumption is partly associated with energy drink perception, but little is known about this in the Pacific Island Countries and Territories. The aim of this cross-sectional study was to identify the relationships between energy drink consumption, energy drink perception, weight status and sociodemographic characteristics in a school-going sample of Pacific adolescents.A cross-sectional study carried out in the schools during school hours between July 2015 and April 2016.t tests, multivariate logistic regressions and multiple linear regressions were used.Sociodemographic characteristics, weight status, energy drink perception, and quantity of energy drinks consumed were obtained. Chi-square tests of independence, independent A representative sample of 678 New Caledonian adolescents (11–16 years).We found that one third of New Caledonian adolescents consume energy drinks. Boys are more likely to drink them than girls and Polynesians drink significantly more than European and Melanesian adolescents. Higher energy drink consumption in the New Caledonian adolescents is associated with good or neutral perceptions of the energy drink impact on health. Moreover, sex  significantly influences the total energy drink consumption per week. Energy drink consumers have a tendency toward better perceptions of energy drinks than non-consumers.Nutritional education targeting energy drink consumers should take these results into account by providing (community-based) educational programs, especially for adolescents from low socioeconomic backgrounds, boys, or those living in rural areas. Energy drinks (EDs) are non-alcoholic beverages containing caffeine, sugar and other stimulant ingredients. According to self-report surveys, 30% to 50% of adolescents and young adults consume EDs . In a EuThe caffeine in EDs can decrease the duration and quality of sleep and may even cause caffeine intoxication . Energy Little is known about EDC and ED perceptions in the Pacific Island Countries and Territories (PICT). Most of the studies in the Pacific area have been conducted in Australia, where 42 to 48% of the youth consume them , 9. In NNew Caledonia, a French archipelago in the South Pacific, is characterized by high diversity in ethnicity and SES. The prevalence of obesity in adults and adolescents is high ,11, as iThis cross-sectional study was conducted with school-going adolescents (11–16 years old) between July 2015 and April 2016. The study was carried out in the schools during school hours.New Caledonia is divided into three provinces with marked differences in ethnic composition, SES, and urbanization. Five secondary public schools were randomly selected: one in Loyalty Islands Province , two in North Province  and two in the capital of South Province, the only urban zone of New Caledonia. Two classes were then selected in each of four grades (levels) by a staff member, for a total of 160 students (8 groups with a mean of 20 students per division). Adolescents absent or with missing data  (14.0%) and those from ethnic groups other than Melanesian, European or Polynesian (1.5%) were excluded. The final number of participants was 678, with ages ranging from 11 to 16 years old.Parents gave informed written consent prior to their children’s participation in the study. The study protocol was approved by the ethics committee of the University of New Caledonia. The protocol also met all legal requirements and the criteria of the Declaration of Helsinki.2 were classified as urban. Rural areas were defined as areas with fewer than 50,000 inhabitants and fewer than 100 inhabitants per km2, and not adjacent to an urban area.The demographic information used in the analyses included age, sex, ethnicity, SES and area of residence. Ethnicity was self-reported by the adolescents and categorized as recommended in the INSERM report on New Caledonia using an anonymous survey tool . BirthdaEDC was assessed with several questions. The first one was: “Do you drink energy beverages?” For non-consumers, the reasons for non-consumption were explored by the question: "You never drink energy drinks because . . . ." The multiple response options were don't like, parental refusal, medical refusal or other. For consumers, the average EDC was assessed with the question: “How many cans of Red Bull/Lift (250 mL), Monster (473 mL), or others of this type (250 mL) do you consume per week on average?” Examples of popular brand names in New Caledonia were provided to allow the participants to distinguish EDs from soft/sports drinks. The total ED intake per week, converted to milliliters, was calculated by adding up the volumes of the total number of cans that were consumed, and the adolescents who answered “No” to the first question were considered as consuming 0 L per week. To allow comparison with other studies, EDC was also converted to the usual categories of: 1 can/week, 2–4 cans/week, 5–6 cans per week, 1 can/day, 1–2 cans/day, and more than 2 cans/day. In this case, can volume (250 or 473 mL) was not taken into account. All the participants were asked to give an opinion on EDs by answering the question: “Do you think that energy drinks are…?” The response options were good for health, rather good for health, with no effect on health, rather bad for health, and bad for health. Three categories of responses were created for this variable: good (good/rather good), neutral (no effect) and bad (bad/rather bad).Anthropometric parameters (height and weight) were collected by trained staff in the school nurse’s office, as previously described . Body maP < .05. As previous studies found that EDC was higher in boys than girls [2 tests .All analyses were conducted using SPSS version 22.0, with the significance level set at an girls , we analWe used multivariate logistic regressions to identify the factors associated independently with EDC. The variables in the models were age (in years as a continuous variable), sex (boys vs. girls), ethnicity , SES , area of residence  and weight status (overweight or not). Similar analyses were conducted to identify the factors associated with poor or good opinions about EDs using the same variables.Multiple linear regression analysis identified the factors associated with the total amount of EDC. The variables in the models were age, sex, ethnicity, SES and weight status (overweight or not). Categorical variables were categorized into groups by creating dummy variables.The sample included 314 boys and 364 girls from 11 to 16 years old (13.6±1.5 years). Out of the whole sample, 42.3% declared that they drank EDs. We examined the reason why some adolescents choose not to drink EDs. Most of them (60.6%) declared that they disliked EDs. The second reason was mainly parental refusal of consumption (35.5%), while the other reasons were very infrequent . In a multivariate analysis, we then examined the factors associated with each of these reasons. No specific profiles emerged concerning adolescents who declared that they disliked EDs. However, we found that adolescents with high SES were more likely to cite parental refusal of EDC than those with low SES . Parental refusal of consuming ED was also negatively associated with age  but not with weight status, ethnicity or area of residence.P < .001; neutral: OR = 4.247 P < .001). Boys were more likely to consume EDs than girls . Low SES girls were more likely than high SES girls to declare that they consumed EDs . Area of residence , weight status and ethnicity were not independently associated with EDC.The factors independently associated with EDC were determined by multivariate analysis. Results are shown in In the ED consumer subgroup (n = 237), participants declared consuming on average 2130 mL/week (304 mL/day). P = .005) and living in a rural area  were positively associated with higher EDC. Moreover, the total amount of EDC was positively associated with positive opinions about ED effects on health . Other factors  were not associated with the total quantity of EDC.The multiple regression model  of the EP < .001). Melanesian adolescents were more likely to think that ED are good for health than Europeans . Similarly, adolescents with high SES, overweight or living in urban areas were more likely to think that ED have a bad effect on health  is very close to that found by other researchers in the Pacific ,20. High% is very choices –28, and  choices ,29. In a choices . MoreoveWe found a high correlation between the opinions of adolescents concerning the ED effect on health and ED consumption. Our results are in line with those obtained by others ,31. MoreInterestingly, Melanesian adolescents and those living in rural areas were more likely to have a good opinion about the ED effect on health, which would explain why EDs were more frequently consumed by these two subgroups. Other studies have also found that EDC may be higher in rural areas ,25 and iPrevious studies have found that digital marketing was more strongly associated with young adults’ EDC than other types of marketing –37, but Concerning the total amount of EDC, we found a mean value of 2130 mL/week (303 mL/day) in the consumer subgroup. This value is notably high compared with the 70 mL/day (2.1L/month) estimated in a large European survey , whereasThe results of this study should be viewed in the light of the potential limitations. First, we determined correlations and not causal relationships because the study design was cross-sectional and not longitudinal. Second, the EDC was evaluated by self-reporting so the consumption may have been over- or under-reported by the participants. Third, the SES indicator was based only on the profession of the head of the household and did not take into account his/her education or income. Last, we did not take into account the availability of EDs although this point might influence consumption.High EDC in New Caledonian adolescents is associated with good or neutral perceptions of the ED impact on health. This perception is correlated with SES (low), ethnicity (Melanesian), and area of residence . Moreover, the association between sex  and the total EDC per week is significant. These findings need to be taken into consideration for health education programs in New Caledonia and, more broadly, in the Pacific region. Recently, Francis et al. suggested several intervention strategies to reduce EDC, including policy changes targeting ED sales, packaging, price, and visibility . Future S1 Table(XLSX)Click here for additional data file.


Processed meat (PM) intake is associated with health risks, but data are lacking in Switzerland. Using national representative data from a recent menuCH Survey, we first aimed to quantify intake of PM and its subtypes, and second to investigate associations with sociodemographic and lifestyle factors by multivariable regression analysis. PM was consumed by 72% of the population, and mean daily intake was 42.7 g/day (standard error of the mean (SEM) 1.2 g/day), ranging considerably across PM subtypes: highest intake of sausages 18.1 g/day (SEM 0.7 g/day) and lowest of bacon 2.0 g/day (SEM 0.2 g/day). PM intake by women was 4.7 g/1000 kcal lower than men : −6.7; −2.7) and 2.9 g/1000 kcal lower in the French- language region compared with the German region . Among sociodemographic and lifestyle factors examined, BMI  and current smoking  were independently associated with PM intake. The results are a first description of PM intake, separate from other meat types, and which identified associations with two unhealthy lifestyle factors in Switzerland. Such data will contribute to better nutritional recommendations and guidance for public health interventions. In Switzerland, processed meat (PM) has a unique role in diet, closely linked to culture and tradition, and is often the main course at festive gatherings. However, concerns for this food group are growing due to epidemiological evidence for its association with chronic diseases such as coronary heart disease, several types of cancers and diabetes type 2 ,2,3, andPM products are whole pieces or mixtures of comminuted meats consisting of mainly pork and beef, less often poultry, and with other animal parts . ProcessProcessed meat is associated with higher health risks than fresh, unprocessed meats (UPM) ,2,9. TypIt is also crucial to gain insights about factors which influence PM consumption, and thus have possible impacts on health and on sustainable nutrition. Many national surveys and studies have shown that men have higher consumption of all types of meat than women ,14,15,16Nutritional data on PM intake of the Swiss population are few and based on methods which did not separately quantify it from UPM . The NatIn view of the evidence-based health risks associated with PM intake, the current study examined the menuCH data more specifically for this meat type. We first aimed to describe the distribution of total meat intake as PM and UPM in Switzerland by sex, language region, and age-category. Then we focused more specifically on PM consumption by quantifying intakes of PM subtypes. Our second aim was to investigate the association between energy-standardized total PM intake and sociodemographic and lifestyle factors.The National Nutrition Survey menuCH was a cross-sectional population-based survey conducted from January 2014 to February 2015 in ten study centers of Switzerland. Recruitment of adults 18 to 75 years old was done randomly  using 35https://doi.org/10.1186/ISRCTN16778734).Ethical approval for the survey was obtained from the main ethics committee in Lausanne  and by the corresponding regional ethics committees. Guidelines of the Declaration of Helsinki were respected, including written informed consent from the study participants. Registration information is: ISRCTN registration number 16778734  [® trilingual databases dated 12 December 2016, IARC, Lyon, France and Federal Food Safety and Veterinary Office, Bern, Switzerland). During the interviews, a food-picture book was used to facilitate food reporting [A first 24 h dietary recall (24HDR) was conducted face-to-face, followed by a second telephone interview two to six weeks later . Intervi France) ,23 adaptA pilot survey was conducted, and results were used to assess and improve the standard operating procedures of the survey team . Data clParticipants completed a questionnaire at the first 24HDR in French, German or Italian which queried on dietary habits and sociodemographic and lifestyle factors . Many ofn = 14) and lactating (n = 13) women  or when measurements were impossible (n = 7), as reported earlier [Four categories of age were used in the present analysis: 18–29; 30–44; 45–59; and 60–75 years old. Language region was determined by the canton of residence of participants . The physical activity of participants was assessed using the short-form International Physical Activity Questionnaire (IPAQ) and categorized as low, moderate, and high physical activity ,26,27. M earlier . ® [Using the consumption data, the analysis was based on the subcategory of meat and meat products defined in Globodiet® ,22 with ® . The catTechnical specifications for PM products  were useUsing reported data from the two 24HDR, mean and standard error of the mean  were used to describe the consumption of the main categories of meat  for the population and by sex, language region, and age category. m = 25).Multivariable linear regression analysis was used to study associations between average energy-standardized PM intake  and selected sociodemographic and lifestyle factors. We selected factors which are typically used in national surveys: sex, age and nationality; and specific to Switzerland, language region was used to investigate possible differences in PM intake between the regions. Economic indicators and other factors relevant for PM consumption were also included  and lifestyle factors with evidence-based health associations . Self-reported health was included, since it was shown to be a strong predictor of health . MultivaAll descriptive and statistical analyses were conducted with R (version 3.6.0). The mice package was used for the multivariate imputation . AdditioWeighting factors were applied to all means and SEM and in the regression model to correct for sampling design and nonresponse. All results were weighted for age, sex, marital status, major area of Switzerland, nationality, and household size. Consumption data were also corrected for season and days of the week. Further details of the menuCH Survey weighting strategy are available in a public data repository .The STROBE-nut guidelines were used to report the findings of the present study .PM consumption was reported by 72.0% of participants , who showed similar representation of the investigated sociodemographic and lifestyle variables compared with the total population. Intakes of UPM were highest in the French-language region, whereas PM intakes were highest in the German-language region . The youp ≤ 0.05), shown in PM intake (and subcategories) were not normally distributed in the total population , followed by the category other PM, ham, and bacon  . Ham conIntakes of total PM, and subcategories of ham, bacon, and sausages were relatively stable across the age groups, with slightly higher total PM intake  for the youngest age  and limitation of PM to once per week  but withOther nutritional societies in Europe have set clearer limits for PM intake, such as 25 g/day or three weekly portions in France ,43; threQuantifying intake of PM subtypes is important due to their differences in composition and processing, which could be linked to differences in health outcomes ,11,50. TOur results show considerable differences in intake across the four PM categories, ranging widest between sausages and bacon . The lowIntakes of sausage were higher in the German-language region, while ham was preferred in the Italian-language region of Switzerland. These findings might reflect the different preferences and cultural influences of neighboring countries, such as high sausage intakes in Germany ,17,54, wIn view of ongoing discussions concerning the safety of dietary nitrate/nitrite , P6M intThe variable sex was shown to be a significant determinant of PM intake in the Swiss population. Indeed, the trend of higher PM consumption by men seems to be very widespread worldwide, as reported in Europe ,8,14,52,The positive association between PM intake and higher BMI is consistent with reports outside of Switzerland where waist circumference was also shown to determine PM intake ,64. BMI The role of PM in cancer pathogenesis, in particular CRC, is still unclear but may involve the production of carcinogenic substances such as N–nitroso compounds (NOCs) formed from nitrite, or at high temperatures from heterocyclic aromatic amines (HAAs). Dietary factors such as protein and heme and high levels of fat may also intervene, leading to increased cancer risk, with evidence being strongest for the digestive tract ,68,69,70According to the most recent Continuous Update Project report (CUP) by the World Cancer Research Fund, for every 50 g/day of PM intake, CRC risk increases by 16% . Based oThis study provides a first in-depth description of PM intake and its subcategories, based on 24HDR and representative population data in Switzerland. The net response rate of 38% in the menuCH study is within the range of other national dietary surveys in Europe, ranging from 33% to 70% . In the Underestimation of PM intakes cannot be excluded due to dietary assessment errors, errors in PM categorization, and healthy participation bias . AdditioThe present results provide a first quantitative basis for consumption of PM and its different subtypes. Considering the evidence-based health risks linked to PM consumption, a regular monitoring of PM intake should be done, and ideally separate from other meat types. This might be achieved by revising the questions on meat in the Swiss Health Survey . Such da


Toxoplasma had a very strong negative effect on quality of life, especially on mental health. However, the infection was not responsible for the observed negative effects of keeping pets, as these effects were much stronger in 1,527 Toxoplasma-free subjects than in the whole population. Any cross-sectional study cannot discriminate between a cause and an effect. However, because of the large and still growing popularity of keeping pets, the existence and nature of the reverse pet phenomenon deserve the outmost attention.Many studies show that keeping cats and dogs has a positive impact on humans’ physical and mental health and quality of life. The existence of this “pet phenomenon” is now widely discussed because other studies performed recently have demonstrated a negative impact of owning pets or no impact at all. The main problem of many studies was the autoselection–participants were informed about the aims of the study during recruitment and later likely described their health and wellbeing according to their personal beliefs and wishes, not according to their real status. To avoid this source of bias, we did not mention pets during participant recruitment and hid the pet-related questions among many hundreds of questions in an 80-minute Internet questionnaire. Results of our explorative study performed on a sample of 10,858 subjects showed that liking dogs has a weak positive association with quality of life. However, keeping pets, especially cats, and even more being injured by pets, were strongly negatively associated with many facets of quality of life. Our data also confirmed that infection by the cat parasite  According to 2016 estimates, about 61 million dogs and 66 million cats are currently kept in the EU and this number is likely still growing  as well a priori expected results of studies [a priori beliefs, regardless of the real effects of pets on their lives. This is in agreement with a common observation that, when directly asked, people often report a positive effect of their pets on wellbeing while the results of detailed questionnaires suggest an absence of such effects [However, in the past twenty years, more and more studies were performed that failed to reproduce the results of these older studies. They either observed no effects of keeping pets on human wellbeing and health , or actu studies . Also, e studies , 32, 33. studies ; however studies . The eco studies , 35. The effects .Toxoplasma  is resp on paws –39. To tth May 2016 and 29th June 2018. All methods were performed in accordance with the relevant guidelines and regulations. The project, including the method of obtaining electronic informed consent to participate in this anonymous study from all participants, was approved by the IRB of the Faculty of Science, Charles University (Komise pro práci s lidmi a lidským materiálem Přírodovědecké Fakulty Univerzity Karlovy)—No. 2015/07.The internet questionnaire was distributed as a Qualtrics survey. Subjects were invited to participate in the study using a Facebook-based snowball method . Potentisex, age, education , body height, body weight, and the size of the communities where they currently live . The anamnestic part of the questionnaire contained several questions about the intensity and nature of the person´s contact with dogs and cats and about sustained animal-related injuries. Subjects were asked to rate how much they like dogs (cats) using the graphic scale 0–100 [preference of dogs to cats was calculated as the difference between liking dogs and liking cats, and then rate the intensity of their past and current contacts with dogs and cats using a 8-points pseudo-scale: (0: our family never kept a dog (cat), 1- we kept a dog (cat) in the past but only for a short time, 2- we kept a dog (cat) only in the past but for several years, 4- we have one dog (cat), 5- we have two dogs (cats), 6- we have three dogs (cats), 7- we have more than three dogs (cats)). Based on their responses, we calculated three variables describing the intensity of contacts with dogs and three with cats: Ever keeping dog (cat) (binary: codes 0 vs 1–7), Now keeping a dog (cat) , Number of dogs (cats) in house . Next, the responders were asked to rate the intensity of sustained animal-related injuries  using the following scales: 0- never, 1- only while playing, 2- only as a warning, 3- yes, minor injury (only skin cut), 4- yes, moderate injury (bleeding), 5- yes, I had to seek medical treatment, 6- I was seriously injured by several dogs (cats). For the purposes of future analyses, we merged the infrequently used category 6 with category 5. To see, whether toxoplasmosis could play a role on studied associations, we also asked the responders whether they had been laboratory tested for this infection, what was the result of this test , and what was the purpose of this testing . As a benchmark for the relative importance of associations of the animals-related variables with the health, wellbeing, and biological fitness, we looked for the associations of health, wellbeing, and fitness with four unrelated but well-known risk factors: body mass index (BMI) calculated from body height and body weight, frequency of smoking, i.e., how many cigarettes they smoke a day , frequency of consuming alcohol “not to be allowed to drive a car for a while for this reason” , and frequency of consuming illegal drugs “not to be allowed to drive a car for a while for this reason” .The electronic survey consisted of several parts that concerned various unrelated projects on evolutionary psychology and psychiatry. In the present study, we inspected and analyzed only responses to the questions concerning health, wellbeing, biological fitness and keeping dogs and cats. The responders were asked about their le 0–100 . The prephysical health problems: six points scale, anchored with 0- definitively better status, 5- definitively worse status), How they rate their mental health status in comparison with other people of the same age , how they rate their family situation, e.g. the quality of an emotional support they can receive, , how they rate the economic situation of their family . To obtain more objective and concrete information on the health status of responders, we also asked them the following questions: how many kinds of drugs prescribed by a medical doctor they were taking currently, how many kinds of drugs non-prescribed by a doctor they were taking currently , how many times they visited their primary care doctor in past 365 days (“not for prevention”), how many times they used antibiotics in the past 365 days, and how many different medical specialists they visited (not for prevention) in the past 5 years. The physical health problems score was calculated as a mean of Z-scores of the last five variables. The responders were also requested to rate how much they suffer with anxieties, phobias, depression, mania, obsessions, auditory hallucinations, visual hallucinations, and headaches using a 0–100 scale. We also counted number of diagnosed and number of undiagnosed mental health disorders of responders and of their partners, all checked on a list of 25 mental health disorders and epilepsy. The mental health problems score was calculated as a mean of Z-scores of the last 10 variables (not the numbers of diagnosed and undiagnosed disorders of the responder’s partner). Using a 0–100 scale they also answered the questions—How intensely they are sexually attracted to men, How intensely they are sexually attracted to women, . They were also asked with how many men (women) they had sex . To respond to these two and the next two questions, the participants used a 0–9 ordinal scale . The higher of these two responses was considered to reflect the number of preferred sex sexual partners. Similarly, the participants were asked with how many men (women) they exchanged in French kissing —the higher of these two responses was considered to reflect the number of preferred sex French kissing-partners. In the other part of the questionnaire, the responders were asked to estimate how many minutes daily they spend engaged in various activities. The list of 22 activities also contained “any form of sex, including consuming pornography”. Score of sexual activity was computed as mean of Z-scores of number of preferred sex sexual partners, preferred sex French kissing partners, and minutes spend engaged in any form of sex per day. As a proxy for direct and inclusive biological fitness we used number of biological children and number of siblings, respectively. For the assessment of quality of life of responders we used the Czech version of the standard 24-item WHOQOL-BREF  [In another part of the questionnaire we collected information concerning the following outcome variables from the responders: How they rate their physical health status in comparison with other people of the same age (subjective QOL-100) . This inQOL-100) . It moniBefore any analyses, records of all subjects who did not answer the pet-related questions and of about 2% of subjects who provided a suspicious combination of answers to other questions  were filtered out.https://figshare.com/s/58a34af3d3590dc2d398.The final set contained data from 10,858 subjects; however, only part of them responded to the questions concerning their health (71%), quality of life (64%), and keeping cats and dogs (79%). The distribution of all relevant  variables was visually checked and then all secondary indices, see above, were computed. Statistical analysis was performed with the statistical package Statistica v. 10.0. . For computing the partial Kendall correlation we used R 3.3.1  and the Through the paper, the statistical relations between  dependent and  independent variables are called “effects,” despite the fact that the real causal relationship between these variables may be different or even non-existent (as pointed out in the Discussion).2 = 42.1, d.f. = 1, p<0.0001) and only 1,257 (34.4%) men and 1,680 (28.6%) women never kept a cat . The people who ever kept a dog also had a higher probability of ever having kept a cat . This result was confirmed by logistic regression with ever keeping a dog as the output binary variable and ever keeping a cat, sex, age, urbanization (size of place of living), and education as the predictors. Similar results showed the logistic analysis for ever keeping a cat as the output variable and ever keeping a dog, sex, age, size of urbanization, and education as the predictors  and 6,584 women , ns. Only 1131 (30.8%) men and 1,454 (24.8%) women never kept a dog  and 1,130 (30.9%) men and 2,303 (39.1%) women kept a cat . Again, the people who were keeping a dog at the time of the study had a higher probability of keeping a cat at the time of the study . This result was confirmed with logistic regressions, see the At the time of the study, 1,147 (31.3%) men and 2,279 (38.8%) women kept a dog . The last surveys showed that seroprevalence of toxoplasmosis in Czech adult women is higher than in adult men [In the sample, 2,044 (18.8%) subjects, namely 420 (9.83%) men and 1,624 (24.7%) women, were aware of their toxoplasmosis status. Among them, about 40.3% men and 34.3% women were tested in our lab during participation in various research projects , 49.4% dult men , 48. Howdult men . Severaldult men .Nearly all focal variables had highly irregular distributions and many of them correlated with sex, age, urbanization, and education ; however, it had a negative effect on economic situation. Number of dogs correlated negatively with health and environment domains, with total wellbeing score, and economic situation. In women, keeping dogs had a negative effect on the environment domain of wellbeing and economic situation, and the number of dogs in a house correlated negatively with health and environment domains, total wellbeing score, and economic situation. Keeping cats and number of cats in a house had minimum effects on the wellbeing of men, except a negative effect on economic situation; however, it had numerous negative effects  on wellbeing and economic situation of women. The effects of keeping pets on wellbeing depended, both in strength and direction, on the age of subjects; stronger positive effects were observed only for older participants Figs  Tables.In men, keeping a dog had small, mostly non-significant effects on mental and physical health; however, number of dogs in a house had a negative effect on physical health. In women, ever having kept a dog, but not keeping a dog now, or number of dogs in a house had negative effects on mental health. Ever keeping a dog also correlated positively with sexual activity, and the number of dogs correlated with both sexual activity and sexual desire. In men, keeping a cat now correlated negatively with mental health and the number of cats in a house correlated positively with the number of undiagnosed mental health disorders in their partners. Ever having kept a cat correlated positively with sexual activity; however, no correlation was observed with sexual desire or number of children. In women, keeping a cat and number of cats correlated positively with mental health problems . It correlated positively with sexual activity and negatively with sexual desire. Ever having kept a cat correlated positively, while keeping a cat now and number of cats in a house negatively, with number of children.The most numerous (strong and negative) effects were observed between focal variables and animal-  related injuries Figs –S13 FigsToxoplasma had strong effects on wellbeing and physical health, even in comparison with cat-related injuries and consumption of illegal drugs. Due to the relatively low number of infected men (77), not all correlations, however, were statistically significant in this group. In men, toxoplasmosis had strong negative effects on all domains of wellbeing except social relationships, on the total wellbeing score, family situation and economic situation. It also had negative effects on physical and mental health, and number of children. A positive relation was observed with sexual activity and especially with number of siblings. In women, a negative correlation existed between toxoplasmosis and the environment domain of wellbeing, family situation and economic situation, with physical health, mental health, and sexual activity and sexual desire.Latent infection with the parasite People who like cats and dogs also have a higher probability of keeping them. To check whether the positive association of liking dogs and wellbeing and negative association between liking cats and dogs and mental health also existed in subjects who never kept these animals, we repeated all analyses on the subsets of men and women who never kept a dog or a cat. The results shown in the Toxoplasma gondii is associated with many mental health disorders and with impaired mental and physical health in general [Toxoplasma oocysts) and in some studies, also keeping dogs, is considered to be an important source of the Toxoplasma infection [Toxoplasma seropositivity was positively related to female sex , age , intensity of being bitten by a cat , and intensity of being bitten by a dog . It was negatively but not significantly associated with urbanization . Also, the associations of Toxoplasma infection with education, keeping a dog and keeping a cat or with being scratched by a cat were nonsignificant (p > 0.80). The partial Kendal correlation analyses performed on the subsets of Toxoplasma seronegative subjects, namely 343 men and 1,184 women, showed that nearly all associations observed on these subsets were much stronger than the same associations observed in the whole set  with the number of partner’s mental health disorders than with the number of the responder’s mental health disorders. It is indicative that this is not true for the cat-related injuries, which, in contrast to the number of cats in the home, affect only the responder and not his/her partner. Here, the association of injuries with the number of mental health disorders was much stronger than with the number of partner’s mental health disorders; in women, the latter association did not exist at all  and wellbeing score (B) could be the result of an association of both A and B with a third latent variable C, here, for example, the general pessimism of the responder. Even if the causality relation between A and B did exist, a cross-sectional study cannot discriminate between causes and effects. For example, a positive correlation between seriousness of sustained cat-related injuries reported by responders and number of diagnosed mental health disorders could be explained by a higher probability of cats to bite and scratch mentally ill people as well as by, for example, transmission of pathogens that are (co)responsible for mental illness, e.g. xoplasma  or Bartortonella , 56, frolasmosis , and a llasmosis . If the t at all .The analyses performed on subjects who never kept a dog showed that, in men, a positive association between liking dogs and mental health and wellbeing  could be the result of keeping a dog by people who like dogs. This conclusion, however, is only preliminary, as the positive association between liking dogs and wellbeing and with mental health still existed in this subpopulation but was much weaker than in the whole population . On the contrary, the negative association of liking dogs with physical health, and also the negative association with number of children in women, also occurred in subjects who never kept a dog. Here, the situation was opposite than it was in men as these two associations were even stronger in women who never kept a dog than in the whole population . No positive association between liking a dog and mental health was observed in women who never kept a dog (Tau = -0.001 vs 0.019). It seems that the positive effects of liking dogs in both men and women  were related to a higher probability of keeping dogs by those who like dogs. On the other hand, the negative association between liking dogs and number of children in men and women as well as the negative association between liking dogs and physical health in women, have no direct relation to keeping a dog.The analyses performed on the subpopulation of subjects who never kept a cat showed different patterns. In men, a negative association between liking cats and mental health also existed in this subpopulation and was only slightly weaker than that observed in the whole population (Tau = 0.039 vs 0.044). Unexpectedly, a positive association between liking cats and physical health was observed in this subpopulation , which was reflected by an even stronger positive association between preferring dogs to cats and physical health problems (Tau = 0.054). These two associations were not detected in the whole population . In women, the strength of the association between liking cats and mental health problems was largely reduced (Tau = 0.023 vs. 0.044) and with number of diagnosed and non-diagnosed mental disorders disappeared entirely . It can therefore be suggested that not the liking of cats but the keeping of cats could be responsible for the association between liking cats and mental health problems in women and probably also in men. However, the negative association between liking cats and number of children was relatively strong in cat-free men (Tau = -0.044 vs. -0.082) and even stronger in cat-free women (Tau = -0.109 vs. -0.080), suggesting no direct relation to keeping a cat. It could be speculated that loving cats canalize parental instincts, and therefore negatively influence the fecundity of men and even more of women. Of course, opposite causation (strengthening of love for cats by the absence of children), could be also responsible for the observed negative association.All analyses were also performed on subpopulations of people who had never been injured by a dog or by a cat. The observed negative association between number of dogs in the home and physical health problems was even stronger (Tau 0.121 vs 0.079) in the subset of men who were not injured by a dog than in the whole population. The same was true for the observed negative association between number of dogs in the home and wellbeing in women (Tau = -0.064 vs. -0.046). Again, a slightly different pattern was revealed in the analyses of subjects who had never been injured by a cat. In men, the negative association between keeping a cat and mental health was absent in the cat injury-free subpopulation . On the other hand, the strong positive associations between keeping a cat or number of cats in the home and number of diagnosed and un-diagnosed mental health disorders in the responder’s partner was also present in the cat injury-free subpopulation . In women, the negative association between keeping a cat and mental health, including the associations with the numbers of diagnosed and un-diagnosed mental health disorders, were only slightly weaker in the cat injury-free subpopulation . On the other hand, the negative association between number of cats in the home and wellbeing and between number of cats in the home and mental health was absent in this subpopulation . It can by concluded that the dog- and cat-related injuries most probably played an important role in the mental health of participants in our study; however, keeping dogs and cats alone also has negative effects on their mental health. Keeping dogs  was positively associated with number of children in the dog injury-free men. This positive association was observed only between ever keeping a dog and number of children in the dog injury-free women. Number of children correlated positively only with ever having kept a cat and only in cat injury-free women; however, the strength of the negative association between number of children and number of cats in the home was the same in the cat injury-free women and whole population of women (Tau = -0.040). Again, animal-related injuries are probably not responsible for the observed association between keeping pets and fecundity.Toxoplasma infection and impaired mental health has been confirmed by prospective cohort study [Toxoplasma was not the cause of the observed associations between the injuries and impaired health of the responders [Bartonella henselae, the agent of cat-scratch disease. This disease probably has many effects on the physical and mental health of patients and on the incidence of some mental health disorders, most strongly on the risk of major depression [The causality relation between the rt study , 58 and rt study   one’s own children has a negative effect on the relative intensity of liking pets. An alternative and more alarming explanation, i.e. the existence of a negative effect of liking pets on, e.g., parental instincts, should be tested in future cohort studies by searching for an association between liking pets and intensity of desire to have children in childless people. Also, we plan to repeat our study after five years to see whether young childless women, registered members of the Lab Bunnies community, who originally reported the more intensive love for cats would report fewer children in the follow-up study than those who originally reported less intensive love for cats.The number of children was also lower in subjects who presently keep animals and even more so in subjects who were more seriously injured by animals. Here, the decrease of biological fitness could be the result of impaired physical and mental health of affected subjects. Despite the negative effects on the number of children, animal-keepers, and even more so subjects who were more seriously injured by dogs or cats, were more sexually active. This could be explained by the adoption of a “quick life strategy” by people in bad mental and physical health conditions. The slow life strategy, i.e., the preferential investment in quality of offspring, to carefully search for the best available sexual partners and to accumulation of resources, including education, before starting the process of reproduction, pays more to healthy subjects. For the subjects with lower life expectancy it pays to adopt the quick strategy, to have a sex soon and, especially in men, with as many partners as possible. In the affected  men, high sexual activity was accompanied by high sexual desire. In contrast, in women, the affected subjects had lower sexual desire regardless of their higher sexual activity. This suggests that psychological mechanisms responsible for the transition from a slow to fast life strategy probably differ in men and women. The slow and fast life strategies were outside of the scope of present study; however, the existence of a highly significant positive correlation between both physical and mental health problems and sexual activity was detected in women, regardless of their contacts with dogs and cats.a priory believe that keeping pets has a positive effect on quality of life [It is widely believed that keeping cats and dogs has a positive impact on the subject’s quality of life despite most studies performed during the past 20 years showing the opposite–for an excellent review see . It seem of life , 32  and after several years of keeping a cat (dog), compare their mental health with that of the unexposed controls. As far as we know, only one such study was published. It was performed on a sample of 48 hypertensive individuals and demonstrated the positive effect of keeping pets for six months .Another limitation of the study is that only the subjects who use the internet, and preferentially those of them who use also Facebook, participated in it. This population is rather heterogeneous, however, some social and age strata could be rather underrepresented among the participants. It is therefore not clear whether the conclusions of the study could be generalized to the whole population.Our results suggest that the more objective indices of health, namely the scores of physical and mental health computed on the basis of concrete parameters such as number of prescribed drugs consumed daily, number of diagnosed mental health disorders etc., better correlate with the animal-related variables than the responders’ subjective assessment of physical and mental health statuses. This suggests that real status, rather than its subjective assessment, is responsible for the observed association between the dog- and cat-related variables and reported health. This is in agreement with previously published observations showing that regardless of the pet keepers’ claim that the animals provide them many psychological and physiological benefits, the standard questionnaires show no evidence for this , 68. It Toxoplasma infected or not. Similarly, some responders who were Toxoplasma-negative during their serological test could have acquired the infection in the time between serological test and participation in the present study. It must be emphasized, however, that presence of misdiagnosed subjects in the population can result in a Type 2, not a Type 1 error–it can increase the risk of failure to detect existing effects but not the risk of detecting non-existing effects.Toxoplasmosis status was self-reported by the participants of the study. It was shown that the information on toxoplasmosis status provided by 3,827 participants of another internet study nearly perfectly (99.5%) corresponded to the information in our file for subjects who were tested for toxoplasmosis in our lab . HoweverWe asked the subjects whether a dog (a cat) had ever been kept in their family. However, most subjects had already two families, the family to which they were born and their own new family. It is possible that keeping pets in original and new family are associated differently with the subjects’ wellbeing and health. Any future study should discriminate between these two kinds of families.Toxoplasma-free subpopulation). It is important to remember, however, that these effects are of similar strength as those of other risk factors–smoking, alcohol, illegal drugs, and high BMI. Most importantly, more than 50% of households in developed countries keep a dog or a cat and this number is continuously rising. Therefore, the real impacts of formally weak effects of keeping of pets on public health and wellbeing could be enormous and growing.From the point of view of statisticians, the effect sizes of the observed associations are small–the cat- and dog-related variables explained just a small percentage of total variability of the output variables. For example, the effect of cat scratching on mental health explained about 2.5% of total variability in the mental health problems score in the total population Click here for additional data file.S2 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S3 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S4 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S5 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S6 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S7 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S8 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S9 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S10 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S11 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S12 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S13 FigThe boxes, spreads, upper numbers and lower numbers show standard errors, standard deviations, numbers of subjects in particular category and p-values of two-sided t-tests, respectively.(PDF)Click here for additional data file.S14 FigThe categories on x-axis describing the intensity of being injured by a pet are: 0- never, 1- only while playing, 2- only as a warning, 3- yes, minor injury (only skin cut), 4- yes, moderate injury (bleeding), 5- yes, serious injury, I had to seek medical treatment.(PDF)Click here for additional data file.S15 FigThe categories on x-axis describing the intensity of being injured by a pet are: 0- never, 1- only while playing, 2- only as a warning, 3- yes, minor injury (only skin cut), 4- yes, moderate injury (bleeding), 5- yes, serious injury, I had to seek medical treatment.(PDF)Click here for additional data file.S1 TableThe column 3 shows mean answer to particular questions and the columns 4–12 the percentage of subjects who provided particular answer (0–8). The questions on variables printed bold were responded by a code of the answer (for meaning of particular codes see the (PDF)Click here for additional data file.S2 TableFor the explanation of codes in the column 1 see the (PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.S5 Table(PDF)Click here for additional data file.S6 Table(PDF)Click here for additional data file.S7 Table(PDF)Click here for additional data file.S8 Table(PDF)Click here for additional data file.S9 Table(PDF)Click here for additional data file.S10 Table(PDF)Click here for additional data file.S11 Table(PDF)Click here for additional data file.S12 Table(PDF)Click here for additional data file.S13 Table(PDF)Click here for additional data file.S14 Table(PDF)Click here for additional data file.S15 Table(PDF)Click here for additional data file.