Few studies examine relationships between intercultural strategies and adaptation among adolescents using a person-oriented approach. Framed from an intercultural psychology perspective, this study used such an approach in order to examine the influence of intercultural profiles, patterns of relationships among variables related to intercultural strategies, on the adaptation of adolescents of both non-dominant and dominant groups. Two hundred and fifty-six adolescents living in Italy and aged from 14 to 18 participated to the study: 127 immigrants from Tunisia  and 129 autochthonous . Data were collected through self-report questionnaires. Using cluster analytic methods to identify profiles, the results showed that immigrant adolescents were divided in two acculturation profiles, ethnic and integrated-national, with adolescents belonging to the latter showing higher self-esteem, life satisfaction and sociocultural competence than the former. Also among autochthonous adolescents two acculturation expectation profiles were identified, not-multicultural and multicultural, with adolescents belonging to the latter showing higher self-esteem and life satisfaction than the former. Findings highlight the importance of using multiple indicators in order to gain a more comprehensive understanding of the acculturation process as well as suggesting implications for the social policies in this field. Italy is facing a rapid enlargement of immigrant population. From the second half of the 1970s the country has witnessed a solid influx of immigrants which have increased with a high rate of growth. In fact the total amount of legal immigrants who are permanent residents in Italy has changed from about 1,000,000 in 2001 to about 5,000,000 in 2013 .This situation results in a patchwork of religions, people and cultures that requires innovative social policies in order to promote the intercultural dialogue and to overcome conflicts between groups, especially during a period of economic recession characterized by high unemployment rates and social dissatisfaction. Psychology and social sciences can effectively contribute to an understanding of those factors which foster personal and societal development in multicultural contexts , 2013.Intercultural psychology has contributed to this understanding through two distinct approaches, named acculturation and ethnic relations , 2006. Ti. The findings presented below come from the Italian section of MIRIPS and refer to adolescents, who are in a critical developmental period for the formation of acculturation processes rocesses .The paper is focused on the concept of intercultural strategies that designates individuals’ and groups’ preferences towards the ways in which they wish to engage with their own and other cultural groups . They arStarting from these considerations the paper tried to answer three critical questions in this field: a) What are the acculturation profiles of immigrant adolescents? b) What are the acculturation expectation profiles of autochthonous adolescents? c) How are these intercultural profiles related to adaptation of both immigrant and autochthonous adolescents?Acculturation strategies are a central concept in the well-known Berry’s model of acculturation  which coThe role of acculturation strategies in affecting immigrant adolescents’ adaptation has been already analyzed by several studies showing that integration is the most adaptive outcome, whereas marginalization the worst . Howeverintegration, national, ethnic, and diffuse.For instance, integration profile (36.40% of the sample) are characterized by a positive orientation towards both original and host society cultures with high levels of both ethnic and national identities, frequent social contacts with people who belong to both their own group and to the host society, and low levels of assimilation, separation, and marginalisation. Adolescents who belong to the national profile (18.70%) are characterized by a strong orientation toward the host society with high levels of national identity, assimilation, social contacts with members of the national group, and low levels of ethnic identity. Adolescents who belong to the ethnic profile (22.50%) show a strong orientation towards their own group with high levels of ethnic identity, separation, and social contacts with members of their ethnic group, together with low levels of assimilation and national identity. Finally, adolescents who belong to the diffuse profile (22.40%) are uncertain about their role in the host society, showing high proficiency in the ethnic language, high levels of assimilation, marginalisation, separation, low ethnic identity, low national identity and social contacts with peers of the host country.Adolescents who belong to the Full bicultural and Partial bicultural), other two resembled a combination of assimilation and integration , one resembled a combination of separation and integration (Separation), and one (Undifferentiated) that did not remind any of Berry’s typologies. The clusters characterized by a combination of assimilation and integration were the most frequent in the sample considered in the study.Other studies that employed similar methods have revealed more complex results that only partly coincide with the four acculturation strategies. For instance, U.S. Practices, was similar to assimilation, whereas cluster labelled Heritage Practices closely resembled the category of separation. The other two clusters, labelled Bicultural Attitudes, and Bicultural Practices & Heritage Identity, were similar to integration . None of the clusters resembled marginalization.Moreover, Taken together, these results highlight that not all of Berry’s categories may exist in a sample or population, as stated by According to The acculturation expectations are usually identified by asking autochthonous people whether immigrants should maintain their cultural attributes and/or seek contact with other cultural groups. On the basis of these two dimensions, four acculturation expectations can be derived: segregation (when autochthonous wish immigrants’ separation), multiculturalism (when autochthonous wish immigrants’ integration), melting pot (when autochthonous wish immigrants’ assimilation), and exclusion .The acculturation expectations were examined in different surveys across the world , 2013. Hacculturation expectation profiles) using a person-oriented approach with variables involved in the process of multicultural acceptance .Although several authors have focused their interest on these expectations , there iFew studies deal with the relationships between intercultural profiles and adaptation. Most of them are focused only on immigrants and investigate the relationships between acculturation profiles and adaptation of immigrant adolescents e.g., . In thesWith regard to the autochthonous adolescents, there are no studies aimed at analyzing the relationships between acculturation expectation profiles and adaptation. However, some authors have found that a positive attitude towards multiculturalism is often associated with high levels of psychological well-being, especially for self-feelings, among adolescents . For exaThe general aim of the present study was to analyze emerging intercultural profiles in relation to the adaptation of immigrant and autochthonous adolescents living in Sicily . In particular, the study has four specific goals. The first goal was to identify some acculturation profiles among Tunisian adolescents on the basis of their scores of acculturation strategies, ethnic and national identities, ethnic and national peer social contacts. In accordance with The second goal was to identify some acculturation expectation profiles among autochthonous adolescents on the basis of their scores of acculturation expectations, national identity, ethnic and national peer social contacts. The third goal of this study was to analyze the relationships between acculturation profiles and psychological and sociocultural adaptation of immigrant adolescents. On the basis of the integration hypothesis , we expeFinally, the fourth goal was to investigate the relationships between the acculturation expectation profiles and the psychological adaptation of autochthonous adolescents. Following the suggestions from the literature on this topic we expected to find an association between the membership to a profile characterized by positive attitude towards multiculturalism and positive adaptation, especially in terms of self-esteem.As already mentioned in the introduction, data came from the Italian section of MIRIPS project. Data about immigrant adolescents referred to Tunisian group that was chosen because it is one of the most prominent non-dominant groups in the research context, that is Sicily. Tunisian community is characterized by strong ties with the heritage culture that are facilitated by the presence of many resources available, such as Tunisian primary schools, places of worship, community centres, and typical restaurants. Despite the existence and the proximity of these resources, many Tunisians are also interested in having good relationships with Sicilian people .SD = 1.19). The group included both first-generation (those who were born in the country of origin and arrived after the age of 6 years) and second-generation immigrants . First-generation adolescents were 54 . All of them were born in their country of origin, had arrived in Italy at an average of 11.75 years (SD = 2.67), and had lived in Italy for an average of 3.97 years (SD = 2.45). Second-generation adolescents were 73 . The majority (53.42%) of them were born in Italy; adolescents who were not Italy-born had arrived in Italy at an average of 2.20 years (SD = 1.73) and had lived in Italy for an average of 13.83 years (SD = 1.65). About eighty percent of immigrant youngsters attended a secondary school, while about 20.00% were workers. All of them were living in one household with their parents and 95.28% of them came from intact two-parents families, 3.94% had divorced or separated parents, and 0.78% came from a family in which one of the parents had died. Socio-economic status (SES) of their families was prevalently low; based on a three-stratum classification of scores from the Barratt Simplified Measure of Social Status . They were randomly selected in the same schools and neighbourhood of the Tunisian adolescents. About ninety percent of Italian youngsters attended a secondary school, while about 10.00% were workers. All of them were living in one household with their parents and 83.72% of them came from intact two-parents families, 14.73% had divorced or separated parents, and 1.55% came from a family in which one of the parents had died. SES of their families was prevalently medium; 24.81% fell into the low stratum, 53.49% into the medium, and 21.70 into the high.The total group of participants consisted of 256 Tunisian and Italian adolescents aged from 14 to 18 years, living in western Sicily  in towns with more than 50,000 inhabitants. Tunisian adolescents were 127 , age, state of birth, age of arrival in the country of residence, and current occupation. Using the information about the state of birth and the age of arrival in the country of residence, we constructed a generation variable  and a length of residence variable, used both as a continuous variable and as a categorical variable . Family characteristics, number of parents, paternal and/or maternal level of school completed and their occupation were assessed using BSMSS .very untrue to 5 = very true) the extent to which each statement was true for them. In the present study, the subscales had adequate internal consistency with Cronbach’s α ranged from .63 to .76.A 16-item scale assessed four acculturation attitudes: assimilation, integration, separation, and marginalisation . The itevery untrue to 5 = very true) the extent to which each statement was true for them. In the present study, the subscales had adequate internal consistency with Cronbach’s α ranged from .62 to .74.A 16-item scale  assessedvery untrue to 5 = very true) the extent to which each statement was true for them. In the present study, Cronbach’s α was .82. National identity was assessed with a 3-item scale assessing national affirmation and the importance of one’s national identity of non-dominant and dominant group adolescents (very untrue to 5 = very true) the extent to which each statement was true for them. In the present study, Cronbach’s α was .90 and .87 for non-dominant and dominant group adolescents respectively.Immigrants’ ethnic identity was measured with an 7-item scale assessing ethnic affirmation  of non-dominant group adolescents . A sampllescents . A samplnone (1) to many (5) in the former case and from never (1) to daily (5) in the latter case. The ethnic peer contact was measured as a composite variable by extracting the square root of the product of the two items.Two items assessed the number and the frequency of contacts with Tunisian peers for non-dominant, and with ethnic minority peers for dominant, group adolescents . The itenone (1) to many (5) in the former case and from never (1) to daily (5) in the latter case. The ethnic peer contact was measured as a composite variable by extracting the square root of the product of the two items.Two items assessed the number and the frequency of contacts with Italian peers for non-dominant and dominant group adolescents . The itevery untrue to 5 = very true) the extent to which each statement was true for them. In the present study, Cronbach’s α was .77 and .79 for non-dominant and dominant group adolescents respectively. Life satisfaction was measured with a 5-item scale which assessed the overall degree of adolescents’ satisfaction with their lives (very untrue to 5 = very true) the extent to which each statement was true for them. In the present study, Cronbach’s α was .82 and .84 for non-dominant and dominant group adolescents respectively. Psychological problems were measured with a 15-item scale assessing depression, anxiety, and psychosomatic symptoms (very untrue to 5 = very true) the extent to which each statement was true for them. In the present study, Cronbach’s α was .88 and .90 for non-dominant and dominant group adolescents respectively.It was measured with three scales assessing self-esteem, life satisfaction, and psychological problems. Self-esteem was measured with the Rosenberg Self-Esteem Scale  which coir lives . A samplsymptoms . A samplno difficulty to 5 = many difficulties) the extent to which each statement was true for them. The final score was reversed indicating few problems and high levels of socio-cultural competence. In the present study, Cronbach’s α was .89.It was measured with a 20-item scale  assessinA cluster analysis was performed to determine whether it was possible to distinguish different profiles of Tunisian adolescents on the basis of their acculturation outcomes , and to determine whether it was possible to distinguish different profiles of Italian adolescents on the basis of their acculturation expectations , national identity, ethnic and national peer social contacts. Chi-square analyses were carried out to determine if profile configurations were related to adolescents’ gender, length of residence and generation for Tunisian adolescents and to adolescents’ gender for Italian adolescents. In order to examine differences in psychological and sociocultural adaptation of Tunisian adolescents, and in psychological adaptation of Italian adolescents, associated to the profile configurations, a one-way MANOVA was then performed. Furthermore, a number of other MANOVAs were carried out to examine the effects of gender  as well as of length of residence and generation (for Tunisian adolescents).Means and standard deviations of, and Pearson product-moment correlation coefficients between, study variables for the Tunisian and the Italian participants are displayed in We determined configurations through Ethnic profile (39.52%). Mean scores above average on separation and ethnic social contact. Mean scores below average on integration, national social contact and national identity.Integrated-national profile (60.48%). Mean scores above average on integration, national identity and national social contact. Mean scores below average on separation.2(1) = 1.13, ns. Second, the two configurations showed a clear pattern of differences across the three length-of-residence categories, χ2(2) = 12.76, p < .01  = 15.60, p < .001. Specifically, 65.31% of ethnic profile was represented by first-generation adolescents, while 70.67% of integrated-national profile was composed of second-generation youngsters. The integrated-national profile was more frequent among adolescents with longer residence; the proportion of this profile among those born in Italy or with 12 years or more of residence was almost the double that of those with 6 years or less of residence. In contrast, the ethnic profile was considerably less frequent in those with longer residence; over 60 per cent of those with 6 years or less residence showed an ethnic profile, while only about 26 per cent of those with the longest residence showed this profile. Third, the analysis indicated an association between cluster membership and generation: χMaintaining the value of ± 0.30 as a useful cutoff for descriptive purposes, the levels of the mean z-scores in relation to the two generation categories differed on assimilation and marginalization for ethnic profile and on ethnic social contact and national identity for integrated-national profile. Specifically, in the first case (ethnic profile) assimilation mean z-score was below average among second-generation adolescents and marginalization mean z-score was just above average among first-generation adolescents. In the second case  ethnic social contact mean z-score was below average and national identity mean z-score was above average among second-generation adolescents.Cluster analysis was carried out with the variables associated with the host process, following the previous procedure. Two configurations were retained because the scree plot indicated that the presence of additional configurations (more than two) did not reduce distance coefficients more than a minimal amount. Not-multicultural profile (36.34%). Mean scores above average on melting pot, segregation and exclusion. Mean scores below average on multiculturalism and national social contact.Multicultural profile (64.56%). Mean scores above average on multiculturalism. Mean scores below average on melting pot, segregation and exclusion.2(1) = 0.14, ns.A 2 (configuration) × 2 (gender) chi-square analysis did not indicate an association between configuration membership and gender: χF = 6.74, p < .001, η2 = .19. Univariate ANOVAs revealed significant effects for self-esteem, life satisfaction, and socio-cultural competence. Results are displayed in F = 2.65, p < .05, η2 = .08. Univariate ANOVAs revealed significant effects for psychological problems, F = 5.14, p < .05, η2 = .04, with girls  having higher scores than boys .In order to examine differences in psychological and sociocultural adaptation associated to cluster membership among Tunisian adolescents, a one-way MANOVA was performed. There was a significant multivariate effect, Wilks’ Lambda = .81, F = 8.38, p < .001, η2 = .17. Univariate ANOVAs revealed significant effects for self-esteem and life satisfaction. Results are displayed in F = 4.61, p < .01, η2 = .10. Univariate ANOVAs revealed significant effects for self-esteem, F = 6.58, p < .05, η2 = .05, and psychological problems, F = 4.15, p < .05, η2 = .03. Italian boys  showed higher levels of self-esteem than girls . In contrast, Italian girls  showed higher levels of psychological problems than boys .In order to examine differences in psychological adaptation associated to cluster membership among Italian adolescents, a one-way MANOVA was performed. There was a significant multivariate effect, Wilks’ Lambda = .83, The general purpose of the present study was to analyze emerging intercultural profiles in relation to adaptation of immigrant and autochthonous adolescents living in Sicily . Our results show that both immigrant and autochthonous adolescents can be divided into two groups or profiles which are associated to different psychosocial outcomes.The first specific goal was to identify some acculturation profiles among Tunisian adolescents. Our hypothesis was only partially supported since the findings produced two acculturation profiles, rather than four. One profile was named ethnic (39.52% of the sample) and it was characterized by a strong preference towards separation as acculturation strategy, and by a predilection for maintaining social contacts with people of the same ethnic group. The second profile was called integrated-national (60.48% of the sample) and it was characterized by a preference towards integration as acculturation strategy, a strong identification with autochthonous group  and a preference towards social contact with Italians. Moreover, it is interesting to note that ethnic profile seems to be prevalent among first-generation immigrants, whereas adolescents of the integrated-national profile are prevalently second-generation immigrants. This is also confirmed by the results related to the association between acculturation profiles and adolescents’ length of residence because the ethnic profile prevailed in immigrants with a lower length of residence while the integrated-national profile was prevailing in adolescents who lived in the society of settlement from their birth or from their early school years on. Thus, the more extended is the period of stay in the new country, the more immigrant adolescents tend to establish ties with the host country culture. This is particular evident for adolescents of the integrated-national profile because our findings showed that second-generation immigrants reported less social contacts with ethnic peers and an higher national identity than first-generation immigrants. Perhaps, it could be hypothesized the existence of a developmental and adaptive process that goes from the prevalence of separation and ethnic social contact to a declarative form of integration along with a behavioural form of assimilation consisting prevalently of national social contact. This is in line with the results of In a certain way, we provided evidence that acculturation is a very complex process that, despite some general features, needs to be analyzed in relation to the context in which takes place e.g., . The useThe last important consideration about the acculturation profiles is related to the absence of a cluster resembling marginalization. This is in line with other studies using empirically based clustering methods that have found small or nonexistent marginalization groups e.g.,  and it iThe second specific goal of the study was to identify some acculturation expectation profiles among autochthonous adolescents. The results confirmed our prediction that two acculturation expectation profiles could be identified. The not-multicultural profile (36.34%) was characterized by preferences towards melting pot, segregation and exclusion as acculturation expectations, and a general negative attitude towards multiculturalism. The multicultural profile (63.56% of the sample) was characterized by a positive attitude towards multiculturalism and low levels of melting pot, segregation and exclusion.These results are in line with the existing literature e.g.,  indicatiThe third specific goal was to analyze the relationships between acculturation profiles and adaptation of the Tunisian adolescents in terms of psychological  and sociocultural adaptation. Our findings provided some empiric evidence for integration hypothesis  stating The fourth goal was to investigate the relationships between the acculturation expectation profiles and the psychological adaptation of the autochthonous adolescents. Our results show that adolescents who belong to multicultural profile showed higher levels of self-esteem and life satisfaction when compared to their not-multicultural counterpart. This is in line with previous studies on similar topics e.g.,  which haTo sum up, our study has interesting implications for the research in this topic as well as providing useful suggestions to elaborate settlement policies in Italy. First, the findings advocate for a position midway between Berry’s model  and someHowever, our results should be interpreted in light of some limitations. First, the study involved a small sample size that needs to be enlarged in further researches. Such a limited sample size did not allow us to perform a replication of cluster analysis splitting Tunisian participants in first- and second-generation immigrants. Similarly, we could not perform neither a 2 (profile) x 2 (gender) x 3 (length of residence) x 2 (generation) MANOVA to examine the relations between acculturation profiles and Tunisian adolescents’ adaptation nor a 2 (profile) x 2 (gender) MANOVA in order to examine the relations between acculturation expectation profiles and Italian adolescents’ adaptation. Second, the study was focused only on a specific group of immigrants (Tunisians) that is the most representative in the context of the research. However, it would be useful to extend the study to the analysis of other cultural groups living in Sicily, such as people from China, Bangladesh, Romania, and Central Africa. Third, more attention to the developmental processes underlying the formation of intercultural profiles during adolescence has to be spent through the use of longitudinal design. Fourth, it would be interesting to set up further studies aimed to shed some light on the dynamic process in which perceptions of dominant group members’ preferences have an impact on non-dominant group members’ acculturation attitudes, as well as on the quality of intergroup relations itself . Fifth,


Rapamycin, an inhibitor of mTOR kinase, increased median lifespan of genetically heterogeneous mice by 23%  to 26%  when tested at a dose threefold higher than that used in our previous studies; maximal longevity was also increased in both sexes. Rapamycin increased lifespan more in females than in males at each dose evaluated, perhaps reflecting sexual dimorphism in blood levels of this drug. Some of the endocrine and metabolic changes seen in diet-restricted mice are not seen in mice exposed to rapamycin, and the pattern of expression of hepatic genes involved in xenobiotic metabolism is also quite distinct in rapamycin-treated and diet-restricted mice, suggesting that these two interventions for extending mouse lifespan differ in many respects. Cox regression, stratified by site, showed a significant effect of dose (P < 0.001) for each sex and a significant difference between males and females, also at P < 0.001.Mice were given food containing encapsulated rapamycin at one of three doses at age 9 months and followed until death to produce the survival data shown in Fig. et al.,  as the pP = 0.002 in males, confirming our earlier report at this dose  at UM. In females, even the lowest dose of rapamycin led to a significant survival benefit by the log-rank test and a significant result in the Wang/Allison test at 90th percentile mortality, at each site. The highest dose led to increases in median of 20%, 22%, and 31% at the three sites, representing good consistency for lifespan experiments of this kind.We also evaluated rapamycin effects at each of the three test sites independently, while recognizing that the lower number of mice at each site leads to a major loss of statistical power. Figure et al., −1 for females at rapamycin doses of 4.7, 14, and 42 ppm, respectively, and the corresponding values in males were 6, 9, and 23 ng mL−1, with N = 4–8 mice in each group  showed significant effects of sex (P = 0.007), rapamycin (P = 0.003), and interaction (P = 0.03), indicating that blood levels of rapamycin were higher in female than in male mice, with steeper dose-dependent increases in blood levels seen in females. In a separate experiment, UM-HET3 mice at UT, at 26 months of age, were fasted overnight and then allowed access to food containing rapamycin at 42 ppm for 1 h. Blood samples were then taken at intervals for the next 6 h. The results, shown in Fig. Rapamycin concentrations were evaluated by HPLC–tandem mass spectroscopy (Livi P < 0.05). Females exposed to rapamycin at 4 and 14 ppm had intermediate values, not significantly different from controls. The estimate for the Gompertz ‘b’ (slope) parameter, an index of age-dependent change in mortality risk, is significantly higher in females receiving rapamycin at 42 ppm. The implications of this are uncertain, however, because in small data sets of this kind, early deaths are few and tend to produce elevation of the slope parameter in association with decreases in the intercept value. For males, as in females, the highest rapamycin dose led to a significantly lower ‘a’ parameter, but for males, there were no significant drug effects on the Gompertz slope. These estimates, for both sexes, should be interpreted with caution, because the calculations do not adjust for site-to-site variation, statistical power is low, and therefore, confidence intervals are correspondingly wide.Maximum likelihood calculations were conducted to estimate fits to the Gompertz parameterization for each of the rapamycin survival tables. Figure Our standard protocol calls for the removal of all mice in cages in which fighting has led to serious injuries; both dominant and nondominant, that is, wounded, mice are removed from the protocol to prevent over-representation of mice with specific personality characteristics. This policy typically leads to the removal of approximately 0–5% of the cages of male mice, and in the current cohort, only 1% of control male cages were culled because of fighting. We noted, however, that the proportion of male mice removed because of fighting was elevated in the group exposed to the highest dose of rapamycin, leading to the removal of 11% of the cages at TJL, 18% at UM, and 22% at UT. We do not know whether this higher incidence of serious fight wounds reflects changes in behavior of dominant or nondominant animals, or rapamycin-mediated interference with wound healing. A more detailed behavior analysis, with controlled tests on wound healing rates, would help to address this unexpected observation.et al., N = 5–8 mice of each sex for each rapamycin dose). In males, the highest dose of rapamycin decreased the proportion of weight due to fat . A similar effect was seen in females (36.6% in treated mice vs. 43.4% in controls), but did not reach statistical significance (P = 0.13). The results are shown in Fig. In principle, a drug might lead to longevity extension by making food unpalatable, thus reducing food intake sufficiently to induce true DR. Figure P = 0.04), but not by DR . The DR and rapamycin mice differ significantly from one another (P < 0.004), for each of the endpoints shown in Fig. Figure P < 0.0001, and there was a significant interaction term (P = 0.003), showing that the effects of rapamycin on glucose tolerance were more dramatic in males than in females. A parallel study of glucose responses after insulin injection (not shown) revealed that rapamycin-treated mice, in general, were mildly insulin resistant. Interestingly, we also noted a paradoxical increase in plasma glucose in males injected with insulin at 14 or 42 ppm, which was not seen in control males or in any of the female groups. It is possible that the increase in glucose seen after insulin injection into rapamycin-treated males reflects a response to the stress of injection, but additional work would be needed to address this idea.A separate experiment conducted at the UT site evaluated glucose tolerance in UM-HET3 mice exposed to rapamycin for one month starting at 4 months of age. As shown in Fig. Caenorhabditis elegans mutants that show increased lifespan . Genes encoding XMEs are frequently overexpressed in 10, or 1000-fold.In the current study, we evaluated expression of XME mRNAs in liver of DR, rapamycin-treated (14 ppm), and control mice at 12 months of age, using a set of mRNAs that varied widely in the degree and direction of sexual dimorphism. The gene expression data are shown in Table The effects of the two interventions on XME gene expression are clearly quite distinct. There is a tendency for ‘female-dominant’ XME genes to be diminished by rapamycin in females and increased by rapamycin in males. ‘Male-dominant’ XME genes show the opposite pattern, tending to increase in females treated with rapamycin and to decrease in rapamycin-treated males. For these sexually dimorphic mRNA, then, rapamycin tends to diminish sexual disparities in both males and females. There are, however, many XME that do not follow this pattern, and large, significant effects are also seen among mRNAs that show little or no sexual dimorphism. Only six of the 52 mRNAs show  significant increases in both males and females exposed to rapamycin, and only a single mRNA shows a significant decrease in both sexes.The pattern of XME expression in livers of DR mice bears some resemblance to that seen after rapamycin, in that there is a tendency for female-dominant genes to be increased in male mice and for male-dominant genes to be increased in female mice after DR. Twenty of the 52 tested mRNA show significant increases in both sexes in response to the DR diet, and one shows a significant decrease. Of these 21 DR-modified XME mRNAs, only three show parallel changes in males and in females exposed to rapamycin. These three are Cyp3a41, Aldh3a2, and Gstt1 at positions 4, 27, and 34 on the plots. Additional work would be needed to see whether levels of the corresponding proteins did or did not show parallel changes. This survey, although limited, does not support the hypothesis that elevation of mRNA for hepatic XME is a feature of rapamycin exposure, or the idea that gene expression changes induced by rapamycin closely parallel those seen after dietary restriction.et al., et al., Rapamycin at 42 ppm leads to 26% increase in median lifespan in females and 23% in males, in each case larger than that seen in previous or current cohorts exposed to lower doses. Survival of the longest-lived 10% of the cohort was increased by 11% in females and by 8% in males, and the drug benefited male and female mice at each of the test sites. It is possible that larger lifespan effects might be seen at still higher doses of rapamycin, or in mice treated with rapamycin in combination with one or more agents that work through other pathways. The lifespan benefit is not accompanied, in either sex, by weight loss to the degree typical of mice exposed to DR .Rapamycin leads to a larger percentage increase in female longevity than in males, even though female controls live longer than male controls at TJL and UT. It seems likely that this differential effect, seen now in three consecutive independent cohorts, reflects higher levels of rapamycin in blood of female UM-HET3 mice compared with males given equal amounts of rapamycin in food. Our data show higher levels in young females at each of three rapamycin doses and higher levels in old females at varying times after consumption of rapamycin-containing food. Similar sex effects were noted in at least two other strains of mice . But it is also likely that males and females may differ in other ways in their response to rapamycin. For one example, gene expression changes induced by rapamycin in males differ radically from those produced in females, at least with respect to XME genes evaluated in Fig. et al., et al., et al., et al., et al., et al., et al., et al., et al., It seems likely that rapamycin-mediated increases in lifespan reflect both broad spectrum antitumor effects as well as deceleration of aging processes more generally. Terminal (end of life) necropsies conducted on mice exposed to 14 ppm rapamycin from nine months of age suggested that the spectrum of specific lethal illnesses, mostly neoplastic, was not altered by rapamycin, even though the age at death was higher in the treated mice compared with controls, suggesting a drug-induced postponement of tumor induction, progression, or lethal effect  rapamycin, have been described at length in earlier papers . For the T4 RIA, the assay was run at 40% of the volumes stated in the manufacturer’s protocol. Insulin levels were quantified via a two-site enzyme immunoassay kit . Plasma leptin levels were determined using an ELISA sandwich assay . Leptin samples were performed in two batches, and a correction factor used to adjust the mean level in each batch to the same level prior to further analysis. Plasma FGF-21 levels were quantified using an ELISA sandwich assay. . All samples were assayed in duplicate.Mice at UM were fasted overnight (18 h), after which blood samples for hormone measurements were collected via tail nick, without anesthesia, using heparin as an anticoagulant. Samples were obtained between 8 and 10 am. Glucose levels were determined using a handheld glucometer, and the plasma samples then stored at −80 °C prior to the assessment of hormone concentrations. Plasma IGF-1 levels were determined with a double-antibody RIA kit . For the IGF-1 RIA, the assay was run at one-quarter of the manufacturer’s recommended protocol volumes. Plasma T−1) in saline. Blood glucose levels were measured at indicated time points from tail vein bleeding by handheld glucometer . Area under curve (AUC) was calculated for each animal using the trapezoid method.UM-HET3 mice housed at UT were fed control, 4.7, 14, and 42 ppm rapamycin diets starting at 4 months of age for 1 month. For the glucose tolerance tests, mice were fasted 6 h (09:00–15:00) prior to each test and then injected intraperitoneally with glucose (1.5 g kgabi prism sequence detection system instrument and software (Applied Biosystems). Ct data, indicating the number of amplification cycles needed to achieve threshold, were available from six male and six female mice per treatment group. The effect of rapamycin or DR diet was estimated as the difference between Ct for the mutant mouse and Ct for sex-matched littermate controls, with a positive value in cases where expression of the mRNA was increased by diet compared with control animals. Because a change in one unit for Ct reflects a twofold change in mRNA abundance, effect sizes in the figures and tables reflect powers of 2. Thus, an effect size of 5 indicates an increase in mRNA concentration of 25 = 32-fold.Liver was taken from mice at 12 months of age, after 8 months exposure to control, rapamycin, or DR diets. Total RNA was isolated from mouse livers using Trizol , cleaned using the Qiagen RNeasy mini RNA cleanup protocol , and quantified using a Nanodrop ND-100. Total RNA was then transcribed to cDNA using iScriptTMcDNA reverse transcription kits . Reverse transcription products were amplified using Power SYBR Green PCR Master Mix  and PCR primers . RT–PCR was performed using et al., This method has been described elsewhere  with the EchoMRI-3-in-1 system , as described  were obtained by pooling deaths and censored observations into 2-week census intervals and calculating ux= −ln(px), where px is the probably of surviving through interval age x. Parameter estimates for the Gompertz mortality model were obtained using maximum likelihood analysis of actual  observation times  was used to determine whether there was a significant difference between males and females; if a sex effect was noted, then the data were analyzed separately for each sex, and the data were pooled for analysis if no sex effect was noted. Differences between treated and control groups, or in some cases between DR and rapamycin groups, were evaluated by t-test, and nominal P-values were reported without adjustment for multiple comparisons. For the gene expression studies, unadjusted Ct values  were compared for each gene between control and treated mice, using a t-test with no adjustments for multiple comparisons. Error bars shown in the figures indicate standard errors of the mean, and all P-values represent two-sided tests. Table Survival curves were compared using the log-rank test, with stratification by site for comparisons that pooled data across sites. Mice that had been removed from the protocol, for example, because of an accident or fighting, were treated as alive on the day of removal and lost to follow up thereafter. Statements about maximal lifespan were based on the method of (Wang


Immediate action is required in the Mediterranean to address environmental degradation that is mainly driven by consumption patterns. Increasing stress on biological and social systems is put by unsustainable consumption patterns. Food consumption patterns are important drivers of environment degradation. The objective of this review paper is to explore natural resources-food nexus in the Mediterranean region by highlighting the environmental footprints of the current consumption and production patterns. Secondary data from different sources such as FAOSTAT, the World Bank, Water Footprint Network (WFN), and Global Footprint Network were used to analyze the situation in 21 Mediterranean countries. The region faces many environmental challenges, e.g., land degradation, water scarcity, environment pollution, biodiversity loss, and climate change. The current consumption patterns imply high ecological, carbon, and water footprints of consumption and unfavorable national virtual-water balances. Food Balance Sheets data show that the contribution of vegetal and animal-based food product groups to food supply is variable among the Mediterranean countries. This has implications also in terms of the WF of food supply, which was calculated for Bosnia, Egypt, Italy, Morocco, and Turkey. The WF of the current diet resulted lower than that of the proposed Mediterranean one in the case of Italy. There is a strong scientific evidence supporting assumption that it is so also for other Mediterranean countries. The Mediterranean is characterized by a high resource use intensity that is further exacerbated by food losses and waste (FLW). In fact, FLW implies the loss of precious resources  and inputs (fertilizers). Therefore, it is crucial to increase adherence to the traditional Mediterranean diet and to reduce FLW in order to foster transition to more sustainable food consumption patterns thus reducing pressure on the scarce resources of the Mediterranean region. In the Mediterranean, immediate action is required to address environmental degradation that is mainly driven by population and consumption. Increasing stress on biological as well as social systems is put by unsustainable consumption patterns, in particular food consumption patterns that are important drivers of environment degradation, e.g., unsustainable water use, declining soil fertility, marine environment degradation, biodiversity loss, climate change (CC), etc. Much of today’s discourse about environmental problems revolves around reducing greenhouse gas (GHG) emissions and water usage.Mediterranean region’s development cannot be “sustainable” except if the fundamental common goods are protected and improved. Protection of the coast, sea, climate and air quality, soil and biodiversity, water resources, cultural and landscape heritage, and traditional knowledge of nature are the priorities to be focused on. It is very important to break the joints that make economic development reliant on an intensive exploitation of natural resources and to promote changes in consumption and production patterns .In this context, the current food system delivers low cost food at a high cost to the environment  and thisIf no changes are implemented in the coming years, there is a high risk of further deterioration of the global food system with consequent degradation of the environment and the natural resource base. This alarming trend can jeopardize the capacity of the worldwide ecosystems to generate enough resources, especially food, to feed the growing world population within the planetary natural limits. Another issue that should be highlighted the externalities of the current food systems. As a matter of fact, food production patterns release huge amounts of GHG and other toxic pollutants . SustainThe Mediterranean Diet (MD), in fact, is widely recognized as a healthy dietary pattern. Furthermore, it was inscribed by UNESCO on the Representative List of intangible cultural heritage of humanity. For these reasons the MD, in its diversity, was chosen by the Food and Agriculture Organization of the United Nations (FAO) as its first case study to develop a methodology for diets sustainability assessment . In Adherence to the MD has been linked to health benefits and considerable nutrition –17.Thus, MDs, to be considered sustainable, should respect and protect biodiversity and ecosystems, have low environmental impact, and optimize natural resources.Recommendations for lowering GHG emissions and energy inputs from household food consumption include diets with more locally produced and fresh foods and less meat and dairy products and more in-season vegetables –20.So, it is important to stress how sustainability, diets, food security, and water are closely connected. With urbanization and rising incomes, typical dietary patterns are shifting toward consumption patterns based on animal products , 22 requIn the Mediterranean region, there are at least four main environmental challenges related to the current Mediterranean production and consumption patterns that should be addressed: water scarcity, land degradation, CC, and biodiversity loss.water scarcity that represents the most critical development problem and by consequence it is the main limit for agricultural growth. In Mediterranean region, since the late 1950s water availability has been declining steadily. By opposite, during the second half of the twentieth century, water demand has doubled and agriculture is the main water-consuming sector accounting for 64% of total water demand. The irrigated land accounts for 20% of all arable land and produces 40% of food production. Half of the “water poor” world population is concentrated in the Southern Mediterranean region , and global warming due to CC. Many Mediterranean lagoons and deltas are disappearing and for surface coastal ecosystems, the most serious threat is posed by the construction of facilities and coastal iversity . The othiversity . To the iversity .Biodiversity is closely associated to agriculture. It is clear that CC will induce changes in agricultural areas suitable for cultivation of specific crops, especially those that are characteristic of Mediterranean area such as olive. CC may increase temperature and changes in rainfall regimes anticipate both an increase and decrease in precipitation, and an increased frequency of dry spells and floods . These cGiven the above-described environmental challenges, the objective of this review paper is to explore natural resources – food nexus in the Mediterranean region by highlighting the environmental footprints of the current consumption and production patterns. In fact, it is assumed that only by decreasing the environmental impacts of the current food consumption patterns, a concrete transition to a more environmentally sustainable food system can be fostered in the area. Indeed, environment is one of the most important pillars of sustainability, therefore, a sustainable food system should rely mostly on the regional domestic biocapacity and natural resource base.The review paper is based on secondary data from different databases and sources such as FAOSTAT, World Development Indicators (WDI) of the World Bank, Water Footprint Network (WFN), Global Footprint Network (GFN), UNEP/MAP-Plan Bleu, European Commission (DG ENV), CIHEAM , Barilla Centre for Food & Nutrition (BCFN), Critical Ecosystem Partnership Fund (CEPF), Intergovernmental Panel on Climate Change (IPCC), Italian Institute of Food Science (La Sapienza university), Stockholm International Water Institute, World Resources Institute, WWF, etc.The geographical coverage of this study is similar to that of the Mediterranean Strategy for Sustainable Development  includinStandard impact data (per kilogram or metric ton of food product and/or food group) were used to calculate and discuss the environmental impacts and footprints of food consumption patterns. This paper focus on ecological footprint (EF), carbon footprint (CF), and water footprint (WF) of consumption.biocapacity refers to the capacity of ecosystems to produce useful biological materials and to absorb waste generated by human activities  across six major land use types: cropland, fishing grounds, grazing land, forest land, CF, and built-up land. The EF methodology uses a consumer-based approach to keep track of both direct and indirect biocapacity needed to support consumption patterns. The EF of consumption (EFC) is calculated for each land use type as: EFC = EF of production + EFI-EFE; where EFI and EFE refer to the EFs embodied in imported (EFI) and exported (EFE) commodities. Comparison was made between the following regions: Middle East , North Africa , Northern Mediterranean countries , Central and Northern Europe , and North America (Canada and USA).The EF method allows knowing how much of the biosphere regenerative capacity is occupied by human-related activities . Regenertivities . Ewing etivities , 43 desc2 emission directly and indirectly caused by an activity or accumulated over the life stages of a product  minus the amount of CO2 absorbed by oceans in a given year translated into the amount of bio-productive forest that would be needed to store it that year , green water (moisture stored in soil strata and rain water), and gray water. The last is defined as the volume of freshwater that is required to assimilate the load of pollutants given existing water quality standards and natural background concentrations , Egypt and Turkey (Eastern Mediterranean), Bosnia , and Morocco (Southern Mediterranean). The methodology used in the present paper for the calculation of the WF of national food supply is similar to that used by Sáez Almendros et al. . Data regarding food consumption patterns in the USA and Finland, that exemplify the western dietary patterns (WD), were obtained as well from the FAO-FBS , starchy roots, sugarcrops, sugar and sweeteners, pulses, treenuts, oilcrops, vegetable oils, vegetables, fruits (excluding wine), stimulants, spices, alcoholic beverages, and aquatic products (other than fish and seafood). Meanwhile, the share of animal-based energy in total dietary energy reflects, in relative terms, the energy supply of the following food groups: meat, offals, animal fats, eggs, milk (excluding butter), fish, and seafood.Food supply data from the Food Balance Sheets (FAO-FBS) were used to characterize the  FAO-FBS . Accordi FAO-FBS , the conEnvironmental cost, in terms of water use, of non-adherences to the Mediterranean dietary pattern was analyzed in the Italian context by comparing the WF of the MD and that of the current dietary pattern in Italy. The dietary composition of the MD in the Italian context was obtained from diet proposed by the Italian Institute of Food Science of the La Sapienza University . Two indFertilizer consumption measures the quantity of plant nutrients used per unit of arable land. Fertilizer products cover nitrogenous, potash, and phosphate fertilizers  used per hectare of national agricultural land. Data are available for the period 2002–2010 from FAOSTAT – Resources database.The paper analyses also fertilizer and mineral nitrogen consumption, as proxy indicators for resource use intensity related to food consumption patterns. tilizers . Data arEF of production, the resources used in 2007 by Mediterranean countries need, in order to regenerate, a period that range from 1 year and 3 months to 5 years and 5 months in Albania and Libya, respectively. Regarding the EFC, the period that is needed to regenerate the resources consumed ranges from 1 year and 6 months to 8 years and 6 months in Croatia and Jordan, respectively. Therefore, the Mediterranean countries have a net demand greater than their respective biocapacity: expressed in average values, 2 years and 3 months are needed to regenerate the resources used for production, whereas 3 years and 4 months are required to regenerate the resources that are effectively consumed.Regarding the biocapacity, except for Albania, Bosnia, Croatia, France, Morocco, Tunisia, and Turkey.As shown in Figure Generally speaking, the northern Mediterranean countries present a higher EF with respect to North Africa and Middle East ones. EFs of production and consumption and CF of North American countries are higher than those recorded in Mediterranean countries even the Northern ones. In the Mediterranean context, the northern region present higher CF (mainly Greece and Spain) and EF of production and consumption  with respect to North Africa and Middle East regions Table .biocapacity has decreased as shown in Figure biocapacity has decreased by 36.4%.In the period 1961–2007, the EF per capita in the Mediterranean has increased except in Albania, Jordan, and Morocco, while the Taking into consideration land use types , Figure 3/year/capita in Palestine and 2505 m3/year/capita in Portugal. Northern Mediterranean countries present higher WF of consumption compared to SEMC and the Balkan countries. The WF per capita in the Mediterranean, especially in SEMC, are lower than in North America but higher than the WF of consumption of Finnish citizens.From 1996 to 2005, WF of consumption varies widely among Mediterranean countries as shown in Figure Most of the WF of consumption is due to the consumption of agricultural products Figure . The shavirtual-water balance  and Turkey (1291.65 m3/capita/year) while the highest is recorded in Bosnia (1849.70 m3/capita/year), which is slightly higher than the WF recorded in Italy (1848.29 m3/capita/year) and in Morocco (1644.85 m3/capita/year). The average WF of an Italian citizen is 35.36, 30.12, 11.01% higher and 0.08% lower than that of an Egyptian, a Turkish, a Moroccan, and a Bosnian one, respectively. Regarding the Southern Mediterranean countries, the average WF in Morocco is 37.68% higher than the one recorded in Egypt. The total WF of food supply in the USA (2198.66 m3/capita/year) is higher than in the other five Mediterranean countries while the Finnish WF (1116.69 m3/capita/year) is lower.Among the five considered Mediterranean countries, the lowest WFs of food supply are recorded in Egypt (1194.70 m3/capita/year). Of the latter 40% is external to Europe. The WF of agricultural products contributes the largest fraction, about 89% of the total WF of consumption (3/capita/year). This shows that by changing the diets the WFcons can be largely reduced  change. In all the Mediterranean countries, except for Egypt , the highest WF is the green one, followed by the gray for Bosnia  and Italy , and the blue one in the case of Morocco  and Turkey . As for Egypt, the first component is the blue one while the green one is ranked second. The reason why the highest share of the blue water component in the total WF is recorded in Egypt is mainly due to the fact that water is used in irrigation.Meat products’ contribution to the total WF is the highest in Bosnia and Italy where about a third of the total WF is due to the consumption of meat products. While the contribution of cereals to the total WF is the highest in SEMCs , where they account for more than a third of virtual-water use. The contribution of vegetable oils  to the WF is relevant in Italy but not in the other countries. When considering both dairy products and meat, they represent more than a half of the total WF of food supply in Bosnia and Italy Table .The food product with greatest impact is the red meat, while fruit and vegetables have definitely limited footprints –61. GeneIntensive livestock production system has several negative impacts on the planet’s resources and ecosystems, and for this reason it is necessary to switch to a more resource-efficient and healthier vegetable-rich diet . At locaWith traditional water use statistics, awareness campaigns and policy have always focused on increasing water efficiency in domestic and industrial water use. However, by reducing food waste and by changing the diet, much more water can be saved in agricultural production processes .The top 10 products contributing to the total WF of food supply change from a country to another Table . Wheat i3/capita/year: 79.10% green, 11.46% blue, and 9.44% gray. Fruit and meat are the most significant contributors to the total WF of the proposed diet. These two food product groups represent about 50% of the total WF of the proposed Italian diet. Each of milk, extra-virgin olive oil, meat cuts, and bread represents more than 5% of the total WF. The seven previously mentioned food products represent about 80% of the proposed diet WF , that is about 70%  higher than that of the proposed diet .The current Italian food consumption pattern presents a WF (1638.30 mThat means that a full adherence to the proposed MD for the last 6 years (from 2006 to the end of 2011) would have allowed saving more than 152,749 million cubic meters of water Table .This water saving represents about 294 times the blue domestic water consumption in Italy in 2005 . In othe3/year  to 696.6 kg/ha recorded in Egypt (2008). In the same period, average fertilizers consumption ranged between 11.6 kg/ha recorded in Algeria and 563.0 kg/ha recorded in Egypt. Fertilizer consumption in Egypt is even 4.5 higher than that recorded in the European Union. That can be explained by the fact that almost the whole arable land in Egypt is irrigated and agriculture is intensive. In the period 2002–2009, the average fertilizers consumption in the 21 target Mediterranean countries was 188.0 kg/ha, so higher than the worldwide average (116.3 kg/ha of arable land). During the same period, the average fertilizers consumption in the Middle East & North Africa (90.6 kg/ha) was lower than the levels of fertilizers consumption in the Euro area (179.9 kg/ha) and the European Union countries (155.5 kg/ha).Considering the period 2002–2009, fertilizers consumption decreased in almost all target Mediterranean countries. In fact, it increased only in Egypt (70.3%), Cyprus (22.3%), Montenegro (11.3%), Tunisia (18.3%), and Turkey (23.7%). The highest decrease was recorded in Lebanon (−188.9%) and Slovenia (−161.6%).In the period 2002–2010, mineral nitrogen consumption ranged between 0.1 kg/ha recorded in Algeria in 2005 and 468.9 kg of mineral nitrogen/ha of agricultural land recorded in Egypt in 2003. In the Mediterranean region are used on average 52.9 kg N/ha. During the same period, the highest average nitrogen use was recorded in Egypt (373.0 kg N/ha) while the lowest was recorded in Algeria (0.9 kg N/ha) , Tunisia (+3.1 kg N/ha), Turkey (+5.3 kg N/ha), and Egypt (+75.7 kg N/ha). The highest decrease was recorded in Croatia (−59.8 kg N/ha).Mineral nitrogen trade balance (export – import) is negative in the Mediterranean area. Considering the period 2002–2010, mineral nitrogen trade deficit increased from −1,275,809 to −1,441,037 tonnes of nitrogen, i.e., +165,228 N tonnes. As of 2010, almost all the Mediterranean countries are net mineral nitrogen importers except Israel, Jordan, Tunisia, Croatia, Libya, Morocco, and Egypt. The top net mineral nitrogen exporters are Egypt  and Morocco . Meanwhile, the top net mineral nitrogen importers are France (−1635 N tonnes), Turkey (−967175 N tonnes), Italy (−409540 N tonnes), Spain (−369243 N tonnes), and Greece (−124780 N tonnes).High fertilizers, especially nitrogen ones, use calls in question the environmental sustainability of the current Mediterranean food consumption patterns.Food losses and waste (FLW) reduction is now considered as essential to reduce the environmental footprint of food systems , 68–72. The long food products journey involves consumption of resources, labor, and, consequently, of GHG emissions. So, when considering a foodstuff throughout its life cycle, one must also take into account the water, energy, and resources consumed, and, therefore, wasted when this food becomes refuse .2 eq.each year  and major source of negative impacts including emissions of GHG at disposal (3.3 billion tons of GHGs released into the atmosphere) , 75. Indach year .Many recent scientific studies have attempted to analyze environmental impacts of FLW usually addressing categories such as GHG emissions (CF) , WF [e.3  of water are lost or wasted by Mediterranean people , holds much of the blame for environment problems .For fostering and speeding up transition toward more sustainable food consumption patterns profound changes in both food consumption and food production are necessary. Efforts relating to the promotion of sustainable agriculture should be complemented by consumption-related measures. In fact, developing a sustainable food system requires transformative and simultaneous interventions covering all phases of the food chain, i.e., from field to fork. It also requires unprecedented, large-scale behavior change. Sustainability in food systems means addressing coherently and simultaneously the consumptive demand and productive supply elements by fostering smarter and efficient food production systems and diets.Improving food consumption patterns in the Mediterranean region implies minimizing pressure on natural resource and externalities over the life cycle. Sustainable food consumption encompasses sustainable diets, water consumption decrease, waste reduction, sustainable supply chains, and energy use efficiency improvement. Preference should be given for diets that have low environmental impacts, but provide the required amount of nutrients (including micronutrients) and energy for a healthy life and a sustainable lifestyle. These diets should be based on local, seasonally produced, minimally processed, ecologically packed, and tasteful foods.biocapacity, i.e., the regenerative capacity of Mediterranean ecosystems, is decreasing.Pressure on the scarce natural resources, especially water, is expected to increase due to demographic changes in SEMCs. Food demand increase will have effects on volumes of irrigation water. Nowadays, almost 65% of Mediterranean freshwater resources are used in irrigated agriculture. The ecological deficit and debt of the Mediterranean region will further increase in the coming years as the EF per capita is increasing while the Resource use intensity is still high in Mediterranean countries. The average fertilizers consumption in the Mediterranean countries is higher than the worldwide average. Mineral nitrogen consumption remains high in many Mediterranean countries especially those that rely on intensive irrigated agriculture . The Mediterranean region is a net mineral nitrogen importer.The WF of consumption varies widely amongst Mediterranean countries. Nevertheless, more than 90% of the total WF of consumption in the Mediterranean region is due to agricultural products consumption. Meat, dairy products, and wheat represent more than a half of the WF of food supply in Mediterranean countries. The contribution of meat and dairy products is higher in northern Mediterranean countries with respect SEMCs. Cereals supply accounts for more than a third of the WF of food supply in some SEMCs such as Egypt, Morocco, and Turkey.The enhancement and promotion of the MD is crucial for food consumption environmental sustainability. MD promotion measures can contribute to sustainable natural resources management. The Italian case study shows clearly that a significant water saving can be yielded thanks to adherence to the Mediterranean dietary pattern. In fact, the WF of the current Italian dietary pattern is much higher than that of the suggested MD.It is important, furthermore, to reduce food wasted throughout the food chain to make the Mediterranean food system more sustainable. For this reason it is of paramount importance to alert consumers to the environmental implications of their food-related behavior . FLW reduction can ease pressure on natural resources and free up water resources and land for other development purposes, societal needs and economic sectors.intersectoral research to simultaneously address food and environmental sustainability. In particular, it is important to assess the environmental sustainability of the Mediterranean food consumption patterns taking into account the different environmental footprints . Food waste is another issue that should be taken into account for assessing more accurately the environmental sustainability of diets.Transition toward a sustainable food system in the Mediterranean region requires developing integrated, coherent, comprehensive and holistic policies dealing with nutrition, health, agriculture, environment and natural resources, economy, society, and culture. Multifaceted actions and interventions should be implemented as a package to yield the desired sustainable changes. Policies and actions at all levels require more and better These activities require a shared regional multi-actor governance model involving policy makers, academia, and scientific community as well as representatives of farmers, the food industry, the civil society and consumer organizations. Coordinated actions are needed at all levels . Local multi-actor partnerships and initiatives to achieve sustainable food systems can be scaled up within sound regional regulatory frameworks.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.


Prevalence estimates of ankylosing spondylitis vary considerably, and there are few nationwide estimates. The present study aimed to describe the national prevalence of clinically diagnosed ankylosing spondylitis in Sweden, stratified according to age, sex, geographical, and socio-economic factors, and according to subgroups with ankylosing spondylitis-related clinical manifestations and pharmacological treatment.All individuals diagnosed with ankylosing spondylitis according to the World Health Organization International Classification of Disease codes, between 1967 and 2009, were identified from the National Patient Register. Data regarding disease manifestations, patient demographics, level of education, pharmacological treatment, and geographical region were retrieved from the National Patient Register and other national registers.P < 0.001), a higher frequency of anterior uveitis  and were more likely to receive tumor necrosis factor inhibitors than women . Women were more likely than men to have peripheral arthritis , psoriasis , and treatment with oral corticosteroids .A total of 11,030 cases with an ankylosing spondylitis diagnosis  were identified in the National Patient Register, giving a point prevalence of 0.18% in 2009. The prevalence was higher in northern Sweden, and lower in those with a higher level of education. Men had a higher prevalence of ankylosing spondylitis  contains supplementary material, which is available to authorized users. Ankylosing spondylitis (AS) is a chronic inflammatory disorder primarily involving the sacroiliac joints and spine. It is associated with both articular and extra-articular clinical manifestations, including peripheral arthritis, enthesitis, anterior uveitis, psoriasis, and inflammatory bowel disease. The first symptoms usually occur before the age of 30 and seldom occur after the age of 45 . The chrCompared with rheumatoid arthritis (RA), few studies have examined the prevalence of AS. The prevalence in Europe, North America, and China is estimated at 0.03 to 1.8% -17; howeThe highly varying estimates in the West may reflect differences in study methodology. Studies used different sampling sources, including local health records ,13,10, sAccurate and contemporary prevalence estimates, including the frequency of AS-related clinical manifestations and pharmacological treatments, as well as socio-economic and geographical variations, are important for healthcare planning, and they may provide clues to possible risk factors for the disease. Furthermore, little is known about differences in disease manifestations and pharmacological treatments between the sexes at the population level. One approach to obtaining such information is to use national healthcare registers, a method that has only been used on a regional level for AS , but wasThe primary aim of the present study was to assess the total national point prevalence of clinically diagnosed AS in Sweden in December 2009, and to stratify the prevalence according to age, sex, geographical and socio-economic factors. We also stratified the prevalence according to AS-related clinical manifestations and pharmacological treatments. The secondary aim was to compare disease manifestations and pharmacological treatments between the sexes.The data used in this nationwide, population-based study were obtained from the Swedish national healthcare registers.Healthcare provision in Sweden is largely funded by the taxpayer and is independent of individual financial or insurance considerations. There is an upper limit to an individual’s yearly costs for medical consultations and prescription medications. Patients with an inflammatory rheumatic disease such as AS are usually diagnosed at public or (less commonly) private rheumatology clinics. Such cases are rarely definitively diagnosed in a primary care setting .Ethical approval for the study was granted by the Regional Ethics Committee, Karolinska Institute, Stockholm, Sweden. Patient consent was waived, as data were derived either from administrative registers that do not require informed consent or quality registers where the consent is already given at the time point of first registration.The NPR comprises the Inpatient Register (IPR) and the Outpatient Register (OPR). The IPR was launched in 1964, and complete national coverage  was achieved in 1987. The IPR contains data  derived from all patients discharged from hospitals in Sweden . The OPRThe Swedish Prescribed Drug Register  containsDemographic data were obtained from Statistics Sweden , which hVital status on 31 December 2009 was determined via the cause-of-death register , which pAll data in the Swedish national healthcare registers are accessed via a personal identification number, which provides the link between all of the registers used in the present analyses .All individuals with an ICD diagnosis registration of AS between 1967 and 2009 were identified from the NPR  in obtaining a definitive diagnosis from a specialist in Sweden ,15, mean years inThere are six healthcare regions in Sweden: one northern, one southern, and four in between . These regions were used to calculate the regional prevalence of clinically diagnosed AS and are presented in Additional file The level of formal education was classified into three categories . The prevalence of clinically diagnosed AS in relation to the level of education is presented for those aged ≥30 years, the age by which the majority of the population is expected to have completed their studies.t-test was used for normally distributed continuous variables. P-values <0.05 were considered statistically significant. For comparisons between geographical location and socio-economic factors, statistical significance was based on the absence of overlap between the estimated 95% confidence interval (CI). Logistic regression models adjusted for age and AS-related clinical manifestations  were used to examine sex-related differences in treatment patterns. All analyses were performed using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp and Microsoft Excel 2010, Microsoft Corporation, One Microsoft Way, Redmond, WA, USA.The total point prevalence of clinically diagnosed AS was estimated on 31 December 2009 according to both the base case and strict case definitions, and after stratification according to sex and age. Despite the cumulative ascertainment of AS cases, the term “point prevalence” is used. Considering that AS is a chronic disease, individuals with a previous registered AS diagnosis, alive and living in Sweden in 2009, are assumed having an AS diagnosis on 31 December 2009 as well. The point prevalence of AS was thus calculated by taking the number of AS individuals according to each definition and dividing it by the Swedish population on 31 December 2009 with similar age. Furthermore, the prevalence was estimated for subgroups based on AS-related clinical manifestations and pharmacological treatment, by taking the number of AS individuals (according to the base case definition) having dispensed prescriptions for each pharmacological treatment during any part of 2009, or those with a registered diagnosis of AS-related disease manifestations between 1967 and 2009, and dividing it by the Swedish population on 31 December 2009 with similar age. Crude and age-/sex-standardized point prevalence estimates according to healthcare region and level of formal education were also calculated. Standardization was performed to the Swedish population aged 16 to 64 years in 2009. For comparisons between the sexes, the Chi-squared test was used for categorical variables, and the Student’s On 31 December 2009, the population of Sweden was about 9.3 million, of which 64%  were aged 16 to 64 years (the denominator in this study). Males accounted for 50.8%.We identified 20,044 AS cases registered in the NPR between 1967 and 2009  on 31 December 2009, according to both base case and strict case definitions, was 0.18%  and 0.14% , respectively. Of the AS cases identified between 1967 and 2009 according to the base case definition, 68.4% had a registered visit in the NPR during the period 2005 to 2009 . The prevalence of AS according to the base case definition having any dispensed prescription for NSAIDs during 2009 was 0.10%, while the prevalence for those with any dispensed prescription for sDMARDs or TNFi during 2009, or those registered with AS-related clinical manifestations between 1967 and 2009, was considerably lower , whereas men were more often treated with TNFi (P < 0.001) (Table P < 0.001), and peripheral arthritis and psoriasis were more common in women  (Table P < 0.001) and oral corticosteroids  remained significant after adjustment for age and AS-related clinical manifestations  in logistic regression models.There were differences between the sexes with regard to pharmacological treatments received during 2009. Women were more often treated with oral corticosteroids than men P < 0.00, whereasData regarding demographics, disease manifestations, pharmacological treatment, and sex-related differences were similar regardless of whether the base case or strict case definitions of AS were used, as shown in detail in Additional file P < 0.001). The male-to-female ratio was highest after the age of 50; however, it was lower for younger age groups , whereas that in the Southern Region was 0.16% ; however, there was no clear north–south gradient with regard to prevalence of AS across the rest of the country . A higher prevalence was observed in those with a lower level of education: ≤9 years  or 10 to 12 years  of schooling, as shown in Additional file This nationwide, register-based study revealed that the point prevalence of clinically diagnosed AS in Sweden in 2009 was 0.18%. The prevalence was lower in those with the highest level of education and higher in those living in the north. Furthermore, the prevalence was higher in men than women. In addition, the frequency of anterior uveitis and treatment with TNFi was higher in men than in women. On the other hand, women had more registered diagnoses related to peripheral arthritis and psoriasis, and were more frequently treated with oral corticosteroids.Estimates of AS prevalence vary considerably. Differences in study design and population genetics are the most likely explanations; however, geographical, environmental, and socio-economic factors may also play a role. In northern Norway, the prevalence of AS is reported to be 0.21% , which iAccording to the results presented herein, sex appears to play a role in AS prevalence. First, the prevalence of AS was higher in men than women across all age groups; this was expected given the results of previous studies ,15,7. FuWe also found geographical and socio-economic differences in AS prevalence. Previous studies may have lacked sufficient data or the power to evaluate such differences ,7. The hThe present study has several strengths. First, it is the first nationwide prevalence study on clinically diagnosed AS. Previous studies were either based on regional or small national population samples, with limited generalizability. Second, in contrast to smaller regional studies, we used a uniform case ascertainment over a large geographical area, enabling us to demonstrate geographical variations in disease occurrence, which may reflect differences in genetic, environmental, and socio-economic factors. Third, the register-based approach (using AS diagnoses made by physicians) reflects the real disease burden as estimates of AS occurrence are based on clinical diagnoses, and enables the assessment of the frequency of AS-related clinical manifestations and pharmacological treatments.The study also has a number of limitations. First, a register-based approach does not identify patients not seeking contact with a healthcare practitioner, since it only identified clinically diagnosed cases. Second, the NPR does not cover AS cases that are managed exclusively in a primary care or private setting. According to a previous study from southern Sweden, only 3% of AS patients are being followed exclusively in primary care , usuallyTo conclude, this nationwide, register-based prevalence estimate of clinically diagnosed AS in Sweden offers a unique opportunity to improve our understanding of the real burden that AS places on the healthcare system. We identified phenotypical and pharmacological treatment differences between the sexes, and differences in disease prevalence related to geographical region and socio-economic factors, suggesting that genetic and (possibly) environmental factors may be important for the development of AS.


Introduction. Impaired placentation and inadequate trophoblast invasion have been associated with the etiology of many pregnancy complications and have been correlated with the first trimester uterine artery resistance. Previous studies have shown the benefits of yoga in improving pregnancy outcomes and those of yogic visualization in revitalizing the human tissues. Methods. 59 high-risk pregnant women were randomized into yoga (n = 27) and control (n = 32) groups. The yoga group received standard care plus yoga sessions , from 12th to 28th week of gestation. The control group received standard care plus conventional antenatal exercises . Measurements were assessed at 12th, 20th, and 28th weeks of gestation. Results. RM-ANOVA showed significantly higher values in the yoga group (28th week) for biparietal diameter (P = 0.001), head circumference (P = 0.002), femur length (P = 0.005), and estimated fetal weight (P = 0.019). The resistance index in the right uterine artery (P = 0.01), umbilical artery (P = 0.011), and fetal middle cerebral artery (P = 0.048) showed significantly lower impedance in the yoga group. Conclusion. The results of this first randomized study of yoga in high-risk pregnancy suggest that guided yogic practices and visualization can improve the intrauterine fetal growth and the utero-fetal-placental circulation. Impaired placentation and fetoplacental hypoxia have been associated with the etiology of a number of pregnancy complications . Proper The word “yoga” is derived from the Sanskrit verb yuj, which means union. This refers to the union of the individual consciousness with that of the Universal Divine Consciousness that can be achieved by a wide variety of practices that range from certain postures (yoga asanas), breathing exercises (pranayama), hand gestures (mudras), cleansing exercises (kriyas), relaxation, and meditation techniques. The latter two include a wide range of practices, including visualization, guided imagery, and sound resonance practices. The rational for using these techniques requires a brief introduction on prana and its movements in the body.The rationale for using techniques requires a brief introduction on prana and its movement in the body. According to the yogic sciences, beyond the physical body is the more subtle, pranic body, where the prana flows, and the mental body, where our thoughts are processed . The freP = 0.018, 0.042, 0.049, and 0.05, resp.) and significantly fewer small-for-gestational-age (SGA) babies and newborns with low APGAR scores (P = 0.006) in the yoga group (P = 0.033) [Being over 5000 years old, the science of yoga has been shown to impact a variety of physical and psychological health conditions, including anxiety, depression, metabolic syndrome, cancer, and cardiovascular, musculoskeletal, and pulmonary disorders , 10. Add= 0.033) . Ultraso= 0.033)  are not α set at 0.05, probability of type I error at 0.01, powered at 0.8, a minimum sample size of 27 per group was obtained. As there were no published studies on yoga in high-risk pregnancies at the time of designing this study, we used the event ratios from the closest study by Kanako [Using the event ratios  reported in a Japanese study, with y Kanako  on simplThis was a randomized controlled prospective stratified single-blind trial. “Single-blind” refers to the fact that gynecologists, obstetricians, radiologists, and laboratory staff were blinded to the group selection. The trial was conducted at the Obstetric Unit of St. John's Medical College and Hospital (SJMCH) and Gunasheela Maternity Hospital (GMH) in Bengaluru, India.Inclusion Criteria. Pregnant women within 12 weeks of gestation and with any of the following risk factors were considered qualified for the study: (1) history of poor obstetrical outcomes ; (2) twin pregnancies; (3) extremes of age: maternal age below 20 or above 35 years; (4) obesity: maternal body mass index of above 30; and/or (5) family history of poor obstetrical outcomes among blood relatives, that is, sister, mother, or grandmother. Groups were stratified at recruitment based on risk factors and the numbers were equal for each risk factor. However missing data during the study did not permit us to keep the groups matched for the analysis. Exclusion criteria: (1) Severe renal, hepatic, gallbladder, or heart disease; (2) structural abnormalities in the reproductive system; (3) hereditary anemia; (4) seizure disorders; (5) sexually transmitted diseases, or (6) any medical conditions that prevented the subject from safely and effectively practicing the interventions. While we did not exclude women with diabetes or essential hypertension, none of the participants enrolled in the study were ever diagnosed with these conditions prior to this pregnancy.www.graphpad.com/quickcalcs/randomize1.cfm, last accessed on June 16, 2013) to randomize a set of numbers into two groups. The selections (yoga or control) were then written on paper slips and placed in opaque envelopes, sealed, numbered, and kept in a locked cabinet. Recruited participants were assigned an ID and were permitted to pick one of the available envelopes to determine their group selection.Subjects within the 12th week of gestation were approached by a research staff at the reception of the Obstetrics Department of SJMCH or GMH and introduced to the project. Those who were interested were escorted by a staff to an annex room in the outpatient department itself, where the study was explained in detail, and then were screened using a written protocol. Qualified subjects were given the opportunity to sign the informed consent form in order to complete the recruitment and begin the randomization process. We used an online random number generator by GraphPad Software . The yoga group received standard care plus one-hour yoga session three times a week at the center and were instructed to practice the same routines at home. The control group received standard care plus walking for half an hour mornings and evenings . The subjects in both groups were asked to keep a diary of their practices and daily physical activities, which was checked by the research staff during each of their visits to the antenatal department. The yoga classes were conducted by trained certified postgraduate yoga therapists, who used an instruction manual to conduct the classes at a reserved room within the premises of SJMCH/GMH. Standard care offered to both groups included the following: (1) pamphlets about diet and nutrition during pregnancy, (2) regular checkups by the obstetrician, and (3) biweekly follow-ups by the research staff. The purpose of these biweekly telephone follow-ups was to check if the subjects were adhering to their intervention practices and routine hospital check-ups.The yoga intervention was selected very carefully from three categories: (1) yogic postures, (2) relaxation and breathing exercises, and (3) visualization with guided imagery. The yogic postures were chosen to reduce the physical side effects of pregnancy, such as edema, and strengthen the perineal muscles for delivery. The relaxation and breathing exercises were aimed at reducing the maternal stress. The visualization with guided imagery exercises were the backbone of this study and the rationale for their use is discussed in detail in Discussion. They were designed to test two hypotheses: (1) when attention moves in an area of the body, it causes the prana in that area also to move and (2) better movement of prana in an area of the body implies better circulation in that area. Due to the importance of these visualization and guided imagery practices in this study, a brief explanation of them is warranted. In the initial visualization and guided imagery session, the subjects were asked to focus their attention on the place between the nostrils and the upper lip where the air is felt during inhalation and exhalation. In the following visualization and guided imagery sessions, the subjects were asked to visualize the fetus in the uterus and the umbilical cord connecting the fetus to the placenta. Then the participants were guided to visualize healthy blood flow from the mother's heart into the placenta, through the umbilical cord, and bringing nourishment to the fetus.t-test was used for variables that followed a Gaussian distribution at baseline and Mann-Whitney nonparametric test for those that did not. Chi-Square test was used to test significance between groups when frequencies were used.For data analysis, PASW Statistics (formerly known as SPSS) version 18.0.3 for Mac was used. Shapiro-Wilk's test was used to test the normality of data. For Doppler and fetal parameters with three measurements in time, repeated measures ANOVA (RM-ANOVA) was performed. However, if the difference between the baseline data of the two groups was statistically significant , then ANCOVA test was used, while keeping the baseline data as covariate. When there were only two measurements in time, Independent Samples The consort diagram is presented in A self-reported questionnaire was used to collect demographic data, which included the subjects' age, weight, height, socioeconomics, education, and religion. The financial status of the subjects was measured in two ways: (1) subjectively, by recording the monthly household income (in Indian rupees) reported by the subjects, and (2) objectively, by having the subjects complete a socioeconomic status (SES) form, used by other Indian research groups at SJMCH, which scored the possessions and household features and produced a total score ranging from 0 to 60. These demographic data are listed in P values, resp.). As the baseline fetal heart rate (FHR) was significantly different (P = 0.036) in the two groups, we used ANCOVA test keeping the baseline values as covariate, which showed significantly lower FHR in the yoga group after 8 weeks (P = 0.012) and 16 weeks (P = 0.001) of intervention.The ultrasound fetal measurements are shown in P = 0.01, RM-ANOVA) and near significance results for the PI . In the left uterine artery, near significant result was obtained for RI  and PI . At baseline (12 weeks of gestation), the right uterine artery diastolic notch was detected in 22.6% of the subjects in the yoga group compared to 18.4% in the control group (P = 0.67). In the left uterine artery, the percentages were 32.3% and 21.1%, respectively (P = 0.29). The number of cases with diastolic notch in the uterine arteries was reduced in both groups as the pregnancy progressed and the interventions were administered. There were much fewer cases in the yoga group compared to the control group, though the differences were not statistically significant.Systolic over diastolic ratio (S/D ratio), pulsatility index (PI), resistance index (RI), and diastolic notch were measured in right and left uterine arteries at the 12th, 20th, and 2nd weeks of gestation. These results are listed in The S/D ratio, the PI, and the RI parameters of the umbilical and fetal middle cerebral arteries were assessed at the 20th and 28th weeks of gestation through ultrasound Doppler velocimetry. It was not possible to measure these parameters at the 12th week of gestation. All the parameters, except for the RI of the umbilical artery, which showed near significant results, were significantly improved in the yoga group at the 28th week of gestation. All the parameters for the umbilical artery were significantly better in the yoga group even at the 20th week of gestation. The results for the fetoplacental circulation are listed in The arterial resistance index (RI) has been defined to be a measure of pulsatile blood flow that reflects the resistance to blood flow caused by microvascular bed distal to the site of measurement . A resisP = 0.01), while it reached near significance (P = 0.08) values for the left uterine artery. Also, the RI in the umbilical artery was significantly better in the study group after 8 weeks of intervention (the 20th week of measurement) and in the fetal MCA after 16 weeks (28th week of measurement) of interventions. Furthermore, significantly fewer occurrences of pregnancy induced hypertension (PIH), preeclampsia, gestational diabetes (GDM), and intrauterine growth restriction (IUGR) cases were observed in the yoga group  [P = 0.033) [P = 0.006) [P < 0.001), the head circumference (P = 0.002), the femur length (P = 0.005), and the estimated fetal weight (P = 0.019) in the yoga group.This randomized control study on yoga-based visualization and relaxation in high-risk pregnancy has shown significantly better uteroplacental and fetoplacental blood flow velocity in the yoga group compared to the control group. The RI in the right uterine artery was significantly better in the yoga group  . Signifi= 0.033) . Also, A= 0.006) . As far P = 0.01) and not significant at the 28th week (P = 0.091). The reading may have been influenced by the growing uterus. If so, the increase in MCA flow in the 28th week may indicate that the blood flow to the fetus was still improved in the yoga group although it did not show in the umbilical artery. This hypothesis is further supported by the fact that, in the yoga group, most fetal measurements were significantly improved and significantly fewer complications were observed.Interestingly, the umbilical RI was highly significant at the 20th week of measurement (P < 0.018). However, this study was not randomized and did not report any data on the resistance indices. We could not find any published Doppler study involving tai chi or qi gong in pregnancy. But use of exercise in pregnancy has been widely studied and the overall results support moderate-to-vigorous intensity exercises during pregnancy [Use of complementary and alternative (CAM) therapies during pregnancy has been on the rise globally . Yoga, dregnancy . Furtherregnancy .Antiplatelet agents, primarily low-dose aspirin , and calThe sample size for this study is too small to draw any definite conclusion on the mechanism of action of yoga on the reproductive blood flow during pregnancy. Nonetheless, we can examine potential previously argued hypothesis for the results that were observed in this study. Pregnancy itself is a stressful period in a woman's life and it is now believed that it exerts a larger load on the cardiovascular system than previously assumed . In contFinally, the yoga intervention used in this study was designed with emphasis on the yogic visualization and guided imagery, which, as previously stated, intended to test the hypothesis that when attention is moved to an area of the body, it causes prana to move in that area, which in turn improves circulation in the surrounding tissues. These are not exactly new ideas. Tirumular, an 8th century South Indian saint, once said, “Where the mind goes, the prana follows” . Using uP = 0.018), preeclampsia (P = 0.042), gestational diabetes (P = 0.049), and intrauterine growth restriction (P = 0.05) were observed in the yoga group. Significantly fewer number had small-for-gestational-age (SGA) babies in the study group (P = 0.033) [P = 0.006).In our earlier publication, we have shown that the yoga group had lesser number of complications than the control group which could be related to this improved blood flow. Significantly fewer occurrences of pregnancy induced hypertension (= 0.033) . Also, AThree participants in the yoga group experienced PIH and none suffered from preeclampsia or eclampsia. In the control group, there were 11 subjects with PIH, 4 with preeclampsia, and 2 with eclampsia . Only onThe sample size was too small to draw any conclusion on the potential effects of yoga on the diastolic notch of uterine arteries. The high-risk nature of the population for this study contributed to the lower sample size by increase of dropouts due to pregnancy complications. Another reason could have been our strict inclusion criteria that made recruitment more difficult. Furthermore, some of the subjects delivered in their hometowns and we were not able to collect all the necessary data required by the study from the corresponding institutions. This resulted in missing data. In addition, the other hospitals may have used different protocols in delivery, performing C-section or administrating medications during the delivery that could have impacted the outcome data but not the Doppler data that is the focus of this paper. Finally, one of the objectives of this pilot study was to gain knowledge for the design of a larger and more comprehensive follow-up study. We plan to include collection of other parameters, such as gravidity and parity, in the future studies.A great deal of efforts was spent in adhering to high standards of randomization and blinding. The data was very carefully entered, double-checked, and analyzed. Also, the sample profile matched closely that of the Bengaluru metropolitan population.We recommend a follow-up multicenter RCT with larger sample size powered by the data from this study. We also suggest three groups for such a trial, one control group  and two study groups. One of the study groups will do only the visualizations and guided imagery while the other study group practices the rest of the interventions alone.The result of this randomized controlled trial of yoga in high-risk pregnancy has shown that yogic visualization and guided imagery can significantly reduce the impedance in the uteroplacental and fetoplacental circulation. This pilot data can be used to power larger studies to confirm these results and elaborate on the mechanism of action.