scholarly journals Dietary patterns and whole grain cereals in the Scandinavian countries – differences and similarities. The HELGA project

2014 ◽  
Vol 18 (5) ◽  
pp. 905-915 ◽  
Author(s):  
Dagrun Engeset ◽  
Dag Hofoss ◽  
Lena M Nilsson ◽  
Anja Olsen ◽  
Anne Tjønneland ◽  
...  
Keyword(s):  
Dietary Patterns ◽  
Principal Component ◽  
Factor Loading ◽  
Health Study ◽  
Food Groups ◽  
Whole Grain ◽  
Food Items ◽  
Diet Pattern ◽  
Study Population ◽  
High Factor Loading

AbstractObjectiveTo identify dietary patterns with whole grains as a main focus to see if there is a similar whole grain pattern in the three Scandinavian countries; Denmark, Sweden and Norway. Another objective is to see if items suggested for a Nordic Food Index will form a typical Nordic pattern when using factor analysis.SettingThe HELGA study population is based on samples of existing cohorts: the Norwegian Women and Cancer Study, the Swedish Västerbotten cohort and the Danish Diet, Cancer and Health study. The HELGA study aims to generate knowledge about the health effects of whole grain foods.SubjectsThe study included a total of 119 913 participants.DesignThe associations among food variables from FFQ were investigated by principal component analysis. Only food groups common for all three cohorts were included. High factor loading of a food item shows high correlation of the item to the specific diet pattern.ResultsThe main whole grain for Denmark and Sweden was rye, while Norway had highest consumption of wheat. Three similar patterns were found: a cereal pattern, a meat pattern and a bread pattern. However, even if the patterns look similar, the food items belonging to the patterns differ between countries.ConclusionsHigh loadings on breakfast cereals and whole grain oat were common in the cereal patterns for all three countries. Thus, the cereal pattern may be considered a common Scandinavian whole grain pattern. Food items belonging to a Nordic Food Index were distributed between different patterns.

scholarly journals The reliability and relative validity of predefined dietary patterns were higher than that of exploratory dietary patterns in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam population

2020 ◽  
pp. 1-11
Author(s):  
Franziska Jannasch ◽  
Daniela Nickel ◽  
Matthias B. Schulze
Keyword(s):  
Mediterranean Diet ◽  
Dietary Patterns ◽  
Principal Component ◽  
Healthy Eating Index ◽  
Food Groups ◽  
Alternative Healthy Eating Index ◽  
Study Population ◽  
Traditional Mediterranean Diet ◽  
Dietary Data ◽  
Prospective Investigation

Abstract The aim of this study was to assess the ability of the FFQ to describe reliable and valid dietary pattern (DP) scores. In a total of 134 participants of the European Prospective Investigation into Cancer and Nutrition-Potsdam study aged 35–67 years, the FFQ was applied twice (baseline and after 1 year) to assess its reliability. Between November 1995 and March 1997, twelve 24-h dietary recalls (24HDR) as reference instrument were applied to assess the validity of the FFQ. Exploratory DP were derived by principal component analyses. Investigated predefined DP were the Alternative Healthy Eating Index (AHEI) and two Mediterranean diet indices. From dietary data of each FFQ, two exploratory DP were retained, but differed in highly loading food groups, resulting in moderate correlations (r 0·45–0·58). The predefined indices showed higher correlations between the FFQ (r(AHEI) 0·62, r(Mediterranean Diet Pyramid Index (MedPyr)) 0·62 and r(traditional Mediterranean Diet Score (tMDS)) 0·51). From 24HDR dietary data, one exploratory DP retained differed in composition to the first FFQ-based DP, but showed similarities to the second DP, reflected by a good correlation (r 0·70). The predefined DP correlated moderately (r 0·40–0·60). To conclude, long-term analyses on exploratory DP should be interpreted with caution, due to only moderate reliability. The validity differed extensively for the two exploratory DP. The investigated predefined DP showed a better reliability and a moderate validity, comparable to other studies. Within the two Mediterranean diet indices, the MedPyr performed better than the tMDs in this middle-aged, semi-urban German study population.

Associations between healthy Japanese dietary patterns and depression in Japanese women

2020 ◽  
pp. 1-13
Author(s):  
Kanae Konishi
Keyword(s):  
Depressive Symptoms ◽  
Dietary Patterns ◽  
Dietary Pattern ◽  
Depression Scale ◽  
Principal Component ◽  
Epidemiologic Studies ◽  
Japanese Women ◽  
Health Study ◽  
Food Groups ◽  
Cross Sectional

Abstract Objective: Higher quality dietary patterns such as healthy/prudent and Mediterranean dietary patterns have been protectively associated with depression. This study examined whether healthy Japanese dietary patterns, which differ from dietary patterns derived from Western areas, are associated with depressive symptoms among Japanese women. Design: A cross-sectional study (the Nagano Nutrition and Health Study). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. Dietary patterns were derived with a principal component analysis of the consumption of fifty-six food and beverage items, which were assessed by a validated brief diet history questionnaire. Setting: Nagano, Japan. Participants: Japanese women (n 1337) aged 20–72 years. Results: We identified three dietary patterns: ‘healthy Japanese’, ‘sweets-fat’ and ‘seafood–alcohol’. The highest quality dietary pattern was ‘healthy Japanese’. It is characterised by a high intake of vegetables, mushrooms, seaweed, soyabean products, potatoes, fish/shellfish and fruit. The age- and multivariate-adjusted OR (95 % CI) of depressive symptoms for the highest quartiles of the ‘healthy Japanese’ pattern score were 0·58 (95 % CI 0·41, 0·82) and 0·69 (95 % CI 0·45, 1·06), respectively. Meanwhile, no associations were observed for ‘sweets-fat’ and ‘seafood–alcohol’ patterns. Conclusions: The ‘healthy Japanese’ pattern may be inversely associated with depressive symptoms with an exposure-response association. The specific Japanese food groups in the ‘healthy Japanese’ pattern included mushrooms, seaweed, soyabean products and potatoes, as well as vegetables, fish/shellfish and fruit. These seem to create an anti-inflammation-prone dietary pattern, and this factor might be associated with better mental health.

scholarly journals The Development of Athlete Performance Capabilities Index (APCI) Model for Male U12 Player Selection using Multivariate Analysis

2018 ◽  
Vol 7 (4.34) ◽  
pp. 97
Author(s):  
Mohamad Razali Abdullah ◽  
Hafizan Juahir ◽  
N. Mohamad Shukri ◽  
N. A. Fuat ◽  
N. A. Mohd Ros ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Factor Score ◽  
Principal Component ◽  
Factor Loading ◽  
Group Classification ◽  
Performance Group ◽  
Two Factors ◽  
Low Performance ◽  
High Factor Loading ◽  
Athlete Performance

This study develops an Athlete Performance Capabilities Index (APCI) model using multivariate analysis for selecting the best player of under twelve (U12).  Measurement of anthropometrics and physical fitness were evaluated among 178 male players aged 12±0.52 years. Factor score derived by Principal Component Analysis were used to obtain a model for APCI and Discriminant Analysis (DA) were conducted to validate the correctness of group classification by APCI. Result was found two factors with eigenvalues greater than 1 were extracted which accounted for 62.00% of the variations present in the original variables. The two factors were used to obtain the factor score coefficients explained by 35.72% and 26.67% of the variations in athlete performance respectively. Factor 1 revealed high factor loading on fitness compared to Factor 2 as it was significantly related to anthropometrics. A model was obtained using standardized coefficient of factor 1. Three clusters of performance were shaped in view by categorizing APCI ≥ 75%, 25% ≤ APCI < 75% and APCI < 25% as high, moderate and low performance group respectively. Three discriminated variables out of thirteen variables were obtained using Forward and Backward stepwise mode of DA, which were weight, standing broad jump, and 40 meters’ speed. Such variables were established as essential indicator for selecting the best player among male U12.   

scholarly journals The food patterns of a multicenter cohort of Brazilian nulliparous pregnant women

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Maria J. Miele ◽  
Renato T. Souza ◽  
Iracema M. Calderon ◽  
Francisco E. Feitosa ◽  
Débora F. Leite ◽  
...  
Keyword(s):  
Pregnant Women ◽  
Dietary Patterns ◽  
Principal Component ◽  
Good Representation ◽  
Processed Foods ◽  
Food Groups ◽  
Dietary Recall ◽  
Complex Process ◽  
Nutrient Consumption ◽  
Main Components

AbstractAssessment of human nutrition is a complex process, in pregnant women identify dietary patterns through mean nutrient consumption can be an opportunity to better educate women on how to improve their overall health through better eating. This exploratory study aimed to identify a posteriori dietary patterns in a cohort of nulliparous pregnant women. The principal component analysis (PCA) technique was performed, with Varimax orthogonal rotation of data extracted from the 24-h dietary recall, applied at 20 weeks of gestation. We analysed 1.145 dietary recalls, identifying five main components that explained 81% of the dietary pattern of the sample. Dietary patterns found were: Obesogenic, represented by ultra-processed foods, processed foods, and food groups rich in carbohydrates, fats and sugars; Traditional, most influenced by natural, minimally processed foods, groups of animal proteins and beans; Intermediate was similar to the obesogenic, although there were lower loads; Vegetarian, which was the only good representation of fruits, vegetables and dairy products; and Protein, which best represented the groups of proteins (animal and vegetable). The obesogenic and intermediate patterns represented over 37% of the variation in food consumption highlighting the opportunity to improve maternal health especially for women at first mothering.

scholarly journals Comparing two methods for deriving dietary patterns associated with risk of metabolic syndrome among middle-aged and elderly Taiwanese adults with impaired kidney function

2020 ◽  
Author(s):  
Adi Lukas Kurniawan ◽  
Chien-Yeh Hsu ◽  
Hsiu-An Lee ◽  
Hsiao-Hsien Rau ◽  
Rathi Paramastri ◽  
...  
Keyword(s):  
Metabolic Syndrome ◽  
Kidney Function ◽  
Dietary Patterns ◽  
Dietary Pattern ◽  
Density Lipoprotein ◽  
Principal Component ◽  
Dietary Guidelines ◽  
Food Groups ◽  
Reduced Rank Regression ◽  
Sugary Drinks

Abstract Background: Dietary patterns were associated with the risk of chronic disease development and outcome-related diseases. In this study, we aimed to compare the correlation between dietary patterns and metabolic syndrome (MetS) using two methods for identifying dietary patterns.Methods: The participants (n = 25,569) aged ≥ 40 years with impaired kidney function were retrieved from Mei Jau (MJ) Health Screening database from 2008 to 2010. Dietary patterns were identified by principal component analysis (PCA) and reduced rank regression (RRR) from twenty-two food groups using PROC FACTOR and PROC PLS functions.Results: We identified two similar dietary pattern characteristics (high intakes of deep fried foods, preserved or processed foods, dipping sauce, meat, sugary drinks, organ meats, jam/honey, fried rice/flour products, instant noodles and eggs) derived by PCA and RRR. Logistic regression analysis revealed that RRR-derived dietary pattern scores were positively associated with an odds ratio (OR = 1.70, 95% CI: 1.56, 1.86) of having MetS than PCA-derived dietary pattern scores (OR = 1.38, 95% CI: 1.27, 1.51). The correlations between RRR-derived dietary pattern scores and elevated systolic and diastolic blood pressure (OR = 1.30 for both) or low high density lipoprotein cholesterol in women (OR = 1.32) were statistically significant but not significant in PCA-derived dietary pattern scores.Conclusions: Our findings suggest that RRR gives better results when studying behavior related dietary patterns in association with MetS. RRR may be more preferable to provide dietary information for developing dietary guidelines among people with MetS. Further studies with prospective measurements are needed to verify whether RRR is a useful analytic tool for the association between dietary patterns and other chronic diseases.

Abstract MP091: Healthy Eating Index and Food Based a Priori Diet Pattern Score and Mortality in Postmenopausal Women: The Iowa Women’s Health Study

Circulation ◽  
2012 ◽  
Vol 125 (suppl_10) ◽  
Author(s):  
Jaakko Mursu ◽  
Katie A Meyer ◽  
Kim Robien ◽  
Lisa Harnack ◽  
David R Jacobs
Keyword(s):  
Fatty Acids ◽  
A Priori ◽  
Total Mortality ◽  
Healthy Eating Index ◽  
Health Study ◽  
Food Groups ◽  
Diet Pattern ◽  
Disease Specific Mortality ◽  
Iowa Women's Health Study ◽  
Diet Score

Introduction Summary measures of food quality such as the Alternative Healthy Eating Index (AHEI) predict the risk of total mortality and cardiovascular disease (CVD). Most of the scores are impractical for public use in that they are based on selected nutrients rather than foods. We have created an a priori diet pattern score which is exhaustive and food based. Hypothesis We assessed the hypothesis that food quality scores (both AHEI and a priori diet score) are associated with a reduced risk of total and disease specific mortality. Methods We analyzed data from 24,859 postmenopausal women free at baseline in 1986 of diabetes, CVD and cancer and mean age 61.4 years in the Iowa Women’s Health Study. Food intake was assessed at baseline using a validated 127-food-item Harvard food frequency questionnaire. The AHEI score was calculated based on the values of 9 components; vegetables, fruits, nuts and soy, the ratio of white (seafood and poultry) to red meat, cereal fiber, trans fatty acids, the ratio of polyunsaturated fatty acids to saturated fatty acids, the use of multivitamins, and alcohol intake. Each component could contribute 0-10 points to the total AHEI score, except multivitamin use (2.5 points for non-users or 7.5 points for users). The a priori food score was based on intake categories for 34 food groups rated by expert judgment as positive (n=17), neutral (n=7) or negative (n=10); these judgments resulted in a plant-centered diet. The total score was the sum of the category scores (0-3) for positively rated food groups plus reverse scores (3-0) for negatively rated food groups. Through December 31, 2008, 8528 total, 2982 CVD, and 2675 cancer deaths were identified through the State Health Registry of Iowa and the National Death Index. Results Mean ± SD AHEI was 35.8 ± 9.5 and a priori diet score 38.5 ± 8.2; correlation between scores was 0.6. In proportional hazard regression models adjusted for age, energy intake, marital status, education, place of residence, high blood pressure, body mass index, waist-hip-ratio, hormone replacement therapy, physical activity and smoking, relative risk (RR) was computed for highest vs. lowest quartile of the diet score. For AHEI, the multivariable adjusted RR was 0.82 (95% CI: 0.77-0.88) for total mortality. For CVD and cancer mortality the multivariable adjusted RRs for AHEI were 0.73 (95% CI: 0.65-0.82) and 0.86 (95% CI: 0.76-0.97), respectively. The a priori diet score had a multivariable adjusted RR for total mortality of 0.76 (95% CI: 0.71-0.81). For CVD and cancer mortality, the multivariable adjusted RRs for a priori diet score were 0.77 (95% CI: 0.69-0.87) and 0.83 (95% CI: 0.73-0.92), respectively. Conclusions In conclusion, both the food-based a priori diet score and the food- and nutrient-based AHEI were associated with a reduced risk of total and disease specific mortality in older women. A food-based score may be more practical for public health policy.

scholarly journals Adherence to Pre-pregnancy DASH Dietary Pattern and Diet Recommendations from the American Heart Association and the Risk of Preeclampsia (OR35-06-19)

2019 ◽  
Vol 3 (Supplement_1) ◽  
Author(s):  
Mariel Arvizu ◽  
Jennifer Stuart ◽  
Janet Rich-Edwards ◽  
Audrey Gaskins ◽  
Bernard Rosner ◽  
...  
Keyword(s):  
Dietary Pattern ◽  
American Heart Association ◽  
American Heart ◽  
Smoking Status ◽  
Heart Association ◽  
Dietary Guidelines ◽  
Health Study ◽  
Dash Score ◽  
Food Groups ◽  
Whole Grain

Abstract Objectives Because the relationship between diet and hypertensive disorders of pregnancy (HDPs), including preeclampsia, remains unclear we aim to evaluate the association between pre-pregnancy adherence to the American Heart Association (AHA) diet recommendations and the Dietary Approaches to Stop Hypertension (DASH) dietary pattern with risk of developing preeclampsia (PE). Methods Our prospective cohort study included 20,024 pregnancies from 13,645 women enrolled in the Nurses’ Health Study II (NHS2) (1991 to 2007). Pre-pregnancy diet was measured in 1991 by a semi-quantitative food frequency questionnaire and updated every four years. Pregnancy outcomes were self-reported every 2 years during follow-up. We derived the DASH scores based on the intake of 8 food groups (fruits and fruit juices, vegetables, whole-grain, red and processed meats, nuts and legumes, sugar sweetened beverages, and sodium). The AHA score was derived from 5 food groups (fruits and vegetables, whole grain, fish, SSBs and sodium) consistent with AHA dietary guidelines to reduce hypertension in the general population. We estimated the RR and 95% CIs of PE by log-Poisson regression employing generalized estimating equations and adjusting for total energy intake, age at pregnancy, BMI, physical activity, parity, smoking status, infertility, marital status, multivitamin use, and gestational diabetes. Results HDPs were reported in 1,089 (5.4%) pregnancies, of which 505 (2.5%) were PE. The DASH score (max points = 40) ranged from 16 to 32 points and the AHA score (max score = 50) ranged from 18 to 41 points in our population. Compared to women in the lowest quintile of adherence to the AHA, the RR (95%CI) of PE in quintiles 2, 3, 4, and 5 were 0.88 (0.68, 1.14), 0.87 (0.66, 1.15), 0.83 (0.64, 1.09), and 0.79 (0.60, 1.06), respectively (p-trend = 0.09). Similarly, the RR (95%CI) of PE among women in increasing quintiles of adherence to the DASH score was 0.88 (0.68, 1.13), 0.72 (0.55, 0.94), 0.80 (0.61, 1.05), and 0.62 (0.45, 0.84) compared to women in the lowest quintile (p-trend = 0.002). Conclusions Stronger pre-pregnancy adherence to the DASH dietary pattern was inversely associated to developing PE among participants of the NHS2. Funding Sources Supported by National Institutes of Health grants UM1-CA176726, P30-DK046200, U54-CA155626, and T32-DK007703-16.

scholarly journals Clustering of Dietary Patterns and Lifestyles Among Spanish Children in the EsNuPI Study †

Nutrients ◽  
2020 ◽  
Vol 12 (9) ◽  
pp. 2536
Author(s):  
Julio Plaza-Díaz ◽  
Esther Molina-Montes ◽  
María José Soto-Méndez ◽  
Casandra Madrigal ◽  
Ángela Hernández-Ruiz ◽  
...  
Keyword(s):  
Dietary Patterns ◽  
Dietary Pattern ◽  
Parental Education ◽  
Dietary Habits ◽  
Pediatric Population ◽  
Age Groups ◽  
Principal Component ◽  
Lifestyle Factors ◽  
Study Cohort ◽  
Food Groups

Dietary patterns (DPs) are known to be tied to lifestyle behaviors. Understanding DPs and their relationships with lifestyle factors can help to prevent children from engaging in unhealthy dietary practices. We aimed to describe DPs in Spanish children aged 1 to <10 years and to examine their associations with sociodemographic and lifestyle variables. The consumption of toddler and young children milk formulas, enriched and fortified milk within the Spanish pediatric population is increasing, and there is a lack of evidence whether the consumption of this type of milk is causing an impact on nutrient intakes and if they are helping to reach the nutrient recommendations. Within the Nutritional Study in the Spanish Pediatric Population (EsNuPI), we considered two study cohorts and three different age groups in three year-intervals in each of them. The study cohort included 740 children in a representative sample of the urban non-vegan Spanish population and 772 children in a convenience cohort of adapted milk consumers (AMS) (including follow-on formula, toddler’s milk, growing up milk, and fortified and enriched milks) who provided information about sociodemographics, lifestyle, and dietary habits; a food frequency questionnaire was used for the latter. Principal component analysis was performed to identify DPs from 18 food groups. Food groups and sociodemographic/lifestyle variables were combined through a hierarchical cluster algorithm. Three DPs predominated in every age group and study sample: a palatable energy-dense food dietary pattern, and two Mediterranean-like DPs. However, children from the AMS showed a predominant dietary pattern markedly related to the Mediterranean diet, with high consumption of cereals, fruits and vegetables, as well as milk and dairy products. The age of children and certain lifestyle factors, namely level of physical activity, parental education, and household income, correlated closely with the dietary clusters. Thus, the findings provide insight into designing lifestyle interventions that could reverse the appearance of unhealthy DPs in the Spanish child population.

scholarly journals Investigating differences in dietary patterns among a small cross-sectional study of young and old Pacific peoples in NZ using exploratory factor analysis: a feasibility study

BMJ Open ◽  
2019 ◽  
Vol 9 (3) ◽  
pp. e023126 ◽  
Author(s):  
Ridvan Tupai-Firestone ◽  
Soo Cheng ◽  
Joseph Kaholokula ◽  
Barry Borman ◽  
Lis Ellison-Loschmann
Keyword(s):  
New Zealand ◽  
Dietary Patterns ◽  
Generational Differences ◽  
Dietary Diversity ◽  
Limited Range ◽  
Healthy Diet ◽  
Food Groups ◽  
Cross Sectional ◽  
Food Items ◽  
The Relationship

ObjectivesObesity among Pasifika people living in New Zealand is a serious health problem with prevalence rates more than twice those of the general population (67% vs 33%, respectively). Due to the high risk of developing obesity for this population, we investigated diet quality of Pacific youth and their parents and grandparents. Therefore, we examined the dietary diversity of 30 youth and their parents and grandparents (n=34) to identify whether there are generational differences in dietary patterns and investigate the relationship between acculturation and dietary patterns.MethodsThe study design of the overarching study was cross-sectional. Face-to-face interviews were conducted with Pasifika youth, parents and grandparents to investigate dietary diversity, that included both nutritious and discretionary food items and food groups over a 7 day period. Study setting was located in 2 large urban cities, New Zealand. Exploratory factor analyses were used to calculate food scores (means) from individual food items based on proportions consumed over the week, and weights were applied to calculate a standardised food score. The relationship between the level of acculturation and deprivation with dietary patterns was also assessed.ResultsThree distinctive dietary patterns across all participants were identified from our analyses. Healthy diet, processed diet and mixed diet. Mean food scores indicated statistically significant differences between the dietary patterns for older and younger generations. Older generations showed greater diversity in food items consumed, as well as eating primarily a ‘healthy diet’. The younger generation was more likely to consume a ‘processed diet’. There was significant association between acculturation and deprivation with the distinctive dietary patterns.ConclusionOur investigation highlighted generational differences in consuming a limited range of food items. Identified dietary components may, in part, be explained by specific acculturation modes (assimilation and marginalised) and high socioeconomic deprivation among this particular study population.

scholarly journals Patterns of food consumption among vegetarians and non-vegetarians

2014 ◽  
Vol 112 (10) ◽  
pp. 1644-1653 ◽  
Author(s):  
Michael J. Orlich ◽  
Karen Jaceldo-Siegl ◽  
Joan Sabaté ◽  
Jing Fan ◽  
Pramil N. Singh ◽  
...  
Keyword(s):  
Health Outcomes ◽  
Food Consumption ◽  
Dietary Patterns ◽  
A Priori ◽  
Food Group ◽  
Epidemiological Studies ◽  
Consumption Patterns ◽  
Health Study ◽  
Food Groups ◽  
Vegetarian Diets

Vegetarian dietary patterns have been reported to be associated with a number of favourable health outcomes in epidemiological studies, including the Adventist Health Study 2 (AHS-2). Such dietary patterns may vary and need further characterisation regarding foods consumed. The aims of the present study were to characterise and compare the food consumption patterns of several vegetarian and non-vegetarian diets. Dietary intake was measured using an FFQ among more than 89 000 members of the AHS-2 cohort. Vegetarian dietary patterns were defined a priori, based on the absence of certain animal foods in the diet. Foods were categorised into fifty-eight minor food groups comprising seventeen major food groups. The adjusted mean consumption of each food group for the vegetarian dietary patterns was compared with that for the non-vegetarian dietary pattern. Mean consumption was found to differ significantly across the dietary patterns for all food groups. Increased consumption of many plant foods including fruits, vegetables, avocados, non-fried potatoes, whole grains, legumes, soya foods, nuts and seeds was observed among vegetarians. Conversely, reduced consumption of meats, dairy products, eggs, refined grains, added fats, sweets, snack foods and non-water beverages was observed among vegetarians. Thus, although vegetarian dietary patterns in the AHS-2 have been defined based on the absence of animal foods in the diet, they differ greatly with respect to the consumption of many other food groups. These differences in food consumption patterns may be important in helping to explain the association of vegetarian diets with several important health outcomes.

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