Changes in Adolescents’ Dietary Intake Following the Initiation of an 8-Week Exercise Program

Purpose: To assess changes in dietary intake of adolescents following an 8-week aerobic exercise program. Methods: Twenty-six adolescents (14–18 years) participated in an 8-week aerobic exercise program on cycle ergometer at their high school in Quebec, Canada. Twenty-four hour recalls were collected pre- and post-intervention. A two-way repeated measures ANOVA and paired sample t-tests were used to assess differences in energy and dietary intake parameters (food quantity, diet quality, eating patterns) between pre- and postintervention. Results: A decrease in total daily energy intake (–287.8 kcal, P = 0.007), in meal size at lunch (–110.1 g, P = 0.02) and dinner (–143.7 g, P = 0.03), in food density at breakfast (–1.8 kcal/g, P = 0.04), in daily carbohydrate intake (–56.1 g, P = 0.005), and in percentage of energy intake consumed at school (–5.1%, P = 0.04) were observed following initiation of an aerobic exercise program. No change in healthy eating index scores or percentage of energy from processed foods was observed. Conclusions: Changes in energy intake, food quantity, and eating pattern but not diet quality (Healthy Eating Index or food processing scores) were observed following the initiation of an aerobic exercise program. Nutrition interventions may be needed, in addition to an exercise program, to target diet quality and promote healthy eating habits in adolescents.

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Higher Protein Intake During Energy Restriction Alters Dietary Patterns and Maintains Diet Quality

Current Developments in Nutrition ◽

10.1093/cdn/nzab038_050 ◽

2021 ◽

Vol 5 (Supplement_2) ◽

pp. 438-438

Author(s):

Anna Ogilvie ◽

Yvette Schlussel ◽

Sue Shapses

Keyword(s):

Weight Loss ◽

Dietary Intake ◽

Energy Intake ◽

Healthy Eating ◽

Diet Quality ◽

Dietary Patterns ◽

Protein Intake ◽

Healthy Eating Index ◽

Quality Score ◽

Obese Adults

Abstract Objectives A higher protein diet can be a successful approach to weight loss and improved health outcomes. However, the effect of a higher protein diet on other foods in the diet is not known. Evidence suggests diet quality scores provide a comprehensive representation of dietary intake and the complex interconnected nature of nutrient intake. In this study, the objective was to examine the effect of protein intake during moderate weight loss using four diet quality scores in overweight and obese adults. Methods Overweight and obese adults (n = 235) were counseled, bimonthly, to reduce energy intake over 6 months following the ADA food lists. The diets were individualized so range of macronutrient intake varied, but all individuals were encouraged to consume > 0.8 g/kg protein. Dietary intake was assessed and validated at baseline and ≥ 6 days during the intervention. In addition to the Healthy Eating Index (HEI), the Alternative Healthy Eating Index (AHEI), Mediterranean Diet Quality Score (MDS), and Dietary Approaches to Stop Hypertension diet quality score (DASH) were adjusted for energy intake and used to calculate diet quality. Results Subjects (55 ± 11 years) were overweight and obese (BMI 28.9 ± 4.0 kg/m2) and consumed 17.5 ± 5.3% energy from protein at baseline. During the intervention, subjects lost 4.5 ± 5.4% body weight, with a 333 ± 605 kcal deficit and 18.7 ± 3.5% protein intake. During the intervention, only the HEI score correlated with protein intake (r = 0.240, P < 0.001); however, all scoring methods (HEI AHEI, MDS, DASH) showed consistent patterns of food groups changing with higher protein intake. As expected, there was greater intake of meat, but also intake of vegetables. In addition, diet quality scores that measured dairy (HEI, DASH, MDS), unsaturated fatty acids (AHEI, MDS) and sodium (HEI, AHEI) showed an increase with higher protein intake. Conclusions In individuals following a weight loss diet, higher protein intake consistently altered dietary patterns of low-protein food components including higher intake of vegetables, unsaturated fat, and sodium. In an overweight and obese population with no comorbidities, HEI, AHEI, MDS, and DASH diet scores are effective methods of measuring diet quality and food patterns during moderate weight loss. Funding Sources Financial support by North American Branch-ILSI and National Institute of Health-NIA is appreciated.

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Effect of a High-Intensity Dietary Intervention on Changes in Dietary Intake and Eating Pathology during a Multicomponent Adolescent Obesity Intervention

Nutrients ◽

10.3390/nu13061850 ◽

2021 ◽

Vol 13 (6) ◽

pp. 1850

Author(s):

Hollie A. Raynor ◽

Suzanne E. Mazzeo ◽

Jessica Gokee LaRose ◽

Elizabeth L. Adams ◽

Laura M. Thornton ◽

...

Keyword(s):

Dietary Intake ◽

Energy Intake ◽

Diet Quality ◽

Dietary Intervention ◽

Secondary Data ◽

Obesity Treatment ◽

Healthy Eating Index ◽

Eating Pathology ◽

Post Treatment ◽

Eating Disorder Examination

Concerns remain about dietary changes during pediatric obesity treatment and eating pathology, which have not been investigated. This secondary data analysis from a randomized clinical trial examined associations between adolescents’ changes in energy intake and diet quality during obesity treatment with post-treatment eating pathology. Adolescents (N = 82: 13.7 ± 1.2 y, 34.9 ± 7.0 kg/m2, 63.4% female, 46.3% black) received TEENS+, a 4-month multicomponent intervention. TEENS+ provided individualized dietary goals (1200–1800 kcal/day; number of “Go” foods/day (low-energy, high-nutrient-dense foods)). At 0 and 4 months, 3-day food records assessed energy intake and diet quality (Healthy Eating Index 2015 (HEI-2015)). Two HEI-2015 subscores were created: components to increase (increase), and components to limit (decrease). The Eating Disorder Examination Questionnaire measured eating pathology (total score and subscales: restraint; and eating, weight, and shape concern). Corrected p-values are reported as q-values. Energy intake decreased (−292 ± 418 kcal/day; q < 0.001), while diet quality improved during treatment (total HEI-2015 (4.5 ± 15.1; q = 0.034) and increase (3.3 ± 9.4; q = 0.011)). Restraint increased (+0.6 ± 1.4; q < 0.001), whereas shape (−0.5 ± 1.3; q = 0.004) and weight (−0.5 ± 1.4; q = 0.015) concerns decreased. Greater decreases in energy intake were associated with greater restraint post-treatment (F = 17.69; q < 0.001). No other significant associations were observed. Changes in adolescents’ dietary intake during obesity treatment were unrelated to increased shape, weight, or eating concerns post-treatment.

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Nutritional intake and overall diet quality of female soccer players before the competition period

Revista de Nutrição ◽

10.1590/1678-98652016000400010 ◽

2016 ◽

Vol 29 (4) ◽

pp. 555-565 ◽

Cited By ~ 2

Author(s):

Daniel dos SANTOS ◽

Jacqueline Queiroz da SILVEIRA ◽

Thais Borges CESAR

Keyword(s):

Nutritional Status ◽

Dietary Intake ◽

Healthy Eating ◽

Diet Quality ◽

Protein Quality ◽

Healthy Eating Index ◽

Soccer Players ◽

Cross Sectional ◽

Professional Soccer

ABSTRACT Objective: To assess the dietary intake and overall diet quality of female soccer players before the competitive games. Methods: This descriptive and cross-sectional study included 21 women aged 20.8±4.5 years from a professional soccer team. Their nutritional status and dietary adequacy during the training period, before competition season, were assessed. Dietary intake was assessed by three 24-hour recalls, one food frequency questionnaire, and the Healthy Eating Index, an overall diet quality index based on food group intake. Results: The athletes have shown proper nutritional status, but a diet deficient in energy due largely to low carbohydrate intake. On the other hand, the intakes of protein, fatty acids, and sodium were above the recommended intakes, even for athletes. Diet quality assessment by the Healthy Eating Index - 2010 resulted in a mean score of 54.6 points of a maximum of 100, indicating a need of improving the overall diet quality. Conclusion: The study found that the dietary patterns of female football players were both quantitatively and qualitatively inappropriate. A nutritional intervention is indicated to improve diet quality, with the inclusion of various foods, such as whole grains, fruits, vegetables, dairy products, and better protein quality, along with a reduction in saturated fats, sodium, and added sugar.

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Associations Between Consumption of Ready to Eat Cereal and Dietary Intake and Diet Quality in Hispanics (P18-052-19)

Current Developments in Nutrition ◽

10.1093/cdn/nzz039.p18-052-19 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

Author(s):

Yong Zhu ◽

Jessica Smith ◽

Vipra Vanage ◽

Neha Jain ◽

Mitesh Sharma ◽

...

Keyword(s):

Dietary Intake ◽

Total Energy ◽

Energy Intake ◽

Diet Quality ◽

Dairy Products ◽

Healthy Eating Index ◽

Total Energy Intake ◽

Hispanic Population ◽

Hispanic Children ◽

Added Sugar

Abstract Objectives To understand consumption pattern of ready to eat cereal (RTEC) in the Hispanic population in the United States and investigate associations between RTEC consumption and dietary intake as well as diet quality in this population. Methods Children aged between 2–17 years old (N = 899) and adults aged 18 years or older (N = 1593) who were Mexican American or other Hispanics from the National Health and Nutrition Examination Survey 2015–2016 were included in the study. Day 1 dietary data were used to determine RTEC consumption status, energy intake, nutrient and food group intake. Diet quality was measured as the Healthy Eating Index 2015 (HEI-2015). Multiple linear regression analyses for surveys were conducted to estimate covariates-adjusted associations between RTEC consumption and dietary intake, as well as diet quality. Results About 40% of Hispanic children reported RTEC consumption whereas only 14% of Hispanic adults were RTEC eaters. RTEC eaters were more likely from lower income families. Compared to non-eaters, both children and adults who reported RTEC consumption had significantly higher intake of whole grains, dairy products, and vitamins and minerals such as calcium, iron, zinc, folate, thiamin, riboflavin, niacin, vitamin B12, vitamin B6, vitamin A, vitamin D; as well as significantly lower intake of sodium and dietary cholesterol (P < 0.05 for all). Total energy intake and added sugar intake did not differ by RTEC consumption status in both age groups. HEI-2015 total score was significantly higher in RTEC eaters than non-eaters in both Hispanic children and adults (P < 0.05 for both). Conclusions Consumption of RTEC is associated with improved diet quality including higher intake of whole grain and dairy products, as well as several vitamins and minerals in both Hispanic children and adults. Consumption of RTEC is not associated with total energy intake or added sugar in the Hispanic population. Funding Sources The study was funded by General Mills, Inc.

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Maternal night-eating and lower diet quality during pregnancy are associated with substantial postpartum weight retention

Proceedings of The Nutrition Society ◽

10.1017/s0029665120000506 ◽

2020 ◽

Vol 79 (OCE2) ◽

Author(s):

See Ling Loy ◽

Yin Bun Cheung ◽

Colega Marjorelee ◽

Airu Chia ◽

Chad Yixian Han ◽

...

Keyword(s):

Healthy Eating ◽

Diet Quality ◽

Healthy Eating Index ◽

Dietary Guidelines ◽

Postpartum Weight Retention ◽

Weight Retention ◽

Eating Pattern ◽

Night Eating ◽

Postpartum Weight ◽

Fasting Duration

AbstractRecent evidence suggests that synchronizing eating-fasting schedules with body's circadian rhythms or day-night cycles is important for metabolic health. Besides food quantity and quality, food timing may contribute to weight regulation. However, it is unclear if this factor during pregnancy can influence maternal weight retention after childbirth. Using data from a prospective cohort, the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study, we examined the associations of maternal circadian eating pattern and diet quality in pregnancy with substantial postpartum weight retention (PPWR) at 18 months. We assessed 687 pregnant women for their circadian eating pattern (night-eating, night-fasting and eating episodes) and diet quality (Healthy Eating Index) based on information derived from 24-h dietary recall at 26–28 weeks’ gestation. Night-eating was defined as > 50% of total energy intake during 1900–0659 h; night-fasting duration was determined based on the longest fasting interval between consumption of a calorie-containing food or beverage during 1900–0659 h; eating episodes were defined as events that provided ≥ 210 kJ with time intervals between eating episodes of ≥ 15 min; diet quality was ascertained using the Healthy Eating Index which measures adherence to the Singapore dietary guidelines for pregnant women. PPWR was calculated by subtracting the weight at the first antenatal clinic visit from weight at 18-month postpartum. Substantial PPWR was defined as weight retention of 5 kg or more. Adjusting for maternal age, ethnicity, education, parity, night shift, mood, body mass index and total energy intake, multivariable binary logistic regression analysis was performed to estimate odds ratio (OR) of substantial PPWR in relation to circadian eating pattern and diet quality. Of 687 women, 110 (16%) had substantial PPWR. After confounders adjustment, night-eating (OR 1.95; 95% confidence interval 1.05, 3.62) and lower diet quality (1.91; 1.17, 3.10) were independently associated with higher odds of substantial PPWR. No associations with substantial PPWR were observed for night-fasting duration and number of eating episodes. During pregnancy, women with higher caloric consumption at night and lower diet quality had a greater likelihood of substantial PPWR. These findings suggest that aligning eating time with day-night cycles and adherence to dietary guidelines during pregnancy may help to alleviate overweight and obesity risk in postpartum life. There is a possibility that these eating patterns persist beyond pregnancy and pose implications for long-term obesity development. Further investigation on this area is required.

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The association between perceived stress and diet quality in women of childbearing age: A systematic review

Proceedings of The Nutrition Society ◽

10.1017/s0029665120005480 ◽

2020 ◽

Vol 79 (OCE2) ◽

Author(s):

Karim Khaled ◽

Vanora Hundley ◽

Fotini Tsofliou

Keyword(s):

Systematic Review ◽

Factor Analysis ◽

Dietary Intake ◽

Psychological Stress ◽

Perceived Stress ◽

Healthy Eating ◽

Diet Quality ◽

Healthy Eating Index ◽

Women Of Childbearing Age ◽

Childbearing Age

AbstractPoor diet quality is a major cause of maternal obesity and associated with adverse metabolic effects for mother and offspring. Psychological stress can increase intake of unhealthy dietary choices (e.g. highly palatable, energy dense diet), but no study has investigated the association between stress and diet quality in women of childbearing age.This systematic review of the association between psychological stress and diet quality used the PEO (Population, Exposure, and Outcome) model.Medline, CINAHL, Scopus, Cochrane Library, Web of Science, and Sciencedirect were searched (October 2018 - January 2019). From 139,552 hits, 471 papers were screened, but only 8 studies met our inclusion criteria: English language, stress (exposure) measured in combination with diet quality (outcome), healthy women (18–49 years of age (population). Data extraction was determined by the PEO. Quality assessment used CASP tool for Cohort studies.The review included eight studies from USA (n = 6), Egypt (n = 1), and Iran (n = 1). The six cross-sectional and two longitudinal studies were published between 2011 and 2017 and had a total of 3,982 participants. Studies were heterogeneous in methods: three used food frequency questionnaires to assess dietary intake while the others used 24-hour dietary recalls. Diet quality was measured using different indices: Alternate Healthy Eating Index (n = 2), Healthy Eating Index (n = 2), Dietary Approach to Stop Hypertension (DASH) Diet Index (n = 2), Dietary Quality Index- Pregnancy (n = 2), and Dietary Guideline Adherence Index (n = 1). Only one study used three diet quality indices. No study explored dietary patterns using factor analysis and other statistical techniques. Most studies used the perceived stress scale to measure stress; however, there were differences regarding the use of this scale to form a continuous or categorical variable (with varying cut-off scores) perceived stress, whereas no study reported biological response to stress. Outcomes also varied in direction of association; no association (n = 4), negative association (n = 3), mixed results (n = 1).This review is the first to systematically examine association between stress and diet quality in women of childbearing age; there was heterogeneity in measures of diet quality and study designs. Future studies that explore diet quality/patterns should include both diet indices and factor analysis and additionally measure biological markers of both dietary intake and stress.

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Healthy Eating Policy Improves Children’s Diet Quality in Early Care and Education in South Carolina

Nutrients ◽

10.3390/nu12061753 ◽

2020 ◽

Vol 12 (6) ◽

pp. 1753 ◽

Cited By ~ 1

Author(s):

Daniel A. Zaltz ◽

Amelie A. Hecht ◽

Roni A. Neff ◽

Russell R. Pate ◽

Brian Neelon ◽

...

Keyword(s):

South Carolina ◽

Dietary Intake ◽

Healthy Eating ◽

Diet Quality ◽

Low Income ◽

The United States ◽

Healthy Eating Index ◽

Early Care And Education ◽

Healthy Foods ◽

Early Care

Policies to promote healthy foods in early care and education (ECE) in the United States exist, but few have been prospectively evaluated. In South Carolina, a statewide program serving low-income children in ECE enacted new policies promoting healthy foods. We conducted an evaluation to measure changes in dietary intake among children in ECE exposed and not exposed to the new policy. Using direct observation, we assessed dietary intake in 112 children from 34 ECE centers in South Carolina and 90 children from 30 ECE centers in North Carolina (a state with no policy). We calculated Healthy Eating Index-2015 (HEI) scores to measure diet quality consumed before and after the policy was enacted. We fit mixed-effects linear models to estimate differences in HEI scores by state from baseline to post-policy, adjusting for child race, number of children enrolled, director education, center years in operation, participation in the Child and Adult Care Food Program (CACFP), and center profit status. The policy increased HEI scores for whole fruits, total fruits, and lean proteins, but decreased scores for dairy. Thus, the policy was associated with some enhancements in dietary intake, but additional support may help improve other components of diet.

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Associations between added sugar (solid vs. liquid) intakes, diet quality, and adiposity indicators in Canadian children

Applied Physiology Nutrition and Metabolism ◽

10.1139/apnm-2014-0447 ◽

2015 ◽

Vol 40 (8) ◽

pp. 835-841 ◽

Cited By ~ 17

Author(s):

JiaWei Wang ◽

Lei Shang ◽

Kelly Light ◽

Jennifer O’Loughlin ◽

Gilles Paradis ◽

...

Keyword(s):

Waist Circumference ◽

Dietary Intake ◽

Total Energy ◽

Energy Intake ◽

Fat Mass ◽

Diet Quality ◽

Healthy Eating Index ◽

Linear Regression Models ◽

Added Sugar ◽

Added Sugars

Little is known about the influence of different forms of added sugar intake on diet quality or their association with obesity among youth. Dietary intake was assessed by three 24-h recalls in 613 Canadian children (aged 8–10 years). Added sugars (mean of 3-day intakes) were categorized according to source (solid or liquid). Dietary intake and the Canadian Healthy Eating Index (« HEI-C ») were compared across tertiles of solid and liquid added sugars separately as were adiposity indicators (body mass index (BMI), fat mass (dual-energy X-ray absorptiometry), and waist circumference). Cross-sectional associations were examined in linear regression models adjusting for age, sex, energy intake, and physical activity (7-day accelerometer). Added sugar contributed 12% of total energy intake (204 kcal) on average, of which 78% was from solid sources. Higher consumption of added sugars from either solid or liquid source was associated with higher total energy, lower intake of micronutrients, vegetables and fruit, and lower HEI-C score. Additionally liquid sources were associated with lower intake of dairy products. A 10-g higher consumption of added sugars from liquid sources was associated with 0.4 serving/day lower of vegetables and fruit, 0.4-kg/m2 higher BMI, a 0.5-kg higher fat mass, and a 0.9-cm higher waist circumference whereas the associations of added sugars from solid sources and adiposity indicators tended to be negative. In conclusion, higher consumption of added sugar from either solid or liquid sources was associated with lower overall diet quality. Adiposity indicators were only positively associated with added sugars from liquid sources.

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Diet Quality in Association with All-Cause, Cardiovascular, and Cancer Mortality Among US Adults: NHANES 1999–2010 (OR14-04-19)

Current Developments in Nutrition ◽

10.1093/cdn/nzz030.or14-04-19 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

Cited By ~ 2

Author(s):

Jiaqi Wang ◽

Danielle Haslam ◽

Mengyuan Ruan ◽

Fan Chen ◽

Mengxi Du ◽

...

Keyword(s):

Healthy Eating ◽

Diet Quality ◽

Cancer Mortality ◽

Lower Risk ◽

Healthy Eating Index ◽

Dietary Guidelines ◽

Mortality Data ◽

Eating Pattern ◽

All Cause Mortality ◽

Risk Of Cancer

Abstract Objectives The 2015 Dietary Guidelines for Americans (DGA) recommend a healthy eating pattern for chronic disease prevention. This study aimed to prospectively evaluate diet quality by adherence to the 2015 DGA in association with mortality outcomes among a representative sample of US adults. Methods Using dietary data collected by 24-hour diet recalls among 29,098 US adults aged 20+ years from the National Health and Nutrition Examination Survey (NHANES) 1999 to 2010, we estimated adherence to the 2015 DGA using the Healthy Eating Index-2015 (HEI-2015). Mortality from all cause, cardiovascular diseases (CVD), and cancer were obtained from linkage to the National Death Index Mortality data. Cox proportional-hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) after multivariable adjustments. Results The mean (SE) of total HEI-2015 was 50.1 (0.2). During a median follow-up of 6.2 years, 2861 total deaths occurred, including 726 CVD and 671 cancer deaths. Compared to individuals in the lowest quartile of HEI-2015, those in the highest quartile had a 16% lower risk of all-cause mortality (Q4 vs. Q1: HR = 0.84; 95% CI: 0.72–0.90; P-trend = 0.04) and a 31% lower risk of cancer mortality (Q4 vs. Q1: HR = 0.69; 95% CI: 0.50–0.95; P-trend = 0.06). The lower all-cause and cancer mortality among those with higher HEI-2015 scores was confined to individuals with comorbidity conditions at baseline (all-cause mortality: Q4 vs. Q1: HR = 0.79; 95% CI: 0.67–0.94; p-trend = 0.005; cancer mortality: Q4 vs. Q1: HR = 0.46; 95% CI: 0.30–0.69; p-trend = 0.001), former smokers (all-cause mortality: Q4 vs. Q1: HR = 0.65; 95% CI: 0.49–0.88; p-trend = 0.006; cancer mortality: Q4 vs. Q1: HR = 0.47; 95% CI: 0.29–0.74; p-trend = 0.005), and those with a body mass index of 18.5–25 kg/m2 (all-cause mortality: Q4 vs. Q1: HR = 0.60; 95% CI: 0.46–0.79; p-trend < 0.001; cancer mortality: Q4 vs. Q1: HR = 0.40; 95% CI: 0.22–0.70; p-trend = 0.001). Similar associations were found between men and women. No significant associations were observed between HEI-2015 and CVD mortality. Conclusions Better adherence to the 2015 Dietary Guidelines of Americans is associated with lower all-cause and cancer mortality among US adults. Funding Sources National Institute of Health/National Institute of Minority Health and Health Disparities. Supporting Tables, Images and/or Graphs

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Higher diet quality is associated with higher diet costs when eating at home and away from home: National Health and Nutrition Examination Survey, 2005-2016

Public Health Nutrition ◽

10.1017/s1368980021002810 ◽

2021 ◽

pp. 1-29

Author(s):

Zach Conrad ◽

Sarah Reinhardt ◽

Rebecca Boehm ◽

Acree McDowell

Keyword(s):

Healthy Eating ◽

National Health ◽

Diet Quality ◽

Healthy Eating Index ◽

Food Prices ◽

Nutrition Examination Survey ◽

Food Away From Home ◽

Health And Nutrition ◽

Food Consumed ◽

At Home

Abstract Objectives: To evaluate the association between diet quality and cost for foods purchased for consumption at home and away from home. Design: Cross-sectional analysis. Multivariable linear regression models evaluated the association between diet quality and cost for all food, food at home, and food away from home. Setting: Daily food intake data from the National Health and Nutrition Examination Survey (2005-2016). Food prices were derived using data from multiple, publicly available databases. Diet quality was assessed using the Healthy Eating Index-2015 and the Alternative Healthy Eating Index-2010. Participants: 30,564 individuals ≥20 y with complete and reliable dietary data. Results: Mean per capita daily diet cost was $14.19 (95% CI: $13.91-14.48), including $6.92 ($6.73-7.10) for food consumed at home and $7.28 ($7.05-7.50) for food consumed away from home. Diet quality was higher for food at home compared to food away from home (P<0.001). Higher diet quality was associated with higher food costs overall, at home, and away from home (P<0.001 for all comparisons). Conclusions: These findings demonstrate that higher diet quality is associated with higher costs for all food, food consumed at home, and food consumed away from home. This research provides policymakers, public health professionals, and clinicians with information needed to support healthy eating habits. These findings are particularly relevant to contemporary health and economic concerns that have worsened because of the COVID-19 pandemic.

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