International Journal of Child Health and Nutrition

194-202

Authors: Ana Cristina Lindsay, Mary Greaney, Judith A. Salkeld, Jennifer Walsh

Background: Racial and ethnic disparities in physical activity (PA) are evident, with non-Hispanic Black and Mexican American children engaging in less vigorous activity than non-Hispanic White children. Collaborating with public health programs serving at-risk populations, such as the WIC program may be an effective way to promote the development of healthful PA behaviors among low-income preschool children and families. This paper explores WIC staff perceptions, attitudes, barriers, and facilitators related to PA levels and behaviors among low-income Latino preschool children and families, as well as the role the WIC program may play in promoting PA among low-income populations. Methods: A qualitative study was conducted with a sample of WIC staff in the State of Rhode Island (RI), Northeast United States. Individual, semi-structured interviews were carried out with 21 WIC staff working directly with Latino clients enrolled in the WIC program. Thematic content analysis was used. Results: The majority of WIC staff reported their Latino clients facing many barriers that limit their ability to be physically active, including busy and multiple shift schedules, lack of access to safe outdoor spaces, financial constraints to attending programs and recreational facilities, lack of transportation getting to safe outdoor spaces and facilities, etc. WIC staff identified several ways that the WIC program could increase the promotion PA among Latino families including partnering with local organizations such as the YMCA, Boys and Girls Club to provide increased access and opportunities for PA among low-income, Latino families. Conclusions: Study findings add to the existing literature suggesting that the WIC program is an important venue for educating low-income, Latino children and families about the importance of establishing early healthy PA habits within the context of overall health and development. Findings also highlight the need for a continuing effort to integrate the promotion of PA as part of the WIC program. In addition, findings highlight WIC staff desire for additional training and resources in promotion of PA

213-218

Authors: Paola Iaccarino Idelson, Eugenio Zito, Enza Mozzillo, Mary Lista, Sara Mobilia, Giuliana Valerio, Adriana Franzese

Obesity is a complex public health issue with increasing prevalence in childhood and with a large burden on physical and mental health. Recent data suggest the effectiveness of multi-component approach, of interventions aimed at changing parenting style, and of group educational sessions. In particular, interventions containing a family-behavioral component produce larger effect sizes than alternative treatment groups. Many models have been developed for the multi-component and multi-stakeholder treatment of childhood obesity, with a frequent discrepancy in the intensity of the treatment programme and in the resources available within clinics. Looking for effective strategies for the treatment of childhood obesity we built a Multi-component Obesity Group Experience (MOGE) model, analysing BMI and fat mass reduction as primary outcomes and qualitative improvements in the behavior towards nutrition and lifestyle as secondary one. Thirty-five consecutive obese children (20 girls, BMI z-score 2.1+0.2), were treated by MOGE model and the results were compared with 35 matched obese subjects of the same age (control group followed with a traditional treatment). After 3, 6 and 12 months of treatment it has been observed a significant reduction of BMI z-score and body fat mass. Moreover, a clinically significant psychological wellness was observed in children of MOGE group

230-239

Authors: Shi-Ying Li, Xiao-Li Dong, Wing-Si Vincy Wong, Yi-Xiang Su, Man-Sau Wong

Long-chain polyunsaturated fatty acids (LC-PUFA), especially linoleic acid (LA), arachidonic acid (AA), alpha- linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are essential to infant growth and development during early life. Up till now, there is only limited number of studies with large sample size on LC-PUFA in breast milk in China. In order to better understand the LC-PUFA levels in Chinese women, we report an analysis that included 44 studies of 3815 subjects from the latest 10-year peer-reviewed papers of breast milk studies of fatty acid profiles from China and other regions: Asia (excluding China), Europe, America and Africa. The results showed that Chinese women had significantly higher LA and ALA levels in the breast milk than European and other Asian women. The DHA level in the breast milk of Chinese women meets the Chinese and international recommended intake for young infants. This review provides comprehensive investigation on the LC-PUFA levels in the mature milk of Chinese women in most recent publications and server as a reference for further studies on human milk in China.

246-250

Authors: Sunday O. Ochigbo, Ifeoma Venn, Anachuna Kingsley

Background: Bilirubin encephalopathy is the clinical syndrome associated with bilirubin toxicity to the central nervous system resulting in chronic and permanent sequelae. It has been estimated that approximately 60% of term babies and 80% of preterm babies develop jaundice within the first week of life.Objective:To determine the prevalence, morbidity and mortality of bilirubin encephalopathy at our centre. Methodology:A retrospective descriptive review of the case files of all babies diagnosed with bilirubin encephalopathy over the past 5 years from January 2010 to December 2014 was undertaken. Information retrieved from the case notes included age, sex, presence of fever, duration of illness, place of delivery, causes and treatment. The outcome measures such as discharged home, discharged against medical advice, and death were also noted.Results:Out ofa total of 2,820 babies, 21 (0.74%) were admitted on account of bilirubin encephalopathy. Of these 21, seventeen (81%) were males and four (19%) females giving M; F ratio of 5:1. Eighteen babies (85.7%) had pyrexia, 8(38.1%) and 6(28.6%) were hypertonic and hypotonic respectively on admission. Only 33.3% of the deliveries took place in the health facilities. The established factors responsible for jaundice included infections (septicaemia) (15/71.4%), ABO incompatibility (4/19.1%), and G6PDeficiency (2/9.5%). The mean maximum serum bilirubin of the subjects was 321.3μmol/l (242.5 – 440.3). The case fatality was 4/21(19%). Conclusion:Neonatal septicaemia is associated with bilirubin encephalopathy. Therefore identification and prompt treatment is of utmost importance to avoid morbidity and mortality

129-134

Authors: Vesal Moeeni, Pardis Shojaee, Hamidreza Kianifar, Tony Walls, Philip Pattemore, Andrew S. Day

Aims: Patients with Cystic Fibrosis (CF) have increased risk of malnutrition. Early detection of nutritional deterioration enables prompt intervention and correction. The aims of this project were to define the nutritional status of CF patients in Iran and New Zealand, compare and contrast the McDonald Nutritional Risk Screening (NRS) tool with the Australasian Guidelines for Nutrition in Cystic Fibrosis, and validate these results with each patient’s evaluation by their CF clinical team. Methods:Children with CF (2 - 18 years) were assessed during routine outpatient visits over one year. Anthropometric measurements were obtained. Both tools were applied and the results compared to their clinical evaluation (as gold standard) with calculation of specificity and sensitivity. Results:Under-nutrition was seen more frequent in the 33 Iranian children than in the 36 New Zealand (NZ) patients (39% versus 0%, p=0.0001), whereas over-nutrition was more prevalent in NZ children (9% versus 17%, p=0.05). At the first visit, both guidelines were able to recognize 77% and 61% of under-nourished Iranian patients, respectively. The mean sensitivity and specificity for all visits for the McDonald tool were 83% & 73% (Iran) and 65% & 86% (NZ). Sensitivity and specificity for the Australasian guidelines were 79% & 79% (Iran) and 70% & 90% (NZ). Conclusions: Both tools successfully recognised patients at risk of malnutrition. The McDonald tool had comparable sensitivity and specificity to that described previously, especially in Iranian patients. This tool may be helpful in recognizing at risk CF patients, particularlyin developing countries with fewer resources.

141-150

Authors: Ping Hu Johnson, Deanne Gerson, Kandice Porter, Jane Petrillo

Background: School lunches that are part of the National School Lunch Program must meet specific nutrition requirements. It is unknown whether students eat school lunches in a balanced manner. This study examined which lunch food items children eat/toss, and consumption differences between sexes, and between students at a Non-Title 1 school where most students purchase school lunches and a Title 1 school where most students receive free or reduced-priced lunches. Methods:Students in both schools were observed unobtrusively for five consecutive days. Trained observers recorded the discarded food items on a checklist listing the menu items for the day. The final analyses (t- tests, z tests) included data from 2,826 student-meals. Results:Entrees similar to those offered in fast food restaurants (i.e., chicken nuggets, pizza, nachos, corndogs) were favored by most students. Fresh fruits and vegetables were not selected or consumed frequently. Boys consumed more food in the fast food, starches, and dessert categories, while girls consumed more soup, salads, and vegetables. Title 1 school students consumed more food in all categories except bread, pasta, and sandwiches than Non-Title 1 school students. Conclusions:Students’ preference of unhealthy lunch items may decrease the health benefits that school lunches attempt to provide.

163-173

Authors: Paul Branscum, Alexandra Housley

Sugar-sweetened beverage (SSB) consumption among children and adolescents is a public health concern, as up to 88% consume them on a daily basis. While much research has been done regarding what types of foods parents feed their children and how that is linked to various health outcomes, research determining how parents monitor there children’s SSB consumption has not been well studied. Identifying important environmental and psychosocial determinants of parental-monitoring behaviors is a greatly needed area for investigation. The purpose of this study was to develop and validate a theory-based instrument related to this parenting practice. Initially, a 41-item instrument was developed and face and content validity were established using a panel of 6 experts. Next, the survey was administered to 270 parents (29 parents completed the survey twice). Psychometric properties tested of the instrument included construct validity, using the maximum likelihood extraction method of factor analysis, internal consistency reliability, using Cronbach’s alpha, and test-retest reliability using Pearson-product moment correlations between instrument results taken at two separate occasions. Initial results suggested some scales required re-specification, which included removing weak and/or non-related items. Results from this study can be used to assist future health professionals and researchers for measuring theory-based determinants of parental practices related to monitoring SSB consumption. This process can also be replicated to construct instruments measuring other critical obesogenic behaviors, such as monitoring fruit and vegetable consumption, or physical activity.

180-193

Authors: Paloma Rohlfs Domínguez

Objective:The objective wasto reviewthe literature on school-based interventions during compulsory education (published in 2009-2013) that may be effective in increasing healthful nutritional outcomes in children. Specific strategies and their limitations will be identified. Methods: A qualitative systematic analysis of seventeen school-based interventions applied to six-eleven year-old children, and published in peer-reviewed journals from 2009-2013 was carried out. Results: These studies taken as a whole used a variety of fourteen strategies, such as provision of nutritional and gardening education; repeated exposure to vegetables (V); peer and adult modelling; chefs going into schools to teach healthy nutritional issues. These studies showed four types of limitations: limitations derived from the experimental designs and experimental procedures used and limitations affecting participant samples and data collection. Fifteen recommendations for overcoming the targeted research limitations were identified, such as applying the intervention during longer time intervals; examining the effectiveness of these interventions in different ethnicities and socioeconomic groups; including larger participant samples; using randomized designs. Finally, six new working hypotheses to guide future studies are proposed here. For example, a small number of V offered might lead to insufficient opportunities to learn to like the flavour of V; schools’ previous experience with these interventions might distort children’s post-intervention data related to their nutritional outcomes; providing children with nutritional and gardening education might increase their fruit (F) selection, consumption and preferences and application of evaluative conditioning under more appropriate experimental conditions might increase child V consumption. Conclusion:seventeen school-based interventions were included. These studies taken as a whole used a variety of strategies (fourteen), and showed four types of limitations. Fifteen recommendations for overcoming the targeted research limitations as well as six new hypotheses are proposed here. Future research in this field should focus on overcoming its research limitations, such as the ones highlighted here, and building new working hypotheses, such as those proposed here

67-77

Authors: Ibrahim Awad Eljack, Abdel Rahman Al-Asha Hamedel Niel

Objective:To study child health status in Shareq Elneel Locality and its administrative units, Khartoum State, Sudan. Methods: A two stages cluster sampling, cross-sectional study was conducted in Shareq Elneel Locality and it is eight administrative units in Khartoum State, Sudan, in 2008. Questionnaires were collected from the caretakers of 5858child under-5 years of age and anthropometric measurements were taken for children whose parents were consented. Results:69.4% of under 5 years children received the third dose of Poliomyelitis vaccine (Polio3) in the locality, 66.5% of under 5 years children received DPT3 vaccination in the locality, 71.9% of under 5 years children received Measles vaccination in the locality and 91.4% of the children under- 5 years in the locality had immunization card. There was evidence of a significant association between children under -5 measles vaccination and women’s highest level of school attended (P-Value= 0.04). Nearly one third of the under 5 children were moderately underweight and 16.2% them were severely underweight, More than one fifth of under 5 years children were moderately wasted, and 12% of children under -5 years old were severely wasted, 44.6% of children under -5 years of age were moderately stunted with obviously high percentage in the rural administrative units. More than one quarter of the children under- 5 years old were severely stunted and overweight prevalence of children under-5 years old in the locality was 14.6%. Only 21.4% of the children aged less than 2 years in the locality were exclusively breastfed. 27.5% of children under -5 years of age in the locality had diarrhea in the last 2 weeks preceding the survey, highest percentage found in the rural administrative units.6.5% of children under 5 years of age in the locality had fever in the last 2 weeks preceding the survey and nearly one third of under 5 years children in the locality had cough in the last 2 weeks preceding the survey. 87.9% of children targeted by vitamin A supplementation in the locality ever receive vitamin A dose. Conclusions: The study reveal pronounced variations among urban and rural administrative units in regard to many of the survey indicators. Immunization activities do not reach their target in almost all the times in the locality and there were other aspects of child health related to hygiene, poverty, malnutrition and health services like diarrhea, respiratory tract infections and malnutrition which need more consideration to be improved. Malnutrition prevalence was high. The rates of diarrhea and suspected pneumonia are somehow higher in the study area than previous studies figures. Reduce the pronounced variations among urban and rural administrative units in regard to Primary Health Care services and activities in order to improve many of the Child Health indicators in the rural areas. Use effective methods of health promotion and new attractive material of health education in the locality concerning the weak Child Health indicators.

83-89

Authors: Fatima Al-Haddad, Abdulrahman Musaiger, S. Mahmood Al-Qallaf, Kathryn Hart

Background & Objectives: Bahrain is reported to rank amongst the top 10 countries for diabetes prevalence worldwide. In particular, growing numbers of children are being diagnosed with Type 1 diabetes mellitus (T1DM). The objective of this study was to describe the dietary intake of Bahraini children with T1DM as compared to a sample of healthy counterparts and to determine whether the nutrient intakes of Bahraini children with T1DM meet the current recommendations. Design & Setting: This was a case-control study. Dietary intake, estimated using a24-hour dietary recall, for the cases was gathered from the Pediatric Endocrine and Diabetes Unit at the Salmaniya Medical Complex and compared to the 24-hour recalls of children without diabetes recruited from Local Health Centers. Patients & Methods: 50 children aged 6-12 years receiving a confirmed diagnosis of T1DM in the years 2009 and 2010 compared with 55 healthy comparators. Results: Children with T1DM consumed significantly more calories than controls (p<0.001) and significantly more protein relative to their RDA (p<0.029). Both groups failed to meet the RDA values for dietary fiber and for Vitamin D. Sodium intakes were in excess of RDA values although no significant difference was observed between groups (p=0.403). Conclusion: The diets of both children with and without T1DM were found to contain excess protein and sodium and inadequate fiber, vitamin D and calcium. Children with T1DM also appeared to consume excess energy and fat. There is a need to endorse existing dietary guidelines for children with T1DM.

94-102

Authors: Allison E. James, Guy H. Palmer

Childhood undernutrition is a health crisis in the rapidly expanding informal settlements of low-income countries worldwide. Nearly half of Kenyan children in the Kibera settlement, in Nairobi, were reported to be stunted, indicating low height-for-age. Stunted children are at greater risk for poor cognitive and physical health outcomes in the long-term, problems that tend to be perpetuated in subsequent generations. Animal-source foods (ASF) supply a calorically dense source of micro- and macronutrients, and supplementation with ASF has been shown to improve linear growth and cognition. Correspondingly, increasing consumption of ASF by pregnant women and children has been proposed as a means to disrupt the intergenerational cycle of undernutrition caused by food insecurity. Household surveys indicate that consumption of ASF is low in urban slums, despite the availability of these foods in local markets. Here we review the studies addressing the role of ASF in the diets of the urban poor and identify knowledge gaps relevant to improving nutrition by increasing consumption of ASF. Based predominantly on studies in Kibera and greater Nairobi, these gaps include determining the minimal amount and frequency of dietary ASF to prevent stunting, defining how consumer preferences, markets, and income interact to impede or promote ASF consumption, and understanding the interaction between diet and both clinical and sub-clinical enteric disease on growth outcomes.

122-128

Authors: Sunil Kumar, M. Amruth, Prashant Kumar, A.G. Balakrishna, M.C. Prabhudeva

Background:Obesity is defined by WHO “as a condition of abnormal or excessive fat accumulation in adipose tissue, to the extent that health may be impaired”. The problem of childhood obesity is quite high in rich and affluent countries. 1. To estimate the prevalence of obesity among school children aged 6-15 years in three affluent schools of Tumkur. 2. To study the influencing factors of obesity among school children. Methods: Study Design: Case Control study. Study Settings: Three affluent schools of Tumkur city, Karnataka, South India. Sample size was2000 Students of three affluent schools and duration of study was fromJune to August 2014. Each Child’s height and weight were measured by adopting standard procedure. Body mass index (BMI) was calculated using BMI charts based on NCHS (national center for health statistics) standards. A child was considered obese if the BMI was > 95th percentile cutoff point which is specific to the age and sex of the child. To determine the association of (life style) influencing factors of obesity in children, mothers were interviewed in presence of children to gather information’ about their child’s daily (24 hour) activity. Results:Out of 2000 children 66 were obese. The prevalence was 3.3% in school children in the age group of 6-15 years in three affluent schools of Tumkur. In our study, Prevalence of obesity was more in boys (3.47%) on comparison to girls (3.04%). There is increased prevalence of obesity in age group of six, eleven and twelve years. In this study 77.2% cases spent less than 2 hrs in a day and 22.7% cases spent more than 2 hrs in physical activities. Prevalence of obesity was more in children who spent less than 2 hrs in a day in physical activities. This was statistically significant. Conclusions:Prevalence of obesity in school children aged 6-15 yrs is 3.3% in three affluent schools of Tumkur. Prevalence of obesity was more in boys on comparison with girls. Physical activity was the significant influencing factor of obesity among school children.

1-13

Authors: "Mo'ez Al-Islam" Faris, Suneetha Epuru, Saud Al-Shimmari, Egab Al-Shimmari

Saudi Arabia (KSA) is one among the countries for top energy drink markets. Amid growing controversies globally surrounding the increasing usage of energy drinks by children, it is felt important to understand how these trends are reflected in KSA. A cross-sectional survey was conducted to explore the trends of energy drink consumption among, and differences between, middle and secondary school children, and the associated socioeconomic and behavioral factors. Randomly selected 1006 male children from secondary and middle schools from Hail region in KSA were included in the study, using a self-administered validated questionnaire. Results revealed that about 60% of school children were current energy drink consumers. Secondary school children were significantly (P<0.001) higher than middle schoolers in terms of both frequency and quantity. Concomitantly, unhealthy dietary and lifestyle behaviors were reported in significantly higher proportions (P<0.001) among secondary school children. Home was the first place for exposure for majority of children while unreliable resources were the major sources of knowledge about energy drink composition and health effects. Poor knowledge concerning energy drink composition was reported. Taste and being energized were the major driving forces for energy drink consumption. Higher disposable income on hand and poor lifestyle behaviors were all significantly associated with energy drink consumption. It can be concluded that high proportion of energy drink consumption was reported among school children in Hail, with higher proportions in secondary than middle schools. This matter raises the significance of mounting awareness of community concerning the ingredients and potential hazards of energy drinks.

33-39

Authors: Jayna M. Dave, Tzu-An Chen, Amanda M. Oceguera, Karen W. Cullen, Deborah I. Thompson

Background: Every school day, over 31 million U.S. children eat school lunches. Unfortunately, students often do not choose the healthy options in the school cafeteria. This paper describes outcome results of a pilot study using “nudges” to improve elementary school students’ fruits and vegetables selections. Methods: A pilot study was conducted from January to May 2012, in six intervention schools and 2 control schools. A behavioral economics-based intervention was conducted using “nudges” or cues from the cafeteria (staff encouragement to select fruit and vegetables, food labels, “Harvest of the Month” posters), school (morning announcement messages, prompts regarding cafeteria food selections), and parents (school newsletter articles, parent listserve messages) to promote students’ selection of fruits and vegetables in the school cafeteria. The serving data from the point-of-servic e machine provided fruits and vegetables served per student per day. Results:There were no significant differences in the number of servings of fruits and vegetables served per student per day, averaged over the study period. Process data revealed low implementation of the intervention components, which may partially explain results. Conclusions: Low implementation of nudges led to non-significant results in this pilot study. However, providing environmental cues are important and warrant further research with full implementation. Starting 2012, the new meal pattern includes two vegetables and a fruit serving for lunch; and two fruit servings for breakfast. Minimal cost interventions should be explored to facilitate successful implementation of new school meal guidelines.

50-53

Authors: Aurea Lumbau, Giovanni Spano, Silvio Mario Meloni, Francesca Sanna, Pietrina Francesca Lugliè

Aim: To analyze the knowledge and experience of dentists with private practices in the Sassari district with regard to eating disorders and clinical stomatology manifestations. Methods: A questionnaire to investigate dentists’ knowledge and experience was created and submitted to a random sample of dentists. Data were collected and analysed using the Stata SE 10 software. Results: In total, 150 dentists were enrolled (a representative sample). After questionnaire evaluation, the following results were obtained: 80.7% (121) of the participants had a degree in dentistry and 19.3% (29) had degrees in medicine with a dentistry master of science diploma, 46% (69) were males and 54% (81) were females, their age range was 25-62 (mean, 36.1) years, and the average work experience was 11.5 (range, 1-36) years. More than 90% of the participants defined eating disorders only as bulimia and anorexia. Of the dentists, 77.3% (116) correctly identified Western populations as the most affected, whereas 52.7% identified only whites as the most affected people. In total, 80% of the dentists recognised dental erosion and abrasion as typical oral manifestations. Only 62% stated that salivary pH decreases in these conditions, and 63% did not recognise parotid gland tumefaction as a clinical sign. Regarding operator experience, 60.7% (91 dentists) had clinical experience of patients with eating disorders: 43.9% of them had made diagnoses from oral manifestations, 51.3% (77) were not able to treat these patients, and 69.3% (104) would refer patients to specialized centres for treatment. Moreover, 119 (79.3%) considered that a dental hygienist was a valid collaborator for the treatment of oral cavity manifestations. Regarding prophylaxis, 16.7% (25) suggested fluoride prophylaxis and 21.3% (32) oral hygiene education. Only 1.3% indicated the use of bicarbonate to change salivary pH values, suggested conservative or prosthetic restorations, suggested the use of saliva substitutes, or the sealing of permanent teeth. Difficulties in clinically treating these patients were related to a lack of knowledge for 72% (108) of participants. Of them, 36.7% (55) had studied the clinical aspects of this pathology while attending dental school and 24.7% (37) after their degree. In total, 94.7% (142) expressed the need for further information and only 2% (3) considered they had sufficient clinical knowledge. Conclusions: It is evident that there is a lack of knowledge regarding the problem and there would seem to be an urgent need to provide more training programs and to establish guidelines for the diagnosis and treatment of eating disorders among dentists. In our opinion, the acquisition of such knowledge will change the approach to related pathology, improving clinical skills, and subsequently diagnosis and treatment.

61-66

Authors: Zahra Gholampour, Mina Hosseininasab, Gholamreza Khademi, Majid Sezavar, Nooshin Abdollahpour, Bahareh Imani

Background & Objective: Malnutrition is very common in hospitalized children and is associated with related clinical consequences such as increased risk of infections, increased muscle loss, impaired wound healing, longer hospital stay and higher morbidity and mortality. The estimated prevalence of acute malnutrition in hospitalized children varies from 6.1 to 40.9% in different countries. The current study was conducted with the aim of evaluating the efficiency of STRONGkids (Screening Tool for Risk On Nutritional Status and Growth) tool for assessing malnutrition in hospitalized children in Iran. Methods: All children older than 28 days admitted to the pediatric hospital (Dr. Sheikh, Mashhad, Iran) were enrolled in this study and the screening tool named STRONGkids was applied for them. The anthropometric measurements were measured by a trained operator using standard methods and equipments. The children were classified in three groups of being at high risk, moderate risk and low risk of malnutrition. Results: According to STRONGkids score; 17% of children were classified as low risk, 75% as moderate risk and 8% as high risk group. According to WFH, HFA and WFA z-scores31.4%, 19.2% and 28% of children were identified as moderately and severely malnourished respectively. According to MUAC cut-offs, 3.4% of children were classified as having moderate malnutrition and there was no child with severe malnutrition. Conclusion: It is very important to recognize the nutritional status of the children as early as possible because of its effects on children’s growth. Therefore, evaluating the nutritional status of the hospitalized children is an essential step inclinical assessment. We suggest to apply the STRONGkids score aside with other clinical and anthropometric data.