Preschool Executive Control, Temperament, and Adolescent Dietary Behaviors.

BACKGROUND: Child temperament styles characterized by increased emotionality or pleasure seeking may increase risk for less healthful eating patterns, while strong executive control (EC) may be protective. The interaction of these characteristics with longitudinal outcomes has not yet been examined. PURPOSE: The aim of this study was to examine the association of preschool temperament and EC, as well as their interaction with adolescent eating. METHODS: Preschoolers (N = 313) were recruited into a longitudinal study, with behavioral measurement of EC at age 5.25 years, temperament assessed multiple times across preschool, and eating outcomes assessed in adolescence (mean age = 15.34 years). RESULTS: Separate latent moderated structural equation models demonstrated that weaker EC was associated with eating less healthful foods, including high sugar foods, sugar-sweetened beverages (SSBs), and convenience foods (p < .05). In the moderation models, negative affectivity temperament was correlated with eating less healthful foods, high sugar foods, and SSBs (p < .05). Children lower in surgency/extraversion temperament were more likely to drink SSBs. There was an interaction between temperament and EC, such that children high in negative affectivity with weaker EC were particularly more likely to consume less healthful foods, high sugar foods, and SSBs (p < .05). There was no interaction of surgency with EC and food consumption. CONCLUSIONS: Child characteristics measured early in development were associated with later adolescent eating behaviors. Adequate EC could be necessary to counteract the drive toward eating associated with temperaments high in negative affectivity.

A preschool temperament style called Negative Affectivity, characterized by high levels of reactivity and negative emotion, predicted eating patterns a decade later. These children were more likely to eat less healthful foods and drink sugary drinks as adolescents. Strong executive function skills were important for redirecting toward healthful eating in children with Negative Affectivity.

Insight Into the Adolescent Patient Experience With Nonalcoholic Fatty Liver Disease.

OBJECTIVES: Nonalcoholic fatty liver disease (NAFLD) is the leading chronic liver disease in youth, yet little is known about the adolescent patient's experience with NAFLD, which is key for treatment engagement. We examined adolescents' experiences with NAFLD diagnosis, thoughts on how NAFLD affects their daily life, understanding and perceptions of diagnosis and treatment, and impressions of how to improve care. METHODS: Utilizing a mixed-method design, adolescents with NAFLD (N = 16; Mean age = 15.8 years; Mean BMI = 37 kg/m 2 ) participated in focus groups. To supplement qualitative data, adolescents and their caregiver completed measures assessing illness perceptions, adolescent quality of life, and eating/activity behaviors. RESULTS: Focus group themes suggested reactions to diagnosis varied from unconcerned to anxious. NAFLD diagnosis occurred within the context of other psychological/medical concerns and was not perceived to affect most adolescents' daily lives. Although adolescents understood general contributors to NAFLD, comprehension of their diagnosis varied. Adolescents were more likely to make lifestyle changes when families were supportive, and they preferred tailored recommendations for health behavior change from the healthcare team. Notably, 62.5% of adolescents were more concerned about their weight than NAFLD. Almost half (43.8%) identified as food insecure. CONCLUSIONS: Adolescents with NAFLD may benefit from personalized treatment. Care could be enhanced by ensuring comprehension of diagnosis, problem-solving personal, and family barriers and increasing family support. Harnessing adolescents' desire for weight loss may be a more salient driver for change in disease status. Interventions should also address systemic barriers such as food insecurity to ensure equitable care.

Stress and eating responses in adolescent females predisposed to obesity: A pilot and feasibility study.

OBJECTIVE: To explore how chronic stress, reactivity to acute stress, and obesogenic eating are linked in adolescent females predisposed to obesity. METHODS: Participants included 21 adolescent females (mage = 14.57 years) and their biological mothers with obesity (body mass index [BMI] ≥ 30 kg/m2). The pilot and feasibility study involved adolescent self-report of chronic stress, an acute stress-induction paradigm (Trier Social Stress Task, TSST), salivary cortisol collection to assess stress reactivity, and both subjective (self-report) and objective (snack buffet) measures of obesogenic eating. RESULTS: Adolescent females reporting high chronic stress were significantly more likely to engage in self-reported emotional and external eating and to have higher food cravings (p's < .05) compared to adolescents with low chronic stress. Effect size estimates suggested a blunting effect of cortisol in the high chronic stress group. Blunted cortisol reactivity significantly predicted higher self-reported food cravings for the high chronic stress group (p = .04). Associations among chronic stress, cortisol, and self-reported and objective obesogenic eating reflected medium to large effect sizes. CONCLUSIONS: This study built on limited extant research on stress and eating to demonstrate that chronic stress was associated with self-reported obesogenic eating patterns in adolescent females predisposed to obesity. Different patterns of cortisol reactivity and eating emerged depending on chronic stress group (low versus high). Understanding these eating patterns in the context of chronic stress can inform interventions to reduce obesity risks in adolescence.

Weight status and health behaviors of adolescents and young adults with sickle cell disease: The emerging risk for obesity.

Historically, youth with sickle cell disease (SCD) were at risk for being underweight, but recent data suggests this population is replicating obesity trends of youth in the United States. The current observational study assessed the weight status and health behaviors of 44 adolescents and young adults with SCD via a self-report survey and chart review. Using height and weight data closest to survey completion date, 27% of participants were either overweight or obese. With respect to obesogenic risk behaviors, 77% ate fast food 1-3 times per week, 25% had no fruits/vegetables with any of their meals, 11% drank no water, and 57% watched 4 or more hours of television per day. Though more research is needed, this preliminary study adds to the SCD literature suggesting an emerging shift toward obesity in this population. As such, adolescents with SCD may benefit from interventions to decrease obesity risk factors as being overweight or obese has the potential to worsen SCD-related symptoms and complications.

Change, predictors and correlates of weight- and health-related quality of life in adolescents 2-years following bariatric surgery.

BACKGROUND/OBJECTIVES: Weight-related quality of life (WRQOL) and generic health-related quality of life (HRQOL) have been identified as important patient-reported outcomes for obesity treatment and outcome research. This study evaluated patterns of WRQOL and HRQOL outcomes for adolescents at 24-months post-bariatric surgery relative to a nonsurgical comparator sample of youth with severe obesity, and examined potential weight-based (e.g., BMI, weight dissatisfaction) and psychosocial predictors and correlates of these outcomes. SUBJECTS/METHODS: Multi-site data from 139 adolescents undergoing bariatric surgery (Mage = 16.9; 79.9% female, 66.2% White; MBody Mass Index [BMI] = 51.5 kg/m2) and 83 comparators (Mage = 16.1; 81.9 % female, 54.2% White; MBMI = 46.9 kg/m2) were collected at pre-surgery/baseline, 6-, 12-, and 24-months post-surgery/baseline with high participation rates across time points (>85%). Self-reports with standardized measures of WRQOL/HRQOL as well as predictors/covariates (e.g., weight dissatisfaction, social support, peer victimization, family dysfunction, loss of control eating, self-worth, and internalizing symptoms) were obtained. Growth curve models using structural equation modeling examined WRQOL/HRQOL over time and linear regressions examined predictors and correlates of WRQOL/HRQOL outcomes. RESULTS: Significant improvement in WRQOL and Physical HRQOL, particularly in the first postoperative year with a leveling off subsequently, was found for the surgical group relative to comparators, but with no significant Mental HRQOL change. At 24 months, the surgical group had significantly greater WRQOL/HRQOL across most subscales. Within the surgical group at 24 months, weight-based variables were significantly associated with WRQOL and Physical HRQOL, but not Mental HRQOL. Mental HRQOL was associated with greater internalizing symptoms and loss of control eating. CONCLUSIONS: For adolescents undergoing bariatric surgery, most clinically meaningful changes in WRQOL and Physical HRQOL occurred early postoperatively, with weight-based variables as the primary drivers of 24-month levels. In contrast, expectations for Mental HRQOL improvement following surgery should be tempered, with 24-month levels significantly associated with psychosocial rather than weight-based correlates.

Confirmatory factor analysis of the parental feeding style questionnaire with a preschool sample.

PURPOSE: Despite being widely used, there has not yet been a confirmatory factor analysis (CFA) on the English version of the Parental Feeding Style Questionnaire (PFSQ). Preschool is a critical time to assess parental feeding styles, and the PFSQ is one of the few measures that can be used with young children. As such, the current study conducted the first CFA on the PFSQ in an English-speaking sample in the United States to establish preliminary evidence of its factor structure. METHODS: Parents of preschoolers aged 3-5 years (N = 297; M = 33.47 years; 85.2% mothers) presenting to a pediatric dentistry office in the Midwest of the United States were recruited to participate in this cross-sectional study. Parents completed the PFSQ in the waiting room of the dental office. Robust maximum likelihood factor analyses were conducted on the PFSQ. RESULTS: The original four-factor model was not confirmed, but rather, results provided preliminary support for a five-factor solution: Control over Eating, Instrumental Feeding, Emotional Feeding, Encouragement of Variety, and Prompting of Eating, CFI = 0.91, SRMR = 0.06, RMSEA = 0.05. CONCLUSIONS: The PFSQ is a widely used measure for assessing parental feeding styles in young children. However, the CFA indicated that the originally proposed four-factor structure did not fit well. Certain modifications to the measure were necessary to improve model fit. A five-factor model fit better, and six items were removed, reducing the original 27-item scale to 21 items. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Acceptability and Feasibility of a Disease-specific Patient Portal in Adolescents With Sickle Cell Disease.

OBJECTIVE: To examine the acceptability, feasibility, and efficacy of a health care portal. OBSERVATIONS: Adolescents and young adults with sickle cell disease were taught how to use sickle cell disease conditions page in MyChart and completed questionnaires at baseline, postintervention (T2, 6 wk after baseline) and after 3 months (T3). In total, 44 participants (M age=18.82, SD=2.72) viewed an average of 58.07 pages from T1 to T2. The portal was highly accepted (90.32%). Efficacy data indicated that portal use was associated with improved patient-provider communication. CONCLUSIONS: Electronic portals are promising tools for improving medical self-management.

Halo or horn? A qualitative study of mothers' experiences with feeding children during the first year following bariatric surgery.

BACKGROUND: Obesity is a chronic condition that has an intergenerational effect. The aims of the study were to better understand the impact of maternal bariatric surgery on obesogenic risks to child offspring in the home via documenting mothers' thoughts, behaviors, and experiences around child feeding, family meals, and the home food environment during her first year postsurgery. METHOD: Utilizing a mixed-method cross-sectional design, 20 mothers (Mage = 39.6 ±â€¯5.7 years, 75% White, MBMI = 33.6 ±â€¯4.3 kg/m2, Mtime = 7.7 ±â€¯3.1 months post-surgery) of children ages 6-12 years completed validated self-report measures and participated in a focus group. Mother and child heights/weights were measured. RESULTS: The majority of children (N = 20; Mage = 9.2 ±â€¯2.3 years, 65% White, 60% female) were overweight (N = 12; BMI≥85th percentile) and were not meeting the American Academy of Pediatrics healthy eating and activity recommendations to treat/reduce obesity risk. As child zBMI increased, mothers expressed significantly more weight concern (r = 0.59, p = 0.01) and lower obesity-specific quality of life (r = -0.56, p = 0.01), yet assumed less responsibility for child eating choices (r = -0.47, p = 0.04). Qualitative data demonstrated disconnects between mothers' changes to achieve her own healthier weight and applying this knowledge to feeding her child/family. CONCLUSIONS: While bariatric surgery and requisite lifestyle change are effective tools for weight loss at the individual level, there is a great need for innovative family-based solutions. Pediatric obesity is preventable or risk-diminished if addressed early. Maternal bariatric surgery may be a unique (yet missed) opportunity to intervene.

Concurrent and Longitudinal Associations Among Temperament, Parental Feeding Styles, and Selective Eating in a Preschool Sample.

Objective: To examine the associations among negative/reactive temperament, feeding styles, and selective eating in a sample of preschoolers because preschool eating behaviors likely have lasting implications for children's health. Methods: A community sample of preschoolers aged 3-5 years (M = 4.49 years, 49.5% female, 75.7% European American) in the Midwest of the United States was recruited to participate in the study (N = 297). Parents completed measures of temperament and feeding styles at two time points 6 months apart. Results: A series of regressions indicated that children who had temperaments high in negative affectivity were significantly more likely to experience instrumental and emotional feeding styles. They were also significantly more likely to be selective eaters. These associations were present when examined both concurrently and after 6 months. Conclusions: This study provides a novel investigation of child temperament and eating behaviors, allowing for a better understanding of how negative affectivity is associated with instrumental feeding, emotional feeding, and selective eating. These results inform interventions to improve child health.

Preschool executive control and sleep problems in early adolescence.

OBJECTIVE: Although numerous studies have documented the effects of sleep loss on executive control (EC) and related abilities, research examining the impact of early EC on subsequent sleep problems is lacking. Therefore, the current study reports on a longitudinal investigation of EC in preschool as a predictor of sleep-wake problems and daytime sleepiness in early adolescence. PARTICIPANTS: The participants were 141 children (48.6% female) recruited from the community for a longitudinal study spanning preschool through early adolescence, with an oversampling for high sociodemographic risk (34.1% based on eligibility for public medical insurance, free or reduced lunch status, or family income-to-needs below the federal poverty line). METHODS: Participants completed a battery of developmentally appropriate tasks assessing major aspects of EC (working memory, inhibitory control, flexible shifting) during a laboratory visit at age 4 years, 6 months. Participants also completed a follow-up session in early adolescence (between ages 11 years and 13.5 years; mean age = 11.82 years, SD = .62 years), during which they completed self-report measures of sleep-wake problems and daytime sleepiness. RESULTS: Structural equation modeling results indicate that preschool EC (represented by a single latent construct) significantly negatively predicted both sleep-wake problems and daytime sleepiness in early adolescence, with poorer EC predicting greater subsequent sleep problems. CONCLUSIONS: Poorer EC abilities during the critical period of preschool may be a risk factor for later sleep problems in adolescence. Given that EC appears to be modifiable, early interventions to promote EC development may help prevent subsequent sleep problems and promote long-term health trajectories.

A Longitudinal Study of Maternal and Child Internalizing Symptoms Predicting Early Adolescent Emotional Eating.

Objective: To examine maternal and child internalizing symptoms as predictors of early adolescent emotional eating in a longitudinal framework spanning three critical developmental periods (preschool, elementary school, and early adolescence). Methods: Participants were 170 children recruited at preschool age for a longitudinal study. When children were 5.25 years, their mothers completed ratings of their own internalizing symptoms. During the spring of 4th grade, children completed measures of internalizing symptoms. In early adolescence, youth completed a measure of emotional eating. Results: Maternal and child internalizing symptoms predicted adolescent emotional eating. The results indicated that child psychopathology moderated the association between maternal psychopathology (except for maternal anxiety) and early adolescent emotional eating. There was no evidence of mediation. Conclusions: Pediatric psychologists are encouraged to provide early screening of, and interventions for, maternal and child internalizing symptoms to prevent children's emotional eating.

Weight Status as a Mediator of the Association Between Preschool Extraversion and Adolescent Restrained Eating.

Objectives: To determine the longitudinal association between preschool extraversion and weight/dieting outcomes in adolescence. Methods: Children (N = 180) were recruited as part of a longitudinal study, with child temperament assessed in preschool (age 5.25 years), weight assessed in 2nd grade and early adolescence, and eating outcomes assessed in early adolescence (mean age = 12.02 years). Results: Preschoolers high in extraversion were significantly more likely to have higher body mass index z-scores (zBMI) and more restrained eating behaviors in adolescence. zBMI was found to mediate the relationship between extraversion and restrained eating, such that children with high levels of extraversion were more likely to have higher zBMI in adolescence and, owing to this higher weight status, to engage in more restrained eating. Conclusions: Temperament is an important predictor of later maladaptive weight/dieting outcomes in adolescence, making it a potentially important early factor to consider in weight management interventions.

Child Executive Control as a Moderator of the Longitudinal Association Between Sleep Problems and Subsequent Attention-Deficit/Hyperactivity Disorder Symptoms.

Objective: To examine the longitudinal associations among sleep, executive control (EC), and attention-deficit/hyperactivity disorder (ADHD) symptoms in childhood. Methods: In this longitudinal study (N = 271), parents answered questions about sleep problems when children were 3 years old, children completed a comprehensive EC task battery at 4.5 years, and teachers completed standardized measures of child ADHD symptoms in 4th grade. Results: Latent moderated structural equation models demonstrated that sleep problems at 3 years and EC deficits at 4.5 years were associated with ADHD symptoms in 4th grade. EC moderated the relationship between sleep problems and hyperactivity/impulsivity, such that children with both sleep problems and poor EC were particularly at risk for hyperactivity/impulsivity. Conclusions: Sleep problems and EC deficits early in development were associated with increased risk for ADHD symptoms in elementary school. Early assessment and intervention to promote healthy sleep and EC development may be helpful in ADHD prevention.

Latina and Non-Latina Mothers' Perceived Health Barriers and Benefits and Their Relationship to Children's Health Behaviors.

Objectives Disparities exist in rates of overweight/obesity between Latino and non-Latino populations. Attention should be given to risk factors that may be modifiable through interventions involving both the parent and child. The current study sought to identify ethnic differences in parental health beliefs and their relation to children's health behaviors. Methods Latina and non-Latina mothers (N = 203) at rural and urban clinics and health departments completed self-report questionnaires. Key information included beliefs about barriers and benefits to health practices and children's health behaviors. Results Children of Latina mothers consumed significantly more soda and fried foods and exercised less than children of non-Latina mothers. Latina mothers were significantly more likely to perceive barriers to healthy eating and significantly less likely to perceive benefits to healthy eating and physical activity than non-Latina mothers. Ethnicity mediated the relationship between maternal views of health benefits and soda consumption. Conclusions Policy changes are needed to promote health education and increase the accessibility of healthy foods and safe places to exercise for Latino families.

Parental misperceptions of children's underweight status: a meta-analysis.

BACKGROUND: Accurate parental perceptions of their children's underweight status are needed to prevent overlooking potential disordered eating patterns or health conditions affecting growth. PURPOSE: The aim of this study is to determine overall proportion of parents who misperceive children's underweight status and correlates of such misperceptions. METHODS: Original studies published to January 2013 were chosen through a literature search in established databases. Studies included assessed parental perceptions of their children's underweight and then compared perceptions to recognized standards for defining underweight based on anthropometric measures. Random- and mixed-effects models were used. RESULTS: Thirty-seven articles (representing 39 studies; N = 4,039) were included. Pooled effect sizes indicated that 46.58 % (95 % CI 40.90-52.35 %) of parents misperceive their children's underweight status, though the extent of misperceptions depended on a number of moderators. CONCLUSIONS: Nearly half of parents perceive their underweight children as weighing more than they actually do. Health care professionals are well positioned to take steps to remedy misperceptions and encourage healthy behaviors.

Emotional Eating Prevalence and Correlates in Adolescents in the United States.

Background: Adolescent obesity rates continue to rise. A better understanding of who engages in emotional eating, a maladaptive eating style, is needed. Despite emotional eating being a frequent research target, the prevalence of emotional eating in US adolescents is currently unknown. Methods: Nationally representative adolescents (n = 1622, m = 14.48 years, 63.8% non-Hispanic White, 50.6% female) reported eating behaviors in the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating (FLASHE) study. Frequencies and one-way ANOVAs were conducted to examine the rates of emotional eating across demographic and weight status groups. Correlations between emotional eating and dietary intake were examined. Results: In total, 30% of adolescents engaged in emotional eating. Older adolescents (35% of 17-year-olds), females (39%), non-Hispanic White individuals (32%), and adolescents with obesity (44%) had significantly higher rates of emotional eating. Controlling for weight status, greater adolescent emotional eating was correlated with more frequent intake of energy-dense/nutrient-poor foods (ß = 0.10, p < 0.001), junk food (ß = 0.12, p < 0.001), and convenience foods (ß = 0.13, p < 0.001). Conclusions: This study fills a critical gap by providing insight into how common adolescent emotional eating is and highlighting demographic factors that are associated with higher rates. Nearly a third of adolescents in the United States reported eating due to anxiety or sadness, with rates higher in older adolescents, girls, non-Hispanic White adolescents, and adolescents with obesity. Emotional eating was associated with consuming less healthy foods, which conveys immediate and long-term health risks. Practitioners can intervene with emotional eating to reduce obesity and comorbid health risks.

Attention-deficit/hyperactivity symptoms and loss of control eating in emerging adults: Role of psychological resilience.

OBJECTIVE: This study aimed to fill a gap in the literature regarding the role of resilience in the relationship between symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) and loss of control (LOC) eating in a nonclinical sample of emerging adults. Resilience was examined as a potential moderator and as a potential mediator of ADHD symptoms and engagement in LOC eating behaviors. Improved understanding of this relationship may inform clinical intervention and risk screening methodologies for disordered eating behaviors in college students. METHODS: Participants were undergraduate students (N = 386) from a private university in the northeastern United States. Linear regression analysis examined whether greater ADHD symptoms related to greater LOC eating. Pathway analyses examined resilience as either a moderator or mediator of the relationship between ADHD symptoms and LOC eating. RESULTS: A direct positive relationship was found between ADHD symptoms and LOC eating (p < .05). Resilience partially mediated this relationship, such that increased ADHD symptoms indirectly related to increased LOC eating through low resilience (p < .05). CONCLUSION: Findings indicate that undergraduate students with greater ADHD symptoms engaged in more frequent LOC eating, and that low resilience was a partial mediator of this positive relationship.

Screen time and mental health in college students: Time in nature as a protective factor.

Objective: To examine how time spent on handheld screens was related to internalizing mental health symptoms in college students and whether time spent in nature was associated with fewer mental health symptoms. Participants: Three hundred seventy-two college students (Mage = 19.47 ± 1.74, 63.8% female; 62.8% college freshman). Methods: College students completed questionnaires for research credit in their psychology courses. Results: Screen time significantly predicted higher anxiety, depression, and stress. Spending time outdoors ("green time") significantly predicted lower stress and depression, but not lower anxiety. Green time moderated the relationship, such that college students who spent less time outside (1SD below mean) had consistent rates of mental health symptoms across hours of screentime, but individuals who spent average/above average (mean, 1SD above mean) time outside had fewer mental health symptoms at lower levels of screentime. Conclusions: Promoting green time in students may be an effective way of improving stress and depression.

Feasibility of Electronic Medication Monitoring Among Adolescents and Emerging Adults with Sickle Cell Disease.

Purpose: To examine the feasibility of using MEMS® bottles to assess adherence among adolescents and emerging adults with sickle cell disease. Patients and Methods: Eighteen non-Hispanic Black participants with HbSS (M = 17.8 years; 61% male) were given a MEMS® bottle to store hydroxyurea (n = 14) or deferasirox (n = 4). Results: One hundred percent initiated MEMS® use and 61% sustained use through the 18-week study; at follow-up, only 11% returned their bottle on time. Barriers to MEMS® use included medication changes and transition to adult care; facilitators included tip sheets and reminders. Conclusion: While MEMS® is acceptable to this population, ensuring sustained use and timely provision of bottles will require additional supports.

Cigarette Use and Adolescent Metabolic and Bariatric Surgery.

OBJECTIVE: This study aimed to track conventional cigarette smoking behaviors and associated correlates in adolescents with severe obesity who did or did not undergo metabolic and bariatric surgery to 4 years after surgery/baseline. METHODS: Utilizing a prospective controlled design, surgical (n = 153; mean BMI = 52) and nonsurgical (n = 70; mean BMI = 47) groups that completed assessments before surgery/at baseline and at Years 2 and 4 post surgery (Year 4: n = 117 surgical [mean BMI = 38]; n = 56 nonsurgical [mean BMI = 48]) were compared. Separate logistic regression models tested correlates of Year 4 current smoking. RESULTS: More than half of participants (surgical: 55%; nonsurgical: 60%) had ever smoked a cigarette, with current smoking increasing with time. Groups did not differ in Year 4 current smoking (surgical: 23%; nonsurgical: 33%), with ≈ 50% meeting criteria for "heavy" smoking (≥ half pack/day) and ≈ 40% smoking their first cigarette before ninth grade. Factors associated with higher odds of Year 4 current smoking included dysregulation (P < 0.001), internalizing symptoms (P = 0.01), alcohol use (P = 0.04), caregiver smoking (P < 0.001), friend smoking (P = 0.001), and perceiving low harm (P = 0.02), plus greater percent weight loss (P = 0.03) in the surgical group. CONCLUSIONS: Smoking is a clinical health challenge for adolescents and young adults with severe obesity, including those who have undergone metabolic and bariatric surgery. Upstream identification, monitoring, and intervention to prevent smoking uptake and escalation in youth with obesity across settings should be prioritized.