Exploration of a Swedish community-based family-oriented setting for promoting healthy food habits: professionals' experiences.

Health is created in everyday life and settings, where food literacy (FL) and health literacy (HL) are recognized as important for autonomy over one's own health. Though it is acknowledged that bridging the gap between healthcare settings and community settings may be necessary to reach those requiring extra support. Open preschool (OP) is a low threshold community setting which parents with their young children can visit voluntarily, where the various activities offered can be opportunities to address topics related to food and health. The aim of this study is to explore preschool teachers and health practitioners' thoughts and experience of OP as a setting for health promotion, with focus on food and eating. The study is localized to OP's in a multicultural district in Gothenburg, Sweden. Semi-structured interviews were conducted with three preschool teachers and seven health practitioners (one dental hygienist, three dietitians and three public health strategists). With an inductive approach, data were analysed using qualitative content analysis. From the perspective of teachers and health practitioners, the findings indicate that OP can be a setting for mutual learning in a supportive environment. OP provides various possibilities for improved FL and HL by linking health practitioners with families, providing the opportunity to socialize and by eating together. The results also reveal that language barriers can sometimes hinder communication, and that OP does not reach all families. Continuous collaboration between OP and health organizations and practitioners along with regular use of intercultural mediators is recommended by the professionals.

Consumption of foods with the Keyhole front-of-pack nutrition label: potential impact on energy and nutrient intakes of Swedish adolescents.

OBJECTIVE: The Keyhole is an internationally recognised front-of-pack nutrition label, guiding consumers to healthier food options. It indicates products in accordance with specific criteria for dietary fats, sugars, fibres, salt and wholegrains. The objective of this study was to simulate the potential impact of the Keyhole on adolescents' energy and nutrient intakes by modelling a shift from reported food intakes to foods meeting the Keyhole criteria. DESIGN: Self-reported dietary intake data were derived from a cross-sectional survey. Multiple replacement scenarios were calculated, where foods meeting the Keyhole criteria replaced reported non-compliant foods with varying proportions of replacement. SETTING: Dietary survey 'Riksmaten Adolescents 2016-2017' in schools across Sweden. PARTICIPANTS: A nationally representative sample of 3099 adolescents in school years 5, 8 and 11 (55 % girls). RESULTS: Overall, replacement with foods meeting the Keyhole criteria led to more adolescents meeting nutrition recommendations. Largest median intake improvements were seen for wholegrains (+196 %), SFA (-13 %), PUFA (+17 %) and fibres (+15 %). Smallest improvements were seen for free sugars (-3 %) and salt (-2 %), partly explained by the ineligibility of main food sources of free sugars for the Keyhole, and non-inclusion of ready meals that are often high in salt. Most micronutrient intakes were stable or improved. Unintentional effects included decreases in vitamin A, MUFA and energy intakes. Largest potential improvements in fat and fibre sources were observed in the youngest age group. CONCLUSIONS: A shift to Keyhole alternatives for everyday foods would improve adolescents' nutrient intakes, even with smaller exchanges.

Facilitating health promoting ideas and actions: participatory research in an underserved Swedish residential area.

BACKGROUND: For an intervention to contribute to decreased health gaps, people living in underserved areas must participate in the research-to-action process during the development of the intervention. The purpose of this study was to collaborate with residents living in a Swedish underserved area to generate health and wellness priorities and actions. METHODS: We applied Group Level Assessment (GLA) together with people living in a Swedish neighborhood where obesity, dental caries and other illnesses are prevalent. GLA is a qualitative, participatory methodology that is designed for a large group to generate and evaluate relevant needs and priorities within a lens of action for positive social change. Residents were recruited by posters, postcards and snowball sampling. In total, 47 residents participated. Eight GLA sessions were held over a five-month time period. RESULTS: The GLA sessions resulted in reflections, proposals and actions for change by the residents. Adolescent and parent need for support, improved communication and more meeting places were highlighted as priorities for promoting health and well-being. The results were presented for stakeholders in a report and an exhibition and some of the participants started a language café. CONCLUSIONS: GLA emphasised the participants' perspective. The participatory process helped them identify what they thought valuable and relevant concerning health issues and supported them in taking actions to achieve change.

Dieting, body weight concerns and health: trends and associations in Swedish schoolchildren.

BACKGROUND: Dieting is a risk factor of both eating disorders and obesity. The aim was to examine time trends of dieting in Swedish adolescents, and explore how dieting and body weight dissatisfaction are related to self-reported health, wellbeing and health behaviours. METHODS: Analyses of cross-sectional Swedish data from HBSC (Health Behaviour in School-aged Children) surveys 1994-2014. In total, about 30,000 girls and boys in the age of 11, 13 and 15 years participated. Data was collected by using classroom administered questionnaires in 5th, 7th and 9th grade. Logistic regressions was used to analyse secular trends of dieting, and how dieting and body dissatisfaction were associated with self-reported overall health, health behaviours, BMI and various physical, psychological and social aspects of health in 2014. RESULTS: Dieting increased from 1994 to 2014 in both girls and boys in all age groups, and in 2014, the prevalence was 14% in girls and 8% in boys. The prevalence of body satisfaction was 65% respectively 69%. Body weight dissatisfaction and dieting were present in all body weight classes and were associated with self-reported poor health and many other negative health aspects. In comparison with the participants that were satisfied with their body weight the odds ratio (95% CI) for self-reported poor health was 3.4 (2.6-4.4) in dieters, 4.9 (3.8-6.4) in participants who perceived a need to lose weight and 2.1 (1.5-2.8) in those who perceived a need to gain weight, when adjusting for age, sex and body weight class. CONCLUSIONS: When promoting health among school age children body weight dissatisfaction and dieting ought to be considered. Furthermore, it is important to support girls and boys in all weight classes to reach and maintain a healthy body image and weight.

Food appearances in children's television programmes in Iceland.

OBJECTIVE: Exposure to advertisements cannot fully explain the associations between young children's dietary intake and the time they spend in front of the television. It is therefore of importance to study television content other than advertisements in this aspect. The present study aimed to examine the nature and extent of verbal and visual appearances of foods and beverages in children's television programmes on Icelandic public service television. DESIGN: A total of 27 h of children's programmes (domestic and internationally produced) were watched. All verbal and visual appearances of foods and beverages were coded, as well as the context in which the foods/beverages were discussed or appeared. SETTING: Children's programmes on Icelandic public service television. SUBJECTS: Two food groups were of special interest for their importance from a public health perspective: high-calorie and low-nutrient (HCLN) foods and fruits and vegetables (F&V). The χ 2 test and logistic regression were performed to analyse if the occurrence of the two groups was associated with the context where foods/beverages appeared. RESULTS: Of the 125 different programmes, a food or beverage appeared in 86 %. Of the total food appearances (n 599), HCLN foods accounted for 26 % and F&V for 23 %. HCLN foods were presented as desirable by appearing more frequently with child characters (P<0·01) than F&V. CONCLUSIONS: Public service television has the potential to improve the way food and eating is presented in children's programmes, as young childhood is a critical period for founding healthy habits for later life.

Strengthening the Reporting of Observational Studies in Epidemiology-Nutritional Epidemiology (STROBE-nut): An Extension of the STROBE Statement.

BACKGROUND: Concerns have been raised about the quality of reporting in nutritional epidemiology. Research reporting guidelines such as the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement can improve quality of reporting in observational studies. Herein, we propose recommendations for reporting nutritional epidemiology and dietary assessment research by extending the STROBE statement into Strengthening the Reporting of Observational Studies in Epidemiology-Nutritional Epidemiology (STROBE-nut). METHODS AND FINDINGS: Recommendations for the reporting of nutritional epidemiology and dietary assessment research were developed following a systematic and consultative process, coordinated by a multidisciplinary group of 21 experts. Consensus on reporting guidelines was reached through a three-round Delphi consultation process with 53 external experts. In total, 24 recommendations for nutritional epidemiology were added to the STROBE checklist. CONCLUSION: When used appropriately, reporting guidelines for nutritional epidemiology can contribute to improve reporting of observational studies with a focus on diet and health.

FTO gene variation, macronutrient intake and coronary heart disease risk: a gene-diet interaction analysis.

PURPOSE: The fat mass and obesity-associated gene (FTO) is related to obesity and coronary heart disease (CHD). We studied interaction between macronutrient intake and FTO in association with CHD risk or body mass index (BMI). METHODS: The pooled population-based case-control studies, SHEEP and INTERGENE, included 1,381 first-time CHD patients and 4,290 population controls genotyped for FTO rs9939609 (T/A). Diet data were collected in self-administered food frequency questionnaires. Macronutrients were dichotomized into low/high energy percentages (E%) by median levels in controls. Association of FTO genotype (TA/AA vs. TT) with CHD risk was analysed by multiple logistic regression, and with BMI by multiple linear regression. Interaction between FTO and macronutrient was assessed by introducing an interaction term FTO × macronutrient. Interaction on CHD as deviation from additive effects was assessed by calculating relative excess risk due to interaction. RESULTS: No statistically significant interaction was found between FTO genotype and any macronutrient on CHD risk or BMI on either the multiplicative or additive scale. However, FTO genotype (TA/AA vs. TT) was associated with significantly increased CHD risk only in subjects with low E% from fat (OR 1.36, 95% CI 1.11-1.66) or saturated fatty acids (OR 1.36, 95% CI 1.10-1.69), or in subjects with high E% from carbohydrate (OR 1.32, 95% CI 1.07-1.61) or protein (OR 1.41, 95% CI 1.13-1.75). Mean BMI was 0.3-0.6 kg/m(2) higher in control subjects with TA/AA compared to TT, regardless of macronutrient E%. CONCLUSIONS: We found no evidence of interactions between FTO genotype and macronutrient intake on CHD risk or BMI.

Adolescents' presentation of food in social media: An explorative study.

The study aimed to explore how adolescents communicate food images in a widely used social media image-sharing application. We examined how and in what context food was presented and the type of food items that were frequently portrayed by following a youth related hashtag on Instagram. The hashtag #14år ("14 years") was used to find adolescent users on Instagram: these users public photo streams were then searched for food items they had shared with others. Food items were identified and categorized based on type of food and how the food items were presented. Most of the adolescent users (85%) shared images containing food items. A majority of the images (67.7%) depicted foods high in calories but low in nutrients. Almost half of these images were arranged as a still life with food brand names clearly exposed. Many of these images were influenced by major food marketing campaigns. Fruits and vegetables occurred in 21.8% of all images. This food group was frequently portrayed zoomed in with focus solely on the food, with a hashtag or caption expressing palatability. These images were often presented in the style of a cook book. Food was thus presented in varied ways. Adolescents themselves produced images copying food advertisements. This has clear health promotion implications since it becomes more challenging to monitor and tackle young people's exposure to marketing of unhealthy foods in these popular online networks because images are part of a lifestyle that the young people want to promote. Shared images contain personal recommendations, which mean that they may have a more powerful effect than commercial advertising.

Hydration status in elite wrestlers, judokas, boxers, and taekwondo athletes on competition day.

Weight category athletes are known for practicing rapid weight loss before competition weigh-in. After weigh-in, athletes strive to restore euhydration and body mass through food and fluid intake. The aim of the current study was to assess prevalence of hypohydration at competition time among elite athletes' in four different combat sports, and how water intake and timing of official weigh-in were related to hydration status. Participants were 31 taekwondo practitioners and wrestlers who performed evening weigh-in (EWI) the night before competition day and had thus time for rehydration, and 32 boxers and judokas conducting competition day morning weigh-in (MWI). In total, 32% were female. Urine specific gravity (USG) was measured by refractometry on the competition day's first morning urine sample. Hypohydration was defined as USG ≥ 1.020 and serious hypohydration as USG > 1.030. Water intake was measured by means of dietary records. The prevalence of hypohydration was 89% in the morning of competition day. Serious hypohydration was also prevalent. This was found in over 50% of MWI athletes and in 42% of the EWI group. A higher water intake, from both fluids and solid foods, in the evening before competition day was not associated with a more favorable hydration status the following morning. In conclusion, neither weigh-in close to competition nor evening weigh-in with more time for rehydration seems to prevent hypohydration before competition.

Dietary intake at competition in elite Olympic combat sports.

The purpose of the current study was to investigate elite female (n = 21) and male (n = 47) combat sports athletes' (n = 68; mean age (± SD) 21.3 ± 3.8 years; mean height 177 ± 10.2 cm) dietary intake between weigh-in and the first bout in Olympic combat sports. The data were collected at 6 separate tournaments and measurements included estimated food records, time for recovery, and body weight (BW) at weigh-in and first match. In total, 33 athletes participated in wrestling and taekwondo, sports with extended recovery times, and 35 athletes in judo and boxing, sports with limited recovery time. The results displayed that despite a mean consumption of food and drinks corresponding to 4.2 kg, the athletes only regained an average of 1.9 kg BW during recovery. Water accounted for 86% of the total intake. For each liter of water consumed, athletes gained 0.57 kg BW, when excluding heavy weight athletes (n = 5). Carbohydrate consumption was 5.5 g/kg BW, compared with the recommended 8-10 g/kg BW. In total, one-quarter of the consumed water originated from carbohydrate-rich drinks. Given the average recovery time of 18 (wrestling, taekwondo) versus 8 hr (judo, boxing), the former group consumed twice the amount of water, carbohydrates, protein, and fat as the latter group. In conclusion, a large proportion of the participants did not meet the recovery nutrition guidelines for carbohydrates. In addition, the discrepancy between nutrient intake and weight gain points to the physiological barriers to retaining fluids during a limited recovery time after engaging in weight making practices.

Domain-Specific Physical Activity and Stroke in Sweden.

Importance: Associations of domain-specific physical activity with stroke incidence and poststroke outcomes have not been extensively studied using long-term, population-based data. Objective: To investigate associations of leisure time, work time, transport, and household physical activity with stroke incidence and death or dependency in activities of daily living (ADL) 3 months after stroke. Design, Setting, and Participants: The prospective, population-based Interplay Between Genetic Susceptibility and External Factors (INTERGENE) cohort study was conducted among a random sample of individuals from an urban-rural area covering western Sweden; 3614 individuals aged 24 to 77 years were examined in 2001 to 2004, and 1394 individuals were reexamined in 2014 to 2016. The median (range) follow-up was 20.0 years (56 days to 21.9 years). Data were analyzed from September through October 2023. Exposure: Physical activity levels were self-reported for leisure time, work time, transportation, and household domains. The mean number of steps taken over a 6-day period was collected in a subgroup of participants using a sealed pedometer. Main Outcomes and Measures: Follow-up for stroke incidence and mortality rates continued until December 31, 2022. The composite outcome of death or ADL dependency was assessed at 3 months after stroke. Results: Among 3614 individuals (mean [SD] age, 51.4 [13.1] years; 1910 female [52.9%]); 269 individuals (7.4%) developed stroke, of whom 120 individuals (44.6%) were dead or ADL dependent at 3 months. Intermediate (adjusted hazard ratio [aHR], 0.54; 95% CI, 0.38-0.77) and high (aHR, 0.47; 95% CI, 0.31-0.73) levels of leisure time physical activity were associated with a reduced incidence of stroke compared with low levels, as was an intermediate level of physical activity in transportation (aHR, 0.69; 95% CI, 0.52-0.93). High levels of leisure time physical activity were also associated with a reduced risk of poststroke death or ADL dependency (adjusted odds ratio, 0.34; 95% CI, 0.16-0.71) compared with low levels. Work time and household physical activity were not associated with stroke incidence or stroke outcomes. In exploratory subgroup analyses, there were interactions between physical activity and smoking (current smoking or smoking in the past year associated with stroke risk only in participants with low or intermediate physical activity: aHR, 2.33; 95% CI, 1.72-3.15) and family history of stroke (first-degree relative with a history of stroke associated with stroke risk only in participants with low or intermediate physical activity: aHR, 1.73; 95% CI, 1.27-2.38). Conclusions and Relevance: In this study, leisure time and transport-related physical activities were associated with a reduced risk of stroke. A high level of leisure time physical activity was also associated with a lower risk of death or ADL dependency 3 months after stroke.

The food and weight combat. A problematic fight for the elite combat sports athlete.

Weight reduction in athletes is motivated by optimisation of performance, aesthetic reasons or to achieve a pre-designated weight. Previous research has shown that dietary restraint and short term weight regulation frequently takes place among combat sports athletes such as wrestlers and judokas. The aim of this study was to explore negative experiences related to dietary strategies and weight-making practises used by elite combat sports athletes. Using semi-structured interviews, 14 Swedish national team athletes in wrestling, judo and taekwondo were asked about their dietary intake and their engagement in both long- and short-term weight regulation practises. Content analysis of the transcribed interviews, display a constant struggle regarding nutritional standpoints. Sport demands such as achieving an optimal weight and nutritional intake were considered as central in order for excellent performance. Adhering to these demands was found to be problematic however, primarily because of; (1) negative physiological responses and (2) opposing ideals of a non-sport related nature, such as the importance of the athletes to be healthy and social in their everyday lives.

Health discourse in Swedish television food advertising during children's peak viewing times.

Food marketing influences children's food preferences and consumption and is important to consider in the prevention of child obesity. In this paper, health messages in commercials during children's peak viewing times were analysed by examining how food is articulated in the health discourse. In total, 82 food commercials from 66h of television recordings of the most popular commercial channels with children in Sweden (TV3, TV4 and Channel 5) were analysed with discourse theoretical tools according to Laclau and Mouffe and with a focus on rhetoric. Physical, mental and social health aspects were present in 71% of the commercials. Three health discourse types; a medical (food as protection and treatment), a hedonic (food as feeling good) and a social discourse type (food as caring) were discerned. In relation to these, the heart symbol, lifestyle associations and nature/the natural were elements that could be interpreted in different ways. Moreover, foods carrying unhealthy associations were promoted in the health discourse and presented as especially healthy by offensive rhetoric. The analysis raises awareness of the prevailing health messages in food marketing. Children and parents should be encouraged to develop their critical thinking about television food advertising and how it may influence social norms and dietary practices.

Television food advertising to children: a global perspective.

OBJECTIVES: We compared television food advertising to children in several countries. METHODS: We undertook a collaboration among 13 research groups in Australia, Asia, Western Europe, and North and South America. Each group recorded programming for 2 weekdays and 2 weekend days between 6:00 and 22:00, for the 3 channels most watched by children, between October 2007 and March 2008. We classified food advertisements as core (nutrient dense, low in energy), noncore (high in undesirable nutrients or energy, as defined by dietary standards), or miscellaneous. We also categorized thematic content (promotional characters and premiums). RESULTS: Food advertisements composed 11% to 29% of advertisements. Noncore foods were featured in 53% to 87% of food advertisements, and the rate of noncore food advertising was higher during children's peak viewing times. Most food advertisements containing persuasive marketing were for noncore products. CONCLUSIONS: Across all sampled countries, children were exposed to high volumes of television advertising for unhealthy foods, featuring child-oriented persuasive techniques. Because of the proven connections between food advertising, preferences, and consumption, our findings lend support to calls for regulation of food advertising during children's peak viewing times.

Selection bias in a population survey with registry linkage: potential effect on socioeconomic gradient in cardiovascular risk.

Non-participation in population studies is likely to be a source of bias in many types of epidemiologic studies, including those describing social disparities in health. The objective of this paper is to present a non-attendance analysis evaluating the possible impact of selection bias, when investigating the association between education level and cardiovascular risk factors. Data from the INTERGENE research programme including 3,610 randomly selected individuals aged 25-74 (1,908 women and 1,702 men), in West Sweden were used. Only 42% of the invited population participated. Non-attendance analyses were done by comparing data from official registries (Statistics Sweden) covering the entire invited study population. This analysis revealed that participants were more likely to be women, have university education, high income, be married and of Nordic origin compared to non-participants. Among participants, all health behaviours studied were significantly related to education. Physical activity, alcohol use and breakfast consumption were higher in the more educated group, while there were more smokers in the less educated group. Central obesity, obesity and hypertension were also significantly associated with lower education level. Weaker associations were observed for blood lipids, diabetes, high plasma glucose level and perceived stress. The socio-demographic differences between participants and non-participants indicated by the register analysis imply potential biases in epidemiological research. For instance, the positive association between education level and frequent alcohol consumption, may, in part be explained by participation bias. For other risk factors studied, an underestimation of the importance of low socioeconomic status may be more likely.

Eating patterns and portion size associated with obesity in a Swedish population.

The objective of this study was to describe the association between meal pattern and obesity. The study is based on data from the INTERGENE research programme, and the study population consists of randomly selected women and men, aged 25-74, living in the Västra Götaland Region in Sweden. A total of 3610 were examined. Participants with measured BMI> or =30 were compared with others (BMI<30) with respect to questionnaire data on habitual meal patterns and intake of energy estimated from food frequencies and standard portions. Odds ratios (OR) with 95% confidence intervals were adjusted for age, sex, smoking and physical activity in logistic regression models. Being obese was significantly associated with omitting breakfast, OR 1.41 (1.05-1.90), omitting lunch OR 1.31 (1.04-1.66) and eating at night OR 1.62 (1.10-2.39). Obesity was also related to significantly larger self-reported portion sizes of main meals. No statistically significant relationship with intake of total energy was revealed. Thus, the results indicate that examination of meal patterns and portion sizes might tell us more about obesogenic food patterns than traditional nutrient analyses of food frequencies. Being obese was associated with a meal pattern shifted to later in the day and significantly larger self-reported portions of main meals.

Health literacy in a complex digital media landscape: Pediatric obesity patients' experiences with online weight, food, and health information.

This study aimed to explore experiences with online information regarding food, weight management, and health in a group of adolescents in treatment for obesity. Individual semi-structured interviews with 20 adolescents were conducted. Participants used a screen-recorded laptop to demonstrate their search procedures and online information sources. The transcribed interviews were categorized using qualitative content analysis. The adolescents described both encouraging and discouraging experiences. On one hand, they said that online forums could provide nutritious meal ideas and inspiration as well as social support for behavior change. On the other hand, they mentioned that there was a confusing amount of misleading commercial content online and also experiences of peer-facilitated food marketing in online networks. An overarching theme was generated: social media might be a resource for health inspiration, health information, and social support, but requires awareness and competencies. Implications for clinical practice are discussed in light of these findings.

Procedure to Estimate Added and Free Sugars in Food Items from the Swedish Food Composition Database Used in the National Dietary Survey Riksmaten Adolescents 2016-17.

A high intake of added and free sugars is associated with poor diet quality, caries, and potentially has a role in non-communicable diseases. As a result, dietary guidelines advice limitation. However, there is no standardized method for estimation of added and free sugars in food items and consequently intake is difficult to measure. This study aimed to refine a procedure for sugars estimation and apply it to a Swedish dietary survey on adolescents (Riksmaten Adolescents 2016-17). A national sample of 3099 adolescents in school year 5, 8 and 11 participated (55% girls). Individual dietary intake data from two non-consecutive days was collected retrospectively and used for analysis. A ten-step systematic procedure for estimation of sugars in a Swedish context has been developed by combining two earlier methods, one for estimation of added sugars and one for free sugars. Sugars estimates were made for all food items comprising the survey database. Mainly objective decisions were necessary to make the estimates (92% and 93% for the sugars respectively); meaning that the procedure was largely transparent. In relation to Nordic Nutrition Recommendations, 45% of the participants had an intake that adhered to the guidelines. However, the majority of intakes was close to the recommendation. Further research on how specific food sources contribute to added and free sugars is necessary to facilitate further guidance on sugars and how to reach recommended target levels in Sweden.

Self-presentation in digital media among adolescent patients with obesity: Striving for integrity, risk-reduction, and social recognition.

BACKGROUND: Emerging research suggests that social media has the potential in clinical settings to enhance interaction with and between pediatric patients with various conditions. However, appearance norms and weight stigmatization can make adolescents with obesity uncomfortable about using these visual-based media. It is therefore important to explore these adolescents' perspectives to identify the implications and concerns regarding the use of social media in clinical settings. OBJECTIVE: To explore the experiences of adolescents in treatment for obesity in terms of how they present themselves on social media, their rationale behind their presentations, and their feelings related to self-presentation. METHODS: Interviews were conducted with 20 adolescents enrolled in a pediatric outpatient obesity clinic, then transcribed and categorized using qualitative content analysis and Goffman's dramaturgical model. Participants used a screen-recorded laptop to demonstrate their online self-presentation practices.Findings: Adolescent girls and boys undergoing treatment for obesity used visual-based social media, but girls in particular experienced weight stigma online and undertook self-presentation strategies to conceal weight-related content such as avoiding showing close-up photos of their bodies and not posting images of unhealthy "fattening" foods. Participants perceived the potential use of social media in clinical settings as being too risky and private. CONCLUSIONS: Given the complexity of general visual-based social media use by adolescents, and not wanting their patient status to be visible to peers, healthcare should primarily focus on working with more restricted instant messaging when engaging with adolescents with obesity.