Biomedical subjects

Jennifer O'Loughlin

Publications and source records attributed to Jennifer O'Loughlin.

At least 19 recordsLinked to original sources

PubMed2006

Delays to reperfusion therapy in acute ST-segment elevation myocardial infarction: results from the AMI-QUEBEC Study.

BACKGROUND: Through the AMI-QUEBEC Study we sought to describe delays to reperfusion therapy for ST-segment elevation myocardial infarction (STEMI) and to identify factors associated with prolonged delays. METHODS: We reviewed the charts of all consecutive patients with STEMI admitted to 17 hospitals in the province of Quebec in 2003 to obtain data on the time from presentation to reperfusion therapy. Data were available for 1189 (83.0%) of 1432 patients. RESULTS: The median delay to reperfusion therapy was 32 minutes (first and third quartile [Q1, Q3] 20, 49) for 535 patients who received fibrinolytic therapy, 109 minutes (Q1, Q3 79, 150) for 455 patients who underwent primary percutaneous coronary intervention (PCI) at the initial hospital of presentation and 142 minutes (Q1, Q3 115, 194) for 199 patients who underwent primary PCI after an interhospital transfer. Patients who presented outside daytime working hours, those who received primary PCI and those who required interhospital transfer for primary PCI were less likely to receive reperfusion therapy within current recommended times (odds ratios [ORs] 0.49, 0.56 and 0.15, respectively). Increased age was associated with prolonged delays only among patients who received fibrinolytic therapy (OR for each 10-year increase in age 0.95, 95% credible interval [CrI] 0.93-0.99 for fibrinolytic therapy and 0.99, 95% CrI 0.95-1.05, for primary PCI). INTERPRETATION: In 2003, many patients with STEMI in Quebec were not treated within the recommended times. Delays may be reduced by reorganizing pre-and in-hospital care for patients with STEMI to expedite delivery of reperfusion therapy.

Age Factors↗

PubMed2006

Emergence of sex differences in prevalence of high systolic blood pressure: analysis of a longitudinal adolescent cohort.

BACKGROUND: High systolic blood pressure (SBP) occurs more frequently both among men and boys than among women and girls. No longitudinal study has investigated whether the impact of SBP determinants differ according to sex in youth. METHODS AND RESULTS: Between 1999 and 2005, an adolescent cohort (n=1267) completed a questionnaire survey and underwent biannual blood pressure and anthropometric assessment (grades 7, 9, and 11). Boys accounted for approximately 50% of those with high SBP at grade 7 and 9 assessments but 67% of those with high SBP at the grade 11 assessment. As computed through a generalized estimating equations logistic regression model (sex, age, sex and age interaction term, overweight, physical activity, sedentary behavior, heart rate, household income, tobacco use, and 4 language categories), the likelihood of high SBP values among boys compared with girls was 1.29 (95% CI, 0.77 to 2.16) in grade 7, 1.98 (95% CI, 1.35 to 2.93) in grade 9, and 2.74 (95% CI, 1.52 to 4.94) in grade 11. Although there was a significant interaction between sex and age, interaction terms of sex with overweight, sedentary behavior, and physical activity were not statistically significant. Overweight (odds ratio [OR], 2.63; 95% CI, 1.76 to 3.92) and sedentary behavior (OR, 1.17 for increment of 5 hours weekly; 95% CI 1.04 to 1.33) demonstrated positive associations with high SBP values. Physical activity was inversely associated with the presence of high SBP (OR, 0.92 for increment of 5 activities in 7 days; 95% CI, 0.84 to 1.00). CONCLUSIONS: Boys are more likely than girls to develop high SBP as they approach adulthood. Even among overweight adolescents, reducing sedentary behavior and increasing physical activity may lower the risk of high SBP.

Adolescent↗

PubMed2006

Association between fruit and vegetable consumption in mothers and children in low-income, urban neighborhoods.

To understand factors influencing fruit and vegetable (F&V) consumption in children, the authors studied the association between F&V consumption in mothers and children in a sample of 1,106 boys and girls in Grades 4-6 in 24 elementary schools in low-income, multiethnic neighborhoods in Montreal, Canada. Approximately 10% of girls and 19% of boys reported not having eaten any vegetables in the week prior to questionnaire administration; 53% of girls and 63% of boys did not consume whole fruits daily. Each unit increase in F&V consumption in mothers was associated with a 10% to 20% increase in F&V consumption in children. Interventions to improve F&V consumption should aim to improve awareness among parents of the importance of fruits and vegetables and of the impact of their own behavior on their children's F&V consumption.

Adolescent↗

PubMed2006

Milestones in the natural course of onset of cigarette use among adolescents.

BACKGROUND: The natural course of onset of cigarette use has been conceptualized as progressing sequentially through 5 stages (preparation, trying, irregular use, regular use, nicotine-dependent smoking). However, recent studies suggest that symptoms of nicotine dependence can occur early in the onset process, raising questions about the validity of this model. The objective of our study was to describe the sequence and timing of 12 milestones (6 related to cigarette use and 6 to symptoms of nicotine dependence) during onset of cigarette use. METHODS: Grade 7 students in 10 secondary schools in Montréal (n = 1293) were followed prospectively every 3-4 months for 5 years. Using Kaplan-Meier analysis, we computed the number of months after first puff at which the cumulative probability of attaining each milestone was 25%, among 311 participants who initiated cigarette use during follow-up. RESULTS: Inhalation rapidly followed first puff. The cumulative probability of inhalation was 25% at 1.5 months (95% confidence interval [CI] 1.5-2.5). The cumulative probability (and 95% CI) was 2.5 months (1.5-2.5) for mental addiction, 2.5 (1.0-3.0) for smoking a whole cigarette, 4.5 (2.5-8.8) for cravings, 5.4 (3.8-9.7) for physical addiction, 8.8 (7.0-11.9) for monthly smoking, 11.0 (6.4-16.8) for withdrawal symptoms, 13.0 (10.3-20.5) for tolerance, 19.4 (14.5-31.7) for weekly smoking, 19.5 (14.0-23.9) for lifetime total of 100 cigarettes, 23.1 (19.7-37.6) for daily smoking and 40.6 (35.1-56.0) for conversion to tobacco dependence. INTERPRETATION: Symptoms of nicotine dependence develop soon after first puff and can precede monthly, weekly and daily smoking. Cessation interventions that manage dependence symptoms may be needed soon after first puff.

Adolescent↗

PubMed2006

Effect of a ban on extracurricular sports activities by secondary school teachers on physical activity levels of adolescents: a multilevel analysis.

To study the effect of a teachers' ban on supervising sports-related extracurricular physical activities (ECAs), levels of physical activity among 979 grade 7 students (mean age=12.7 [0.5] years at baseline) were compared during and after the ban in seven schools that fully implemented the ban, and three schools that did not implement the ban fully. On average, schools offered 18.0 (SD=5.1) ECAs during a no-ban school year. Students attending full implementation schools were significantly more likely than students in nonimplementation schools to be active after the ban ended (odds ratio for being active=1.89 [95% confidence interval: 1.39, 2.58]). They also increased the number of physical activities in which they participated (coefficient=4.04; SE=1.01). Ending a teachers' ban on sports-related ECAs was associated with increased involvement in physical activity among secondary school students.

Adolescent↗

PubMed2006

Opportunities for student physical activity in elementary schools: a cross-sectional survey of frequency and correlates.

The objectives of this study were to describe opportunities for student physical activity (PA) in elementary schools and to identify factors in the school environment associated with higher PA opportunity. Self-report questionnaires were completed by school principals and physical education teachers in 277 schools (88% response) in metropolitan Montreal. Correlates of opportunity were identified using ordinal logistic regression. There was substantial variation in PA opportunities between schools. Higher opportunity was associated with role modeling of PA by school principals, their interest in increasing PA through links to the municipality, adequate financial and human resources, access to school sports facilities, adequate space for storing student sports equipment, and suburban location. There is both the need and the potential for intervention to increase PA opportunities in elementary schools. Addressing barriers related to resources and access to sports facilities may help reduce disparities between schools in opportunities for students to engage in PA.

Attitude↗

PubMed2005

Reliability of self-reports of cigarette use in novice smokers.

This analysis reports the 3-month test-retest reliability of self-reports of cigarette use in novice smokers, and identifies factors associated with adequate recall. Participants included 63 novice smokers (mean age 14.1 years) from the McGill University Study on the Natural History of Nicotine Dependence in Teens. We compared data for three cigarette use indicators obtained in a 1-month recall of smoking, to data obtained for that same month, 3 months later. Forty-three participants (68.3%) smoked infrequently; 12.7%, 6.4%, and 12.7% were monthly, weekly, and daily smokers, respectively. Test-retest reliability for the cigarette use frequency and intensity indicators was good (kappa=0.78 and 0.75, respectively); it was lower for total number of cigarettes smoked per month (ICC=0.64). Older age was independently associated with adequate recall for all three indicators. These data suggest that novice smokers recall the frequency and intensity of their cigarette use reliably after 3 months, and that older adolescents have better recall than younger adolescents.

Adolescent↗

PubMed2005

Distribution of LDL particle size in a population-based sample of children and adolescents and relationship with other cardiovascular risk factors.

BACKGROUND: Smaller, denser LDL particles are associated with an increased risk for cardiovascular diseases (CVD). In youths, data on the distribution of LDL particle size and on its association with other CVD risk factors are limited. METHODS: We determined LDL peak particle size by nondenaturing 2%-16% gradient gel electrophoresis in a representative sample of 2249 youths 9, 13, and 16 years of age who participated in a school-based survey conducted in 1999 in the province of Quebec, Canada. Standardized clinical measurements and fasting plasma lipid, glucose, and insulin concentrations were available. RESULTS: The LDL peak particle size distribution was gaussian. The 5th, 50th (median), and 95th percentiles by age and sex were 255.5-258.6, 262.1-263.2, and 268.1-269.5 A, respectively. The prevalence of the small, dense LDL phenotype (LDL peak particle size <or=255 A) was 10% in participants with insulin resistance syndrome (IRS), in contrast to 1% in those without IRS. In a multiple regression analysis, the association of LDL size with other CVD risk factors [apolipoprotein B, HDL-cholesterol (HDL-C), triglyceride (TG), and insulin concentrations, and body mass index] was strongest with TG and HDL-C concentrations: a 1 SD increase in log(e)-transformed TG concentration was associated with a 1.2 A reduction in LDL size, and a 1 SD increase in HDL-C was associated with a 1.1 A increase in LDL size. CONCLUSIONS: Although the small, dense LDL phenotype is less prevalent in youths than adults, its prevalence is clearly increased in childhood IRS. Metabolic correlates of LDL size are similar in youths and adults.

Adolescent↗

PubMed2005

Smoking trajectories of adolescent novice smokers in a longitudinal study of tobacco use.

PURPOSE: To describe longitudinal trajectories of smoking intensity in adolescent novice smokers and to identify predictors of trajectory class membership. METHODS: Cigarette consumption among 369 novice smokers (mean age 13 years) was measured over a mean 24 months of follow-up after smoking onset. Classes of smoking intensity trajectories were identified using latent class growth modeling. Predictors of trajectory class membership were identified in polytomous logistic regression. RESULTS: There was considerable between-subject heterogeneity in individual trajectories over time. Four classes of smoking intensity trajectories were identified: low-intensity, non-progressing smokers (72.4% of subjects), and slow, moderate, and rapid escalators (11.1%, 10.8%, and 5.7% of subjects, respectively). Gender, poor academic performance, and having more than half of friends who smoke at smoking onset independently predicted development of trajectory pattern. Escalating trajectory patterns were associated with earlier development of nicotine dependence and tolerance. CONCLUSIONS: Cigarette consumption will not escalate rapidly among three-quarters of adolescent novice smokers. Novice smokers who do escalate rapidly should be targeted for early tobacco control intervention to prevent development of nicotine dependence and sustained smoking.

Adolescent↗

PubMed2004

Using linking systems to build capacity and enhance dissemination in heart health promotion: a Canadian multiple-case study.

The purpose of this paper is to examine the utility of linking systems between public health resource and user organizations for health promotion dissemination and capacity building, and to identify factors related to the success of linking systems. The design is a parallel-case study using key informant interviews and content analysis of project reports (synthesized qualitative and quantitative data) of three provincial dissemination projects of the Canadian Heart Health Initiative-Dissemination Phase. Each provincial project used linking activities with public health user groups including meetings, skill building, resources, collaboration, networking and research feedback to facilitate capacity building for and implementation of heart health promotion activities. This paper presents empirical examples of linking system designs, activities, and qualitative and quantitative changes in the public health user groups' health promotion capacity, program delivery and sustainability. The findings indicate enhanced health promotion skills, partnerships, resources, infrastructure, and increased programming and sustainability in the targeted public health organizations of all three provincial projects. Identified barriers to the success of linking systems included lack of appropriately skilled personnel, funds, buy-in and leadership. We conclude that linking systems can be flexibly used to build capacity and disseminate health promotion innovations, and suggest conditions for success.

Canada↗

PubMed2004

Blood pressure and adiposity in children and adolescents.

BACKGROUND: Although obesity is associated with important hemodynamic disturbances, there are few data on population-wide blood pressure (BP) distribution in children and adolescents in this era of endemic pediatric obesity. METHODS AND RESULTS: We conducted a school-based survey of a representative sample of youth aged 9, 13, and 16 years in Quebec, Canada. Resting BP was measured with an oscillometric device in 3589 subjects (80% response). Additional measures included height, weight, and subscapular and triceps skinfold thickness, an age-appropriate questionnaire, and a fasting blood draw. Mean (SD) systolic/diastolic BP (SBP/DBP) levels in 9-, 13-, and 16-year-olds were 103 (9)/57 (6), 113 (12)/58 (7), and 124 (14)/61 (7) mm Hg in males and 103 (10)/57 (6), 111 (11)/60 (7), and 114 (11)/62 (7) mm Hg in females. The prevalence of high-normal or elevated SBP was 12%, 22%, and 30% among 9-, 13-, and 16-year-old males, respectively, and 14%, 19%, and 17% among same-aged females. The prevalence of high-normal or elevated DBP was <1%. In multiple linear regression analysis, body mass index was consistently associated with SBP and DBP in all age-gender groups. CONCLUSIONS: Mean SBP and the prevalence of high-normal and elevated SBP are elevated in children and adolescents. Public policy, public health programs, and clinical preventive measures are urgently needed to address the obesity epidemic and its hemodynamic consequences.

Adolescent↗

PubMed2004

C-reactive protein and features of the metabolic syndrome in a population-based sample of children and adolescents.

BACKGROUND: C-Reactive protein (CRP) is a risk marker for type 2 diabetes and cardiovascular diseases. In youth, limited data are available on the distribution of high-sensitivity CRP as well as on its association with components of the metabolic syndrome. METHODS: In 1999, we conducted a school-based survey of a representative sample of youths 9, 13, and 16 years of age in the province of Quebec, Canada. Standardized clinical measurements and fasting plasma lipid, glucose, insulin, and CRP concentrations were available for 2224 individuals. RESULTS: The distribution of CRP was positively skewed. The median and 95th percentile values by age and sex ranged from < 0.2 to 0.56 mg/L and from 2.72 to 6.28 mg/L, respectively. A total of 7.7% of 9-year-olds, 5.5% of 13-year-olds, and 12.8% of 16-year-olds had CRP concentrations > 3.0 mg/L, the threshold defining the adult high-risk category. We observed a strong relationship between CRP concentrations and both body mass index (BMI) and fasting insulin values. The association between CRP and insulin concentration was markedly attenuated after adjustment for BMI, whereas that between CRP and BMI remained unchanged after adjustment for insulin: a 1 SD increase in BMI was associated with a 52% increase in CRP concentration. An increased CRP concentration was independently associated with a worsening of the lipid profile, whereas the association between increased CRP values and high systolic blood pressure was no longer statistically significant after adjustment for BMI. CONCLUSIONS: The metabolic correlates of excess weight, including a state of low-grade systemic inflammation, are detectable early in life. Their health impact in adults remains to be fully examined.

Adolescent↗

PubMed2004

Qualitative investigation of young smokers' and ex-smokers' views on smoking cessation methods.

The analysis reported in this paper was conducted to further explore initially negative findings of a study intended to help orient the development, implementation, and evaluation of smoking cessation programs for junior college students. A total of 69 students (39 males and 30 females) participated in nine focus group discussions held at one French-speaking and one English-speaking college in central Montreal. Three groups consisted of ex-smokers, and the remainder were current smokers. Group participants were asked to react to a series of proposed smoking cessation interventions identified from the literature. Qualitative analysis was undertaken of verbatim transcriptions of five of the focus group discussions, with input from the four others. Second-level analysis of the focus group data suggested that the students' reactions to proposed smoking cessation interventions could be understood using Eriksonian developmental theory, in particular how the cessation programs could contribute to the process of consolidating personal and social identity. Implications for the design of cessation programs were then identified. The results of these exploratory analyses suggested that to attract and maintain participation of college students, smoking cessation interventions should not necessarily be centered on smoking but rather (a) provide opportunities and support for exploration of, and commitment to, personal and social identities that exclude smoking, (b) target naturally occurring social groups while responding to students' needs for social support and validation, and (c) help students cope with stress and life demands and not add to these.

Adaptation, Psychological↗

PubMed2004

Usefulness of the American Academy of Pediatrics recommendations for identifying youths with hypercholesterolemia.

OBJECTIVE: To determine the usefulness of parent history of hypercholesterolemia and cardiovascular disease as a screening criterion for hypercholesterolemia in youths. METHODS: Data were available from a population-based survey of 3665 Quebec youths aged 9, 13, and 16 years (81.2% of eligible subjects). Blood specimens were collected from 2475 subjects (54.8% of those eligible), and questionnaire data were obtained from 3048 parents (67.5% of those eligible). Lipids were measured in a Centers for Disease Control and Prevention standardized laboratory. Usefulness of parent history in identifying borderline/high low-density lipoprotein cholesterol (LDL-C) (> or =2.8 mmol/L [> or =110 mg/dL]) and high LDL-C (> or =3.4 mmol/L [> or =130 mg/dL]) was assessed according to test performance statistics (sensitivity, specificity, positive predictive value, and negative predictive value). RESULTS: The prevalence of a positive parent history was 25.6%; 18.3% of subjects had borderline/high LDL-C, and 4.8% had high LDL-C. Sensitivity, specificity, positive predictive value, and negative predictive value of parent history were 33.1%, 76.0%, 23.7%, and 83.5%, respectively, for identifying borderline/high LDL-C; they were 40.7%, 75.1%, 7.7%, and 96.1% for identifying high LDL-C. Test performance statistics were not improved in subgroups defined according to age, gender, parent education, household income, family status, and family origin (French Canadian, other); neither were they improved by adding screening criteria (parent history of diabetes or hypertension, or youth overweight). CONCLUSION: Parent history screening criteria offer little improvement over random population screening in identifying youths with hypercholesterolemia.

Adolescent↗

PubMed2004

Lifestyle risk factors for chronic disease by family origin among children in multiethnic, low-income, urban neighborhoods.

OBJECTIVES: To describe the prevalence of lifestyle risk factors (LRF) for chronic disease by family origin (FO) among children in multiethnic, low-income, urban neighborhoods. DESIGN: Cross-sectional analysis. SETTING: 16 elementary schools located in disadvantaged, multiethnic neighborhoods in Montreal, Canada. PARTICIPANTS: 4659 schoolchildren aged 9-12 in grades 4-6. OUTCOME MEASURES: Smoking, level of physical activity, dietary habits, body mass index, sedentary behavior. METHODS: Subjects completed self-report questionnaires on sociodemographic characteristics and lifestyle behaviors; height and weight were measured in a standardized protocol. Fourteen FO groupings were identified based on language(s) spoken and countries of birth of both subjects and parents. We tested FO as an independent correlate of having 2 or more LRF, using the generalized estimating equations method. RESULTS: Relative to Canadian children, a higher proportion of Haitian, Portuguese, and other Central American/Caribbean children had 2 or more LRF, the proportion was similar among Cambodian, Vietnamese, Chinese, South American, East European, Arabic, Italian, and South Asian children, and lower among Salvadorean children. CONCLUSION: Prevention programs for youth should take differential distribution of LRF by ethnicity into account.

Attitude to Health↗

PubMed2003

Nicotine-dependence symptoms are associated with smoking frequency in adolescents.

BACKGROUND: Although many sociodemographic and psychosocial factors have been identified as related to adolescent smoking, few studies have examined the role of nicotine-dependence (ND) symptoms. The objective was to study the association between ND symptoms and smoking status among adolescents in the early stages of the smoking onset process. METHODS: The McGill University Study on the Natural History of Nicotine Dependence is an ongoing 6-year prospective investigation of the natural history of ND among 1267 grade 7 students in ten Montreal high schools. The baseline response was 55.4%. Subjects for this cross-sectional analysis of baseline data, collected in 1999, included 241 past 3-month smokers (mean age [SD]=13.0+/-0.7 years at baseline). ND symptoms were measured in five indicators, including a measure based on the criteria for tobacco dependence in the International Classification of Diseases-10th Revision (ICD-10), the Hooked on Nicotine Checklist, and three symptom clusters (withdrawal, self-medication, and ND/cravings symptoms). The association between ND symptom indicators and each of sporadic, monthly, weekly, and daily smoking relative to less frequent smoking was investigated in multiple logistic regression analysis. RESULTS: Despite low cigarette exposure, 16.6% (95% confidence interval [CI], 11.9%-21.3%) of past 3-month smokers were tobacco dependent. The proportion increased from 0%, 3.1% (95% CI, 0.0%-9.2%), and 4.6% (95% CI, 0.2%-9.0%) among triers, sporadic smokers, and monthly smokers, respectively, to 19.4% (95% CI, 5.5%-33.3%) and 65.9% (95% CI, 51.9%-79.9%) among weekly and daily smokers, respectively. ND/cravings consistently distinguished each smoking category from less frequent smokers; the odds ratios (95% CI) for ND/cravings symptoms were 1.16 (0.99-1.35) in sporadic smokers; 1.17 (1.06-1.29) in monthly smokers; 1.34 (1.19-1.50) in weekly smokers; and 1.39 (1.22-1.59) in daily smokers. CONCLUSIONS: These data challenge current smoking onset models, which suggest that ND develops only after several years of heavy or daily smoking. ND symptoms are associated, at least cross-sectionally, with increased smoking in adolescents. To increase the likelihood of being effective, tobacco-control programs for children and adolescents will need to take early ND symptoms into account.

Adolescent↗

PubMed2003

The G8 Heart Health Projects Database: testing the compatibility of an Internet-based resource with health promotion planning processes.

This study examined the context and processes in which health promotion policy and program decisions are made to ensure that an Internet-based information system on heart health promotion programs provides appropriate information for decision makers' needs and is compatible with their decision-making processes. Five focus groups and six individual interviews were conducted with potential users of and contributors to the G8 Heart Health Projects Database. Results suggest that Internet-based systems such as this are seen as useful tools, but will only be used at certain critical points in program development and then, only when they meet several rigorous criteria. Systems must be completely credible and up-to-date, providing instant answers to complex questions about program design, implementation, and effectiveness, with adequate qualitative information for assessing contextual applicability. Participants also provided information about the conditions required if they were to submit project information to the system.

Benchmarking↗

PubMed2003

Distribution of fasting plasma insulin, free fatty acids, and glucose concentrations and of homeostasis model assessment of insulin resistance in a representative sample of Quebec children and adolescents.

BACKGROUND: Plasma fasting insulin and the homeostasis model assessment of insulin resistance (HOMA-IR) are markers of IR, which, at least in part, mediates the relation of obesity to increased cardiovascular risk. Increased free fatty acids (FFAs) may be involved in the pathogenesis of IR. Our objectives were to describe the distributions of fasting plasma insulin, glucose, and FFAs and HOMA-IR in youth and to assess the relationship between FFAs and markers of IR. METHODS: Fasting plasma insulin, glucose, and FFAs were measured in a representative sample of Quebec youth comprising 2244 individuals 9, 13, and 16 years of age. RESULTS: In all age and sex groups, glucose exhibited remarkably tight distributions (median CV, 7.1%) in contrast to insulin, HOMA-IR, and FFAs (median CVs, 52%, 54% and 45%, respectively). For every percentile examined, 9-year-olds had lower insulin concentrations and HOMA-IR values than 13- and 16-year-olds. We observed strong correlations between insulin concentrations and HOMA-IR values, as well as close similarity in their rankings of individuals. The mean concentrations of glucose were higher in our population than in other Caucasian pediatric populations. No positive correlations were detected between FFAs and markers of IR. CONCLUSIONS: We report some of the first data on the distributions of fasting plasma insulin, HOMA-IR, and FFAs from a representative sample of youth. HOMA-IR does not appear more informative than fasting insulin as a marker of IR. Our findings on higher mean glucose concentrations in this population require confirmation in other representative samples of youth to assess whether the North American distribution of glucose concentrations is shifting positively.

Adolescent↗