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Results for “Weight Reduction Programs”

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PubMed1994

Evaluating success of weight loss programs, with an application to fluoxetine weight reduction clinical trial data.

We modified criteria for judging successful obesity treatment proposed by Atkinson to provide objective criteria for successful benefit from weight reduction programs with respect to data from a clinical trial. The criteria include assessments of changes in both weight-related factors (e.g. excess weight, excess body fat) and obesity-related risk factors (e.g. hypertension, hyperglycemia, hyperlipemia). To demonstrate the use of this methodology, we applied the criteria in an analysis of eight randomized, double-blind controlled trials comparing fluoxetine (n = 522) with placebo (n = 504) for weight loss. The results suggest these criteria can be useful for evaluating a treatment program or for comparing treatments from clinical trials.

Adolescent↗

PubMed2000

Weight loss and growth velocity in obese children after very low calorie diet, exercise, and behavior modification.

UNLABELLED: The prevalence of obesity in American youth is increasing and treatment of the condition is difficult. We have developed a multi-disciplinary weight reduction program that extends over 1 y and includes a very low-calorie diet (VLCD) followed by a hypocaloric diet, exercise, and behavior modification. Based on data collected at baseline, at the end of the acute intervention phase (10-20 wk), and at 1-y evaluation, we assessed the efficacy of this outpatient weight reduction program in treating obese children and adolescents in a follow-up of a series of cases. Furthermore, we examined the impact of the approach on growth velocity and maintenance of weight loss at 1 y. Fifty-six overweight children (aged 7-17 y) were recruited during a period of 18 mo to participate in the weight management program; 52 (93%) completed the acute phase of treatment and 35 (62.5%) successfully completed the 1-y program. There was a significant decrease in body weight and body fat, as assessed by weight determinations and skinfold measurements (p <0.0001; results not corrected for age). The body mass index for the 35 individuals who completed the 1-y program decreased significantly from 32.7 on entry to 28.72 at 1 y (p < 0.0001; results not corrected for age). CONCLUSION: We conclude that a multidisciplinary weight reduction program that combines a VLCD, followed by a balanced hypocaloric diet, with a moderate-intensity progressive exercise program and behavior modification is an effective means for weight reduction in obese children and adolescents.

Adolescent↗

PubMed2006

Exercise motivation, eating, and body image variables as predictors of weight control.

PURPOSE: This study investigated changes in psychosocial variables related to exercise, eating, and body image during a weight reduction program and evaluated their association with weight loss in middle-aged overweight and obese women up to 1 yr after intervention. METHODS: The 136 participants (age, 48.1 +/- 4.4 yr; weight, 30.6 +/- 5.6 kg x m(-2)) who completed the 4-month lifestyle weight reduction program (86% retention), losing -6.2 +/- 4.6% (P < 0.001) of their initial weight, were followed up for 12 additional months. Of these, 82% completed 16-month assessments (weight change, -5.5 +/- 7.7%, P < 0.001). Psychosocial variables were assessed by validated instruments in standardized conditions at baseline and after the intervention (4 months). RESULTS: Compared with 4-month assessments, body weight did not change at 16 months (P > 0.09). Changes in eating restraint, disinhibition, and hunger; exercise, self-efficacy, and intrinsic motivation; body shape concerns; and physical self-worth were associated with weight change at 4 months (P < 0.001, except hunger, P < 0.05). Baseline-adjusted 4-month scores in all psychosocial variables also predicted weight change from baseline to 16 months (P < 0.01), except hunger (P > 0.05). After controlling for 4-month weight change and other covariates, increases in exercise intrinsic motivation remained predictive of weight loss at 16 months (P < 0.05). Multiple linear regression showed that eating variables were significant and independent correlates of short-term weight change, whereas changes in exercise variables were stronger predictors of longer term weight outcomes. CONCLUSIONS: Results highlight the importance of cognitive processes during weight control and support the notion that initial focus on diet is associated with short-term weight loss, while change in exercise-related motivational factors, with a special emphasis on intrinsic sources of motivation (e.g., interest and enjoyment in exercise), play a more important role in longer term weight management.

Adult↗

PubMed2000

Association between basal serum and leptin levels and changes in abdominal fat distribution during weight loss.

The aim of this study was to evaluate the relationship between changes in abdominal fat areas and the baseline serum leptin levels of Japanese obese women during weight reduction. The study was performed on 100 obese female Japanese volunteers. We measured the BMI and abdominal fat areas (visceral, subcutaneous and total) by magnetic resonance imaging and determined the fasting serum leptin levels before and after a 3 month weight reduction program. We examined whether or not a relationship exists between the baseline leptin levels and the subsequent changes in the abdominal fat areas after a weight reduction program. Multiple linear regression analysis was performed to examine the relationship between the baseline leptin levels and changes in abdominal visceral, subcutaneous, and total fat areas, and demonstrated that the baseline leptin level was a significant predictive factor for changes in the abdominal visceral fat area in both pre and postmenopausal Japanese obese women. We thus concluded the relatively higher baseline leptin levels in Japanese obese women to be associated with a relatively smaller reduction in the amount of abdominal visceral fat after undergoing a weight reduction program.

Abdomen↗

PubMed2006

Weight loss reduces plasma endothelin-1 concentration in obese men.

Obesity is associated with endothelial dysfunction that may contribute to the development of diabetes, hypertension, and atherosclerosis. Endothelin-1 (ET-1), which is produced mostly by vascular endothelial cells, has potent vasoconstrictor and proliferative activity in vascular smooth muscle cells and, therefore, has been implicated in regulation of vascular tonus and the progression of atherosclerosis, suggesting that ET-1 may be important in endothelial dysfunction. We studied whether diet-induced weight loss (i.e., lifestyle modification) affects plasma ET-1 concentration in obese individuals. We measured plasma ET-1 concentration in seven obese men (age: 48 +/- 4 years old, body mass index: 27.7 +/- 0.5 kg/m2) before and after a 3-month, diet-induced weight reduction program (i.e., lifestyle modification program). Caloric restriction reduced body weight from 78 +/- 3 to 68 +/- 2 kg (P < 0.001) and resulted in 12.1 +/- 1.2% reduction in body mass index (24.3 +/- 0.3 kg/m(2), P < 0.0001). After the weight reduction program, systolic and diastolic blood pressure significantly decreased (128 +/- 7 vs. 115 +/- 4 mm Hg, P < 0.05 and 88 +/- 4 vs. 77 +/- 2 mm Hg, P < 0.01, respectively). The plasma level of ET-1 significantly decreased after the program (5.1 +/- 0.4 vs. 4.0 +/- 0.3 pg/ml, P < 0.05). The percentage systolic blood pressure reduction and percentage plasma ET-1 concentration reduction was in a linear relationship (r = 0.86, P < 0.05). Furthermore, the relationship between percentage weight reduction and percentage plasma ET-1 concentration reduction was linear (r = 0.87, P < 0.05). We conclude that weight loss by low-calorie diet (i.e., lifestyle modification) reduces plasma ET-1 concentration in obese individuals. This reduction may contribute to the improvement of obesity-induced endothelial dysfunction.

Adult↗

PubMedDate not supplied

[Impact of the mass-reductive therapy with orlistat on 25-(OH)-D3 and PTH concentration in sera of obese, menopausal women].

UNLABELLED: Epidemiological studies suggest a protective influence of obesity against postmenopausal bone loss. Lower risk of osteoporotic fractures was described in obese patients. However there were only a few studies which examined the effect of weight reduction on bone metabolism and results of these studies are controversial. The aim of the study was to evaluate the influence of weight reduction program using Orlistat on bone metabolism in perimenopausal women. Twenty obese women with simple obesity and without concomitant diseases (BMI 37.1 +/- 3.0 kg/m2, mean age 49.8 +/- 4.6 yrs) were enrolled into this study. The control group consisted of 20 healthy women (mean age 53.5 +/- 5.4 yrs, BMI 24.1 +/- 2.2 kg/m2). All patients have participated in a 3-month weight reduction therapy that consisted of: a 1000-1200 kcal/ day balanced diet (daily calcium consumption about 500mg), Orlistat 3 x 120mg a day and regular physical exercises. Before the weight reduction therapy and after 10% reduction of body weight, serum concentrations of PTH, 25-(OH)-D3, total calcium and phosphorus, total cholesterol were assessed. Dual energy x-ray absorptiometry (DEXA method) of lumbar spine and femoral neck, measuring BMD was performed once, after a 3-month weight reduction therapy using Lunar DPXL. All these measurements were performed only once in control subjects. After a 3-month weight reduction program in patients treated with Orlistat the mean weight loss was 11.6 +/- 5.1 kg which is 12.1 +/- 4.78 %. BMI decreased from 37.1 +/- 3.0 kg/m2 at baseline to 32.6 +/- 2.7 kg/m2 post-treatment. The body weight reduction resulted in significant decrease of body fat and total cholesterol concentration. In obese subjects serum concentration of 25-(OH)-D3 was significantly lower and serum concentration of PTH was significantly higher in comparison to healthy controls, both before and after weight reduction therapy. Serum concentration of PTH, 25-(OH)-D3, total calcium and phosphorus did not change significantly after therapy with Orlistat. CONCLUSION: 3-month weight reduction program using Orlistat did not influence significantly bone metabolism.

Adult↗

PubMed2006

Association of the IL6-174(G/C) polymorphism with C-reactive protein concentration after weight loss in obese men.

Elevated plasma concentration of C-reactive protein has emerged as an important predictor of future cardiovascular diseases and metabolic abnormalities in apparently healthy individuals. Obese individuals tend to have elevated C-reactive protein concentrations. Weight loss induces a change in this protein, and single nucleotide polymorphisms in regulating genes might affect this change, since C-reactive protein concentration is known to be approximately 40-50% heritable. Our aim was to study the association between the IL6 -174(G/C), IL1B +3,954(C/T) and CRP +1,059(G/C) single nucleotide polymorphisms, and CRP concentrations in obese men during a weight reduction program. We genotyped 72 obese men who had participated in a weight reduction program. Their C-reactive protein concentrations, interleukin-6 levels and fat mass were determined at two time points: at baseline and after weight reduction (after 2 months). After weight reduction, the mean weight loss was 14.3 kg. Median C-reactive protein concentrations decreased, after weight reduction, from 1.72 to 1.22 mg/l (p < 0.02). The baseline C-reactive protein concentration did not differ between the IL6-174(G/C) genotypes, but after weight loss, concentrations differed (p = 0.03 Kruskal-Wallis test); the highest concentration was found in the CC genotype (CC 1.01 versus GG 1.93 mg/l, p = 0.007 ANOVA post-hoc test). This change in concentration was associated with the IL6-174(G/C) genotype (p = 0.01, Kruskal-Wallis test), being least in the CC genotype. The other single nucleotide polymorphisms studied were not associated with CRP concentrations. Our results show that, at baseline, there is no difference in C-reactive protein concentrations among the different IL6-174(G/C) genotypes, but after weight loss the CC genotype is associated with highest C-reactive protein concentrations, resulting from the fact that C-reactive protein seems not to decrease with weight loss in this genotype.

Adult↗

PubMed1981

[Behavior therapeutic training for weight reduction].

A behaviour therapeutic program for weight reduction was worked out by a team of psychologists, dieticians and doctors. A 10 week's course for weight reduction was given by 8 dieticians to a group of 5-7 female overweights (N=50). All dieticians based their work on a written handout. 4 of them had an additional training in behaviour and group therapy prior to the course. During the course all participants showed a significant weight loss and a change in their eating behaviour, the patients counselled by an additionally trained dietician (group E1) showing a significantly greater weight loss than the others (group E2). A follow-up after 3 1/2 months revealed similar differences but subsequent controls after 6 and 20 months showed a gradual decrease of the difference between the two groups. However three different patterns of the patient's weight curve could be distinguished. Pattern a): 26.3% of the participants showed a sinking tendency over all 20 months. Pattern b): 21.4% of the participants showed a significant weight loss over the 20 months with a slight upward tendency after the second follow-up (6 months). Pattern c): 52.3% of the participants lost weight only during the course which was regained in the following 3 months period. In pattern a) and c) group E1 and E2 are evenly represented. Pattern b) was only seen with participants of group E1. The results suggest that there are different characteristics of obese persons which influence the success of weight reduction programs. Further studies will have to describe these characteristics and define their therapeutical implications.

Behavior Therapy↗

PubMed2003

Effect of a multidisciplinary program of weight reduction on endothelial functions in obese women.

Obesity is associated with an increased risk of developing atherosclerosis and atherosclerotic lesions are essentially an inflammatory response. The aim of this study was to evaluate the effect of a medically supervised, multidisciplinary weight loss program on endothelial functions and circulating levels of proinflammatory cytokines in obese women. Twenty healthy pre-menopausal obese women and 20 age-matched normal weight women were studied. Endothelial functions were assessed by evaluating the response of blood pressure and platelet aggregation to an intravenous bolus of L-arginine (3 g), the natural precursor of nitric oxide. In obese women, the vascular and rheological responses to L-arginine were significantly lower (p < 0.05) at baseline, as compared with non-obese women, indicating endothelial dysfunction; on the contrary, basal concentrations of tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) were significantly higher (p < 0.01). After one year of a multidisciplinary program of weight reduction consisting of diet, exercise and liposuction surgery, all obese women lost at least 10% of their original weight (10.5 +/- 1.7 kg, range 7.9-13.9 kg). Compared with baseline, sustained weight loss was associated with reduction of cytokine (p < 0.01) concentrations and with improvement of vascular responses to L-arginine. In conclusion, a multidisciplinary approach aimed at inducing a sustained reduction of body weight in obese women is feasible and is associated with improvement of endothelial functions and reduction of circulating proinflammatory cytokine concentrations.

Adult↗

PubMed2001

Determinants of homocysteine during weight reduction in obese children and adolescents.

Plasma homocysteine levels have been shown to be associated with indexes of obesity and insulin resistance in obese children and adolescents. We, therefore, investigated the contribution of changes in body composition, markers of insulin resistance, folate, and vitamin B(12) to changes in homocysteine during a weight reduction program in obese children and adolescents. Thirty-seven obese white girls (mean SD; age, 12 +/- 1.8 years, body mass index [BMI], 26.9 +/- 5.25) and 19 obese white boys (age, 11.9 +/- 1.7 years; BMI, 26.2 +/- 5.2) were investigated for body composition, fasting total plasma homocysteine (tHcy), insulin, C-peptide, folate, and vitamin B(12) before and after a 3-week weight reduction program including physical activities. During weight reduction BMI, fat mass (FM), percentage fat mass, insulin, and C-peptide decreased significantly, whereas homocysteine and vitamin B(12) showed a significant increase. Folate and lean body mass (LBM) remained unchanged. tHcy concentration before weight reduction was a function of age, folate, and C-peptide, whereas tHcy concentration after weight reduction was a function of folate and baseline LBM. Changes in tHcy during weight reduction correlated significantly with baseline LBM and were related inversely to changes in LBM during weight reduction. Children who increased LBM showed lower increases in tHcy compared with children who lost LBM. In multiple linear regression analysis, only baseline LBM contributed independently and significantly to changes in tHcy. Our study suggests that LBM has a significant impact on tHcy metabolism during weight reduction.

Adolescent↗

PubMed1999

A multidisciplinary approach to the treatment of childhood obesity.

Childhood obesity is a chronic disease that is associated with significant co-morbidity. Successful treatment and prevention of childhood obesity requires a multidisciplinary approach, including diet, nutrition education, behavior modification, and exercise. We studied 87 children (39 males, 48 females; aged 7-17 years) enrolled in a one-year multidisciplinary weight reduction program. Subjects were placed on a very low calorie/high protein diet, a moderate-intensity progressive exercise program, and behavior modification sessions for 10 weeks. Measures were taken at baseline 10 weeks, and 1 year. Significant anthropometric changes in weight, percent of ideal body weight, and percent body-fat were observed in all patients. We conclude that a multidisciplinary weight reduction program including diet, behavior modification, and exercise is an effective instrument to achieve weight loss in obese children and adolescents.

Adolescent↗

PubMed2005

Reduction in visceral adiposity is highly related to improvement in vascular endothelial dysfunction among obese women: an assessment of endothelial function by radial artery pulse wave analysis.

Because obesity is frequently complicated by other cardiovascular risk factors, the impact of a reduction in visceral adiposity on vascular endothelial dysfunction (VED) in obese patients is difficult to determine. In the present study, we evaluated the impact of a reduction in visceral adiposity on VED in obese women. Thirty-six premenopausal obese women (BMI >/= 25 kg/m2) without complications were enrolled in the study. VED was evaluated by determining the augmentation index (AIx) from radial artery pulse waves obtained by applanation tonometry. Changes in AIx in response to nitroglycerin- induced endothelium-independent vasodilatation (DeltaAIx-NTG) and in response to salbutamol administration (DeltaAIx-Salb) were determined before and after weight reduction. After a 12-week weight reduction program, the average weight loss was 7.96 +/- 3.47 kg, with losses of 21.88 +/- 20.39 cm2 in visceral fat areas (p < 0.001). Pulse wave analysis combined with provocative pharmacological testing demonstrated preserved endothelium-independent vasodilation in healthy premenopausal obese women (DeltaAIx-NTG: 31.36 +/- 9.80% before weight reduction vs. 28.25 +/- 11.21% after weight reduction, p > 0.1) and an improvement in endothelial-dependent vasodilation following weight reduction (DeltaAIx-Salb: 10.03 +/- 6.49% before weight reduction vs. 19.33 +/- 9.28% after reduction, p < 0.001). A reduction in visceral adipose tissue was found to be most significantly related to an increase in DeltaAIx-Salb (beta=-0.57, p < 0.001). A reduction in visceral adiposity was significantly related to an improvement in VED. This finding suggests that reduction of visceral adiposity may be as important as the control of other major risk factors in the prevention of atherosclerosis in obese women.

Adipose Tissue↗

PubMed2004

Correlation between dietary glycemic index and cardiovascular disease risk factors among Japanese women.

OBJECTIVE: To examine the correlation between dietary glycemic index (GI) and cardiovascular disease (CVD) risk factors among subjects who consume white rice as a staple food. DESIGN: A cross-sectional study was conducted to explore the associations between dietary GI, dietary glycemic load (GL) and dietary intakes, and CVD risk factors. Dietary GI and GL were calculated from a 3-day (including two consecutive weekdays and one holiday) dietary records. SETTING: A weight-reduction program at a municipal health center in Tokyo, Japan. SUBJECTS: A total of 32 women aged 52.5+/-7.2 y participated in the weight-reduction program. RESULT: The GI food list made for the current study calculated for 91% of carbohydrate intakes measured. The mean dietary GI was 64+/-6, and the mean dietary GL was 150+/-37. Individuals in the highest tertile of GI consumed more carbohydrate, mostly from white rice (P<0.001), and less fat (P<0.01). Individuals in all three groups by tertile of GL showed similar tendencies. In the lowest GI tertile, the highest concentration of HDL-cholesterol and lowest concentration of triacylglycerol and immunoreactive insulin were observed (P<0.01). In the lowest GL tertile, the highest concentration of HDL-cholesterol and the lowest concentration of triacylglycerol were observed (P<0.05). CONCLUSION: Calculated dietary GI and GL were positively associated with CVD risk factors among the Japanese women who consumed white rice as a staple food.

Area Under Curve↗

PubMed2002

Weight loss readiness in middle-aged women: psychosocial predictors of success for behavioral weight reduction.

Accurate prediction of weight loss success and failure has eluded researchers for many years. Thus, we administered a comprehensive psychometric battery before a 4-month lifestyle behavioral weight reduction program and analyzed weight changes during that period to identify baseline characteristics of successful and unsuccessful participants, among 112 overweight and obese middle-aged women (age, 47.8 +/- 4.4 years; BMI, 31.4 +/- 3.9 kg/m2). Mean weight and percentage fat losses among the 89 completers were -5.4 kg and -3.4%, respectively (p < .001). A higher number of recent dieting attempts and recent weight loss, more stringent weight outcome evaluations, a higher perceived negative impact of weight on quality of life, lower self-motivation, higher body size dissatisfaction, and lower self-esteem were associated with less weight loss and significantly distinguished responders from nonresponders among all participants. These findings are discussed as to their usefulness (i) to screen individuals before treatment, (ii) to provide a better match between interventions to participants, and (iii) to build a weight loss readiness questionnaire.

Adult↗

PubMed1995

The role of exercise in weight loss.

Aerobic exercise has traditionally been viewed as a critical component of most weight-reduction programs. The resulting weight loss from the exercise alone, however, is often disappointing. Researchers too frequently fail to take into account the normal energy expenditure associated with living; the degree of obesity; the intensity and duration of the exercise itself; the activity during the recovery period; food intake before and after the exercise; and the age, gender, and training status of the individuals. Nor do they consider variations in baseline resting metabolic rates. In this article, the authors explore the effect of the intensity of aerobic exercise on weight loss, emphasizing the inability of many obese individuals to maintain an intensity level sufficient to produce significant weight loss. Aerobic exercise should be emphasized for its health benefits rather than as a short-term method of enhancing weight loss.

Biotransformation↗

PubMed1986

Is weight loss an effective treatment for hypertension? The evidence against.

Although there are many studies reporting correlations between relative body weight and blood pressure, the correlations are generally of low order. Furthermore, these observational studies provide, at best, circumstantial evidence concerning the effect of weight reduction on elevated blood pressure. After outlining key methodologic criteria for testing the hypothesis that weight loss lowers blood pressure among hypertensive obese subjects, this article reviews the best intervention studies that are available. Despite the demonstration in these randomized trials that weight reduction programs can lower weight successfully, the results for blood pressure lowering are in considerable disagreement. Two studies reported significant lowering of both systolic and diastolic blood pressure, one found significant lowering of systolic pressure only, and two failed to find significant differences in either. The definitive study of substantial weight loss among patients receiving no other antihypertensive treatment or standardized medical treatment with long-term follow-up has yet to be done. At best, weight loss offers very limited benefit for overweight hypertensives. At worst, weight loss programs are expensive to run, cause considerable patient discomfort and may delay the implementation of more effective therapy.

Blood Pressure↗

PubMed1992

Personal and job characteristics of musculoskeletal injuries in an industrial population.

A cross-sectional study was conducted of 10,350 full-time regular employees who worked at Shell Oil Company's manufacturing facilities between 1987 and 1989. Two hundred seventy-five employees with low-back and 456 with nonlow-back musculoskeletal injuries were compared with 8295 employees who did not have musculoskeletal injuries during this period. Based on morbidity data collected from a prospective health surveillance system, this study shows that estimated relative risks (RRs) for low-back injuries are significantly higher among smokers (RR = 1.54, P less than .01) and overweight persons (RR = 1.42, P less than .01). This observation is also true for nonlow-back musculoskeletal injury (RR = 1.23, P = .05 for smokers and RR = 1.53, P less than .01 for overweight persons). In addition, persons in potentially more physically demanding jobs (primarily maintenance job titles) had an increased RR for both low-back and nonlow-back musculoskeletal injuries (RR = 1.57, P less than .01 and RR = 1.35, P = .02, respectively). The findings of this study suggest that it may be possible to reduce the impact of musculoskeletal injury through implementation of an integrated injury prevention program. Such programs would include not only the traditional elements of job factors evaluation and modifications, employee education and training, and an overall increased attention to ergonomics but also medical counseling and support for personal fitness programs, workplace smoking cessation programs, and weight-reduction programs.

Accidents, Occupational↗

PubMed2004

Beneficial effects of weight loss on plasma apolipoproteins in postmenopausal women.

A total of 39 postmenopausal women 40-70 years of age and undergoing hormone replacement therapy participated in a 6-month weight reduction program, which consisted of a low calorie diet (5040 KJ/day) and phentermine hydrochloride therapy. Subjects had an average body mass index of 35.95+/-5.32 kg/m(2) and 42.20+/-11.0 kg of total fat. Body mass index, plasma lipids, total and trunk fat, and plasma apoproteins were measured at baseline and after 3 and 6 months of the weight reduction program. Subjects experienced an overall 10% weight loss during the treatment period (P<0.001). Plasma LDL cholesterol and triglycerides were reduced by 18% and 15% (P<0.01) respectively, whereas HDL cholesterol was increased by 9% (P<0.01) over the 6-month period. Plasma apoproteins were significantly affected by weight loss. Plasma apolipoprotein (apo) B concentrations were reduced 6.5% (P<0.01), and apo C-III and apo E were reduced by 9% over 6 months (P<0.01). The observed decreases in plasma apo B were significantly correlated with the observed changes in plasma cholesterol (r=0.356, P<0.01) over 3 months. In addition, changes in plasma triglycerides were correlated with changes in both apo C-III (r=0.436) and apo E (r=0.354) over 6 months. These results suggest that weight loss may have multifactorial effects on lipoprotein metabolism, resulting in better plasma lipid and apoprotein profiles.

Adult↗