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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Nutrition and Public Health".

Deadline for manuscript submissions: closed (15 July 2024) | Viewed by 19208

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Dr. Areti Triantafyllou

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School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
Interests: evidence-based nutrition and dietetics; hypertension; vascular ageing
Special Issues, Collections and Topics in MDPI journals

Dr. Xenophon Theodoridis

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Guest Editor Assistant

School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
Interests: evidence-based nutrition and dietetics; hypertension; vascular ageing

Special Issue Information

Dear Colleagues,

Cardiovascular diseases (CVDs) are unequivocally established as prominent contributors to global mortality, consistently ranking among the leading causes of death worldwide. In light of this considerable impact, concerted efforts in prevention, early detection, and optimal management strategies are imperative for addressing CVDs as an urgent global public health priority.

Diet and nutrition play a pivotal role in cardiovascular health, exerting profound effects on the prevention and management of CVDs. The assortment of published articles underscores the paramount importance of a healthy-heart diet, emphasizing the influence of critical nutrients, dietary patterns, such as the Mediterranean diet and DASH diet, and specific food groups on cardiovascular health.

This Special Issue aims to provide insights into the complex relationship between diet, nutrition, and cardiovascular health. It will explore the latest research findings, cutting-edge interventions, and evidence-based recommendations to empower healthcare professionals that can contribute to improved cardiovascular outcomes.

Dr. Areti Triantafyllou
Guest Editor

Xenophon Theodoridis
Guest Editor Assistant

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Keywords

evidence-based nutrition and dietetics
prevention
management
cardiovascular disease
cardiovascular risk factors

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Published Papers (10 papers)

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Research

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13 pages, 306 KiB

Open AccessArticle

Mediterranean Diet Prior to Ischemic Stroke and Potential Circulating Mediators of Favorable Outcomes

by María Castañón-Apilánez, Carmen García-Cabo, Cristina Martin-Martin, Belén Prieto, Eva Cernuda-Morollón, Pablo Rodríguez-González, Daniela Pineda-Cevallos, Lorena Benavente, Sergio Calleja and Elena López-Cancio

Nutrients 2024, 16(18), 3218; https://doi.org/10.3390/nu16183218 - 23 Sep 2024

Viewed by 1128

Abstract

Background/Objectives. A Mediterranean diet (MD) has been associated with neuroprotective effects. We aimed to assess the MD’s association with stroke prognosis and the potential mediators involved. Methods. Seventy patients with acute anterior circulation ischemic stroke were included. Dietary patterns were evaluated using the MEDAS scale, a food-frequency questionnaire, and a 24 h recall. Circulating biomarkers including insulin resistance (HOMA index), adipokines (resistin, adiponectin, leptin), choline pathway metabolites (TMAO, betaine, choline), and endothelial progenitor cells (EPCs) were measured. Early neurological improvement (ENI) at 24 h, final infarct volume, and functional outcome at 3 months were assessed. Results. Adherence to MD and olive oil consumption were associated with a lower prevalence of diabetes and atherothrombotic stroke, and with lower levels of fasting glycemia, hemoglobinA1C, insulin resistance, and TMAO levels. Monounsaturated fatty acids and oleic acid consumption correlated with lower resistin levels, while olive oil consumption was significantly associated with EPC mobilization. Multivariate analysis showed that higher MD adherence was independently associated with ENI and good functional prognosis at 3 months. EPC mobilization, lower HOMA levels, and lower resistin levels were associated with ENI, a smaller infarct volume, and good functional outcome. Conclusions. MD was associated with better prognosis after ischemic stroke, potentially mediated by lower insulin resistance, increased EPC mobilization, and lower resistin levels, among other factors. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

10 pages, 2331 KiB

Open AccessArticle

Differences in Vitamin A Levels and Their Association with the Atherogenic Index of Plasma and Subclinical Hypothyroidism in Adults: A Cross-Sectional Analysis in China

by Guangming Mao, Manman Chen, Lichun Huang, Zhe Mo, Danting Su, Simeng Gu, Fanjia Guo, Yuanyang Wang, Zhijian Chen, Ronghua Zhang, Xiaoming Lou, Xiaofeng Wang, Jie Hu, Fang Gu and Bin Dong

Nutrients 2024, 16(16), 2613; https://doi.org/10.3390/nu16162613 - 8 Aug 2024

Viewed by 1050

Abstract

Background: This study evaluates the association between vitamin A levels, AIP (the atherogenic index of plasma), and subclinical hypothyroidism. Methods: A cross-sectional analysis was conducted involving a representative sample of 3530 Chinese adults. Linear and logistic regression models were utilized to evaluate the associations between AIP and subclinical hypothyroidism, stratified by vitamin A levels. These analyses were further differentiated by sex and age groups to identify any demographic-specific associations. Results: In the vitamin A-sufficient group, an increase in AIP was associated with elevated total triiodothyronine (TT3) levels (β = 0.26, 95%CI: 0.09, 0.41, p = 0.003). Conversely, in the group with severe vitamin A deficiency, higher AIP levels were linked to increased free triiodothyronine (fT3) and TT3 levels and decreased free thyroxine (fT4) levels (β = 0.12, 0.03, and −0.29, respectively). Additionally, severe vitamin A deficiency increased the risk associated with AIP and subclinical hypothyroidism (OR = 1.66, 95%CI: 1.07, 2.58, p = 0.025). This risk was notably more pronounced in women and older adults, with odds ratios of 2.44 (95%CI: 1.55, 3.86, p < 0.001) and 2.14 (95%CI: 1.36, 3.38, p = 0.001), respectively. Conclusions: Vitamin A deficiency may increase the risk of the association between AIP and subclinical hypothyroidism, particularly among women and the elderly. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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23 pages, 2483 KiB

Open AccessArticle

Adherence to a Healthy Diet and Risk of Multiple Carotid Atherosclerosis Subtypes: Insights from the China MJ Health Check-Up Cohort

by Jingzhu Fu, Yuhan Deng, Yuan Ma, Sailimai Man, Xiaochen Yang, Canqing Yu, Jun Lv, Hui Liu, Bo Wang and Liming Li

Nutrients 2024, 16(14), 2338; https://doi.org/10.3390/nu16142338 - 19 Jul 2024

Viewed by 1013

Abstract

Aim: Early-stage phenotypes of carotid atherosclerosis (CAS), such as increased carotid intima-media thickness (cIMT), and advanced-stage phenotypes, such as carotid plaque (CP), are at risk for adverse ischemic stroke events. There is limited evidence regarding the causal association between dietary patterns and the risk of CAS in Chinese adults. We therefore examined multiple dietary patterns associated with the risk of CAS and identified the optimal dietary pattern for preventing CAS. Methods: We analyzed data collected from the prospective MJ Health Check-up Study (2004–2020), including 13,989 participants 18–80 years of age without CAS. The dietary intake was measured using validated food frequency questionnaires, and dietary pattern scores were calculated for four a priori and four a posteriori dietary patterns. The Cox model was used to estimate the adjusted hazard ratios (HRs) relating various dietary pattern scores to the risk of CAS. Results: During 43,903.4 person-years of follow-up, 3732 incidents of increased cIMT and 2861 incident CP events were documented. Overall, the seven dietary patterns, except for the high-protein diet, exhibited significant associations with the risk of increased cIMT and CP. Comparing the highest and lowest quartiles, the a posteriori high-fiber dietary pattern (HFIDP) score demonstrated the strongest inverse associations with the risk of increased cIMT (HR 0.65 [95% confidence interval (CI) 0.59–0.71]) and CP (HR 0.65 [95% CI 0.59–0.73]); conversely, another a posteriori high-fat dietary pattern (HFADP; i.e., incorporating high-fat and processed foods) demonstrated the strongest positive associations with the risk of increased cIMT (HR 1.96 [95% CI 1.75–2.20]) and CP (HR 1.83 [95% CI 1.61–2.08]) (all p for trend < 0.01). Conclusions: Multiple dietary patterns are significantly associated with the risk of early- and advanced-stage phenotypes of CAS. Notably, a high adherence to an HFIDP and low adherence to an HFADP may confer the greatest risk reduction for CAS. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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18 pages, 3313 KiB

Open AccessArticle

High-Fat Diet Augments Myocardial Inflammation and Cardiac Dysfunction in Arrhythmogenic Cardiomyopathy

by Ann M. Centner, Emily A. Shiel, Waleed Farra, Elisa N. Cannon, Maicon Landim-Vieira, Gloria Salazar and Stephen P. Chelko

Nutrients 2024, 16(13), 2087; https://doi.org/10.3390/nu16132087 - 29 Jun 2024

Viewed by 1600

Abstract

Arrhythmogenic cardiomyopathy (ACM) is a familial heart disease characterized by cardiac dysfunction, arrhythmias, and myocardial inflammation. Exercise and stress can influence the disease’s progression. Thus, an investigation of whether a high-fat diet (HFD) contributes to ACM pathogenesis is warranted. In a robust ACM mouse model, 8-week-old Desmoglein-2 mutant (Dsg2^mut/mut) mice were fed either an HFD or rodent chow for 8 weeks. Chow-fed wildtype (WT) mice served as controls. Echo- and electrocardiography images pre- and post-dietary intervention were obtained, and the lipid burden, inflammatory markers, and myocardial fibrosis were assessed at the study endpoint. HFD-fed Dsg2^mut/mut mice showed numerous P-wave perturbations, reduced R-amplitude, left ventricle (LV) remodeling, and reduced ejection fraction (%LVEF). Notable elevations in plasma high-density lipoprotein (HDL) were observed, which correlated with the %LVEF. The myocardial inflammatory adipokines, adiponectin (AdipoQ) and fibroblast growth factor-1, were substantially elevated in HFD-fed Dsg2^mut/mut mice, albeit no compounding effect was observed in cardiac fibrosis. The HFD not only potentiated cardiac dysfunction but additionally promoted adverse cardiac remodeling. Further investigation is warranted, particularly given elevated AdipoQ levels and the positive correlation of HDL with the %LVEF, which may suggest a protective effect. Altogether, the HFD worsened some, but not all, disease phenotypes in Dsg2^mut/mut mice. Notwithstanding, diet may be a modifiable environmental factor in ACM disease progression. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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17 pages, 2391 KiB

Open AccessArticle

The Impact of Dietary Carbohydrates on Inflammation-Related Cardiovascular Disease Risk: The ATTICA Study (2002–2022)

by Sofia-Panagiota Giannakopoulou, Smaragdi Antonopoulou, Christina Chrysohoou, Fotios Barkas, Costas Tsioufis, Christos Pitsavos, Evangelos Liberopoulos, Petros P. Sfikakis and Demosthenes Panagiotakos

Nutrients 2024, 16(13), 2051; https://doi.org/10.3390/nu16132051 - 27 Jun 2024

Viewed by 2921

Abstract

The aim of this study was to evaluate the potential interplay between a carbohydrate diet and inflammation in atherosclerotic cardiovascular disease (ASCVD) development. ATTICA is a prospective observational study of 3042 adults free of cardiovascular disease (CVD) who were recruited in 2002 and followed for 20 years. Baseline data on carbohydrate intake and inflammatory biomarker levels were collected. Participants were stratified by carbohydrate intake (low vs. high: </> 190 g/day) and carbohydrate quality. At the 20-year follow-up in 2022, 1988 participants had complete data for CVD assessment. The overall quantity and quality of carbohydrate intake did not show a significant association with CVD incidence; inflammatory markers were positively correlated with an increased risk of CVD (p-values < 0.05). Chronic systemic inflammation seems to affect the CVD risk of participants who had a higher carbohydrate intake more substantially, as compared to those with low intake. Additionally, individuals with higher high carbohydrate/low fiber intake experienced a higher risk of inflammation-related CVD, compared to those with high carbohydrate/high fiber intake. The presented findings revealed that the effect of inflammation markers on the CVD risk is influenced both by the amount and quality of carbohydrate intake, irrespective of overall dietary habits and clinical and lifestyle characteristics. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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21 pages, 300 KiB

Open AccessArticle

The Association of Total Meat Intake with Cardio-Metabolic Disease Risk Factors and Measures of Sub-Clinical Atherosclerosis in an Urbanising Community of Southern India: A Cross-Sectional Analysis for the APCAPS Cohort

by Hemant Mahajan, Poppy Alice Carson Mallinson, Judith Lieber, Santhi Bhogadi, Santosh Kumar Banjara, Vadde Sudhakar Reddy, Geereddy Bhanuprakash Reddy, Bharati Kulkarni and Sanjay Kinra

Nutrients 2024, 16(5), 746; https://doi.org/10.3390/nu16050746 - 5 Mar 2024

Cited by 2 | Viewed by 2426

Abstract

Aim: Meat is commonly consumed in India; however, in comparison to Western settings, it is eaten in relatively lower quantities and with minimal processing. The association between meat intake and cardio-metabolic diseases (CMDs) and their risk factors in India is currently uncertain. We examined whether meat intake is associated with risk factors for CMDs and the measures of subclinical atherosclerosis in urbanising villages in southern India. Methods: We conducted a cross-sectional analysis of 6012 adults (52.3% male) participating in the Andhra Pradesh Children and Parents’ Study (APCAPS), which is a large prospective, intergenerational cohort study in Southern India that began with the long-term follow-up of the Hyderabad Nutrition Trial (1987–1990). We used cross-sectional data from the third wave of data collection conducted in 2010–2012, where total meat intake was assessed using 100-item, semi-quantitative validated food frequency questionnaires (FFQ). The FFQs were validated using multiple weighed 24 h dietary recalls. The main predictor, ‘total meat intake’, was calculated as the sum of chicken, red meat, and fish consumption. The risk factors for CMDs [systolic blood pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), waist circumference (WC), fasting glucose, total cholesterol, homeostasis model assessment insulin resistance (HOMA-IR), total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol, triglycerides, and C-reactive protein] and measures of subclinical atherosclerosis [Carotid Intima-Media Thickness, Pulse Wave Velocity, and Augmentation Index] were assessed using standardised clinical procedures. Stratified by gender, the association of meat intake with the risk factors of CMDs and measures of subclinical atherosclerosis was examined using linear multilevel models with random intercept at the household level. Results: The mean (SD) age of the male (n = 3128) and female participants (n = 2828) was 34.09 years (15.55) and 34.27 years (12.73), respectively. The median (IQR) intake of meat was 17.79 g/day (8.90, 30.26) in males and 8.90 g/day (4.15, 18.82) in females. In males, a 10 g increase in total meat intake/1000 Kcal/day was positively associated with DBP, BMI, WC, total cholesterol, LDL-C, and triglycerides, whereas in females, a 10 g increase in total meat intake/1000 Kcal/day was positively associated with SBP, DBP, fasting glucose, HOMA-IR, total cholesterol, LDL-C, and triglycerides. There was no relationship between meat consumption and measures of subclinical atherosclerosis. Conclusions: Meat intake had a linear positive association with CMD risk factors among the relatively younger Indian population who were consuming meat at lower levels compared to their European counterparts. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

17 pages, 2245 KiB

Open AccessArticle

Increase in Vascular Function Parameters According to Lifestyles in a Spanish Population without Previous Cardiovascular Disease—EVA Follow-Up Study

by Alicia Navarro Cáceres, Elena Navarro-Matías, Marta Gómez-Sánchez, Olaya Tamayo-Morales, Cristina Lugones-Sánchez, Susana González-Sánchez, Emiliano Rodríguez-Sánchez, Luis García-Ortiz, Leticia Gómez-Sánchez, Manuel A. Gómez-Marcos and EVA-Follow-Up Investigators Group

Nutrients 2023, 15(21), 4614; https://doi.org/10.3390/nu15214614 - 30 Oct 2023

Cited by 3 | Viewed by 1759

Abstract

The aim of this longitudinal descriptive observational study was to analyze the influence of different lifestyles on arterial stiffness (AS) throughout five years of follow-up and to describe the differences by sex in a Spanish adult population without cardiovascular disease at the start of the study. A random stratified sampling by age and sex was used to obtain 501 subjects included in the initial assessment. No cardiovascular disease was allowed in the subjects. The average age was 55.9 years, and 50.3% were women. A total of 480 subjects were analyzed again five years later. Alcohol and tobacco consumption were collected with standardized questionnaires. Adherence to the Mediterranean diet was assessed with the Mediterranean diet adherence screener (MEDAS) questionnaire. Physical activity was assessed with the short version of the International Physical Activity Questionnaire-Short Form (IPAQ-SF) and sedentary time was assessed with the Marshall Sitting Questionnaire (MSQ). AS was assessed by measuring carotid–femoral pulse wave velocity (cfPWV) and central augmentation index (CAIx) with SphygmoCor System^®, and ankle pulse wave velocity (baPWV) and cardio ankle vascular index (CAVI) with Vasera VS-1500^®. Increases in vascular function measures per year of follow-up were: cfPWV = 0.228 ± 0.360 m/s, baPWV = 0.186 ± 0.308 m/s, CAVI = 0.041 ± 0.181 m/s, and CAIx = 0.387 ± 2.664 m/s. In multiple regression analysis, positive association was shown between an increase in baPWV and tobacco index (β = 0.007) and alcohol consumption (β = 0.005). Negative association was shown between CAVI and Mediterranean diet score (β = −0.051). In multinomial logistic regression analysis, the OR of tobacco index of subjects with a cfPWV increase >P75 was OR = 1.025 and of subjects classified between P25 and P75 was OR = 1.026 regarding subjects classified with an increase <P25. The OR for alcohol consumption of participants with a baPWV increase >P75 was OR = 1.006 regarding subjects classified with an increase <P25. An OR = 0.838 was found in the Mediterranean diet score of subjects with an increased CAVI > P75, and an OR = 0.841 was found of subjects classified between P25–75 regarding subjects classified with an increase <P25. In conclusion, the association of lifestyle between an increase in AS measures at 5 year follow-up differs according to the AS measure analyzed. A positive association was shown with increased cfPWV and tobacco index, as well as alcohol consumption with increased baPWV. However, a negative association with CAVI and adherence to the Mediterranean diet was found. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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14 pages, 299 KiB

Open AccessArticle

Dietary Patterns and the Prevalence of Noncommunicable Diseases in the PURE Poland Study Participants

by Dorota Różańska, Krzysztof Kujawa, Andrzej Szuba, Katarzyna Zatońska and Bożena Regulska-Ilow

Nutrients 2023, 15(16), 3524; https://doi.org/10.3390/nu15163524 - 10 Aug 2023

Cited by 2 | Viewed by 1664

Abstract

The aim of the study was to analyze the association between dietary patterns (DP) identified in the group of Lower Silesia (Poland) inhabitants and the prevalence of selected noncommunicable diseases, such as total cardiovascular diseases (CVD), hypertension, diabetes, impaired fasting glucose (IFG), visceral obesity, and excessive body weight. This study involved 2023 subjects aged 35–70 years, from Wroclaw and surrounding villages. The assessment of food intake in the study group was assessed using the standardized Food Frequency Questionnaire. Dietary patterns were identified using the principal components analysis (PCA) with varimax rotation. Three dietary patterns were identified in the study group: unhealthy, healthy, and traditional. The prevalence of hypertension, diabetes, IFG, and visceral obesity decreased across the quartiles of healthy DP. Prevalence of IFG increased across the quartiles of unhealthy DP, but the prevalence of hypertension decreased. When the diet was more adherent to the traditional DP the prevalence of CVD, diabetes, IFG, visceral obesity, obesity, and being overweight was higher. DP abundant in fruits, vegetables, seeds, nuts, raisins, and unrefined grains, named “healthy dietary pattern”, had a beneficial association with lower prevalence of selected noncommunicable diseases. DP abundant in meat products, but poor in fruits and vegetables were positively associated with higher prevalence of total CVD, diabetes, IFG, excessive body weight, and visceral obesity. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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16 pages, 655 KiB

Open AccessReview

Effect of Different Dietary Patterns on Cardiometabolic Risk Factors: An Umbrella Review of Systematic Reviews and Meta-Analyses

by Christina A. Chatzi, Athanasios Basios, Georgios Markozannes, Evangelia E. Ntzani, Konstantinos K. Tsilidis, Kyriakos Kazakos, Aris P. Agouridis, Fotios Barkas, Maria Pappa, Niki Katsiki and Evangelos C. Rizos

Nutrients 2024, 16(22), 3873; https://doi.org/10.3390/nu16223873 - 13 Nov 2024

Viewed by 623

Abstract

Background/Objectives: Lifestyle interventions such as dietary changes have been proposed to control the cardiometabolic risk factors and thus prevent cardiovascular (CV) disease (CVD). We performed an umbrella review to investigate whether different dietary patterns affect CV risk in individuals with at least one cardiometabolic risk factor (hypertension, dyslipidemia, obesity, diabetes, metabolic syndrome) but not established CVD. Methods: We systematically searched the PubMed and Scopus databases (up to August 2024) for the systematic reviews and meta-analyses of randomized controlled trials (RCTs). Articles should be written in English and refer to a specific dietary pattern (such as Mediterranean diet, etc.). The population studied referred to adults with at least one cardiovascular (CV) risk factor. Results: From 4512 records identified, we finally included 25 meta-analyses with a total of 329 associations. Strong evidence for a benefit was found for LCD with reductions in BW [MD: −4.79 (95% CI −5.85, −3.72) kg, p ≤ 0.001], SBP [MD: −6.38 (95% CI −7.84, −4.93) mmHg, p ≤ 0.001], TG [WMD: −5.81 (95% CI −7.96, −3.66) mg/dL, p ≤ 0.001], and fasting plasma insulin [MD: −15.35 (95% CI −19.58, −11.12) pmol/L, p ≤ 0.001], as well as for low-GI diet for the reduction of BW [SMD: −0.66 (95% CI −0.90, −0.43) kg, p ≤ 0.001]. Conclusions: Across many dietary patterns, LCD showed strong or highly suggestive evidence for a benefit on SBP, BW reduction, and lipid profile improvement. Secondarily, low-GI, DASH, and Portfolio and Nordic diets suggested beneficial effects on controlling CV risk. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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26 pages, 1510 KiB

Open AccessReview

The Role of Antioxidants in the Therapy of Cardiovascular Diseases—A Literature Review

by Ewelina Młynarska, Joanna Hajdys, Witold Czarnik, Piotr Fularski, Klaudia Leszto, Gabriela Majchrowicz, Wiktoria Lisińska, Jacek Rysz and Beata Franczyk

Nutrients 2024, 16(16), 2587; https://doi.org/10.3390/nu16162587 - 6 Aug 2024

Cited by 1 | Viewed by 4037

Abstract

Antioxidants are endogenous and exogenous substances with the ability to inhibit oxidation processes by interacting with reactive oxygen species (ROS). ROS, in turn, are small, highly reactive substances capable of oxidizing a wide range of molecules in the human body, including nucleic acids, proteins, lipids, carbohydrates, and even small inorganic compounds. The overproduction of ROS leads to oxidative stress, which constitutes a significant factor contributing to the development of disease, not only markedly diminishing the quality of life but also representing the most common cause of death in developed countries, namely, cardiovascular disease (CVD). The aim of this review is to demonstrate the effect of selected antioxidants, such as coenzyme Q10 (CoQ10), flavonoids, carotenoids, and resveratrol, as well as to introduce new antioxidant therapies utilizing miRNA and nanoparticles, in reducing the incidence and progression of CVD. In addition, new antioxidant therapies in the context of the aforementioned diseases will be considered. This review emphasizes the pleiotropic effects and benefits stemming from the presence of the mentioned substances in the organism, leading to an overall reduction in cardiovascular risk, including coronary heart disease, dyslipidaemia, hypertension, atherosclerosis, and myocardial hypertrophy. Full article

(This article belongs to the Special Issue Diet, Nutrition and Cardiovascular Health)

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