A Twelve-Week Lifestyle Program to Improve Cardiometabolic,Behavioral,and Psychological Health in Hispanic Children and Adolescents

Abstract

Objectives:

To examine the effectiveness of a 12-week lifestyle program on cardiometabolic, behavioral, and psychological outcomes among overweight Hispanic children and adolescents.

Design:

A case series study with pre- and post-test analyses.

Subjects/Settings/Location:

A convenience sample of high-risk pediatric primary care patients (n = 22; 6 girls, 16 boys; M age = 11.73 ± 1.39 years) and their guardians in the Southeast United States.

Intervention:

Twice per week 60 min (total of 24 h) of moderate-to-vigorous intensity boxing exercise training, 12 h of nutrition education for guardians, and a 30-min pediatrician appointment.

Outcome measures:

Cardiometabolic (height [m], weight [kg], waist circumference [cm], body–mass index [BMI], BMI-z, BMI%, cholesterol [mg/dL], triglycerides [mg/dL], glucose [mg/dL], and low-density lipoprotein and high-density lipoprotein cholesterol [mg/dL]), behavioral (objective free time physical activity [PA] and sedentary time [min/day]), and psychological (self-determined exercise motivation) outcomes were measured/calculated, and paired-samples t-tests were conducted.

Results:

A significant reduction was observed in waist circumference t(17) = −2.57, p = 0.020, d = 0.64; BMI% t(15) = −2.53, p = 0.023, d = 0.20; fasting glucose t(15) = −6.43, p < 0.001, d = 1.67; and amotivation (−) t(17) = −2.29, p = 0.036, d = 0.64; whereas a significant increase was identified in moderate t(10) = 4.01, p = 0.002, d = 1.23 and vigorous t(10) = 3.41, p = 0.007, d = 1.07 intensity PA; intrinsic motivation t(17) = 2.71, p = 0.015, d = 0.38; and introjected regulation t(17) = 2.74, p = 0.014, d = 0.64.

Conclusions:

A 12-week lifestyle program can be effective in improving selected health markers among overweight Hispanic children and adolescents. The positive changes in fasting glucose, BMI, and waist suggest that the participants are currently at lower risk for both type 2 diabetes and cardiovascular disease as a result of the Confidence, Ownership, Responsibility, and Exercise program.

Introduction

The prevalence of overweight and obesity has reached epidemic proportions, and it includes not only adults¹ but also children and adolescents.^2,3 It has been reported worldwide that overweight and obesity impacts approximately 110 million children,² whereas in the United States (US), an estimated 17% (95% confidence interval [CI] [15.5%–18.6%]) of 2- to 19-year-olds are obese.⁴ According to the World Health Organization, school-aged children and youth whose body–mass index (BMI) is greater than the 85th centile for age are overweight, and those whose weight is above the 97th centile for age are obese.⁵ Behavioral, educational, pharmacologic, and drug interventions in school and clinical settings have been conducted to improve child and adolescent weight management.^6

–9 Current recommendations to prevent childhood obesity in the United States, based on the national expert committee, highlight the importance of interdisciplinary expert collaboration and the use of lifestyle interventions, that is, interventions comprising exercise, nutrition education, and/or behavior modification.^10,11 In addition, research has shown that although lifestyle interventions are promising in improving children's health, programs that combine lifestyle intervention with family and motivational components are the most effective.^6,7

Theoretical framework

The most successful public health programs are based on an understanding of health behaviors and the contexts in which they occur.¹² The present study applied a socioecological approach understanding that health-related changes are not happening only on the intraindividual (child) level but also occur on the interindividual (e.g., family), organizational (e.g., family), and community (e.g., primary care) level.¹³ For this study, a community partnership with a local nonprofit organization, university, and primary care system was established, to provide resources and expertise to achieve sustainable change in the health status of Hispanic/Latino hereafter referred to as “Hispanic” children with weight-related health concerns. Hispanic children are important populations of interest because inequities in access to healthcare and opportunities to make healthy choices have shown to contribute to the higher rates of obesity in Hispanics compared with non-Hispanic children.¹⁴ In addition, in the nationally representative study entitled National Health and Nutrition Examination Survey, Hispanic youth were shown to exhibit a higher prevalence of obesity than non-Hispanic white youth (2011–2014, 21.9% vs. 14.7%).⁴ Moreover, Hispanics are the fastest growing population in the United States, thus addressing these health disparities is essential for the well-being and productivity of Hispanic families.¹⁵

Changes in participants' cardiometabolic markers were derived from the height, weight, waist circumferences, and blood panel, physical activity (PA) behavior through objective activity tracker (accelerometer), and exercise motivation utilizing the self-determination theory (SDT) perspective.¹⁶ SDT is a macrotheory of human personality and motivated behavior, and it is explained in detail elsewhere.¹⁷ In brief, SDT distinguishes between intrinsic and extrinsic types of motivation regulating one's behavior. Whereas intrinsic motivation refers to activities that are performed due to inherent satisfaction, extrinsic motivation refers to doing an activity for instrumental reasons, such as to gain a tangible or social reward or to avoid disapproval. SDT conceptualizes qualitatively different types of extrinsic motivation that differ in terms of their relative autonomy. External (behavior performed to comply with externally administered reward/punishment contingencies) and introjected (behavior is driven by the desire to seek acceptance from others) regulation are controlling and thus maladaptive.¹⁷ These controlled forms of extrinsic motivation are expected within SDT to sometimes regulate (or motivate) short-term behavior, but not to sustain maintenance over time.¹⁶ On the contrary, integrated and identified regulations are extrinsic motives but are autonomous and adaptive. Identified and integrated forms of behavioral regulation are defined as those in which one's actions are self-endorsed because they are personally valued.¹⁸ Individuals with identified regulation participate in the activity because of the goal, that is, health is personally important and valued. Integrated regulation is the most autonomous kind of extrinsic motivation, occurring when regulations are fully assimilated with self, so they are included in a person's self-evaluations and beliefs on personal needs.¹⁸ Integrated regulation is not usually assessed in children and adolescents because younger populations may not yet have experienced a sense of integration.¹⁹ Thus, integrated regulation was omitted from the present study. Research has shown that adaptive motivation relates to higher amounts and intensities of PA behaviors^20
–22 and better health,²³ whereas maladaptive motivation and amotivation (total absence of motivation) have been found to relate to lower levels of PA.^21,22

Effective lifestyle interventions for children's health

Lifestyle interventions are regarded as the therapy of choice in children with obesity.^24,25 Several meta-analyses have been published that review the effectiveness of lifestyle interventions on children's cardiometabolic health.^6
–8,26,27 For instance, the meta-analysis of Ho et al.⁶ included 38 articles from year 1975 to 2010 and showed that the lifestyle interventions produced statistically significant weight loss compared to no-treatment control conditions in children's BMI (−1.25 kg/m², 95% confidence interval [CI] [−2.18, −0.32]), BMI-z (−0.10, 95% CI [−0.18, −0.02]), low-density lipoprotein (LDL) cholesterol (−0.30 mmol/L, 95% CI [−0.45, −0.15]), triglycerides (−0.15 mmol/L, 95% CI [−0.24, −0.07]), and fasting insulin (−55.1 pmol/L, 95% CI [−71.2, −39.1]), but no significant effects have been established on high-density lipoprotein (HDL) cholesterol.⁶ Similarly, when lifestyle interventions were compared to usual care, these resulted in significant acute (−1.30 kg/m², 95% CI [−1.58, −1.03]) and post-treatment (−0.92 kg/m², 95% CI [−1.31, −0.54]) effects on BMI.⁶

Whereas the central goal of lifestyle interventions has been to reduce participants' obesity and/or cardiometabolic risk factors, participants' PA behavior and exercise motivation outcomes have been targeted with specifically tailored PA and motivational interventions. Several meta-analyses have summarized the effectiveness of PA interventions on children's PA.^28,29 The meta-analysis of Metcalf et al.²⁸ showed a small to negligible effect for total PA (standardized mean difference 0.12, 95% CI [0.04, 0.20]) and a small effect for moderate or vigorous PA (0.16, 95% CI [0.08, 0.24]).²⁹ Similarly, the meta-analysis examining the effectiveness of family-based interventions on children's PA demonstrated a significant small effect (0.41, 95% CI [0.15, 0.67]).³⁰ These meta-analyses have shown that 66% of PA interventions have contributed toward positive changes in children's PA behaviors, the most effective strategies in the family context being interventions with psychological components, such as goal setting and reinforcement.²⁹

On PA and exercise motivation, studies have supported the theorized notion that suggests that efforts to facilitate adaptive over maladaptive controlling motivation are effective in increasing participants' exercise and PA behaviors in both adults²² and children.²¹ The recent systematic review showed that (1) autonomous motivation was a positive and consistent predictor of exercise behavior (in 82% of the reviewed studies) and (2) controlling motivation negatively predicted exercise behavior (60%), or there was a null association between controlling forms of motivation and exercise (40%).²² When examining the predictive impact of the separate motivational regulations, Teixeira et al.²² showed a positive association between identified regulations and exercise in 74% of the reviewed studies and between intrinsic motivation and exercise in 92% of the reviewed studies. Few studies examining the relationships between introjected regulation and exercise showed no clear pattern of associations (30%, 5%, and 65% of the studies showed positive, negative, or no relationship, respectively).²² Finally, the study by Teixeira et al.²² found that 43% of the studies reported a negative relationship between extrinsic regulations and exercise, whereas 57% showed no statistically significant associations. Similar findings were evident when examining PA motivation and PA leisure-time behavior in children²¹: (1) autonomous motivation had weak to moderate, positive associations with PA (ρ = 0.25–0.34), (2) a weak positive effect size was found between introjection and PA (ρ = 0.22, 95% CI [0.08, 0.35]), (3) no statistically significant effect between external regulation and PA, and (4) a negative association between amotivation and PA (ρ = −0.11, 95% CI [−0.20, −0.02]).

Shortcomings of current interventions

Although current recommendations advocate for the usage of lifestyle interventions on childhood obesity prevention, and the previous studies have shown lifestyle interventions to be an effective strategy to treat childhood obesity, there are limited studies examining the broad impact of lifestyle interventions on cardiometabolic, behavioral, and psychological outcomes in overweight children. Similarly, although assumed and frequently discussed, there are few studies demonstrating an effect of lifestyle interventions on Hispanic families with underprivileged socioeconomic status and the migration background.³⁰ This study applied a novel community-based and physician referral approach to address weight-related health issues in a local Hispanic community. Thus, the purpose of this study was to examine the effectiveness of the Confidence, Ownership, Responsibility, and Exercise (CORE) lifestyle intervention program on selected cardiometabolic, behavioral, and psychological health outcomes among Hispanic children referred by a physician due to overweight and obesity.

Method

Participants

A convenience sample consisted of 22 high-risk (n overweight = 2; n obese = 20) patients (6 girls, 16 boys; M _age = 11.73, standard deviation [SD]_age = 1.39 years) and their guardians referred from a pediatric primary care center located in the Southeast United States. The primary care center is part of the local major health system and the referring pediatrician serves a mostly indigent and Hispanic patient census because of (1) the demographics of the area, (2) the pediatrician speaks fluent Spanish, and (3) the center accepts Medicaid patients. Referred potential participants were contacted by the researchers and invited to participate in the study. Each family's participation was voluntary, and all participants and their guardians signed and returned assent and parental permission forms as well as an HIPAA (Health Insurance Portability and Accountability Act of 1996) privacy authorization form. Study approval was obtained from the university's Institutional Review Board for Human Subjects.

All participants were Hispanic (bilingual in English and Spanish), and more than 90% of the families were Medicaid recipients. Participants were recruited due to elevated health concerns, that is, their BMI-for-age percentile was above the 85th (overweight or obese) for children of the same age and sex.⁵ A large majority of guardians were Hispanic and were thus able to communicate only in Spanish. Out of 22 recruited participants, 18 completed both questionnaires, 16 completed the blood draw and height/weight measurements, and 14 completed the objective PA measurements. However, the PA data of three participants included anomalies and thus were omitted.

Program description

CORE is a novel program designed to improve the health status of overweight and obese children and includes exercise, nutrition, and behavior modification components. CORE is a nonprofit program operated by an independent company that partnered with the local pediatric primary care center to pilot the program. The first year cost of the program was $738 per participant, and the pilot program was funded, in part, by generous community donations. All program fees for the participants were waived for this research project. This is an ongoing program with primary care physicians referring their patients to the program as an extension to clinical care. The 12-week program consists of group fitness instruction and 60-min exercise sessions using high-impact, high-intensity interval training with increasing periods of duration within the 60 min. Sessions incorporate warm-up methods, comprehensive stretches, and cardio and body weight exercises. One leading instructor led exercise sessions (provided structure and ran the exercises) and 2–3 assistant instructors provided participants with some extra individual guidance. Nutritional counseling includes 12 sessions that focus on dietary and health information and awareness for the family in a group setting. The nutrition curriculum incorporated established programs for goal setting, recognition of high-sugar beverages, nutrition labels, balanced plate, and incorporation of healthful fruits and vegetables, grains, and dietary fats into the diet. One dietitian with the help of a Spanish translator delivered the nutrition counseling. Group behavior modification introduced goal setting for exercise and diet with a focus on building intrinsic motivation for exercise and nutritional awareness to instill lifestyle changes and healthier habits. Finally, each participant and his or her guardian had one 30-min one-to-one meeting with a regular pediatrician during week 6 or 7. This meeting encouraged participants to engage in the program and to go through the program materials. Exercise sessions and counseling for children were instructed in English, but nutrition counseling sessions for guardians were instructed in English and Spanish.

Testing procedures

Pretests were conducted before the program (baseline) and post-tests occurred during the last day of the program (12 weeks). Participants underwent testing phases following the same procedures: (1) demographic and health history (only baseline) and exercise motivation surveys; (2) height, weight, and waist circumference; (3) provision of accelerometer (a wristband) to wear and an activity monitor log to be completed daily, participants pre-CORE free time PA was measured for four days before the first CORE exercise sessions; and (4) participants' free time PA during the CORE program was measured during weeks 10 and 11 following the identical protocol of pre-CORE. Finally, a medically trained registered nurse employed at a local laboratory drew the blood for the study.

Measures

Anthropometric and cardiometabolic data

Height (m), weight (kg), and waist circumference (cm) were measured by trained research assistants, with BMI, BMI%, and BMI-z scores calculated. Fasting serum samples were collected for determination of total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, and glucose.

Behavioral data

Participants' sedentary time and free time PA were measured objectively using the ActiGraph Link wrist-worn accelerometers (ActiGraph, LLC, Fort Walton Beach, FL).³⁰ Participants wore the monitors on the nondominant wrist, and the research team provided detailed verbal and written instructions on how and when to wear the monitors and the PA log to track the wear time. The accelerometers were worn for four consecutive days (96 h). Nonwearing time was calculated as periods of more than 30 minutes of consecutive zero counts. At least 80% of wearing time was required. National Health and Nutrition Examination Survey PA data collection protocols were followed,³¹ and data were reduced using the methods described elsewhere.^32
–34

Psychological data

Exercise motivation was measured using the Behavioral Regulation in Exercise Questionnaire³⁵ consisting of a 16-item scale with five subscales that measured intrinsic motivation, identified, introjected, and external regulation, and amotivation. For each dimension, four items (except for identified regulation, which had three) were rated on a 5-point Likert scale (1 = absolutely untrue …5 = absolutely true). The stem was “I do physical exercise…,” and items represented possible motives to that question, reflecting the different types of motivation. Previous studies have shown this scale to be valid and reliable for examining children and adolescent motivation.³⁵ The internal consistency of the different categories was 0.93, 0.73, 0.68, 0.80, and 0.89 for the pretest and 0.92, 0.70, 0.67, 0.72, and 0.80 for the post-test, for intrinsic motivation, identified, introjected, external regulation, and amotivation, respectively.

Data analyses

Data analysis processes began with preliminary analyses, such as normality, outlier, internal consistency, and descriptive analyses. No modifications due to normality were required. No statistically significant outliers were detected through the covariance matrix based on the Mahalanobis distance test (p < 0.001) of standardized values (±3.00).³⁶ Cronbach's alphas showed acceptable (α > 0.70) internal consistency for all psychological dimensions except for introjected regulation (α pre = 0.68; α post = 0.67). Second, means and SDs were calculated for all research variables. Finally, paired t-tests with Morris and DeShon³⁷ equation for mean dependence corrected effect sizes (Cohen's d) were tabulated to test the effect of the CORE program on participants' cardiometabolic, behavioral, and psychological outcomes. Cohen's effect size standard (>0.8 = large; <0.8 to >0.2 = medium; <0.2 = small) was utilized to determine the practical meaningfulness of the p-values.³⁸

Results

The results presented in Table 1 showed a statistically significant reduction in waist circumference t(17) = −2.57, p = 0.020, d = 0.64; BMI t(15) = −2.20, p = 0.044, d = 0.57; BMI-z t(15) = −3.64, p = 0.002, d = 0.19; BMI% t(15) = −2.53, p = 0.023, d = 0.20; fasting glucose t(15) = −6.43, p < 0.001, d = 1.67; and amotivation (−) t(17) = −2.29, p = 0.036, d = 0.64. Significant increases were found in moderate-intensity PA t(10) = 4.01, p = 0.002, d = 1.23; vigorous-intensity PA t(10) = 3.41, p = 0.007, d = 1.07; intrinsic motivation t(17) = 2.71, p = 0.015, d = 0.38; and introjected regulation t(17) = 2.74, p = 0.014, d = 0.64.

Table 1.

Changes in Cardiometabolic, Body Composition, Behavioral, and Psychological Variables Following the Twelve-Week Confidence, Ownership, Responsibility, and Exercise Lifestyle Program

Variable	Baseline, mean (SD)	12 Weeks, mean (SD)	t	p	d
Cardiometabolic variables
Waist circumference (cm)	97.37 (13.15)	95.81 (12.37)	−2.57	0.020	0.64
BMI (kg/m²)	28.69 (4.80)	28.21 (4.57)	−2.20	0.044	0.57
BMI-z	2.01 (0.45)	1.92 (0.49)	−3.64	0.002	0.19
BMI%	96.56 (3.93)	95.63 (5.08)	−2.53	0.023	0.20
Glucose (mg/dL)	94.93 (6.27)	86.67 (6.75)	−6.43	<0.001	1.67
Cholesterol (mg/dL)	150.00 (22.20)	143.00 (20.17)	−1.65	0.120	0.46
Triglycerides (mg/dL)	130.73 (63.71)	132.40 (89.62)	0.11	0.911	0.03
LDL-C (mg/dL)	83.27 (19.87)	76.87 (13.08)	−1.86	0.085	0.55
HDL-C (mg/dL)	40.67 (6.32)	40.03 (6.05)	−0.45	0.657	0.12
Behavioral variables
Sedentary time (min/day)	887.58 (233.70)	710.00 (236.30)	−2.176	0.055	0.68
Light-intensity PA (min/day)	391.53 (166.83)	439.39 (147.46)	0.888	0.395	0.27
Moderate-intensity PA (min/day)	154.07 (74.33)	253.34 (90.89)	4.010	0.002	1.23
Vigorous-intensity PA (min/day)	2.75 (9.12)	28.18 (20.51)	3.405	0.007	1.07
Psychological variables
Intrinsic motivation	3.74 (0.97)	4.33 (0.53)	2.71	0.015	0.69
“Goal is inherently satisfying”	3.74 (0.97)	4.33 (0.53)	2.71	0.015	0.69
Identified regulation	3.81 (0.96)	4.19 (0.57)	1.51	0.149	0.38
“Goal is personally valued”	3.81 (0.96)	4.19 (0.57)	1.51	0.149	0.38
Introjected regulation	2.98 (0.80)	3.44 (0.86)	2.74	0.014	0.64
“Behavior is driven by the acceptance of others”	2.98 (0.80)	3.44 (0.86)	2.74	0.014	0.64
Extrinsic motivation	2.82 (0.95)	2.44 (0.94)	−1.84	0.083	0.43
“Compliance with externally administered reward/punishment”	2.82 (0.95)	2.44 (0.94)	−1.84	0.083	0.43
Amotivation	1.69 (0.95)	1.15 (0.28)	−2.29	0.036	0.64
“No motivation for goal”	1.69 (0.95)	1.15 (0.28)	−2.29	0.036	0.64

Behavioral data are accelerometer derived and represent minutes per day. Psychological scores range from 1 to 5, with one referring to a low value and 5 to a high value.

BMI, body–mass index; BMI-z, body–mass index standard deviation score; BMI%, BMI/age percentile; SD, standard deviation; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; PA, physical activity.

Discussion

The results show that the CORE lifestyle program was effective in improving selected health markers in these study participants. The study showed moderate positive effects in participants' waist circumference, BMI, BMI-z, and BMI%. These demonstrated changes are similar compared to the summarized findings of the earlier studies, although the degree of reduction in this study was greater than changes in previous lifestyle studies.⁶ The BMI and BMI-z reductions, however, were slightly smaller compared to the 12-month study with obese 9- to 17-year-old Mexican youth but this was expected as this study was shorter in duration (12 weeks).³⁹ It is well established that increased BMI during childhood/adolescence correlates with obesity and increased risk of metabolic syndrome as adults.⁶ In addition, a large waist circumference is also a strong marker of metabolic syndrome and, in many studies, correlates better with insulin resistance than BMI.⁴⁰

In accordance with the previous lifestyle intervention findings among children,⁶ this study showed large reductions in participants' fasting glucose concentrations from 94.93 mg/dL at baseline to 86.67 mg/dL at 12 weeks. This study is one of the first to identify positive changes in fasting glucose concentrations after a relatively short 12-week intervention. The findings of this study are larger compared to the results of Davis et al.⁴¹ that examined the effect of a 16-week nutrition and combination of aerobic and strength training program on overweight Hispanic adolescent girls (14- to 16-year olds).

This result is encouraging because fasting glucose has been shown to be an extremely important cardiometabolic health marker, not only for the risk of type 2 diabetes mellitus but also for cardiovascular disease.^42,43 Also, it has been shown among individuals with glucose concentrations ranging from 95 to 99 mg/dL that they are 2.33 times more likely to develop type 2 diabetes mellitus compared to those with concentrations <85 mg/dL.⁴⁴ Moreover, each rise in milligram per deciliter of fasting plasma glucose increases a risk of diabetes by 6%.⁴²

This study showed that the CORE program had a positive effect on participants' PA behavior and exercise motivation. Large-sized effects were found in moderate- and vigorous-intensity PA. This change is important because moderate-to-vigorous intensity PA compared to lower intensities has been shown to have greater benefits in children's health.^20,44 It is worth noticing that participants had very limited amounts of vigorous-intensity PA during their regular day before the intervention (mean 2.75 [9.12] min/day). In addition, although there were changes in participants' daily sedentary time, these changes were not statistically significant (presedentary time 887.58 [233.70]; postsedentary time 710.00 [236.30]). Similarly, participants' intrinsic motivation and introjected regulation were shown to improve and amotivation was shown to decline in this study. The improvements in participants' intrinsic motivation toward exercise are highly encouraging because research has shown intrinsic motivation relates to long-term exercise adherence and higher intensity physical activities (see review by Teixeira et al.²²). Although SDT postulates introjected regulation as controlling motivation, thus having a negative effect on health outcomes, such as PA, previous findings in this area have been mixed.²² The present study showed an increase in participants' introjected regulation. It may be that CORE participants were starting to internalize motivation for exercise, that is, moving from external motivation (e.g., the behavior is performed to avoid feelings of guilt or for ego enhancement) toward intrinsic motivation (e.g., exercise itself is satisfactory). The study also showed that participants' amotivation in exercise was relatively low and it declined across the program. This finding is important because high levels of amotivation have been found to relate to negative health outcomes.²²

Limitations

Limitations of this study include the single-group pre–post design and a relatively small sample size. Although it was established that the program was partially effective, the lack of a random assignment and a comparison group prevents us from concluding that the effects did not result from unmeasured factors. In addition, behavior modification strategies in this study were not theory based but followed the established recommendation.⁴⁵ Although this study had a small sample size, the project was an unfunded pilot intended to serve as a hypothesis-generating study.

Conclusions

The findings of this pilot study are promising and suggest that this unique, community-based, physician referral, 12-week lifestyle program, based on interdisciplinary expert collaboration, can be effective in improving at-risk Hispanic children's and adolescents' selected cardiometabolic, behavioral, and psychological outcomes. The positive changes in fasting glucose, BMI, and waist circumference suggest that the child participants are currently at lower risk of both type 2 diabetes and cardiovascular disease as a result of the CORE program. Future research is needed to test the findings using a randomized controlled design and determine the long-term effectiveness of the CORE program.

Footnotes

Acknowledgments

This project was funded by the Mulherin Foundation and Jackson EMC.

Author Disclosure Statement

No competing financial interests exist.

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