Obesity and COVID-19: The Two Sides of the Coin

The World Health Organization declared COVID-19, the infectious disease caused by the coronavirus SARS-CoV-2, a pandemic on March 12, 2020. COVID-19 is causing massive health problems and economic suffering around the world. The European Association for the Study of Obesity (EASO) promptly recognised the impact that the outbreak could have on people with obesity. On one side, emerging data suggest that obesity represents a risk factor for a more serious and complicated course of COVID-19 in adults. On the other side, the health emergency caused by the outbreak diverts attention from the prevention and care of non-communicable chronic diseases to communicable diseases. This might be particularly true for obesity, a chronic and relapsing disease frequently neglected and linked to significant bias and stigmatization. The Obesity Management Task Force (OMTF) of EASO contributes in this paper to highlighting the key aspects of these two sides of the coin and suggests some specific actions.     

Obesity as a Showcase for Transdisciplinary Research

Obesity is one of the main health problems in the world with high societal and individual costs. To tackle the obesity epidemic, we need to collaborate across scientific boarders to fundamentally broaden the perspectives on the obesity epidemic as a complex phenomenon.Key Words: Obesity, Transdisciplinarity, SSH, Horizon2020, EUObesity is a rapidly growing public health challenge heading to be one of the main health problems in the world with high societal and individual costs. More so, severe obesity is a gateway to many other chronic diseases such as type-2 diabetes, cardiovascular and heart diseases and cancer as well as to a multitude of social and psychological adverse conditions affecting quality of life, mental health, physical health and health and care costs as well as the efficiency of the workforce. We already know that to fully unravel the challenge of the obesity epidemic we must take into account the obesogenic environment, the obese citizens and the way society and individuals address obesity. Insights from Social Sciences and Humanities (SSH) will radically broaden the perspective on the obesity epidemic. The point of view of the obese, their rights and statuses as citizens, their life stories, narratives etc. will be included, as well as questions about the impact of obesity discourse on the non-obese population and on other societal issues pertaining to history, social conditions, morality, law, aesthetics, psychology and so forth.In other words, to address obesity as a complex phenomenon, there is a need for integrating and mobilizing all relevant scientific disciplines building true transdisciplinary research, which requires determination from all sides. We need to change and broaden our view on obesity by looking at the role of social structures, social inequality and stigma associated with obesity, the cost-effectiveness of initiatives and interventions and critically evaluate the potentials in choice architecture, behaviour change and various forms of policy development and political regulation. At the same time, we also need to heighten the awareness of societal effects and consequences of the obesity epidemic.Sciences such as economics, anthropology, sociology, psychology, political sciences, architecture and urban planning, ethnology, philosophy, history, geography, communication and information sciences, science and technology studies and many more disciplines within the SSH all hold a piece of this highly complex puzzle. By combining these scientific fields with nutritional and clinical research, physical activity, biomedical sciences and epidemiology, we will be able to answer new questions and thereby securing new findings, solutions and greater impact in obesity research. Thus, the future potentials in obesity research aim at adding to our understanding of the complex system of mechanism of obesity. The impact of such research includes identification of arenas for health promotion, prevention and policy making and offers a spectrum of refined and personalized approaches to treatment, which balance the responsibility of the society and the autonomy of the citizens.     

Carrying the Pain of Abuse: Gender-Specific Findings on the Relationship between Childhood Physical Abuse and Obesity in Adulthood

BackgroundChildhood abuse has been associated with negative adult health outcomes, including obesity. This study sought to investigate the association between childhood physical abuse and adult obesity, while controlling for five clusters of potentially confounding factors: childhood stressors, socioeconomic indicators, marital status, health behaviors, and mental health.MethodsRepresentative data from the 2005 Canadian Community Health Survey were selected. The response rate was approximately 84%. Gender-specific logistic regression analyses determined the association between abuse and obesity, while controlling for age and race and five clusters of potentially confounding factors. Of the 12,590 respondents with complete data, 2,787 were obese and 976 reported physical abuse as a child or adolescent by someone close to them.ResultsAmong women with childhood physical abuse compared to no abuse, the odds of obesity were 35% higher, even when controlling for age, race, and the five clusters of factors (odds ratio (OR) = 1.35; 95% confidence interval (CI) = 1.09, 1.67). Childhood physical abuse was not associated with adult obesity among men (OR = 1.12; 95% CI = 0.82, 1.53).ConclusionsThis study provides one of the first population-based, gender-specific analyses of the association between childhood physical abuse and obesity controlling for a wide range of factors. The gender-specific findings require further exploration.Key Words: Childhood physical abuse, Adverse childhood experiences, Gender, Health behaviors, Socioeconomic status, Mental health     

Criteria for EASO-collaborating centres for obesity management

Obesity is recognised as a global epidemic and the most prevalent metabolic disease world-wide. Specialised obesity services, however, are not widely available in Europe, and obesity care can vary enormously across European regions. The European Association for the Study of Obesity (EASO, www.easo.org) has developed these criteria to form a pan-European network of accredited EASO-Collaborating Centres for Obesity Management (EASO-COMs) in accordance with accepted European and academic guidelines. This network will include university, public and private clinics and will ensure that the obese and overweight patient is managed by a holistic team of specialists and receives comprehensive state-ofthe-art clinical care. Furthermore, the participating centres, under the umbrella of EASO, will work closely for quality control, data collection, and analysis as well as for education and research for the advancement of obesity care and obesity science.     

Neighbourhood Deprivation,Individual-Level Familial and Socio-Demographic Factors and Diagnosed Childhood Obesity: A Nationwide Multilevel Study from Sweden

ObjectivesTo examine whether there is an association between neighbourhood deprivation and diagnosed childhood obesity, after accounting for family- and individual-level socio-demographic characteristics.MethodsAn open cohort of all children aged 0-14 years was followed between January 1, 2000 and December 31, 2010. Childhood residential locations were geocoded and classified according to neighbourhood deprivation. Data were analysed by multilevel logistic regression, with family- and individual-level characteristics at the first level and level of neighbourhood deprivation at the second level.ResultsDuring the study period, among a total of 948,062 children, 10,799 were diagnosed with childhood obesity. Age-adjusted cumulative incidence for diagnosed childhood obesity increased with increasing level of neighbourhood deprivation. Incidence of diagnosed childhood obesity increased with increasing neighbourhood-level deprivation across all family and individual-level socio-demographic categories. The odds ratio (OR) for diagnosed childhood obesity for those living in high-deprivation neighbourhoods versus those living in low-deprivation neighbourhoods was 2.44 (95% confidence interval (CI) = 2.22-2.68). High neighbourhood deprivation remained significantly associated with higher odds of diagnosed childhood obesity after adjustment for family- and individual-level socio-demographic characteristics (OR = 1.70, 95% CI = 1.55-1.89). Age, middle level family income, maternal marital status, low level education, living in large cities, advanced paternal and maternal age, family history of obesity, parental history of diabetes, chronic obstructive pulmonary disease, alcoholism and personal history of diabetes were all associated with higher odds of diagnosed childhood obesity.ConclusionsOur results suggest that neighbourhood characteristics affect the odds of diagnosed childhood obesity independently of family- and individual-level socio-demographic characteristics.Key Words: Childhood obesity, Neighbourhood-level deprivation, Incidence, Socio-demographic factors, Multilevel modelling     

Childhood maltreatment and pre-pregnancy obesity: a comparison of obese,overweight, and normal weight pregnant women

Pre-pregnancy overweight and obesity is associated with poor health outcomes for the mother and the child. General population studies suggest that childhood maltreatment is associated with obesity in adulthood. The aim of our study was to examine the association between pre-pregnancy overweight and obesity and a history of childhood abuse or neglect including different stages of severity of abuse and neglect. Three hundred twenty-six normal weight, overweight, or obese pregnant women reported demographic data, height and weight, and general psychological distress at 18–22 weeks of gestation. Childhood maltreatment was assessed using the Childhood Trauma Questionnaire. Associations were examined using logistic regression analyses and a reference group of normal weight women. Fifty percent reported a history of abuse or neglect. After adjusting for age, education, income, marital status, and the number of previous children, pre-pregnancy overweight and obesity were strongly associated with severe physical abuse (overweight: OR?=?8.33, 95 % CI 1.48–47.03; obesity: OR?=?6.31, 95 % CI 1.06–37.60). Women with severe physical neglect (OR?=?4.25, 95 % CI 1.23–14.74) were at increased risk of pregnancy overweight. We found a dose-response relationship between physical abuse and pre-pregnancy overweight and obesity. Whereas other studies report an association between childhood maltreatment and pre-pregnancy obesity, this is the first study that found an association between childhood maltreatment and pre-pregnancy overweight. Considering the severe health risks of pre-pregnancy overweight and obesity and the long-term consequences of childhood maltreatment, affected women constitute a subgroup with special needs in prenatal care. Further research is needed to improve the understanding of the underlying mechanisms.     

Obesity as disease and as social problem

This text is part of a broader line of study that aims to analyze how and why certain eating habits and bodily practices have become social problems, as is the case with fatness. We will show that the ideas that support the definition of obesity as a chronic and avoidable disease are leading experts and health authorities, and other social workers, to know and to think about its evolution in terms of "global" illness (epidemic) and to consider cultural factors as their main cause (obesogenic environment). Paradoxically, the international and national preventive measures taken are focused on changing individual behavior and, in particular, eating habits. The concepts about the regulation of excess weight and food provide interesting information about a particular understanding of lifestyles and culture and they take into account the current promotion of health patterns.     

European Guidelines for Obesity Management in Adults

Obesity is a chronic metabolic disease characterised by an increase of body fat stores. It is a gateway to ill health, and it has become one of the leading causes of disability and death, affecting not only adults but also children and adolescents worldwide. In clinical practice, the body fatness is estimated by BMI, and the accumulation of intra-abdominal fat (marker for higher metabolic and cardiovascular disease risk) can be assessed by waist circumference. Complex interactions between biological, behavioural, social and environmental factors are involved in regulation of energy balance and fat stores. A comprehensive history, physical examination and laboratory assessment relevant to the patient''s obesity should be obtained. Appropriate goals of weight management emphasise realistic weight loss to achieve a reduction in health risks and should include promotion of weight loss, maintenance and prevention of weight regain. Management of co-morbidities and improving quality of life of obese patients are also included in treatment aims. Balanced hypocaloric diets result in clinically meaningful weight loss regardless of which macronutrients they emphasise. Aerobic training is the optimal mode of exercise for reducing fat mass while a programme including resistance training is needed for increasing lean mass in middle-aged and overweight/obese individuals. Cognitive behavioural therapy directly addresses behaviours that require change for successful weight loss and weight loss maintenance. Pharmacotherapy can help patients to maintain compliance and ameliorate obesity-related health risks. Surgery is the most effective treatment for morbid obesity in terms of long-term weight loss. A comprehensive obesity management can only be accomplished by a multidisciplinary obesity management team. We conclude that physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment. Treatment should be based on good clinical care, and evidence-based interventions; should focus on realistic goals and lifelong multidisciplinary management.Key Words: European guidelines, Obesity management, Multidisciplinary, Primary care, OMTF, COMs     

Definition and Diagnostic Criteria for Sarcopenic Obesity: ESPEN and EASO Consensus Statement

IntroductionLoss of skeletal muscle mass and function (sarcopenia) is common in individuals with obesity due to metabolic changes associated with a sedentary lifestyle, adipose tissue derangements, comorbidities (acute and chronic diseases) and during the ageing process. Co-existence of excess adiposity and low muscle mass/function is referred to as sarcopenic obesity (SO), a condition increasingly recognized for its clinical and functional features that negatively influence important patient-centred outcomes. Effective prevention and treatment strategies for SO are urgently needed, but efforts are hampered by the lack of a universally established SO definition and diagnostic criteria. Resulting inconsistencies in the literature also negatively affect the ability to define prevalence as well as clinical relevance of SO for negative health outcomes.Aims and MethodsThe European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) launched an initiative to reach expert consensus on a definition and diagnostic criteria for SO. The jointly appointed international expert panel proposes that SO is defined as the co-existence of excess adiposity and low muscle mass/function. The diagnosis of SO should be considered in at-risk individuals who screen positive for a co-occurring elevated body mass index or waist circumference, and markers of low skeletal muscle mass and function (risk factors, clinical symptoms, or validated questionnaires). Diagnostic procedures should initially include assessment of skeletal muscle function, followed by assessment of body composition where presence of excess adiposity and low skeletal muscle mass or related body compartments confirm the diagnosis of SO. Individuals with SO should be further stratified into stage I in the absence of clinical complications or stage II if cases are associated with complications linked to altered body composition or skeletal muscle dysfunction.ConclusionsESPEN and EASO, as well as the expert international panel, advocate that the proposed SO definition and diagnostic criteria be implemented into routine clinical practice. The panel also encourages prospective studies in addition to secondary analysis of existing data sets, to study the predictive value, treatment efficacy and clinical impact of this SO definition.     

Psychological Aspects of Childhood Obesity: A Controlled Study in a Clinical and Nonclinical Sample

Explored the relationship between obesity and psycholsocialadjustment in a combined clinical and nonclinical sample of139 obese children and 150 non–obsess children (ages from9 to 12 years and matched for age, socioeconomic status, andgender) who filled out the Perceived Competence Scale for Children;their parents completed the Child Behaviour Checklist. All obesechildren, independent of their help–seeking status, status,reported more negative physical self–perceptions thantheir nonobese peers and they scored lower on general self–worth.According to their parents, the obese children of the clinicalsample appeared to have more behaviour problems. Findings suggestthat psychopathology depends on a clinical obese status, andthey provide evidence for a psychosocial at–risk profilefor a subgroup of obese children.     

Obesity and aging: Molecular mechanisms and therapeutic approaches

The epidemic of obesity is a major challenge for health policymakers due to its far-reaching effects on population health and potentially overwhelming financial burden on healthcare systems. Obesity is associated with an increased risk of developing acute and chronic diseases, including hypertension, stroke, myocardial infarction, cardiovascular disease, diabetes, and cancer. Interestingly, the metabolic dysregulation associated with obesity is similar to that observed in normal aging, and substantial evidence suggests the potential of obesity to accelerate aging. Therefore, understanding the mechanism of fat tissue dysfunction in obesity could provide insights into the processes that contribute to the metabolic dysfunction associated with the aging process.Here, we review the molecular and cellular mechanisms underlying both obesity and aging, and how obesity and aging can predispose individuals to chronic health complications. The potential of lifestyle and pharmacological interventions to counter obesity and obesity-related pathologies, as well as aging, is also addressed.     

Macrophages and scavenger receptors in obesity-associated non-alcoholic liver fatty disease (NAFLD)

With an increase in sedentary lifestyle and dietary over nutrition, obesity has become one of the major public health problems worldwide and is a prevalent predisposing risk factor to non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease in Western developed countries. NAFLD represents a series of diseased states ranging from non-alcoholic fatty liver (NAFL) to steatohepatitis (NASH), which can lead to fibrosis and eventually to cirrhosis and hepatocellular carcinoma. Currently, the only effective treatment to cure end-stage liver disease is liver transplantation. Macrophages have been reported to play a crucial role in the progression of NAFLD, thereby are a potential target for therapy. In this review, we discuss the current knowledge on the role of macrophages and inflammatory signalling pathways associated with obesity and chronic liver inflammation, and their contribution to NAFLD development and progression.     

A school nursing approach to childhood obesity: an early chronic inflammatory disease

Background and aim: Childhood obesity is widespread in all industrialized European countries and it contributes significantly to population morbidity and mortality.

Moreover, obesity is a chronic disease with a multifactorial etiology including genetics, environment, metabolism, lifestyle and behavioral components. This article addresses the school nursing approach thought: education of children and their families, participation in policy-making process to improve nutrition and activities for children.

Conclusions: The future policies surrounding pediatric obesity must include continued focus on prevention and treatment. Forming broad partnerships that include the government, communities, professional organizations, industries, schools, preschools, day care, and family will improve the likelihood for successful implementation.     

Epidemiological Influences and Requirements of Global Childhood Obesity Research

IntroductionObesity is classified as a global epidemic and judged to be the greatest public health threat in Western countries. The tremendously increasing prevalence rates in children lead to morbidity and mortality in adults. In many countries, prevalence has doubled since the 1980s. Other countries show a continuous increase or stagnate at a very high level. Given these regional differences, this study aims to draw a global world map of childhood obesity research, including regional epidemiological characteristics, to comprehensively assess research influences and needs.MethodsIn addition to established bibliometric parameters, this study uses epidemiological data to interpret metadata on childhood obesity research from the Web of Science in combination with state-of-the-art visualization methods, such as density equalizing map projections.ResultsIt was not until the 1990s that belated recognition of the dangerous effects of childhood obesity led to an increase in the number of publications worldwide. In addition, our findings show that countries'' study output does not correlate with epidemiologic rates of childhood obesity. In contrast, the primary driver of the research efforts on childhood obesity appears to be largely driven government funding structures.Discussion/ConclusionThe geographical differences in the epidemiological background of childhood obesity complicate the implementation of transnational research projects and cross-border prevention programs. Effective realization requires a sound scientific basis, which is facilitated by globally valid approaches. Hence, there is a need for information exchange between researchers, policy makers, and private initiatives worldwide.     

The Impact of Familial Predisposition to Obesity and Cardiovascular Disease on Childhood Obesity

The prevalence of childhood obesity has reached alarming rates world-wide. The aetiology seems to be an interplay between genetic and environmental factors, and a surrogate measure of this complex interaction is suggested as familial predisposition. Familial predisposition to obesity and related cardiovascular disease (CVD) complications constitute the presence of obesity and/or obesity-related complications in primarily blood-related family members. The approaches of its measurement and applicability vary, and the evidence especially of its influence on obesity and obesity treatment in childhood is limited. Studies have linked a familial predisposition of obesity, CVD (hypertension, dyslipidaemia and thromboembolic events), and type 2 diabetes mellitus to BMI as well as other adiposity measures in children, suggesting degrees of familial aggregation of metabolic derangements. A pattern of predispositions arising from mothers, parents or grandparents as being most influential have been found, but further comprehensive studies are needed in order to specify the exact implications of familial predisposition. In the scope of childhood obesity this article reviews the current literature regarding familial predisposition to obesity and obesity-related complications, and how these familial predispositions may impact obesity in the offspring.Key Words: Pediatric obesity, Familial predisposition, Cardiovascular diseases, Diabetes mellitus type 2     

单纯性肥胖儿童行为问题配对研究

儿童单纯性肥胖症近年来呈上升的趋势[1] ,已成为医学界和家长们关心的问题。肥胖不仅对身体健康构成威胁 ,且严重引起儿童心理损害[2 ] 。本研究对武汉市城区 4所小学和幼儿园 345 0名儿童进行了有关单纯性肥胖儿童心理行为调查 ,旨在了解肥胖儿童心理行为影响因素 ,为进一步制定干预措施提供依据。1　对象与方法1.1　对象按照ＷＨＯ身高标准体重制定肥胖标准 :超重—体重超过标准值的 15 %～ 19% ;轻度肥胖—体重超过标准值的 2 0 %～ 2 9% ;中度肥胖—体重超过标准值的 30 %～ 4 9% ;重度肥胖—体重超过标准值的5 0 %以上。除外内分泌、…     

Child Overweight and Obesity in Shanghai,China: Contextualizing Chinese Socioeconomic and Gender Differences

Purpose

Childhood overweight and obesity is on the rise in China and in Chinese cities in particular. The aim of this study is to explore the extent of income differences in childhood overweight in Shanghai, China, and examine demographic, social, and behavioral explanations for these differences.

Methods

Using the 2014 Child Well-Being Study of Shanghai, China—a survey that included extensive contextual information on children and their families in China’s most populous city, prevalence rates and adjusted odds ratios of child overweight and obesity at age 7 were calculated by income tercile controlling for a wide variety of sociodemographic variables.

Results

District aggregate income increases the odds of child overweight/obesity, but only for boys. In contrast, rural hukou status was associated with lower odds of overweight/obesity for girls.

Conclusions

Boys at age 7 are more likely to be overweight and obese than girls. District income further increases this likelihood for boys, while rural hukou status decreases this likelihood for girls, suggesting that preferences for boys and thinness ideals for girls may play a role in the income patterning of childhood overweight and obesity.

     

Knowledge,attitude and practices of health personnel with regard to HIV/AIDS in Tamatave (Madagascar)

BACKGROUND: Health care workers are key players in the prevention and management of HIV-infection. We surveyed HIV/AIDS-related knowledge, attitudes and practices of health care workers in Tamatave (Madagascar), to assess the feasibility of voluntary counselling and testing for HIV infection in antenatal care. MATERIALS AND METHOD: A Knowledge Attitude and Practice study was conducted during July 2000 in the antenatal health care centres and the hospital of Tamatave. The health workers completed a self-administrated questionnaire on HIV transmission, attitudes and practices regarding AIDS testing and counselling, HIV risk perception and attitudes regarding patients with HIV disease. RESULTS: A 90% response rate was obtained, with completed questionnaires from 45 health care workers. The sample included physicians, midwives, nurses, medical students and nursing auxiliaries. Scientific knowledge about transmissibility of HIV infection was poor: transmission was believed possible by living together without having sex (7%), by breastfeeding a HIV-positive child (9%), by using toilets after a HIV-positive patient (13%) and by blood donation (76%). 73% of the health staff believed a child born of an HIV-positive woman would systematically be infected and interventions to reduce this risk were unknown. Sixty one per cent of the health-workers reported never having advised patients to be tested and less then 10% mentioned correct counselling precautions. Seventy nine percent believed that they were at risk of acquiring AIDS, mainly through occupational exposure. Negative attitudes towards HIV-positive patients were also noted: twenty per cent of the health workers mentioned that AIDS patients should be isolated in quarantine. Physicians and paramedical staff differed only in their better knowledge about transmissibility of HIV. Physicians had the same restrictive attitude towards patients with HIV as paramedical health workers and did not differ by their counselling practice. CONCLUSIONS: Our study revealed gaps in the knowledge of health care workers about HIV infection. Before implementing voluntary counselling and testing in antenatal care, additional HIV/AIDS training for health staff seems necessary.     

Vulnerability to intimate partner violence and poor mental health in the first 4-year postpartum among mothers reporting childhood abuse: an Australian pregnancy cohort study

The purpose of this study was to investigate intergenerational patterns of abuse and trauma and the health consequences for women in the early childbearing years. A prospective pregnancy cohort of 1507 nulliparous women (≦24 weeks gestation) were recruited in Melbourne, Australia, 2003–2005. Follow-up was scheduled in late pregnancy, 3-, 6- and 12-month and 4-year postpartum. Childhood abuse was retrospectively reported at 4-year postpartum using the Child Maltreatment History Self Report. Intimate partner violence (IPV) was assessed at 1- and 4-year postpartum with the Composite Abuse Scale. Maternal depressive symptoms were assessed in all follow-ups using the Edinburgh Postnatal Depression Scale. Multivariable logistic regression was used to examine associations between childhood abuse, maternal mental health and IPV. Childhood abuse was reported by 41.1 % of women. In the 4 years after having their first child, 28.2 % of women reported IPV, 25.2 % depression and 31.6 % anxiety. Childhood abuse was associated with odds of depression or anxiety 1.5–2.6 times greater and 1.8–3.2 times greater for IPV. Childhood physical abuse remained significantly associated with depression and anxiety in pregnancy and postpartum after adjusting for IPV and stressful life events, while sexual abuse remained significantly associated only with anxiety. Women who begin childbearing with a history of childhood abuse are more vulnerable to IPV and poor mental health. All health care services and agencies in contact with children, young people and families should have adequate training to identify trauma associated with abuse and IPV and provide first line supportive care and referral.     

Addressing obesity and diabetes among African American men: examination of a community-based model of prevention

The Save Our Sons study is a community-based, culturally responsive, and gender-specific intervention aimed at reducing obesity and diabetes among a small sample (n = 42) of African American men. The goals of the study were to: (1) test the feasibility of implementing a group health education and intervention model to reduce the incidence of diabetes and obesity among African American men; (2) improve regular access to and utilization of health care services and community supportive resources to promote healthy lifestyles among African American men; and (3) build community networks and capacity for advocacy and addressing some of the health needs of African American men residing in Lorain County, Ohio. Trained community health workers facilitated activities to achieve program aims. Following the 6-week intervention, results indicated that participant's had greater knowledge about strategies for prevention and management of obesity and diabetes; increased engagement in exercise and fitness activities; decreased blood pressure, weight, and body mass index levels; and visited a primary care doctor more frequently. Also, local residents elevated African American men's health and identified it as a priority in their community. This model of prevention appears to be a substantial, robust, and replicable approach for improving the health and wellbeing of African American men.