Prospective relevance of dietary patterns at the beginning and during the course of primary school to the development of body composition

Impact of Covid-19 lockdowns on the anthropometric development in primary school children in the Rhein-Neckar Region, Germany

BACKGROUND

Published data suggests that lockdowns during the COVID-19 pandemic may have negatively affected children's weight development. This study aims to assess the prevalence of overweight and obesity after the COVID-19 lockdowns as well as anthropometric development among primary school children in the Rhein-Neckar Region, Germany.

METHODS

In this cross-sectional study, schools were selected in cooperation with the local health authority to include different socioeconomic backgrounds. Participation was voluntary at school and individual level, requiring written informed consent from legal guardians. Study visits in schools were conducted between October 2021 and July 2022. Anthropometric data from nationally recommended medical examinations at 4 years (U8) and 5 years (U9), data on nutrition, physical activity, and socioeconomic data was collected using questionnaires. zBMI and weight category were calculated based on German reference data.

RESULTS

256 children with a mean age of 8.0 years (7.1-9.3 years) were included in the study. Most participants were from households with an above average income. 5.1% of the children were overweight, 4.7% were obese, 15.6% were underweight, and 74.6% were normal weight with a mean zBMI of -0.25 (SD 1.10), which is significantly lower than the mean zBMI of the German reference population (p < 0.001). No significant changes in zBMI were observed between U8 and U9 (p = 0.16). The mean zBMI decreased by 0.17 (SD 0.72) between U9 and the study visit (p = 0.02). A zBMI decrease of 0.5 was documented for the subgroup of overweight and obese children (p = 0.028) as well as a decrease of 0.23 (SD 0.63) for the normal-weight children subgroup (p < 0.001).

CONCLUSIONS

Contrary to previous reports mean zBMI decreased significantly in the children studied. No significant changes in zBMI were observed between U8 and U9 examinations, which supports the hypothesis that the decrease in zBMI could be attributed to lockdown measures. The study was registered at clinicaltrials.gov on September 21st 2021 under the registration number NCT05077059.

Plasma boron concentrations in the general population: a cross-sectional analysis of cardio-metabolic and dietary correlates

Purpose

Experimental evidence suggests positive effects of boron on health and metabolism, but human data are still scarce. We aimed to identify dietary and cardio-metabolic correlates of plasma boron concentrations in the general population.

Methods

In a community-based sample (n = 899, 57% men, mean age 61 years), plasma boron (median [IQR]: 33.80 µg/L [25.61; 44.65]) concentrations were measured by inductively coupled plasma-mass spectrometry. Overall (PDI), healthy (hPDI), and unhealthy (uPDI) plant-based diet indices were derived from a validated food frequency questionnaire. Reduced rank regression (RRR) yielded a dietary pattern explaining 30% of the variation of circulating boron. Cross-sectional associations of dietary indices and cardio-metabolic traits with plasma boron concentrations were assessed using multivariable-adjusted linear regression analysis.

Results

The RRR pattern was characterized by high intake of fruits, nuts/seeds, tea, wine and low intake of e.g. bread, poultry, processed meat, chocolate/sweets, and soft drinks. 10-point increments in PDI, hPDI, and uPDI were associated with 8.7% (95% CI: 4.2; 13.4), 10.4% (95% CI: 6.6; 14.3), and −8.8% (95% CI: −12.1; −5.4) change in plasma boron concentrations, respectively. Age and phosphate were directly, while BMI, plasma lipid concentrations, and CRP were inversely associated with circulating boron. Plasma boron concentrations were higher in summer vs. winter, in individuals taking vs. not taking antihypertensive medication, and in individuals with high or medium vs. low education level.

Conclusion

Higher plasma boron concentrations appeared to associate with a healthier diet, were related to lower BMI and a more favorable cardio-metabolic risk profile, and showed seasonal variations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00394-021-02730-w.

Advances in dietary pattern analysis in nutritional epidemiology

Background and Purpose

It used to be a common practice in the field of nutritional epidemiology to analyze separate nutrients, foods, or food groups. However, in reality, nutrients and foods are consumed in combination. The introduction of dietary patterns (DP) and their analysis has revolutionized this field, making it possible to take into account the synergistic effects of foods and to account for the complex interaction among nutrients and foods. Three approaches of DP analysis exist: (1) the hypothesis-based approach (based on prior knowledge regarding the current understanding of dietary components and their health relation), (2) the exploratory approach (solely relying on dietary intake data), and (3) the hybrid approach (a combination of both approaches). During the recent past, complementary approaches for DP analysis have emerged both conceptually and methodologically.

Method

We have summarized the recent developments that include incorporating the Treelet transformation method as a complementary exploratory approach in a narrative review.

Results

Uses, peculiarities, strengths, limitations, and scope of recent developments in DP analysis are outlined. Next, the narrative review gives an overview of the literature that takes into account potential relevant dietary-related factors, specifically the metabolome and the gut microbiome in DP analysis. Then the review deals with the aspect of data processing that is needed prior to DP analysis, particularly when dietary data arise from assessment methods other than the long-established food frequency questionnaire. Lastly, potential opportunities for upcoming DP analysis are summarized in the outlook.

Conclusion

Biological factors like the metabolome and the microbiome are crucial to understand diet-disease relationships. Therefore, the inclusion of these factors in DP analysis might provide deeper insights.

Nutrition beyond the first 1000 days: diet quality and 7-year change in BMI and overweight in 3-year old children from the Dutch GECKO Drenthe birth cohort

The identification of early-life determinants of overweight is crucial to start early prevention. As weight gain accelerates between 2 and 6 years, we studied the association between diet quality in children aged 3 years and the change in BMI and overweight incidence in the following 7 years. From the Dutch GECKO Drenthe birth cohort, 1001 children born in 2006 or 2007 with complete data on diet (food frequency questionnaire at the age of 3 years) and growth at the age of 3 and 10 years were included. Diet quality was estimated with the evidence-based Lifelines Diet Score (LLDS). Measured height and weight at the age of 3 and 10 years were used to calculate BMI z-scores standardized for age and sex. The associations of the LLDS (in quintiles) with BMI-z change and overweight incidence were studied with linear and logistic regression analyses. Overweight prevalence in the total study population increased from 8.3% at the age of 3 years to 16.7% at the age of 10 years. The increase in overweight prevalence ranged from 14.7% in Q1 to 3.5% in Q5. Children with a better diet quality (higher quintiles of LLDS) increased significantly less in BMI-z (confounder adjusted βLLDS = -0.064 (-0.101; -0.026)). Children with a poor diet quality at the age of 3 years had a considerably higher risk for overweight at the age of 10 years (confounder adjusted OR for Q1 vs. Q5 was 2.86 (95% CI 1.34-6.13). These results show the importance of diet in healthy development in the early life following the first 1000 days when new habits for a mature diet composed of food groups with lifelong importance are developed, providing a relevant window for overweight prevention early in life.

Obesity à la carte? Children’s meal options in German full-service restaurants

Objective:

In light of the increasing prevalence of juvenile obesity seen around the world, obesogenic environments in general and the food environment in particular are receiving increasing attention in current public health research. Restaurants play a significant role in the food environment. The present study aimed to quantitatively describe and qualitatively evaluate the range of children’s meals available in full-service restaurants in Germany.

Design:

Five hundred restaurants were identified using a systematic quota sampling technique. The individual meals were evaluated using quality standards stipulated by the German Nutrition Society (DGE).

Setting:

Nationwide sample of menus from full-service restaurants.

Participants:

Meals (n 1877) from 500 menus were analysed.

Results:

Menus included 3·76 (sd 1·31) meals for children. About 70 % of the meals were limited to six typical dishes of low nutritional quality. In total, 54 % of meals included French fries or another form of fried potatoes. Of all meals, 23 % did not fulfil any of the eleven quality criteria set by the DGE and 38 % satisfied only one criterion. The majority of dishes on offer featured high energy density while simultaneously having low nutrient density. Healthy dishes were not highlighted visually in any menu.

Conclusions:

The range of dishes on offer for children in German restaurants is severely lacking in variety and in need of improvement from a nutritional point of view. Considering the growing importance of restaurants as food environments, there is a need to improve the presentation of menus and the meals offered.

Dietary Patterns in Primary School are of Prospective Relevance for the Development of Body Composition in Two German Pediatric Populations

This study performed comparative analyses in two pediatric cohorts to identify dietary patterns during primary school years and examined their relevance to body composition development. Nutritional and anthropometric data at the beginning of primary school and two or four years later were available from 298 and 372 participants of IDEFICS-Germany (Identification and prevention of Dietary-induced and lifestyle-induced health Effects In Children and infants Study) and the KOPS (Kiel Obesity Prevention Study) cohort, respectively. Principal component analyses (PCA) and reduced rank regression (RRR) were used to identify dietary patterns at baseline and patterns of change in food group intake during primary school years. RRR extracted patterns explaining variations in changes in body mass index (BMI), fat mass index (FMI), and waist-to-height-ratio (WtHR). Associations between pattern adherence and excess gain in BMI, FMI, or WtHR (>75th percentile) during primary school years were examined using logistic regression. Among PCA patterns, only a change towards a more Mediterranean food choice during primary school years were associated with a favorable body composition development in IDEFICS-Germany (p < 0.05). In KOPS, RRR patterns characterized by a frequent consumption of fast foods or starchy carbohydrate foods were consistently associated with an excess gain in BMI and WtHR (all p < 0.005). In IDEFICS-Germany, excess gain in BMI, FMI, and WtHR were predicted by a frequent consumption of nuts, meat, and pizza at baseline and a decrease in the consumption frequency of protein sources and snack carbohydrates during primary school years (all p < 0.01). The study confirms an adverse impact of fast food consumption on body composition during primary school years. Combinations of protein and carbohydrate sources deserve further investigation.

Snack cost and percentage of body fat in Chinese children and adolescents: a longitudinal study

PURPOSE

Only a few studies examined the relationship between snack cost and change in the percentage of body fat in children. We thus conducted a longitudinal study to investigate whether high snack cost is associated with fast increase in the percentage of body fat in Chinese children.

METHODS

The study included 2368 children (1126 girls and 1242 boys, aged 6-14 years). Percentage of body fat was repeatedly assessed by bioelectrical impedance analysis in 2014 (baseline), 2015 and 2016. Snack cost in 2014 was estimated by self-report associated with purchasing snacks at school and classified into low, moderate, and high group. Association between snack cost and repeated percentage of body fat was analyzed with linear mixed models, adjusting for demographic factors, diet, physical activity, and parental BMI and education.

RESULTS

High snack cost was significantly associated with a fast increase in the percentage of body fat over time (p trend = 0.04). Adjusted difference in annual increase rate in percentage of body fat between the high and low snack cost group was 0.31% [95% confident interval (CI) 0.04%, 0.58%], after adjusting for potential confounders. The impacts of snack cost on change in the percentage of body fat were more pronounced in boys, younger participants and those with higher BMI z-score at the baseline, relative to their counterparts (p interaction < 0.001 for all).

CONCLUSIONS

High snack cost was associated with more gain of body fat in Chinese school-aged children.

Sex consideration in diet-biomarker-related indices: a systematic review

OBJECTIVE

An index of biomarkers derived from dietary factors (diet-biomarker-related index) identifies foods and nutrients that encompass physiological potentials and provides scientific evidence for dietary patterns that increase the risk of disease associated with specific biomarkers. Although men and women have different dietary patterns and physiological characteristics, sex is not often considered when investigators develop a diet-biomarker-related index. We aimed to review whether epidemiological studies developed diet-biomarker-related indices in a sex-specific way.

DESIGN

We systematically searched for epidemiological studies that developed diet-biomarker-related indices, including (i) biomarker prediction indices that include dietary factors as explanatory variables and (ii) dietary patterns to explain biomarker variations, in the PubMed and EMBASE databases. We qualitatively reviewed the sex consideration in index development.

RESULTS

We identified seventy-nine studies that developed a diet-biomarker-related index. We found that fifty-four studies included both men and women. Of these fifty-four studies, twenty-nine (53·7 %) did not consider sex, eleven (20·3 %) included sex in the development model, seven (13·0 %) considered sex but did not include sex in the development model, and seven (13·0 %) derived a diet-biomarker-related index for men and women separately. A list of selected dietary factors that explained levels of biomarkers generally differed by sex in the studies that developed a diet-biomarker-related index in a sex-specific way.

CONCLUSIONS

Most studies that included both men and women did not develop the diet-biomarker-related index in a sex-specific way. Further research is needed to identify whether a sex-specific diet-biomarker-related index is more predictive of the disease of interest than an index without sex consideration.

Consumption of ultra-processed foods and body fat during childhood and adolescence: a systematic review

Objective

To review the available literature on the association between consumption of ultra-processed foods and body fat during childhood and adolescence.

Design

A systematic review was conducted in the PubMed, Web of Science and LILACS databases. Studies that evaluated the association between consumption of ultra-processed food (exposure) and body fat (outcome) during childhood and adolescence were eligible.

Subjects

Healthy children and adolescents.

Results

Twenty-six studies that evaluated groups of ultra-processed foods (such as snacks, fast foods, junk foods and convenience foods) or specific ultra-processed foods (soft drinks/sweetened beverages, sweets, chocolate and ready-to-eat cereals) were selected. Most of the studies (n15) had a cohort design. Consumption was generally evaluated by means of FFQ or food records; and body composition, by means of double indirect methods (bioelectrical impedance analysis and skinfolds). Most of the studies that evaluated consumption of groups of ultra-processed foods and soft drinks/sweetened beverages found positive associations with body fat.

Conclusions

Our review showed that most studies have found positive associations between consumption of ultra-processed food and body fat during childhood and adolescence. There is a need to use a standardized classification that considers the level of food processing to promote comparability between studies.

Processed and ultra-processed foods are associated with lower-quality nutrient profiles in children from Colombia

Objective

To determine if processed and ultra-processed foods consumed by children in Colombia are associated with lower-quality nutrition profiles than less processed foods.

Design

We obtained information on sociodemographic and anthropometric variables and dietary information through dietary records and 24 h recalls from a convenience sample of the Bogotá School Children Cohort. Foods were classified into three categories: (i) unprocessed and minimally processed foods, (ii) processed culinary ingredients and (iii) processed and ultra-processed foods. We also examined the combination of unprocessed foods and processed culinary ingredients.

Setting

Representative sample of children from low- to middle-income families in Bogotá, Colombia.

Subjects

Children aged 5–12 years in 2011 Bogotá School Children Cohort.

Results

We found that processed and ultra-processed foods are of lower dietary quality in general. Nutrients that were lower in processed and ultra-processed foods following adjustment for total energy intake included: n-3 PUFA, vitamins A, B12, C and E, Ca and Zn. Nutrients that were higher in energy-adjusted processed and ultra-processed foods compared with unprocessed foods included: Na, sugar and trans-fatty acids, although we also found that some healthy nutrients, including folate and Fe, were higher in processed and ultra-processed foods compared with unprocessed and minimally processed foods.

Conclusions

Processed and ultra-processed foods generally have unhealthy nutrition profiles. Our findings suggest the categorization of foods based on processing characteristics is promising for understanding the influence of food processing on children’s dietary quality. More studies accounting for the type and degree of food processing are needed.

Stability and change in dietary scores and patterns across six waves of the Longitudinal Study of Australian Children

This study aimed to derive and compare longitudinal trajectories of dietary scores and patterns from 2–3 to 10–11 years and from 4–5 to 14–15 years of age. In waves two to six of the Baby (B) Cohort and one to six of the Kindergarten (K) Cohort of the population-based Longitudinal Study of Australian Children, parents or children reported biennially on the study child’s consumption of twelve to sixteen healthy and less healthy food or drink items for the previous 24 h. For each wave, we derived a dietary score from 0 to 14, based on the 2013 Australian Dietary Guidelines (higher scores indicating healthier diet). We then used factor analyses to empirically derive dietary patterns for separate waves. Using group-based trajectory modelling, we generated trajectories of dietary scores and empirical patterns in 4504 B and 4640 K Cohort children. Four similar trajectories of dietary scores emerged for the B and K Cohorts, containing comparable proportions of children in each cohort: ‘never healthy’ (8·8 and 11·9 %, respectively), ‘moderately healthy’ (24·0 and 20·7 %), ‘becoming less healthy’ (16·6 and 27·3 %) and ‘always healthy’ (50·7 and 40·2 %). Deriving trajectories based on dietary patterns, rather than dietary scores, produced similar findings. For ‘becoming less healthy’ trajectories, dietary quality appeared to worsen from 7 years of age in both cohorts. In conclusion, a brief dietary measure administered repeatedly across childhood generated robust, nuanced dietary trajectories that were replicable across two cohorts and two methodologies. These trajectories appear ideal for future research into dietary determinants and health outcomes.

Dietary patterns of early childhood and maternal socioeconomic status in a unique prospective sample from a randomized controlled trial of Prenatal DHA Supplementation

BACKGROUND

Dietary habits established in early childhood and maternal socioeconomic status (SES) are important, complex, interrelated factors that influence a child's growth and development. The aim of this study was to define the major dietary patterns in a cohort of young US children, construct a maternal SES index, and evaluate their associations.

METHODS

The diets of 190 children from a randomized, controlled trial of prenatal supplementation of docosahexaenoic acid (DHA) were recorded at 6-mo intervals from 2-4.5 years by 24-h dietary recall. Hierarchical cluster analysis of age-adjusted, average daily intake of 24 food and beverage groups was used to categorize diet. Unrotated factor analysis generated an SES score from maternal race, ethnicity, age, education, and neighborhood income.

RESULTS

We identified two major dietary patterns: "Prudent" and "Western." The 85 (45%) children with a Prudent diet consumed more whole grains, fruit, yogurt and low-fat milk, green and non-starchy vegetables, and nuts and seeds. Conversely, those with a Western diet had greater intake of red meat, discretionary fat and condiments, sweet beverages, refined grains, French fries and potato chips, eggs, starchy vegetables, processed meats, chicken and seafood, and whole-fat milk. Compared to a Western diet, a Prudent diet was associated with one standard deviation higher maternal SES (95% CI: 0.80 to 1.30).

CONCLUSIONS

We found two major dietary patterns of young US children and defined a single, continuous axis of maternal SES that differed strongly between groups. This is an important first step to investigate how child diet, SES, and prenatal DHA supplementation interact to influence health outcomes.

TRIAL REGISTRATION

NCT00266825 . Prospectively registered on December 15, 2005.

Associations between explorative dietary patterns and serum lipid levels and their interactions with ApoA5 and ApoE haplotype in patients with recently diagnosed type 2 diabetes

Aims

In patients with type 2 diabetes (T2D), responsiveness of serum lipid concentrations to dietary patterns may vary by genotype. The aims of the present study were to identify explorative dietary patterns and to examine their independent associations with serum lipid levels and interactions with apolipoprotein (Apo)A5 and ApoE variants among patients recently diagnosed with T2D.

Methods

Within a cross-sectional analysis, participants of the German Diabetes Study (n = 348) with mean T2D duration of 6 months were investigated for fasting serum lipid levels, ApoA5 and ApoE genotypes; food consumption frequencies were assessed by a food propensity questionnaire. Dietary patterns were derived using principal component analysis (PCA) and reduced rank regression (RRR), which extracts patterns explaining variation in serum lipid concentrations.

Results

PCA yielded interpretable dietary patterns which were, however, not related to serum lipid levels. Relevance of the RRR patterns varied by genotype: a preferred consumption of fruit gum, fruit juice, and potato dumpling, whilst avoiding fruits and vegetables independently associated with higher triglyceride levels among ApoA5*2. Patients in the highest compared to the lowest tertile of pattern adherence had 99 % higher triglycerides. Lower consumption frequencies of butter, cream cake, French fries, or high-percentage alcoholic beverages were independently related to lower LDL-cholesterol among ApoE2 carriers, with those in the highest compared to the lowest tertile of pattern adherence having 40 % lower LDL-cholesterol (both P_interaction < 0.05).

Conclusions

Our explorative data analyses suggest that associations of dietary patterns with triglycerides and LDL-cholesterol differ by ApoA5 and ApoE haplotype in recently diagnosed T2D.

Trial registration Clinicaltrials.gov: NCT01055093. Date of registration: January 22, 2010 (retrospectively registered). Date of enrolment of first participant to the trial: September 2005

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0455-9) contains supplementary material, which is available to authorized users.

Nutritional composition of school meals serving children from 7 to 36 months of age in municipal day-care centres in the metropolitan area of Curitiba, Paraná, Brazil

The Brazilian National School Feeding Program (PNAE) seeks to meet student's nutritional needs during the period they remain in school. This study aimed to determine the nutritional composition of meals provided in municipal day-care centres serving children of 7-11 months (group A) and 12-36 months (group B) of age and to compare observed values with the PNAE's and dietary reference intakes' (DRI) recommendations. This cross-sectional study was conducted in 4 day-care centres in the metropolitan area of Curitiba, Paraná, Brazil, between June and November 2013. Food samples of six daily meals were collected during 20 non-consecutive days, totalling 120 samples. For each meal, average served and consumed portions were submitted for laboratory analysis of moisture, ash, proteins, lipids, carbohydrates, dietary fibre, Na, Ca and Fe and compared with the PNAE's and DRI's values. No statistically significant difference was found between age groups (P=0·793) regarding portion sizes and nutritional composition. The same menu was offered to both groups in 95 % of the meals (n 114), although the groups' nutritional needs were different. For group A, served meals met PNAE's recommendations for energy, carbohydrates, proteins, Na and Ca content, and consumed portions provided 70 % of the nutritional needs for carbohydrates, proteins and Ca. For group B, served portions complied with the PNAE's values for proteins, Na and Ca. Proteins and Na reached 70 % of the nutritional needs when consumed food was evaluated. School feeding in day-care centres partially meet PNAE's guidelines and children's nutritional requirements, contradicting the primary objective established by the national programme.

Clustering of Dietary Patterns, Lifestyles, and Overweight among Spanish Children and Adolescents in the ANIBES Study

Weight gain has been associated with behaviors related to diet, sedentary lifestyle, and physical activity. We investigated dietary patterns and possible meaningful clustering of physical activity, sedentary behavior, and sleep time in Spanish children and adolescents and whether the identified clusters could be associated with overweight. Analysis was based on a subsample (n = 415) of the cross-sectional ANIBES study in Spain. We performed exploratory factor analysis and subsequent cluster analysis of dietary patterns, physical activity, sedentary behaviors, and sleep time. Logistic regression analysis was used to explore the association between the cluster solutions and overweight. Factor analysis identified four dietary patterns, one reflecting a profile closer to the traditional Mediterranean diet. Dietary patterns, physical activity behaviors, sedentary behaviors and sleep time on weekdays in Spanish children and adolescents clustered into two different groups. A low physical activity-poorer diet lifestyle pattern, which included a higher proportion of girls, and a high physical activity, low sedentary behavior, longer sleep duration, healthier diet lifestyle pattern. Although increased risk of being overweight was not significant, the Prevalence Ratios (PRs) for the low physical activity-poorer diet lifestyle pattern were >1 in children and in adolescents. The healthier lifestyle pattern included lower proportions of children and adolescents from low socioeconomic status backgrounds.

Early Diet and Later Cancer Risk: Prospective Associations of Dietary Patterns During Critical Periods of Childhood with the GH-IGF Axis, Insulin Resistance and Body Fatness in Younger Adulthood

Early life, adiposity rebound, and puberty represent critical growth periods when food choices could have long-term relevance for cancer risk. We aimed to relate dietary patterns during these periods to the growth hormone-insulin-like-growth-factor (GH-IGF) axis, insulin resistance, and body fatness in adulthood. Data from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study participants with outcome data at 18-37 years, and ≥2 dietary records during early life (1-2 yr; n = 128), adiposity rebound (4-6 years, n = 179), or puberty (girls 9-14, boys 10-15 yr; n = 213) were used. Dietary patterns at these ages were derived by 1) reduced rank regression (RRR) to explain variation in adult IGF-I, IGF-binding protein-3 (IGFBP-3), homoeostasis model assessment for insulin resistance (HOMA-IR) and fat-mass index; 2) principal component analysis (PCA). Regarding RRR, the patterns "cake/canned fruit/cheese & eggs" (early life), "sweets & dairy" (adiposity rebound) and "high-fat foods" (pubertal boys) were independently associated with higher adult HOMA-IR. Furthermore, the patterns "favorable carbohydrate sources" (early life), "snack & convenience foods" (adiposity rebound), and "traditional & convenience carbohydrates" (pubertal boys) were related to adult IGFBP-3 (P trend < 0.01). PCA identified "healthy" patterns for all periods, but none was associated with the outcomes (P trend > 0.1). In conclusion, dietary patterns during sensitive growth periods may be of long-term relevance for adult insulin resistance and IGFBP-3.