Food consumed outside the home in Brazil according to places of purchase

Deserts, Swamps and Food Oases: Mapping around the Schools in Bahia, Brazil and Implications for Ensuring Food and Nutritional Security

Deserts, swamps and food oases terms have been used to characterize the food environment according to the identified food availability. Food swamps are defined as neighborhoods with a predominance of food establishments selling ultra-processed foods compared to establishments selling healthy options. In contrast, food oases are areas with easy access to healthy and nutritious foods, such as fruits, vegetables, and other fresh foods. Food deserts describe densely populated urban areas where residents face difficulty obtaining healthy food. In this context, this work aimed to map deserts, swamps, and food oases around federal schools in Bahia, Brazil, emphasizing the importance of implementing the Brazilian National School Feeding Program (PNAE) in these schools, to guarantee food security and nutrition. An ecological study was carried out in all 35 federal schools in Bahia, Brazil, using an 800 m buffer analysis, with the school as the centroid. The geographic coordinates of schools and food establishments were initially obtained using Google Maps and later confirmed onsite. To evaluate food deserts and swamps, the methodology proposed by the CDC was used and the Modified Retail Food Environment Index (mRFEI) was calculated; when the result was equal to zero, the surrounding area was considered a food desert and values between 0.01 and 20 determined food swamps; for values above 20, the neighborhood was classified as mixed. Food oases were considered regions containing at least one supermarket within the analyzed buffer. Descriptive analyses were carried out with frequency measurements, measures of central tendency (mean and median) and dispersion (standard deviation). The food environment of schools was compared considering the number of students impacted, the area where the school was located (urban or rural) and the size of the municipalities. The average number of food establishments found was 22.39 (±13.03), with the highest averages for snack bars (7.33 ± 4.43), grocery stores (5.83 ± 4.09) and restaurants (2.94 ± 2.19). Food deserts and mixed environments were identified in 40% of the sample, while swamps represented 20% and oases 65%. An association was observed between food deserts and social vulnerability, making it necessary to emphasize the importance of adequate implementation of the PNAE in these schools to reduce food and nutritional insecurity, guaranteeing the human right to adequate and healthy food and providing better nutrition and health perspectives within the school environment and impact on students' lives through food and nutrition education actions, which are also part of the context of PNAE activities.

Evolution of beverage portion sizes consumed in Brazil between 2008 and 2018

Objective

To describe the evolution of beverage portion sizes consumed in Brazil between 2008 and 2018.

Methods

Data from the dietary surveys of 2008-2009 and 2017-2018 Brazilian Household Budget Surveys, conducted with 34,003 and 46,164 individuals, respectively, were used to analyze the portion size of beverages. Food consumption data were used to group beverages according to nutritional characteristics, type and size of portions into eight groups: high-calorie soft drinks, fruit refreshments, alcoholic beverages, coffee/tea, fruit juices, milk and milk substitutes and ultra-processed milk-based beverages. The two-day food record and recall were considered to analyze the consumed portions. Comparisons between the surveys were done using Chi-Square tests and linear regression models.

Results

Between 2008 and 2018, the average portion consumed showed a significant increase for the group of alcoholic beverages (+29%), flavored juices (+11%), caloric soft drinks (+8%), milk and milk substitutes (+6%) and fruit juices (+5%); and reduction for the coffee/tea group (-11%). Analyzes by age group showed that among individuals between 20 and 40 years of age, the soft drinks and alcoholic beverage groups showed the greatest increase in portion size, +12 and +44%, respectively.

Conclusion

The beverage portion sizes consumed in Brazil between 2008 and 2018 increased for the group of alcoholic beverages, flavored juices, caloric soft drinks, milk and milk substitutes, and fruit juices.

Carbon Footprint of Away-From-Home Food Consumption in Brazilian Diet

Environmentally unsustainable diets are often characterized by being high in calories, processed foods, and red meats, characteristics related to away-from-home food (AFHF). The aim of this study is to evaluate if AFHF consumption is related to environmental sustainability. Data of 20,780 adults from 24 h recalls collected in the 2017-2018 Brazilian National Dietary Survey (NDS) were used to estimate carbon footprint coefficients. The mean carbon footprint was estimated among individuals who consumed AFHF and non-consumers. Linear regression models were used to evaluate differences between away-from-home eating and the carbon footprint of the diet, adjusting for age and income. A total of 41% of Brazilians consumed AFHF during the previous day. The mean carbon footprint from foods consumed away from home represented 18% of the total carbon footprint. AFHF was positively associated with increased total carbon footprint (β: 204.1; p-value: 0.0145). In conclusion, the consumption of foods away from home in urban areas of Brazil was associated with atmospheric greenhouse gas emissions independently of age and income. Away-from-home food consumption should be considered to reinforce the influence of diet on individual and planet health.

Dietary Environmental Footprints and Their Association with Socioeconomic Factors and Food Purchase Practices: BRAZUCA Natal Study

The analysis of dietary environmental impacts has proven to be an important tool for guiding the adoption of healthier and more sustainable diets. This study aimed to estimate the dietary carbon (CF), water (WF), and ecological (EF) footprints of residents in the city of Natal, Brazil; the study also aimed to verify their association with socioeconomic factors and food purchase practices. This is a cross-sectional study that used dietary data from 411 adults and elderlies, which was collected via a questionnaire that applied to the respondents. The results showed that the dietary CF was 1901.88 g CO₂ eq/day/1000 kcal, the WF was 1834.03 L/day/1000 kcal, and the EF was 14.29 m²/day/1000 kcal. The highest environmental footprint values showed an association (p ≤ 0.05) with the factors of male sex, white ethnicity, and higher income and schooling, whereas the lowest environmental footprint values were associated with social vulnerability variables such as female sex, non-white ethnicity, and lower income and schooling (p ≤ 0.05). Moreover, people with lower environmental footprints consumed less fast food, had fewer meals at snack bars, and used food delivery services less often than those with higher footprints. The foods that most contributed to the CFs and WFs were beef and chicken, while fish and beef contribute the most to the EFs. The data in the present study show that a diet with a lower environmental impact is not always equal to a sustainable diet. This relationship is paradoxical and relates to food justice, as people with lower environmental footprint values are the same ones with worse socioeconomic conditions. In this sense, is it essential to consider the influence of the social context when assessing dietary environmental impacts and when assessing actions that promote healthier and more sustainable diets.

Retail food environment in a Brazilian metropolis over the course of a decade: evidence of restricted availability of healthy foods

OBJECTIVE

To evaluate changes in the retail food environment profile in a Brazilian metropolis over a 10-year period.

DESIGN

An ecological study was conducted in the city of Belo Horizonte, Minas Gerais, Brazil. The addresses of formal food establishments were geocoded and classified according to their sold-food profile. Density changes were analysed according to neighbourhood, population size, income level and geospatial distribution.

SETTING

Totally, 468 neighbourhoods in the city of Belo Horizonte, Minas Gerais, Brazil.

PARTICIPANTS

Totally, 83 752 formal food establishments registered for operation in any one or more of those years: 2008, 2011, 2015 and 2018.

RESULTS

There was an increase in unhealthy establishments (154 %), followed by mixed (51 %) and healthy establishments (32 %), during the period evaluated, in addition to an increase in density according to income categories. There was a higher proportion of unhealthy establishments in relation to healthy establishments, indicating worsening of the community food environment over time.

CONCLUSIONS

Over the course of 10 years, changes in the neighbourhood's food environment were unfavourable for adequate access to healthy foods in lower-income neighbourhoods. The findings reinforce the need for interventions aimed at increasing the availability of businesses that offer healthy food in the city.

Food swamps in Campinas, Brazil

The characteristics of the food environment can interfere with physical access to healthy foods and accentuate health inequalities. The presence of food swamps, i.e., the greater availability of ultra-processed food and commercial establishments compared to those that sell healthier options, are associated with the consumption of unhealthy foods. This study identified the spatial distribution of these establishments in Campinas, São Paulo. Fast-food restaurants, open-air organic/agroecological food markets and supermarkets were geocoded. Regional administrations (RAs) with greater social vulnerability according to the 2010 Census and with a greater availability of fast-food restaurants in relation to open-air food markets and supermarkets were considered food swamps. The less vulnerable neighborhoods had a higher concentration of all types of commercial food establishments compared to the most vulnerable regions. In Campinas, of eighteen RAs, five were considered food swamps. The findings reinforce the need for actions to improve exposure to healthy foods in more vulnerable neighborhoods.

Avaliação dos produtos alimentícios adquiridos por adultos com obesidade e o grau de processamento dos alimentos

Introdução: O aumento da obesidade está relacionado a mudanças no padrão de aquisição e de consumo de produtos alimentícios ultraprocessados em detrimento de alimentos in natura e minimamente processados. O objetivo do presente estudo foi investigar a prevalência de obesidade em um território adstrito à Unidade Básica de Saúde, em município de pequeno porte, e avaliar os produtos alimentícios adquiridos pelos indivíduos com obesidade de acordo com o grau de processamento. Métodos: Estudo analítico transversal dividido em duas etapas. Na primeira, foi investigado o índice de massa corporal (IMC) de 533 indivíduos da cidade de pequeno porte. Selecionou-se 60 indivíduos para a segunda etapa, em que foram investigados determinantes do perfil nutricional, tais como aquisição de alimentos e gasto com alimentação. Resultados: Na primeira etapa, foi encontrada a prevalência de 30,39% de obesidade. Na segunda, não houve diferença significativa na aquisição de alimentos por grau de processamento. No entanto, chama atenção a quantidade adquirida de processados e ultraprocessados. Mais de 18% dos entrevistados relataram omitir o café da manhã e quase 22% disseram almoçar no trabalho. Não houve diferenças nos gastos totais, por local de compra e na proporção de gastos com alimentação em relação à renda familiar e às categorias de obesidade. Conclusões: A prevalência de obesidade no distrito estudado é alta, tendo em vista sua população. Sugerimos que essa prevalência possa ser influenciada pela aquisição de ultraprocessados, pela alimentação fora do lar e pela omissão do café da manhã.

How to Measure Organic Fruit Consumer Behavior: A Systematic Review

This review article seeks to systematically identify appropriate ways to measure the consumption behavior of organic fruits. The systematic review of the literature was performed according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the eligibility criteria were declared through the PICOS (population, interventions, comparators, outcomes, and study) tool based on 277 article records scientiometrically identified in both the Journal Citation Report databases from Web of Science. The literature review stages determined a reduced set of articles that presented valid and reliable measurement scales that covered determinant constructs in organic fruit consumer behavior (OFCB). The measurement scale with the best results reported within the screened articles covered the constructs related to health, fear, environment, effort, and economy, allowing it to serve as a reference instrument in further studies on food consumer behavior.

Food swamps in Campinas, Brazil

Abstract The characteristics of the food environment can interfere with physical access to healthy foods and accentuate health inequalities. The presence of food swamps, i.e., the greater availability of ultra-processed food and commercial establishments compared to those that sell healthier options, are associated with the consumption of unhealthy foods. This study identified the spatial distribution of these establishments in Campinas, São Paulo. Fast-food restaurants, open-air organic/agroecological food markets and supermarkets were geocoded. Regional administrations (RAs) with greater social vulnerability according to the 2010 Census and with a greater availability of fast-food restaurants in relation to open-air food markets and supermarkets were considered food swamps. The less vulnerable neighborhoods had a higher concentration of all types of commercial food establishments compared to the most vulnerable regions. In Campinas, of eighteen RAs, five were considered food swamps. The findings reinforce the need for actions to improve exposure to healthy foods in more vulnerable neighborhoods.

Evolution of out-of-home food consumption in Brazil in 2008-2009 and 2017-2018

OBJECTIVE

To describe the evolution of out-of-home food consumption in Brazil in 2008–2018.

METHODS

We used the 2008–2009 and 2017–2018 data from the Inquéritos Nacionais de Alimentação (INA - National Food Surveys), conducted amid 34,003 and 46,164 individuals, to estimate the frequency of out-of-home food consumption and the contribution of this consumption to specific foods. Food consumption was analyzed using food records in the 2008–2009 INA and 24-hour recalls in 2017–2018. Estimates were generated for Brazil in general, for urban and rural areas, for age groups (adolescent, adult, elderly), and for income bracket.

RESULTS

The frequency of out-of-home consumption decreased by 8.8% between the two surveys, with no change in the rural area, in the Northeast and South regions, and for the lowest income brackets. We observed a slight increase among the elderly and in the Midwest region. The contribution of out-of-home food consumption to daily energy intake also decreased (16.3% vs. 12.7%), excepting the rural area, where there was a reduction in the difference in relation to the urban area between the two surveys. For most items evaluated, the out-of-home food consumption decreased. The most consumed out-of-home food were alcoholic beverages, fried and baked snacks, soft drinks, pizza, sweets, and sandwiches in both surveys.

CONCLUSION

In 10 years, the prevalence of food consumption and the percentage of contribution of out-of-home food decreased in Brazil, but ultra-processed foods still figure as the most consumed food group outside the home.

Fruit and vegetable consumption across generations of primary Brazilian care users

OBJECTIVES

Despite the importance of generational approach to understand dietary patterns, studies on the topic are scarce, especially in primary health care. Thus, we aimed to analyze the association between generational status and fruit and vegetable (F + V) consumption across users of the Brazilian Primary Care Program, adjusted by health aspects, socioeconomic factors, and body mass index.

METHODS

A cross-sectional study was performed from the baseline, randomized, controlled, community trial. Generational status was defined according to the year of birth as traditionalists (1934-1945), baby boomer (BB; 1946-1964), generation X (GX; 1965-1980), and generation Y (GY; 1981-1993). The consumption of F + V was classified as regular (≥5 times/wk) and adequate (3 servings of fruit/d and 3 of vegetables/d), analyzed together (F + V) and separately (fruit or vegetable) by food group.

RESULTS

Of the 3356 participants, 18.1% were traditionalist, 59.0% BB, 19.7% GX, and 3.2% GY. The prevalence of regular and adequate F + V consumption was 61.7% and 37.2%, respectively. There were fewer chances of regular consumption of fruit and F + V for all generations in comparison with traditionalists. With regard to adequate consumption, there was less chance of consuming F + V only for individuals from GY and of F + V for GX and GY.

CONCLUSIONS

This is one of the first studies to investigate differences in F + V consumption according to the generational status in a health service. The findings are likely to support the design of strategies to promote F + V consumption, focusing on the younger population to promote health in the present and the future.

[Community food environment and presence of food swamps around schools in a Brazilian metropolis]

The study aimed to assess the community food environment and the existence of food swamps around schools in a Brazilian metropolis. This was an ecological study in public and private schools in Belo Horizonte, Minas Gerais State, Brazil, with a 250-meter buffer as the analytical unit. The study included all preschool, elementary, and middle schools. In relation to the schools, the study evaluated administrative regimen (public versus private), type of teaching, and per capita income in the schools' census tracts. Information was also compiled on the retail food establishments inside the buffer zone around the schools. The food environment was characterized only according to the establishments around the schools that sold food for immediate consumption. Analysis of the buffers revealed that 97.4% of the schools had at least one establishment in the vicinity that sold food for immediate consumption. The most available establishments around schools were snack bars, restaurants, and bars. Schools located in higher-income census tracts showed higher mean numbers of all establishments in their vicinity, except for grocery stores and supermarkets. In addition, 54.6% of the schools were in neighborhoods classified as food swamps. The results that the among the target categories, there was a predominance of establishments that mainly sell ultra-processed foods such as bars and snack bars in the vicinity of schools in Belo Horizonte, which exposes children and adolescents to an unhealthy food environment.

The Pandemic Health Crisis and Its Implications for Food and Nutritional Security in Latin America

The inequalities in health are directly linked to food and to the nutritional profile; hunger and malnutrition, as well as overweight and obesity, increase in proportion to poverty. In the current COVID-19 pandemic scenario, social isolation measures implemented in several countries to prevent the collapse of health systems impose new rhythms on people’s lives and their daily routines, implying a reorganization of their vital structure and the necessary activities for its maintenance and reproduction. The restriction of circulation with the requirement to prepare food inside the home imposes food planning with options with some degree of industrial processing. In the diet of isolation, among the likely changes in food consumption models, there will certainly be an increase in ultraprocessed foods, mainly because containment measures have altered the dynamics of circulation and local trade of fresh products.

Microbiological quality and safety of minimally processed parsley (Petroselinum crispum) sold in food markets, southeastern Brazil

AIMS

This study evaluated the microbiological quality and safety of minimally processed parsley sold in southeastern Brazilian food markets.

METHODS AND RESULTS

One hundred samples were submitted to the enumeration of Enterobacteriaceae by plating on MacConkey agar. Colonies of Enterobacteriaceae were randomly selected and identified by MALDI-TOF MS. Samples were also tested for Listeria monocytogenes and Salmonella sp. The mean count of Enterobacteriaceae was 6·0 ± 1·0 log CFU per gram, while 18 genera (including 30 species) of bacteria belonging to this family were identified. Salmonella and L. monocytogenes were not detected, while L. innocua was found in two samples and L. fleischmannii was found in one sample. Moreover generic Escherichia coli was found in three samples, all from different brands of minimally processed parsley.

CONCLUSIONS

Even though microbial pathogens were not isolated, a variety of indicator micro-organisms were identified, including vegetable spoilers and species capable of causing human opportunistic infections. These results suggest hygienic failures and/or lack of temperature control during processing and storage of these ready-to-eat products.

SIGNIFICANCE AND IMPACT OF STUDY

This study highlights the need for control measures during the production chain of minimally processed parsley in order to reduce microbial contamination and the risks of foodborne diseases.

Sociodemographic inequalities in eating practices and concerns

OBJECTIVE

To evaluate associations between selected dietary concerns and eating practices and determine the association of these concerns/practices with demographic and socio-economic characteristics in a population from a large Brazilian city.

DESIGN

Population-based cross-sectional study. We investigated concerns regarding salt intake, the use of highly processed seasoning and the custom of reading the Na content on food labels. We also analysed concerns regarding the use of pesticides on food products and the practice of consuming organic foods. These variables were analysed according to sex, age group, schooling and income. Multivariate Poisson regression analysis was performed for the estimation of prevalence ratios.

SETTING

Campinas, state of São Paulo, Brazil.

PARTICIPANTS

The representative sample consisted of 1710 adults and seniors.

RESULTS

A total 62·3 % of the population were concerned with salt intake, 34·7 % did not use highly processed seasoning and 10·6 % checked the Na content on food labels; 27·5 % were concerned with pesticides and 26·5 % consumed organic foods. The practices analysed were associated with the respective concerns. Women and seniors had a better profile, except for reading Na content in both groups and the consumption of organic foods among seniors. The frequency of checking the Na content and consuming organic foods increased with the level of schooling. The higher income group had a better profile, except for concern with salt intake.

CONCLUSIONS

Considerable social differences were found regarding the dietary practices, and the practices were associated with concerns. The present findings underscore the need for different dietary counseling strategies targeting specific groups.

Microbiological safety of ready-to-eat minimally processed vegetables in Brazil: an overview

The market of ready-to-eat minimally processed vegetables (RTE-MPV) is increasing in Brazil and many other countries. During processing, these vegetables go through several steps that modify their natural structure while maintaining the same nutritional and sensory attributes as the fresh produce. One of the most important steps is washing-disinfection, which aims to reduce the microbial load, prevent cross-contamination and inactivate pathogenic microorganisms that may be present. Nonetheless, the presence of pathogens and occurrence of foodborne illnesses associated with consumption of RTE-MPV concern consumers, governments and the food industry. This review brings an overview on the microbiological safety of RTE-MPV, focusing on Brazilian findings. Most of the published data are on detection of Salmonella spp. and Listeria monocytogenes, indicating that their prevalence may range from 0.4% to 12.5% and from 0.6% to 3.1%, respectively. The presence of these pathogens in fresh produce is unacceptable and risky, mainly in RTE-MPV, because consumers expect them to be clean and sanitized and consequently safe for consumption without any additional care. Therefore, proper control during the production of RTE-MPV is mandatory to guarantee products with quality and safety to consumers. © 2020 Society of Chemical Industry.

Contribution of away-from-home food to the energy and nutrient intake among Brazilian adolescents

OBJECTIVE

To compare the contribution of different food consumption places to the energy and nutrient intake among Brazilian adolescents.

DESIGN

We analysed data from the Study of Cardiovascular Risk in Adolescents - ERICA, carried out in 2013-2014. Foods were categorised into thirty-three food groups. Energy, nutrients and food groups were analysed according to home, public and private schools, and other places of foods consumption. Linear regression models were used to test the association between eating away from home and nutrient intake.

SETTING

Brazilian public and private schools.

PARTICIPANTS

All adolescents who had undergone anthropometric evaluation and provided information through the questionnaires, including the 24-h recall (n 71 740).

RESULTS

The main portion of energy intake per day was consumed within the adolescent households (8112·776 kJ (1939 kcal), 95 % CI 1892, 1985). Away-from-home eating was reported by 52 % of students in a given day, but it contributed to only 15 % of total energy intake. This contribution was mainly due to high energy-dense food intake. The percentage contribution of foods consumed at public school and other places was very similar with respect to nutrients. However, food consumption at other places meant less intake of protein, fibre and Fe, in addition to increasing the intake of added sugar and fats.

CONCLUSIONS

The frequency of food consumption outside the home by adolescents is high, although the main contribution to energy intake occurs at home, and despite the similarity of nutrients consumed in school and restaurants, the latter tends to worsen the nutritional quality of meals.

Is the local food environment associated with excess body weight in adolescents in São Paulo, Brazil?

The obesogenic environment stimulates an inadequate diet by hampering healthy choices. This cross-sectional study evaluated the association between the local food environment and the prevalence of overweight and obesity in a representative sample population of adolescents living in the city of São Paulo, Brazil, using multilevel logistic regression models. Among the adolescents, 29.6% were overweight/obese. There were no significant differences between food environment and adolescents’ weight status. However, the presence of fast food restaurants near their home increased the chances of being overweight or obese (OR = 2.53; 95%CI: 1.02-6.27). Results suggest the need to intensify food and nutrition policies, development of culinary skills, and the reduction in prices of healthy foods to facilitate access to these foods, so that adolescents have options in locations to socialize with friends and family.

Parental Perceived Travel Time to and Reported Use of Food Retailers in Association with School Children's Dietary Patterns

Considering the association between the neighborhood food environment and individual eating behaviors, this study aimed to assess the association between parents’ reported use of food facilities by their children, and parental perceived travel time to food facilities, with their children’s dietary patterns. Parents reported the use of supermarkets, full-service and fast-food restaurants, and perceived travel time to these food retailers. To assess school children’s food consumption, a previous day dietary recall was applied. Factor analysis was conducted to identify dietary patterns. To test the association between reported use and perceived travel time to food retailers and school children’s dietary patterns, we performed multilevel linear regression analyses. Parents’ reported use of supermarkets was associated with children’s higher score in the “Morning/Evening Meal” pattern. The use of full-service and fast-food restaurants was associated with children’s higher score in the “Fast Food” pattern. Higher parental perceived travel time to full-service and fast-food restaurants was associated with children’s lower score in the “Fast Food” pattern. Although the use of full-service and fast-food restaurants was associated with a less healthy dietary pattern, the perception of living further away from these food retailers may pose a barrier for the use of these facilities.

Measured energy content of frequently purchased restaurant meals: multi-country cross sectional study

OBJECTIVE

To measure the energy content of frequently ordered meals from full service and fast food restaurants in five countries and compare values with US data.

DESIGN

Cross sectional survey.

SETTING

223 meals from 111 randomly selected full service and fast food restaurants serving popular cuisines in Brazil, China, Finland, Ghana, and India were the primary sampling unit; 10 meals from five worksite canteens were also studied in Finland. The observational unit was frequently ordered meals in selected restaurants.

MAIN OUTCOME MEASURE

Meal energy content, measured by bomb calorimetry.

RESULTS

Compared with the US, weighted mean energy of restaurant meals was lower only in China (719 (95% confidence interval 646 to 799) kcal versus 1088 (1002 to 1181) kcal; P<0.001). In analysis of variance models, fast food contained 33% less energy than full service meals (P<0.001). In Finland, worksite canteens provided 25% less energy than full service and fast food restaurants (mean 880 (SD 156) versus 1166 (298); P=0.009). Country, restaurant type, number of meal components, and meal weight predicted meal energy in a factorial analysis of variance (R²=0.62, P<0.001). Ninety four per cent of full service meals and 72% of fast food meals contained at least 600 kcal. Modeling indicated that, except in China, consuming current servings of a full service and a fast food meal daily would supply between 70% and 120% of the daily energy requirements for a sedentary woman, without additional meals, drinks, snacks, appetizers, or desserts.

CONCLUSION

Very high dietary energy content of both full service and fast food restaurant meals is a widespread phenomenon that is probably supporting global obesity and provides a valid intervention target.