Obesity in Adolescents –Obesity in Adolescents –Indian scenarioIndian scenario

Convener Convener Adolescent Interest group of IPAAdolescent Interest group of IPA( International Pediatric association ) ( International Pediatric association )

Chairperson Chairperson IAPIAP Indian academy of Pediatrics ) Indian academy of Pediatrics ) ADOL chapter Research & Training wing ADOL chapter Research & Training wing

Dr Swati Bhave

Member WHO SEARO Regional Adolescent Technical Advisory Committee

Obesity & Life style Obesity & Life style diseases ……Importance for diseases ……Importance for adol age adol age Adolescent physicians and pediatricians Adolescent physicians and pediatricians

have an important role in the prevention have an important role in the prevention and control of the ‘epidemic.’ of Life style and control of the ‘epidemic.’ of Life style disorders disorders

As they begin in childhood (or even earlier, As they begin in childhood (or even earlier, in fetal life), and Manifest due to in fetal life), and Manifest due to interactions & accumulation of various risk interactions & accumulation of various risk factors, throughout the life cycle.factors, throughout the life cycle.

WHO/NMH/NPH/ Life course perspectives on coronary heart disease, stroke, and diabetes. WHO, Geneva, 0.1.4:2001.

Fall CHD. The fetal and early origins of adult disease. Review. Indian Pediatr 2003; 40:480-502

Obesity in developing countries Obesity in developing countries

Rapid epidemiological transitions : Rapid epidemiological transitions : nutritional nutritional & socio-economic . & socio-economic .

A complex picture : A complex picture : simultaneous under nutrition & simultaneous under nutrition & overweight in all parts of India overweight in all parts of India

Indian mothers :Indian mothers : chronically malnourished chronically malnourished (stunted) (stunted)

Indian babies : Indian babies : small LBW > 25% of all ‘normal small LBW > 25% of all ‘normal births’births’..

In this background, we are now witnessing In this background, we are now witnessing problems of plenty such as obesity problems of plenty such as obesity with with its attendant risks.its attendant risks.

Barker DJP. Mothers, babies and health in later life. Edinburgh: Churchill Livingstone, 1998.Yajnik CS. The insulin resistance epidemic in India: Fetal origins, Later lifestyle, or both ?

Nutr Rev 2001; 59: 1-9.

Obesity in Urban Obesity in Urban SlumsSlums

Most cases malnutrition but obesity also on Most cases malnutrition but obesity also on rise rise

Poor knowledge of healthy food habits Poor knowledge of healthy food habits

Whatever little they earn is spent on junk food Whatever little they earn is spent on junk food and soft drinks due to the impact of and soft drinks due to the impact of advertisements that are rampant on TV advertisements that are rampant on TV which is also seen avidly in the slums which is also seen avidly in the slums

PPopkin BM. opkin BM. Food Nutr Bull 2001; 22(S4): 3-4Food Nutr Bull 2001; 22(S4): 3-4

Prevalance of obesity in IndiaPrevalance of obesity in India

School children in ChennaiSchool children in Chennai

> 22% HSE group > 22% HSE group 15% from MSE groups .15% from MSE groups .

only 4.5% from LSE grouponly 4.5% from LSE group urban well-off children : highest risk . urban well-off children : highest risk .

Ramachandran A, Snehalatha C, Vinitha R, Thayyil M, Sathish Kumar CK, Sheeba L, et al. Prevalence of overweight in urban Indian adolescent school children. Diabetes Res Clin Pract 2002; 57: 185 -190.

KS, Prabhakaran D, Shah P, Shah D. Differences in body mass index and waist: hip ratios in north Indian rural and urban population. Obes Rev 2002; 3: 197- 202.

Prevalence ranges from 6 to 8% and occasionally higher but clubbed to mean Prevalence ranges from 6 to 8% and occasionally higher but clubbed to mean overweight and obesity collectively. On a more positive note, tendency for overweight and obesity collectively. On a more positive note, tendency for overweight is moreoverweight is more

Urban Delhi, >25% of adult males and 47% of adult females Urban Delhi, >25% of adult males and 47% of adult females were found to be overweight or obese. were found to be overweight or obese.

Affluent Adolescent Affluent Adolescent School childrenSchool childrenDelhiDelhi

31% overweight;31% overweight;7.5% obese.7.5% obese.22

PunePune

24% overweight.24% overweight.33 ChennaiChennai

22% overweight.22% overweight.11

1.1. Indian Pediatr 2002; 39: 449-452.Indian Pediatr 2002; 39: 449-452. 2.2. Indian Pediatr 2004; 41: 559-575.Indian Pediatr 2004; 41: 559-575.3.3. Diabetes Res Clin Pract 2002; 57: 185-Diabetes Res Clin Pract 2002; 57: 185-

190.190.

Rural India

Poverty and Undernutrition

Urban India Elite classes Urban slums

Fattening

Factors responsibleFactors responsible

Changes in Life Style (Urbanisation)•Unhealthy eating patterns•Wrong choices of food, increased portions•Increased oil consumption•Snacks, colas, rewards……

Sedentary pursuits• Long school hours, tuitions,

Reduced physical activity vehicles, reduced play areas TV, telephones

Other factorsHigh glycemic index of foods

Genetic / Constitutional predisposition ‘Early life origins’ -- programmed to accumulate fat

Silent genes unmasked? Thrifty genotype Gestational diabetes – intergenerational effects7

Bhave S, Bavdekar A, Otiv M. IAP National Task Force for Childhood ,Prevention of Adult Diseases: Childhood Obesity. Indian Pediatr 2004; 41:559- 75.

Khadilkar VV, Khadilkar AV. Prevalence of obesity in affluent schoolboys in Pune. Indian Pediatr 2004; 41: 857-858

Indian scenario Indian scenario

Midst of a rapidly escalating epidemic T2DM and Midst of a rapidly escalating epidemic T2DM and CHDCHD

Prevalence T2DM increased in urban Indian adults Prevalence T2DM increased in urban Indian adults from < 3% in 1975 to > 12% in the year 2000from < 3% in 1975 to > 12% in the year 2000

By the year 2025 it is predicted that India will have By the year 2025 it is predicted that India will have a rise of 59% of diabetics in the population... a rise of 59% of diabetics in the population... Which is the highest number of diabetic patients in Which is the highest number of diabetic patients in the world.the world.

Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al. High prevalence of diabetes and impaired glucose tolerance in India: National urban diabetes survey. Diabetologia, 2001; 9: 1094-1111.

NY Times Sep 13 2006 NR Kelinfield NY Times Sep 13 2006 NR Kelinfield Modern ways open India’s door to diabetesModern ways open India’s door to diabetes

Type 2 DM India -1Type 2 DM India -1

10% of newly diagnosed DM are in age group of 10 – 18 10% of newly diagnosed DM are in age group of 10 – 18 years years

Most were asymptomatic: picked up on screening for Most were asymptomatic: picked up on screening for obesity or strong family history.obesity or strong family history.

Venkatnarayan KM. Type 2 Diabetes in Children: A problem lurking for India ? Indian Pediatr (editorial) 2001; 38: 701-704.

High incidence of gestational diabetes in young High incidence of gestational diabetes in young mothers, with intergenerational effects.mothers, with intergenerational effects.

High (14%) prevalence of impaired glucose tolerance High (14%) prevalence of impaired glucose tolerance suggests a large pool of potential diabetics.suggests a large pool of potential diabetics.

Bhatia V. IAP National task for childhood prevention of adult diseases: Insulin resistance Type 2 Diabetes Mellitus in Childhood. Indian Pediatr 2002: 41: 443-457.

Cut off values of BMI for Cut off values of BMI for overweight overweight

Agency Tendency for overweight

State of overweight

WHO > 25 kg/m2 > 30 kg/m2

IOTF > 23 kg/m2 > 25 kg/m2

NCHS > 85thcentile(90th centile recently)

> 95th centile(97th centile recently)

Cutoff Values for BMI For Obesity in Cutoff Values for BMI For Obesity in Indian StudiesIndian Studies

95th centile Girls

Author Range Range Year Year

Vedavati 22-27 kg/m2 19981998

Agarwal 23-27 kg/ m2 1988-1994

Cole 24-29 kg/m2 1963-1993

95th centile Boys

Khadilkar 24-27 kg/m2 2004

Agarwal 22-27 kg/m2 1988-1994

Cole 23-28 kg/m2 1963-1993

BMI values show BMI values show wide variations wide variations between regions, between regions, and the period of and the period of the studies. the studies.

Pune study, age Pune study, age 10-13 years, BMI 10-13 years, BMI of boys have of boys have been even higher been even higher than the than the international international values.values.

Delhi Agarwal’s Delhi Agarwal’s chart for the 85th chart for the 85th and 95th centile and 95th centile show lower BMI show lower BMI values than the values than the WHO values WHO values

Local BMI values are collected on smaller samples and comparison Local BMI values are collected on smaller samples and comparison between them and with international norms are not feasible.between them and with international norms are not feasible.

Some thoughts on BMI …..1Some thoughts on BMI …..1

Cut of BMI > 25 kg/m2 in adults - tendency for Cut of BMI > 25 kg/m2 in adults - tendency for overweight- based on the concept of what is overweight- based on the concept of what is considered ideal for an adult of stable stature. considered ideal for an adult of stable stature.

Similarly, IOTF values have been projected from an Similarly, IOTF values have been projected from an optimum BMI of 25 kg/m2 at age 18 years. These optimum BMI of 25 kg/m2 at age 18 years. These valuable sets of values unfortunately, may not be valuable sets of values unfortunately, may not be applicable during the adolescent growth spurt .applicable during the adolescent growth spurt .

Till such time, we have our nationally representative values for BMI Till such time, we have our nationally representative values for BMI appropriate for age and sex; we are using the Task Force’s policy of IOTF appropriate for age and sex; we are using the Task Force’s policy of IOTF values.values.

Some thoughts on BMI …2Some thoughts on BMI …2

BMI BMI per se per se or 95th centile or 95th centile by itself may not be by itself may not be definitive indices of definitive indices of overweight.overweight.Waist measurement and Waist measurement and waist/hip (W/H) ratios may not waist/hip (W/H) ratios may not be applicable for adolescents be applicable for adolescents due to their physiologically due to their physiologically changing body shapechanging body shape

Whether this will translate into a Whether this will translate into a yardstick for optimum health in yardstick for optimum health in adolescents needs to be seen by adolescents needs to be seen by long term studies on the long term studies on the comorbidities and the ultimate BMI of comorbidities and the ultimate BMI of these adolescents in the Indian these adolescents in the Indian context.context.

TSFT also needs TSFT also needs considerationconsideration

Increased BMI / Increased BMI / normal TSFT, normal TSFT, likely to be likely to be overweight and overweight and not over-fat, not over-fat,

As skin fat As skin fat thickness doubles thickness doubles normally between normally between sexual maturity sexual maturity rating of breast rating of breast stage 2-5 in girls.stage 2-5 in girls.

EHPA EHPA Chart Chart Elizabeth Elizabeth

health path health path for adults for adults and and adolescents adolescents is a novel is a novel and easy and easy chart, which chart, which is ideal for is ideal for screening screening adolescents adolescents for risk of for risk of overweight .overweight .

Elizabeth KE. A novel growth assessment chart for adolescents. Indian Pediatrics 2001; 38: 1061-1064

Barker’s Barker’s Hypothesis FOAD Hypothesis FOAD 19861986

Fetal origins of adult-onset diseases (FOAD) Fetal origins of adult-onset diseases (FOAD)

Under nutrition and unfavorable intrauterine Under nutrition and unfavorable intrauterine environment at critical periods in early life can environment at critical periods in early life can cause permanent changes (in both structure cause permanent changes (in both structure and function) in developing systems of the and function) in developing systems of the fetus (i.e. programming). fetus (i.e. programming).

May manifest as disease over a period of time May manifest as disease over a period of time due to `dysadaptation’ with changed due to `dysadaptation’ with changed environmental circumstances environmental circumstances

Barker DJP. Mothers, babies and health in later life. Edinburgh: Churchill Livingstone, 1998.

Maternal malnutrition

FETAL UNDERNUTRITION(Nutrient demand exceeds supply)

HYPERLIPIDAEMIAHYPERTENSION CENTRAL OBESITY INSULIN RESISTANCE

Type 2 Diabetes and CHD

Muscle mass Cortisol Impaired development Fat mass (Liver, Pancreas, Blood vessels)

Placental transfer

Fetal genome

Altered body composition Early maturation Brain sparingDown regulation of growth

Fall CHD. The fetal and early origins of adult disease. Review. Indian Pediatr 2003; 40:480-502

Developmental origins of adult disease: hypothesis

Characteristics of obesity in Characteristics of obesity in India India Frank obesity not as high as in the WestFrank obesity not as high as in the WestBut body composition & metabolism of Indians But body composition & metabolism of Indians

(asians in general) make them especially (asians in general) make them especially prone to ‘adiposity’ (fat content in the body) prone to ‘adiposity’ (fat content in the body) and its consequences. and its consequences.

South Asians have at least 3 to 5% higher South Asians have at least 3 to 5% higher body fat for the same BMI as compared to body fat for the same BMI as compared to Caucasians. Caucasians.

The fat is typically located ‘centrally’ (i.e. The fat is typically located ‘centrally’ (i.e. waist, trunk) and around visceral organs - waist, trunk) and around visceral organs - metabolically more dangerous than metabolically more dangerous than peripheral fat.peripheral fat.

Additional features associated with Metabolic Syndrome

Insulin resistance (fasting insulin, HOMA IR)

•Dyslipidemia (in addition to above, increased small dense LDL)

•Hypercoagulability of blood (increased plasminogen activator inhibitor)

•Vascular dysregulation (beyond elevated blood pressure)

•Endothelial dysfunction – microalbuminuria

•Pro-inflammatory state – raised high sensitive C-reactive protein,TNC-alpha and IL 6

• Polycystic ovarian disease (PCOS)• Acanthosis nigricans

Adapted from * International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome. Brussels: IDF, 2005 http://www.idf.org/webdata/docs/IDF-Metasyndrome,definition.pdf (May 2005)3

Acanthosis Nigricans Acanthosis Nigricans Indian studiesIndian studies

This simple diagnostic marker in a This simple diagnostic marker in a clinical examination in office practice clinical examination in office practice was seen in seen in 20% of obese was seen in seen in 20% of obese adolescents, adolescents,

who also had high insulin and C-peptide levels who also had high insulin and C-peptide levels with normal HbA1c levelwith normal HbA1c level

Subramaniam V, Jayashree R, Rafi M. Prevalence Overweight and obesity in Chennai 1981& 1998. Indian Pediatrics 2003; 40: 332-336.

Constituents of the Metabolic Syndrome Constituents of the Metabolic Syndrome (Syndrome X, Insulin Resistance Syndrome) (Syndrome X, Insulin Resistance Syndrome)

Central Obesity: waist circumference > 90 cms for males and > 80 cms for females)

As per the new 2005 International Diabetes Federation definition 3, the criteria for the diagnosis of the metabolic syndrome are: central obesity + any two of the following four factors*•Raised serum triglycerides > 150 mg /dl•Reduced serum HDL cholesterol < 45 mg / dl•Raised blood pressure (BP systolic > 130, and diastolic

> 85 mm Hg)•Raised fasting blood sugar level ( > 100 mg/dl)

Hypertension and other CVS Risk factors Hypertension and other CVS Risk factors (Hyperlipidemia, hypercoagulability)(Hyperlipidemia, hypercoagulability)

Indian cohort studies :high risk factors for CVS Indian cohort studies :high risk factors for CVS diseases are associated with both fetal origins and diseases are associated with both fetal origins and later life styles. later life styles.

High incidence of mortality & morbidity due to MI and High incidence of mortality & morbidity due to MI and stroke in young adults implies : start insidiously in stroke in young adults implies : start insidiously in childhood / adolescence and are obviously childhood / adolescence and are obviously asymptomatic for long periods. asymptomatic for long periods.

Other ‘life style’ risk factors developed during Other ‘life style’ risk factors developed during childhood / adolescence (food habits, alcohol, physical childhood / adolescence (food habits, alcohol, physical activity, drugs) also track through into adult life. activity, drugs) also track through into adult life.

Reddy KS. Cardiovascular diseases in developing countries: dimensions, determinants dynamics and directions for public health action.

Pub Hlth Nut 2002; 5:231-237.

Indian scenario- CHD Indian scenario- CHD

Central obesity adversely influences (SBP) i.e. Central obesity adversely influences (SBP) i.e. peak response minus mean pre-stressor level, peak response minus mean pre-stressor level, and greater (DBP) reactivity to postural change and greater (DBP) reactivity to postural change

Increase is seen in left ventricular mass in obese Increase is seen in left ventricular mass in obese children and adol related to central obesity and children and adol related to central obesity and elevated insulin levels.elevated insulin levels.

Predicted CHD will soon over-take infectious Predicted CHD will soon over-take infectious diseases as the leading cause of premature death diseases as the leading cause of premature death in adults.in adults.

20-25% of obese adolescents : hypertension, 20-25% of obese adolescents : hypertension, dyslipidemia & PCOSdyslipidemia & PCOS

Gupta AK, Ahmad I. Childhood obesity and hypertension. Indian Pediatr 1990; 27: 333-337

Studies of FOAD in India Studies of FOAD in India

Affluent countries, emphasized the importance Affluent countries, emphasized the importance of birth weight and other measures of poor of birth weight and other measures of poor fetal growth in the genesis of FOAD disorders. fetal growth in the genesis of FOAD disorders.

The role of genes especially ‘thrifty genotype’ The role of genes especially ‘thrifty genotype’ had also been suggested.had also been suggested.

In recent years cohort studies from india In recent years cohort studies from india however, have highlighted the however, have highlighted the importance of importance of subsequent over nutrition in the development subsequent over nutrition in the development of this disorder.of this disorder.

(beginning in Pune in 1990, followed by (beginning in Pune in 1990, followed by cohorts in Mysore, Delhi and Vellore) cohorts in Mysore, Delhi and Vellore)

Yajnik CS, Fall CHD, Koyaji KJ, Hirve SS, Rao S, Barker DJP, et al. Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study. Int J Obes 2003;27:173-180.

Indian cohort studies –pune -1Indian cohort studies –pune -1

Deleterious effects of accelerated weight gain Deleterious effects of accelerated weight gain in childhood i.e. ‘crossing of centiles’ in childhood i.e. ‘crossing of centiles’ especially in LBW babies. especially in LBW babies.

Indices of insulin resistance and CV risk Indices of insulin resistance and CV risk factors were found to be highest in those that factors were found to be highest in those that were born `small’ but were big by 8 years were born `small’ but were big by 8 years even though they were not obese in absolute even though they were not obese in absolute terms.terms.

accelerated growth in childhood is associated accelerated growth in childhood is associated with early puberty and greater risk of obesity.with early puberty and greater risk of obesity.

Bavdekar A, Yajnik CS, Caroline HD, Bapat S, Pandit A, Deshpande V., et al. Insulin resistance syndrome in 8-year-old Indian children – Small at birth, big at 8 years, or both ? Diabetes 1999; 48: 2422 – 2429.

FOAD now DOHaD – FOAD now DOHaD – Developmental Origins of Health & disease Developmental Origins of Health & disease Hypothesis for D O H a DHypothesis for D O H a D

Multiphasic Nutritional Insult Multiphasic Nutritional Insult

Genes + early Under nutritionGenes + early Under nutrition + subsequent Over nutrition+ subsequent Over nutrition

Fetal origins or later lifestyles or both `Fetal origins or later lifestyles or both `

Yajnik CS. The insulin resistance epidemic in India: Fetal origins, Later lifestyle, or both ?

Nutr Rev 2001; 59: 1-9

Indian cohort studies –pune -2Indian cohort studies –pune -2

Maternal Nutritional Studies have shown convincingly Maternal Nutritional Studies have shown convincingly that this high risk body composition is present even at that this high risk body composition is present even at birth, birth,

i.e. lower birth weight, lower muscle mass but i.e. lower birth weight, lower muscle mass but relatively high fat mass and hyper insulinemia relatively high fat mass and hyper insulinemia (`thin fat’ phenotype)(`thin fat’ phenotype)

It is possible that such fat offers survival It is possible that such fat offers survival benefits to newborns but also endangers benefits to newborns but also endangers predisposition to insulin resistance from birth predisposition to insulin resistance from birth itself. itself.

Yajnik CS, Fall CHD, Koyaji KJ, Hirve SS, Rao S, Barker DJP, et al. Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study. Int J Obes 2003;27:173-180.

“ “ Thin-fat “ babyThin-fat “ baby

Newborns, even relatively small at birth Newborns, even relatively small at birth (BW < 2.9 kg) reported to have greater (BW < 2.9 kg) reported to have greater subscapular skin fold thickness, which is subscapular skin fold thickness, which is shown to correlate well with truncal obesity shown to correlate well with truncal obesity

Also been shown that this adiposity tracks Also been shown that this adiposity tracks to 4 years of ageto 4 years of age

Krishnaveni GV, Hill JC, Veena SR, Fall CHD. Truncal obesity is present at birth and in early childhood in south Indian children. Indian Pediatr 2005; 42: 527-538

Agarwal KN, Saxena A, Bansal AK, Agarwal DK Physical growth assessment in adolescence Indian Pediatr 2001; 38:

Indian cohort studies-Indian cohort studies-delhi delhi An increase of BMI of 1 SD from 2 to 12 years of An increase of BMI of 1 SD from 2 to 12 years of

age, age, increased the odds ratio for disease (IGT / DM) by increased the odds ratio for disease (IGT / DM) by

1.36. in young adults 1.36. in young adults It is now evident that our traditional understanding of It is now evident that our traditional understanding of

concepts of `catch up growth’ in childhood, and concepts of `catch up growth’ in childhood, and ‘healthy’ weight gain during adolescence may need ‘healthy’ weight gain during adolescence may need redefining. redefining.

Bhargava SK, Sachdev HPS, Fall CHD, Osmond C, Lakshmy R, Barker DJP, et al. Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood

New Eng J Med 2004; 350: 865-875.

MONITORING AND COUNSELLING THE ADOLMONITORING AND COUNSELLING THE ADOL

Most FOAD related disorders can be prevented or Most FOAD related disorders can be prevented or effectively managed if picked up early in life.effectively managed if picked up early in life.

Main focus of preventive programmes should be Main focus of preventive programmes should be directed towards prevention of obesity throughout directed towards prevention of obesity throughout childhood and adolescence. childhood and adolescence.

Public health campaign directed towards life style Public health campaign directed towards life style changes in the family / society as a whole. changes in the family / society as a whole.

Benefits of healthy eating, increased physical Benefits of healthy eating, increased physical activity & reduction in sedentary activities have to activity & reduction in sedentary activities have to be inculcated from early age. be inculcated from early age.

School based programmes most likely to be School based programmes most likely to be successful but health authorities and media have successful but health authorities and media have an important role to play to spread awareness.an important role to play to spread awareness.

Greydanus DE, Bhave Swati. Obesity and adolescents. Time for increased activity. Indian Pediatr 2004; 41: No 6

Life style diseases Life style diseases prevention programsprevention programs

Chairperson Swati Bhave Chairperson Swati Bhave

Five year program advocacy and awareness Five year program advocacy and awareness Standard set of slides and Training modules Standard set of slides and Training modules

for for Pediatricians Pediatricians school teachers & parents school teachers & parents community community

Pre and post assessment of the intervention Pre and post assessment of the intervention strategies strategies

Colloboration with USA universities Colloboration with USA universities

KEY MESSAGESKEY MESSAGES India : alarming epidemic of T2 DM, CHD & other India : alarming epidemic of T2 DM, CHD & other

LSD associated with the IRS (metabolic LSD associated with the IRS (metabolic syndrome X). Ethnically, Indians have lower syndrome X). Ethnically, Indians have lower muscle mass and higher body fat (especially muscle mass and higher body fat (especially central obesity).central obesity).

The fetal origins hypothesis proposes : The fetal origins hypothesis proposes : dysadaptation between fetal growth restriction dysadaptation between fetal growth restriction (LBW ) & subsequent over nutrition (obesity).(LBW ) & subsequent over nutrition (obesity).

The FOAD epidemic is potentially preventable The FOAD epidemic is potentially preventable with life style changes in childhood and with life style changes in childhood and adolescence. adolescence.

Targeted effectively through school / college Targeted effectively through school / college campaigns to focus on healthy eating, campaigns to focus on healthy eating, increased physical activity and reduction in increased physical activity and reduction in sedentary habits.sedentary habits.