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Objectives To identified the core components of professional ethics for medical sign language interpreters and develop a framework based on empirical data from Colombian sign language (CSL) interpreters.Design Purposive and snowball sampling methods were used in this qualitative study, which involved conducting semistructured interviews to CSL interpreters. Inductive data analysis was performed using the constant comparative method, where data collection and analysis occurred simultaneously. Transcriptional coding was performed line by line, and the data results were organised into themes and subthemes.Setting The research was conducted in Colombia.Participants A total of 17 CSL interpreters were included.Results We identified key themes (confidentiality, privacy, professionalism, business practices and professional development). Our data analyses show the need for codes of conduct and establishment of professional codes of ethics for sign language interpreters working in a health context. The proposed framework addresses the challenges within the professional ethics of sign language interpreters in healthcare.Conclusions These findings offer unique insights into the ethical experiences of CSL interpreters. This framework can be a valuable reference for interpreters facing ethical dilemmas. The clarity of ethical considerations is crucial for overcoming barriers to healthcare for the D/deaf population. The identified ethical issues underscore the necessity of education, training and the establishment of codes of ethics and legislation for sign language interpreters. These findings can serve as a foundational reference for crafting ethical guidelines for sign language interpreters in other low- and middle-income countries.

Background: Migrants are disproportionately affected by several infectious diseases differing the risk within migrant groups. This study aimed to estimate the prevalence of six chronic infections in asymptomatic migrants attended at primary care or specialized units where health assessments are offered. Methods: A multicentric cross-sectional study was conducted to estimate the prevalence of human immunodeficiency virus (HIV), hepatitis B and C virus, Strongyloides stercoralis, Schistosoma spp., and Trypanosoma cruzi infections in the migrant population who participated in a screening programme implemented at six primary health care centres, and two infectious diseases outpatient clinics in Catalonia, Spain. Results: Of the 314 recruited migrants, 284 (90.4 %) were tested for at least one infection. The prevalence of the infections was as follows: 1.8 % for HIV, 1.8 % for chronic hepatitis B virus, 14.1 % for previous exposure to a hepatitis B virus infection, 0.4 % for hepatitis C virus infection, 2.6 % for S.stercoralis infection, and 7.0 % for T.cruzi infection. No cases infected with Schistosoma spp. were reported. A higher prevalence of HIV, hepatitis B and C virus was observed in Sub-Saharan Africans, whereas a higher prevalence of S.stercoralis and T.cruzi infections was reported in migrants from Latin-America and the Caribbean. Conclusion: Findings suggest a high burden of the studied infections, including parasitic infections, in the migrant population with variations within migrant groups based on areas of birth.

Background: We aimed to evaluate the performance of a novel multiplex serological assay, able to simultaneously detect IgG of six infections, as a screening tool for imported diseases in migrants. Methods: Six panels of 40 (n = 240) anonymized serum samples with confirmed infections were used as positive controls to assess the multiplex assay's sensitivity. One panel of 40 sera from non-infected subjects was used to estimate the seropositivity cutoffs, and 32 non-infected sera were used as negative controls to estimate each serology's sensitivity and specificity. The multi-infection screening test was validated in a prospective cohort of 48 migrants from endemic areas.The sensitivity of the Luminex assay was calculated as the proportion of positive results over all positive samples identified by reference tests. The specificity was calculated using 32 negative samples. Uncertainty was quantified with 95 % confidence intervals using receiver operating characteristic analyses. Results: The sensitivity/specificity were 100 %/100 % for HIV (gp41 antigen), 97.5 %/100 % for Hepatitis B virus (HBV-core antigen), 100 %/100 % for Hepatitis C virus (HCV-core antigen), 92.5 %/90.6 % for strongyloidiasis [31-kDa recombinant antigen (NIE)], 97.5 %/100 % for schistosomiasis (combined serpin Schistosoma mansoni and S.haematobium antigens) and 95 %/90.6 % for Chagas disease [combined Trypanosoma cruzi kinetoplastid membrane protein-11 (KMP11) and paraflagellar rod proteins 2 (PFR2) antigens].In the migrant cohort, antibody response to the combination of the T.cruzi antigens correctly identified 100 % individuals, whereas HBV-core antigen correctly identified 91.7 % and Strongyloides-NIE antigen 86.4 %. Conclusions: We developed a new, robust and accurate 8-plex Luminex assay that could facilitate the implementation of screening programmes targeting migrant populations.

IntroductionEarly menarche is associated with obesity, and metabolic and mental health risks, among other diseases. Thus, it is relevant to identify modifiable risk factors of early menarche. Some nutrients and foods have been linked to pubertal timing, but how menarche relates to overall dietary patterns is unclear.MethodsThe aim of this study was to analyze the association between dietary patterns and age at menarche in a prospective cohort of Chilean girls from low and middle-income families. We conducted a survival analysis of 215 girls (median = 12.7 years, IQR = 12.2–13.2) from the Growth and Obesity Cohort Study (GOCS) who had been followed prospectively since 4 years of age (2006). Age at menarche and anthropometric measurements were recorded every 6 months since 7 years of age while diet (24-hour dietary recall) was collected for 11 years. Dietary patterns were obtained from exploratory factor analysis. Accelerated Failure Time models adjusted for potential confounding variables were used to study the association between dietary patterns and age at menarche.ResultsGirls' median age at menarche was 12.7 years. Three dietary patterns were identified: “Breakfast/Light Dinner,” “Prudent” and “Snacking” which explained 19.5% of the diet variation. Girls in the lowest tertile of the “Prudent” pattern had menarche 3 months earlier than girls in the highest tertile (β: 0.022; 95% CI: 0.003; 0.041). “Breakfast/Light Dinner” and “Snacking” patterns were not associated with age at menarche.ConclusionOur results suggest that healthier dietary patterns during puberty might be associated with menarche timing. Nevertheless, further studies are required to confirm this result and to clarify the association between diet and puberty.

Background: Misreporting of energy intake (EI) in self-reported dietary assessment is inevitable, and even less is known about which food items are misreported by low-middle income adolescents. We evaluated the prevalence of misreporting of energy intake and its relationship with nutrients and food intake. Methods: We analyzed 24 h dietary recalls collected from 576 adolescents (52.08% boys) from southeastern Santiago. Anthropometrics measurements and information about sociodemographic characteristics were obtained during clinical visits. The method proposed by McCrory et al. was used to identify under-reporters (UnRs), over-reporters (OvRs), or plausible reporters (PRs). Food items were collapsed into 28 categories and every food item was expressed as a percentage of total EI. Logistic regression models were performed to investigate the factors associated with misreporting, and a two-part model was used to estimate the difference in the percentage of EI between UnRs versus PRs, and OvRs versus PRs in each food item. Results: Half of the participants were classified as UnRs and 9% were OvRs. UnR was higher among boys (62%) and adolescents with overweight and obesity (72%). OvR was higher among adolescents with normal weight. UnRs had a lower intake of energy from cookies/cake, chocolate/confectionery, and a higher intake of vegetables and eggs than PRs. OvRs had a higher intake of cookies/cake, chocolate/confectionery, and a lower intake of fruit, white milk, and yogurt than PRs. Conclusions: A high frequency of UnR among boys and participants with excess weight was found in this study. Healthy and unhealthy foods are reported differently between UnRs and OvRs of energy intake, indicating that bias is specific for some food items that adolescents commonly eat.

BackgroundIn addition to the lack of COVID-19 diagnostic tests for the whole Spanish population, the current strategy is to identify the disease early to limit contagion in the community.AimTo determine clinical factors of a poor prognosis in patients with COVID-19 infection.Design and settingDescriptive, observational, retrospective study in three primary healthcare centres with an assigned population of 100,000.MethodExamination of the medical records of patients with COVID-19 infections confirmed by polymerase chain reaction. Logistic multivariate regression models adjusted for age and sex were constructed to analyse independent predictive factors associated with death, ICU admission and hospitalization.ResultsWe included 322 patients (mean age 56.7 years, 50% female, 115 (35.7%) aged ≥ 65 years): 123 (38.2) were health workers (doctors, nurses, auxiliaries). Predictors of ICU admission or death were greater age (OR = 1.05; 95%CI = 1.03 to 1.07), male sex (OR = 2.94; 95%CI = 1.55 to 5.82), autoimmune disease (OR = 2.82; 95%CI = 1.00 to 7.84), bilateral pulmonary infiltrates (OR = 2.86; 95%CI = 1.41 to 6.13), elevated lactate-dehydrogenase (OR = 2.85; 95%CI = 1.28 to 6.90), elevated D-dimer (OR = 2.85; 95%CI = 1.22 to 6.98) and elevated C-reactive protein (OR = 2.38; 95%CI = 1.22 to 4.68). Myalgia or arthralgia (OR = 0.31; 95%CI = 0.12 to 0.70) was protective factor against ICU admission and death. Predictors of hospitalization were chills (OR = 5.66; 95%CI = 1.68 to 23.49), fever (OR = 3.33; 95%CI = 1.89 to 5.96), dyspnoea (OR = 2.92; 95%CI = 1.62 to 5.42), depression (OR = 6.06; 95%CI = 1.54 to 40.42), lymphopenia (OR = 3.48; 95%CI = 1.67 to 7.40) and elevated C-reactive protein (OR = 3.27; 95%CI = 1.59 to 7.18). Anosmia (OR = 0.42; 95%CI = 0.19 to 0.90) was the only significant protective factor for hospitalization after adjusting for age and sex.ConclusionDetermining the clinical, biological and radiological characteristics of patients with suspected COVID-19 infection will be key to early treatment and isolation and the tracing of contacts.

Objective: We aimed to determine the prevalence of self-reported swallowing difficulty (dysphagia) among older Colombians and to explore the factors associated with this condition. Methods: This study presents a secondary analysis of the SABE-Colombia survey, a cross-sectional study of community-dwelling older adults. The dependent variable was self-reported swallowing difficulty, assessed through the question: “How often do you have difficulty or discomfort swallowing?” Descriptive and bivariate analyses of the sample were performed, followed by multivariate analysis, adjusting for confounding variables. Results: The final sample included 19 004 older Colombians, whose mean age was 69 years (56% women). The overall prevalence of swallowing difficulty was 12.2%. In the multivariate analysis, significant associations were observed between swallowing difficulty and several factors, including male sex (OR 1.14, 95%CI 1.03 – 1.26), age > 80 years (OR 1.26, 95%CI 1.08 – 1.47), dependence in activities of daily living (OR 1.62, 95%CI 1.23 – 2.13), cognitive impairment (OR 1.49, 95%CI 1.30 – 1.70), depressive symptoms (OR 1.38, 95%CI 1.15 – 1.65), sarcopenia (OR 1.32, 95%CI 1.02 – 1.69), malnutrition (OR 1.35, 95%CI 1.23 – 1.49), and osteoarticular disease (OR 1.18, 95%CI 1.07 – 1.38). Conclusion: There was a high prevalence of swallowing difficulty among older community-dwelling Colombians. Our results showed a strong correlation between swallowing difficulty and risk factors such as cognitive impairment, depressive symptoms, osteoarticular disease, and dependence in activities of daily living, but not with malnutrition or sarcopenia.

This article analyzes the current state of weakening suffered by the class analysis and the hypothetical "death" of the working class, that is, it starts from a contextual framework in which the working-class is put in doubt (Olin Wright 2018). Along with the discourses of the social space, culture also intervenes and reproduces this state of confusion, weakening and stigmatization through products that shape the working-class referent in different ideological directions. Thus, the cultural territory of the new millennium intervenes in the battles for the meaning of the working class and wields two possibilities: the revitalization of the working class referent or the negation and invisibilization in favor of other structures of thought that do not use the social class as an axis. In this second variant, considered hegemonic in recent decades, a specific current emerges that uses "monstrification" (Jaume Peris Blanes 2019) to associate the working class with the abject values of the monsters of fiction. In this way, cultural logics relate the working class with characteristics of the monstrous and reinforce demonizing imaginaries that serve to project prejudices towards the working class social strata. We use, as a paradigm of how this works, a cinematographic proposal (Las colinas tienen ojos 2006) and observe how its logics of monstrification are reproduced in Spain through reality television programs (Hermano mayor 2009). We wonder, then, to what extent the tools used by American horror cinema can be translated into the most popular makeover shows of the last decade (Mercè Oliva 2013), those in which the abject working class is the object of representation. The article traces, in short, the forms that culture uses to intervene in the procedures of weakening the working class.

El presente artículo utiliza la novela de Juan Marsé, Rabos de lagartija (2000), como una plataforma desde la que intervenir en dos ejes relacionados. Por un lado, el análisis del ‘fantasma’ como un elemento político que recorre el campo cultural español y permite repensar los procesos de memoria abiertos en el contexto democrático. Y, por otro lado, el estudio de Juan Marsé desde un marco de lectura fantástico que ha sido invisibilizado por el encasillamiento de su producción en el compendio realista. El objetivo es observar cómo operan los fantasmas en la novela y repensar a partir de ellos los sentidos ideológicos de memoria, así como abrir la posibilidad de leer al autor desde los códigos de lo fantástico.

BackgroundThe current standard of interpretation provision is not efficacious or not acceptable to Deaf patients who communicate using sign language. In-person or video relay interpretation (VRI) sign language interpretation is largely unavailable. There are no clear data on the availability of VRI or in-person interpretation. Given the limited number of available sign language interpreters and the cost, VRI may be more available than in-person. Existing evidence tends to focus on assessing personal preferences of Deaf users regarding interpretation and interpreters’ preferences. Although respecting preferences is essential, there is a vacuum of knowledge on how the format of access to interpretation impacts the quality of communication between Deaf persons and health personnel. ObjectiveThis study aims to look at the effectiveness of the VRI system in improving communication outcomes between Deaf patients and doctors versus the available standard of care of the usual communication tools, including informal interpretation, lip- or note-reading, and using their mobile phones to contact a formal or informal interpreter, for Deaf patients aged 18 years and older in Bogota, Colombia. MethodsThis is a randomized controlled trial with a total sample size of 216 participants, divided into 2 groups: an intervention group, which receives a medical appointment using VRI, and a control group, which receives a medical appointment using standard communication. Both the Deaf participants and the health care professionals will be blinded to the allocation, as they will not know whether the appointment will involve VRI or standard communication until they arrive at the office. The primary outcome measure will be an assessment of communication using a Doctor-Patient Communication Scale. This scale was translated into Colombian Sign Language following a rigorous cultural adaptation and translation procedure. Furthermore, the database contains key clinical variables and recommendations provided by the doctor during a general medicine appointment. We will compute associations. ResultsRecruitment opened on August 24, 2023. As of July 2024, 180 participants had been enrolled. The intervention and data collection were finalized in October 2024. The findings of this study are expected to be submitted for publication in early 2025. ConclusionsThis study will provide rigorous evidence regarding information and communications technology intervention in health care, addressing empirical challenges in using inclusive research designs in public health. In addition, effective VRI models that address the challenges faced by Deaf people will be tested, implemented, and maintained in low- and middle-income countries. A disability-inclusive evaluative tool for quality communication mediated by VRI in health care is also tested. Ultimately, this will lead to evidence-based recommendations for implementing the Convention on the Rights of Persons with Disabilities (CRPD) in mobile health contexts. Trial RegistrationClinicalTrials.gov NCT05966623; https://clinicaltrials.gov/study/NCT05966623 International Registered Report Identifier (IRRID)DERR1-10.2196/64590

Introduction ISMiHealth is a clinical decision support system, integrated as a software tool in the electronic health record system of primary care, that aims to improve the screening performance on infectious diseases and female genital mutilation (FGM) in migrants. The aim of this study is to assess the health impact of the tool and to perform a process evaluation of its feasibility and acceptability when implemented in primary care in Catalonia (Spain).Methods and analysis This study is a cluster randomised control trial where 35 primary care centres in Catalonia, Spain will be allocated into one of the two groups: intervention and control. The health professionals in the intervention centres will receive prompts, through the ISMiHealth software, with screening recommendations for infectious diseases and FGM targeting the migrant population based on an individualised risk assessment. Health professionals of the control centres will follow the current routine practice.A difference in differences analysis of the diagnostic rates for all aggregated infections and each individual condition between the intervention and control centres will be performed. Mixed-effects logistic regression models will be carried out to identify associations between the screening coverage and predictor factors. In addition, a process evaluation will be carried out using mixed methodology.Ethics and dissemination The study protocol has been approved by the institutional review boards at Hospital Clínic (16 June 2022, HCB/2022/0363), Clinical Research Ethics Committee of the Primary Care Research Institute IDIAPJGol (22 June 2022, 22/113-P) and the Almería Research Ethics Committee (27 July 2022, EMC/apg). The study will follow the tenets of the Declaration of Helsinki and Good Clinical Practice. All researchers and associates signed a collaboration agreement in which they undertake to abide by good clinical practice standards.Findings will be disseminated in peer-reviewed journals and communications to congresses.Trial registration number NCT05868005.

Introducción. En los países de medianos y bajos ingresos, los datos sobre la mortalidad y los factores de riesgo en pacientes con enfermedad pulmonar obstructiva crónica son limitados. Objetivo. Identificar la incidencia de muerte y sus variables relacionadas en una población colombiana durante 12 meses de seguimiento. Materiales y métodos. Se llevó a cabo un estudio retrospectivo de sujetos con diagnóstico de enfermedad pulmonar obstructiva crónica en una clínica de tercer nivel en Colombia. Los cocientes de probabilidades se calcularon mediante un análisis de regresión logística multivariable con la variable de resultado “mortalidad a los 12 meses”. Resultados. Ingresaron 524 pacientes, de los cuales el 18,1 % (95 / 524) murió. La edad promedio fue de 69,7 (DE = 8,92) y el 59,2 % (310 / 524) eran mujeres. Las variables asociadas con la mortalidad fueron la edad (OR = 6,54; IC95%: 3,65-11,36; p < 0,001), años de exposición al humo de leña (OR = 4,59; IC95%: 1,64-12,82; p = 0,002), insuficiencia cardiaca crónica (OR = 1,81; IC95%: 1,13-2,91; p = 0,014), enfermedad cerebrovascular (OR = 3,35; IC95%: 1,04-10,75; p = 0,032) y enfermedad renal crónica (OR=6,96; IC 95%:1,15-41,67; p = 0,015). Al ajustar las variables en el análisis multivariado únicamente se mostró asociación entre el sexo (OR = 1,55; IC95%: 0,95-2,54; p = 0,008) y la edad (OR = 5,94; IC95%: 3,3-10,69; p < 0,001). Conclusión. La edad, los años de exposición al humo de leña, la insuficiencia cardiaca crónica, la enfermedad cerebrovascular y la renal crónica fueron variables clínicas asociadas a un desenlace fatal. Sin embargo, la edad y el sexo fueron las únicas relacionadas con la mortalidad al ajustarlas por factores de confusión.

The increased prevalence and significant negative consequences associated with cyberbullying justify the need for empirical research that helps provide a deeper understanding of the problem. The objective of this study was to identify the existence of different cyberbullying profiles (according to degree of cybervictimization and cyberaggression of students) and whether these profiles vary with regard to anxiety, depression, and stress. The sample consisted of 1,185 students aged 12 to 18 ( M = 14.01; DT = 2.36). A latent class analysis and ANOVA were carried out. The data showed four profiles: not-involved (low scores for cybervictimization and cyberaggression), cybervictims (moderately high scores for cybervictimization and low scores for cyberaggression), cyberbullies (low scores for cybervictimization and moderately high scores for cyberaggression), and cybervictims-cyberbullies (high scores for cybervictimization and cyberaggression). Statistically significant differences in anxiety, depression, and stress were found between the profiles. The group of cybervictims and cybervictims-cyberbullies presented higher anxiety than the not-involved group and cyberbullies. The cybervictims-cyberbullies group showed higher depression and stress levels than the other groups, and the cyberbully group showed a higher level of depression than the not-involved group.

This article proposes an analysis of Juan Marsé’s work based on the theme of memory. In order to do so, we start by differentiating between the diverse processes concerning memory and we find that in the author’s fictional project the so-called “subaltern memory” takes on special relevance. The protagonists, Charnegos from the Catalan periphery, and their use of popular tradition (through cinema and aventis) run uninterruptedly through Juan Marsé’s narrative and are placed at the service of a literary truth that functions in opposition of the truth imposed by the Franco regime. The aim is to detect not only what kind of memories proliferate in Marsé’s narrative, but also what political sense they have in relation to the dictatorial past; that is, how the subaltern memories of the Kabileños construct in fiction a universe of reference different from that imposed by official memory.

Resumen Las redes sociales han generado una esfera pública híbrida con una creciente atención al papel de los sentimientos en el discurso público. Para los políticos, las redes son útiles al generar entornos de sentimientos individuales y colectivos, más que al dar razones y propiciar el diálogo público. El objetivo de esta investigación es analizar si existe sintonía afectiva entre los mensajes de líderes políticos y la respuesta que provocan en las redes. Para ello, se estudiaron los posts de los principales políticos colombianos, durante las manifestaciones del Paro Nacional, de 2021 y las reacciones emotivas que provocaron en Facebook. Tras el estudio, se comprobó la congruencia afectiva entre los mensajes y las reacciones y que el discurso público online se sustenta más en compartir criterios emotivos, que en una línea deliberativa racional.

Abstract Root-knot nematodes (RKNs) are obligate endoparasites that feed on their host plants to complete its life cycle, representing a major threat to agriculture and economy worldwide. The development of new management strategies becomes essential as effective chemical nematicides are progressively being restricted. Hence, we analysed grape pomace-derived biochars, pyrolysed at 350 °C (BC350) and 700 °C (BC700), focusing on their potential for RKN control. The thermal treatment of grape pomace caused an increase in the concentration of carbon and plant macro- and micronutrients, which were largely present in a water-soluble form. Synchrotron radiation-based Fourier transform infrared microspectroscopy data showed a general loss of carboxylic functional groups during pyrolysis, partially contributing to the alkalinisation of both biochars, mostly in BC700. Scanning electron microscopy coupled with energy-dispersive X-ray spectroscopy analysis revealed a highly porous structure filled with different crystals composed of elements such as K, Ca, Mg, P, Si or Al, which could be a suitable environment for the growth of microorganisms. Biochar-derived aqueous extracts showed phytotoxicity to tomato seedlings at high concentrations, and disappeared upon dilution, but no toxic effect was observed on the nematode’s infective stage. However, the infective and reproductive traits of a Meloidogyne javanica population in tomato were significantly reduced (i.e. egg masses and eggs per plant) in washed-biochar-treated soil in pots (0.75%; BC350W). Therefore, the large amount of grape waste generated after wine production can be transformed into a valuable product such as biochar, effective for RKNs control, thus reducing the waste management problem and contributing to a circular economy. Graphical abstract

Multidrug-resistant (MDR) bacteria have become one of the most important health problems. We aimed to assess whether international travel may facilitate their spread through the colonization of asymptomatic travelers. A cross-sectional study was conducted (November 2018 to February 2022). Pharyngeal and rectal swabs were obtained from long-term travelers and recently arrived migrants from non-European countries, and an epidemiological survey was performed. Colonization by Gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) was determined by chromogenic media and MALDI-TOF-MS. Resistance mechanisms were determined by the biochip-based molecular biology technique. Risk factors for colonization were assessed by logistic regression. In total, 122 participants were included: 59 (48.4%) recently arrived migrants and 63 (51.6%) long-term travelers. After their trip, 14 (11.5%) participants—5 (8.5%) migrants and 9 (14.3%) travelers—had rectal colonization by one MDR bacterium. Escherichia coli carrying the extended-spectrum beta-lactamase (ESBL) CTX-M-15 was the most frequent. No participants were colonized by MRSA or carbapenemase-producing Enterobacteriaceae. The only risk factor independently associated with MDR bacterial colonization was previous hospital attention [OR, 95% CI: 10.16 (2.06–50.06)]. The risk of colonization by MDR bacteria among recently arrived migrants and long-term travelers is similar in both groups and independently associated with previous hospital attention.

The challenges in the characterization of the nutritional quality of grain foods comprise obstacles to public health actions toward promotion of healthier grain-based foods. The present study investigated how carbohydrate metrics related to glycemic index (GI), glycemic load (GL), and warning labels of grain foods consumed by individuals living in São Paulo, Brazil. Information on intake of grain foods at individual level was obtained using 24 h recalls within a cross-sectional population-based survey conducted in 2015. There were 244 unique grain products reported by individuals in the survey, assessed through four metrics of carbohydrate quality, considering contents per 10 g of total carbohydrate: (1) ≥1 g fiber, (2) ≥1 g fiber and p-values < 0.001]), and GL (−12.5 to −10.3 [p-values < 0.001]). Warning systems showed a certain degree of discrimination between products according to the metrics (p-value < 0.01 each); however, >50% of products with good nutritional quality according to the carbohydrate metrics still would receive warnings. Findings suggest that carbohydrate metrics identified products with lower GI and GL, and current warning labels may not adequately capture overall nutritional quality of grain foods.