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VOL. 5 • NO. 3
© January 2011
Adolescent Health: Youthful decisions impact future quality of life — sometimes for the better It’s not only physical changes that mark Robertho Gay is a 16-year-old junior at this period of life. Teens experience psychoCodman Academy Charter Public School. He logical, behavioral, emotional and personality gets up at 4 a.m. to hit the gym before school, changes as well, some of which evoke a hefty and his extracurricular activities and homework toll. The Youth Risk Behavior Surveillance keep him up later than he’d like. But he’s not re(YRBS), a survey of students in grades 9 to 12, ally worried about his schedule. “Not a lot really examines six health-risk behaviors — injuries bothers me,” he said. and violence, tobacco use, alcohol and drug use, Robertho has his sights on a career in busisexual behaviors, dietary behavior and physical ness, but for now nutrition holds his interest. He’s inactivity — that significantly impact the quality a member of the Academy’s Nutrition Action of life. The survey is conducted by the Centers Club in which a group of students meet regularly for Disease Control and Prevention as well as to discuss health, fitness and nutrition to promote state and local education and health agencies. a healthy lifestyle. He confided that he actually The reason for the survey is clear. Accordjoined the club to learn how to cook. ing to the National Center for Health Statistics, But he got a little more than he bargained for. 84 percent of deaths in youth ages 11 to 19 in Not only has he learned that roasting chicken is this country results from injuries and violence. more healthy than frying it, he got an eye-opener What’s worse, one additional risk behavior on risks of certain illnesses — risks closely linked — alcohol and drug use — often contributes to to nutrition. “I learned about the risks of high these deaths. blood pressure, a heart attack and stroke,” he said. Often lost in the discussion of healthy teens If only all teenagers were as curious as is the subject of healthy bones. Dr. Catherine Robertho. Adolescence, which straddles childM. Gordon, the director of the Bone Health hood and adulthood, is a period of change — and Program at Children’s Hospital Boston, admits confusion. The adolescent is neither a child nor that bone health might not be the sexiest of an adult. And the decisions and choices made topics, but this relatively new area of focus during this period of major transition can have an Robertho Gay, 16, credits the student-led Nutrition Action Club at Codman Academy Charter in pediatrics is gaining momentum. With a everlasting impact. The medical conditions common in teens are Public School for his understanding of healthy eating and risk factors. (Ernesto Arroyo photo) combined training in adolescent medicine and endocrinology, Gordon ticks off the diagnoses she many — asthma, sexually transmitted diseases and major growth and transition. “It is when young people establish treats — anorexia, cystic fibrosis and both vitamin reproductive problems — to name a few. Obesity, D deficiency and insufficiency — a plight all too common in health habits,” said Emans. “Patterns can be set at 10 or 12.” the precursor to cardiovascular and other diseases, is becoming Puberty starts the whole process in motion. There’s a really African American teens. more prevalent in youth. A recent study published in the Journal Bone health may not be the topic of conversation, but of the American Medical Association reported that across the perhaps it should be. “About half of the skeleton is laid down in country, more than one third of adolescents between the ages of The Center for Young Women’s Health the teenage years,” said Gordon. “Hormones cause bones to be12 and 19 were overweight or obese. come denser,” she said, referring to the amount of calcium and When asked to define the age of adolescence, Dr. S. www.youngwomenshealth.org other minerals and protein packed in bones. People reach their Jean Emans, chief of the Division of Adolescent and Young Young Men’s Health peak bone mass — the amount of bony tissue present when the Adult Medicine at Children’s Hospital Boston, did not have skeleton completes maturation — around the age of 20. a ready answer. “That’s a good question,” she said. “There www.youngmenshealthsite.org There’s one catch though. If a person fails to reach peak isn’t one answer.” bone mass during adolescence, there’s no catch-up period. The She’s right about that. Often young adults are included missed opportunity can remain silent for 30 to 40 years until a fast growth spurt; some grow four or more inches in a year. In in the mix. The age delineations vary by organization and can person trips and falls and breaks a hip. Or sneezes and fractures males, the voice changes, the shoulders broaden, muscles derange anywhere from 10 to 24 years — the definition used by a bone in the back. velop and facial hair emerges. Females develop breasts, become the U.S. Department of Health Human Services. What everyone a bit curvier and begin monthly menstrual cycles. does agree on is the challenge that accompanies this period of Gay, continued to page 4
Marching toward a healthier beat In many ways, Terrance Miles, 18, is a typical teenager — he has a set of headphones seemingly glued to his head. “I listen every chance I get,” he says, “on my way to school, on my way home from school, on my way to work.” But in listening to an eclectic list of musicians — everyone from Eric B and Rakim to Jay-Z and Lupe Fiasco — Miles says he came to a not-so surprising conclusion: a lot of the lyrics are in bad taste and promote unhealthy lifestyles and relationships. So significant is the impact of music on risk behaviors that the American Academy of Pediatrics (AAP) in 2009 took a stand and developed a policy statement to make pediatricians and parents aware of music’s influence on children and youth. According to the AAP, a staggering 42 percent of songs on the top 10 CDs contain very explicit sexual content. Furthermore,
some types of music in particular — rap, rock and heavy metal — often revolve around sexual promiscuity, death, homicide, suicide and substance abuse, all risk factors relating to high mortality rates in adolescents. The AAP has a lot of support. The Center on Media and Child Health at Children’s Hospital Boston researches the impact of media on children’s health. The Boston Public Health Commission’s Start Strong Initiative not only educates teens about healthy relationships, it has developed a tool to analyze the “health” of lyrics. Like many health-conscious teenagers, Miles decided to do something and recently became a mentor for the Initiative. “I hope it has an effect,” he said. At first, he explained, he did not put that much stock in the theory that lyrics could have that sort of impact. They had little Miles, continued to page 4
Terrance Miles (right) is shown (from left to right) with Haxin Zeng, a Start Strong Initiative peer leader, U.S. Congressman John Lewis of Georgia and Cherri Allison, the executive director of the Family Violence Law Center in Oakland, Calif. The group attended a Start Strong national meeting in Washington, D.C., which focused on violence prevention. (Photo courtesy of Start Strong Initiative)
Teen depression: More than just a bleak mood Teen years can be tumultuous, full of mood shifts and eye-popping drama. If bleak moods or other troubling signs stretch on for weeks, however, it’s wise to take a closer look. One national survey of 13 to 17 year olds found 8 percent of participants had experienced depression. Girls were almost three times as likely to do so as boys. A separate national survey of African Americans and blacks of Caribbean descent estimated 7 percent of black teenage girls — and 4 percent of all black teens — will attempt suicide by age 17, a tragic act often tied to depression. In this issue of Be Healthy, Dr. M. Elyce Kearns, M.P.H., child psychiatrist and physician reviewer at Blue Cross Blue Shield of Massachusetts, offers important tips to help parents recognize signs of depression and act on their concerns.
your child best. This is not to say your son or daughter won’t have a good day here and there. But overall, look for persistent changes in mood, activities and physiology.”
between thoughts, feelings and behaviors, and encourages teens to practice coping skills in real-life situations. When a prescribed treatment isn’t sufficient, switching medicines or combining medicine with CBT often helps, according to a study of resistant depression in teenagers recently published in the American Journal of Psychiatry. Be sure to check with your child’s doctor for advice on an appropriate course of treatment.
What can parents do? • If you suspect depression: Call your child’s doctor, who can refer you to a therapist or counselor who specializes in teen depression for evaluation and treatment, if necessary. A school guidance counselor or local crisis centermay also be helpful. • If a teen talks about suicide — take it seriously. Call your child’s doctor right away, or engage emergency services through 911, the closest crisis evaluation service or emergency room for evaluation.
What are the signs of depression in teens? While sad moods affect everyone at times, a true depression clings for weeks or months on end, derailing daily activities. According to the National Institute of Mental Health, these signs of depression may occur in people at any age: • Persistent sad, anxious or “empty” moods; • Feelings of hopelessness, pessimism; • Feelings of guilt, worthlessness, helplessness; • Loss of interest or pleasure in once-enjoyed activities. Signals of depression can differ in teens, says Kearns, and vary from one teenager to another. Often, early signs of distress are physiological changes, such as marked shifts in appetite, sleeping habits, energy and hygiene. Moods are also likely to change, with bleaker emotions taking hold. A teen may appear depressed, sullen, disinterested and withdrawn, or irritable and short-fused, possibly even aggressive. Difficulty making decisions, restlessness and hyperactivity may also be part of the mix. Given the wired world teens inhabit, other clues are changes in time spent on texting, social networking sites like Facebook, surfing the net, playing computer games, and even “old-school” phone calls or time spent with friends. A big upswing — texting or gaming late into the night, let’s say — or downswing — pulling back from deep friendships, perhaps, or fights with friends — is cause for concern. “The key here is change,” Kearns emphasizes. “You know
Where else can parents turn? What triggers depression? Underlying reasons for depression vary. Often, several issues are entwined. One possibility is genetic vulnerability. If parents or other family members have suffered depression, a teen is more likely to experience it, too. Genes aren’t destiny, however, and not all people who have these genes wrestle with depression. Stressful situations or traumas may also spark depression. Big problems like financial hardships or having a parent overseas can take a stressful toll on a teen. Worries about violence and personal safety, bullying, competing pulls of school work and social lives, and pressure to own costly clothes and electronics, or engage in dangerous activities can be overwhelming. During the holiday season, glittering wish lists and happy family stories can highlight sorrows and painful differences in family circumstances.
How is depression treated in teens? Therapy, exercise and perhaps medicine can do a great deal to relieve depression. Especially successful in teenagers is cognitive behavior therapy (CBT), which explores connections
Check online for additional information on depression or suicide prevention: • The Blue Cross Blue Shield of Massachusetts website www. AHealthyMe.com. • The National Institute of Mental Health (www.nimh.nih. gov) reports on research and has many helpful free publications. • National Alliance on Mental Illness (www.nami.org) offers information directed at teens and families. • The American Academy of Child and Adolescent Psychiatry has an extensive website (www.aacap.org) with resources for families including Facts for Families. • The National Suicide Prevention Lifeline (www.suicidepre ventionlifeline.org) and Samaritans (www.samaritansofboston.org) have quizzes, suicide-prevention tips and help lines. The National Suicide Prevention Lifeline (800-273-8255) and Samariteens (800252-8336) also operate help lines 24/7. Staying in tune with your teen’s moods, habits and physiological changes, such as shifts in appetite or sleeping habits, can help you recognize changes early on that may be caused by stress or depression so you can work together with your teen (and a professional — if needed) toward an effective solution.
START YOUNG TO DEFUSE STRESS
“Parents can help children develop resilience by learning ways to cope with stress early on,” says Dr. M. Elyce Kearns, child psychiatrist . Try to model healthy stress-easing tactics when life runs you ragged. Encourage children to find a mix of calming choices that work for them (see bullets). Stick to sleep and mealtime routines, and keep communicating. Checking in daily about homework, plans and activities, and what happened during the day helps keep communication lines open for more difficult times. • Time out: Take a break to do anything you enjoy. • Deep breathing: Try this in a quiet spot or while walking. For five minutes, breathe in through the nose while silently counting 1-2-34. Breathe out through the mouth while silently counting 4-3-2-1. • Activity: Go for a run or walk, bounce around, skip rope, do jumping jacks or push-ups, shoot hoops, practice yoga or get moving any way you like. • Creative outlets: Scribble, draw, paint or try journal writing.
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Questions & Answers 1. Why is TDaP immunization — a vaccine that protects against tetanus, diphtheria and whooping cough — necessary if a teen has received protection against these diseases as a child? Children between the ages of 2 months to 4 years should receive 5 injections of DTaP, the vaccine that Sophie Allende-Richter, M.D. protects against tetanus, Pediatrics/Adolescent Medicine diphteria and pertussis, Martha Eliot Health Center which causes whooping cough. But unfortunately with time, the protection against these infections — all of which can be very serious or even fatal — decreases. This is why the Centers for Disease Control and Prevention currently recommends vaccinating all children, ideally by 11 to 12 years, with one single dose of a booster called TDaP. 2. Since bone weakness, such as osteoporosis, is more common in females, is it necessary for male adolescents to be concerned about calcium and vitamin D? Both males and females can develop osteoporosis. Vitamin D deficiency, considered a precursor to osteoporosis, is just as common in male teenagers as it is in females. African American and Hispanic teens are more susceptible to vitamin D deficiency for several reasons. Darker skin, obesity and wintry climates impair the production of vitamin D, whose greatest source is sun exposure. In addition, it is hard to find vitamin D in foods. Therefore, males as well as females are susceptible to developing some degree of osteoporosis in their older age.
Think immunizations are just for kids? Think again. The protection provided by some early childhood vaccines can wear off, and risks for other diseases increase as children approach their teen years. Recommendations for immunization are made by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Make sure your adolescent is fully protected. If your teen was not immunized at the recommended age, for most illnesses, there’s still time to catch up. Check the list below and ask advice from your pediatrician.
RECOMMENDED IMMUNIZATIONS ADOLESCENTS 11 TO 19 YEARS
FOR
DOSING REQUIREMENTS
Tetanus, Diptheria toxoids, acellular Pertussis (TDaP) Hepatitis B
3 doses
Measles, mumps, rubella (MMR)
2 doses
Chickenpox (varicella)
2 doses
Human Papillomavirus (HPV)
3 doses
Meningococcal (MCV4)
1 dose
Polio 3. Is tobacco more detrimental to the health of a teenager than an adult? It is detrimental to both age groups, but clearly the longer the exposure to tobacco, the more harmful it is to one’s health. 4. At what age should a parent transfer the care of his or her child to an internist or family practitioner? That depends on where you live. In some areas it is difficult to find a pediatrician or an adolescent medicine provider. In such cases a family practitioner or an internist is your best choice. In urban settings, where doctors are more plentiful, it is typical to transition a patient between the ages of 18 and 21 to an adult provider. The expectation is that by the age of 21 a person has made the choice of an adult primary care physician that he or she is feel comfortable with.
1 dose
3 doses
Influenza
Yearly
Hepatitis A
High risk*
Pneumococcal (PPSV)
High risk*
*Recommended for adolescents with certain chronic health problems. Visit www.vaccinesforteens.net/index.html for more information.
5. Is it necessary for adolescents to be tested for high blood pressure, high cholesterol and diabetes — illnesses more common in adults? Yes. It is possible to see cases of cardiovascular diseases and type 2 diabetes in teenagers and young adults. Lifestyle is partly to blame — highcarbohydrate, low-fiber diet and lack of exercise. But genetic predisposition may also be a factor. For these reasons, in an effort to prevent these negative outcomes, starting at the age of 11 or 12, it is recommended to obtain a detailed family medical history and screen for cholesterol and diabetes in an effort to assess risk factors and provide appropriate health advice. 6. Should males as well as females be immunized against human papillomavirus (HPV), which can cause cervical cancer and genital warts? The Advisory Committee on Immunization Practices, a federallyappointed panel of experts, does not currently recommend routine HPV vaccination in males. The Committee does recommend, however, routine vaccination of three doses of HPV vaccine for females between the ages of 9 and 26. 7. Is chewing tobacco or snuff safer to use than cigarettes? No, both are associated with oral cancer which is not any better than any known form of cancer. 8. How many servings of vegetables and fruits a day is recommended for adolescents? It is recommended that adolescents eat five or more servings of fruits and vegetable every day. 9.Why should teens eat breakfast every day? Eating breakfast prevents teens from snacking in between meals and refraining from junk food, which typically are high in empty carbohydrates and calories. Furthermore, the carbohydrates found in healthier food, such as whole grain bread and cereal, and proteins, found in milk, are slowly metabolized by the body which can enhance school performance by allowing a steady blood glucose concentration at a time of the day when a teenager needs it the most. 10. How often should adolescents have their body mass index (BMI) — which estimates a healthy body weight — measured? It is standard to measure the BMI during the yearly physical. Additional measurements are taken on a case by case basis.
The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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Gay, continued from page 1 The good news is that many adolescents are able to build and maintain good bone health, especially if they observe a few lifestyle changes by consuming 1,300 milligrams of calcium and a minimum of 600 International Units (IU)
Catherine M. Gordon, M.D., M.Sc. Director, Bone Health Program Children’s Hospital Boston
of vitamin D a day. Also helpful is participating in weight-bearing exercises like walking and maintaining a healthy weight. “It’s very hard to get vitamin D from diet,” Gordon said. “Most kids don’t eat fatty fish,” one of the few natural sources of vitamin D. The sun is the most effective source of vitamin D. “In the winter when the rays are less strong, some teens at high risk for deficiency — those who are obese, for example — may need 2,000 IU,” she said, pointing out that the amount is more than three times the 600 IU recommended by the Institute of Medicine. Robertho admits that he still has work to do. He does not always get the daily six cups of fresh fruits and vegetables for his age, gender and exercise level, as recommended by the United States Department of Agriculture. He’s short on the daily requirements of vitamin D and calcium and he prefers white rice to healthier whole grain brown rice. But he continues to make strides in his understanding of diseases. His school nutrition club recently launched a diabetes screening program in which 70 percent of the students participated and learned that 11 percent had elevated levels of blood glucose, a warning sign of diabetes. There may be a light at the end of the tunnel. The 2009 YRBS data for students in Massachusetts show improvement in many health risks over the past 10 years. Although a smaller percentage of kids said they rarely or never buckled up in the past, there is still a long way to go because Massachusetts youth
are less likely to use seat belts than their peers nationally. Fewer drove when drinking or rode with a person who had been drinking. Cigarette smoking declined as well as alcohol, marijuana and heroin use. Only 14 percent versus 21 percent in 1999 seriously considered attempting suicide. Some things, however, remained the same. Kids were still likely to carry weapons and be injured in fights. Although cigarette smoking declined, teens continued to smoke cigars or cigarillos. Sexual behavior remained unchanged in the 10-year interval. About the same percentage of adolescents had sexual intercourse for the first time or had sex with four or more persons. What’s disturbing is that almost 43 percent failed to use a condom during their last sexual contact. Although sexual behavior is not a lifethreatening activity, the consequences — unwanted pregnancies or infection with a deadly virus — can be dire. Some behaviors got worse, however. More students were considered obese at a time when obesity is causing higher rates of diabetes, high blood pressure and cholesterol. And soda is still replacing the recommended three glasses of milk a day. According to Emans, parents have a very active role in the health of their teens. They have to make sure their kids get yearly physicals and are up to date in shots. “They have to be on the look out for any kind of change — emotional as well as physical — in their
LONG-TERM PLANNING … STOCK UP ON HEALTHY BONE NOW When you think of osteoporosis, you see visions of older women with stooped posture. But actually, you should think of teens and vitamin D and calcium. Although osteoporosis usually is manifested in older people, its groundwork is laid in youth. If children and adolescents fail to reach optimal bone mass and strength, they are more likely to develop osteoporosis. But there’s a way to “add bone to the bone bank” while you’re young.
1. Take the recommended dietary allowance of calcium and vitamin D each day.
VITAMIN
CALCIUM
Age
D
Age
Amount
9 to 18 years
1,300 milligrams (mg)
1 to 70
600 International Units (IU)
19 to 50 years
1,000 mg
70+
800 IU
Amount
Source: Institute of Medicine (IOM) * Although IOM recommends 600 to 800 IU of vitamin D a day, some health providers recommended higher levels. Ask your doctor what works best for you.
Test your knowledge Q: Which is the greatest source of calcium? A. Collard greens B. Low fat milk C. Low fat yogurt D. Sardines
Q: Which is the greatest source of vitamin D? A. Fortified milk B. Sockeye salmon C. Fortified orange juice D. Egg
Answer: All contain calcium, but yogurt contains more than 400 mg in an 8-ounce serving.
A: Three ounces of sockeye salmon contain almost 800 IU vitamin D. The sun is the greatest source of vitamin D, but is not strong enough in the Northeast during the winter to make a sufficient supply.
If you are unable to get the required daily dose of calcium and vitamin D, supplements are recommended.
2. Be physically active 60 minutes a day. • Weight-bearing exercises, like walking, jogging and even dancing, help establish and maintain strong bones. • Include muscle strengthening activities, such as gymnastics or push-ups, at least 3 days per week as part of your child’s 60 or more minutes.
3. Maintain a healthy weight. S. Jean Emans, M.D. Chief, Division of Adolescent Medicine Co-Director, Center for Young Women’s Health Children’s Hospital Boston
children,” said Emans. In addition, parents have to walk the talk. It’s futile to convince children to not smoke or drink while holding a beer in one hand and a cigarette in another. And healthy eating and exercise begins at home. “Communication is key,” said Emans. “Parents have to talk to their kids.”
SO WHAT’S TO EAT? YOU CHOOSE There is no one eating plan that all adolescents should follow. The amount of food to meet a teen’s daily nutritional needs depends on height, weight, gender, physical activity and health status. The following estimate, based on 2,200 calories, is designed for a 16year-old female of average height and weight who exercises 30 to 60 minutes a day. Each person should develop his or her own eating plan. Visit www.mypyramid.gov to get ideas and get started. Fruit
Vegetables 3 cups
2 cups
SAMPLE 1 CUP EQUIVALENT 1 cup collard greens 1 cup cabbage 1 ear of corn 2 cups lettuce
SAMPLE 1 CUP EQUIVALENT 1 large banana 1 large orange ½ cup raisins 1 small wedge watermelon
Legumes, nuts, seeds 4 servings a week
Lean meats, poultry, fish 6 ounces or less
SAMPLE SERVING
SAMPLE SERVING
1/3 cup nuts ½ cup black-eyed peas 2 tablespoons peanut butter or seeds
small lean hamburger 3 ounce salmon steak - 5 ounce chicken breast half 3 ounce
Dairy products 3 servings
Whole grains 7 servings
SAMPLE SERVING
SAMPLE SERVING
1 cup non-or low-fat milk 1 cup non-or low-fat yogurt 1½ ounces cheese
1 slice whole wheat bread ½ cup brown rice 1 cup dry cereal ½ cup cooked oatmeal
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Too little weight and too much weight are both detrimental. A low weight can cause decreased bone density, while overweight can interfere with the body’s ability to produce vitamin D.
4. Establish healthy behaviors. Smoking cigarettes is closely linked to not only cancer and heart disease, but to low bone density in adolescents as well. Experts also believe that high consumption of alcohol in youth is detrimental to bone health.
Miles, continued from page 1
effect on him, he says, in part because strong parental guidance kept him on the straight and narrow. But when he witnessed abusive relationships in his friends, he realized the problem was more severe than he thought. “It’s impossible to avoid,” he said. Annika Nielsen, an 18-year-old senior at Boston Latin School, is another teen who is actually doing something to encourage healthier lifestyles. Nielsen said that she’s always been conscious of good health. She’s a member of the track team at Latin and she’s starting a club at school for staying healthy and fit. “I generally eat very healthy,” she said. “Although I’m not opposed to cookies and cakes now and then.” She gets a yearly physical and takes her vitamins every day. When asked about soda, she answered “never.” Nielsen is a member of Breath of Life Dorchester (B.O.L.D.) Teens, a nonprofit community based group that already has changed life for the better. Her work with B.O.L.D. Teens has given her a more global perspective. “It’s no longer me, myself and I,” she said. When several of its members recognized that the tobacco industry was targeting black youth through rap music and billboard advertisements, they went into attack mode. They protested the sale of tobacco products in pharmacies and worked with the Boston Public Health Commission to increase fines for selling tobacco products to minors. Their greatest accomplishment, which
was praised by the Center for Tobacco Products, was the design of bright pink warning labels that are affixed to cigarette packs. According to the teens, about 15 merchants in the area have supported and allowed the distribution of the labels. Their actions may have had an effect. Black teens in Massachusetts are less likely to smoke than white teens. B.O.L.D. Teens are now focused on another front: healthy eating. “There are a lot of health disparities,” Nielsen said. “I believe access to healthy foods and knowing a healthy lifestyle is important for everyone.” And she knew teens are hit hard. According to the Centers for Disease Control and Prevention, in 2009, less than one-fourth of high school students interviewed reported eating fruits and vegetables five or more times daily. Nielsen saw part of the problem, “There was no way to get a healthy meal in my neighborhood,” she said. “A person would have to travel to get healthy food.” And that’s when the farmer’s market was born. Nielsen and the B.O.L.D. Teens contacted several farmers in the area. They listened and they came. For the past three years a farmer’s market has run in Dorchester every Thursday from the end of June to October. Nielsen sees the results. Not only was the community supplied with a wide variety of fresh fruits and vegetables — strawberries, apples, squash, turnips and green beans, for example — this past year more men and young people took part.
Comments on Be Healthy? Contact Health Editor Karen Miller at kmiller@bannerpub.com.