**1. Introduction**

Austenitic stainless steels, particularly 316L grade, have received much attention because of their good mechanical properties and high corrosion resistance [1]. This material contains a maximum carbon content of 0.03 by weight, which provides an extra level of corrosion resistance as well as the high rate of weldability. Several domains, notably marine and petrochemical industry, architecture, chemical production, and also biomedical sector, use this stainless steel due to its superior tensile strength, fracture toughness, and good formability [2]. 316L is non-magnetic and has excellent biocompatibility, which makes him a good candidate in the production of biomedical parts such as knee joints of total hip replacements [3]. In addition, 316L became very attractive to the industry owing to its low-cost and easy fabrication.

In almost engineering applications, an important interest is directed to the aspect of surface as it strongly influences the functional properties of mechanical parts such as their corrosion resistance, tribological behavior, and fatigue durability. Most failures of manufactured parts initiate from the outer layers which are exposed to the environmental conditions of service [4]. Mechanical, metallurgical, or chemical changes are the most common causes of the initiation of alterations in the surface [5]. In the case of wear, repeated contact actions between surfaces lead to the abrasion and/or delamination of the superficial layer which causes a loss in material quantity as well as in wear resistance. This loss is also produced in the case of corrosion where chemical changes in the surface are provoked after the contact between the surface and the environment under which the material operates. As a result, of these phenomena, the properties of surfaces become poor and unacceptable to fulfill the intended requirements of service. Some examples of components because of surface damages are: (a) environmental stress cracking of plastics by some chemical environments [6], (b) turbine vane and blade material surface deterioration caused by erosion [7], (c) surface corrosion [8], etc. The surface quality of materials therefore greatly needs attention to guarantee a good longevity of manufactured products.

The surface integrity notion, as it is understood is manufacturing processes, was defined by Field and Kahles [9] as *the inherent or enhanced condition of a surface produced in machining or other surface generation operation*. This term concerns many parameters:

Among the aforementioned parameters, surface roughness and microhardness are the major ones influencing the functional properties of parts. By far, the two parameters are remaining extensively studied to achieve better surface integrity. Surface roughness is a measurement of surface texture. A lower surface roughness indicates a smaller contact area with other materials, which is advantageous to improve corrosion resistance, frictional resistance, and fatigue life. Generally, the high quality of surface roughness is highlighted by the low values of amplitude parameters of surface topography. These parameters clarify the aspect of the topography which is related to the distance of a point on the surface from the mean plane, i.e., it gives information about the height or depth of a surface [10]. Hardness is the ability of a material to resist deformation. It is commonly preferred to produce surfaces with high values of microhardness as it prevents failures by wear and fatigue.

One way of improving the surface roughness and microhardness of parts is by applying surface treatments during the finishing step. Ball burnishing is a common mechanical surface treatment that has been widely applied on engineering parts for the finishing of their functional surfaces. This post-machining process is based on causing plastic deformation of the superficial layers through compressing a hard ball on the surface of the workpiece (**Figure 1**). As the ball is continuously moving, it transfers a material flow from peaks to valleys of superficial asperities. As a result, surface irregularities are reduced and compressive residual stresses are induced in the deformed layer. These two simultaneous actions improve the physical and mechanical characteristics of the surface which becomes smoother and also harder. Ball burnishing is easy, simple, and fast process which enhance the long-term properties of materials with low energy and almost no environmental pollution.

At present, there are rich literature sources about the effect of ball burnishing on surface roughness and microhardness of materials and also on the service performance of manufactured parts. The positive effect of this treatment in reducing the surface roughness [12–16] and raising the microhardness [12, 15–18] was widely reported. As a result, of these changes caused in surface characteristics, wear delamination was restricted as the interlocking movements of micro-irregularities were limited during friction [4, 19]. Fatigue resistance, yield and tensile strength, and also corrosion resistance were improved [20, 21].

*Surface Integrity of Ball Burnished 316L Stainless Steel DOI: http://dx.doi.org/10.5772/intechopen.101782*

**Figure 1.** *Ball burnishing concept [11].*

High surface finishing after ball burnishing is dependant on whether appropriate parameters of the process were well chosen or not. While the penetration depth and the initial state of the surface play a secondary role in obtaining good surface integrity, other parameters such as the burnishing force, the feed rate, and the number of passes contribute fundamentally to the final aspect of the treated surface [22]. Thus, it is very necessary to choose the right combination of process parameters and to master their effect on the surface integrity.

This research tackles the surface integrity of 316L after being subjected to the ball burnishing process. The effect of the number of burnishing passes, as an important process parameter, will be investigated. The results will be analyzed in terms of surface texture and microhardness after processing. At the sight of the results, an appropriate combination between burnishing force, feed rate, ball size, and a number of passes shall be proposed to execute the operation according to the right objective. This is important for 316L to confer its parts the special properties intended in the different industrial applications.


**8.7 Coping skills training with parents and children or adolescents**

Family environment has been found to play an important role in the adaptation of children with type 1 diabetes (McDougal, 2002). It has been shown that family interventions decrease parent-child conflicts about diabetes and improve metabolic control (Grey et al, 2003; Wysocki et al, 2000; Wysocki et al, 2001). One study that includes 119 families of adolescents with type 1 diabetes mellitus, assessed the effectiveness of an experimental group receiving Behavioral-Family Systems Therapy compared to both education and support groups in reducing parent-adolescent conflict in diabetes management. The Behavioral-Family Systems Therapy intervention targeted parent-adolescent conflict by focusing on family problem solving, communication skills training, cognitive restructuring, and aspects of functional and structural family therapy over 10 sessions. The results revealed that the experimental group showed significant improvement in parent-adolescent relationships, decreased diabetes-specific family conflicts, and increased treatment adherence when compared with education and support groups. At 6-month follow-up, parent-adolescent relationships remained significantly improved for the experimental group as compared to the control group. At 12 months, diabetes-specific family conflict was significantly improved compared to the control group. The experimental group showed improved treatment adherence compared with the control and education groups that both showed deteriorated adherence (Wysocki et al, 2000; Wysocki et al, 2001).

When parental involvement decreases, which is frequent in early adolescence, the metabolic control tends to deteriorate. Anderson et al. (Anderson et al, 1995) studied an office-based intervention to maintain parent adolescent teamwork in diabetes management. The study variables included parental involvement in diabetes care, family conflict, and subsequent metabolic control. Eighty-five patients aged 10 to 15 years were randomly assigned to one of three groups, which included teamwork, attention control, or standard control for 24 months. The teamwork families reported less conflict at 12 months. More adolescents in the teamwork group when compared to the comparison groups improved their HbA1c levels

Inadequate Coping Attitudes, Disordered Eating

**9.1 Diabetes treatment**

physical and mental health.

Jones & Khan, 2007).

**9.2 Nutritional management**

Behaviours and Eating Disorders in Type 1 Diabetic Patients 107

The diabetes team has the important responsibility of monitoring insulin regimens and providing education about diabetes management and potential complications to patients and families (Krakoff, 1991). There are no studies looking at treatment of ED/DEB in youth with type 1 diabetes. The traditional approaches to poor blood glucose control involving a stricter and more intensive monitoring of the diabetic management may increase the risk for disordered eating (Colton et al, 1999). For this reason, it is recommended a less rigid approach in the insulin regimen and nutrition therapy to improve DEB. Lowering the amount of time spent on diabetes management during the day may help to lessen stress associated with the diabetes, which may in turn help alleviate DEB. Krokoff (Krokoff, 1991) suggested that self-destructive insulin manipulation within the context of an ED may also be an indirect call for help, signaling the need for more parental/adult intervention in patient's

Trento et al, (Trento et al, 2009) suggest that offering a carbohydrate counting program within a group care management approach may help patients with type 1 diabetes acquire

Technological advances can also be used to address specific treatment issues seen in these patients. For example, the first challenge that most patients face is weight gain associated with insulin restart. Patients need to be taught to indentify insulin edema, which may make them feel fat, bloated and uncomfortable, as temporary water retention that is different from the development of fatty tissue. Special tools designed to measure water-related weight versus lean muscle mass versus fat mass could help patients tolerate the temporary weight gain related to edema (Goebel-Fabbri 2008). Additionally, newer insulin analogs show evidence of improving weight profiles which could be of help (Goebel-Fabbri 2008; Russell-

The dietician must balance the difficult tasks of providing diabetes education, ED education, writing meal plans and defining weight goals for patients and families (Anzai et al, 2002; Krakoff, 1991). The challenge presents when trying to balance the goal of slow weight gain and /or maintenance with diabetes meal planning. As the patient continues to increase calorie intake, insulin doses will need to be adjusted to match the amount of food eaten avoiding hyperglycemia. It is recommend a realistic goal of good blood glucose control instead of optimal blood glucose levels as the body readjusts to refeeding and the patient begins to benefit from psychotherapy. Multiple daily injections regimens that use insulin to carbohydrate ratios provide greater flexibility with meal times and amounts of food but do require increased blood glucose monitoring and insulin injections. Such intense diabetes management may increase the potential for disordered eating as the child or adolescent must think constantly about the effects of food, insulin and exercise on his or her blood glucose levels. This may not be an ideal approach to diabetes meal planning during the treatment and recovery from the ED. As the individual's physical and psychological health improves, the incorporation of more flexible meal-planning strategies may be useful. Care professionals, including nutrition therapists and diabetes educators, should be sensitive to weight-related changes and concerns in youth with type 1 diabetes. It is important for all health care professionals to be aware that weight loss may be related to glycaemia control.

better self-efficacy and restructure their cognitive and lifestyle potential.

from the 12- to 24-month period. The results suggested the value of parent-adolescent partnership in diabetes management.

The results of the mentioned studies of coping skills training and problem-solving interventions in children, and adolescents with diabetes, as well as parents of children with diabetes, have demonstrated that these interventions are effective in assisting people to improve diabetes self management and to achieve better diabetes outcomes (Grey & Berry, 2004).


**2. Additive methods to produce tools (rapid tooling)**

There are two main categories. One category includes indirect methods using AM techniques for prototyping master designs to manufacture a mold, while the other category is a direct strategy, where the rapid prototyping machine constructs the real inserts of the core and cavity mold.

Due to its market potential, many businesses prefer AM techniques for tool produce and growth. Each method comes with a number of strengths that are contracted by limitations. Yet these advances cause a flurry of requests from businesses in the Americas, Europe, Asia, and other advanced markets due to their potential effect. Meanwhile, in both of these methods, numerous facilities are working hard to determine whether the time is correct to phase further information can be seen in **Table 1**.


Table 3 shows the median HSR and nutrient composition of HF and RA snack products. Overall ('all categories'), the median HSR for HF snack products was significantly higher than RA products, 2.5 versus 2.0, respectively (*p* < 0.001). Compared to RA snacks, the median HSR for HF snack products was significantly higher for all categories, except beverages and confectionary. Overall ('all categories'), HF snack products were significantly higher in protein, total fat and fibre and RA snack products were significantly higher in carbohydrates and sugar (*p* < 0.001). No difference in energy, saturated fat or sodium was evident. For HF snack products, all categories, except beverages and confectionary, were significantly higher in fibre than RA products (*p* < 0.001).

**Table 3.** Comparative analysis of the differences in median (IQR) for HSR and nutrient content between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets. Differences in median (IQR) nutrient values were assessed via Mann-Whitney U tests.

#### *3.3. Price*

Figure 1 shows HF snack products in all food categories were substantially more expensive than RA foods. The largest overall price difference was between HF snack products and RA products was confectionary (253%). Median unit price (\$) of HF snack products was significantly higher than RA products for all product categories (supplementary material Table S3).

**Figure 1.** Median unit cost (\$) per 100 g percent difference (%), per product category, between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets.

Figure 2 shows unit cost (\$) differences between product types, per HSR category. Health foods were substantially more expensive for all HSR categories. No clear trend between unit price (\$) and HSR was evident. The greatest price difference was between HF and RA snack products scoring highest HSR of 5.0 (579%), followed by products scoring the lowest three HSR of 1.5, 1.0 and 0.5.

**Figure 2.** Median unit cost per 100 g percent difference (%), per HSR category, between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets.

#### **4. Discussion**

This study sought to examine and compare NCC, health claims and 'buzzwords' displayed on pre-packaged snack HF products sold in supermarkets and specialty health food stores to equivalent products sold in RA of supermarkets. Secondary aims were to compare the nutrition profile and cost. The main findings of this study revealed manufactures of HF snack products use significantly more NCC, health claims and buzzwords to market their products compared to equivalent products sold in RA of supermarkets irrespective of their overall 'healthfulness'. Surprisingly, the greatest use of NCC, health claims and buzzwords was found on HF snack products with HSR ≤2.5 (median five claims per product). In contrast, equivalent products sold in RA only displayed one NCC, health claim or buzzword per product, revealing the presence and quantity of claims often does not relate to product healthfulness, and particularly for HF snack products, may instead encourage consumption of foods associated with increased health risks misleading consumers [8,21,23,26,33,46,47]. Furthermore, it must also be noted that the health halos that NCC may help create, also applies to the absence of misunderstood constituents, such as gluten. In the current study, a substantially higher proportion of HF snack products were labelled gluten free, despite 50% of products displaying an HSR ≤ 2.5. This is not surprising considering consumers often consider gluten free foods to be more beneficial to health [11,48].

The HSRC algorithm was used as a proxy to estimate a foods 'healthfulness' [44]. Overall, HF snack products were marginally superior to equivalent products sold in RA with a small but significant difference evident, median 2.5 versus 2.0, respectively. The slightly higher HSR achieved by HF snack products is likely attributed to greater fibre and lower sugar found across several categories, but no differences were evident for energy, saturated fat or sodium, all noted to be of concern by the World Health Organisation as detrimental to human health [9]. The significantly higher total fat and lower carbohydrate content in HF snack products was also notable and likely attributed to increased use of plant-based fats, nuts and seeds evident from the product ingredient lists. While our research used the mid-point of HSR system 2.5/5 to broadly classify foods into two distinct groups when examining differences in product labelling, a higher HSR cut-off ≥ 3.5 has been used by others to more clearly distinguish 'healthier' food choices and reduce the likelihood of discretionary foods being classified as healthy foods [7,37,49]. Accordingly, neither HF snacks nor equivalent RA products would meet this cut-off. This may be expected for products in RA, which are not always manufactured or viewed as the healthier options, but emphasises the concern surrounding HF snack products. Thus, the median HF score of 2.5/5 should be considered a minimum passing grade at best, a marked difference from the health halo surrounding products marketed as health foods [34].

Despite the limited research in this area, overall, these results were consistent with previous findings. Studies that have examined a range of products with and without NCC and health claims, or claimed to be 'organic', found that most products showed no difference in overall nutrient profile [8,21,23,26,33,46,47,50]. Pertinent to our own findings, Hughes et al. [33] found that a large number of NCC and health claims used on Australian products did not meet FSANZ nutrient profiling criteria [51] and this is likely true for a proportion of products examined in this study.

Previous literature has sought to determine appropriate FoPL to improve consumer perception of a products nutrition, without the strong influence of NCC, health claims and buzzwords, though not specifically for HF products [21,52–59]. Research shows that consumers have a poor understanding of food labels and cannot appropriately interpret the NIP [39,40], especially when a product claim is present [41,42]. In addition, qualitative literature has consistently found that consumers believe labels such as 'organic' [12,17,60], 'natural' and 'not artificial' [13] indicate that products are more nutritious [17] and are lower in sugar, fat and sodium [13]. Likewise, the placement of snack products within HF aisles and specialty HF stores marketed as 'health foods' (for which there is limited regulation) may act as a buzzword itself influencing consumer purchases. Evidence suggests the "reductive style" [55] of the HSR reduces consumer inclination to buy unhealthy products and guide more accurate interpretations [21,47,59,61]. However, our data show most products did not display HSRs. Due to the voluntary nature of HSR, manufacturers may preferentially display HSRs on healthier products, therefore increasing consumer reliance on other product labels and claims [62]. Additionally, in agreement with other research, our data show that discretionary foods can obtain HSR scores >2.5, potentially distracting from the consumption of foods from the five food groups and showing poor alignment with the Australian Dietary Guidelines [34–37,49]. Together, these findings provide strong evidence for revised labelling regulations, and increased education initiatives for consumers on how to interpret nutrition labels, to make informed purchasing decisions [14,54].

Though the number of NCC, health claims and buzzwords that HF snack products displayed did not correlate to a higher HSR, they may partly explain the higher price of HF products. The majority of HF snack products in some categories claimed to be vegan, organic, environmentally conscious or made 'good sugar' claims. Thus, in conjunction with (likely) smaller production, the cost of organic and alternative ingredients such as coconut oil, increased use of nuts, wheat and cane sugar alternatives are likely more expensive. However, the large price differences observed are not likely due to production costs alone. In addition, the price premium for purchasing HF products was not related to the HSR. Other research has reported similar findings, with foods labelled 'organic' found to have a similar nutrition profile but cost significantly more than those that are not [50,63,64]. This is of significance as the use of 'buzzwords', along with higher price points, have been found to strongly influence consumers and generate a misleading health halo effect [13,15,17,29,31,32,65]. Consumers should have the right to seek and pay a premium for ethical, organic and sustainable food options, though this should not be confused with purchasing healthier choices.

When interpreting these data, limitations must be considered. The study was limited to snack foods, and therefore did not assess all products found in HF stores and aisles, such as cereal products. However, the remaining products (excluding whole foods e.g., nuts) do represent most other products found in HF stores and HF aisles. Over 80% of the HSR for all products from all store types were derived using the HSRC [44]. Furthermore, some fibre values also had to be derived for HSR calculation. Despite the sensitivity analysis conducted, and a validated approach used by others [8,62], the derived values are only estimates and might differ from the true values. Additionally, several researchers have raised concerns regarding the HSRC to appropriately assess foods 'healthfulness' [34–37]; thus, the system is not without limitations. 'Buzzwords' regarding environmentally conscious claims were grouped within the overall results for interpretation but do not directly imply a product is healthier. Some values may also be skewed due to the placement of supermarket products. For example, gluten free sections are often contained within HF aisles; thus, our HF data contains both formulated gluten free product alternatives such as gluten free biscuits and other HF products simply marketed as gluten free along with other buzzwords. Thus, the marketing intent of the gluten free label may be different between products. Due to nutrition labelling regulations in Australia, added sugars were not distinguished from natural sugars. Future research could analyse the difference between added and natural sugars between these store types using other datasets. Finally, these data are a snapshot of products from the Sydney metropolitan area, across a certain time. Due to constant fluctuation in product availability and pricing, the packaged food supply may have changed at time of publication. However, with over 2000 products analysed, the study has provided a reliable sample, and thus comparison, of packaged snack foods in HF stores, HF aisles and regular aisles in 2019.

#### **5. Conclusions**

The main findings of this study revealed manufactures of HF snack products use substantially more NCC, health claims and 'buzzwords' to market their products compared to equivalent products sold in RA of supermarkets irrespective of their overall 'healthfulness', and may actually encourage the consumption of foods associated with increased health risks, misleading consumers. Although the nutrition profiles of HF snack products were marginally better than equivalent products found in RA, overall, the HF snack products examined in the study often received low HSR ≤ 2.5, with most being discretionary choices, a marked difference from the consumer perception and health halo surrounding

HF products. Health food snack products were also found to be substantially more expensive, but this was not consistent with the 'healthfulness' of a product. If consumers pay a premium for ethical, organic and sustainable foods, they should not be confused with purchasing foods that are healthier. Thus, the findings of this research provide strong evidence to support recommendations for revised labelling regulations, particularly surrounding HF snack products. Increased efforts to educate consumers on label reading are required to help consumers make informed and healthy choices.

**Supplementary Materials:** The following are available online at http://www.mdpi.com/2072-6643/12/5/1513/s1, Table S1. Product category and subcategory descriptions. Table S2. Product claim categories. Table S3. Comparative analysis of median unit cost (\$/100g) between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets.

**Author Contributions:** Conceptualization, M.B., H.J., A.R. and L.G.; Formal analysis, M.B. and H.J.; Investigation, M.B. and H.J.; Methodology, M.B., H.J., A.R. and L.G.; Supervision, A.R. and L.G.; Writing—original draft, M.B., H.J. and L.G.; Writing—review and editing, M.B., H.J., A.R. and L.G. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external financial funding.

**Acknowledgments:** The authors would like to thank Clare Chow and Angela Lau for their contribution in data collection.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

*Article*


*2.6. Analytical Methods*

Concentration of furosemide and metoprolol was evaluated using an UPLC instrument Waters Acquity UPLC H-Class (Milford, MA, USA), with a photodiode array detector and Empower software. Furosemide and metoprolol were separated on Acquity UPLC XTerra C18 3.5 μm 4.6 mm × 250 mm column (Waters Co., Milford, MA, USA). Gradient mobile phase, going from 70:30% to 90:10% *v*/*v* 0.1% trifluoroacetic acid in water/acetonitrile, respectively, on a flow rate of 1 mL/min (25 ◦C). The inter- and intraday coefficients of variation were < 1.0% and 0.5%, respectively.


**6. Conclusion**

Hemodialysis central venous catheters CVCs are commonly used in patients with renal failure requiring dialysis once other vascular options have been exhausted. Long-term catheters should be inserted using the Seldinger technique with a dilator and hemostasis valve under ultrasound guidance and fluoroscopic screening. Tunneled catheters with cuffs may be used both temporarily and permanently. The subcutaneous tunnel and cuff ensure stabilization of their position and limiting the migration of microorganisms on its external surface hence reducing the risk of infections. Finally, it must be emphasized that a well-functioning arteriovenous fistula is the best vascular access inducing the lowest number of complications.


*2.2.1 Failure of step 1: decidua-associated remodeling is defective*

Late luteal phase secretory endometrium decidualization is associated with infiltration of natural killer cells, which are now considered to be major effector cells at trophoblast-uterine interphase interactions. It has also been postulated that repeated cycles of menstrual shedding of decidualizing endometrium may act as preconditioning for successful implantation and deep placentation [13]. This might explain the increased risk of preeclampsia in teenage pregnancy, short interval of pregnancy since menarche, and primipaternity. This may also explain the lowered risk of preeclampsia in women who have intercourse earlier with partner who fathers the current pregnancy. Recent research also suggests that natural killer cells' associated defects of implantation are due to disturbed ligand receptor interphase. Uterine natural killer cells are absent in the JZ myometrium, but their angiogenic action is mediated by interstitial trophoblast.


**3.3 Fibroblast growth factor (FGF)**

There are two FGF members used in cartilage regeneration. One of them is called as basic FGF (bFGF) or FGF-2, and the other one is called as FGF-18. FGF-2 increases anabolic material levels and decreases aggrecanase levels in cartilage. In vivo study has indicated that bFGF can promote cartilage repair [60]. However, some study indicated that the concentration of FGF-2 in synovial fluid samples of OA patients is approximately twice that of normal healthy knee joints [61]. Further studies found that FGF-2 promoted the repair of partial thickness defects of articular cartilage in immature rabbits but not in mature rabbits [62].

A rat model study has shown that FGF-18 stimulates chondrogenesis and cartilage repair in a concentration-dependent manner [63]. More studies have demonstrated that FGF-18 may present a therapeutic agent for osteoarthritis [64, 65]. A recombinant form of human FGF-18 has been used for cartilage injury treatment [66].