Public Health Nutrition

BackgroundOverweight and obesity are causing growing public health, economic and clinical burden, particularly within under-resourced communities. There is an urgent need to develop an in-depth understanding of experiences of weight management, and preferences for support within under-resourced communities, with a view to developing more effective weight management interventions. MethodsFocus groups were run in under-resourced communities using storyboarding; a method to facilitate inclusive communication (n=37). Thematic analysis was applied to textual and visual data, and a realist lens applied to provide in-depth insight into weight management experiences and needs. We believe this is the first study to use this combined methodology to explore weight management experiences and needs. ResultsCombining storyboarding with a realist lens, generated four themes. Living circumstances indicated that mental health, individual needs, and cost of weight management services were key contextual factors. Mechanisms of weight management identified emotional eating and portion control to be central to individual weight management. Yo-yo dieting centred on participants experiences of weight regain after attempting weight loss. Weight management intervention needs indicated psychological support was perceived as severely lacking, and the only route to attain sustained weight management. Offering both in-person and online support for weight management was considered important to reach more people. ConclusionMoving weight management support from short- to long-term and incorporating more robust psychological support would better serve the needs of people living in under-resourced communities who are overweight or obese. Ideally interventions should be multicomponent and tailored to individual needs and circumstances.

BackgroundPacked lunches are a common feature of early childhood food provision, yet evidence describing their nutritional composition in early years settings remains limited. Understanding the foods provided during this developmental period is important, given the potential influence of early dietary exposures on later health. AimTo characterise the composition, nutritional quality, cost, and dietary patterns of packed lunches brought from home in Early Childhood Education and Care settings, and to examine variation by child age and area-level deprivation. MethodsA cross-sectional analysis was conducted using a remote food photography method to assess packed lunches provided for children aged 1-4 years attending early years settings across Essex, UK. Food items were categorised into predefined groups, and nutrient composition was estimated. Area-level deprivation was determined using the English Index of Multiple Deprivation (2019). Non-parametric tests assessed between-group differences. Principal components analysis (PCA) was used to identify patterns of co-occurring foods. ResultsA total of 389 packed lunches were analysed. Starchy foods (82%), fruit (81%), dairy or alternatives (72%), and savoury snacks (74%) were commonly provided, while vegetables were less frequent and fish was rarely observed (1.5%). Overall, 97.7% of lunches contained at least one ultra-processed food (UPF), with a median of three UPF items per lunch and 74% of total energy derived from UPFs. Median energy provision was 400 kcal (IQR 309-518). Nutrient composition was broadly similar across deprivation groups, although cake and biscuit counts and UPF item counts were modestly higher in more deprived areas. The median estimated lunch cost was {pound}1.79 and did not differ by deprivation. ConclusionsPacked lunches in early years settings frequently contained ultra-processed foods and showed considerable variability in nutritional quality. Socioeconomic differences were limited, suggesting that contemporary packed lunch practices may reflect influences operating across population groups. Further research across diverse regions is warranted to better understand the provision of packed lunches and their implications for early dietary exposure.

ObjectiveTo investigate the burden of environmental enteric dysfunction (EED) and its association with water, sanitation, and hygiene (WASH) and linear growth amongst infants in rural Central Java, Indonesia. Study designA longitudinal study of 119 infants aged between 5-19 months was conducted in five villages of Wonosobo District, Central Java, Indonesia. Anthropometric measurements of infants and their mothers were performed at baseline and 5-month follow-up alongside a quantitative questionnaire on household, socio-economic, WASH and caregiving variables and stool sample collection for the investigation of alpha-1-antitrypsin (AAT), neopterin (NEO), and myeloperoxidase (MPO) levels. Linear mixed-effects regression models estimated the associations between WASH and height-for-age z-score (HAZ) on log-transformed EED biomarkers. ResultsBiomarkers increased from baseline to follow-up despite a declining trend with age and 68.7%, 79.0%, and 71.4% of infants experienced elevated AAT, NEO, and MPO respectively follow-up. Infants had higher AAT if they averaged > 30 minutes playing on soiled surfaces per day ({beta} = 0.11, p<0.05). NEO was elevated in infants with diarrhoea ({beta} = 1.04, p<0.05), municipal water source ( = {beta} 0.71, p<0.05), and in infants who mouthed soiled fomites weekly ({beta} = 0.55, p<0.05). Infants in houses with municipal water source had higher MPO ({beta} = 0.56, p<0.05) and higher MPO if mouthing soil weekly ({beta} = 0.41, p<0.05). Compared to infants at risk of stunting, stunted infants at baseline had lower AAT at follow-up ({beta} = -0.39, p<0.05) while infants with HAZ > -1 had lower AAT at baseline ( = -0.43, p<0.05). HAZ at baseline was positively associated with NEO at follow-up ({beta} = 0.36, p<0.05). MPO was higher in infants with HAZ > -1 at follow-up ({beta} = 0.59, p<0.05) and stunted infants ({beta} = -0.54, p<0.05) compared to infants at risk of stunting. ConclusionElevated EED biomarker levels were frequent and associated weakly with WASH and HAZ with bi-directionality, highlighting the need for quality birth cohort studies to improve understanding of EED and develop interventions.

IntroductionDepression is highly prevalent among young adults worldwide. While research links health behaviours, such as dietary intake, to depression, few studies have examined these associations among young adults in low- and middle-income countries, including South Africa. This study investigated whether dietary intake was associated with an increased risk of depression in a cohort of young South African adults, aged 20-30 years, as part of the Global burden of disease Lifestyle And mental Disorder (GLAD) project. MethodsThis five-year prospective cohort study was conducted in the North West Province of South Africa in accordance with the GLAD project protocol (DERR1-10.2196/65576). Dietary exposures were evaluated using three non-consecutive 24-hour dietary recalls, measuring daily intake of various food groups and nutrients as defined by the Global Burden of Disease study. Depression outcomes were assessed at baseline (N=1039) and follow-up (N=551) using the Patient Health Questionnaire (PHQ-9, cut-off [&ge;]10). Logistic and Poisson regression analyses were performed, with results presented as odds ratios (OR) and relative risk ratios (RR), respectively. Four models were run: unadjusted, sociodemographic-adjusted, total energy (TE) intake-adjusted and fully adjusted (including sociodemographic information and TE intake). For longitudinal analyses of incident depression, baseline depression cases were additionally excluded (n=403). ResultsParticipants (average age 24.55 years) had a balanced distribution of sex (51.4% female) and race (48.6% Black), and a 29.45% baseline prevalence of depression. Higher milk intake was associated with a lower risk of incident depression (RR=0.94, 95% CI 0.91-0.98) in the TE-adjusted longitudinal model. Cross-sectionally, higher sugar-sweetened beverage consumption associated with higher odds of depression, while higher calcium intake (OR=0.48, 95% CI 0.31; 0.76) and vegetable consumption (OR=0.74, 95% CI 0.61, 0.91) were associated with lower odds of depression after TE intake adjustment. Higher fibre intake was associated with lower odds of depression in the unadjusted model. ConclusionHigher daily milk intake was associated with a lower risk of depression, while higher calcium, vegetable, and fibre intake were associated with a lower prevalence of depression in young adults. These findings suggest that prevention strategies for common mental disorders could include dietary approaches within mental health care.

IntroductionBreastfeeding supports multiple aspects of child development and maternal health. However, research findings are often inconsistent due to methodological limitations, including inadequate control for sociodemographic factors, variation in feeding practices, health conditions across the life course, and heterogeneity in human milk (HM) composition. The Manitoba Interdisciplinary Lactation Center (MILC) is a globally accessible, bench-to-population research platform that enables integrated study of HM composition, maternal-child health, and the societal and structural determinants of lactation and HM feeding. Methods and AnalysisMILC combines cross-sectional questionnaire data and HM sample collection with longitudinal administrative data derived from provincial government databases. MILC recruits lactating parents currently feeding their HM to at least one child. Participants follow a standardized full breast expression protocol. All collected HM samples have their macronutrient profiles characterized and are bio-banked for unspecified future research. Questionnaires capture child and parent demographic, dietary and health characteristics, and detailed HM feeding practices. Administrative data include over 90 databases spanning health and social services utilization and education; these de-identified records are housed at the Manitoba Population Research Data Repository and linked with MILC study samples and data. MILC questionnaires and HM collection protocols can be customized to accommodate specific research projects (e.g. additional surveys or questions; snap freezing, addition of preservatives, cell or extra-cellular vesicle isolation, etc.). MILC began recruiting participants in October 2024 and is currently ongoing. Researchers may access MILC data and biospecimens subject to appropriate ethical approvals and data-sharing agreements. Ethics and disseminationMILC is approved by the University of Manitoba Human Research Ethics Board and the Provincial Health Research Privacy Committee. Participation is voluntary and based on informed consent. Research updates and findings will be disseminated via peer-reviewed journal publications, academic and clinical conferences, social media, public knowledge sharing events (e.g. information booths and virtual "Ask Me Anything" sessions), the MILC website (https://www.milcresearch.com) and the MILC Club (monthly meetings among researchers, trainees, healthcare providers, and community partners). MILC members also engage with agenda-setting organizations (e.g. Breastfeeding Committee for Canada, North American Board for Breastfeeding and Lactation Medicine) to accelerate translation of research knowledge into policy and practice. STRENGTHS AND LIMITATIONS OF THIS STUDYO_LIMILC combines low-burden cross-sectional human milk samples and questionnaire data with lifelong/longitudinal administrative data. C_LIO_LIParent-child dyad human milk feeding practices and history are captured in a high level of detail, filling a gap frequently experienced in human milk and lactation research. C_LIO_LIOur questionnaires have been partially harmonized with other biorepositories and/or utilize valid and reliable measurement scales. C_LIO_LIThe initial MILC study pilot population lacks diversity; this will be intentionally addressed going forward. C_LIO_LIThe cost to maintain a long-term biorepository facility is high. C_LI

BackgroundHuman milk (HM) bioactive components can have immune modulatory functions, impact the gut microbiome, and may result in functional benefits when added to infant formula (IF). In this single-arm, prospective, intervention study, we tested the effectiveness of an IF with a whey protein concentrate co-enriched in -lactalbumin, milk fat globule membrane (MFGM), and Sn-2 palmitate resulting in protein and lipid profiles observed in HM. The outcomes tested were feeding tolerance, Bifidobacteria abundance, and intestinal and immune health of Chinese infants. MethodsPredominantly formula-fed (FF) and breastfed (BF) infants were enrolled between 3 and 28 days and assigned to the FF (N= 60) or BF (N=60) group, per their feeding practice, for 6 weeks. The primary endpoint was Infant Gastrointestinal Symptom Questionnaire (IGSQ) index score assessed using a validated IGSQ-13 questionnaire after 6 weeks of intervention; non-inferiority of FF vs BF was tested. Secondary endpoints included fecal Bifidobacteria abundance assessed using shotgun metagenomics sequencing; fecal short chain fatty acids (SCFAs) analyzed by ultra-performance liquid chromatography-tandem mass spectrometry; fecal markers of immune response, inflammation, intestinal barrier integrity (secretory immunoglobulin A sIgA), cytokines, calprotectin, 1 antitrypsin, lipocalin-2) assessed using enzyme-linked immunosorbent assay; stool consistency assessed using gastrointestinal (GI) diary; anthropometric assessments; quality of life; physician reported adverse events; and use of medications. ResultsGood GI tolerance was observed in both groups at V2 (mean{+/-}SD IGSQ score FF: 19.9{+/-}7.4; BF: 16.8{+/-}4.2); difference of means 1.35 [95% CI: -1.312, 4.012]). After 6 weeks, Bifidobacterium genus relative abundance was not significantly different between the groups. Total SCFAs were significantly higher (p<0.05) in the FF versus BF group, driven by increased levels of valeric and propanoic acids (p<0.05 for both). The IGSQ domain scores, stool consistency, fecal markers of immunity, inflammation, and intestinal barrier integrity (except lipocalin-2 which was significantly higher in BF vs FF), anthropometric Z-scores, common illnesses, antibiotic use, and adverse events were not significantly different between groups at week 6. ConclusionsOur results support the effectiveness of this tested infant formula in supporting good GI tolerance, growth, specific intestinal and immune health markers, and Bifidobacteria abundance similar to that of the BF group. Trial registrationNCT04880083 (2021-05-06)

Outcomes from the COSMOS trial have reinforced the notion of flavanols as important plant-derived bioactives contributing to cardiovascular health. As discussions continue on whether specific dietary reference values for flavanols are warranted, it is possible that existing dietary guidelines emphasizing fruits and vegetables already yield sufficient flavanol intake levels. If this were the case, developing flavanol specific dietary reference values might be unnecessary. This study therefore aimed at assessing whether adherence to dietary recommendations for fruit and vegetable intake and overall diet quality achieves flavanol intake levels of 500 mg/day, the amount proven to mediate cardiovascular benefits in the COSMOS trial. Flavanol intake was objectively evaluated using two validated and complementary biomarkers, 5-(3{square},4{square}-dihydroxyphenyl)-{gamma}-valerolactone metabolites (gVLMB) and structurally related (-)-epicatechin metabolites (SREMB), in two geographically distinct studies: COSMOS (US; n=6,509) and EPIC-Norfolk (UK; n=24,154). The results showed that higher fruit and vegetable intakes and diet quality (assessed via the alternative healthy eating index-aHEI) were associated with increased flavanol intake in COSMOS. Nevertheless, fewer than 25% of participants meeting dietary guidelines achieved an estimated flavanol intake of [&ge;]500 mg/day. Similar findings were observed in EPIC-Norfolk as well as through flavanol intake simulations considering fruits and vegetables commonly consumed in the US diet. In conclusion, adherence to existing dietary guidelines does not yield flavanol intake levels comparable to those shown to provide cardiovascular benefits in COSMOS. Thus, specific dietary reference values for flavanols may still be necessary if aiming to increase the intake of these dietary compounds. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=101 SRC="FIGDIR/small/26346949v1_ufig1.gif" ALT="Figure 1"> View larger version (39K): org.highwire.dtl.DTLVardef@24faeaorg.highwire.dtl.DTLVardef@1d52a29org.highwire.dtl.DTLVardef@1c2ff33org.highwire.dtl.DTLVardef@100a384_HPS_FORMAT_FIGEXP M_FIG C_FIG

Background Acute malnutrition remains a major public health challenge among children under five in Malawi due to undetected and untreated cases. While several policies and programmes are in place, they face significant resource input and implementation constraints. In this study, we evaluate the potential health impact and cost-effectiveness of three interventions designed to address constraints along the care pathway in childhood acute malnutrition management. These include improving early recognition of symptoms by caregivers, increasing attendance at routine growth monitoring visits through community outreach, and scaling up the availability of therapeutic food supplements. Methods and Findings We use a newly developed model representing the natural history and management of acute malnutrition, implemented within the Thanzi La Onse (TLO) dynamic individual-based simulation framework, which captures the public health system in Malawi. Each of the three interventions is assessed both individually and in combination, translated into seven scenarios which we evaluate in comparison to the status quo. The optimal strategy combines two interventions, improved caregiver awareness of early symptoms with increased availability of therapeutic food supplements. Over five years, this strategy is predicted to avert 840,470 (95% CI: 682,057-998,883) DALYs with total incremental costs of $34 million. This corresponds to an annual health expenditure increase of $0.32 per capita. At a cost-effectiveness threshold of $76 per DALY averted, the strategy results in an incremental net health benefit of 394,252 (95% CI: 235,839-552,665) DALYs averted. Conclusions The cost-effective strategy for addressing constraints in childhood acute malnutrition management is simultaneously improving caregiver recognition of early symptoms and expanding therapeutic food supplement availability. Out of the seven scenarios evaluated, this integrated approach was found to be the optimal strategy within the Malawian public health system, yielding substantial health at modest costs. These findings provide critical evidence to inform national policy and guide investment prioritisation for the management of childhood acute malnutrition.

IntroductionMechanistic research has shown that prior obesity induces durable transcriptomic and epigenetic reprogramming in adipose tissue that persists after weight loss and predisposes individuals to weight regain. This phenomenon, termed obesogenic memory (OM), is currently conceptualized primarily as a molecular process. We propose extending OM beyond adipose tissue biology to include interacting biological and sociocultural processes through which past exposures shape present physiological regulation and health-related behavior. MethodsIn-depth qualitative interviews were conducted with individuals living with obesity (n=31) and with healthcare professionals (n=18). The data were analyzed abductively to examine participants lived experiences of obesogenesis. ResultsWe developed a three-phase model of OM comprising memorizing, remembering, and rescribing. The memorizing phase describes the initial acquisition and encoding of biological and sociocultural obesogenic influences. The remembering phase captures the persistence of these influences, contributing to long-term obesity maintenance. The rescribing phase refers to processes through which obesogenic influences may be attenuated or reversed, creating conditions for sustainable health behavior change. ConclusionExtending OM to include sociocultural dimensions provides a more comprehensive understanding of obesity persistence. This integrative framework identifies multilevel targets for obesity prevention and treatment that acknowledge past exposures while supporting resilience and long-term weight management.

Childhood malnutrition remains a major public health challenge in Ethiopia, where stunting and wasting co-exist but may arise from distinct spatial and etiological processes. Analyses focusing on a single outcome may overlook the interdependence of these conditions and their geographic heterogeneity. This study aimed to disentangle the determinants of stunting and wasting among children under five years of age using a Bayesian bivariate spatial modelling framework. Data from 5,405 children included in the 2019 Ethiopia Mini Demographic and Health Survey were analyzed. Stunting and wasting were modelled as correlated binary outcomes using Bayesian bivariate hierarchical geostatistical models implemented through SPDE-INLA, accounting for child, maternal, household, and environmental covariates, non-linear age effects, and spatial dependence. Model performance was assessed using the deviance information criterion, Watanabe-Akaike information criterion, and marginal log-likelihood. The bivariate model identified shared socio-economic and biological determinants. Multiple births, male sex, low maternal education, a higher number of under-five children, and household poverty were associated with increased risks of both outcomes. Female-headed households were associated with lower odds of stunting but higher odds of wasting. Spatial analysis revealed elevated residual stunting risk in the northern and central highlands, whereas wasting hotspots were concentrated in northeastern pastoralist regions. Residual spatial correlation was weak ({rho} = -0.12), indicating largely independent geographic patterns. These findings suggest that effective child nutrition policies in Ethiopia require outcome-specific and regionally tailored interventions addressing both chronic and acute forms of malnutrition.

Abstract Background: Enhanced Recovery After Surgery (ERAS) optimizes perioperative management for colorectal cancer (CRC), improving short-term outcomes, but its impact on long-term outcomes remains inconclusive, supporting the need for this meta-analysis. This study evaluates the effect of perioperative ERAS (therapy-focused) on 1-, 2-, 3-, and 5-year postoperative survival in patients with CRC. Methods: We conducted a systematic review and meta-analysis following a pre-registered protocol in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Web of Science, Embase, Medline Ovid, and Cochrane Library Wiley were searched up to December 31, 2025, for clinical studies reporting long-term postoperative survival outcomes of patients with CRC undergoing ERAS implementation. Of 1,063 retrieved reports, 10 studies (5,876 patients) were included in Kaplan-Meier-based meta-analyses and eight studies (5,556 patients) in aggregated data meta-analyses. Data extraction was performed independently by two reviewers, with study quality and risk of bias assessed using the Newcastle-Ottawa Scale (NOS) and RevMan software. Effect sizes were pooled using fixed-or random-effects models according to heterogeneity, with cross-validation and subgroup analyses examining the influence of tumor stage and ERAS adherence. The pre-specified primary outcome was postoperative overall survival (OS) [&ge;]12 months, and the secondary outcome was disease-free survival (DFS). Results: ERAS significantly improved OS at 1 year (93.2%, 95% CI: 92.3-94.2 vs. 90.2%, 95% CI: 89.1-91.2), 2 years (86.7% vs. 81.3%), 3 years (81.1% vs. 72.4%), 5 years (70.9% vs. 60.6%) (all P<0.01). The pooled HR for mortality was 0.72 (95% CI: 0.63-0.83, P<0.01), indicating a 28% reduction in long-term mortality. Stage I-II tumors and ERAS adherence [&ge;]70% conferred the greatest benefits. DFS did not show a statistically significant improvement (HR=0.90, 95% CI: 0.68-1.19, P=0.45). Included studies were of moderate to high quality (NOS score 6-9). Conclusions: Perioperative ERAS significantly improves 1- to 5-year OS and reduces long-term mortality in patients with CRC, with the greatest benefits in early-stage disease and high adherence. These findings support ERAS as a critical component of comprehensive CRC care.

Poor sleep is linked to consumption of sugary foods/beverages and high neural responsivity to palatable food cues. Yet, whether hedonic liking for sweet taste explains these associations remains unclear. We examined cross-sectional associations of five sleep traits (chronotype, sleep duration, insomnia frequency, snoring, daytime dozing) and a composite sleep score with sweet food liking, and total and free sugar intake in 76,734 UK Biobank participants (39-72 years, 56.3% female). Models adjusted for age, sex, ethnicity, socioeconomic deprivation, and body mass index (Bonferroni-corrected =0.0025). Evening chronotype, more frequent insomnia and daytime dozing, and lower composite sleep score were associated with higher sweet food liking. Associations with intake were stronger for free than total sugar. Evening chronotype was associated with higher free sugar intake (g/day: {beta}=1.523, 1.309-1.737; g/1000 kcal: {beta}=0.450, 0.361-0.538), and daytime dozing showed a dose-response (dozing often vs never/rarely: g/day {beta}=6.307, 4.631-7.983). Snoring was associated with higher absolute (but not energy-adjusted) free sugar intake. A healthier sleep score was associated with lower free sugar intake (g/day {beta}=-2.193 [-2.464 to -1.922]; g/1000 kcal {beta}=-0.691 [-0.804 to -0.579]) but higher energy-adjusted total sugar intake ({beta}=0.633 [0.485-0.781]). Mediation analyses indicated sweet liking accounted for 15%-91% of several sleep trait and free sugar intake associations (indirect effects p<0.001). Poorer sleep health, particularly evening chronotype and daytime sleepiness, was associated with greater sweet liking and higher free sugar intake, with sweet liking partially mediating associations between sleep traits and sugar consumption. Sweet-taste liking may represent an underexamined pathway linking sleep/circadian disruption to free sugar intake.

BackgroundThe surgical stress response is a predictable, physician-managed metabolic state triggered by anesthesia and tissue injury, marked by insulin resistance and hypercatabolism that create unique nutritional needs unmet by standard, pre-surgical fasting diets. We developed a multi-nutrient medical food to support perioperative metabolic homeostasis and piloted its safety/tolerability and exploratory outcomes. MethodsIn a single-center pilot trial (n=67) of adults undergoing elective abdominal, cardiac/thoracic, gynecological, or orthopedic surgery, participants were allocated to medical food or no-treatment control. The product was taken twice preoperatively (evening before and 4 h pre-op) with standard care. Primary safety outcomes were adverse events, postoperative nausea/vomiting (PONV), 30-day readmission, and infections. Exploratory outcomes were fasting glucose, HbA1c, electrolytes, cortisol, pre-operative emotional state, and post-operative pain. ResultsAll participants completed the intervention. No product-attributed adverse events occurred. Gastric clearance was achieved within 2 h in all, and there were no 30-day readmissions or infections. PONV occurred in 30.3% vs 35.3% (risk ratio 0.86, 95% CI 0.43-1.71, p=0.796). Post-operative glycemia favored the intervention; at 48 hr the intervention group showed lower glucose (HL -9 mg/dL, g=0.35, p=0.030), while earlier timepoints were nonsignificant. Post-operative magnesium was numerically lower with intervention (4.76 vs 5.10) without statistical significance; other electrolytes and cortisol showed minimal differences. Post-operative pain was 5.33 vs 5.62 (g=0.19, p=0.43). Positive pre-operative emotion was more frequent with intervention (17/33 vs 9/34; risk ratio 1.95, p=0.046). ConclusionThe medical food was safe and well tolerated without increased PONV or readmissions. Preliminary metabolic and emotional signals justify a larger, adequately powered efficacy trial. Clinical Relevancy StatementThis pilot trial demonstrates that a preoperative multi-nutrient medical food was well tolerated and feasible to administer in a routine clinical setting: all participants achieved gastric clearance within 2 hours of the pre-operative dose, with no increase in PONV and no readmissions. Exploratory findings indicate potential benefits that could nutritionally support recovery if confirmed. These results support the feasibility of administering a targeted nutrition intervention shortly before surgery and justify evaluation in a larger efficacy trial. Clinical Trial RegistrationNCT07359222

The gut microbiota has been implicated in regulating body composition, insulin resistance, and energy metabolism through microbial metabolites, including short-chain fatty acids (SCFAs) and amino acids. However, evidence in adolescents, particularly regarding sex-specific differences and lifestyle such as alcohol intake, remains limited. Characterizing sex-specific metabolic signatures in adolescence may improve early identification of metabolic risk. To address this gap, we investigated associations between fecal metabolites, body composition, insulin resistance, and energy expenditure in 158 adolescents aged 18 from the Copenhagen Prospective Studies on Asthma in Childhood (COPSAC2000). Quantitative fecal metabolomics was performed using proton nuclear magnetic resonance (1H-NMR) spectroscopy, profiling 32 metabolites. Associations with body composition, insulin resistance, and energy expenditure were evaluated using sex-stratified univariate and multivariate modelling with false discovery rate (FDR [&le;] 0.05 and 0.2). Fecal acetate and ethanol were more associated with fat-free mass index (FFMI) and waist-to-height ratio (WHtR) than with body mass index (BMI) in females; in males, no associations remained after FDR. Lysine and leucine showed associations with BMI and insulin resistance in females. Acetate, butyrate, glucose, and methanol were associated with total energy expenditure (TEE) in females, whereas no association survived in males. Alcohol intake was positively associated with fecal ethanol, glucose, and methanol, and inversely with trimethylamine in females, while galactose showed a positive association in males. These findings demonstrate that gut microbiota-derived metabolites are related to body composition, insulin sensitivity, and energy balance in adolescents, particularly females, highlighting the utility of fecal metabolomics in exploring mechanisms underlying metabolic variation.

ObjectiveTo characterize associations between tattooing and health status. MethodsWe used data from [~]27,000 respondents to the 2020-2022 Utah Behavioral Risk Factor Surveillance System (BRFSS). Multivariable Poisson regression was used to calculate prevalence ratios (PR) and 95% confidence intervals (CI) associating ever receiving a tattoo with physical/mental health status. ResultsIn this cross-sectional study, ever receiving a tattoo was associated with self-reported "poorer" vs. "excellent" overall health, particularly among women (PR=3.08 [95% CI: 2.26- 4.21]). Tattooing was also associated with obesity (women, PR=1.40 [95% CI: 1.22-1.61]; men, PR=1.21 [95% CI: 1.04-1.40]) and chronic pain (women, PR=1.59 [95% CI: 1.43-1.77]; men, PR=1.55 [95% CI: 1.37-1.76]). Tattooed individuals were more likely to have been diagnosed with a depressive disorder (women, PR=1.64 [95% CI: 1.53-1.75]; men, PR=1.55 [95% CI: 1.39-1.73]) and to have had six or more teeth removed, vs. none (women, PR=2.18 [95% CI: 1.61-2.96]; men, PR=2.88 [95% CI: 2.10-3.95]). ConclusionsPublic health entities may consider partnering with tattoo studios and conventions to provide information about nutrition, exercise, dental care, mental health resources, and health screenings.

ObjectivesTo examine associations between cardiometabolic conditions and health-related quality of life (HRQoL) and to evaluate whether condition-associated HRQoL changed from 2001 to 2022. MethodsWe analyzed nationally representative data from U.S. adults aged [&ge;]18 years in the Medical Expenditure Panel Survey, 2001-2022. Survey years without BMI data (2017, 2019, 2021) were excluded. EQ-5D utilities were mapped from SF-12 scores using a validated algorithm. For each survey year, survey-weighted multivariable regression models estimated associations of sociodemographic characteristics, BMI, and cardiometabolic conditions (diabetes, heart disease, high blood pressure, high cholesterol, obesity, stroke) with HRQoL measured by EQ-5D. Temporal changes in condition-associated HRQoL decrements were assessed using meta-regression across years. Associations in recent survey years were summarized using pooled estimates from 2015, 2016, 2018, and 2022. ResultsOverall HRQoL improved from 2001 to 2022 across age groups, with the largest improvement among older adults. In pooled analyses, stroke was associated with the largest adjusted HRQoL decrement (-0.0714), followed by heart disease (-0.0503), diabetes (-0.0427), high blood pressure (-0.0328), obesity (-0.0305), and high cholesterol (-0.0236). Additional adjustment for BMI attenuated condition-associated decrements, most notably for obesity (-0.0305 to -0.0183), diabetes (-0.0427 to -0.0414), and high blood pressure (-0.0328 to -0.0316). Over time, diabetes- and heart disease-associated decrements attenuated linearly (diabetes: - 0.0489 in 2001 to -0.0406 in 2022; heart disease: -0.0591 to -0.0493). High blood pressure (-0.0337 in 2001, -0.0415 in 2012, -0.0306 in 2022) and obesity (-0.0305 in 2001, -0.0283 in 2012, -0.0367 in 2022) showed nonlinear patterns. ConclusionsCondition-associated HRQoL decrements varied over time, and recent-year utility estimates are recommended for population health research. HRQoL decrements for diabetes and heart disease attenuated, consistent with improvements in treatment and survival. High blood pressure-associated were lowest around 2012, and obesity-associated became more negative after 2012, consistent with worsening blood pressure control and obesity severity.

ImportanceCurrent guidelines from the World Health Organization, Centers for Disease Control and Prevention, and Academy of Breastfeeding Medicine recommend discarding all milk remaining in bottles immediately after infant feeding. However, these recommendations lack supporting microbiological evidence from studies of actual infant feeding, imposing substantial financial and emotional burden on the 78 million families worldwide who bottle-feed their infants. ObjectiveTo determine (1) the financial, emotional, and time burden associated with bottle feeding and parental milk disposal practices, and (2) bacterial growth in leftover human milk and formula under different storage conditions. Design(1) Cross-sectional online survey (January 2023-February 2024) and (2) prospective microbiological cohort study. Setting(1) Online survey, (2) infants recruited in Hannover, Germany Participants(1) Survey respondents (n=1056; 99% mothers) and (2) healthy, full-term, bottle-fed infants (n=44; 17 humanmilk, 27 formula) aged 0-12 months. Main Outcomes and MeasuresParental burden scores, milk disposal frequency, and bacterial colony-forming units (CFU)/ml in milk samples before feeding, immediately after feeding, and at 4, 8, and 24 hours post-feeding at 4{degrees}C and 20{degrees}C. ResultsAmong surveyed parents, 46% discarded leftover milk daily, yet 84% reported they would keep milk longer if deemed safe. In microbiological testing, median bacterial burden in humanmilk increased from 4200 CFU/ml (range 300-350,000) pre-feeding to 24,600 CFU/ml (range 1900-29,004,400) post-feeding, but showed no significant further increase at 4 hours (p=0.82) or 8 hours (p=0.64) when stored at either 4{degrees}C or 20{degrees}C. Formula showed similar stability: median CFU/ml increased from 0 (range 0-10,700) to 11,700 (range 1900-630,000) post-feeding, with no significant change at 4 hours (p=0.91) or 8 hours (p=0.73) at either temperature. Significant bacterial growth occurred only after 24 hours at 20{degrees}C (p<0.001). Conclusions and RelevanceBacterial burden in leftover infant milk remained stable below concerning thresholds for 8 hours when refrigerated and 4-8 hours at room temperature, challenging current guidelines that mandate immediate disposal. Evidence-based guideline revision could reduce financial burden and milk waste for families around the globe without compromising infant safety. Key PointsO_ST_ABSQuestionC_ST_ABSHow long is it safe to offer leftover milk in a bottle to an infant that has previously drunk from it? FindingsThe number of bacteria in leftover human milk or formula did not significantly increase from 0 to 8h post-feeding in milk bottles sampled from 44 infants, regardless of whether the milk was kept at room temperature or refrigerated. MeaningLeftover milk may be safely reoffered beyond the limits of the current guidelines.

BackgroundCaloric restriction (CR) improves markers of biological aging, yet long-term effects on the human metabolome remain unclear. ObjectiveThis study examined the effects of CR (2 years) in healthy adults without obesity on circulating metabolites linked to aging and metabolic adaptations. MethodsUntargeted metabolomics was performed using fasted plasma samples collected at baseline, 12, and 24 months (BL, 12M, 24M) from CALERIE participants randomized to CR or ad libitum (AL) control. A total of 864 known metabolites were identified and grouped into nine biologically coherent super pathways to support pathway-level interpretation (amino acid, peptide, carbohydrate, energy, lipid, nucleotide, cofactors and vitamins, xenobiotics, and partially characterized molecules). Principal component analysis (PCA) summarized metabolite variation, and linear mixed models assessed intervention effects on each PC in group-by-time interactions. ResultsThree principal components showed significant group-by-time interactions: PC2 (carbohydrate), PC5 (partially characterized molecules), and PC4 (lipid). Carbohydrate (PC2) and partially characterized metabolites (PC5) decreased from baseline to 12M in both groups; from 12M to 24M, levels stabilized in CR but increased in AL for PC2, while PC5 continued to decline in CR and increased in AL. Lipid metabolites (PC4) decreased in CR and increased in AL at 12M, with the pattern reversing from 12M to 24M. Key contributors included malto-saccharides and related carbohydrate intermediates for PC2, glutamine degradants and lactone sulfates for PC5, and sphingolipids for PC4. ConclusionThis study provided insights into metabolic changes during CR, particularly for carbohydrate and lipid metabolism. Carbohydrate and lipid metabolites that were reduced by CR during the weight loss phase (BL to 12M) followed by stabilization or compensatory responses during the weight maintenance phase (12M to 24M) may link CR-induced changes in metabolism to inflammation. Future research is needed to tease out CR adaptations versus diet related changes in metabolites and explore the functional significance of these metabolic changes during CR for aging and long-term metabolic health. ConclusionCR produced distinct, time-dependent shifts in carbohydrate and lipid pathways. Early reductions during weight loss followed by stabilization or compensatory responses during weight maintenance suggest dynamic metabolic remodeling that may relate to inflammation-linked mechanisms. Further work is needed to distinguish CR-specific adaptations from dietary influences and to clarify the functional significance of these metabolic changes for aging and long-term metabolic health.

As programs for azithromycin mass drug administration to reduce child mortality have begun in some parts of West Africa, it is imperative to understand their financial costs. We combined a micro-costing framework and observations from an implementation-focused sub-study within the AVENIR trials in 80 communities in the Dosso region of Niger to estimate the national health sector costs of a scaled-up programmatic approach for azithromycin biannual distribution to children aged 1-59 months of age living in nonurban areas, using the door-to-door modality. Our outcomes of interest were the annual budget at the regional and national levels for Niger and the cost per dose delivered. We found that the annual national budget required for azithromycin mass drug administration (MDA) achieving 90% average coverage would be $12.5M (95% Uncertainty Interval (UI) $12.2M, $13.0M) translating to $1.59 (95% UI $1.40, $2.30) per dose delivered. Across regions, cost per dose would vary from $1.17 (95% UI $1.03, $1.69) to $3.61 (95% UI $3.20, $5.16), with higher cost per dose expected for more sparsely populated regions. Training costs represented a large fraction (16.4%) of total costs, and integration of training with that for existing health interventions may provide opportunities for efficiency.

IntroductionObesity and related health conditions are unevenly distributed across neighborhoods, often co-occuring with multiple health challenges and socioeconomic disadvantages. Using an ecosyndemic framework, which integrates ecological and social dimensions that contribute to the clustering of health problems, this study examines how adverse obesity-related health outcomes spatially cluster in relation to obesogenic environments and socioeconomic position (SEP) across Dutch neighborhoods. MethodsNationwide neighborhood-level data on health outcomes, obesogenic environmental exposures (food environment, walkability, drivability, bikeability, sports facilities), and SEP were combined for all inhabited Dutch administrative neighborhoods in 2016 (N=12,420). Cluster analysis was used to identify distinct neighborhood profiles and descriptive statistics to characterize each cluster, with spatial patterns visualized using an interactive heatmap and principal component plots. ResultsFive neighborhood clusters were identified. The Ecosyndemic cluster (N=1,070 neighborhoods) exhibited the highest burden of obesity (17% [IQR 16;19), chronic diseases (36% [IQR 33;38%) and risk of anxiety/depression (55% [IQR 51;58]), unhealthy food environments and low SEP. In contrast, the Privileged cluster (N=6,425) had more favorable health outcomes and living conditions, including lower obesity prevalence (12% [IQR 11;14]). The Psychosocial Vulnerability cluster (N=991) was notable for elevated risk of anxiety/depression (47% [IQR 43;51]) combined with relatively low obesity (11% [IQR 8;12]). The Syndemic cluster (N=1,836; obesity 15% [IQR 14;17]) and Towards Privileged cluster (N=2,098; obesity 12% [IQR 10;13]) represented intermediate profiles. ConclusionObesity and related health issues frequently cluster with unfavorable environment and SEP at the neighborhood level. The ecosyndemic framework offers a novel approach for identifying high-risk areas and supports targeted, social and place-based interventions.