Public Health Nutrition

To evaluate the international interoperability of food composition databases, we assessed the compatibility of seven national food composition tables with USDA FoodData Central (FDC) using the LLM-based matching method reported previously (Nakagawa and Yamamoto, 2026). Databases from four English-speaking countries (Canada, United Kingdom, Australia, and New Zealand), South Korea, and Japan were compared with 8,158 USDA FDC entries (SR Legacy and Foundation Foods, excluding Survey/FNDDS). Match rates varied by country (62.0-89.7%) and food category. After excluding six USDA categories unsuitable for cross-national comparison, 45.2% of the remaining 6,290 entries were not matched by any country. Canada showed the highest concordance, reflecting shared North American food supply. Japan and South Korea showed similar low coverage for vegetables and spices. These findings suggest that while USDA FDC represents a practical foundation for a globally comprehensive food composition database given its breadth, systematic incorporation of country-specific foods and classification schemes will be necessary to achieve true international interoperability.

Background/Objectives: Children aged 6-24 months are highly vulnerable to malnutrition during conflict because they depend on breastfeeding, complementary feeding and functioning nutrition services. This study assessed nutritional status, socioeconomic correlates, maternal knowledge and primary health care centre (PHCC) nutrition service gaps in Gaza. Subjects/Methods: This cross-sectional study was conducted at Al-Daraj Martyrs Health Centre, one of the remaining functioning PHCCs in Gaza City during the study period, between late August and October 2025. Mother-child pairs were recruited by convenience sampling. Of 276 approached, 200 were included after non-response and exclusion of questionnaires with missing anthropometric data. Data came from structured interviews and medical records; haemoglobin results were available for 55 children. Results: Stunting affected 12.5% of children, underweight 20.1%, wasting 20.8%, and anaemia 63.6% of the haemoglobin-tested subsample. Underweight was associated with household food shortage (p=0.013) and previous malnutrition treatment (p=0.002), wasting with child age category (p=0.0024), and anaemia with paternal unemployment (p=0.020). Maternal knowledge and practice scores were positively correlated (r=0.177, p=0.012), but neither was independently associated with stunting or underweight in adjusted models. PHCC nutrition support was limited, with 71.0% of mothers reporting nurse-provided nutrition advice and 52.5% reporting growth-chart review. Conclusions: In this clinic-based sample from conflict-affected Gaza, malnutrition among children aged 6-24 months was substantial. The overall pattern suggests that nutritional risk was shaped more by structural deprivation and weakened PHCC support than by maternal knowledge alone. These findings underline the need to restore essential nutrition services and improve access to adequate food for young children.

This study examines the effects of rural out-migration and remittance inflows on food consumption outcomes among rural households in the Tigray region of Ethiopia. Utilizing household survey data collected from 521 rural households across three distinct Weredas (districts) (Tahtay Maichew, Kola Tembien, and Kilte-awlaelo). A Binary Probit model was employed to identify factors influencing migration decisions, while an Endogenous Switching Regression (ESR) model was used to estimate the impact of migration on food consumption outcomes while controlling for selection bias and unobserved heterogeneity. Food security was measured using the Food Consumption Score (FCS) and dietary diversity indicators. The empirical results reveal that severe food insecurity is widespread, with over 60% of all surveyed households falling into the "Poor" food consumption category. Descriptive baseline comparisons show that migration and remittance transfers marginally shift the raw average FCS upward from 23.86 to 25.48. However, this impact is profoundly nuanced: remittances serve as an immediate consumption-smoothing safety net but run parallel to a "labor-lost" constraint that reduces own-production capacities, forcing households to rely increasingly on market purchases for staple foods. The findings reveal that migration creates short-term labor shortages in agricultural production; however, remittance inflows substantially improve household food consumption frequencies, particularly for pulses, vegetables, and other nutrient-rich foods. After accounting for self-selection bias and unobserved traits, the rigorous ESR estimates indicate that migration increases the Food Consumption Score of participating households by an average Treatment Effect on the Treated (ATT) of 10.75 points, shifting them into more secure dietary tiers. Moreover, remittances help households mitigate the adverse effects of drought and other shocks by relaxing liquidity constraints and supporting both food purchases and agricultural investments. The study recommends establishing target food security safety nets for non-remittance households, promoting scale-appropriate labor-saving agricultural technologies, expanding traditional communal labor-sharing innovations, and boosting irrigation and agricultural input support programs to enhance rural food security and livelihood resilience.

Abstract Objective: This study aimed to assess the magnitude of undernutrition and associated factors among pregnant women attending public health facilities in the Goba district, Bale zone, Oromia Region, Ethiopia, 2022. Design: Institution-based, cross-sectional study design was used. Setting: The study was conducted in selected public health facilities from May to June 2022. Participants: The study population consisted of pregnant women who lived for at least 6 months in the study area and who attended antenatal care follow-up at selected public health facilities during the study period. Pregnant women who lived for less than six months in the study area and those who were critically ill were excluded from the study. Results: 487 respondents participated in this study with a 100% response rate. More than half (50.7%) of pregnant mothers were undernourished. The significant factors associated with maternal undernutrition during pregnancy in this study were mothers with no formal education (AOR = 5.050; 95% CI: 1.470- 17.346), a history of illness during pregnancy (AOR = 2.089; 95% CI: 1.246-3.504), and eating frequency of meals less than or equal to three times per day (AOR = 3.292; 95% CI: 1.040- 10.42). Poor nutritional knowledge (AOR = 5.588; 95% CI: 2.921-10.689), poor household (HH) wealth status (AOR = 4.774; 95% CI: 2.216- 10.285), and mothers who had >= 4 pregnancies were included (AOR = 0.852; 95% CI: 342-0.989). Conclusion: The magnitude of Undernutrition among pregnant women was 50.7%. Significant associations with Undernutrition were found in mothers with no formal education, poor dietary knowledge, a meal frequency of three or fewer times per day, a history of illness during pregnancy, lower and medium household wealth status, and those who had experienced four or more pregnancies while attending antenatal care (ANC) services at public health facilities.

Background Early onset obesity in children, almost always accompanied by significant health complications, may be driven by rare genetic variants that influence appetite, metabolism, and nutrient absorption. Traditional treatment approaches are usually insufficient for those with monogenic obesity of this type. Glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide, and related drugs such as melanocortin 4 receptor agonists, have emerged as promising first-line treatments for severe obesity. There is no established protocol or pathway in England for identifying children with monogenic obesity who could benefit from these and similar treatments Methods We undertook early economic modelling to examine the cost-effectiveness, from a health service perspective, of implementing a new pharmacotherapeutic care pathway for the identification and treatment of monogenic obesity in children. We modelled a hypothetical population of children with hyperphagia and body mass index (BMI) three standard deviations above mean values for age and sex. We evaluated the clinical decision to initiate the pathway using a decision tree model with patient quality-adjusted life years (QALYs) and NHS healthcare costs 12 months from an initial clinic visit as outcomes, and calculated incremental cost effectiveness ratios and a cost-effectiveness acceptability curve. Results Both costs and QALYs were higher under further investigation (GBP3,247 and 0.47 QALYs) compared to no further investigation (GBP1,589 and 0.24 QALYs). The incremental cost-effectiveness ratio in the base case was GBP7,133 per QALY. Further examination of these children was therefore likely to be cost effective in this model. Conclusion A decision-tree model suggested that further investigation of severely obese children potentially eligible for treatment with semaglutide is likely to be cost-effective for the NHS. However, this result is associated with uncertainty arising from a lack of evidence for many key model parameters.

Background: Obesity is becoming a global health crisis, and it leads to various metabolic disorders. Body mass index fails to differentiate fat mass from lean mass and systematically misclassifies adiposity risk - a limitation particularly pronounced in South Asian adults, who exhibit characteristically elevated visceral adiposity and reduced appendicular lean mass at a normal BMI. The 2025 Lancet Commission explicitly recommends direct adiposity measurement beyond BMI for obesity diagnosis. Weight loss interventions - whether dietary, behavioural, or pharmacological - are consistently associated with concurrent reductions in both fat mass and lean mass, making body composition monitoring essential beyond scale weight alone. Although DEXA is globally accepted as a gold standard for body composition analysis, the accessibility of DEXA is limited, particularly in resource-constrained low and middle-income countries such as India. BIA devices are a convenient low-cost option to DEXA and can be used for body composition analysis more frequently than a DEXA scan to provide longitudinal data. The aim of this study is to validate 8 electrode BIA devices as a viable alternative to DEXA scan for the South Asian population. Methods: A prospective cross-sectional validation study was conducted following ethics committee approval, with a priori sample size estimation ( = 0.05, power = 80%). Fifty-eight healthy adults (n=58) underwent three BIA measurements and one DEXA scan each. To ensure statistical independence, the three BIA readings per participant were averaged, yielding 58 final measurements for validation. Body fat percentage, lean mass and fat mass were evaluated using Python with statistical analyses like Bland Altman analysis, Pearson correlation, ICC and regression analysis. Results: In this BIA vs DEXA study, the Pearson correlation was strong across all three outcomes (fat%: r = 0.97; fat mass: r = 0.98; lean mass: r = 0.96), with ICC (2,1) values of 0.94, 0.97, and 0.91 confirming excellent absolute agreement. Mean absolute error was 3.40% for fat percentage, 1.96 kg for fat mass, and 3.37 kg for lean mass. BIA systematically underestimated body fat percentage (bias -1.96%, 95% CI: -2.91% to -1.01%; LoA: -9.04% to +5.12%) and fat mass (bias -0.72 kg, 95% CI: -1.38 to -0.07 kg; LoA: -5.59 to +4.14 kg), while overestimating lean mass by +3.08 kg (95% CI: +2.34 to +3.82 kg; LoA: -2.46 to +8.62 kg). Conclusions: The 8-electrode BIA device shows clinically acceptable agreement with DEXA for body composition assessment in healthy Indian adults. It offers a radiation-free, cost-effective, accessible, and portable alternative to DEXA, making it suitable for longitudinal monitoring and trend detection. The device is particularly valuable for obesity screening and for tracking body composition changes during weight loss interventions at the population level, addressing the critical need for accessible body composition assessment in resource-limited settings.

Background: Recent food-based recommendations for flavan-3-ols highlight a growing need to understand the breadth of our dietary polyphenol exposure. However, estimation of dietary polyphenol intake remains challenging, requiring custom computational tools that are often difficult to implement or not fully reproducible. Objective: We aimed to an automated, user-friendly tool to estimate polyphenol intake from diet recalls and records. Methods: We developed Polyphenol Estimator, a tool that processes dietary data from the Automated Self-Administered 24-Hour (ASA24) Dietary Assessment Tool or the Automated Multiple-Pass Method from the National Health and Examination Survey (NHANES). Polyphenol Estimator disaggregates foods using the FDA Food Disaggregation Database into ingredients, matches these ingredients to FooDB, and estimates polyphenol intake at the total, class, and compound level. Optionally, these polyphenol estimates can be used to calculate the Dietary Inflammatory Index (DII). Polyphenol Estimator is freely available online (https://swi1.github.io/polyphenol_estimator) with a tutorial for users with limited programming experience. Results: To illustrate Polyphenol Estimator, we applied it to two days of diet recalls from adults ([≥] 20 years) in NHANES 2021-2023 (n = 2778). For 97.7% of participants, less than 2.5% of reported foods went unmapped, with 75.7% of participants having complete mappings. Total polyphenol intake was 517 +/- 439 (mean +/- SD) mg/1000 kcal, largely from green tea, coffee, black tea, apples, wine, oranges, and blueberries. At the class level, polyphenols classified as organooxygen compounds, flavonoids, and cinnamic acids and derivatives were top intake contributors. At the compound level, cyptochlorogenic acid, neocholorogenic acid, and caffeic acid were top contributors. Lastly, the DII was 1.4 +/- 1.9, indicating the average diet had proinflammatory potential. Conclusions: Polyphenol Estimator offers an automated method to obtain total, class, and compound-level polyphenol estimates from dietary data to aid future efforts to understand polyphenol intake exposures and their biological impact on health.

Purpose: To assess maternal knowledge of preterm infant care in Gaza and identify clinically actionable education priorities in a resource-constrained neonatal setting. Methods: A cross-sectional survey was conducted among 170 mothers of premature infants admitted to neonatal departments in four government hospitals. A 30-item interviewer-administered questionnaire assessed knowledge across thermoregulation, feeding, phototherapy, and infection and skin care. Bivariate analyses, ordinal logistic regression, adjusted predicted probabilities, and exploratory clinical-priority gap analyses were conducted. Results: Overall knowledge was moderate, with a mean score of 64.1% (SD 22.3). Knowledge was classified as poor in 53 mothers (31.2%), good in 41 (24.1%), and excellent in 76 (44.7%). Knowledge differed across domains (p<0.001), with feeding weakest (53.6%) and infection and skin care strongest (73.8%). Not receiving specialist premature-care antenatal follow-up was independently associated with lower odds of higher knowledge (adjusted OR 0.34, 95% CI 0.15-0.80, p=0.013). Mothers without specialist follow-up also had a higher adjusted probability of poor knowledge than those who received it (37.4% vs 18.1%) and more clinical-priority gaps (IRR 1.28, 95% CI 1.04-1.57, p=0.019). Among the 10 lowest-scoring items, 110 mothers (64.7%) had five or more gaps. Conclusion: Maternal knowledge was uneven, with clinically important gaps in practical care domains. Domain-specific education checklists may strengthen antenatal counselling, bedside teaching, and discharge preparation in similar constrained neonatal settings.

Introduction: Hypertension is the world's leading cause of death, and depression its leading cause of disability. Control rates for these noncommunicable diseases (NCDs) are low in low and middle-income countries (LMICs). Many LMICs have programs to screen and treat underserved communities for infectious diseases, but evidence to adapt them to treat NCDs is limited. We developed and tested a non-communicable disease program through Ghana's Community-Based Health Planning and Services (CHPS) primary care initiative. Methods: We trained 8 CHPS nurses to diagnose and treat hypertension and depression through door-to-door screening and pharmacotherapy. Physician assistants provided telehealth supervision. We combined this treatment with volunteer counseling to boost medication adherence, improve mood, and change health behaviors. We called the 90-day intervention the CHPS Opportunity for Mentally and Behaviorally Integrated NCD Engagement (COMBINE). Results: We recruited 60 adults from 580 screened: 37 with hypertension (mean blood pressure (BP) of 149/91 mm Hg) and 23 with depression (mean physician health questionnaire (PHQ-9) score of 13.3). After 90 days, 57/60 (95%) completed the intervention: 32/37 (86%) achieved blood pressure control (mean BP 122/75 mm Hg), and 19 of 20 (95%) achieved depression control (mean PHQ-9 score 2.0). After 12 months, 51/60 were retained: 33/37 with hypertension (89%) and 18/23 with depression (78%), with a mean BP of 121/75 and PHQ-9 score of 1.4 respectively. All 51 (100%) achieved disease control at 12 months. 5 persons left by migration and 4 by escalation to higher-level care. Conclusions: The COMBINE model achieved high levels of diagnosis, care retention, and disease control, with minimal adverse events, in a remote setting with limited usual NCD care. This model suggests a novel means to improve the care cascade for these and other noncommunicable diseases through existing non-physician care models in LMICs, warranting further controlled testing at scale.

Background: An increasing demand for organic food has risen due to perceived health benefits. Current evidence for the health effects of organic food is limited. Objective: To evaluate the association between organic food purchase as a proxy for organic food consumption and hypertension in a nationally representative population of the US. Methods: This was a cross-sectional study that included 9173 participants aged >= 18 and had available data of both organic food purchase and hypertension from the National Health and Nutrition Examination Survey 2007-2010. Organic food purchase and frequency were obtained from survey questionnaires. Hypertension was defined as having either a systolic BP >= 130 mm Hg/ diastolic BP >= 80 mm Hg, currently taking antihypertensive medication, or self-reported diagnosis of hypertension. We used multivariable logistic regression with sample weights and adjustment of potential confounders to assess associations (adjusted odds ratio [aOR] and 95% confidence intervals [CI]) between organic food purchase and hypertension status. Results: Findings suggest an 11% decrease in odds of hypertension (aOR = 0.89, 95% CI: 0.75-1.06) among organic food purchasers compared to non-purchasers. Lower odds of hypertension were observed across all categories of organic food purchasing frequency, with 13% lower among rarely purchasing organic food (aOR = 0.87, 95% CI: 0.67-1.14), 9% lower (aOR = 0.91, 95% CI: 0.71-1.16) among sometimes purchasing organic food, and 17% lower (aOR = 0.83, 95% CI: 0.55-1.27) among always or mostly purchasing organic food, as compared to those who never purchased organic food. Conclusion: Our findings suggest that organic food purchase, a proxy for organic food consumption, may be associated with lower odds of hypertension. These findings may reflect either the true benefits of organic food consumption, including lower pesticide amounts and higher nutrient content, or the health-seeking behaviors among health-conscious, healthy, and highly educated individuals.

Background In the Democratic Republic of the Congo (DRC), health care financing relies heavily on out-of-pocket payments, limiting access to essential services. In a context of declining external funding and ongoing efforts toward Universal Health Coverage (UHC), understanding households willingness to pay (WTP) for health care is critical for designing sustainable financing strategies. This study aimed to assess WTP for primary health care services and identify its associated factors in Eastern Kasai Province. Methods A cross-sectional study based on the contingent valuation method was conducted from 10 to 30 July 2025 among 633 randomly selected households using a multistage probabilistic sampling approach. Data were collected through semi-structured interviews using KoboToolBox. WTP was assessed using a stated preference approach. Logistic regression analyses using R 4.5.0 were performed to identify factors associated with WTP at a significance level of p < 0.05. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were reported. Results Overall, 70% of household heads reported willingness to pay for their own health care, and 73% for other household members. WTP decreased significantly as the cost of services increased, dropping from 95.5% for free care to 6.3% at the highest cost levels (above CDF 230,000). Poor perceived quality of care was a consistent reason for refusal, alongside financial constraints such as low income and indebtedness. Multivariable analysis showed that having a professional activity (OR = 1.9; 95% CI: 1.2-3.0; p = 0.006), residence in rural areas (OR = 2.1; 95% CI: 1.3-3.7; p = 0.008), and higher household income (OR = 2.2; 95% CI: 1.2-4.0; p = 0.011) were significantly associated with WTP. Despite relatively low absolute health care costs, the majority of households perceived them as high. Conclusion Willingness to pay for health care services in Eastern Kasai is moderate but highly sensitive to cost and strongly influenced by socioeconomic conditions and perceived quality of care. These findings underscore the need to strengthen financial protection mechanisms, particularly prepayment and risk-pooling systems, while improving service quality to enhance health care utilization and progress toward UHC in the DRC.

Background Colorectal cancer is a growing public health concern in low- and middle-income countries, particularly in the context of nutritional transition and changing lifestyles. In Mauritania, evidence on factors associated with colorectal cancer remains limited. This study sought to identify nutritional, behavioral and anthropometric factors associated with colorectal cancer among adults living in Nouakchott. Methods A case-control study was conducted in Nouakchott between January and April 2026. The study included 50 confirmed colorectal cancer cases and 100 controls with no personal history of cancer. Data were collected using a standardized questionnaire covering sociodemographic characteristics, dietary habits, behavioral factors and anthropometric measurements. Crude and adjusted odds ratios with 95% confidence intervals were calculated using binary logistic regression. Results Low educational level was more frequent among cases than controls, 70.0% versus 27.0%, and remained independently associated with case status after adjustment (aOR = 4.98; 95% CI: 1.81-13.70; p = 0.002). Being married or living with a partner was also associated with case status (aOR = 3.72; 95% CI: 1.19-11.66; p = 0.024). Abdominal obesity was associated with colorectal cancer in bivariate analysis but not after adjustment. High consumption of salty foods remained associated with case status in the multivariate model (aOR = 47.45; 95% CI: 4.83-466.40; p = 0.001). However, this estimate should be interpreted with caution given the wide confidence interval and the limited sample size (n=50 cases). Refined sugars and canned foods were associated with case status only in bivariate analysis. Inverse associations observed for coffee and sugar-sweetened beverages should be interpreted cautiously because of possible reverse causality. Conclusion Low educational level and high consumption of salty foods were the most defensible factors associated with colorectal cancer in this study. These findings support strengthening nutrition-related prevention and health education interventions in Nouakchott. Larger studies with more detailed dietary assessment are needed to confirm these associations.

Background: Black adults bear a disproportionate burden of cardiometabolic dysfunction, yet most dietary trial evidence comes from predominantly White cohorts. Objective: To evaluate whether a personalized whole-food dietary intervention improves cardiometabolic outcomes more in Black than White young adults with overweight or obesity. Methods: In this 8-week randomized, controlled trial (ClinicalTrials.gov: NCT04635917), 112 Black and White adults (18-35 years; BMI 25-45 kg/m2) were block-randomized by race to a personalized dietary intervention providing whole foods (PD, n=57) or conventional dietary counseling at baseline (BL) using MyPlate guidelines (CD, n=55). Primary outcomes were Matsuda Index and fasting and OGTT-derived glucose, insulin, and non-esterified fatty acids. Other glucoregulatory, cardiovascular, anthropometric, appetite, and cognitive outcomes were also assessed. Outcomes were analyzed using baseline-adjusted linear models with sensitivity analyses adjusting for baseline BMI and food security score. Results: Compliance with study food consumption was 85-91%. Diet quality was higher in PD than CD (P < 0.05), with larger gains in vegetable-related outcomes among Black participants (group x race, P < 0.05). HOMA-{beta} was lower in PD than CD overall (P < 0.05). In sensitivity analyses, Black PD participants had greater fasting insulin reductions than White, especially in the latter half of intervention (week x group x race, P < 0.05), with a similar tendency for HOMA-IR. Glucose AUC 0-30 min was higher in White than Black PD participants (group x race, P < 0.05). Concentration performance was higher in PD than CD overall (P < 0.05), with larger gains in processing speed and accuracy among Black than White participants (group x race, P < 0.05). No effects were observed for cardiovascular or appetite outcomes. Conclusions: The personalized whole-food intervention produced differential effects in fasting insulin and early-phase glucose handling, and greater benefits in attention, in Black compared with White young adults with overweight or obesity during weight maintenance.

Background In 2016, the World Health Organization revised its antenatal care (ANC) recommendation from four to eight visits. For low- and middle-income countries like Uganda, where achieving even four visits remains a challenge, this transition has significant cost implications for both the health system and households. This study estimated the incremental costs of adopting the eight-visit model from a societal perspective. Methods The study was conducted in six government health facilities in southwestern Uganda. A micro-costing approach estimated health facility costs (personnel, equipment, consumables, and overhead). Costs incurred at patients end (transport, ultrasound, medical expenses, and time) were collected from 785 women using a questionnaire, with all costs in 2025 USD. Results For an average of 4.3 visits, total cost per woman was $100.1: facility costs $43.7 (43.7%), and patient costs $56.4 (56.3%). Transitioning to eight visits would increase total cost by $57.8 (57.8%), of which $36.4 (63.0%) would fall on households, equivalent to 68.8% of average monthly household income. Total costs would rise by 55.4% ($115.5 to $179.5) at Health Center IVs and 64.3% ($102.3 to $168.1) at Health Center IIIs, with facility costs up 43.4% and 62.9% and patient costs up 61.2% and 65.7%, respectively. Conclusion Transitioning to eight ANC visits would impose a large financial burden on households, with the incremental patient cost equivalent to more than two-thirds of average monthly household income. Equitable implementation requires improving availability of medicines and diagnostics, subsidizing transport, exploring telemedicine or community-based models, and improving efficiency at lower-tier health centers.

Background: Obesity is globally recognized as a complex, multifactorial chronic disease, with biological, psychological, environmental and behavioural factors involved in both disease pathogenesis and maintenance. Although previous group-based studies demonstrated involvement of each of these factors, there is large inter-individual variability in the factors contributing to disease development as well as intervention outcomes, causing limited translatability to the individual level. This heterogeneity in treatment effectiveness might be due to differential causal and maintenance factors of obesity. To enable the transition from a one-size-fits-all approach to a more personalized approach for individuals with overweight or obesity, this study aims to investigate if and how the degree of weight loss and changes in daily life behaviour after a combined lifestyle intervention depend on individual baseline profiles comprising of person characteristics, biological, psychological, environmental and behavioural factors. Methods: This study will include 600 individuals varying in BMI, 200 participants with a healthy BMI (18.5-24.9kg/m2), 200 with overweight (BMI 25.0-29.9kg/m2), and 200 with obesity (BMI [&ge;]30.0kg/m2). For all participants, a comprehensive individual baseline profile is created, including person characteristics, biological, psychological, environmental and behavioural factors. A clustering method is applied to identify clusters of participants with similar characteristics. Next, we examine if and how these clusters are linked to bodyweight indicators measured at baseline, and how they relate to daily lifestyle behaviour, as measured by ecological momentary assessment (EMA) using a smartphone app and sensor technology (3-week measurements). Individuals with overweight or obesity will be randomized to the intensive lifestyle intervention or a lifestyle information condition, to determine if treatment response can be predicted based on cluster characteristics, how daily lifestyle behaviour changes after an intervention, and how changes in daily lifestyle behaviour relate to treatment response. Discussion: The End of Average study aims to characterize a large set of individuals varying in body weight to predict intervention effectiveness measured as changes in body weight indicators and in daily lifestyle behaviours. If reliable predictors of treatment success can be identified, these can be applied in personalized lifestyle interventions to improve lifestyle behaviour, body weight management and overall health.

Objective To assess serum 25-hydroxyvitamin D [25(OH)D] levels in a health examination population in Guiyang, a low-latitude, high-altitude, and cloudy city in southwestern China, and to identify key determinants using machine learning. Methods This retrospective study included 10,931 adults (>20 years) who underwent health checkups at Guiyang First People's Hospital between February 2019 and April 2025. Beyond conventional statistical comparisons, a two-stage machine learning approach was applied: LASSO regression for feature selection, followed by an optimized Random Forest regression model (mtry = 2). SHapley Additive exPlanations (SHAP) were used to quantify variable importance. Results The median serum 25(OH)D level was 36.63 (IQR 24.77,53.17) nmol/L. Vitamin D deficiency (<50 nmol/L) was present in 70.98% of participants, while sufficiency (>75 nmol/L) was only 7.35%. Significantly lower levels were observed in females, in adults aged <30 years (deficiency rate 85.6%), and during spring. The optimized Random Forest model achieved a cross-validated RMSE of 21.427. SHAP analysis revealed a clear hierarchy of importance: age (mean SHAP = 5.604) > season (4.104) > sex (1.533) {approx} BMI (1.501). Conclusion Vitamin D deficiency is highly prevalent in the Guiyang health examination population. Age and season are the dominant determinants, far outweighing sex and BMI. Targeted interventions should focus on young adults, females, and the spring season, especially in regions with similar cloudy highland climates.

Introduction: Menstrual cycle phase has been proposed as a source of intra-individual variability in resting energy expenditure and the thermic effect of food in premenopausal females, yet studies examining the thermic effect of food across menstrual cycle phases report conflicting findings. Methods: This protocol describes a secondary analysis of prespecified outcomes from a non-randomized, two-period crossover trial primarily designed to assess postprandial plasma triglyceride concentrations across menstrual cycle phases (ClinicalTrials.gov: NCT07459465) in 12 premenopausal females aged 18-30 years, free of chronic disease and hormonal contraceptive use, recruited in Ottawa, Canada. Participants complete two experimental sessions: one in the early follicular phase and one in the mid-luteal phase, each involving consumption of a high-fat meal. Eleven secondary outcomes will be reported: fasting resting energy expenditure, thermic effect of food, respiratory exchange ratio, carbohydrate oxidation rate, lipid oxidation rate, desire to eat, hunger, fullness, prospective food consumption, serum beta-estradiol, and serum progesterone. Masked outcome analyses are performed using linear mixed-effects models. Results: Recruitment began on 26 March 2026; results will be reported in the Stage 2 manuscript. Discussion: Findings from this trial may help clarify whether menstrual cycle phase constitutes a meaningful source of intra-individual variability in energy metabolism, with implications for the design of metabolic research in premenopausal females.

Background Cancer is a growing public health challenge in low- and middle-income countries, where urbanization, nutritional transition and lifestyle changes contribute to modifiable risk factors. In Mauritania, population-based data on cancer-related nutritional, behavioral and anthropometric risk factors remain limited. Objective To describe the frequency of the main nutritional, behavioral and anthropometric cancer-related risk factors among adults living in the three wilayas of Nouakchott. Methods A cross-sectional study was conducted among 1,000 adults aged 18 years and older in Nouakchott. Data were collected using a standardized questionnaire covering sociodemographic characteristics, dietary habits, physical activity and selected health behaviors. Anthropometric measurements were performed to assess body mass index and abdominal adiposity. Abdominal obesity was defined using sex-specific waist circumference cut-off points recommended by the World Health Organization: [&ge;] 88 cm in women and [&ge;] 102 cm in men. Results were presented as frequencies and proportions, with comparisons by sex, age group and wilaya of residence. Results Women represented 52.0% of participants, and 53.5% were aged 18-34 years. Excess body weight was frequent, with 38.6% overweight and 28.0% obese. Abdominal adiposity was also common, with 58.0% having increased or substantially increased waist circumference and 48.3% having an elevated waist-to-hip ratio. Physical inactivity was reported by 64.7% of participants, and 15.7% were current smokers. Dietary exposures included high red meat consumption in 66.8%, daily refined cereal intake in 67.5%, daily sugar-sweetened beverage consumption in 14.9%, and limited daily fresh fruit consumption in 13.8%. Significant differences were observed by sex for anthropometric indicators, by age for selected dietary habits, and by wilaya for physical activity, smoking and selected dietary behaviors. Conclusion This study shows a high frequency of modifiable cancer-related risk factors among adults in Nouakchott, particularly excess body weight, abdominal adiposity, physical inactivity and unfavorable dietary habits. These findings support the need to strengthen primary prevention strategies targeting nutrition, physical activity and tobacco control in Mauritania.

Diagnosed diabetes disproportionately burdens socioeconomically disadvantaged populations in the United States, particularly Hispanic communities in the Texas-Mexico border region. Few studies have quantified whether geographic border-region status is independently associated with county-level diagnosed diabetes prevalence after accounting for lifestyle and food-environment factors. This cross-sectional ecological study examined 253 Texas counties using CDC PLACES 2025 health estimates and USDA Food Environment Atlas food-access data, including the 2015 county-level low-food-access measure. Border-region counties were defined using the official La Paz Agreement 32-county definition, which includes counties within 100 km of the US-Mexico boundary. Multiple linear regression with HC3 robust standard errors was used to estimate associations between border-region status, low food access, physical inactivity, and diagnosed diabetes prevalence. Variance inflation factor analysis assessed multicollinearity, and Global Moran's I tested spatial autocorrelation in diagnosed diabetes prevalence and OLS residuals. Border-region counties had 33% higher unadjusted mean diagnosed diabetes prevalence than non-border counties (16.1% vs. 12.1%). After adjustment, border-region status remained significantly associated with a 0.625 percentage-point higher diagnosed diabetes prevalence ({beta} = 0.625, 95% CI [0.357, 0.893], p < 0.001). Physical inactivity was the strongest independent predictor ({beta} = 0.404, 95% CI [0.391, 0.417], p < 0.001). The model explained 96.0% of county-level variance (R{superscript 2} = 0.960, N = 253), reflecting ecological associations among modeled county-level health indicators. Global Moran's I confirmed strong spatial clustering of diagnosed diabetes prevalence (I = 0.5734, p = 0.001), with reduced but significant residual spatial autocorrelation after OLS adjustment (I = 0.1696, p = 0.001). These findings suggest that border-region status is associated with elevated diagnosed diabetes prevalence beyond physical inactivity and low food access, supporting targeted public health investment in the Texas-Mexico border region

Background: The traditional wealth index, based on principal component analysis (PCA), used in the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), suffers from urban bias, distorting estimates of health inequality. We compared the traditional index (PEAR1) with an alternative two-component polychoric PCA index (POLY2) using annual expenditure from 12 LSMS surveys as the gold standard to determine which provides more accurate SEP measures for equitable policy targeting. Methods: We compared the traditional wealth index (PEAR1) with a two-component polychoric PCA approach (POLY2) using 12 LSMS (Living Standards Measurement Study) surveys (2015-2022) from 12 African countries. Annual household consumption expenditure was the gold standard. We assessed agreement using weighted Cohen's kappa and validated against education (proportion of households with secondary or higher education) using the concentration index (CIX) and slope index of inequality (SII). Results: The POLY2 index showed higher agreement with expenditure quintiles (average national weighted kappa = 43.3%) than the PEAR1 index (35.1%), with notable improvements in urban (43.5% vs. 27.5%) and rural (35.3% vs. 22.4%) areas. POLY2 also attenuated extreme household distributions observed in PEAR1. Education validation showed that POLY2 produced intermediate inequality gradients between the flatter expenditure-based gradient and the steeper PEAR1-based gradient. Conclusion: The POLY2 wealth index is superior to the traditional index, reducing urban-rural bias and providing more accurate socioeconomic classifications. Its adoption in large-scale surveys such as DHS and MICS is recommended to improve equitable monitoring of health inequalities in low- and middle-income countries.