The Journal of Nutrition

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

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

Iron deficiency (ID) is the most common nutritional deficiency worldwide, often caused by insufficient dietary intakes. Oral supplementation is one of the means to improve iron status. This study evaluated the efficacy and safety of two low-dose iron supplements - >Your< Iron Forte Capsules (YIFC) and Ferrous Sulfate Capsules (FSC) - in individuals with dietary ID. One hundred and one participants (mean age 30.6 years; 98% women) with low iron stores (mean serum ferritin 16.1 {micro}g/L) were randomized to receive either YIFC or FSC once daily for 12 weeks. Changes in blood indices and iron-related parameters were assessed at four and 12 weeks of intervention relative to baseline. The primary outcome was the change in hemoglobin (Hb) after 12 weeks. Eighty-seven participants completed the study. Both supplements significantly increased Hb at 12 weeks (YIFC: mean 6.52 g/L, p<0.001; FSC: mean 5.71 g/L, p<0.001). Product-related adverse events (AEs) were few (17% of all AEs) and of mild to moderate intensity only. One participant receiving FSC withdrew due to a probable product-related AE. The frequencies of product-related AEs were similar between study arms, however, statistically significantly more AEs judged to be definitely related to the product occurred in in the FSC arm. While product-related AEs were confined to the gastrointestinal tract in the YIFC arm, they affected multiple organ systems in the FSC arm. Supplementation with either YIFC or FSC proved as an effective, well-tolerated, and safe strategy for improving iron status in non-anemic dietary iron deficiency. In terms of the AE profile, supplementation with YIFC may offer advantages over supplementation with FSC.

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.

Aims/hypothesisTo investigate the feasibility and preliminary efficacy of a 12-week remotely-delivered exercise snacks (ES) intervention in adults with type 2 diabetes. MethodsInsufficiently active adults with type 2 diabetes (N=69; 46 females; mean age {+/-} SD: 58{+/-}11 years) were randomized to an ES or mobility/stretching comparator group (CON), which involved 4 x 1-min bouts of either vigorous or low intensity exercise, respectively, on [&ge;]5 days/week. The primary outcome was feasibility based on adherence. Secondary outcomes included exercise enjoyment (1-7 scale), rating of perceived exertion (RPE; 0-10 scale), heart rate (HR), hemoglobin A1c (HbA1c), blood biomarkers of cardiometabolic health, 30-second sit-to-stand capacity, grip strength, estimated maximal oxygen uptake, and anthropometrics. ResultsWeekly adherence (estimated marginal mean [95% confidence interval]: 18 bouts [16 to 21] for both groups; P=0.99) and total enjoyment (ES: 4.5 [4.1 to 4.8] vs CON: 4.3 [4.0 to 4.7]; P=0.64) were high and not different between groups. Despite higher RPE (5.7 [5.4 to 6.1]) and peak HR (73 [70 to 77] % of age-predicted HR maximum) in ES vs CON (2.0 [1.7 to 2.4] and 61 [58 to 64] % of age-predicted HR maximum, respectively) (all P<0.001), there were no between-group differences in the change in any secondary outcome (all P>0.05) except for greater sit-to-stand capacity in ES after training (between-group effect estimate [95% confidence interval]: 1.9 repetitions [0.3 to 3.4]; P=0.02). Conclusions/interpretationExercise snacks were feasible to perform in the real-world and improved physical capacity to a greater extent than CON in adults living with type 2 diabetes. Trial registrationClinicalTrials.gov ID: NCT06407245 Research in ContextO_ST_ABSWhat is already known about this subject?C_ST_ABSO_LIExercise snacks ([&le;]1-min bouts of vigorous exercise spaced out across the day) are a time-efficient and practical approach to promote vigorous exercise and break up sedentary time. C_LIO_LIReal-world exercise snack interventions appear feasible for middle-aged and older adults. C_LI What is the key question?O_LIAre 12 weeks of exercise snacks performed in the real-world feasible for insufficiently active adults living with non-insulin treated type 2 diabetes? C_LI What are the new findings?O_LIExercise snacks are feasible for those living with type 2 diabetes to perform unsupervised in the real-world based on high adherence, enjoyment, and participant retention rates. C_LIO_LIExercise snacks improved 30-second sit-to-stand capacity and reduced waist circumference suggesting enhancements in physical capacity and body composition. C_LI How might this impact on clinical practice in the foreseeable future?O_LIExercise snacks could be utilized to help individuals living with type 2 diabetes build a routine or habit of incorporating small amounts of physical activity into their daily lives. C_LIO_LIThe improved physical capacity observed in the current study could contribute to lower fall risk and greater lower body strength in those with type 2 diabetes as they age. C_LI

BackgroundVitamin D supplementation has been investigated for potential associations with cardiometabolic risk factors related to cardiovascular disease (CVD); however, findings from randomized controlled trials (RCTs) remain inconsistent. This meta-analysis aimed to assess the effects of vitamin D supplementation on cardiometabolic risk factors--including lipid profile, blood pressure, and glycaemic parameters--and to explore whether age and baseline serum vitamin D concentrations modify these associations. Research Design and MethodsWe conducted a systematic review and meta-analysis of RCTs comparing oral vitamin D supplementation with placebo in adults. PubMed, the Cochrane Library, and ClinicalTrials.gov. Risk of bias was evaluated using the Cochrane tool, and pooled effect sizes with 95% confidence intervals (CIs) were calculated using random-effects models. Results14,051 abstracts were retrieved, of which 45 were used for data analysis. Vitamin D supplementation reduced low-density lipoprotein cholesterol (LDL-C) by 0.136 mmol/L (95%CI: -0.215, -0.56), systolic blood pressure by 2.79 mm Hg (95% CI: -4.648, -0.938), fasting blood glucose by -0.11 (95%CI:-0.185, -0.036), and hemoglobin A1c by 0.164% (95%CI: -0.322, -0.006) compared with placebo. Subgroup analyses revealed reductions in SBP and LDL cholesterol among participants aged [&ge;]55 years and reductions in fasting blood glucose in participants with age < 55 years. While favourable effects on fasting blood glucose and hemoglobin A1c were observed with a baseline blood level of vitamin D of concentrations (<50 nmol/L). ConclusionsVitamin D supplementation may be associated with modest modifications in selected cardiometabolic risk factors; including systolic blood pressure, LDL-cholesterol, fasting blood glucose, and hemoglobin A1c. Age and baseline vitamin D status appear to modulate these effects. The clinical relevance of these modest effects remains uncertain. Well-designed RCTs with standardized protocols are required to clarify potential effect modification by age and baseline vitamin D status. Trial RegistrationPROSPERO (CRD42020165293) FundingThis research received funding from the Hashemite University, P.O. Box 330127, Zarqa 13133, Jordan

AimsThis study aimed to examine the prevalence of malnutrition and its associations with functional capacity and quality of life (QoL) in AL and ATTR cardiac amyloidosis patients. Methods and ResultsThis cross-sectional pilot study included 29 patients with confirmed CA (14 AL, 15 ATTR). Data were collected between January 2020 and September 2021. Nutritional status was assessed using body mass index (BMI), anthropometric measures, and the Subjective Global Assessment (SGA). Functional capacity was evaluated via handgrip strength and the 6-minute walk test, while QoL was assessed using the SF-36 and Kansas City Cardiomyopathy Questionnaire. Malnutrition, as determined by SGA, was present in 62% of patients, with no significant difference between AL and ATTR subtypes. In contrast, BMI according to WHO criteria failed to identify any cases of malnutrition, highlighting its limited utility in this population. These results suggest that conventional indicators may underestimate nutritional impairment in CA. Although overall QoL and functional capacity did not differ significantly between nutritional groups, malnourished AL patients showed notably lower QoL scores compared with well-nourished peers. ConclusionMalnutrition is highly prevalent in cardiac amyloidosis and seems to particularly affect the AL subtype. These findings underscore the importance of routine nutritional screening and targeted interventions, as early identification and management of malnutrition may improve patients quality of life and long-term outcomes.

BackgroundDigital health self-monitoring tools are widely used to support weight management and metabolic health. Higher engagement with these tools is often associated with better clinical outcomes; however, real-world engagement-outcome relationships for consumer metabolic monitoring devices remain incompletely characterized, particularly in heterogeneous user populations. ObjectiveTo evaluate whether engagement with a portable breath-based metabolic device (Lumen; Metaflow Ltd.) is associated with greater weight loss and reduction in body fat among real-world glucagon-like peptide-1 receptor agonist (GLP-1RA) users. The study also explores correlations between engagement and a device-specific measure of metabolic flexibility (FLEX score). MethodsWe retrospectively analyzed 2,296 adult Lumen users who self-reported GLP-1RA use over 24 weeks. Engagement was quantified as total engagement days over a 24-week period and ordered engagement consistency groups defined by weekly use frequency thresholds. Weight and body fat percentage data were collected by a combination of connected devices and manual user input in the Lumen smartphone application. Associations with weight loss and reduction in body fat percentage were evaluated using linear regression and ANCOVA adjusted for age, baseline BMI, and sex, with HC3 robust standard errors. Body fat percentage data were available for only 490 of the 2,296 subjects. In addition, similar associations were evaluated for FLEX score. GLP-1RA exposure was self-reported at onboarding and not verified longitudinally. ResultsAt 24 weeks, low/medium/high engagement users lost 3.2%, 4.6%, and 5.2% of body weight (trend p=2.36x10-11). Engagement days were associated with percent weight change (slope -0.0214% per day; P(HC3)=7.9x10- 18). Engagement days showed modest association with body fat percentage change (n=490; slope -0.0105% per day; P(HC3)=.010). The adjusted ANCOVA trend across engagement groups was not significant (P=.19). Engagement days and consistency both showed a highly significant trend in increase in FLEX score (slope +0.0185 per day; P(HC3)=2.0x10- 36). ConclusionsIn a real-world digital health dataset, higher engagement with a breath-based metabolic monitoring device and its smartphone application was associated with greater 24-week weight loss after adjustment for age, baseline BMI, and sex. The absolute difference between low and high engagement (2.0% body weight) is modest but clinically meaningful in real-world settings after 24 weeks of tracking. Associations with body fat percentage change were smaller and not consistently significant in adjusted analyses. Associations with metabolic flexibility were highly significant, but it remains unknown whether this parameter is predictive or reflective. Prospective controlled studies are needed to test causality and determine whether device-driven biofeedback and sustained engagement independently improve outcomes because GLP-1RA use was self-reported and unverified, and the present analysis was observational. These findings should be interpreted as engagement-outcome associations and reflect behavioral motivation and adherence rather than evidence of device efficacy.