Janet Elizabeth Cade

Traditional methods of measuring diet, mainly FFQ, are not fit for purpose. Diet is complex, with over 150 000 different food items available in UK supermarkets. This review describes the limitations of nutritional assessment methods used in the past. It provides an overview of recent methods using newer technologies, including online tool myfood24. Limitations of dietary assessment methods include recall bias; inability to estimate portion sizes; lack of adaptability across diverse populations; and inadequate food composition data. New tools include mobile apps for real-time intake tracking; use of image-based approaches for portion sizes and food identification; sensor technologies such as smart utensils and bite counters. Online platforms provide an economical approach for large-scale epidemiology. myfood24 is an online tool, developed for research and validated using biomarkers. Having demonstrated success with >250 000 research participants in over 27 countries; myfood24 is also used in healthcare, for student education and other settings. myfood24 focuses on accurate data and ease of participant use. The underlying food composition database curated by nutritionists has fewer missing data and more nutrient variables than standard generic tables. The database includes diet quality and sustainability measures. A new app includes the novel myfood24 Diet Optimization Engine suggesting individual dietary changes to meet nutrition targets. New dietary assessment tools provide more accurate data with deeper insights into dietary behaviour. They need to be used in large epidemiological surveys; for public health population screening and with patients to fully realise their potential.

Background: Vegetarian diets might influence cancer risk. Methods: We studied 1,645,555 meat eaters, 57,016 poultry eaters, 42,910 pescatarians, 63,147 vegetarians and 8849 vegans in 9 cohorts (UK, US, Taiwan, India). After a median 16 years follow-up, incident cancers were: 4504 mouth and pharynx, 1308 oesophagus (squamous cell), 2105 oesophagus (adenocarcinoma), 3578 stomach, 30,528 colorectum, 2970 liver, 8030 pancreas, 3077 lung (never smokers), 61,368 breast, 11,220 endometrium, 8076 ovary, 45,946 prostate, 7193 kidney, 6869 bladder, 11,651 non-Hodgkin lymphoma, 4658 multiple myeloma and 7306 leukaemia. Multivariable Cox regression was used to estimate cohort-specific hazard ratios (HRs) and 95% confidence intervals (CIs), and the results were combined using meta-analysis. Results: Compared to meat eaters, poultry eaters had lower risk of prostate cancer (0.93, 0.88–0.98), pescatarians had lower risks of colorectal (0.85, 0.77–0.93), breast (0.93, 0.88–0.98) and kidney cancer (0.73, 0.58–0.93), vegetarians had lower risks of cancers of the pancreas (0.79, 0.65–0.97), breast (0.91, 0.86–0.97), prostate (0.88, 0.79–0.97), kidney (0.72, 0.57–0.92) and multiple myeloma (0.69, 0.51–0.93) but higher risk of squamous cell carcinoma of the oesophagus (1.93, 1.30–2.87), and vegans had higher risk of colorectal cancer (1.40, 1.12–1.75). Conclusions: Vegetarian diets might influence risk for several cancers. The generalisability should be considered cautiously.

BACKGROUND Mobile applications (apps) have emerged as a convenient and accessible solution to support weight management. More than 28,000 apps related to weight loss are available across various platforms. However, there is a lack of understanding of the most effective approach to evaluate the quality of these apps. Existing studies have focused only on popular apps or specific user groups. OBJECTIVE To identify the approaches employed to assess the quality of weight loss apps and to determine which app features are considered important for enhancing their effectiveness. METHODS This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive literature search was carried out across four databases: PubMed, Embase, Medline, and Web of Science. As inclusion criteria, studies were eligible if they specifically assessed weight-loss apps among healthy adult users (aged ≥18 years) and were published between January 1st 2019, and June 30th 2024. Studies were excluded if they focused on non-digital interventions, were not in English, involved clinical, military, or athletic populations, or were review articles, meta-analyses, conference abstracts, or reports. Search terms were derived from the concepts of quality, weight loss, and mobile applications. Data extraction focused on the approaches used to evaluate app quality. RESULTS Eleven studies met the inclusion criteria, evaluating a total of 46 distinct weight loss apps. Seven generic app evaluation approaches and two supporting frameworks were identified, with the most frequently used being the Mobile App Rating Scale (MARS) (n=39 apps), Evidence-based Strategies (EBS) Assessment (n=25 apps), and Six Sigma (n=25 apps). Only two approaches, MARS and the System Usability Score (SUS), have been validated to evaluate mobile apps. A total of 8 feature categories were identified as present in the apps across the studies. The most frequently observed were nutrition education (5), self-monitoring and tracking (5), exercise content & tools (5), behavioural support (4), social features (4), coaching and feedback (3), planning and goal setting (3), and technical functionality (2). Nine features were also recommended by the study authors to enhance app effectiveness through behaviour change. These features are progress reports (4), self-monitoring (2), reminders (3), gamification (2), and expert monitoring (1), comprehensive nutrition databases (3), food entry options (2), barcode scanning of calorie content (2), and affordability (2). Only the initial five are associated with behaviour change elements as per the BCT Taxonomy framework. CONCLUSIONS A range of approaches are currently employed to evaluate the quality of weight loss apps. This review identified seven commonly used evaluation approaches and two supporting frameworks, with MARS being the most frequently applied. Additionally, this study identifies a set of common and key features that should be prioritised in the development of weight loss apps for adults living with obesity to potentially enhance their overall effectiveness.

Background: National Health Service England piloted a low-calorie diet programme, delivered through total diet replacement and behaviour change support via 1 : 1, group or digital delivery, to improve type 2 diabetes in adults with excess weight. Aim: To coproduce a qualitative and economic evaluation of the National Health Service low-calorie diet pilot, integrated with National Health Service data to provide an enhanced understanding of the long-term cost-effectiveness, implementation, equity and transferability across broad and diverse populations. Research questions: What are the theoretical principles, behaviour change components, content and mode of delivery of the programme, and is it delivered with fidelity to National Health Service specifications? What are the service provider, user and National Health Service staff experiences of the programme? Do sociodemographics influence programme access, uptake, compliance and success? What aspects of the service work and what do not work, for whom, in what context and why? Can the programme be improved to enhance patient experience and address inequities? What are the programme delivery costs, and policy implications for wide-spread adoption? Methods: A mixed-methods study underpinned by a realist-informed approach was delivered across five work packages, involving: semistructured interviews with service users (n = 67), National Health Service staff (n = 55), service providers (n = 9); 13 service provider focus groups; and service user surveys (n = 719). Findings were triangulated with clinical data from the National Health Service England’s first cohort analysis (n = 7540). Results: Fifty-five per cent of service users who started total diet replacement completed the programme and lost an average of 10.3 kg; 32% of those with data available to measure remission achieved it. Examination of programme mobilisation identified barriers around referral equality and the impact of COVID-19, while effective cross-stakeholder working and communication were key facilitators. Service delivery and fidelity assessments identified a drift in implementation fidelity, alongside variation in the behaviour change content across providers. Perceived barriers to programme uptake and engagement aligned across service providers and users, resulting in key learning on: the importance of person-centred care, service user support needs, improvements to total diet replacement and the social and cultural impact of the programme. Early National Health Service quantitative analyses suggest some socioeconomic variation in programme uptake, completion and outcomes. Insights from the evaluation and National Health Service data were combined to develop the programme theory and underpinning context, mechanisms and outcomes. These were used to develop a list of recommendations to improve the cultural competency of programme delivery, total diet replacement delivery, peer support and address psychological support needs. Cost-effectiveness analyses using short-term follow-up data indicated there is potential for the programme to be cost-effective, but not cost saving. Conclusions: The National Health Service low-calorie diet can provide a clinically effective and potentially cost-effective programme to support weight loss and glycaemic control in adults with type 2 diabetes. However, this evaluation identified areas for improvement in referral equity, uptake and completion, and fidelity of delivery, which have informed the development of the programme, which has now been rolled out nationally. Ongoing programme monitoring and long-term follow-up are now required. Future work and limitations: The real-world setting limited some data collection and analysis. Future work will focus on the analysis of long-term clinical and cost-effectiveness, and addressing inequalities. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132075.

Background: Many children receive some or all their nutritional intake via a gastrostomy. More parents are using home-blended meals to feed their children, reporting beneficial effects, such as improved gastro-oesophageal reflux and less distress. Aim: To compare safety, outcomes and resource use of those on home-blended diets compared to formula diets. Methods: A mixed-methods study of gastrostomy-fed children. Workstream 1: Qualitative study involving semistructured interviews with parents (n ≈ 20) and young people (n ≈ 2) and focus groups with health professionals (n ≈ 41). Workstream 2: Cohort study; data were collected on 180 children at months 0, 12 and 18 from parents and clinicians using standardised measures. Data included gastrointestinal symptoms, quality of life, sleep (child and parent), dietary intake, anthropometry, healthcare usage, safety outcomes and resource use. Outcomes were compared using propensity scored weighted multiple regression analyses. Results: Workstream 1: Participants believed the type of diet would most likely affect gastrointestinal symptoms, time spent on feeding, sleep and physical health. Workstream 2: Baseline: Children receiving a home-blended diet and those receiving a formula diet were similar in terms of diagnoses and age, but those receiving a home-blended diet were more likely to live in areas of lower deprivation and their parents had higher levels of education. They also had a higher dietary fibre intake and demonstrated significantly better gastrointestinal symptom scores compared to those receiving a formula diet (beta 13.8, p < 0.001). The number of gut infections and tube blockages were similar between the two groups, but stoma site infections were lower in those receiving a home-blended diet. Follow-up: There were 134 (74%) and 105 (58%) children who provided follow-up data at 12 and 18 months. Gastrointestinal symptoms were lower at all time points in the home-blended diet group, but there was no difference in change over time within or between the groups. The nutritional intake of those on a home-blended diet had higher calories/kg and fibre, and both home-blended and formula-fed children have values above the Dietary Reference Values for most micronutrients. Safety outcomes were similar between groups and over time. Total costs to the statutory sector were higher among children who were formula fed, but costs of purchasing special equipment for home-blended food and the total time spent on child care were higher for families with home-blended diet. Conclusion: Findings show that home-blended diets for children who are gastrostomy fed should be seen as a safe alternative to formula feeding for children unless there is a clinical contraindication. Limitations: The target sample for children in workstream 1 was not achieved. The observational study design means unmeasured confounding may still be an issue. Children in this cohort had been on their home-blended diets for different periods of time. A lack of good reference data for nutritional and anthropometric data for disabled children does hinder further interpretation of nutritional adequacy. Future work: Future research on: impact of a home-blended diet on the gut microbiome in children who are gastrostomy fed and equality of access. Children’s experiences of living with a gastrostomy, nutritional requirements and quality of life should also be prioritised. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/76/06.

Introduction Amyotrophic lateral sclerosis (ALS) is a devastating illness that leads to muscle weakness and death usually within around 3 years of diagnosis. People with ALS (pwALS) often lose weight due to raised energy requirements and symptoms of the disease presenting significant challenges to taking adequate oral diet, with those who lose more weight being at a greater chance of earlier death. There is also some evidence to suggest that a higher calorie diet may benefit the disease course in pwALS, but further research is needed. Methods and analysis Two armed, parallel group, superiority, open labelled, randomised controlled trial, with internal pilot, to assess the effectiveness of an early high calorie diet on functional outcomes in ALS, comprising two treatment arms: (1) standard care, (2) standard care with additional active management using the OptiCALS complex intervention to achieve a high calorie diet (initially randomised 1:1, then 1:2 following a protocol amendment). Using a food first approach, pwALS will be encouraged and supported to follow a diet that meets an individualised calorie target from food before prescribing oral nutritional supplements. 259 pwALS will be recruited from up to 20 ALS centres across the United Kingdom and Ireland and followed up for a period of 12 months. Primary outcome is functional change measured over 12 months, using the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale. Secondary end points include measures of functional health, quality of life, calorie intake and weight, as well as time to gastrostomy and survival. A health economic analysis and process evaluation will also be undertaken. Participant recruitment is expected to complete in September 2025, and participant follow-up is expected to complete in September 2026. The results of this study are expected in March 2027. Ethics and dissemination The trial was approved by Greater Manchester—North West Research Ethics Committee, reference 20/NW/0334 on 8 September 2020. We will publish the study findings in peer-reviewed academic journals and present at local, national and international conferences where possible. Trial registration number ISRCTN30588041.

The first 1000 days of life are crucial for health, making it essential that foods for infants and young children (FIYC) meet high nutritional standards, as defined by the World Health Organization's (WHO) Nutrient and Promotion Profile Model (NPPM). There is high reliance on commercially available highly processed FIYC for children under 3 years of age, and a growing market. The aim of this study is to analyse the nutrient profiles of FIYC using the WHO NPPM and determine the proportion of products available in Spain suitable for promotion. Data on 830 FIYC available from brands sold by major retailers in Spain were collected. Product nutrient composition and label information were assessed using the WHO NPPM for the European Region. The processed fruit and vegetables were the most common FIYC category, accounting for 46% of the products surveyed. Overall, only 23% met all NPPM nutritional standards. About 60% of products had excessive sugar content, with 98% of fruit and vegetable purees qualifying for a front-of-pack sugar warning. One in four savoury meals was protein-deficient and one in four of all FIYC was energy-deficient. Only 7% and 2% exceeded the sodium and fat limits, respectively. No product fully met the NPPM promotion recommendations. Conclusion: Nearly 80% of FIYC products in Spain do not meet WHO’s NPPM criteria for nutrient quality, with many high in sugar, low in protein and too watery (low energy). None met the promotional recommendations, highlighting the need for better regulation to improve the nutritional content and appropriate marketing of products for young children. What is Known?• The first 1,000 days of life are critical for child development and require optimal nutrition.• The WHO European Region developed the Nutrient and Promotion Profile Model (NPPM) to evaluate foods for infants and young children (FIYC). What is New?• This is the first comprehensive study applying the WHO NPPM to 830 FIYC products on the Spanish market.• Nearly 80% of products failed to meet the nutritional standards, and none complied with the promotion criteria.

Objectives: To estimate the association between various indicators of obesity-related health risk and the incidence of rheumatoid arthritis (RA) in a large cohort of women. Methods: The UK Women’s Cohort Study is a prospective cohort of 35,372 middle-aged women (aged 35–69 at recruitment) initiated in 1995–1998. Obesity was assessed using body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), categorised according to WHO and NICE guidelines, as well as clothing size. Incident RA cases were identified via Hospital Episode Statistics (HES) linkage up to March 2019. Cox regression models were used to estimate RA risk, adjusting for demographics, reproductive factors, and lifestyle factors. Non-linear associations were examined using restricted cubic splines. Results: Among 27,968 eligible subjects with complete data linkage (625,269 person-years of follow-up), there were 255 incident RA cases. Obesity (≥30.0 kg/m²) was associated with increased RA risk (HR (95% CI) 1.48 (1.02, 2.17), as were abdominal obesity (WC > 88 cm: 1.58 (1.10, 2.27)), WHR ≥ 0.85 (1.56 (1.03, 2.36)), and WHtR ≥ 0.6 (2.25 (1.34, 3.80)). Each 2.5 kg/m² increase in BMI was associated with a 9% higher risk of RA; each 5 cm increase in WC with 6%; each 0.1 increase in WHR with 20%, and each 0.1 increase in WHtR with 27%. Larger clothing sizes were associated with a greater RA risk: for each onesize increment in blouse size and skirt size, the HRs were 1.13 (95% CI: 1.04, 1.22) and 1.13 (95% CI: 1.05, 1.22), respectively. Notably, skirt size ≥ 20 was associated with a 2.36-fold increased risk of RA. There was evidence of effect modification by weight change and menopausal status in obesity-related RA risk. Conclusions: Our findings suggest that managing obesity and central adiposity in middle-aged women may be associated with the risk of developing RA. WHtR may serve as a practical alternative to BMI in assessing RA risk. Clothing size, particularly skirt size, could provide a simple, cost-effective proxy for identifying at high risk of RA.