This abstract was awarded the Student Competition Prize.

Periconception is the period spanning the weeks directly before and after conception and is a crucial window for optimising neurodevelopment in offspring(1-4). Iron and omega-3 fatty acids (n-3 FAs) are two vital nutrients for the development of the nervous system however, little research has been conducted into their importance during the periconceptional window(5-8). This study investigated whether supplementing iron and n-3 FA deficient (ID and n-3 FAD) rat dams before conception compared to after conception results in different neurodevelopmental outcomes in offspring. We hypothesised that initiating iron and n-3 FA supplementation in deficient dams after conception would not be as efficacious in preventing impaired offspring neurodevelopment induced by double- deficiency, compared to initiating supplementation before conception.

Female rats consuming an ID and n-3 FAD diet were randomly allocated to receive iron and DHA/EPA supplementation either 10 days before (Pre-Fe+DHA/EPA) or 10 days after conception (Post-Fe+DHA/EPA). Dams and offspring (Pre-: n = 24; Post-: n = 26) were subsequently maintained on supplemented diets throughout the experiment. Between postnatal days 31–41, cognitive and behavioural tests were conducted on offspring. Offspring were euthanised between postnatal day 42–45 and n-3 FAs, iron and monoamine concentrations were measured in the hippocampus, striatum and frontal cortex. All outcomes were compared to offspring who were either iron and n-3 FA deficient (ID+n-3 FAD: n = 24) or sufficient (Control+Fe+DHA/EPA: n = 22). One-way ANCOVA, with sex as a covariate, was used to determine between-group differences and two-way ANOVA was used to explore diet-sex interactions.

There were no differences in brain iron or n-3 FA levels between Pre- and Post-Fe+DHA/EPA offspring (P > 0.05). Female Post-Fe+DHA/EPA offspring had greater norepinephrine concentrations in the frontal cortex (Pre-: 3.21± 0.57 ng/mg vs Post-: 2.50± 0.55 ng/mg; P = 0.014) and consumed less sucrose in the sucrose preference test (Pre-: 96.16± 1.73%; Post-: 90.15± 1.66%; P = 0.010) compared to Pre-Fe+DHA/EPA offspring. Female Post-Fe+DHA/EPA offspring also had significantly lower liver iron concentrations compared to female Pre-Fe+DHA/EPA offspring (Pre-: 537± 47.13 μg/L vs Post-: 310± 45.28 μg/L; P = 0.034). There were no other significant differences in monoamine concentrations or behavioural tests.

Our results indicate that supplementing ID and n-3 FAD mothers both before and after conception is efficacious in preventing neurodevelopmental deficits associated with deficiency. However, ID and n-3 FAD during the periconceptional period may alter reward-based learning in female offspring(9-11). Additionally, optimising iron provision during periconception may have important implications for the prevention of postnatal ID-anaemia, particular during early infancy(12).

Gastrointestinal (GI) disorders are becoming increasingly common in young people in India and globally (1). Diet (eating habits, nutrient intake, and dietary diversity) and mental health (stress and anxiety levels) factors can independently and synergistically regulate gut health through dietary modulation of gut microbiota composition and gut-brain axis-related mechanistic pathways (2-3). However, few studies have investigated the associations between diet, mental health, and GI-related disturbances. Hence, this observational study was conducted to explore the possible effects of eating behaviors and stress and anxiety symptoms on self-reported measures of gastrointestinal health among 18-45-year-old adults in India.

A purposive cluster sampling method guided the recruitment of participants (n=407). Two non- consecutive day 24-hour diet recalls were conducted to estimate nutrient intakes and calculate Individual Diet Diversity (IDD) and Food Variety Scores (FVS). Gastrointestinal health was assessed using a validated instrument comprising 35 items related to gastric, small intestine, and colon function, and GI inflammation. Perceived Stress Scale (PSS-10 scores 0 to 40 with higher scores representing higher levels of stress), and Generalized Anxiety Disorder Scale (GAD-7 scores >5 (mild), >10 (moderate), and >15 (severe)) were used to evaluate perceived stress and anxiety (4-5). Socioeconomic status and eating habits were self-reported and the anthropometry measurements were recorded. Multivariable logistic regression analysis was performed using sociodemographic characteristics, anthropometry measurements, eating habits, and stress and anxiety levels as independent (predictor) variables, and composite gastrointestinal health risk scores as the dependent variables.

Participants reported mild anxiety (mean (M) = 7.09, standard deviation (SD)= 3.25) and moderate stress (M=18.44; SD= 9.89) with preponderance among females, higher age groups (> 35 years), and lower socioeconomic status. Overall, 38.8% and 45.3% were at high-risk score categories for gastric function and GI inflammation respectively. Higher energy and fat consumption, frequent breakfast skipping, and lower IDDS and FVS scores were associated with higher scores for stress and anxiety. Moreover, participants having moderate to severe anxiety reported a higher frequency of GI symptoms such as indigestion (M= 3.23 SD= 2.1-4.6, p= 0.023), excessive belching (M= 2.36 SD =1.21, p=0.043), and post-meal lower abdominal discomfort and cramps (M= 3.07, SD = 2.22, p < 0.001) as compared to those having nominal/mild anxiety. Age-adjusted regression models showed higher waist circumference (OR= 4.69, 95% CI =1.33- 7.28, p= 0.034), and stress scores (OR= 1.66, 95% CI= 1.32-1.90, p = 0.042), lower IDDS (OR= 2.34, 95% CI=1.80- 2.91, p <0.001) and presence of > 2 co-morbid conditions (OR= 8.12, 95% CI = 5.34- 11.21, p < 0.001) as predictors of higher GI disorder risk scores.

The preliminary findings of the study highlight associations between diet, stress, and GI health, presenting opportunities to modulate diet and optimize mental health to prevent and reduce the severity of GI disorders.

Multiple-long term conditions (MLTCs), also known as multimorbidity, are commonly defined as the presence of two or more long-term medical conditions in one individual(1). More than half of all adults over 60 years are affected by multimorbidity worldwide(2) and its increasing prevalence demands a shift in focus for research and healthcare towards multiple clusters of disease, rather than single conditions(3).

Current epidemiological evidence on diet as preventative lifestyle factor in relation to MLTCs is limited(4). Therefore we reviewed the existing evidence to summarise methods of assessment of diet and multimorbidity measure to identify further research needs in a scoping review.

Medline, Embase, CINAHL, Web of Science and Scopus were searched systematically following the methodological approach for scoping reviews by PRISMA. The protocol was published on Open Science Framework under DOI10.17605/OSF.IO/9FP5D. The search yielded a total of 10,937 results. After de-duplication, title and abstract screening and a final inclusion round of in-text screening by two reviewers, 53 articles met the inclusion criteria. Observational studies were included if they examined the relationship between any dietary factor and the prevalence/or development of MLTCs in community-dwelling adults.

Publication dates of included research papers ranged from 2014 to 2023, with over half of studies published in the last three years. There was high variability between dietary assessment methods used: in the majority of studies (n=21, 39.6%) fruit and vegetable intake was the only diet-related variable reported. A priori diet quality scores were used in n=15 (28.3%) studies and n=6 (11.3%) studies used a posteriori approaches to identify dietary patterns, n=11 used other methods (20.8%). Only n=3 (5.7%) studies also focussed on micronutrients. MLTCs were generally defined as presence of ≥2 chronic conditions by most papers, however the number of qualifying conditions ranged from 2-60 conditions.

Overall, 60.4% (n=32) of studies were cross-sectional with various dietary components and patterns showing either mixed results, (n=10, 31.3%), no association (n=5, 15.6%) or inverse associations (n=12, 37.5%), i.e. higher diet score/adherence/consumption of diet components was associated with lower MLTCs, to positive relationships e.g. individuals with MLTCs consumed higher intakes of fruit and vegetables (n=5, 15.6%). Varying results were also found in longitudinal studies (n= 21, 39.6%). Some studies found inverse associations (n=8, 38.1%) i.e. higher adherence/more healthy food consumption was associated with lower MLTCs. However, other studies showed either no significant association (n=4, 19%), mixed results (n=5, 23.8%) or positive associations (n=4, 19.1%).

The evidence relating MLTCs to dietary intakes is relatively recent with most studies being reported within the last 3 years. Studies showed various outcomes and more detailed information is needed on the effect of dietary patterns and their compounds on the prevalence and development of multimorbidity. Following a standardized method of multimorbidity-quantification is highly important.

Plant-based foods encompass all food products derived from plant sources, such as fruits, vegetables, grains, legumes, herbs and spices, and nuts and seeds, plant-based fats and oils (e.g. olive oil) and plant-based beverages (e.g. tea and coffee). Consumption of diverse plant-based foods is a dietary pattern that has gained significant attention amongst the public, due to its perceived benefits for maintenance of health(1). Plant-based foods provide a rich source of macronutrients, micronutrients and non-nutrient bio-actives that are often reported to improve health outcomes. Despite this, there are no standard definitions of plant-based diversity, or consensus on methods of measurement in nutrition research studies. The objective of the current research was to conduct a scoping review of the literature to identify studies investigating plant-based food diversity and it’s impact on human health outcomes, and to subsequently characterize a) definitions of plant-based diversity used, b) methods used to assess plant-based food intake, c) methods used to assess plant- based food diversity, and d) health outcomes assessed and key findings.

Eligible studies were those investigating the relationship or impact of plant-based food diversity on any health related or lifestyle outcome, by any study design, in high income countries only. Studies were identified by systematic searches of two electronic databases and manual searches of reference lists. No restrictions were applied for language or year of publication. The review was performed in line with the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (2).

Forty-four studies were eligible for inclusion in this review. The majority of studies were observational in design (39/44; 87%) and included fruits and vegetables only in their definitions of plant-based food diversity (32/44, 72%). Methods of measurement of both plant-based food intake and diversity varied greatly among studies, with only four studies (9%) utilizing a tool validated for assessment of plant-based food diversity in their population of interest. Health outcomes included dietary intake and behaviour, socioeconomic factors, cardiometabolic risk factors, and cancer risk,. No randomized controlled trials investigating the impact of plant food diversity on health outcomes were identified.

There is a need for a consensus definition of “diverse plant-based foods” incorporating all relevant foods from plant sources (e.g. legumes, nuts, herbs). Robust measurement tools and reporting guidelines for the assessment of plant-based food diversity in nutrition research studies will help to standardize research in this area. Within countries, an assessment of standard levels of intake of plant-based foods would be beneficial, in identifying whether diverse plant-based eating may be a target for dietary improvement. Observational studies report associations between plant-based food diversity and health outcomes, that warrant investigation in future randomized controlled trials.

Restriction of energy intake is an effective strategy for achieving body mass loss(1). However, it leads to gastrointestinal appetite hormonal changes, which are expected to enhance hunger, reduce satiety, and possibly impair the ability to comply with prescribed intervention(2). Exercise interventions, on the other hand, did not modify gastrointestinal appetite hormones(3) and there is some evidence that postprandial appetite hormone responses after a low carbohydrate-high fat meal (LCHF) are more favorable than after high carbohydrate-low fat meal (HCLF) meal (4). This study investigated how energy-restricted diets based on LCHF and HCLF meals and combined with exercise affect body weight, and gastrointestinal appetite hormones and explored the relationship between body mass changes and changes in gastrointestinal appetite hormones.

Twenty-seven overweight and obese females (age: 35 ± 9.35 years, BMI: 31.64 ± 5.08 kg/m2) completed a randomized parallel design study and underwent a 4-week intervention consisting of brisk walking combined with either consumption of calorie-restricted HCLF or LCHF diet. Participants underwent a 5-hour experimental trial before and after the interventions, which included body weight measurements and fasting and postprandial blood sample collection for gastrointestinal appetite hormone measurements.

Both interventions significantly reduced body mass (HCLF group, −2.1 ± 1.7 Kg: LCHF group, -1.7 ± 1.7 Kg, P < 0.05 for both groups), but changes between the groups were not significant (P>0.05). Body mass changes were individual and ranged from -0.4 kg to −5.3 kg and from +1 kg to −4.4 kg in the HCLF and LCHF groups, respectively. The interventions had no impact on mean values of time- averaged postprandial concentrations of ghrelin, PYY, and GLP-1 but there was large individual variability in changes of these hormones. Results combined from both groups revealed that changes in ghrelin ranged from +549.3 to -407.7 pg/ml, in PYY from −132.5 to + 96.4 pg/ml and in GLP-1 from −6.6 to +19.5 pg/ml. Correlation, investigated on the data from both groups combined, between changes in body mass and changes in ghrelin (r = −0.18, P= 0.41), PYY (r = −0.04, P =0.87), and GLP-1 (r = 0.11, P = 0.64) were not significant.

In conclusion, the extent of body mass loss during interventions based on restricted energy intake diets combined with exercise is not related to the carbohydrate and fat content of the diet. Our findings also suggest that the success of body mass loss cannot be predicted by changes in postprandial concentrations of gastrointestinal appetite hormones.

There are known differences in biological functionality between vitamin D2 and D3. It is suspected from randomised control trial (RCT) data that vitamin D2 supplementation causes a reduction in serum 25-hydroxyvitamin D3 (25(OH)D3) concentrations (1), but the size of the effect has yet to be fully assessed across multiple studies. The aim of this study was to undertake a systematic review and meta-analysis of the effect of vitamin D2 supplementation on serum 25(OH)D3 concentrations.

PUBMED was searched for publications from 1st January 1975 to 1st February 2023. Of the 182 papers retrieved, 29 were included in the systematic review, and of those, 18 were suitable for meta-analysis.

The meta-analysis found significant reductions in serum D3 after vitamin D2 supplementation compared with control, for both end of trial between groups data (weighted mean difference (WMD) (random) = −13.51 nmol/L; 95% CI: −20.14, −6.89; P < 0.0001) and absolute change over the trial (WMD (random) = −9.25 nmol/L; 95% CI: −14.40, −4.10; P = 0.0004). Similar results were found when D2 supplementation was compared to D3 supplementation, although as expected, the magnitude of the difference was larger, with WMD (random) = −46.20 nmol/L (95% CI: −60.80, −31.60; P < 0.00001) for end of trial data, and WMD (random) = −56.23 nmol/L (95% CI: -69.17, −43.28; P < 0.00001) for absolute change.

Overall, we found that vitamin D2 supplementation produces significant reductions in serum 25(OH)D3 concentrations, when compared to either control or vitamin D3 supplementation. An inverse relationship between vitamin D2 and D3 concentrations has been proposed in the literature (2). A regulatory mechanism that disposes of 25(OH)D after an increase in vitamin D concentrations could explain our results (3). Moreover, supplementation with vitamins D2 and D3 has differential effects on gene expression (4). However, longer-term research is needed to establish whether clinical advice should recommend vitamin D3 supplements over vitamin D2 supplements, where appropriate.

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves, and is associated with declines across sensory, neurological, cardiovascular, and musculoskeletal systems(1). Previously, relationships have been identified between high dietary nitrate intake and several components of frailty including muscle strength and cognitive function, as well as vascular disease(2). However, little is known about the relationship between dietary nitrate intake and frailty in older adults. We investigated if higher habitual nitrate intake, derived from plant (e.g., vegetables, grains, beans, and fruits) and animal foods (e.g., meats, cheese, yoghurt) was associated with frailty in older women.

1390 community-dwelling older women (mean age 75.1 ± 2.7 years) from the Perth Longitudinal Study of Ageing Women completed a validated semi-quantitative food frequency questionnaire (FFQ) at baseline (1998). Nitrate concentrations in food were obtained from our recently published international plant and animal nitrate databases and applied to each of the plant and animal foods within the FFQ (described in3). Frailty was operationalised using a standardised frailty index (FI) of cumulative deficits from 33 variables across multiple health domains (physical, mental, comorbidities), with a score ≥0.25 indicating frailty. Cross-sectional associations between dietary nitrate derived from plant and animal foods (separately) with frailty were analysed using multivariable-adjusted logistic regression models as part of restricted cubic splines. Models were adjusted for lifestyle and dietary factors (not used in the FI) that included age, smoking history, protein, alcohol, and energy intake.

Frailty was observed in 276 (19.9 %) women. Median (IQR) daily plant and animal nitrate were 72.1 (55.6-90.0) mg/day and 3.5 (2.2-5.1) mg/day, respectively. A significant non-linear relationship was observed between higher plant nitrate intake and frailty, with a nadir recorded once intakes of ~64 mg/day were achieved (median of quartile [Q]2). Specifically, compared to women with the lowest intake of plant-derived nitrate (Q1, median 45 mg/day), women in Q2 (OR 0.69 95%CI 0.56-0.84), Q3 (OR 0.67 95%CI 0.50-0.90) and Q4 (OR 0.66 95%CI 0.45-0.98) had lower odds for frailty (all p<0.05). Additional adjustment for diet quality (Nutrient Rich Food Index per 1000 kJ) or total plasma 25-hydroxyvitamin D did not alter the findings. Nitrate derived specifically from vegetables and grains were found to drive these results. No relationship was observed between animal-derived nitrate and frailty.

Community-dwelling older women consuming higher amounts of nitrate derived primarily from plants were less likely to present with frailty. Consuming 1-2 servings (75-150 g) per day of nitrate- rich green leafy vegetables, as part of total vegetable intake, will provide adequate nitrate levels (>70 mg/day) that could serve as a novel intervention to limit frailty.

Nutrition smartphone apps have become a popular and readily accessible approach to improving dietary behaviour. Hypertension is often associated with a poor diet, and its prevalence is increasing in Saudi Arabia(1). The Dietary Approaches to Stop Hypertension (DASH) eating plan has been shown to reduce blood pressure in people with hypertension(2). A previous study identified two high-quality, safe, and potentially effective smartphone apps for managing hypertension: NOOM and DASH To TEN(3). This study aimed to explore the potential of these two DASH diet self- management apps for controlling blood pressure in the Saudi Arabian context.

Fifteen patients were recruited at King Abdullah bin Abdulaziz University Hospital in Riyadh, Saudi Arabia. Ten patients had hypertension, and five had prehypertension (mean age = 45). Patients were given the two apps and asked to try each for one week. Focus groups (n=4) were held at the end of the trial to understand the patient perceptions of the apps. Discussions were recorded, and the transcriptions were analysed using a thematic framework analysis(4).

The following four themes emerged:

1. 1. Managing hypertension through diet was perceived as important. Most patients reported that

   adhering to the DASH diet was challenging due to a lack of motivation and willpower,

   inadequate support from household members, and high prices for healthy food.

2. 2. The potential and current reach of dietary apps emerged as a main theme, and many

   comments related to patients’ belief that dietary apps could increase their motivation and awareness about the DASH diet. Barriers to the use of apps were also identified including their difficulty of use, a preference for dietetic monitoring, and cost.

3. 3. Interactive app functionality was identified as a key theme, as evidenced by comments about a straightforward sign-up process, an extensive food database for dietary self-monitoring, feedback, goal setting, and reminders, considered essential for diet adherence.

4. 4. A preference for the NOOM app emerged. Patients perceived the NOOM app more suitable in the Saudi context. Noom was deemed to support DASH self-management because it supports weight reduction, which helps lower blood pressure. NOOM was perceived as highly interactive, offering motivational reminders, feedback, realistic dietary plans, and a comprehensive food database. Patients made several recommendations for app improvement; these included Arabic language support, automatic calculation of sodium and potassium consumption, and lower cost. Patients also expressed a desire for training in the use of the app.

This qualitative analysis suggests that the NOOM app could be suitable for use with hypertensive patients in Saudi Arabia. Further research is needed to determine the feasibility and efficacy of long- term use of the NOOM app with a Saudi Arabia population.

Steatotic liver disease, defined as >5% of hepatic fat content, is a major contributor to global morbidity and mortality, in particular due to its category metabolic associated steatotic liver disease (MASLD)(1). While its prevention focuses on promoting physical activity and maintaining a healthy weight and balanced diet, the associations between dietary fatty acids and liver fat remain unclear(2,3). The aim of this study was to examine the associations between dietary fatty acids and liver fat in the absence of excessive alcohol intake, independently of energy intake.

Analyses were conducted on 9,268 non-diabetic participants from the UK Biobank with no pre- existing liver chronic illness or cardiovascular disease at baseline, and without excessive alcohol consumption. Dietary intake of total fat, saturated fatty acids (SFAs), polyunsaturated fatty acids (PUFAs) and monounsaturated fatty acids (MUFAs) was measured using the mean of ≥2 Oxford WebQ 24-hr dietary assessments, responded to between 2009 and 2012. Liver proton density fat fraction (LPDFF) was measured by magnetic resonance imaging between 2016 and 2020. Multivariable linear regression models were calculated to assess the associations between fatty acid intakes and LPDFF, adjusting for key demographic and lifestyle confounders. In addition, associations between LPDFF and 10 individual SFAs, 7 PUFAs, and 4 MUFAs were also examined. Sensitivity analyses were carried out including participants who responded ≥4 dietary assessments (N=2,828).

After fully adjusting for confounders, no significant associations between LPDFF (%) and MUFAs were found. Inverse associations with LPDFF were observed for PUFAs (−5.8% relative difference [95% confidence interval −0.6, −1.9]), per 5% increase in intake, while SFAs were positively associated with LPDFF (5.8% [3.3, 8.3]). Positive associations were observed per 1 SD increase in intake of individual fatty acids SFA stearic acid (4.20% [2.84, 5.57]) and palmitic acid (3.15% [1.78, 4.54]). Negative associations were observed for PUFAs alpha-linoleic acid (−2.32% [−3.47, −1.17]) and docosahexaenoic acid (−2.14% [−3.23, −1.0.3], and for MUFA erucic acid (−2.52% [−3.61, −1.43]). Sensitivity analyses presented similar results, and the associations between PUFAs and liver fat became slightly stronger (−10.73%, [−17.58, −3.32]).

This observational study suggests that SFAs and PUFAs are associated with liver fat in opposite directions, independently of energy intake. While total MUFAs did not present significant associations with LPDFF, erucic acid was inversely associated with liver fat, highlighting the value of studying individual fatty acids. These different associations provide valuable information for the design of dietary trials that compare interventions with different types of fatty acids. These further studies would allow a better understanding of the ideal dietary advice to prevent liver steatosis and its global health impact.

Approximately 40% of cancers in the UK are attributable to modifiable, lifestyle risk factors such as overweight and obesity and low dietary fibre intake(1). The WCRF and AICR published ten lifestyle- based Cancer Prevention Recommendations with the aim of reducing the risk of cancer and other non-communicable diseases(2). In the UK Biobank cohort, we have found reduced risk of cancer overall and of breast and colorectal cancers with greater adherence to these Cancer Prevention Recommendations (i.e., healthier lifestyles). The present study aimed to investigate whether the magnitude of these associations is modified by the presence of co-morbidities, such as diabetes and cardiovascular disease, at baseline.

We used data from 94,778 participants (53% female, mean age 56 years) from the UK Biobank prospective cohort study, recruited between 2006 and 2010 and free from cancer at baseline. Adherence to the 2018 WCRF/AICR Cancer Prevention Recommendations was calculated from dietary, physical activity, and body composition data using a standardised score(3). Multimorbidity (list of 43 chronic diseases) was self-reported at baseline and categorised into: 0, 1, 2, or 3+ chronic illnesses. Incident cancer cases were identified using population-based cancer registries available until July 2019 for England and Wales and October 2015 for Scotland. Participants were categorised into approximate score tertiles, and the lowest tertile (lowest adherence, 0-3.5 points) was used as the reference category. Cox proportional hazard models were used to investigate associations between total score and incidence of cancer, adjusting for confounders, and to test for an interaction between total score and multimorbidity.

55,191 (58%) participants had one chronic illness at baseline and 8,430 (9%) had ≥3. Mean total 2018 WCRF/AICR score was 3.8 (SD 1.0) points, and participants with the presence of chronic illnesses had a significantly lower total score (mean for ≥3 illnesses = 3.58 points vs 3.96 points for participants without chronic illness, p<0.001). During a median follow-up of 8 years, 3,303 individuals developed cancer. When investigating associations between score tertiles and the risk of cancer overall, there was a significant interaction between the total score and multimorbidity (HR for interaction: 1.59, p=0.002). There was also evidence for an interaction between total score and multimorbidity with breast cancer risk (HR for interaction: 1.23, p=0.030), but no evidence of an interaction between total score and multimorbidity for risk of colorectal cancer.

We found stronger associations between total adherence score and the risk of cancer in participants with ≥3 chronic illnesses. This suggests that the chemoprotective effects of greater adherence to the 2018 WCRF/AICR Cancer Prevention Recommendations may be particularly beneficial for individuals with multimorbidity.

It is widely accepted that meeting recommended protein intake is protective of muscle mass(1). Insufficient intake is related to accelerated sarcopenia and impaired physical function, contributing to increased mortality and morbidity. The recommended target set by the American dietary guidelines is 0.8 g of protein per kg of body weight, based on data collated by the National Academies published in 2005(2). Currently approximately 50% of women and 30% of men do not meet these targets(3). It is of public interest to analyse current patterns of intake to allow for improved strategy through awareness of factors that impact protein intake.

To investigate the factors which determine an individual’s protein intake and how they can be used to predict daily intake.

A secondary data analysis of longitudinal data collected in the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2020 has been carried out(4). Data was accessed from the public domain on the Centers for Disease Control and Prevention (CDC) website. The study protocol received approval from the research ethics review board of the National Center for Health Statistics (NCHS) of the CDC. Average protein intake has been calculated and participant demographics reported. STATA software has been used to carry out a bivariate regression of factors associated with protein intake, an adjusted multivariate regression analysis and a parsimonious model.

19601 participants (52.4% women) aged 20 and over had valid protein data. Adjusted regression analysis generated three model fits, with the parsimonious model excluding BMI categories and household income had a statistically insignificant impact on protein intake. Men consumed 23.99g more protein per day compared to women (p<0.001: 95% CI 23.09 to 24.89). Individuals over 65 consumed 13.92g less protein per day compared to those aged 20-35 years old (p<0.001: 95% CI − 15.25 to −12.59). Mexican American individuals consumed 7.47g more protein than Non-Hispanic White individuals (p<0.001: 95% CI 5.89 to 9.04) and Non-Hispanic White individuals consumed 2.95g more protein compared to non-Hispanic Black individuals (p<0.001: 95% CI 4.13 to 1.77). Those with the lowest educational attainment consumed 10.77g less protein compared to individuals with a college degree (p<0.001: 95% CI −12.79 to −8.74). From 2011 to 2020, there was a gradual decline in protein intake which is statistically significant when comparing 2011/12 with 2015/16 and 2017/2020.

Protein intake can be predicted by an individual’s gender, age, ethnicity, level of education attainment and time period. This study informs policymakers that individuals aged 65 and above are at risk of insufficient protein intake and there has been a general decrease in protein consumption over time. This provides evidence to support initiatives focused on this age category to maximise change and reduce rates of sarcopenia.

Although in recent decades progress has been made in reducing the global burden of micronutrient deficiencies (MNDs), nonetheless MNDs prevalence remains high in some populations(1). Among the micronutrients, deficiencies in iron, zinc and vitamin A are particularly prevalent, and causally associated with adverse health outcomes for children and adolescents. The aim of this study was to examine the prevalence and associations between MNDs and components of the double burden of malnutrition in female adolescents utilizing the nationally representative Vietnam General Nutrition Survey 2020.

1,471 female adolescents were included and categorised into: pre-adolescent (10-12-year-old), middle-adolescent (13-15-year-old), and late-adolescent (16-18-year-old) groups. Biomarkers of micronutrients, anthropometry, and sociodemographic data were selected for analyses. WHO growth reference values were applied to define stunting (height-for-age z-score (HAZ) < −2 SD), thinness (BMI-for-age z-score (BAZ) < −2 SD) and overweight (BAZ > 1). Iron deficiency was defined as serum ferritin<15μg/L (<70 μg/L for individuals with inflammation), vitamin A insufficiency (VAI) as serum retinol<1.05 μmol/L, zinc deficiency was based on Zinc International Consultative Group Recommendation, and inflammation as C-reactive protein >5 mg/L or α1-acid glycoprotein >1 g/L. One or multiple MNDs were defined as individuals with ≥ 1 MNDs.

Data were analysed by STATA 17 (STATA Corporation, US). Descriptive and logistic regression analyses were performed based on the sampling weight adjustments for the estimation at population level. Multivariate logistic regressions between MNDs and growth indicators were presented as crude (COR) and 95% confidence intervals or adjusted odds ratio (AOR), after adjusting for sociodemographic variables (age, ecological area, demographic, ethnicity, and wealth index) and inflammation.

Compared to the pre-adolescent group, prevalence of stunting doubled in late adolescence (12.4% to 26.8%). Meanwhile, the prevalence of overweight and thinness decreased with age (29.7% to 22.0% and 9.4% to 2.7%, respectively). Overall, the prevalence of MNDs increased with age. Zinc deficiency occurred most often in the entire cohort (39.8% in 10-18) and contributed the most to multi-MNDs. Prevalence of one or multiple MNDs increased with age, from 58.1% in pre-adolescence to 80% in late adolescence. In logistic regression analyses adjusting for inflammation and sociodemographic factors, stunting increased the risk of having ≥1 MNDs (AOR: 1.94 (1.3, 2.88), p=0.002), but not individual MND alone. Thinness increased the risk of VAI (AOR: 2.38 (1.34, 4.22), p=0.005). No association was found between any MND and overweight, although overweight was protective against zinc deficiency (COR: 0.76 (0.59, 0.99), p=0.04) in the unadjusted model.

Female late adolescents in Vietnam had a higher prevalence of stunting and MNDs, but lower prevalence of thinness and overweight in comparison to pre-adolescents. Stunting was a risk factor associated with having one or multiple MNDs. Thinness was associated with higher risk of VAI. No association was found between overweight and MNDs in this cohort.

Parkinson’s Disease (PD) is a neurodegenerative disorder in which dopaminergic neurons of the substantia nigra, a region of the brain that controls movement, are lost over time (1). This results in motor symptoms, such as bradykinesia, and non-motor symptoms such as depression (2). Evidence- based resources and programmes utilising exercise for symptom management are widely available (3). However, despite emerging evidence showing that diet changes can improve quality of life and reduce disease severity (4), there are few dietary guidelines and programmes. This study aims to address a current literature gap in qualitative studies assessing the opinions of healthcare professionals (HCPs) towards diet and exercise in PD care, and to identify barriers and facilitators of this in care.

A qualitative design was used to assess the views and beliefs of HCPs. Semi-structured interviews were conducted via telephone, using a topic guide developed by the research team, consisting of 20 questions. The data were analysed using the six-phase process of Reflexive Thematic analysis to determine key themes in the data (5).

Five HCPs participated in this study. One main theme and two subthemes were identified. The main theme was that provisions of care and dietary advice are limited by a lack of knowledge of evidence- based, PD-specific, dietary guidelines. Subtheme 1 was that evidence-based exercise guidelines have been important facilitators in supporting care provision. Subtheme 2 was that lack of dietary guidance has been a barrier to optimum care provision and self-efficacy of HCPs.

HCPs were less likely to discuss diet, due to barriers including lack of available resources or knowledge thereof, self-efficacy to recommend dietary changes, time constraints in the clinic, and less well-established referral pathways for dietitians. HCPs were unaware of the influence of diet in PD treatment, despite diet’s impact on symptoms being discussed in clinic. However, HCPs agreed that evidence-based resources would benefit HCPs’ practice, to improve symptom severity and nutritional status of patients. Exercise was more likely to be discussed, as evidence-based guidelines and empirical understanding meant HCPs were more aware of the beneficial effects on symptoms.

While limited by small numbers, these findings suggest that a lack of knowledge, low self-efficacy, and time pressures mean that patients may not receive dietary guidelines which may be beneficial to their care. Self-efficacy of HCPs should be improved through PD-specific nutritional education, development and dissemination of PD-specific nutrition guidelines and resources. Future research should aim to determine the effectiveness of relevant dietary strategies’ in managing and caring for PD.

Energy restriction is commonly used as body weight-loss interventions (1). However, it modifies secretion of gastrointestinal appetite hormones, which might be expected to upregulate appetite and thus impair the ability to comply with prescribed intervention(1). Supplementation with soluble fibre may potentially counteract this matter (2). This study aimed to investigate whether addition of β- glucan to energy and carbohydrate-restricted meals impacts postprandial responses of gastrointestinal appetite hormones and subjective appetite in overweight adults.

Twenty-three sedentary individuals living with overweight or obesity (age: 36 ± 8.5 years, BMI: 31.12 ± 4.04 kg/m2) participated in a double-blind randomised crossover study with two experimental arms, each lasting over two days. On day 1, participants consumed Counterweight PRO800 meal replacement shakes/soups for breakfast and dinner at home, each providing ~200 kcal and a carbohydrate-restricted lunch providing 35% of their habitual energy intake. On day 2, participants attended the metabolic investigation room where they consumed the same breakfast and lunch as on day 1. On both days, each meal was taken with either 3g β-glucan (Oat Well) or cellulose (Comprecel) as placebo. On Day 2, fasting and postprandial appetite scores were recorded, and fasting and postprandial blood samples were obtained for the measurements of plasma concentration of acylated ghrelin, PYY, and GLP-1. The study is registered at www.clinicaltrials.gov as NCT05981404.

Two-way ANOVA showed that the postprandial concentrations of acylated ghrelin (β-glucan arm, 383 ± 23 pg/ml; placebo arm, 428 ± 23 pg/ml, P=0.02, treatment effect) and composite appetite scores (P=0.003, treatment effect) were significantly lower and PYY concentrations (β-glucan arm, 132 ± 5 pg/ml; Placebo arm, 110 ± 4 pg/ml, P= 0.003, treatment effect) significantly higher in the β- glucan arm than in the Placebo arm. The concentrations of GLP-1 were not different between arms (β-glucan arm, 29 ± 1 pM; placebo arm, 28 ± 0.9 pM, P=0.36, treatment effect).

The obtained data suggests that consuming β -glucan with energy and carbohydrate-restricted meals can be expected to attenuate reduction in satiety and diminish increase in hunger. Therefore, supplementation with β-glucan during energy restriction intervention applied to body weight loss might lead to improve compliance and reduce discomfort of negative energy balance.

Obesity can increase the risk of diseases such as type 2 diabetes mellitus and cardiovascular disease(1). Glucose control is critical to both preventing and managing diabetes and can be achieved by enhancing secretion of insulin, limiting absorption of glucose from the gut and by upregulating the use of glucose in the muscles(2). Abnormalities in glucose management(3) and blood pressure control(4) are known to impair cognitive function. Epidemiological studies report an inverse risk of type 2 diabetes with increased intake of polyphenols. These data are also supported by in vitro and animal studies reporting positive effects of polyphenols on insulin sensitivity, carbohydrate digestion and glucose regulation(5). Here we aimed to evaluate postprandial glucose metabolism, blood pressure and cognitive function following a high carbohydrate meal accompanied by different doses of anthocyanin containing blueberry drinks.

A double-blind, placebo-controlled, dose-response study was designed and received ethical approval and 22 participants were recruited. Each participant attended four study days in a crossover design, separated by a minimum of 5 days during which, they consumed a high carbohydrate meal consisting of two slices of toast and one of three doses of blueberry beverage or a control beverage. Memory performance was assessed using the visual verbal learning test (VVLT), measured at baseline and 90 minutes post consumption. Glucose was monitored every 15 minutes using a continuous glucose monitor which was worn across 10 days, and blood pressure was assessed every 30 minutes for a period of 4 hours in the laboratory. Glucose area under the curve (AUC) were analysed using linear mixed models. Blood pressure and VVLT data were analysed using repeated measures ANOVA.

The analysis was performed blind to condition. In total, 22 participants completed all four study visits (mean age 28 ± 5.9, mean weight 61kg ± 10.4, mean height, 1.64m ± 0.9, mean BMI 22.7 ± 2.27, N=20 female, N=2 male). There was a significant effect of treatment on total words recalled in the VVLT with best performance following condition B compared to condition C, and condition D compared to condition C (p < 0.05). Condition B also resulted in significant systolic blood pressure lowering compared to condition C (-2.47mmHg, P <0.003). There was no effect of treatment on area under the curve for glucose over 3 hours postprandial (p > 0.05).

Taken together these results suggest that condition B conferred greatest benefit for memory performance and that this was associated with anthocyanin related effects on systolic blood pressure.

This study was funded by the Wild Blueberry Association of North America (WBANA).

Carrot consumption reduces tumour development in several animal models. The constituent alpha- carotene has not by itself shown anti-cancer properties, however carrots typically provide >85% of alpha-carotene dietary intake(1-3), justifying its use as an indicator of carrot intake(3). We conducted a meta-analysis to investigate inverse associations of carrot/dietary α-carotene intakes and cancer risk, and to quantify potential dose–response relationships.

PubMed, Cochrane Library, Web of Science, Scopus, EBSCO, and JSTOR were searched (from database inception to August 2021) for studies reporting risk estimates with 95% CIs for the relationship between carrot intake or α-carotene and cancer risk. Meta-analyses were conducted using a random-effects model comparing highest and lowest intakes to estimate summary risk estimates (RRs).

Of 80 prospective studies included, 15 (with 25738 cases) reported data on carrot intake, 35 (26262 cases) on dietary α-carotene intake and 30 (9331 cases) on plasma α-carotene levels. A significantly (P<0.01) decreased risk of overall cancer was associated with carrot intake (RR = 0·90), dietary α- carotene intake (RR = 0·90) and plasma α-carotene (RR = 0·80). In addition, both carrot intake and plasma α-carotene level manifested linear dose-response relationships with cancer risk, with increasing carrot intake reaching 20% risk reduction at 5 servings (400g) per week (p < 0·0001),and successive 50μg/L increments in plasma α-carotene associated with 11% risk reduction (p < 0·0058).

Carrot consumption is robustly associated with decreased cancer risk. Carrot consumption should be encouraged, and the causal mechanisms further investigated.

People with type 2 diabetes are more likely to experience binge eating than the general population, which may interfere with their diabetes management. Guided Self-Help (GSH) is the recommended treatment for binge eating disorder (1), but there is currently a lack of evidenced treatment for binge eating in individuals living with type 2 diabetes.

The aims of this pilot study were to test the feasibility and acceptability of recruiting and delivering a 12-week, online psychological GSH intervention which has been adapted in an earlier study to the needs of adults with T2 diabetes and binge eating (2).

The intervention comprises GSH materials presented online in 7-sections delivered over 12-weeks, supported by a trained Guide. In total 22 participants were recruited in a case series design, through GP practices, NHS specialist weight management and diabetes services and via social media. Outcome measures were collected pre and post-intervention and at 12-week follow-up. The primary outcome was the Gormally Binge Eating Scale and secondary outcomes included eating disorder psychopathology, depression, anxiety, quality of life and HBA1C. Following the intervention, we conducted semi-structured interviews with 6 participants and 4 Guides. Data were analysed using a random intercept multi-level model.

Results showed at baseline that 67% of the sample met the criteria for moderate to severe binge eating (cut-off (≤17). At post-intervention there was a statistically significant reduction in self- reported binge eating on the Gormally binge eating scale with a reduction in mean score moving from 26.8 to 14.2, (t= -4.181, p < 0.001) and only 9% meeting criteria for binge eating. There were also notable improvements in anxiety, depression and quality of life scores, but not eating disorder psychopathology.

In the interviews both Guides and participants found the adapted online platform easy to use and the sessional support sufficient. They highlighted what a large commitment it was and therefore the importance of the Guide and working in ‘partnership’. The intervention appeared particularly suited to ‘stress eaters’, those experiencing ‘severe binge eating’ episodes and physical symptoms of diabetes. As a result of the intervention, participants reported ‘making broader lifestyle changes’, ‘improvements in their diabetes management’ and ‘confidence’. Guides found the training and supervision helpful but reflected on some ‘challenges with engagement’. On ending the intervention, participants requested ‘ongoing support’, such as an optional follow-up appointment and continued access to the materials.

In conclusion, the study shows preliminary evidence for online GSH tailored to the needs of individuals with T2D as a promising approach to improving binge eating, diabetes management, mental wellbeing and quality of life, however effectiveness evidence is needed.

Parallel to the escalating burden of obesity is the steadily increasing prevalence of metabolic dysfunction associated steatotic liver diseases (MASLD), a chronic condition that progresses from simple steatosis to advanced stages of steatohepatitis, fibrosis, and cirrhosis (1-2). MASLD, regarded as the hepatic manifestation of metabolic syndrome is known to be exacerbated by unhealthy lifestyle choices and the presence of comorbidities such as diabetes, dyslipidemia, and obesity (3-4). Therefore, early identification of the general population at risk of MASLD and the development of multicomponent interventions that can prevent the progression of liver damage and mitigate associated adverse cardiometabolic health outcomes are important. Our study aimed to evaluate the effects of a lifestyle modification program on glucose levels, lipid profile, liver function, and body composition measures in community-living adults with elevated hepatic steatosis index in Mumbai, India.

Adults (n= 231, mean age 46.1(13.7) years), 58.6% men) were screened for risk of MASLD using a non-invasive screening tool, Hepatic Steatosis Index (HSI) (calculated as (HSI)= 8 x (ALT/AST ratio) +BMI (+2, if female; +2, if diabetes mellitus) (5). Eligible participants with HSI >36 (predictive of the presence of MASLD) were randomized to receive either a multicomponent lifestyle intervention (experimental group, EG) comprising weekly sessions of individualized dietary counseling (Participants having BMI >23kg/m2 (n = 36) received hypocaloric diets with 40% carbohydrates, 40% fat and 30% proteins (WLD) and those having BMI <22.9kg/m2 (n= 22) received weight maintenance diet (WMD) plans including 55% carbohydrates, 15% protein and 30% fats) and fortnightly group sessions of structured exercise and nutrition education or a standard of care package (control group, CG, n= 43) including general healthy eating and activity guidelines for the 8- week study duration. Paired t test and independent sample t tests were used to determine within and between group changes in variables from baseline to endline.

Trial Registration: This study is registered as CTRI/2022/05/042927.

Overall, the prevalence of MASLD was 52.2%, 32.8% were hypertensive, and 26.7% and 15.4% had diabetes and hypertriglyceridemia respectively. The intervention (WLD) resulted in decreased weight (mean (M)= 3.4 kg, standard error (SE) = 1.88 k, p = 0.02), body fat percent (M = 2.2%, SE = 1.1%, p= 0.042), serum triglycerides (M=28.8mg/dL, SE 8.5mg/dL, p<0.001) and AST (M= 3.8 U/L, SE= 2.2U/L, p <0.05) values. The WMD group reported improvements in serum cholesterol levels, and ALT/ AST ratio as compared to CG (p <0.001). In WMD, HDL-C increased from 45.8 mg/dl to 47.2 mg/dl and the mean AST values reduced from 28.8 (10.6) U/L to 25.6 (9.9) U/L, but these changes were not statistically significant.

Multicomponent lifestyle modification programs integrating diet, physical activity and education are effective strategies to improve liver outcomes and optimize cardiometabolic health in people with MASLD.

Unhealthy dietary patterns stand as the foremost risk factor for noncommunicable disease- associated morbidity and mortality(1). As widely accessible healthcare providers, pharmacy professionals’ potential to catalyze improvements in public health nutrition is substantial, offering a means to combat the escalating epidemic of obesity and NCDs through tailored interventions, services, and education(2,3).

Our study employed a mixed-methods approach to assess the role of pharmacy professionals in promoting nutrition advice and healthy dietary practices.

An online questionnaire (N=200) was designed and conducted to evaluate pharmacy professionals’ nutrition knowledge, the advice given in various diet-related conditions (e.g. obesity, type 2 diabetes, cardiovascular disease risk factors, malnutrition, sustainable diets), practices in delivering diet- related guidance within their routine practice and perceived roles and future ambitions of pharmacy professionals towards nutrition counselling, yielding both quantitative and qualitative insights.

Subsequently, qualitative interviews and focus group discussions (N=19) were conducted, engaging pharmacists, nutritionists and dietitians to gather insights essential for the development of a comprehensive nutrition toolkit tailored for pharmacy practice.

These interviews delved deeper into the subject, with the goal of designing a nutrition toolkit that empowers pharmacists with the knowledge, tools, and resources needed to play a more active and impactful role in promoting nutrition and healthy lifestyle practices among their patients. Thematic analysis was conducted, and emerging themes and subthemes were identified.

Our findings indicate that a significant portion of participants in our study are involved in providing nutrition and diet advice for various health conditions. The majority of pharmacists considered diabetes programmes having a high level of importance (84%), followed by weight management services (78%), hypertension management (86%), and healthy diet campaigns (63.5%). However, our knowledge and confidence rating questions revealed a significant gap in training and a clear need for educational materials tailored for pharmacists to enhance their ability to provide nutrition advice effectively. Key themes identified in open-text questions were referrals and collaboration, training and education needs, wider needs (changes in the public health system, materials/resources, integration and implementation of nutrition in pharmacy practice) and perceived roles as pharmacists in providing nutrition advice (patient support, feeling responsible, specialised focus areas).

Qualitative findings underscore the pressing demand for nutrition training and education to deliver comprehensive services, as well as the necessity for collaborative efforts with dietitians and nutritionists to ensure effective care and the improvement of referral pathways in pharmacy practice.

This research contributes to the advancement of public health nutrition by recognizing the potential role of pharmacy professionals as key players in the dissemination of nutrition knowledge and fostering healthy behaviours within the community. The results will guide us in the collaborative development of a nutrition toolkit tailored for pharmacy practice, employing a co-design approach.

Adequate dietary fibre (25-30g/day) is essential in a healthy diet preventing several health problems (1). Age-related changes reduce gut function and increase risk of constipation. A better understanding of fibre in those over 60y is required. This study aimed to measure fibre intake in those over 60y in Kuwait using the Kuwaiti Food Frequency Questionnaire for fibre (KWFFQ-DF) and explore local food sources of fibre and laxative use.

Recruitment was conducted Dec 2022 to April 2023 in Geriatric Health Services in Kuwait and geriatric units across the six main governorates in Kuwait. The study was approved by the University of Glasgow Research Ethics Committee (project No. 200220066) and the Medical Research Ethics Committee of the Ministry of Health in Kuwait (project No 9512018)18). The validated KWFFQ-DF assessed intake of total fibre (TDF), soluble fibre (SF) and insoluble fibre and included seven food groups and 134 food items. The last two questions asked if the participant consumed supplementary fibre and if they took laxatives (type and amount). The associations between fibre intake and gender, age and governorate and between TDF and laxative use were assessed by Chi squared test (P < 0.05 considered significant).

The study recruited 210 people (61 males and 149 females; 61- 96y (median 66y). BMI ranged from 18 to 68 (median 29). Mean TDF intake was 28.7 g/d (SD 6.6; 13 to 46 g/ day). Most participants (n= 186, 89%) did not use laxatives. Several foods high in fibre were frequently consumed by participants including dates, as a snack with coffee eaten 2-6 times/day at 2.2 g TDF per portion and almonds once a day as a snack with 12 g of TDF. Whole grain toast, eaten 1-2 times daily contributed 4g TDF but with eggs or cheese at breakfast so higher in fat. Other key sources were barley bread, (8g TDF), vegetable soup, 2-4 times a week (4 g/d TDF) and Tabouleh Salad, typically eaten with grilled meat or chicken at 2g/d TDF. There was no significant association between fibre intake and gender (χ2= 1.033; P < 0.597) or governorates (χ2= 14.66; P < 0.145). However, the findings identified a significant association between fibre intake and age of participants (χ2= 10.066; P < 0.039). Moreover, there was a highly significant negative association between the TDF intake and laxative use frequency (χ2= 25.63, P<0.001).

In contrast to some populations, fibre intake for people in Kuwait over 60y is within dietary guidelines and laxative use is low. Foods high in fibre in Kuwaiti cuisine can be, however, associated with high calories due to the sugar and fat content and may be associated with high BMI. The consequences of this need to be explored.

Acknowledgements

We would like to express our sincere gratitude to Dr Ali Alqattan and the medical team at the Geriatric Clinic in Mubarak Hospital for their valuable assistance in facilitating the interviews with participants in this research project.