The distribution of energy intake and types of food consumed throughout the day may influence health. This study investigated the association of energy intake and ultra-processed food (UPF) consumption in the morning, at midday, and in the evening with indicators of obesity. A pooled cross-sectional analysis of the National Diet and Nutrition Survey (2008-2019) of adults residing in England, Wales, Scotland, and Northern Ireland was conducted. Food consumption was assessed using 4-day food diaries. UPFs intake was assessed based on the Nova food classification. The 3 time periods were classified as morning (5:00 am to 10:59 am), midday (11:00 am to 4:59 pm), and evening (5:00 pm to 4:59 am). This study included 5749 adults aged 19 to 64 years residing in private households in the United Kingdom. The main outcome measures were overweight, obesity, and abdominal obesity. Body mass index (calculated as kg / m2) values ≥25 and ≥30 were used to classify overweight (including obesity) and obesity, respectively. Abdominal obesity was defined as a waist circumference ≥102 cm for men and ≥88 cm for women. Multivariable logistic regression assessed the associations between the percentage of energy intake and the percentage of energy intake from UPFs in the morning, at midday, and in the evening, and indicators of obesity. Models were adjusted for sociodemographic variables (ie, sex, age, ethnicity, region, year of the survey, and social class occupation), behavioral variables (ie, physical activity, smoking status, frequency of alcohol consumption, sleep duration, and weight-loss diet), and variables related to food consumption. The highest percentage of energy intake in the morning (third tertile) was associated with a 19% reduction in the odds of being overweight (95% CI, 0.68 to 0.96), and the highest percentage in the evening was associated with a 21% higher odds of being overweight (95% CI, 1.01 to 1.44). A 10% increase in the percentage of energy intake from UPFs at midday and in the evening was associated with an 11% (95% CI, 1.02 to 1.20) and 10% (95% CI, 1.02 to 1.18) higher odds of overweight, respectively. The highest percentage of energy intake from UPFs in the morning, at midday, and in the evening (third tertile) was associated with a 26%, 25%, and 45% higher odds of obesity, respectively. A 10% increase in the percentage of energy intake from UPFs in the evening was associated with a 12% (95% CI, 1.03 to 1.22) higher odds of abdominal obesity. The timing of energy intake was associated with overweight, and higher consumption of UPFs at all times of day was associated with obesity. The strength of the association between UPFs consumption and indicators of obesity was greater in the evening compared with the morning and midday.
Associations of iron deficit with learning disability (LD) and attention deficit/hyperactivity disorder (ADHD) have been fully investigated. However, the association of high body iron levels with LD and ADHD in children and adolescents has seldom been investigated. This study aimed to examine the association of serum ferritin concentrations, a biomarker of body iron status, with LD and ADHD in a large population-based cross-sectional study. This study utilized a cross-sectional study design. This study used data from the 1999 to 2002 National Health and Nutrition Examination Survey, which is a nationwide, population-based, cross-sectional survey in the United States. Participants with missing data on serum ferritin concentration, or LD and ADHD diagnosis, as well as those with anemia, were removed, and data of 4520 children and adolescents aged 4 to 15 years were included in the final analyses. Outcome variables were LD and ADHD diagnoses, which were reported by the children's parents. The characteristics of the participants according to quartiles of serum ferritin concentrations were calculated. Analysis of variance and Rao-Scott χ2 tests were used to compare differences in continuous variables and categorical variables, respectively. Multivariable logistic regression was used to estimate the odds ratio (OR) and 95% CI of LD and ADHD according to quartiles of serum ferritin concentration. Several covariates were adjusted for in the models, including age, sex, race/ethnicity, family poverty-to-income ratio, cotinine concentration (tobacco exposure marker), total energy intake, body mass index, and serum C-reactive protein concentration. Higher serum ferritin concentrations were associated with a higher odds of LD in US children and adolescents. The adjusted OR for LD across increasing quartiles of serum ferritin levels was 1.00 (reference), 1.61 (95% CI, 1.11 to 2.32), 1.47 (95% CI, 0.93 to 2.32), and 1.89 (95% CI, 1.13 to 3.13), respectively (P for trend < .05). Each 10 ng/mL increase of serum ferritin level (to convert ng/mL to pmol/L, multiply by 2.247) was associated with a 13% higher odds of LD (adjusted OR, 1.13; 95% CI, 1.01 to 1.24). In addition, no significant association between serum ferritin levels and ADHD prevalence was found, and the adjusted ORs for ADHD across increasing quartiles of serum ferritin levels were 1.00 (reference), 1.16 (OR, 0.66 to 2.01), 1.04 (95% CI, 0.64 to 1.70), and 1.63 (OR, 0.95 to 2.82), respectively (P for trend was .08). Stratified analyses found that significant associations between serum ferritin level and LD prevalence were only found in boys with the highest quartile of serum ferritin (adjusted OR, 2.21; 95% CI, 1.05 to 4.67), and in children and adolescents whose race/ethnicity was non-Hispanic White with serum ferritin levels in quartile 2 (adjusted OR 1.73; 95% CI, 1.05 to 2.85) and quartile 4 (adjusted OR, 2.29; 95% CI, 1.08 to 4.88). In addition, the association between serum ferritin concentration and prevalence of ADHD was only significant for the highest quartile in boys, with an adjusted OR of 2.06 (95% CI, 1.01 to 4.20). In a nationally representative, multiracial/ethnic population of US children and adolescents, high serum ferritin levels were found to be significantly associated with higher odds of LD, and when the serum ferritin level was ≥43 ng/mL, increased odds of LD and ADHD were both observed in boys.
Flooding puts young children at risk of adverse nutritional outcomes. With climate change expected to increase the frequency and intensity of flooding, it is important to understand relationships between flooding and childhood undernutrition to inform policy design. This study aims to examine the relationship between flood exposure and undernutrition in children younger than age 5 years in Bangladesh; investigate heterogeneity in this relationship by geography, child sex, and child age; and test whether socioeconomic status, water access, and repeated flood exposure moderate the relationship between flood exposure and undernutrition. Satellite flood inundation data for Bangladesh's severe monsoon flooding in August 2017 were combined with nationally representative, cross-sectional household survey data from the Bangladesh Demographic and Health Survey. Surveys were collected between October 2017 and March 2018. Households were classified as flood-exposed if their home location overlapped with the flood inundation map. The sample includes 6638 children younger than age 5 years in Bangladesh. After applying survey weights, the adjusted sample size is 6620. Nutritional outcomes include height-for-age and weight-for-age z scores, along with indicators for stunting and underweight. Indicator variables for stunting and underweight describe children ≥2 SD below the reference median height-for-age (stunting) or weight-for-age (underweight) z score. Logistic and linear regressions with individual-level, household-level, and cluster-level controls, and district and month fixed effects were used to compare nutritional outcomes among children who were flood-exposed with those who were not. In heterogeneity analyses, models were subset by geography, child sex, and child age. Interaction models were used to examine the moderating characteristics of socioeconomic status, water access, and repeated flood exposure. Flood-exposed children had 1.30 times the odds of experiencing stunting (95% CI, 1.10 to 1.54) and 0.14 lower height-for-age z scores (95% CI, -0.24 to -0.03) compared with children who were not exposed to floods. These relationships were more pronounced in coastal districts, where flood exposure was associated with 1.60 times the odds of stunting (95% CI, 1.08 to 2.35), 0.21 lower height-for-age z scores (95% CI, -0.41 to -0.00), and 0.21 lower weight-for-age z scores (95% CI, -0.36 to -0.07). Among children aged 2 years and younger, flood exposure had a significant association with all measures of undernutrition. Finally, interaction models point to water access as a moderating factor in the relationship between flood exposure and undernutrition. Monsoon flooding is associated with undernutrition in children, particularly in coastal areas and among very young children. Addressing underlying population-level influences of undernutrition, such as the development of high-quality water sources near the home, may improve the nutritional status of children, especially in areas vulnerable to floods.
It is the position of the Academy of Nutrition and Dietetics that all individuals with nutrition-related health conditions or risk factors should have access to medical nutrition therapy (MNT) provided by a registered dietitian nutritionist (RDN). MNT provided by RDNs is effective in improving health outcomes for many chronic conditions that are leading drivers of morbidity, mortality, and health care costs in the United States. Widespread access to MNT using an individualized, client-centered, and evidence-based approach has the potential to improve population health, reduce health disparities, and reduce health care costs associated with nutrition-related health conditions. This Academy of Nutrition and Dietetics position paper summarizes recent evidence from systematic reviews on the effectiveness of MNT provided by an RDN for the prevention and treatment of nutrition-related health conditions. A total of 25 systematic reviews published between 2017 and 2024 were summarized and assessed for certainty of evidence. Systematic reviews with high or moderate certainty of evidence demonstrate that MNT is likely effective in improving a range of health outcomes in adults with pre-diabetes, type 1 diabetes, type 2 diabetes, obesity, pre-hypertension, hypertension, dyslipidemia, chronic kidney disease, head and neck cancer, and chronic obstructive pulmonary disease compared with no MNT or standard care. Barriers exist to accessing MNT, including inadequate staffing of RDNs in some areas, a lack of provider referrals to an RDN for MNT, and a lack of payer coverage and reimbursement. This position was approved in September 2025 and will remain in effect until December 31, 2032.
Despite the well-known health benefits of fruit and vegetable (FV) intake, dietary quality among Americans remains poor. Barriers to healthy food intake, such as cost, may contribute to suboptimal FV intake. The aim of this study was to assess the effects of multi-level supermarket price discounts of 30%, 15%, or 0% (control) on fruits, vegetables, and noncaloric beverage (NCB) on FV and NCB intake and health outcomes. In this randomized controlled trial (RCT), Multi-level Supermarket Discounts of Fruits and Vegetables' Impact on Intake and Health, participants underwent an 8-week baseline without price discounts, a 32-week intervention, and a 16-week follow-up period. At week 8, participants were randomized to receive a 30%, 15%, or 0% price discount on FV and NCB. Adult supermarket shoppers (n = 312) were recruited in New York City, starting in September 2018 through August 2021. Participants had BMIs of 25-50 kg/m2, were between the ages 18-70, and were primary household shoppers. Of those recruited, 167 were randomized. The final intention-to-treat analysis was based on 33 participants in the 30% discount group, 38 participants in the 15% discount group, and 36 participants in the 0% discount group. At week 8, participants were equally randomized into one of three price discount intervention groups: 30%, 15%, or 0% (control) discount on qualifying FV and NCB. The primary outcomes were FV and NCB intake (g/day) and body weight (kg). FV and NCB intake were assessed through unannounced 24-hour dietary recalls conducted on 2 weekdays and 1 weekend day, covering the previous day's consumption. Dietary outcomes were collected a month before weeks 8, 24, 40, and 56, while body weight was obtained at weeks 0, 8, 24, 40, and 56. Linear mixed models were used to detect significant group-by-time interactions with planned contrasts to examine the differential change (shown as mean ± standard error (SE)) in primary outcomes between groups over time for the intention-to-treat and complete case samples. A sensitivity analysis was then performed on the intention-to-treat sample by adding key covariates to the model: sex, age at enrollment, season at enrollment, primary supermarket, income level, and COVID-19 pandemic presence. Planned contrasts (shown as mean ± SE) showed that the 15% discount group had greater fruit intake from baseline to the end of the follow-up (+137.4 g/day ± 38.7, p < 0.001) vs the 0% discount group. Contrasts also revealed the 30% discount group had increased vegetable intake during the mid-intervention period (+88.6 g/day ± 40.1, p = 0.028) vs the 0% discount group. Additionally, contrasts showed that diet soda intake increased in the 30% discount group (vs 0% discount group) from baseline to mid-intervention (+67.5 g/day ± 20.3, p = 0.001), to the end of intervention (+42.5 g/day ± 21.2, p = 0.046), and follow-up (+56.7 g/day ± 22.4, p = 0.012). Lastly, contrasts showed that the 30% discount group lost more weight from baseline to mid-intervention vs the 0% discount group (-2.4 kg ± 0.918, p = 0.010). The results showed that the 15% discount on fruits led to increased intake during the follow-up period. The 30% discount on vegetables and diet soda led to greater intake during the first half of the intervention and sustained increases in diet soda intake throughout the intervention and follow-up periods. Participants in the 30% discount group also exhibited decreased body weight during the first half of the intervention, compared to controls. These findings support the use of supermarket-based economic incentives as an effective strategy to promote healthier food intake.
Critically ill adults in intensive care unit settings are at high risk of malnutrition, which is linked to poor outcomes. Delivery of optimal nutrition support in this population is challenging due to patient complexity and inconsistent nutrition care recommendations. To provide a comprehensive overview of guidelines and systematic reviews relevant to clinicians managing enteral and parenteral nutrition in critically ill adults and determine whether or not an update to the Academy of Nutrition and Dietetics Nutrition Support Guideline is warranted. The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a scoping review following methodologies adapted from Arksey and O'Malley, Levac and colleagues, and the Joanna Briggs Institute. A comprehensive search was performed on January 13, 2025, in MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews, the Guidelines International Network, and the Guideline Central databases. Included sources were English-language guidelines published in 2015 or after, or systematic reviews published after 2020, on nutrition support for adults (aged 18 years or older) in intensive care units. Data were extracted using standardized templates. Guideline quality was assessed independently by 2 blinded reviewers using the Appraisal of Guidelines for Research & Evaluation II (AGREE II); systematic reviews were appraised using critical domains from A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR2). Results were summarized using charts and maps. Eleven guidelines and 58 systematic reviews were included. Guideline topics included provision of enteral vs parenteral nutrition, timing of initiation, and energy/protein provision. Systematic reviews most often cover energy/protein amounts, delivery rates, and fiber/prebiotics. All guidelines had notable quality issues, often lacking patient input, peer review, or implementation strategies. More than half of the systematic reviews met key AMSTAR2 criteria, although many had methodological concerns. There are numerous guidelines and systematic reviews on nutrition support interventions for critically ill adults, with substantial variability in quality and scope. A comprehensive, high-quality guideline should be developed through the Grading of Recommendations Assessment, Development and Evaluation approach to Adoption, Adaption, and De novo development (GRADE-ADOLOPMENT) process to leverage current resources. Future systematic reviews of subpopulations are needed to address evidence gaps.
Breastfeeding can improve public health and reduce the economic burden associated with illness, hospitalization, and mortality of infants and mothers. Despite the potential for registered dietitian nutritionists (RDNs) to contribute to this area of practice, there are no studies that have analyzed the influence of RDNs on breastfeeding-related health outcomes, such as breastfeeding duration. The Breastfeeding Registry study aims to describe the nutrition care and health-related outcomes of breastfeeding infants receiving care from RDNs. This is a pilot prospective cohort registry study. Participants are breastfeeding infants receiving care from RDNs as well as RDNs providing care to enrolled infants. RDNs will provide usual care and document for up to 6 months in an electronic Nutrition Care Process database (the Academy of Nutrition and Dietetics Health Informatics Infrastructure). The validated Nutrition Care Process-Quality Evaluation and Standardization Tool will assess documentation quality. RDNs will document initial and follow-up encounters for infants, aiming to analyze documentation from at least 60 infants. RDNs will be surveyed on site characteristics, individual education, training, and professional experience to account for possible confounding. The primary health outcome is breastfeeding duration. Secondary outcomes include the frequencies of NCP Terminology documented by NCP step, documentation quality, and rates of nutrition diagnosis resolution and goal attainment. Using the NCP framework, complete NCP cycles that demonstrate improvement in the most prevalent nutrition problems (defined as impactful care plans) will also be presented. Recruitment challenges and large variability in tracked indicators are anticipated, as is common in registry studies. Training and documentation requirements may limit enrollment.
It is the position of the Academy of Nutrition and Dietetics that, in adults, appropriately planned vegetarian and vegan dietary patterns can be nutritionally adequate and can offer long-term health benefits such as improving several health outcomes associated with cardiometabolic diseases. Vegetarian dietary patterns exclude meat, poultry, and seafood, and vegan dietary patterns exclude all foods of animal origin. Registered dietitian nutritionists (RDNs) and nutrition and dietetics technicians, registered (NDTRs) play a pivotal role in providing meal-planning strategies and evidence-based nutrition information to clients currently following vegetarian or vegan dietary patterns or who may benefit from and express interest in following vegetarian or vegan dietary patterns. RDNs and NDTRs can work with their clients to create tailored, lifestyle-oriented, nutritionally balanced, and culturally suitable vegetarian and vegan dietary patterns that optimize health benefits while reducing concerns about nutrient inadequacies. Adults follow vegetarian and vegan dietary patterns for various reasons. The aim of this position paper is to inform health care practitioners, including RDNs and NDTRs, about the evidence-based benefits and potential concerns of following vegetarian and vegan dietary patterns for different populations of nonpregnant, nonlactating adults. This position paper is supported by current evidence, including several systematic reviews. As leaders in evidence-based nutrition care, RDNs and NDTRs should aim to support the development and facilitation of vegetarian and vegan dietary patterns and access to nutrient-dense plant-based meals. Promoting a nutrient-balanced vegetarian dietary pattern on both individual and community scales may be an effective tool for preventing and managing many diet-related conditions. This position was approved in January 2025 and will remain in effect until December 31, 2032.
Updates to the meal pattern requirements for the Child and Adult Care Food Program (CACFP) took effect in 2017. The updates were designed to align CACFP meals and snacks with the 2015-2020 Dietary Guidelines for Americans and represented the first major revision of the CACFP meal patterns since the program's inception in 1968. The aim of the study was to examine changes in the nutritional quality of CACFP meals and snacks served to children aged 3 to 5 years in early child care programs before and after the updated meal patterns were implemented. The US Department of Agriculture's Study of Nutrition and Activity in Child Care Settings (SNACS-I) collected data in program year 2016-2017, and SNACS-II collected data in program year 2022-2023 from nationally representative samples of CACFP programs and the children they served. Both studies used a menu survey to collect detailed descriptions and recipes for all foods and beverages served in CACFP meals and snacks during a 1-week period, and on-site measurements of reference portions to estimate portion sizes for the foods and beverages served. The analysis included data from 664 early child care programs in SNACS-I and 759 early child care programs in SNACS-II. Mean Healthy Eating Index 2015 (HEI-2015) scores were calculated for all CACFP meals and snacks served combined, in addition to separate HEI-2015 scores for breakfast, lunch, morning snack, and afternoon snack. Differences in the mean HEI-2015 scores between the 2 time periods were estimated, and 2-tailed Welch's t tests were conducted to test for statistical significance. After the meal pattern updates, mean total HEI-2015 scores significantly improved for CACFP breakfasts by 6.1 points (P < .001), lunches by 5.4 points (P < .001), afternoon snacks by 4.7 points (P < .05), and all meals and snacks combined by 5.1 points (P < .001). Results of this analysis showed that CACFP meals and snacks served in early child care programs were more consistent with the 2015-2020 Dietary Guidelines for Americans after updated CACFP meal pattern requirements were implemented in 2017. This work underscores the importance of updating meal pattern requirements for nutrition assistance programs such as the CACFP to ensure meals provided to children are aligned with the Dietary Guidelines for Americans.
The US Food and Drug Administration has proposed a mandatory "Nutrition Info" label be placed on the front of packaged foods, showing whether products have low, medium, or high amounts of saturated fat, sodium, and added sugar. The agency also has considered a "High-In" labeling system, which would require labels on products with high levels of these nutrients. The aim of this study was to analyze the proportion of purchased packaged foods that would display specific front-of-package labels under the Nutrition Info and High-In front-of-package labeling systems overall and across 15 food groups. This was a cross-sectional study of 1 year of sales data. This study used sales and nutrition data from 2022 from a supermarket chain with 184 stores in the Northeast United States. The sales-weighted percentage of products that would display different Nutrition Info labels ("non-mixed": all nutrients have the same level; "slightly mixed": mix of low/medium or medium/high; "severely mixed": a mix of low/high) and High-In labels (eg, percentage with ≥1 High-In label) was determined overall and by food group. Descriptive statistics and χ2 tests were calculated. Under Nutrition Info labeling, 12% of products would display non-mixed labels, and 40% would display severely mixed labels. In 7 food groups (eg, pizza, candy), >50% of products would display severely mixed labels. Under High-In labeling, 49% of products would display ≥1 High-In label. The Nutrition Info front-of-package label would place severely mixed labels on a large proportion of products in unhealthy food groups, which may confuse consumers. High-In front-of-package labeling would place labels on a large proportion of these products without mixed messaging.
Household food insecurity is a major public health concern that disproportionately burdens mothers. Infants may be especially vulnerable to its negative impacts, given the central role mothers play in their feeding. Mothers' insights on infant complementary feeding while experiencing household food insecurity are needed to expand on previous research focused on breastfeeding. The aim of the study was to explore the experiences of New Zealand mothers introducing complementary foods to their infants in the context of household food insecurity. This qualitative study involved in-person, semi-structured interviews (conducted in 2022) with participants from the First Foods New Zealand study (conducted in 2020-2022), focusing on mothers' infant feeding experiences and particularly complementary feeding. Participants were mothers (n = 15) living in Dunedin (New Zealand) who had been identified as experiencing moderate or severe household food insecurity when their infant was aged 7 to 10 months. Thematic analysis of transcripts was performed using a reflexive thematic analysis approach. Three main themes and 1 subtheme were generated: (1) Food purchasing strategies were used to stretch money; (2) the infant's nutrition was prioritized (subtheme: breast milk was perceived to support the infant's nutrition); and (3) support was appreciated, but seeking money or food often brought a sense of shame and disempowerment. Mothers prioritized feeding their infants by stretching limited resources, compromising their own diets, and seeking support despite considerable challenges. Their determination and skill in feeding their infants nutritiously highlight the extensive labor involved in infant feeding and food provision in the context of household food insecurity. However, these efforts also contributed to ongoing cognitive and emotional strain for the mothers themselves.
The 'gold standard' for successful blinding in controlled food-based dietary interventional trials includes a sham diet. This study aimed to develop and evaluate a sham diet intended for use as a comparator in ulcerative colitis dietary trials. A sham diet to the experimental 4-Strategies to SUlfide REduction (4-SURE) diet was systematically constructed using a six-step process. Healthcare professionals' naïve to the sham and 4-SURE diet were surveyed to evaluate the impression of the sham diet as an intervention. Healthy adult volunteers then received dietary education and implemented the sham diet for 7-days to evaluate blinding. /setting: Twenty-two health professionals were recruited from the hospital and research institute in Adelaide, South Australia from September - October 2020 to complete the survey. Twenty health professionals met eligibility criteria and completed the survey. Twenty-five healthy adults were recruited via advertisements on notice boards and email distribution lists at the hospital and a university in Adelaide, South Australia from March - June 2021 to complete the 7-day diet trial. Twelve healthy adults met eligibility requirements, agreed to participate and completed the 7-day trial. The combined primary outcome was believability the sham diet could be an intervention diet and success of blinding by asking if the diet was designed to be an intervention or placebo for ulcerative colitis trials. Secondary outcomes included acceptability and tolerability (visual analogue scales), adherence, nutrient intake and dietary education. Descriptive data are presented as mean (95% CI) or median (interquartile ranges (IQR)) for continuous variables. T-tests were used to compare between meal plans and trial time points. Of 20 healthcare professionals surveyed, 19 (95%) agreed both diets impressed a similar complexity and 15/20 (75%) agreed both set meal plans gave the impression of therapeutic dietary prescriptions. Eight (40%) correctly identified the 4-SURE diet. Twelve adults, 10 female and 2 males, completed the sham diet trial. Blinding was successful. All believed the diet could be the intervention diet. The diet was highly tolerable (mean 83 mm; 95% CI 75, 92 mm). The nutrient composition of volunteers' diets remained uniformly unchanged between baseline and end of 7-days. This sham diet is credible as a therapeutic dietary prescription. It was highly tolerable, did not alter nutrients of therapeutic interest to the 4-SURE diet and is suitable to deploy in food-based trials for ulcerative colitis as a control to diets with a similar dietary scaffold.
The US Department of Agriculture (USDA) Summer Meal Programs (SMPs) are funded to ensure children from low-income households continue to have access to food over the summer months when most schools are closed for instruction. However, these programs are underutilized compared with school meal programs, in part due to barriers to accessing SMPs. During the COVID-19 pandemic, USDA waived several restrictions related to area eligibility and meal distribution. To systematically review the evidence of the association between USDA pandemic waivers and SMPs access (ie, scope and coverage) and participation. Three electronic databases were searched (PubMed, Education Resources Information Center, and Thomson Reuters Web of Science) to identify peer-reviewed and government studies that examined associations between USDA pandemic waivers and changes in the number of SMP sponsors, sites, participants, and/or meals served. Inclusion criteria included studies conducted in the United States and published in English between August 2021 and June 2024. Qualitative studies, studies conducted only during the school year, or studies that did not examine the association between the waivers and relevant outcomes were excluded. Risk of bias was assessed using an adapted version of the Newcastle-Ottawa Scale. Articles were narratively synthesized. Twelve articles met the inclusion criteria. The majority found increases in the number of SMP sites that were sponsored by public schools after the pandemic waivers. However, some studies found decreases specifically among nonpublic school-sponsored sites. The majority also found increases in the number of children and/or meals served, even in the presence of fewer sites. Evidence suggests that the pandemic waivers were associated with improvements in scope, coverage, and participation in SMPs. Continued support of state agencies to administer SMPs using flexible and innovative strategies should be considered.
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a potentially curative treatment for peritoneal metastasis in colorectal cancer. The procedure is extensive, and colorectal cancer survivors experience prolonged nutrition-impact symptoms and significant weight loss. The aim of this study was to explore colorectal cancer survivors' and caregivers' experiences with managing nutrition after the CRS-HIPEC procedure. A qualitative descriptive design was used to gain insight into colorectal cancer survivors' and caregivers' experiences with nutrition. Participants included 20 colorectal cancer survivors who underwent CRS-HIPEC in the past 3-12 months and 10 colorectal cancer caregivers at a single cancer center. Semi-structured interviews were conducted in 2024 and 2025 by videoconference. Interviews were recorded, transcribed verbatim, and analyzed using rapid qualitative analysis. Four key themes were observed: (1) Nutrition-impact symptoms, such as diarrhea, early satiety, and pain, were more severe and lasted longer after the CRS-HIPEC procedure than anticipated; (2) After the procedure, survivors had difficulty purchasing, preparing, and eating food, which led to anxiety and frustration; (3) Caregivers struggled to implement nutrition guidance from the care team and expressed a desire for more tailored resources, such as recipes and meal plans tailored based on the surgical procedure (eg, presence of colostomy); and (4) The timing and continuity of registered dietitian nutritionist support affected readiness for self-managing nutrition after the procedure. Early and proactive registered dietitian nutritionist support may help colorectal cancer survivors and caregivers cope with nutrition challenges after CRS-HIPEC. Future interventions are needed to test early and proactive delivery of nutrition counseling and tailored nutrition education based on the surgical procedure (eg, colostomy).
Consultation with rural dietitians can inform the development of rural telehealth medical nutrition therapy (MNT) interventions and contribute to their effectiveness. This study aimed to explore dietitians' experiences and perceptions delivering in-person and telehealth MNT in rural primary health care settings in New South Wales (NSW), Australia, to inform the development of a rural-based telehealth MNT intervention for cardiovascular disease (CVD) risk reduction. Qualitative study design whereby semistructured interviews were conducted between March and April 2021. Interview topic areas included experiences and perceptions of working in rural areas, delivering telehealth consultations, key factors for successful dietetic consults, the influence of dietetics care on cardiovascular disease prevention, relationships with other health professionals, and the importance of continuity of care. Dietitians in rural NSW, Australia, who held Accredited Practising Dietitian (APD) status or qualified for APD status were eligible to be interviewed. Interview data were interpreted thematically. Actionable items were developed through iterative discussion and applied to a rural telehealth MNT intervention design. All dietitians recruited (N = 9) participated in an interview. Key themes interpreted from the data included building trusting therapeutic relationships, using telehealth as a nuanced tool, and valuing each health care team member. Actionable items developed from these themes included recruiting rural-based dietitians for service delivery, training dietitians in online rapport-building skills and telehealth software, providing a flexible telehealth service, and ensuring the service facilitates optimal communication with general practitioner (GP) physicians. Consultation with dietitians working in rural areas can offer valuable insight into rural dietetics practice and inform the development of rural telehealth MNT interventions. Future research investigating telehealth MNT interventions could consider using the actionable items developed in this research study. Researchers and service designers may also consider consultation with local practitioners to inform place-based solutions for their own telehealth interventions.
Children from low-income neighborhoods and of Black or Hispanic/Latinx minority groups are at relatively high risk of accelerated unhealthy weight gain during prolonged school break times when children lose access to a structured environment that provides healthy meals and snacks and opportunities for physical activity. To identify child and caregiver perceptions of the neighborhood- and household-level environmental barriers and facilitators to healthy eating and active living during the summer months in low-income neighborhoods with a high percentage of Hispanic/Latinx residents. Qualitative study, using the Healthy Eating Active Living: Mapping Assets Using Participatory Photographic Surveys protocol to conduct in-depth interviews and participant photographs. A convenience sample of elementary-school-aged children (n = 22; kindergarten to sixth grade) and their caregivers (n = 12) living in low-income neighborhoods with a high percentage of Hispanic/Latinx residents in Cleveland, OH, June to August 2021. Participating child(ren) and their caregivers provided their perceptions of barriers and facilitators to healthy eating and active living during the summer months. A priori categories from the Healthy Eating Active Living: Mapping Assets Using Participatory Photographic Surveys protocol framed the analysis. Researchers (n = 2) used comparative analysis to develop a codebook and determine major themes. Ten major themes emerged within 4 a priori categories: facilitators to healthy eating, barriers to healthy eating, facilitators to active living, and barriers to active living. Participants contextualized these barriers and facilitators through comparisons of the summertime vs the school year. Future efforts should further and more expansively explore the food and physical activity environmental disparities that persist among low-income, minority populations that are most greatly influenced by childhood obesity. Appropriate interventions, particularly during the summertime when children are out of school and interact with these environments more extensively, should be developed.
Consistent evidence indicates existing associations between food parenting practices and children's dietary quality, yet these associations are likely to be different in adolescents as they are exposed to a wider social network. To expand the existing literature by examining sex-specific associations between maternal and paternal food parenting practices and the dietary quality of male and female adolescents using sex-stratified analyses. A cross-sectional study was conducted between October 2021 and January 2022. A total of 2000 adolescents and their parents were recruited from 16 schools located in the western region of Saudi Arabia. A triadic dataset of 656 adolescents (aged 11 to 18 years) and their mothers and fathers was included in the analytic sample. Food parenting practices questionnaires were completed for each adolescent by their mothers and fathers separately using the Comprehensive Feeding Practice Questionnaire-Arabic. Dietary quality of adolescents was assessed using a modified version of the Short Form Food Frequency Questionnaire. Sex-stratified linear regression analyses were conducted to examine the association between each food parenting practice and dietary quality score of adolescents, adjusting for adolescents' age, maternal education status, city of residence, and family income. In male adolescents, maternal modeling, teaching about nutrition, and monitoring (B = .37; 95% CI, 0.14 to 0.60; B = .26, 95% CI, 0.01 to 0.51; and B = .31; 95% CI, 0.08 to .54, respectively) and paternal restriction for weight (B = .22; 95% CI, 0.01 to 0.44) were associated with higher dietary quality scores. In female adolescents, maternal restriction for health was associated with a lower dietary quality score (B = -.24; 95% CI, -0.43 to -0.05), whereas paternal teaching about nutrition was positively associated (B = .21; 95% CI, 0.02 to 0.40). Findings suggest distinct patterns of association between maternal and paternal food parenting practices and dietary quality within male and female adolescents. Future interventions aimed at enhancing adolescent dietary quality may benefit from considering sex-specific associations between parental practices and dietary quality.
Late sleep timing and sleep irregularity are associated with an increased risk of diabetes, and high diet quality is associated with a lower risk of diabetes. However, the associations of sleep timing and regularity with diabetes, as well as the potential interactions of diet quality with these associations, are unclear. The aims of the study were to examine the associations of sleep timing and sleep regularity with diabetes and to examine whether sleep timing and sleep regularity interact with diet quality in relation to diabetes. This was a cross-sectional analysis of data from the National Health and Nutrition Examination Survey 2017-March 2020. US adults 20 years or older who responded to questions regarding sleep health and completed at least 1 valid 24-hour diet recall were included in the analysis (n = 7270). Diabetes was defined as having received a diagnosis of diabetes from a physician or health care professional; glycated hemoglobin ≥6.5%; fasting blood glucose ≥126 mg/dL (to convert to mmol/L, multiply by 0.0555); and taking insulin or oral medication for diabetes. Survey-multivariable logistic regression models were used to estimate the associations of sleep timing, sleep regularity, and their interactions with diet quality and diabetes. A total of 1494 participants (15.3%) were identified as having diabetes. Late chronotype (odds ratio [OR] 1.45; 95% CI, 1.12 to 1.87; Bonferroni corrected P = .02) and social jet lag of >0.5 hours (OR 1.44; 95% CI, 1.10 to 1.87; Bonferroni corrected P = .03) were associated with higher ORs of diabetes. Interactions were observed for diet quality with social jet lag (P for interaction = .02) on diabetes. Among participants with social jet lag of >0.5 hour, medium (OR 0.62; 95% CI, 0.41 to 0.92) and high diet quality (OR 0.63; 95% CI, 0.43 to 0.94) were associated with lower ORs of diabetes compared with low diet quality. Later chronotype and more severe social jet lag were associated with higher ORs of diabetes. Higher diet quality may attenuate the adverse association of social jet lag with diabetes.
Indexes are a standardized tool for assessing dietary exposures from foods/beverages (F&B) and have recently been extended to include dietary supplements (DS). The Total Nutrient Index (TNI; F&B+DS) and the Food Nutrient Index (FNI; F&B only) were developed to assess micronutrient intakes relative to Dietary Reference Intakes (DRI) for micronutrients and were previously examined for relative validity among U.S. adults. This study examined the micronutrient quality (i.e., TNI and FNI) of the diet across all age groups and compared TNI and FNI total and component scores to Healthy Eating Index (HEI)-2020 scores among the U.S. This analysis also sought to demonstrate the flexibility of the TNI/FNI framework across the life course. A nationally representative, cross-sectional analysis of the 2015-2020 National Health and Nutrition Examination Survey (NHANES) demographic, dietary and dietary supplement data (i.e., 24-hr dietary recall and DS inventory) was conducted among the U.S. /setting: This study included U.S. adults and children (≥1y; n=19,903) who participated in the 2015-2020 NHANES. The main outcome measures were TNI and FNI total and component scores (range: 0-100) overall and by age-group, with higher scores indicating greater adherence to the DRIs. TNI/FNI scores were calculated via the simple algorithm method, for 11 age-group dependent micronutrients (calcium, choline, magnesium, phosphorus, potassium, and vitamins A, B12, C, D, E, K), and compared to HEI-2020 scores. Americans scored a 72 out of 100 on TNI, but scores varied by age and were higher for the TNI than FNI (∼3-11 pts.). Younger children (1-3y, TNI=87; 4-8y, TNI=82) and older adults (≥71y, TNI=77) exhibited higher TNI scores than other ages, due to higher calcium, magnesium, vitamins A, C, and B12 intake. HEI-2020 total scores were low (HEI=52) overall and followed similar scoring trajectories by age-group as the TNI/FNI. Evaluating total dietary exposures is important, considering the differential intake patterns from F&B, versus those with DS. Given low DRI adherence for some nutrients across the lifespan, these findings warrant improved diet quality and micronutrient density for many, to optimize nutrition and reduce diet-related chronic disease risk among Americans.
Malnutrition is common in adults with hematologic malignancies and can negatively influence treatment outcomes. This systematic review evaluated the association between nutrition support interventions compared with alternative or usual care, and primary outcomes (nutritional status, anthropometric measures, length of stay, readmissions, and quality of life) and secondary outcomes (survival, mucositis, graft-vs-host disease, delayed engraftment, inflammation, cost, and calorie or protein intake), in adults with hematologic malignancies. MEDLINE, CINAHL, Cochrane CENTRAL, Food Science Source, and SPORTDiscus databases were searched for controlled trials and observational studies published in English in peer-reviewed journals from January 2000 to July 2024. Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool for randomized controlled trials (RCTs), RoB in Non-randomized Studies of Interventions for non-RCTs, and RoB in Nonrandomized Studies of Exposures for observational studies. Meta-analyses used a maximum likelihood random-effects model, and heterogeneity was quantified using I2. Certainty of evidence for primary outcomes was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation method. Twenty-one articles (11 RCTs, 9 cohorts, 1 non-RCT) representing 2122 participants were included. RoB was low (2 studies), some concerns/moderate (11 studies), and high (8 studies). Meta-analysis indicated a decrease in length of stay for enteral nutrition over parenteral nutrition, and no effect on length of stay for glutamine-enriched nutrition support; however, evidence was of very low certainty. Individualized nutrition support interventions, including the calculation of estimated needs, demonstrated benefit in decreasing weight loss. Overall, the association between nutrition support interventions and nutritional status, weight, readmissions, quality of life, and secondary outcomes was uncertain (very low certainty). No single nutrition support intervention emerged as superior for all outcomes of interest, although current best practices were supported. Certainty of evidence was very low for primary outcomes, and heterogeneity limited conclusions for secondary outcomes. Further high-quality research is needed.