Maternal nutrition is an important factor in the health of lactating women and their children. Due to increased energy and nutrient needs during lactation, women in middle- and low-income nations are more nutritionally vulnerable than other women of reproductive age. Inadequate energy and macronutrient intake can also contribute to stunting, muscle wasting, edema, loss of bone density, anemia, and increased susceptibility to infections and nutritional deficiencies in women and babies. Some previous studies reported only the descriptive results of energy and macronutrient intake. But the current study assessed both the prevalence and associated factors. Therefore, this study aimed to assess energy and macronutrient intake inadequacy and its associated factors among lactating women in Bahir Dar City, Northwest Ethiopia. A study was conducted in Bahir Dar city from February 27 to March 21, 2021. A systematic random sampling technique was used to select 318 respondents. Data were collected by interviewer-administered, semi-structured questionnaires after the pilot survey had been completed. A single 24-hour multi-step dietary recall was used to collect the respondent's dietary data. Data entry and analysis were performed using EpiData version 3.1 and SPSS version 24, respectively. Energy and macronutrient intake values were calculated from the ESHA Food Processor and the Ethiopian and World Food Composition Tables. The macronutrient intake was evaluated by the Acceptable Macronutrient Distribution Range (AMDR). Bivariable and multivariable binary logistic regression were used to declare the significant variables. The prevalence of energy, carbohydrate, protein, and fat intake inadequacy among respondents was 52%, 66.2%, 17%, and 90.4%, respectively. The percentage of energy derived from carbohydrates, protein, and fat was 74%, 16%, and 10%, respectively. The median energy intake was 2416.8 kcal. Approximately 55%, 84%, and 90% of the respondents had carbohydrate, protein, and fat intakes above, within, and below the acceptable macronutrient distribution range, respectively. Not receiving nutrition education (AOR = 1.32, 95% CI (1.01, 2.83)) and being categorized as medium wealth (AOR = 2.04, 95% CI (1.03, 6.03)) were significantly associated with inadequate energy intake. Having a primary educational level (AOR = 2.56, 95% CI (1.07, 7.17)) and a secondary school educational level (AOR = 0.47, 95% CI (0.24, 0.93)) were associated with inadequacies in carbohydrate intake. Being a merchant (AOR = 2.01, 95% CI (1.12, 6.52)), daily laborer (AOR = 9.28, 95% CI (1.61, 43.65)), or private employee (AOR = 2.12, 95% CI (1.11, 8.07)) was associated with protein intake inadequacy. Due to the low prevalence outcome (< 10% adequacy) of fat intake, regression was not performed. More than half of lactating women's energy intake was lower than recommended. Most of the respondent's carbohydrate, protein, and fat intakes were above, within, and below the acceptable macronutrient distribution range, respectively. Wealth index and nutrition education were associated with energy intake inadequacy. The educational status of the respondents' husbands was associated with carbohydrate intake inadequacy, and the occupational status of the respondents and their husbands was associated with protein intake inadequacy. Therefore, lactating women should receive nutrition education and counseling to consume a diversified diet and enhance their dietary intake through healthcare practice.
The prevalence of e-cigarette use has recently increased globally amongst children and adolescents. In response to this increase and emerging evidence about the potential harms of e-cigarettes in children and adolescents, leading public health organisations have called for approaches to address e-cigarette use. Whilst evaluations of approaches to reduce uptake and use regularly appear in the literature, the collective long-term benefit of these is currently unclear. The co-primary objectives were to: (1) evaluate the effectiveness of interventions to prevent e-cigarette use in children and adolescents (aged 19 years and younger) with no prior use, relative to no intervention, waiting-list control, usual practice, or an alternative intervention; and (2) evaluate the effectiveness of interventions to cease e-cigarette use in children and adolescents (aged 19 years and younger) reporting current use, relative to no intervention, waiting-list control, usual practice, or an alternative intervention. Secondary objectives were to: (1) examine the effect of such interventions on child and adolescent use of other tobacco products (e.g. cigarettes, cigars, chewing tobacco and pouches); and (2) describe the unintended adverse effects of the intervention on individuals, or on organisations where such interventions were being implemented. We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, EBSCO CINAHL and Europe PMC on 1st September 2025. Additionally, we searched two trial registry platforms (WHO International Clinical Trials Registry Platform; ClinicalTrials.gov), and reference lists of relevant systematic reviews. We contacted corresponding authors of articles identified as ongoing studies. We included randomised controlled trials (RCTs), including cluster-RCTs, factorial RCTs, and stepped-wedge RCTs. To be eligible, the primary targets of the interventions were children and adolescents aged 19 years or younger. Interventions could have been conducted in any setting, including the community, school, health services, or the home, and must have sought to influence children or adolescent (or both) e-cigarette use directly. Studies with a comparator of no intervention (i.e. control), waiting-list control, usual practice, or an alternative intervention not targeting e-cigarette use were eligible. Two review authors independently screened the titles and abstracts of references, with any discrepancies resolved through consensus or a third reviewer. The critical review outcome was e-cigarette use in children and adolescents aged 19 years or younger. We included measures to assess the effectiveness of interventions to: prevent child and adolescent e-cigarette use (including measures of e-cigarette use amongst those who were never-users); and cease e-cigarette use (including measures of e-cigarette use amongst children and adolescents who were current e-cigarette users at baseline). We included data measured at least six months post-baseline. Outcomes were current use (defined as use in the past 30 days), ever use (defined as any lifetime use) and adverse effects. Risk of bias for all included studies was assessed using the Cochrane RoB 2 tool. We applied this tool to the critical and important review outcomes from each included study to assess and rate each outcome as low, some concerns or high for all relevant domains. Pairs of review authors independently extracted information from the included studies, with any discrepancies resolved through consensus or a third reviewer when required. Meta-analyses were conducted using a random-effects model where data were suitable for pooling, with two prevention studies measuring e-cigarette use pooled. Studies and outcomes unsuitable for pooling in meta-analyses were instead summarised narratively. We identified three studies with 10,510 participants as eligible for inclusion. A further 30 studies were identified as ongoing and five are awaiting classification and likely to be eligible for a future update. Two studies employed a cluster-RCT design to test the effectiveness of school-based interventions to prevent adolescent e-cigarette use, with one study judged to have 'some concerns' for the overall risk of bias for the e-cigarette ever-use outcome and the other study judged as 'high risk'. The remaining study employed an RCT design to test the effectiveness of a community-based intervention (delivered via text-messages) to support adolescents to cease e-cigarette use. We judged the overall risk of bias as low for this study which reported an e-cigarette current-use outcome. Included studies were conducted in the United States, Australia and Sweden. For the critical outcome of e-cigarette ever use, a meta-analysis of two studies (one high risk of bias, one some concerns) found that prevention interventions may prevent ever use, relative to usual care, although evidence is very uncertain (RR 0.94, 95% CI 0.89 to 0.99; 2 studies; 5306 participants; random-effects model; very-low certainty evidence). The certainty of evidence in this effect was downgraded due to risk of bias, indirectness and imprecision. One study reporting a prevention intervention reported no adverse effects. For the critical outcome of e-cigarette current use, one study reported that a cessation-focused intervention is likely to reduce adolescent current use of e-cigarettes (RR 0.73, 95% CI 0.65 to 0.82; 1 study, 1064 participants; moderate-certainty evidence). The certainty of evidence in this effect was downgraded due to indirectness. The cessation intervention did not report on adverse effects of the intervention. Given only three randomised studies were included in the review, there is limited evidence, of very low-to-moderate-certainty, that interventions may be effective in preventing or ceasing adolescent e-cigarette use. As findings of the 30 ongoing studies are published, certainty of evidence of effects may improve. Until then, the findings of this review should be considered together with evidence from studies employing other trial designs not eligible for inclusion in this review to guide actions to prevent or cease e-cigarette use. This is a living systematic review. We search for new evidence every month and update the review when we identify relevant new evidence. This review was supported by the NHMRC Centre for Research Excellence (No. APP1153479) - 'the National Centre of Implementation Science'. NHMRC also provides support for the editorial and author support function of Cochrane Public Health. This review is registered in the Cochrane Database of Systematic Reviews. The protocol (https://doi.org/10.1002/14651858.CD015511) and previous version of the review (https://doi.org/10.1002/14651858.CD015511.pub2) are published in the Cochrane Library.
Nutritional management of critically ill patients receiving vasopressors is challenging. This survey aimed to describe UK critical care dietitians' practices and confidence regarding the route, timing and dose of artificial nutrition support in critically ill patients receiving vasopressors, and explore relationships of these with intensive care unit (ICU) and dietitian professional characteristics. A cross-sectional, anonymous survey was distributed electronically to UK registered dietitians working in ICU via the British Dietetic Association Critical Care Specialist Group and British Society of Parenteral and Enteral Nutrition mailing lists. The 32-item survey included questions regarding ICU and professional characteristics, dietetic practices (artificial nutrition route, timing, and dose), evidence sufficiency and confidence. Data were compared between ICU and professional characteristics and dietetic practice using Fisher's exact or Kruskal-Wallis tests, as appropriate, and with self-reported confidence using Spearman's rank correlation or Kruskal-Wallis. Of 89 responses, 72 met the eligibility criteria. All respondents completing dietetic practice questions (71/71, 100%) used gastric feeding as the first-line artificial nutrition route, and two thirds (47, 66.2%) initiated this within 24-48 h of ICU admission. Over two thirds (39/57, 68.4%) aimed for < 70% energy targets in the first 72 h, with 48 (84.2%) escalating to full targets thereafter. Despite more than three quarters (41/52, 78.8%) feeling confident in managing critically ill patients receiving vasopressors, most considered evidence to be insufficient. There was no significant association between enteral nutrition practices and any ICU or dietitian professional characteristics or self-reported confidence. Amongst UK critical care dietitians, there is substantial variation in EN initiation and escalation practices for critically ill patients receiving vasopressors. Despite high self-reported confidence, evidence concerning the route, timing and dose of artificial nutrition was perceived insufficient.
This study aimed to acquire a comprehensive understanding of the experiences and needs of healthcare professionals (HCPs) in a university medical center at the medical oncology department regarding the provision of uniform information on nutrition and nutritional supplements to adult patients with cancer. This explanatory sequential mixed-methods study employed an online questionnaire that was sent to HCPs and included questions on indications for providing nutrition advice, knowledge about nutrition and nutritional supplements, and needs regarding providing uniform advice about these topics. This was followed by semi-structured interviews with HCPs to gain deeper insights into their experiences and needs. Thirty-two HCPs completed the questionnaire, and nine HCPs participated in semi-structured interviews. The results identified five themes: knowledge of nutrition and nutritional supplements, interdisciplinary care, patient-centered care, information sources, and (scientific) basis of nutrition information and research. This study shows that HCPs express a need for enhanced knowledge and greater consistency in nutritional care during cancer care. Although HCPs reported confidence in their general nutrition knowledge, they were less familiar with nutritional supplements. Education, awareness of guidelines, access to evidence-based information, a clearer division of roles between HCPs, and interprofessional collaboration are key to improving confidence, quality, and delivering personalized nutritional support in cancer care.
The incidence of perioperative malnutrition in surgical patients is relatively high. Surgical trauma can further aggravate the malnutrition status, which is one of the key factors that increases postoperative complications and affects postoperative recovery. Developed by multidisciplinary domestic experts and scholars organized by the Chinese Society of Parenteral and Enteral Nutrition, "practice guidelines for the whole-course perioperative nutritional management in adults(2026 Edition)"complies with relevant domestic and international codes and adheres to the principles of scientization, standardization, transparency and institutionalization. This guideline is compiled on the basis of the nutritional and metabolic characteristics of surgical patients across preoperative, postoperative and post-discharge stages, as well as the core methodologies and standard procedures for formulating clinical diagnosis and treatment guidelines. It summarizes 18 clinical questions and 39 recommendations. The guideline intends to provide a reference for domestic surgeons to conduct perioperative medical nutritional therapy and benefit all surgical patients in need of nutritional intervention. It will be dynamically revised according to updated domestic and international evidence and research progress, so as to continuously promote the standardized application of perioperative medical nutritional therapy. 外科患者围手术期营养不良发生率较高，手术创伤可进一步加重营养不良状态，是增加术后并发症和影响术后康复的关键因素之一。中华医学会肠外肠内营养学分会组织国内多学科专家学者，遵循国内外相关规范，本着科学化、规范化、透明化和制度化的原则，基于术前、术后和出院后的围手术期不同阶段外科患者的营养代谢特点和临床诊疗指南制订的核心方法与标准流程编撰《成人围手术期全程营养管理应用指南（2026版）》。本指南归纳了18个临床问题，梳理了39条推荐意见，旨在为国内外科医师开展围手术期医学营养治疗提供参考，服务于需要营养治疗的各类外科患者，并将根据国内外相关证据和研究进展对指南进行动态修订，持续推动围手术期医学营养治疗的规范应用。.
Malnutrition, resulting from insufficient nutritional intake or poor dietary choices, significantly affects hospitalized patients, leading to longer hospital stays and increased health care costs. The European Nutrition for Health Alliance and subsequent initiatives have emphasized the importance of nutritional screening. This study aimed to improve nutritional screening among patients aged over 75 years admitted to internal medicine wards by assessing compliance with best practices and identifying and addressing barriers to effective implementation of recommended practices. Using the JBI Evidence Implementation Framework, the project involved a structured audit and feedback process across seven phases. Baseline audit data were collected from all patients aged over 75 years admitted to internal medicine wards over 1 month. The JBI Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit and feedback tools were used to identify barriers and develop strategies to address them. A follow-up audit was conducted 6 months post-implementation to measure changes in compliance with recommended practices. The follow-up audit showed a significant improvement in compliance with best practices, which increased from 22.62% at baseline to 48.26%, reflecting the effectiveness of the targeted interventions. Nurses reported enhanced knowledge and confidence in conducting screenings, although gaps in documentation practices remained. This project successfully improved compliance with nutritional screening practices, highlighting the importance of stakeholder engagement, training, and support. Future efforts should focus on sustaining these improvements through enhanced training and interdisciplinary collaboration, with the aim of improving the outcomes of patients at risk of malnutrition. http://links.lww.com/IJEBH/A521.
Milk is nutritionally rich, but its production poses ethical and environmental concerns. Farming practices can influence milk's nutritional quality and improve its sustainability, creating opportunities for innovation. This study explores consumer willingness to adopt improved products and the interrelationships of knowledge and attitudes towards the dairy industry in relation to purchasing and consumption. We conducted an online survey of UK adults from November 2021 to March 2022, covering knowledge and attitudes towards dairy, dairy consumption, likelihood to purchase improved milk, and socio-demographics. Participants were classified as low or high dairy consumers based on their intake: below or above 1.81 dairy portions per day. Of the 706 dairy consumers who completed the survey, 47% reported consuming ≥1.81 portions of dairy products daily. High dairy consumption predicted more positive attitudes towards dairy farmers than lower consumption. Conversely, low consumption was associated with greater concern for animal welfare and the environmental implications of dairy (p < 0.001). Price was the most important consideration when purchasing milk habitually; however, when presented with four different descriptions of milk, 41% of participants said they would definitely or very probably buy the product with improved trade, welfare, and sustainability standards, despite this product having the highest price per litre. Balancing the nutritional value of cows' milk with the environmental consequences and ethical concerns of its production is a critical part of the debate to foster a food system that supports planetary and human health. Altering production methods and improving products can be part of the food system transformation.
Chronic, non-communicable diseases accounted for 74% of deaths worldwide in 2024, representing a significant social and economic burden. The WHO identifies reducing preventable risk factors as a primary intervention point. Patient-centered care plays a prominent role in modern healthcare, promoting prevention and increasing the effectiveness of lifestyle therapy by taking into account the individual needs, lifestyle, and motivations of patients. Nutritional guidelines play a crucial role in prevention and medical nutrition therapy. However, the effectiveness of personalized dietary care is greatly influenced by the health literacy of the population. Our research aimed to explore the characteristics that emerge in the interpretation of the OKOSTÁNYÉR® nutritional recommendations based on health literacy. Medical nutrition therapy is an important part of lifestyle management for chronic, non-communicable diseases. However, the effectiveness of such interventions is greatly influenced by patients' health literacy. Our research aimed to explore observable characteristics based on health literacy in the interpretation of the OKOSTÁNYÉR® dietary recommendations, with the goal of increasing the effectiveness of dietetic practice. The research was based on a qualitative methodological approach, using focus group interviews. Four online focus group interviews were conducted with 6 participants each (N = 24). 58% of the participants were women (14 people) and 42% were men (10 people); their average age was 50.1 years. A quantitative survey using the HLS-EU47 questionnaire was conducted prior to the selection of participants, during which groups with low and normal health literacy were formed based on internationally validated cut-off scores. The selection of participants was preceded by a quantitative survey, on the basis of which groups with low and normal health literacy were formed. The audio recordings and transcripts of the discussions were analyzed by group and thematic unit, using multi-coded systematic data processing. Coding, analysis, and data visualization were supported by NVivo14 and SmartDraw softwares. Based on the lifestyles, behaviors, and aspirations of individuals with normal and low health literacy, distinctly different character groups can be identified. Higher health literacy is linked to coping strategies that support health maintenance. Awareness of the OKOSTÁNYÉR® recommendation is moderate (33.3%), particularly among those with low health literacy (16.6%). Navigating the vast amount of health information available can be challenging, especially for individuals with low health literacy. When it comes to ideal nutritional advice, participants highlighted the importance of reliable sources, however, they primarily rely on the internet and social media for answers to their nutritional questions, only seeking professional help when a health issue has already been established. They assess recommendations based on their personal habits and beliefs, often modifying them accordingly. Low health literacy can pose a significant barrier to effective dietary interventions. In the future, it will be essential to improve health communication, for example, by developing targeted nutritional recommendations and providing guided support to groups with low health literacy, such as developing nutritional competencies and increasing the effectiveness of personalized, patient-centered dietary counselling. Orv Hetil. 2026; 167(24): 952-964. Bevezetés: A krónikus, nem fertőző betegségek dietoterápiája az életmódkezelés fontos része. A dietetikai intervenció eredményességét ugyanakkor nagymértékben befolyásolja a páciensek egészségműveltsége. Célkitűzés: Kutatásunk célja az OKOSTÁNYÉR® táplálkozási ajánlás értelmezésében, az egészségműveltség alapján megfigyelhető sajátosságok feltárása volt a dietetikusi tevékenység hatékonyságának növelésére. A krónikus, nem fertőző betegségek társadalmi és gazdasági terheinek csökkentésében a WHO elsődleges beavatkozási pontként a megelőzhető rizikófaktorok csökkentését jelöli meg. A modern egészségügyi szemléletben kiemelt szerepet kap a betegközpontú ellátás, amely a páciensek egyéni szükségleteit, életmódját és motivációit figyelembe véve segíti elő a prevenciót és növeli az életmód-terápia hatékonyságát. Minta és módszer: A kutatás kvalitatív módszertani megközelítésen alapult, fókuszcsoportos interjúk alkalmazásával. Négy, 6 fős (n = 24) online fókuszcsoportos interjú készült. A résztvevők 58%-a nő (14 fő) és 42%-a férfi (10 fő); átlagéletkoruk 50,1 év volt. A résztvevők kiválasztását kvantitatív felmérés előzte meg a HLS-EU47 kérdőív alkalmazásával, amelynek során alacsony, illetve normál egészségműveltségű csoportokat alakítottunk ki a nemzetközileg validált küszöbértékek mentén. A beszélgetések hanganyagait és azok leiratait csoportonként, tematikus egységek szerint elemeztük, multikódolt szisztematikus adatfeldolgozást alkalmazva. A kódolás, elemzés és adatvizualizáció során az NVivo14, valamint a SmartDraw szoftvereket használtuk. Eredmények: A normál és alacsony egészségértésű csoportok életmódja, viselkedése, törekvései alapján eltérő karaktercsoportok különíthetők el. A jobb egészségértés az egészségmegőrzést segítő megküzdési stratégiákkal párosult. Az OKOSTÁNYÉR® ajánlás ismertsége mérsékelt (33,3%), különösen az alacsony egészségértésű csoportokban (16,6%). Nehézséget okoz – alacsony egészségműveltség esetén különösen – a sok egészséginformáció közötti navigáció. Egy ideális táplálkozási tanáccsal kapcsolatban a résztvevők kiemelték a hiteles információforrás fontosságát, azonban táplálkozási kérdésekkel elsősorban az internet, a közösségi média felé fordulnak, csak kialakult betegség esetén kérik szakember segítségét. Az ajánlásokat személyes szokásaik, meggyőződésük alapján ítélik meg, ezek tükrében „korrigálják”. Következtetés: Az alacsony egészségműveltség jelentős akadálya lehet a hatékony dietetikai intervencióknak. A jövőben elkerülhetetlen az egészségügyi kommunikáció, például a táplálkozási ajánlások célzott fejlesztése, az alacsony egészségműveltségű csoportok irányított támogatása, mint a táplálkozási kompetenciák fejlesztése, a személyre szabott, páciensközpontú dietetikai tanácsadás hatékonyságának növelésére. Orv Hetil. 2026; 167(24): 952–964.
Agriculture is a central part of human subsistence, with classification of soil texture and nutrition-based crop recommendation being the central aspects of optimal agricultural practice. Nevertheless, traditional methods are subject to limitations of being less precise, computationally less optimal, and less versatile concerning varying soil and environmental conditions. Current deep learning models are frequently unable to compromise between performance and efficiency, whereas traditional optimization methods fail to handle high-dimensional agriculture data efficiently, resulting in suboptimal suggestions and poor real-time usage. To address these issues, this research presents AgriOptNet, a hybrid deep learning and optimization framework for intelligent soil texture classification and crop recommendation based on nutrition. AgriOptNet novelty is founded upon three integral constituents like Crop Recommendation through Entropy-Regularized Dynamic Deep Q-Learning with Adaptation to the Reward Function (MDQL-RA), optimally dynamic recommendations of crop inputs depending upon the health of soil, yield records, and surrounding environmental aspects and utilizing entropy regularization to accelerate exploration; Classification using a newly invented lightweight deep-learning model called SoilCropNet with a compound based on MobileNetV2, EfficientNetV2, and ShuffleNetV2 and provides precise, and computationally favourable classification along with squeeze-and-excitation as well as depth-wise separable convolutional enhanced properties; Feature selection through newly developed hybrid SailDragon Optimizer (SDO), combining Sailfish Optimization (SFOA) and Dragonfly-Based Optimization (DBOA), to obtain best-informing features for predictions without errors. The proposed AgriOptNet framework demonstrates superior performance with an accuracy of 99.87% and an F1-score of 98.75%, significantly outperforming existing techniques and ensuring high precision and efficiency for real-time precision agriculture applications.
Despite strong evidence that nutrition is critical for wound healing, its integration into outpatient practice remains inconsistent. This study aimed to explore how nutrition is perceived, communicated, and experienced in outpatient wound care-encompassing healthcare professionals' clinical practice and professional reasoning, and patients' lived experiences. This multicentre qualitative study using Interpretive Description generated data through 156 h of field observations, five focus groups with nurses (n = 19), and interviews with patients with foot ulcers (n = 9) across six outpatient clinics in Denmark. Nutrition was acknowledged as fundamental to wound healing, yet communication remained brief, non-specific, and rarely actionable. Nurses adopted pragmatic, patient-adapted approaches shaped by unclear role responsibility, time constraints, and limited tools, resulting in opportunistic rather than systematic care. Patients had limited understanding of nutrition's role in wound healing, reflecting insufficient explanation rather than disengagement. Relational continuity and communication quality were determinants of whether nutrition became a meaningful component of care. Patients were willing to engage when advice was concrete and tailored to their everyday context. A persistent gap exists between the acknowledged importance of nutrition and its enactment in outpatient wound care, sustained by organisational, communicative, and role-related ambiguities, with implications for nursing education, interdisciplinary roles, and clinical pathways.
Health literacy is crucial for pregnancy outcomes; yet, 15%-44% of pregnant women have low health literacy, negatively affecting maternal and fetal health. While pregnancy apps are increasingly used to support it, the psychological mechanisms through which they influence behavior remain unclear. Understanding these mechanisms is essential for designing effective interventions. Cognitive load theory (CLT) and the integrated model of cognitive-affective learning with media (ICALM) provide theoretical frameworks for understanding these digital interventions in pregnancy's emotionally intense context. This study aimed to understand the psychological and social-cognitive pathways through which engagement with pregnancy apps may enhance health literacy and behaviors. This cross-sectional survey study included 998 pregnant and early postpartum women aged 18-45 years from the United States and analyzed the data using Bayesian Network (BN) modeling informed by CLT and ICALM. Participants were stratified into Pregnancy+ (Royal Philips) users (n=362), other pregnancy app users (n=507), and nonapp users (n=129). We measured digital engagement, emotions, health literacy levels, support levels and sources, and health behaviors, including physical activity, nutrition, and stress management. The BN model underwent systematic refinement through bootstrap resampling (n=1000) to evaluate arc strength, followed by k-fold cross-validation (k=5) to assess model generalizability and predictive performance. In our study, pregnancy apps improve health literacy or behaviors, but not through direct pathways. Instead, they work through two indirect psychological pathways: (1) digital engagement related to positive emotions, which in turn is related to health literacy and stress management, and (2) digital engagement strengthened support networks, which in turn are related to health literacy. No direct pathways from digital engagement to health literacy or behaviors were retained. Pregnancy+ users demonstrated stronger adherence to these pathways compared with other app users and nonusers, by demonstrating more joyfulness (5.1 vs 4.7; P=.046), elevated support levels (4.1 vs 3.9; P=.03), and higher critical health literacy scores (8.4 vs 8.2 vs 7.7; P<.001). Pregnancy+ users also showed higher engagement frequencies (P<.001) and more frequently cited pregnancy apps as valuable information sources (78% vs 68%, P=.01) compared with users of other pregnancy apps. This study reveals that pregnancy apps may enhance health literacy by fostering positive emotions and strengthening support networks. This finding challenges assumptions about digital health interventions and demonstrates that apps function as psychological support systems rather than mere information sources. The findings validate CLT and ICALM within pregnancy contexts, showing that emotionally supportive apps reduce irrelevant emotional processing that consumes cognitive capacity, thereby enhancing information retention. For practice, app developers should prioritize emotional support and social connection over content volume, while health care providers should recommend apps that enhance emotional well-being. This study demonstrates BN's value for revealing complex psychological relationships in digital health contexts.
A recent consensus report defined anaphylaxis as a serious allergic reaction that may involve the skin/mucosa, respiratory, cardiovascular, and/or gastrointestinal systems that can progress rapidly and may cause death. Epinephrine treatment is recommended in suspected anaphylaxis cases; however, numerous barriers exist to consistent, widespread epinephrine use, including difficulty identifying anaphylaxis signs and symptoms; challenges recognizing when to use epinephrine; low propensity of prescribing and filling prescriptions; low epinephrine carrying rates; knowledge gaps in epinephrine administration techniques; fears of contacting emergency medical services; use of antihistamines, inhaled bronchodilators, and other medications as first-line agents over epinephrine; and limited epinephrine device availability in community settings (e.g., schools, daycares, and restaurants). To address these challenges, healthcare providers should provide training and educational resources to caregivers on signs and symptoms of anaphylaxis that warrant epinephrine use, how to use epinephrine devices, and the importance of having epinephrine readily available at all times. System-level strategies, including measures to improve access, legislative efforts to stock epinephrine in childcare centers, and scalable digital education approaches, are also needed. Furthermore, healthcare providers should implement shared decision-making with caregivers to prepare and empower caregivers to make informed decisions when managing anaphylactic events. Understanding barriers to consistent, widespread epinephrine use when infants and toddlers experience anaphylaxis and providing actionable educational tools to caregivers alongside system-level strategies can improve outcomes in this vulnerable population. Anaphylaxis is a serious, possibly fatal event. The rate of anaphylaxis among young children has been increasing in the USA over the past decade. It is important to educate doctors and caregivers on the signs of anaphylaxis and when to give epinephrine to infants and toddlers during an anaphylactic event. Epinephrine is the standard treatment when someone has a possible anaphylactic event, but people can face challenges when giving epinephrine. These challenges include: correctly identifying the signs of anaphylaxis, knowing when to use epinephrine, low rates of prescribing epinephrine and filling those prescriptions, not carrying epinephrine, not knowing how to administer epinephrine, fears about calling emergency medical services, using other medicines instead of epinephrine, and lack of epinephrine availability in public spaces. To address these challenges, doctors should talk with caregivers and make plans together about how to best prepare for any anaphylactic event their infant or toddler could face. Doctors and caregivers can take steps together such as making an Anaphylaxis Action Plan, training with their epinephrine device, and discussing updated expert guidelines and how to implement them. Understanding the challenges that caregivers face when managing anaphylaxis in infants and toddlers can help improve outcomes in this vulnerable population.
Hypertension (HTN) is a major global health problem and a significant risk factor for cardiovascular disease. Mobile health (mHealth) applications offer an efficient, patient-centered approach to managing chronic conditions like HTN. Given the high prevalence of HTN in Iran, and a recognized lack of approved and scientifically-grounded mHealth applications, this study aimed to address this gap, particularly in Hormozgan Province. This study aimed to design and evaluate a HTN self-care application, named HOPE, to facilitate self-management and enable patients to access health services outside of clinical settings. The research was conducted in four steps: (1) determination of data elements and functional requirements based on a systematic review of guidelines and feedback from 25 cardiologists and 50 patients using a Likert scale questionnaire; (2) content design based on national and international clinical and educational standards; (3) application development using Visual Studio, ASP.NET framework with MVC architecture, and C#; and (4) usability assessment. The final evaluation involved 46 participants with HTN from the Hormoz Clinic, who used the application for one month, followed by an assessment using the Mobile Application Usability Questionnaire (MAUQ). The HOPE application was designed with nine main tabs and 52 sub-tabs, covering key areas such as demographic information, comprehensive education, nutrition tracking, BP recording, medication management, and a dialogue panel for communication with the doctor. The overall usability evaluation for the application yielded an average score of 4.32 (on a 5-point Likert scale), which was categorized as a "very good" level. The highest average score (4.37) was assigned to the "User Interface and Satisfaction" dimension. A significant relationship was determined between satisfaction with the user interface and the participants' level of education (P > 0.05). The HOPE demonstrated very good usability across all evaluated dimensions-ease of use, interface quality, and usefulness. The strong usability performance suggests that the application is well-designed and has high potential to effectively enhance self-care practices and could be a valuable tool in digital health management programs for patients with HTN. Future research should explore the long-term impacts of using HOPE on clinical outcomes and patient adherence, as well as its integration into routine healthcare practice to optimize HTN management.
In patients receiving extracorporeal membrane oxygenation (ECMO), standard practice is full-dose intravenous unfractionated heparin (UFH) targeting an activated partial thromboplastin time of 2·0-2·5 times baseline to reduce thrombotic risk. This approach can increase bleeding without further reducing thrombosis compared with low-dose UFH. Robust evidence to guide anticoagulation targets is absent because anticoagulation targets in ECMO have never been assessed in a sufficiently powered randomised trial. We aimed to determine whether low-dose UFH or therapeutic low-molecular-weight heparin (LMWH) is non-inferior to standard-dose UFH in patients receiving ECMO. In this open-label, three-arm, randomised, non-inferiority trial at seven Dutch intensive care units (ICUs), adults aged 18 years or older supported with veno-venous or veno-arterial ECMO at the ICU without vital indication for full-dose anticoagulation (eg, mechanical mitral valve) were randomly assigned to intravenous standard-dose UFH (activated partial thromboplastin time 2·0-2·5 times baseline), intravenous low-dose UFH (1·5-2·0 times baseline), or therapeutic subcutaneous LMWH. The primary outcome was a composite of severe bleeding during ECMO support, severe thromboembolic complications during ECMO support, or all-cause mortality at 6 months, and was assessed in all randomly assigned patients with deferred informed consent and 6-month follow-up data according to the intention-to-treat principle. Non-inferiority was met if the upper 95% CI limit for the absolute risk difference was less than 7·5 percentage points. This trial is registered at ClinicalTrials.gov (NCT04536272) and the Dutch trial register (NL7976). Between Oct 22, 2020, and Sept 12, 2024, 330 patients were enrolled: 110 were randomly assigned to standard-dose UFH, 110 to low-dose UFH, and 110 to LMWH. Of 330 enrolled patients, 320 (225 [70%] males, 95 [30%] females; median age 56 years [IQR 45-65]; 255 [80%] White ethnicity) were analysed at 6 months. The composite primary outcome occurred in 87 (81%) of 107 patients with standard-dose UFH, 78 (72%) of 108 with low-dose UFH (absolute risk difference -9·1 percentage points [95% CI -20·3 to 2·1]), and 79 (75%) of 105 with LMWH (-6·1 percentage points [-17·2 to 5·0]), meeting non-inferiority for both interventions. The frequency of severe bleeding was lower with low-dose UFH and LMWH than with standard-dose UFH (63 [58%] patients and 62 [59%] vs 70 [65%]), without excess severe thromboembolic complications (11 [10%] and nine [9%] vs 12 [11%]), although these differences did not reach statistical significance. At 6 months, 54 (50%) patients in the standard-dose UFH group, 45 (42%) in the low-dose UFH group, and 46 (44%) in the LMWH group had died. Low-dose UFH and therapeutic LMWH were non-inferior to standard-dose UFH. This finding supports reconsideration of anticoagulation targets in ECMO. Given the global expansion of ECMO, these findings suggest that reduced anticoagulation targets could substantially reduce bleeding-related harm. ZonMw.
Type 2 diabetes mellitus poses a major challenge to public health globally due to its rising prevalence and high proportion of patients who are undiagnosed, untreated and/or uncontrolled. Lifestyle interventions targeting nutrition, physical activity, and further health-related behaviors such as weight and stress management can prevent the onset of type 2 diabetes mellitus or delay progression from prediabetes to manifest disease. Although lifestyle interventions are widely used in clinical trials and national programs, there is limited evidence on how such interventions are designed, adapted, and reported in community, municipal, and public health settings. A scoping review was conducted using the Population Concept Context framework. Systematic searches were performed in PubMed, Web of Science Core Collection, CINAHL, and CENTRAL. The CDSR was used for citation tracking to identify relevant primary studies. Additional searches included grey literature, organizational websites, and an AI-assisted search (undermind.ai). Searches covered studies published in English or German between January 2014 and May 2025 and were conducted on 28 May 2025. Eligible studies examined lifestyle-based interventions targeting physical activity, nutrition, or broader behavioral change among healthy adults and adults at increased risk of developing type 2 diabetes, including individuals with prediabetes or metabolic syndrome, delivered in community, municipal, or public health settings. Inclusion was restricted to controlled study designs ((cluster-)randomized controlled trials, non-randomized controlled studies, or controlled clinical trials). Feasibility studies, pilot studies, uncontrolled implementation studies, and process evaluations were excluded. Pharmacological interventions were not considered. Data were charted and synthesized descriptively. Of 464 records identified, 26 studies were included. Interventions were largely adapted from established prevention programs and delivered through group-based education, with limited reporting of theoretical frameworks. Definitions and operationalization of "community-based" delivery varied across studies, and intervention duration and maintenance components were heterogeneous. The evidence base was dominated by studies conducted in high-income countries, with limited representation from lower-resource settings. This scoping review highlights the need for greater representation of studies from lower-resource settings and theoretically grounded and methodologically rigorous prevention approaches in the community setting. The potential of community-based initiatives offers valuable guidance for further development and scaling future diabetes prevention efforts. Open Science Framework (osf.io/zafg5).
BackgroundLow-glycaemic diet may alleviate migraine; however, individual blood glucose variability can affect efficacy. In this open-label randomised controlled trial in Germany, we assessed whether the digital therapeutic (DTx) sinCephalea, which delivers personalised low-glycaemic nutritional recommendations supported by intermittent continuous glucose monitoring (CGM), reduces migraine frequency compared with a design-matched control application.MethodsThis open-label trial in Germany assessed the DTx sinCephalea for migraine prevention. Adults aged 18-65 years with episodic migraine were randomised 1:1 (in addition to standard treatment) to the digital therapeutic (intervention) or a design-matched control application. Patients completed a daily headache and medication diary, and 4-weekly patient-reported outcome questionnaires. Adherence to nutritional recommendations was monitored. Primary endpoint (Week 12): change from baseline in monthly migraine days (every 4 weeks) for intervention versus control. Secondary endpoints: change from baseline in monthly migraine days in patients with ≥50% adherence to nutritional recommendations, 30% response rates, migraine- and headache-related impairment, quality-of-life, and acute medication use for intervention versus control. Adverse events were recorded.Results842 patients were randomised between July 2021 and August 2023 (full analysis set: intervention = 416; control = 419). There were significantly greater reductions in monthly migraine days at week 12 for intervention versus control (mean [SD] change: 1.7 [3.4] versus 1.2 [3.2] days; between-group difference estimate: -0.53 [95% CI -0.98 to -0.09]; p = 0.0195) with similar monthly migraine days reductions observed in adherent patients (p = 0.0062; adjusted α = 0.05). Response rate was 54.9% (185/337) in intervention versus 42.9% (168/392) in control (odds ratio: 1.63 [95% CI 1.21-2.19]; p = 0.0012; adjusted α = 0.0125). Migraine- and headache-related impairment were lower at week 12 for intervention versus control (p = 0.0247, adjusted α = 0.0167and p = 0.0001, adjusted α = 0.01, respectively). There was no significant difference in quality-of-life or acute medication use and no digital therapeutic-related adverse events.ConclusionPersonalised nutrition, supported by intermittent CGM, via the DTx sinCephalea, was efficacious for migraine prevention without DTx-related adverse events. This study provides evidence in support of the link between diet and migraine frequency and symptoms. Additionally, as this is a non-pharmacological treatment with no DTx-related side effects, it may be an attractive option for patients. DTx could also reduce the burden of migraine on healthcare systems by providing a scalable, remote, non-invasive and convenient treatment option.
Adverse childhood experiences (ACEs), toxic stress, relational insecurity, and structural adversity are major public-health concerns for children and adolescents, but ACE evidence should not be treated as an individual diagnostic score or deterministic prognosis. This Hypothesis and Theory article proposes developmental literacy and epistemic dignity as linked upstream constructs for primary child protection. Developmental literacy is defined as developmentally staged and disability-inclusive neurobiopsychosocial knowledge and skills concerning bodies, emotions, stress, attachment, co-regulation, play, nutrition, safety, rights, boundaries, non-violent care, and help-seeking. Epistemic dignity refers to the supported capacity and right of children-including preverbal, disabled, neurodivergent, and communication-diverse children-to have bodily, emotional, relational, play-based, and communicative signals interpreted with seriousness, humility, and appropriate response. Drawing on research on ACEs and positive childhood experiences (PCEs), nurturing care, relational health, health-promoting schools, social and emotional learning, mental-health literacy, sexuality/safety education, child participation, epistemic injustice, disability studies, implementation science, and critiques of ACE and trauma-informed practice, the article develops a universal, proportionate, relationally safe, anti-bias, and non-coercive public-health framework. It argues that early-childhood services, schools, pediatric/public-health touchpoints, caregiver support, and community systems can provide age-appropriate developmental knowledge without turning schools into clinics, teachers into trauma detectors, or children into individual risk scores. The framework does not recommend routine individual ACE-score screening in schools as a default practice; it supports ethically governed, service-linked pathways for recognizing distress and unmet support needs. Coercive reproductive control is treated only as a rejected comparator because it targets reproductive status rather than modifiable developmental environments, support access, and institutional trust. The article concludes with safeguards and testable hypotheses for evaluating developmental literacy, epistemic dignity, relational safety, accessibility, help-seeking, response quality, caregiver support, referral continuity, and unintended harms.
Pyruvate dehydrogenase deficiency (PDHD) is a rare mitochondrial disorder characterized by impaired carbohydrate metabolism, resulting in lactic acidosis and neurological dysfunction. Ketogenic diet therapy (KDT) is commonly used to bypass defective glucose metabolism; however, evidence guiding clinical practice remains limited. To evaluate global clinical practice and published evidence regarding the use of KDT in children and young people with PDHD. A combined literature review and international clinician survey were conducted. A systematic search identified studies reporting KDT use in PDHD. Two international surveys targeting registered dietitians and medical doctors collected data on clinical practice, diet initiation, monitoring, outcomes, and adverse effects. Forty studies describing 129 patients were identified, predominantly case reports or series. Survey responses were obtained from 41 dietitians (142 patients) and 14 physicians (64 patients) across multiple regions. All physician respondents supported referral for KDT at diagnosis regardless of genotype. Classical ketogenic diets were most commonly prescribed, though modified approaches were frequently used in clinical practice to improve feasibility and palatability. Target β-hydroxybutyrate levels typically ranged between 2 and 4 mmol/L, although treatment was frequently individualized. Findings demonstrated improvements in seizure control, motor function, cognition, and quality of life. Adverse effects were primarily gastrointestinal. KDT is a widely used and generally well tolerated therapeutic strategy for PDHD across genotypes and age groups, with reported clinical benefits extending beyond seizure control. Clinical practice demonstrates variability, reflecting the limited high-quality evidence base. Development of standardized but flexible clinical guidelines and further longitudinal studies are needed to optimize patient outcomes.
Vitamin D is a pleiotropic secosteroid with established skeletal functions and proposed extraskeletal effects; however, its clinical application remains contentious. Despite extensive observational evidence linking low 25(OH)D concentrations to chronic diseases, randomized controlled trials (RCTs) have largely failed to confirm many of these associations. This review focuses on the practical clinical management of vitamin D, integrating determinants of vitamin D status, assay-related limitations, targeted testing, evidence-based supplementation, and decision-making within a precision-nutrition context. The discordance between observational and interventional evidence is partly explained by the inclusion of vitamin D-replete populations in major trials, background supplementation, non-linear dose-response relationships, and assay variability. For skeletal outcomes, clinically meaningful effects are mainly observed in deficiency, whereas selected benefits have been reported in specific populations, including mortality reduction in adults aged ≥ 75 years, a modest reduction in cancer mortality, and reduced progression to diabetes in adults with high-risk prediabetes. The 2024 Endocrine Society guideline recommends empiric supplementation for selected groups and discourages routine screening in healthy adults. Daily or weekly dosing is preferred to intermittent high-dose regimens, which may increase falls and fractures. Standardization initiatives have improved 25(OH)D measurement accuracy, but inter-method variability persists, complicating thresholds and cross-study comparisons. Genetic polymorphisms in GC, CYP2R1, CYP24A1, and VDR contribute to variability in supplementation response, although precision-nutrition approaches remain investigational. Vitamin D should be viewed as a context-dependent, threshold-driven nutrient rather than a universal preventive therapy. Clinically, priority should be given to preventing and correcting severe deficiency (< 12 ng/mL [< 30 nmol/L]), a threshold below which adverse skeletal outcomes are well documented. Supplementation should target evidence-based indications, and laboratory testing should be reserved for situations in which results inform management. Bridging evidence and practice requires trials in deficient populations, improved assay harmonization, and integration of individualized risk factors into clinical decision-making.
Creatine is among the most extensively studied dietary supplements in sports nutrition, yet real-world supplementation patterns, knowledge, and outcomes remain poorly characterized. Prior survey research has focused on competitive athletes and younger male samples, even as the evidence base has expanded to support applications in healthy aging, cognition, and female physiology. Whether use patterns, perceived benefits, and adverse effects among the broader and more diverse population now using creatine align with trial evidence, and whether they differ by gender identity and age, has not been systematically assessed. An online cross-sectional survey was distributed to approximately 110,000 users of a supplement tracking application (SuppCo, Inc.) with recorded creatine use, yielding 2,178 analyzable responses from individuals reporting current or past-12-month creatine use (1,077 women and 1,101 men; median age, 55 years). The survey assessed supplementation patterns, goals, creatine knowledge (six-item battery scored via generalized partial credit item response theory [IRT] modeling), side effects, satisfaction, and information needs. Multivariable analyses included logistic regression for perceived benefit, modified Poisson regression for side-effect prevalence, and OLS regression for satisfaction, with Benjamini-Hochberg correction for multiple comparisons. As an exploratory analysis, a mixed graphical model (MGM) characterized conditional associations across measurement domains, and IRT discrimination parameters were combined with network centrality to identify candidate keystone misconceptions. Despite 98% intending to continue supplementation and mean satisfaction of 7.8/10, only 55% perceived benefit. Cognitive performance was the most commonly endorsed goal (67.8%) yet showed the largest within-person unmet-expectation rate (64.4% of cognitive-goal endorsers did not perceive a matched cognitive benefit; McNemar p < .001). Women reported higher self-reported side-effect prevalence (PR = 1.48; 95% CI 1.15-1.91) and lower odds of perceived benefit (OR = 0.66; 95% CI 0.55-0.80) than men, with a flatter dose-benefit slope (women × dose OR = 0.65; 95% CI 0.53-0.80). Knowledge of creatine, scored via IRT theta from a five-item battery, was the most consistent positive correlate across all primary outcomes: perceived benefit, satisfaction, the positive experience composite, and above-common dosing. An exploratory IRT-by-network analysis identified kidney damage as the candidate keystone misconception, with the highest IRT discrimination and above-median cross-domain centrality; the network also identified long-term safety beliefs as conditionally associated with intent to continue, consistent with the hypothesis that safety beliefs track behavioral persistence. In this middle-aged, gender-balanced community sample of creatine users, behavioral loyalty was high yet substantial knowledge gaps, unmet benefit expectations, and self-reported side-effect burdens disproportionately affected women and older adults, who together comprise an increasingly important share of contemporary creatine users. Knowledge appeared as the most consistent positive correlate of supplementation experience, suggesting education may be a tractable lever for improving real-world outcomes; misconceptions about kidney safety and long-term tolerability may warrant particular attention as educational targets. The cognitive expectation gap may reflect a dose-translation issue rather than absence of efficacy. These findings generate hypotheses for prospective evaluation of education, gender-tailored dosing guidance, and expectation-setting interventions in real-world creatine users.