Non-pharmacological and non-surgical interventions are increasingly recognised as essential components of management of Parkinson's disease (PD). However, as PD progresses to its advanced stages, limited mobility, cognitive impairment, treatment-refractory symptoms, and increasing dependence on care partners dominate. However, the evidence base for therapies in this stage becomes scarce. Most clinical practice guidelines and systematic reviews address PD as a whole, without highlighting specific recommendations tailored to advanced disease stage. This narrative review examines the current evidence for non-pharmacological and non-surgical therapies specifically in the context of advanced PD. This includes physiotherapy and exercise, freezing of gait management, dysphagia rehabilitation, nutrition and dietetics, neuropsychiatric care, autonomic dysfunction, pain management, and palliative care. We synthesised evidence from recent systematic reviews of clinical practice guidelines, scoping reviews of rehabilitation interventions in advanced PD, systematic reviews and meta-analyses of non-pharmacological treatments for specific symptom domains, the published literature on advanced PD management, and expert consensus. A recent systematic review identified 40 summary statements for non-pharmacological interventions in PD, yet these were developed without stage-specific differentiation. A scoping review of rehabilitation interventions specifically targeting advanced PD identified only 13 studies, predominantly focused on physical functioning. On the other hand, while interventions for freezing of gait, swallowing therapies, cognitive behavioural therapy for neuropsychiatric symptoms, non-invasive brain stimulation, non-pharmacological autonomic management, and multimodal exercise have demonstrated promise in PD, robust evidence for advanced PD remains largely absent. People with advanced PD represent a neglected population in non-pharmacological therapy research. There is a clear need for inclusion of people with advanced PD in guideline development and a holistic approach addressing factors such as demoralisation, caregiver strain, autonomic dysfunction, and spiritual wellbeing alongside physical rehabilitation.
This study aimed to explore the experiences of Māori dietitians and students in Aotearoa New Zealand, with a focus on how racism, marginalism and tokenism affect their training, workplaces and wellbeing. A kaupapa Māori community research approach was undertaken in partnership with Te Kāhui Manukura o Kai Ora (Māori Dietitians Association). A focus group was held with Māori dietitians and students in March 2024. Data were analysed using reflexive thematic analysis, guided by kaupapa Māori research principles. Candidate themes were then shared with participants in March 2025, and a dissemination strategy was co-designed to protect anonymity. Composite narratives were then developed to illustrate how individual experiences connect to systemic issues. Three composite narratives were developed to highlight shared experiences of racism, tokenism and marginalism across the dietetic journey. Participants described culturally unsafe training environments where deficit stereotypes and staff silence placed additional burdens on Māori students. In workplaces, participants observed Māori patients being subject to inequitable care shaped by racialised assumptions, while Māori dietitians often carried the cultural load of being positioned as 'the Māori voice' without adequate support. These pressures contributed to isolation, burnout and challenges to professional identity, belonging and wellbeing. Systemic racism underpins these experiences, creating culturally unsafe environments and unsustainable cultural loading for Māori dietitians and students. Addressing these issues requires profession-wide action to strengthen cultural safety, support the retention and wellbeing of Māori within dietetics.
BackgroundMyotonic dystrophy type 1 (DM1) is associated with reduced physical activity, overweight and cardiovascular morbidity. Nutritional management requires accurate estimation of total daily energy expenditure (TEE), based on basal metabolic rate (BMR) and physical activity level (PAL). However, DM1-related changes in body composition may reduce the accuracy of commonly used BMR equations. This study evaluated BMR equation accuracy in DM1 versus controls, and assessed PAL and substrate oxidation.MethodsIn this secondary analysis of a prospective case-control study, 15 DM1 patients were compared with 15 age-, sex-, and BMI-matched controls. Body composition was measured using dual-energy X-ray absorptiometry. Overnight metabolic rate (OMR) was assessed by room calorimetry and compared with standard predictive equations (Harris-Benedict, WHO, Mifflin-St Jeor). Additionally, OMR was compared to body composition-based equations (Wang, Nelson, Sabounchi structures 4, 5, and 11). TEE was measured over 15 days using doubly labeled water. PAL was calculated as TEE/OMR, and substrate oxidation was assessed using the respiratory exchange ratio (RER).ResultsStandard predictive equations significantly overestimated metabolic rate in DM1, with median biases of +100 to +165 kcal/day (+7% to +12%, p<0.01), with no significant bias in controls. Structure 11 performed best in DM1 (+0.0%, p=1.000). PAL was lower in DM1 than in controls (1.42 vs. 1.69, p<0.001), whereas RER did not differ.ConclusionCommon predictive equations overestimate energy requirements in DM1. Body composition-based approaches or correction factors may improve estimation, while low PAL should be considered when estimating TEE. These findings have direct implications for nutritional management in DM1.
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative treatment for acute leukemia; however, the first year after transplantation is associated with an increased risk of morbidity and mortality. This study aimed to evaluate changes in nutritional intake and body composition during the first 100 days following allo-HSCT and to examine their associations with one-year all-cause mortality. In this single-center prospective study, 152 adults scheduled to undergo allo-HSCT were assessed at baseline and on days +30 and +100 after transplantation. Assessments included anthropometric and body-composition measurements, dietary intake evaluation, and nutritional risk screening using the Nutritional Risk Screening 2002 (NRS-2002) tool. The prevalence of nutritional risk increased from 8.6% at baseline to 69.1% on day +30. In the primary analysis, a greater decline in fat-free mass (FFM) was associated with an increased risk of death within one year after transplantation (adjusted HR = 1.04 per 1-kg loss). However, this association was no longer observed in the landmark sensitivity analysis. During the first 100 days following allo-HSCT, nutritional status and body composition deteriorated markedly. A greater decline in FFM was associated with higher one-year mortality in the primary analysis; however, this association was attenuated and was no longer statistically significant in the landmark sensitivity analysis.
[This corrects the article DOI: 10.3389/fnagi.2026.1833368.].
Socioeconomic disparities influence diet quality, but it remains unclear how income-related differences in nutritional adequacy vary by household composition, particularly the presence of children. We examined income-related differences in nutritional adequacy among Japanese adults. We analyzed data from 7,265 adults aged 20-79 years from the 2014 and 2018 National Health and Nutrition Surveys. Nutritional adequacy was assessed using a composite score based on dietary reference intakes. Household income was categorized as <2 million JPY, 2-<6 million JPY, or ≥6 million JPY. Linear mixed-effects models were used to estimate sex-specific associations, adjusting for sociodemographic, lifestyle, and health factors. Lower income was associated with lower nutritional adequacy (p for trend < 0.001), and these associations persisted after adjustment. Income-related gradients were observed in both households with and without children and were steeper among households with children, with the lowest nutritional adequacy scores observed among low-income households with children. In contrast, patterns were less apparent among older women and individuals living alone. Income-related differences in nutritional adequacy were observed across Japanese adults and varied according to household composition. These findings suggest that household context, particularly the presence of children, may modify income-related patterns in dietary quality.
Substantial and persistent barriers to achieving adequate nutritional intake exist for adult survivors of critical illness in the year following hospital discharge. Despite the clear burden, nutrition rehabilitation remains a largely neglected component of post-ICU recovery. Greater understanding of lived experiences is needed to inform person-centred dietetic interventions. The aim was to explore how survivors of critical illness describe, interpret, and navigate their nutritional recovery after hospital discharge, and the personal, relational, and systemic factors that shape these experiences. A qualitative study adopted a narrative enquiry approach to elicit participants lived experiences and stories using in-depth interviews. The Transtheoretical Model was used as a sensitising concept that emerged during analysis. Participants were recruited through convenience sampling, and sample size determined using information power. Narrative analysis and reflexive thematic analysis was used. Sixteen participants (11 women, 5 men) took part (median age 53 years; median of 2.4 years since discharge). Four coexisting themes were identified: (1) Eating in the shadow of critical illness, (2) Nutritional care that worked (3) Unmet nutritional needs, and (4) What we wish we'd had. Integration of narrative and thematic analysis revealed two broad nutritional recovery processes, an enabling and a constraining recovery process, shaped by psychological readiness, agency, relational support, and access to care. Nutritional recovery after critical illness is dynamic and multidimensional shaped not only by physical symptoms, but also by trauma, identity disruption, readiness to change, relational environments and systemic support. These findings provide groundwork for person-centred dietetic interventions following hospital discharge.
In this study, the presence of microplastics was investigated in a total of 50 commercially available intravenous fluid samples in Türkiye, and ATR/FT-IR spectroscopy was used for particle identification. As a result of the analyses, microplastic contamination was detected in only 9 samples. Considering all samples examined, the average amount of microplastics was calculated as 0.40±0.90 MPs/L. Accordingly, microplastic exposure associated with the single-use administration of intravenous fluids (all samples) was determined to be approximately 0.20 MPs per unit. While the microplastic diversity index indicated very limited diversity at 0.02±0.11, the average polymeric risk index was 5.64±18.2, indicating a low overall risk level. The average pollution load index for all samples was 1.06, corresponding to a moderate contamination level. The findings show that intravenous fluids generally exhibit a safe profile; however, microplastics represent an increasingly important quality and exposure parameter in medical products that should be monitored.
Cardiac rehabilitation (CR) aims to enhance cardiovascular health and quality of life, as well as survival through structured exercise training, lifestyle education, cardiovascular risk factor management, and psychosocial support. Despite growing evidence linking sleep disorders, poor sleep health, and circadian rhythm disruption to impaired cardiac recovery, reduced exercise adherence, and increased adverse cardiovascular events, systematic assessment and management of sleep and circadian health remain underutilized in CR programs. In this narrative review, we aim to explore and characterize the gap and address the potential benefits of incorporating sleep and circadian rhythm assessment into CR practice. Sleep disorders commonly encountered in patients undergoing CR, including obstructive sleep apnea, central sleep apnea, and insomnia, may adversely affect CR participation, functional recovery, and cardiovascular prognosis. Practical strategies include routine sleep screening with validated assessment tools, selective use of objective sleep assessments, sleep hygiene education, chronotype-informed exercise scheduling, and referral pathways to sleep medicine specialists. Integrating sleep-circadian considerations into CR may enhance cardiac recovery, improve exercise tolerance and adherence, and support more comprehensive, personalized secondary prevention strategies. Artificial intelligence may further support early detection of sleep disturbances, individualized exercise prescription, remote monitoring, and precision CR approaches integrating sleep and circadian health.
Interrupting evening sedentary time with activity breaks in a laboratory setting improves postprandial metabolism and sleep duration. This pilot study aimed to assess if a theory-informed intervention was able to increase the number of activity breaks performed in the evening at home, and to describe changes in movement patterns, glycaemic response and blood pressure. Twenty participants (mean age 34 ± 12 years, female n = 18) completed a 2-week intervention which supported them to perform 2-3 min activity breaks every 30 min during periods of prolonged sitting in the evening. The intervention utilised behaviour change techniques and a mobile application. The number of activity breaks performed was assessed via self-report, mobile app data, and accelerometer data. Other outcomes included: glycaemic control; 24-h movement patterns; blood pressure; self-reported sleep and capability, opportunity and motivation to interrupt evening sitting. Data was collected at baseline, 2-weeks (immediately post-intervention) and 4-weeks (following a 2-week follow-up period). On average, participants self-reported completing 3.6 activity breaks per evening during the intervention. There was little change in objective measures of sedentary time, sleep, physical activity, and glycaemic outcomes. A reduction in sleep disturbances (-0.35, 95% CI -0.6 to -0.1), as measured by the PSQI, was observed. Participants reported improved automatic motivation to interrupt evening sitting, but capability, opportunity and reflective motivation were unchanged. Increases in the number of activity breaks performed in the evening can be achieved and were accompanied by small improvements in sleep quality. A full-scale effectiveness RCT based on this intervention is warranted.
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Although oral nutritional supplements (ONSs) are widely prescribed to combat cancer-related malnutrition and enhance treatment outcomes, patient adherence is often inadequate. This study aims to examine patient-reported barriers and facilitators to ONS use in cancer care, with the goal of supporting healthcare professionals in developing patients' nutritional strategies. A qualitative study was conducted. Between November 2023 and August 2024, semistructured interviews were conducted with 20 purposively selected cancer patients until data saturation was achieved. The health belief model (HBM) guided data collection and interpretation. Adherence patterns were derived from participants' self-reports. Data were analyzed using a two-stage approach: inductive, experience-oriented thematic analysis followed by theory-informed mapping of finalized themes onto HBM constructs. Sixteen themes were identified reflecting perceptions of ONS use. Participants perceived their adherence as suboptimal and described inconsistent consumption of prescribed supplements. While participants acknowledged that poor nutritional intake could compromise recovery, barriers were prominent. These included unpleasant taste and odor, gastrointestinal side effects, sensory fatigue from limited flavors, misconceptions such as "sugar feeds cancer," and inadequate professional guidance. Barriers were shaped by individual health beliefs, emotional responses, and contextual support systems. Facilitators included motivation for recovery, family support, and supportive interactions with healthcare professionals. Adherence to ONS among cancer patients is influenced by multifaceted factors extending beyond medical prescription. Addressing misconceptions, improving palatability and product variety, and strengthening professional and psychosocial support may enhance adherence. Tailored interventions guided by patient beliefs and experiences are essential to optimize nutritional outcomes during cancer treatment.
Malnutrition is common in patients with cancer. Limited data exist on the association between nutritional status, chemotherapy cycles and therapeutic responses in low-resource settings. This study investigated the association between pretreatment nutritional status, chemotherapy cycles and treatment response in Addis Ababa, Ethiopia, providing insights through count data analysis. A multicentre prospective cohort study was conducted from February 2024 to June 2025, involving 400 patients with solid tumours followed from prior to chemotherapy to 1 month after completing treatment. Nutritional status was assessed using the Patient-Generated Subjective Global Assessment, and treatment response was measured using the Response Evaluation Criteria in Solid Tumours (V.1.1). Multivariable logistic and Poisson regression analyses were used to determine the association between malnutrition, treatment response and number of chemotherapy cycles. At baseline, 39% of the patients exhibited severe malnutrition. Of the 400 recruited participants, only 204 (51%) completed six or more chemotherapy cycles, and 19.6% showed progressive disease (PD). In bivariate analysis, severe malnutrition was associated with PD (crude OR = 2.67 (95% CI: 1.12 to 6.1)). In the multivariable logistic regression analysis, low dietary diversity (adjusted OR (AOR) = 3.63 (95% CI: 1.19 to 11.05)) and low performance status (AOR = 4.3 (95% CI 1.35 to 13.67)) were associated with PD. Additionally, based on Poisson regression, patients with severe malnutrition received 17% fewer chemotherapy cycles than well-nourished patients (incidence rate ratio = 0.83 (95% CI: 0.73 to 0.93)). Based on a prospective cohort study, malnutrition may not predict chemotherapy response. However, it was associated with a reduced number of chemotherapy cycles. Therefore, early nutritional assessment and intervention are imperative to reduce treatment dropouts. Patients should also be encouraged to consume a diverse diet rich in essential nutrients to improve their treatment responses.
Malnutrition is common among older adults and is associated with adverse outcomes, yet its impact and relationship with geriatric vulnerability in emergency department (ED) patients remain underrecognized. To determine the prevalence, associated factors, and prognostic impact of malnutrition in noncritically ill older adults in the ED. We conducted an observational study of patients aged ≥ 65 years presenting to the ED. Nutritional status was assessed using the Mini Nutritional Assessment-Short Form (MNA-SF) and categorized as normal, at risk of malnutrition, or malnourished. Comprehensive geriatric assessment included functional status (activities of daily living (ADL)), frailty, cognitive function, and handgrip strength. Multivariable logistic regression identified factors associated with malnutrition. Kaplan-Meier survival analysis and multivariable Cox proportional hazards regression were performed to evaluate the association between nutritional status and 30- and 90-day all-cause mortality. Among 1487 patients, 23.3% were malnourished and 46.4% were at risk, with 59.7% overall having impaired nutritional status. Malnourished patients had significantly worse functional status, cognition, and physical performance. Independent factors associated with malnutrition included lower ADL, frailty, and decreased handgrip strength. Malnutrition was associated with significantly lower 30- and 90-day survival (both log-rank p < 0.001) and remained independently associated with both 30-day mortality (adjusted HR, 5.32; 95% CI, 1.36-20.73) and 90-day mortality (adjusted HR, 6.92; 95% CI, 2.16-22.13) after multivariable adjustment. Malnutrition is highly prevalent among older ED patients and is independently associated with increased short-term mortality. Functional decline, frailty, and reduced muscle strength are closely linked to both malnutrition and nutritional risk. Integrating nutritional screening with functional and physical assessment in the ED may improve early identification of high-risk patients and support timely interventions.
There is limited information regarding real-world use of parenteral nutrition in hospitals. The objective of the study was to provide a real-world description of parenteral nutrition administration in hospitalized patients. This was a descriptive cohort study in 507 hospitalized adults who received parenteral nutrition at five Australian hospitals from 2015 to 2020. Adult patients (≥18 years) receiving parenteral nutrition in the hospital were eligible. Data collected included baseline demographics, comorbidities, clinician-determined indication and administration details for parenteral nutrition. The primary outcome was the indication for parenteral nutrition. Secondary outcomes included the use of supplemental parenteral nutrition and the vascular access devices used. Of the 507 enrolled patients, 263 (52%) were in the intensive care unit and 244 (48%) in the ward at the time of enrolment. The most common indication for parenteral nutrition was a non-functioning gastrointestinal tract (45% [390/864 indications]), mostly because of ileus (18% [71/390]), followed by inadequate nutrition (35% [304/864]). More than half the patients (347/507, 68%) had a nil by mouth order by their treating team. The median duration of parenteral nutrition administration was 7 (4;14) days. Supplemental parenteral nutrition was more common for patients in the intensive care unit. Vascular access was most achieved via central venous catheter in intensive care unit patients (81%) compared to a peripherally inserted central catheter line in ward patients (75%). This study provides novel real-world data on the demographics, indications, provision and outcomes of parenteral nutrition for hospitalized patients. Commonly reported indications for parenteral nutrition were ileus and nil by mouth orders, which may warrant further study.
Given the anti-inflammatory properties of nuts, their consumption might play a role in reducing inflammation and the severity of pemphigus vulgaris (PV). However, limited evidence exists regarding the association between nut intake and PV severity. Thus, this cross-sectional study investigates the relationship between PV severity and the consumption of total nuts as well as specific nut varieties. This study included 138 PV patients, of whom 108 had a Pemphigus Disease Area Index (PDAI)<15 and 30 had a PDAI≥15. Dietary intake was evaluated using a validated 168-item food frequency questionnaire, and consumption of total nuts and subtypes (peanuts, hazelnuts, almonds, walnuts and pistachios) was categorised into quartiles. While no significant association was found between individual nut types and PV severity, individuals with the highest total nut intake (including peanuts, hazelnuts, almonds, walnuts and pistachios) were 92% less likely to experience increased PV severity compared with those with the lowest intake (OR: 0.08; 95% CI 0.01 to 0.38). This association remained significant after adjusting for age, sex and energy intake (OR: 0.072; 95% CI 0.01 to 0.36). Further adjustments for corticosteroid use and physical activity did not alter the strength or significance of the association (OR: 0.08; 95% CI 0.01 to 0.42). Our findings suggest that higher total nut consumption is inversely associated with PV severity, though no such link was observed for specific nut subtypes. Prospective cohort studies are needed to validate these results.
Prenatal visceral (VAT) and total (TAT) adipose tissue are associated with gestational diabetes and preeclampsia risk, yet cannot be routinely assessed in clinical or epidemiologic settings. Although anthropometric measures reflect adiposity in non-pregnant individuals, their utility in early pregnancy remains unclear. We examined associations between anthropometrics and TAT and VAT in the early second trimester and evaluated differences by prepregnancy BMI. Among pregnant women (n = 61) in the Mother and Infant NuTrition (MINT) cohort, TAT and VAT were assessed via whole-body MRI at 15-weeks gestation. Anthropometrics included waist (WC), hip (HC), mid-upper arm (MUAC), calf (CC), thigh (TC), and skinfolds (SF) for iliac crest, subscapular, thigh, and triceps. Linear regression evaluated predictors of TAT and VAT by BMI category. TAT demonstrated strong positive correlations with BMI, WC, HC, MUAC, and TC (r = 0.76-0.92) while VAT demonstrated moderate positive correlations with BMI, MUAC, HC (r = 0.48-0.58), and strongest with WC (r = 0.60). The healthy BMI (n = 36) TAT prediction model included MUAC, HC, and iliac SF (R2 = 0.86), and VAT model included MUAC and iliac SF (R2 = 0.60). The overweight and obesity (n = 25) TAT prediction model (R2 = 0.93) included WC and HC and the VAT model (R2 = 0.79) included HC and subscapular SF. Anthropometric measures associated with prenatal adiposity differed by prepregnancy BMI. The TAT prediction model showed an acceptable R2 and included HC, MUAC, and iliac SF for healthy BMI, and WC and HC for overweight or obesity. Incorporating comprehensive anthropometrics into prenatal research and clinical care may improve risk identification and understanding of prenatal adiposity.
Cancer survivors face unique and persistent health-related quality of life (HRQoL) challenges. Existing HRQoL questionnaires for survivors lack content regarding chronic physical issues and have typically included limited cancer types and languages/cultures, affecting breadth of content and generalisability. We developed and validated the EORTC QLQ-SURV100, a questionnaire to assess HRQoL in disease-free survivors of diverse cancers. A conceptual framework of HRQoL in cancer survivors, developed in previous study phases and conceptualised as survivors' self-reported physical, mental and social functioning and well-being, formed the basis for questionnaire content. The QLQ-SURV100 was administered to 1480 participants across 46 centres in 21 countries (31% breast cancer, 23% colorectal, 22% prostate, 24% other cancers), who had completed primary treatment 1-10 years earlier and had no evidence of active disease. Structural validity of the 21 multi-item questionnaire scales was assessed via confirmatory factor analysis; test-retest reliability via intraclass correlation coefficients (ICCs); construct validity through known-group comparisons; and cross-cultural validity and sex invariance through differential item functioning (DIF). Item response theory (IRT) analyses evaluated item redundancy and performance. The QLQ-SURV100 showed strong structural validity (Comparative Fit Index = 0.951; Tucker-Lewis Index = 0.944; Root Mean Square Error of Approximation = 0.046), with most standardised factor loadings > 0.7. Test-retest ICCs exceeded 0.7 for 27 of 35 scales and 0.6 for 34 scales. Known-groups analyses supported most hypotheses, confirming sensitivity to treatment, comorbidity, age, sex, and education. DIF analysis indicated minor cross-cultural item bias, but no sex-related DIF. IRT analysis found no redundant items. The EORTC QLQ-SURV100 showed satisfactory structural validity, test-retest reliability and construct validity; limited item redundancy; and measurement invariance across the sex and language groups examined.
This perspective explores the paradox in plant-based diets: while whole plant foods offer established health benefits, the rapidly expanding market of ultraprocessed plant-based alternatives presents both opportunities and challenges for nutrition education. We examine evidence suggesting these products serve as valuable "gateway foods" facilitating dietary transitions while acknowledging concerns about processing levels and nutrient profiles (high in sodium, refined oils, and added sugars). A balanced approach is proposed whereby nutrition educators recognize plant-based alternatives' dual role, as transitional foods easing adherence to plant-based eating, while guiding consumers toward less processed options when feasible and considering socioeconomic accessibility in recommendations.