Utilizing technology for diet and exercise change in complex chronic conditions across diverse environments (U-DECIDE): feasibility randomised controlled trial.

BACKGROUND: Diet and exercise are important components of treatment for complex chronic conditions, however access to allied health support is limited. When available, support is often siloed and fragmented. Digital health incorporating patient choice may help to align health care services with preferences and goals. This study evaluated the implementation of a ubiquitously accessible patient-centred digital health diet and exercise service. METHODS: U-DECIDE was a single-centre, 26-week randomised controlled trial set in kidney and liver disease clinics in a tertiary hospital in Brisbane, Australia. Participants were adults with a complex chronic condition referred for dietetic consultation with at least one feature of the metabolic syndrome. All participants received a dietary consultation, an activity monitor and usual care. Intervention participants were offered one text message per week and access to additional digital health options (increased text message frequency, nutrition app, exercise app, group-based diet and/or exercise video consultations). The primary outcome of feasibility was determined by safety (study-related serious adverse events: SRSAEs), recruitment (≥ 50% eligible patients), retention (≥ 70%), exposure uptake (≥ 75% of intervention group had greater access to health professional contact than comparator) and video consultation adherence (≥ 80% attendance). Secondary outcomes included process evaluation metrics and clinical outcomes. RESULTS: Of 67 participants (intervention n = 33, comparator n = 34), 37 (55%) were men, median (IQR) age was 51 (41-58) years. The most chosen digital health options were the nutrition app (n = 29, 88%) and exercise video consultations (n = 26, 79%). Only one participant chose no additional digital health options. The intervention group had no SRSAEs. The study exceeded targets for recruitment (52%), retention (81%) and exposure uptake (94%). Video consultation adherence was 42%. Engagement across digital health options was inconsistent. CONCLUSIONS: Digital health options incorporating patient choice were feasible and can be offered to people with complex chronic disease as a service model option. TRIAL REGISTRATION: Australia and New Zealand Trials Register: Trial Registration Number: ACTRN12620001282976. Registered 27th November 2020.

The effectiveness of the Mediterranean Diet for primary and secondary prevention of cardiovascular disease: An umbrella review.

AIMS: This study aimed to review meta-analyses of randomised controlled trials that evaluated the effectiveness of the Mediterranean Diet for the primary and secondary prevention of cardiovascular disease. METHODS: Five databases (Medline, Embase, Cochrane, CINAHL and ProQuest) were searched from inception to November 2022. Inclusion criteria were: (i) systematic review of randomised controlled studies with metanalysis; (ii) adults ≥18 years from the general population with (secondary prevention) and without (primary prevention) established cardiovascular disease; (iii) Mediterranean Diet compared with another dietary intervention or usual care. Review selection and quality assessment using AMSTAR-2 were completed in duplicate. GRADE was extracted from each review, and results were synthesised narratively. RESULTS: Eighteen meta-analyses of 238 randomised controlled trials were included, with an 8% overlap of primary studies. Compared to usual care, the Mediterranean Diet was associated with reduced cardiovascular disease mortality (n = 4 reviews, GRADE low certainty; risk ratio range: 0.35 [95% confidence interval: 0.15-0.82] to 0.90 [95% confidence interval: 0.72-1.11]). Non-fatal myocardial infarctions were reduced (n = 4 reviews, risk ratio range: 0.47 [95% confidence interval: 0.28-0.79] to 0.60 [95% confidence interval: 0.44-0.82]) when compared with another active intervention. The methodological quality of most reviews (n = 16/18; 84%) was low or critically low and strength of evidence was generally weak. CONCLUSIONS: This review showed that the Mediterranean Diet can reduce fatal cardiovascular disease outcome risk by 10%-67% and non-fatal cardiovascular disease outcome risk by 21%-70%. This preventive effect was more significant in studies that included populations with established cardiovascular disease. Better quality reviews are needed.

Implementing early feeding after liver transplant using implementation frameworks: A multimethod study.

BACKGROUND: Evidence-based guidelines (EBGs) in the nutrition management of advanced liver disease and enhanced recovery after surgery recommendations state that normal diet should recommence 12-24 h following liver transplantation. This study aimed to compare postoperative nutrition practices to guideline recommendations, explore clinician perceptions regarding feeding after transplant surgery, and implement and evaluate strategies to improve postoperative nutrition practices. METHODS: A pre-post multimethod implementation study was undertaken, guided by the knowledge-to-action framework. A retrospective chart audit of postoperative dietary practice and semistructured interviews with clinicians were undertaken. Implementation strategies were informed by the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool and then evaluated. RESULTS: An evidence-practice gap was identified, with the median day to initiation of nutrition (free-fluid or full diet) on postoperative day (POD) 2 and only 25% of patients aligning with the EBGs. Clinician interviews identified belief in the importance of nutrition, with variation in surgical practice in relation to early nutrition, competing clinical priorities, and vulnerabilities in communication contributing to delays in returning to feeding. An endorsed postoperative nutrition protocol was implemented along with a suite of theory- and stakeholder-informed intervention strategies. Following implementation, the median time to initiate nutrition reduced to POD1 and alignment with EBGs improved to 60%. CONCLUSION: This study used implementation frameworks and strategies to understand, implement, and improve early feeding practices in line with EBGs after liver transplant. Ongoing sustainability of practice change as well as the impact on clinical outcomes have yet to be determined.

Patients' acceptability of self-selected digital health services to support diet and exercise among people with complex chronic conditions: Mixed methods study.

Objective: The acceptability of being offered a choice from a suite of digital health service options to support optimal diet and exercise behaviors in adults with complex chronic conditions was evaluated. This study sought to understand many areas of acceptability including satisfaction, ease of use, usefulness and user appropriateness and perceived effectiveness. Methods: This mixed-methods study was embedded within a randomized-controlled feasibility trial providing digital health services managing diet and exercise for adults from specialist kidney and liver disease clinics. Post study surveys and semistructured interviews were used to determine patients' acceptability of the trial interventions. Quantitative (surveys) and qualitative (surveys and interviews) results were merged using integrative analysis and mapped to each construct of the modified version of the Theoretical Framework of Acceptability. Results: Seventeen interviews (intervention group) and 50 surveys (n = 24 intervention, n = 26 comparator) completed from a possible 67 participants were analyzed. In the intervention group, the survey results revealed high areas of acceptability for the digital health services including overall support received, ease of use, timely advice and feeling safe. The interviews also revealed high areas of acceptability including convenience, ability to adopt healthier behaviors and having regular interactions with health professionals. However, the interviews also revealed lower areas of acceptability as a result of absence of individualization, low digital literacy, and limitations from life circumstances. Conclusions: Recipients of digital health services that supported diet and exercise interventions found these useful, effective, and safe. Individualized care, technical support and patient confidence remain important to improve the acceptability of digital health service interventions.

Evaluating the Potential of a Novel Metabolic Syndrome Severity Score to Inform Exercise Interventions for People with Complex Chronic Conditions.

Aims: Exercise interventions positively affect numerous cardiometabolic risk factors. To better evaluate the health effects of exercise training, it may be more appropriate to evaluate risk factors together. The Metabolic Syndrome Severity Score (MetSSS) is a composite score representing cardiometabolic risk. Purpose: To evaluate the relationships between physical activity, neuromuscular fitness, exercise capacity, and the MetSSS in a heterogenous sample of people with complex chronic disease. Material and Methods: Fifty-three people with kidney or liver disease and at least one feature of the metabolic syndrome (MetS) were included. Pearson correlations were conducted between physical activity, neuromuscular fitness, exercise capacity, and the MetSSS. Linear regressions were performed for multi-level categorical variables. Independent variables with an association with MetSSS (P ≤ 0.2) were included in a multiple regression analysis. Results: The 6-minute walk test (6MWT) distance was inversely and independently associated with MetSSS [standardized beta coefficient (ß) = -0.31, P = 0.04]. No relationship was found between MetSSS and physical activity or neuromuscular fitness. Mean 6MWT in the highest tertile was 550 m (range: 505-620 m) and 346 m (range: 233-408 m) in the lowest. The analysis showed a medium-large between-group effect for the difference in MetSSS for the lowest and highest tertile of 6MWT [Eta squared (η2) = 0.16, P = 0.01]. Conclusions: Exercise capacity was inversely and independently associated with MetSSS in people with complex chronic disease. Clinical trials with exercise interventions are needed to further investigate if improvements in exercise capacity result in clinically significant changes in the MetSSS.

The assessment of dietary carotenoid intake of the Cardio-Med FFQ using food records and biomarkers in an Australian cardiology cohort: a pilot validation.

Dietary carotenoids are associated with lower risk of CHD. Assessment of dietary carotenoid intake using questionnaires can be susceptible to measurement error. Consequently, there is a need to validate data collected from FFQs which measure carotenoid intake. This study aimed to assess the performance of the Cardio-Med Survey Tool (CMST)-FFQ-version 2 (v2) as a measure of dietary carotenoid intake over 12-months against plasma carotenoids biomarkers and 7-Day Food Records (7DFR) in an Australian cardiology cohort. Dietary carotenoid intakes (ß- and α-carotene, lycopene, ß-cryptoxanthin and lutein/zeaxanthin) were assessed using the 105-item CMST-FFQ-v2 and compared to intakes measured by 7DFR and plasma carotenoid concentrations. Correlation coefficients were calculated between each dietary method, and validity coefficients (VCs) were calculated between each dietary method and theoretical true intake using the 'methods of triads'. Thirty-nine participants aged 37-77 years with CHD participated in the cross-sectional study. The correlation between FFQ and plasma carotenoids were largest and significant for ß-carotene (0.39, p=0.01), total carotenoids (0.37, p=0.02) and ß-cryptoxanthin (0.33, p=0.04), with weakest correlations observed for α-carotene (0.21, p=0.21) and lycopene (0.21, p=0.21). The FFQ VCs were moderate (0.3-0.6) or larger for all measured carotenoids. The strongest were observed for total carotenoids (0.61) and ß-carotene (0.59), while the weakest were observed for α-carotene (0.33) and lycopene (0.37). In conclusion, the CMST-FFQ-v2 measured dietary carotenoids intakes with moderate confidence for most carotenoids, however, there was less confidence in ability to measure α-carotene and lycopene intake, thus further research is warranted using a larger sample.

Acceptability, Adherence, Safety and Experiences of Low Energy Diets in People With Obesity and Chronic Kidney Disease: A Mixed Methods Study.

OBJECTIVES: Obesity is a modifiable risk factor for chronic kidney disease (CKD) progression. Low energy diets (LEDs) have not been adequately studied in people with CKD. This study aimed to explore acceptability, adherence, safety, and experiences of two LED prescriptions in adults living with obesity and CKD. DESIGN AND METHODS: In a mixed-methods study, obese adults with CKD were prescribed two LEDs (∼800 to 1000 kcal/day each), in a randomised order for 2 weeks each. One diet consisted of four meal replacement products daily (Optifast®, Nestlé Health Science) and the other two pre-prepared frozen meals (Lite n' Easy®, Mitchell's Quality Foods). Participants received weekly dietitian support, completed daily adherence checklists (converted to % of provided meals/replacements consumed) and participated in post-intervention semi-structured interviews to capture their experience. RESULTS: Nine participants were included (mean age 46.5 ± 14.3 years, estimated glomerular filtration rate 64 ± 26 mL/min/1.73 m2, 4/9 male). Mean self-reported adherence was 88 ± 11% and mean 4-week weight change was -7.3 ± 5.6 kg. Two participants withdrew at week two. Most frequently reported side effects were hunger and headaches. Adverse events of interest included one episode each of hyperkalaemia and hypoglycaemia. No serious adverse events occurred. Four overarching themes of patient experiences were identified: strategies used to adapt, disruption to the norm, individual preferences, and influences on acceptability. CONCLUSIONS: LEDs were found to be acceptable and safe with high self-reported adherence rates. Future LED trials should include specialist diabetes management, close monitoring for hyperkalaemia and adequate support to assist with managing side effects and dietary and social adjustments.

Associations between healthy food groups and platelet-activating factor, lipoprotein-associated phospholipase A2 and C-reactive protein: a cross-sectional study.

PURPOSE: To investigate the association between pro-inflammatory markers platelet-activating factor (PAF), lipoprotein-associated phospholipase A2 (Lp-PLA2), hsCRP, and intake of core food groups including fruit, cruciferous and other vegetables, grains, meat and poultry, fish and seafood, nuts and legumes, and dairy. METHODS: A cross-sectional study was conducted. 100 adults (49 ± 13 years, 31% male) with variable cardiovascular disease risk were recruited. Data were collected in 2021 and 2022. Fasting PAF, Lp-PLA2 activity, hsCRP and usual dietary intake (via a validated food frequency questionnaire) were measured. Intake of foods were converted into serves and classified into food groups. Correlations and multiple regressions were performed with adjustment for confounders. RESULTS: A one-serve increase in cruciferous vegetables per day was associated with 20-24% lower PAF levels. An increase of one serve per day of nuts and legumes was associated with 40% lower hsCRP levels. There were small correlations with PAF and Lp-PLA2 and cheese, however, these were not significant at the Bonferroni-adjusted P < 0.005 level. CONCLUSION: The lack of associations between PAF and Lp-PLA2 and other healthy foods may be due to confounding by COVID-19 infection and vaccination programs which prevents any firm conclusion on the relationship between PAF, Lp-PLA2 and food groups. Future research should aim to examine the relationship with these novel markers and healthy food groups in a non-pandemic setting.

Trust and confidence in using telehealth in people with chronic kidney disease: A cross-sectional study.

Consumer trust and confidence in telehealth is pivotal to successful service implementation and effective consultations. This cross-sectional study measured trust and confidence in telephone and video consultations and associated with experience in telehealth modalities among people with chronic kidney disease at a metropolitan hospital in Australia. Self-report data were collected using validated trust and confidence in telehealth scales and 5-point Likert responses. Non-parametric tests were used to compare trust and confidence in telephone and video consultations (Wilcoxon Matched Pairs) and associations with telehealth experience (Mann-Whitney). Of the 156 survey participants, 96.2% had used telephone consultations and 28.9% had used video. Overall trust and confidence in using telehealth were high. Confidence (range 1-5) in using telephone consultations (mean 3.75 ± 0.71) was significantly higher than video consultation (mean 3.64 ± 0.74), p = 0.039. Trust in telephone consultations (mean 3.93 ± 0.64) was significantly higher than in video consultations (mean 3.67 ± 0.66), p < 0.001. There was a significant association between experience with telephone consultations and reported levels of trust and confidence in telephone consultations. Experience with video was significantly related to trust in video consultations, but not confidence. Given the substantial difference in experience between telehealth modalities, trust and confidence may change as further exposure occurs.

The association between dietary quality scores with C-reactive protein and novel biomarkers of inflammation platelet-activating factor and lipoprotein-associated phospholipase A2: a cross-sectional study.

Healthy dietary patterns are associated with lower inflammation and cardiovascular disease (CVD) risk and adherence can be measured using diet quality scores. Inflammation is traditionally measured with C-reactive protein (hsCRP), however there is interest in novel pro-inflammatory markers platelet-activating factor (PAF) and lipoprotein-associated phospholipase A2 (Lp-PLA2) that are specifically involved in endothelial dysfunction and inflammation. This cross-sectional study investigated the association between PAF, Lp-PLA2, hsCRP, and six diet scores. One hundred adults (49 ± 13 years, 31% male) with variable CVD risk were recruited. Fasting PAF, Lp-PLA2 and hsCRP and usual dietary intake were measured. Adherence to Dietary Approaches to Stop Hypertension (DASH), Dairy-adjusted DASH, Vegetarian Lifestyle Index, Healthy Eating Index for Australians (HEIFA), Mediterranean Diet Adherence Screener (MEDAS) and PREDIMED-Plus (erMedDiet) scores were calculated. Correlations and multiple regressions were performed. hsCRP, but not PAF, independently correlated with several diet scores. Lp-PLA2 independently correlated with Vegetarian Lifestyle Index only in unadjusted models. A one-point increase in adherence to the DASH Index, the Dairy-adjusted DASH Index and the Vegetarian Lifestyle Index was associated with a 30%, 30%, and 33% reduction in hsCRP levels, respectively. Smaller effects were seen with the other diet scores with a one-point increase in adherence resulting in a 19%, 22% and 16% reduction in hsCRP with HEIFA, MEDAS, erMedDiet scores, respectively. The lack of stronger associations between the novel markers of inflammation and diet scores may be due to confounding by COVID-19 infection and vaccination programs, which prevents any firm conclusion on the relationship between PAF, Lp-PLA2 and healthy dietary patterns. Future research should aim to examine the relationship with these novel markers and healthy dietary patterns in a non-pandemic setting.

Randomized Trial on the Effect of Oral Potassium Chloride Supplementation on the Thiazide-Sensitive Sodium Chloride Cotransporter in Healthy Adults.

Introduction: The putative "renal-K switch" mechanism links dietary potassium intake with sodium retention and involves activation of the sodium chloride (NaCl) cotransporter (NCC) in the distal convoluted tubule in response to low potassium intake, and suppression in response to high potassium intake. This study examined NCC abundance and phosphorylation (phosphorylated NCC [pNCC]) in urinary extracellular vesicles (uEVs) isolated from healthy adults on a high sodium diet to determine tubular responses to alteration in potassium chloride (KCl) intake. Methods: Healthy adults maintained on a high sodium (∼4.5 g [200 mmol]/d) low potassium (∼2.3 g [60 mmol]/d) diet underwent a 5-day run-in period followed by a crossover study, with 5-day supplementary KCl (active phase, Span-K 3 tablets (potassium 24 mmol) thrice daily) or 5-day placebo administrated in random order and separated by 2-day washout. Ambulatory blood pressure (BP) and biochemistries were assessed, and uEVs were analyzed by western blotting. Results: Among the 18 participants who met analysis criteria, supplementary KCl administration (vs. placebo) was associated with markedly higher levels of plasma potassium and 24-hour urine excretion of potassium, chloride, and aldosterone. KCl supplementation was associated with lower uEV levels of NCC (median fold change (KCl/Placebo) = 0.74 [0.30-1.69], P < 0.01) and pNCC (fold change (KCl/Placebo) = 0.81 [0.19-1.75], P < 0.05). Plasma potassium inversely correlated with uEV NCC (R2 = 0.11, P = 0.05). Conclusions: The lower NCC and pNCC in uEVs in response to oral KCl supplementation provide evidence to support the hypothesis of a functional "renal-K switch" in healthy human subjects.

Cost-effectiveness of telehealth-delivered nutrition interventions: a systematic review of randomized controlled trials.

CONTEXT: Telehealth-delivered nutrition interventions are effective in practice; however, limited evidence exists regarding their cost-effectiveness. OBJECTIVE: To evaluate the cost-effectiveness of telehealth-delivered nutrition interventions for improving health outcomes in adults with chronic disease. DATA SOURCES: PubMed, CENTRAL, CINAHL, and Embase databases were systematically searched from database inception to November 2021. Included studies were randomized controlled trials delivering a telehealth-delivered diet intervention conducted with adults with a chronic disease and that reported on cost-effectiveness or cost-utility analysis outcomes. DATA EXTRACTION: All studies were independently screened and extracted, and quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. DATA ANALYSIS: All extracted data were grouped into subcategories according to their telehealth modality and payer perspective, and were analyzed narratively. RESULTS: Twelve randomized controlled trials comprising 5 phone-only interventions, 3 mobile health (mHealth), 2 online, and 1 each using a combination of phone-online or phone-mHealth interventions, were included in this review. mHealth interventions were the most cost-effective intervention in all studies. Across all telehealth interventions and cost analyses from health service perspectives, 60% of studies were cost-effective. From a societal perspective, however, 33% of studies reported that the interventions were cost-effective. Of the 10 studies using cost-utility analyses, 3 were cost saving and more effective, making the intervention dominant, 1 study reported no difference in costs or effectiveness, and the remaining 6 studies reported increased cost and effectiveness, meaning payers must decide whether this falls within an acceptable willingness-to-pay threshold for them. Quality of study reporting varied with between 63% to 92%, with an average of 77% of CHEERS items reported. CONCLUSION: Telehealth-delivered nutrition interventions in chronic disease populations appear to be cost-effective from a health perspective, and particularly mHealth modalities. These findings support telehealth-delivered nutrition care as a clinically beneficial, cost-effective intervention delivery modality.

Interrelationships among platelet-activating factor and lipoprotein-associated phospholipase A2 activity and traditional cardiovascular risk factors.

Traditionally cardiovascular disease (CVD) risk has been assessed through blood lipids and inflammatory marker C-reactive protein (hsCRP). Recent clinical interest in novel pro-inflammatory markers platelet-activating factor (PAF) and lipoprotein-associated phospholipase A2 (Lp-PLA2 ) recognizes that vascular damage can exist in the absence of traditional risk factors. This cross-sectional study investigated the potential relationship between circulating PAF, Lp-PLA2 , hsCRP, and traditional risk factors for CVD. One hundred adults (49 ± 13 years, 31% male) with variable CVD risk were recruited. Fasting inflammatory markers PAF, Lp-PLA2 and hsCRP and total, high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol, and triglycerides were measured. Blood pressure, body mass index, and waist circumference were measured. Medical and physical activity data were self-reported. Linear and multiple regressions were performed. PAF, Lp-PLA2 , and hsCRP independently correlated with several CVD risk factors. PAF was correlated significantly with risk factors in an unexpected way; there was a medium positive correlation between PAF and HDL cholesterol (r = 0.394, p < 0.001) and medium negative correlations with Total:HDL cholesterol; (r = -0.436, p < 0.001) systolic blood pressure; (r = -0.307, p = 0.001); BMI (r = -0.381, p < 0.001); and waist circumference (r = -0.404, p < 0.001). There were large positive correlations between Lp-PLA2 and LDL (r = 0.525, p < 0.001) and non-HDL cholesterol (r = 0.508, p < 0.001). There were large positive correlations between hsCRP and Total:HDL cholesterol (r = 0.524, p < 0.001); BMI (r = 0.668, p < 0.001); and waist circumference (r = 0.676, p < 0.001). PAF, Lp-PLA2 , and hsCRP are implicated in the pathophysiology of inflammation in CVD; however, the relationships between each marker and traditional risk factors were different suggesting they may be involved in different atherogenic pathways.

Effectiveness of dietary interventions delivered by digital health to adults with chronic conditions: Systematic review and meta-analysis.

BACKGROUND: Digital health interventions may facilitate management of chronic conditions; however, no reviews have systematically assessed the effectiveness of dietary interventions delivered by digital health platforms for improving dietary intake and clinical outcomes for adults with diet-related chronic conditions. METHODS: Databases CINAHL, CENTRAL, Embase and MEDLINE were searched from inception to April 2021 to identify controlled trials for dietary education delivered by digital health (mobile or electronic health) to adults with diet-related chronic conditions. Random effects analysis was performed for diet quality, food groups, nutrients and clinical outcomes. Screening, data extraction and quality checking were completed in duplicate. RESULTS: Thirty-nine studies were included involving 7333 participants. Significant changes were found for Mediterranean diet adherence score (standardised mean difference [SMD] = 0.79; 95% confidence interval [CI] = 0.18 to 1.40), overall fruit and vegetable intake (mean difference [MD]: 0.63 serves/day; 95% CI = 0.27-0.98), fruit intake alone (MD = 0.58 serves/day; 95% CI = 0.39 to 0.77) and sodium intake (SMD = -0.22; 95% CI = -0.44 to -0.01). Improvements were also found for waist circumference [MD = -2.24 centimetres; 95% CI = -4.14 to -0.33], body weight (MD = -1.94 kg; 95% CI = -2.63 to -1.24) and haemoglobin A1c (MD = -0.17%; 95% CI = -0.29 to -0.04). Validity of digital assessment tools to measure dietary intake were not reported. The quality of evidence was considered to have low to moderate certainty. CONCLUSIONS: Modest improvements in diet and clinical outcomes may result from intervention via digital health for those with diet-related chronic conditions. However, additional robust trials with better reporting of digital dietary assessment tools are needed to support implementation within clinical practice.

'We work in silos': Exploring clinicians' perspectives on the dietary management of coronary heart disease and type 2 diabetes in an Australian public hospital and community health service.

AIMS: This study explored clinicians' perspectives on roles, practices and service delivery in the dietary management of coronary heart disease and type 2 diabetes in a public health service. METHODS: Semi-structured individual interviews were conducted with 57 clinicians (21 nurses, 19 doctors, 13 dietitians and 4 physiotherapists) involved in the care of relevant patients across hospital and post-acute community settings in a metropolitan health service in Australia. Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis. RESULTS: A total of 3 themes with 10 subthemes were identified. (a) 'Treatment prioritisation': important role of nutrition in risk factor management; competing priorities with complex patients; weight loss as a priority; and dietitians individualise. (b) 'Diverse roles in providing diet advice': a tension between nutrients, restrictions and diet quality; patients seek and trust advice from non-dietitians; and providing nutrition information materials crosses professions. (c) 'Dietitian access': variable integration and resourcing; access governed by clinician discretion and perceived patient interest; and bespoke application of referral pathways. CONCLUSIONS: Time and resource constraints, variable access and referral to dietitians, and inconsistent advice were key challenges in the dietary management of coronary heart disease and type 2 diabetes. Models of care may be improved with greater investment and integration of dietitians, including to provide professional support across disciplines and disease specialties.

Extra virgin olive oil improves HDL lipid fraction but not HDL-mediated cholesterol efflux capacity: a double-blind, randomised, controlled, cross-over study (OLIVAUS).

Olive oil (OO) polyphenols have been shown to improve HDL anti-atherogenic function, thus demonstrating beneficial effects against cardiovascular risk factors. The aim of the present study was to investigate the effect of extra virgin high polyphenol olive oil (HPOO) v. low polyphenol olive oil (LPOO) on the capacity of HDL to promote cholesterol efflux in healthy adults. In a double-blind, randomised cross-over trial, fifty participants (aged 38·5 (sd 13·9) years, 66 % females) were supplemented with a daily dose (60 ml) of HPOO (320 mg/kg polyphenols) or LPOO (86 mg/kg polyphenols) for 3 weeks. Following a 2-week washout period, participants crossed over to the alternate treatment. Serum HDL-cholesterol efflux capacity, circulating lipids (i.e. total cholesterol, TAG, HDL, LDL) and anthropometrics were measured at baseline and follow-up. No significant between-group differences were observed. Furthermore, no significant changes in HDL-cholesterol efflux were found within either the LPOO and HPOO treatment arms; mean changes were 0·54 % (95 % CI (0·29, 1·37)) and 0·10 % (95 % CI (0·74, 0·94)), respectively. Serum HDL increased significantly after LPOO and HPOO intake by 0·13 mmol/l (95 % CI (0·04, 0·22)) and 0·10 mmol/l (95 % CI (0·02, 0·19)), respectively. A small but significant increase in LDL of 0·14 mmol/l (95 % CI (0·001, 0·28)) was observed following the HPOO intervention. Our results suggest that additional research is warranted to further understand the effect of OO with different phenolic content on mechanisms of cholesterol efflux via different pathways in multi-ethnic populations with diverse diets.

The Effect of Diet and Exercise Interventions on Body Composition in Liver Cirrhosis: A Systematic Review.

Alterations in body composition, in particular sarcopenia and sarcopenic obesity, are complications of liver cirrhosis associated with adverse outcomes. This systematic review aimed to evaluate the effect of diet and/or exercise interventions on body composition (muscle or fat) in adults with cirrhosis. Five databases were searched from inception to November 2021. Controlled trials of diet and/or exercise reporting at least one body composition measure were included. Single-arm interventions were included if guideline-recommended measures were used (computed tomography/magnetic resonance imaging, dual-energy X-ray absorptiometry, bioelectrical impedance analysis, or ultrasound). A total of 22 controlled trials and 5 single-arm interventions were included. Study quality varied (moderate to high risk of bias), mainly due to lack of blinding. Generally, sample sizes were small (n = 6-120). Only one study targeted weight loss in an overweight population. When guideline-recommended measures of body composition were used, the largest improvements occurred with combined diet and exercise interventions. These mostly employed high protein diets with aerobic and or resistance exercises for at least 8 weeks. Benefits were also observed with supplementary branched-chain amino acids. While body composition in cirrhosis may improve with diet and exercise prescription, suitably powered RCTs of combined interventions, targeting overweight/obese populations, and using guideline-recommended body composition measures are needed to clarify if sarcopenia/sarcopenic obesity is modifiable in patients with cirrhosis.

The anti-inflammatory effects of a Mediterranean diet: a review.

PURPOSE OF REVIEW: Chronic noncommunicable diseases remain the leading cause of morbidity and mortality worldwide and the majority are preventable with a healthy diet and lifestyle, but controversy remains as to the best approach. Greater adherence to a traditional Mediterranean diet has consistently been associated with lower morbidity and mortality from cardiovascular disease, diabetes and many cancers, and lower all-cause mortality. Despite the well known benefits on chronic disease risk there remains some scepticism as to the effects of this dietary pattern across populations outside the Mediterranean and the mechanisms of action of this traditional plant-based dietary pattern.This narrative review aims to summarize the latest evidence on the health protective effects of a traditional Mediterranean diet on chronic noncommunicable diseases, specifically focussing on the anti-inflammatory effects of this highly published dietary pattern. RECENT FINDINGS: Recent high-quality evidence now supports a Mediterranean diet in secondary prevention of cardiovascular disease with impacts on atherosclerosis progression, likely through reduction of systemic inflammation and irrespective of changes in cholesterol or weight. The Mediterranean diet has a low Dietary Inflammatory Index illustrating its anti-inflammatory potential. This dietary pattern beneficially modulates the gut microbiota and immune system, including emerging evidence for efficacy against severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019). Emerging evidence shows clinicians are not routinely recommending a Mediterranean diet despite well known evidence due to barriers such as lack of training, patient materials and concerns about potential patient adherence. SUMMARY: The physiological mechanisms of action of this healthy diet pattern are becoming better understood to be multisystem and involving the gut. Larger controlled trials investigating mechanistic effects in broader non-Mediterranean populations are warranted. Although reflected in therapeutic guidelines for chronic disease management worldwide there are individual, clinical practice and health system barriers to its implementation that need a multisectoral approach to address.

Utilizing Technology for Diet and Exercise Change in Complex Chronic Conditions Across Diverse Environments (U-DECIDE): Protocol for a Randomized Controlled Trial.

BACKGROUND: The metabolic syndrome is common across many complex chronic disease groups. Advances in health technology have provided opportunities to support lifestyle interventions. OBJECTIVE: The purpose of this study is to test the feasibility of a health technology-assisted lifestyle intervention in a patient-led model of care. METHODS: The study is a single-center, 26-week, randomized controlled trial. The setting is specialist kidney and liver disease clinics at a large Australian tertiary hospital. The participants will be adults with a complex chronic condition who are referred for dietetic assessment and display at least one feature of the metabolic syndrome. All participants will receive an individualized assessment and advice on diet quality from a dietitian, a wearable activity monitor, and standard care. Participants randomized to the intervention group will receive access to a suite of health technologies from which to choose, including common base components (text messages) and optional components (online and mobile app-based nutrition information, an online home exercise program, and group-based videoconferencing). Exposure to the optional aspects of the intervention will be patient-led, with participants choosing their preferred level of engagement. The primary outcome will be the feasibility of delivering the program, determined by safety, recruitment rate, retention, exposure uptake, and telehealth adherence. Secondary outcomes will be clinical effectiveness, patient-led goal attainment, treatment fidelity, exposure demand, and participant perceptions. Primary outcome data will be assessed descriptively and secondary outcomes will be assessed using an analysis of covariance. This study will provide evidence on the feasibility of the intervention in a tertiary setting for patients with complex chronic disease exhibiting features of the metabolic syndrome. RESULTS: The study was funded in 2019. Enrollment has commenced and is expected to be completed by June 2022. Data collection and follow up are expected to be completed by December 2022. Results from the analyses based on primary outcomes are expected to be submitted for publication by June 2023. CONCLUSIONS: The study will test the implementation of a health technology-assisted lifestyle intervention in a tertiary outpatient setting for a diverse group of patients with complex chronic conditions. It is novel in that it embeds patient choice into intervention exposure and will inform health service decision-makers in regards to the feasibility of scale and spread of technology-assisted access to care for a broader reach of specialist services. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12620001282976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378337. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37556.