Advancing the decadal plan for the science of nutrition: Progressing a framework for implementation.

AIMS: In 2019, the Australian Academy of Science in collaboration with the nutrition community published the decadal plan for the science of nutrition. This article aims to review progress towards each of its pillar goals (societal determinants, nutrition mechanisms, precision and personalised nutrition, and education and training) and two enabling platforms (a national data capability and a trusted voice for nutrition science), prioritise actions, and conceptualise program logic implementation models. This process also brought together public health nutrition researchers to reflect on societal determinants of health, and advise how the next 5 years of the decadal plan could reflect contemporary issues. METHODS: Two engagement events, in 2023, brought together experienced and mid- and early-career nutrition professionals for co-creation of implementation logic models. RESULTS: One hundred and nine early and mid-career professionals were involved. A revised model for the decadal plan pillars emerged from synthesis of all logic models. This new model integrated the precision and personalised nutrition pillar with nutrition mechanisms pillar. These combined pillars build towards the national data capability enabling platform and created new cross-cutting themes for education and training. The need arose for greater focus on respectful engagement with Aboriginal and Torres Strait Islander communities and sustained effort to build cross-disciplinary collaboration to realise the plan's societal determinants goals. A new alliance for nutrition science is proposed to become a unified advocacy voice and build trust in nutrition professionals. CONCLUSIONS: A programmatic approach provides a road map for implementing the decadal plan for the final 5 years.

A scoping review of Australian nutrition resources for feeding children under 5 years of age.

INTRODUCTION: This review identified and appraised Australian open-access online resources relating to feeding and nutrition during the first 5 years of life. METHODS: Eligible resources were identified by hand searching plus a targeted search of pertinent source websites (government, hospitals and health services, peak bodies, and nutrition organisations) published in English with/without translations to other languages between 2012 and 2022. Search terms relating to the population (children) AND topic (nutrition OR feeding) were entered into Google and Bing. Critical appraisal of each resource was conducted using a modified version of the Centres for Disease Control and Prevention Clear Communication Index. RESULTS: The search identified 1327 nutrition resources, of which 1067 were appraised. Forty-five percent were paper-based resources, 47% were online content only, and 8% audio-visual resources. Almost half of the resources (45%) broadly addressed the 0-5 years age range, and 24% provided information on breast or formula feeding. Limited resources were found specifically addressing growth and development (5%) and introducing solids (8%). Only 10% of resources were culturally tailored and only 3% were translated into a language other than English. Appraisal showed the majority included visual cues and appropriate language, but less included images to support the main message of the resource. DISCUSSION: Although there were a large volume of evidence-based nutrition resources available in Australia for feeding children under 5 years, they were highly dispersed and of varying quality. Collating and presenting these resources in an open-access resource hub would empower families and education and health professionals in the nutritional care of young children.

Development and validation of age-specific predictive equations for total energy expenditure and physical activity levels for older adults.

BACKGROUND: Predicting energy requirements for older adults is compromised by the underpinning data being extrapolated from younger adults. OBJECTIVES: To generate and validate new total energy expenditure (TEE) predictive equations specifically for older adults using readily available measures (age, weight, height) and to generate and test new physical activity level (PAL) values derived from 1) reference method of indirect calorimetry and 2) predictive equations in adults aged ≥65 y. METHODS: TEE derived from "gold standard" methods from n = 1657 (n = 1019 females, age range 65-90 y), was used to generate PAL values. PAL ranged 1.28-2.05 for males and 1.26-2.06 for females. Physical activity (PA) coefficients were also estimated and categorized (inactive to very active) from population means. Nonlinear regression was used to develop prediction equations for estimating TEE. Double cross-validation in a randomized, sex-stratified, age-matched 50:50 split, and leave one out cross-validation were performed. Comparisons were made with existing equations. RESULTS: Equations predicting TEE using the Institute of Medicine method are as follows: For males, TEE = -5680.17 - 17.50 × age (years) + PA coefficient × (6.96 × weight [kilograms] + 44.21 × height [centimeters]) + 1.13 × resting metabolic rate (RMR) (kilojoule/day). For females, TEE = -5290.72 - 8.38 × age (years) + PA coefficient × (9.77 × weight [kilograms] + 41.51 × height [centimeters]) + 1.05 × RMR (kilojoule/day), where PA coefficient values range from 1 (inactive) to 1.51 (highly active) in males and 1 to 1.44 in females respectively. Predictive performance for TEE from anthropometric variables and population mean PA was moderate with limits of agreement approximately ±30%. This improved to ±20% if PA was adjusted for activity category (inactive, low active, active, and very active). Where RMR was included as a predictor variable, the performance improved further to ±10% with a median absolute prediction error of approximately 4%. CONCLUSIONS: These new TEE prediction equations require only simple anthropometric data and are accurate and reproducible at a group level while performing better than existing equations. Substantial individual variability in PAL in older adults is the major source of variation when applied at an individual level.

Exploring the short-term impact of swapping consumption from standard protein snacks to higher protein snacks on energy intake in social drinkers: Is protein worth a nudge?

Drinking alcoholic beverages stimulates food intake and contributes to the passive overconsumption of dietary energy. As protein is the most satiating of all the macronutrients, increased levels in snacks taken with alcohol have the potential to minimize excess energy consumption. We hypothesized that swapping consumption from retail-available standard protein (SP) snacks to higher protein (HP) snack foods would increase satiety and reduce acute food energy intake in social drinkers. A randomized single-blind crossover trial with 19 healthy participants aged 19-31 years was conducted. Participants attended two separate testing sessions, where they ingested white wine (30 g alcohol) and were offered ad libitum access to either HP snacks with a protein-fortified dip or SP snacks with a dip. There were no significant differences in mean food mass, food energy intake, or subjective appetite ratings between the high and SP snacks (all p > .05). Mean protein intake was significantly increased with HP snacks compared with standard snacks (p < .001). Plasma glucose median incremental area under the curve and mean peak were significantly higher with the SP snacks (all p < .05) but remained within the reference range. This study demonstrated that consumption of a higher amount of protein after a moderate alcohol dose does not result in a change in food mass and energy intake or promote satiety in healthy young adults. The potential for a simple swap to different snack types is unlikely to bring substantial benefits to social drinkers and reduce passive energy consumption.

Pilot study of a virtual weight management program for Duchenne muscular dystrophy.

INTRODUCTION/AIMS: Young people with Duchenne muscular dystrophy (DMD) are at increased risk of obesity. Weight management is important to families; however, several barriers exist. This pilot study aimed to investigate the feasibility and acceptability of a co-designed weight management program for DMD. METHODS: The Supporting Nutrition and Optimizing Wellbeing Program (SNOW-P) was a single-arm diet and behavior weight management intervention delivered via weekly telehealth/phone visits over 6 weeks to young people with DMD and obesity (body mass index (BMI) ≥95th percentile) and their caregivers. Using an online survey, caregivers of boys with DMD were consulted on the structure and topics delivered in SNOW-P. Primary outcomes were feasibility and acceptability; secondary outcomes were weight, physical function, and quality of life at 6- and 12-weeks follow-up. RESULTS: Of nineteen eligible participants, eight were enrolled (median age 11.4 years, range 4.9-15.8), and seven completed the program. Visit attendance was high (88%-100%); most participants reported high satisfaction and that participation was easy. Suggested changes included online and visual DMD-specific resources. At 6-weeks, median change in weight z-scores was -0.01 (IQR: -0.23, 0.17) indicating that on average, weight gain tracked as expected for age. Waist circumference measured by caregivers lacked accuracy and the completion rate of caregiver-reported secondary outcome measures (e.g., food diaries) was low. DISCUSSION: A co-designed, telehealth/phone weight management program appeared to be feasible and acceptable in a small group of boys with DMD. An adapted, hybrid telehealth and face-to-face program is recommended for efficacy testing.

Exploring caregivers' attitudes and beliefs about nutrition and weight management for young people with Duchenne muscular dystrophy.

INTRODUCTION/AIMS: Obesity disproportionately affects children and adolescents with Duchenne muscular dystrophy (DMD) and with adverse consequences for disease progression. This study aims to: explore barriers, enablers, attitudes, and beliefs about nutrition and weight management; and to obtain caregiver preferences for the design of a weight management program for DMD. METHODS: We surveyed caregivers of young people with DMD from four Australian pediatric neuromuscular clinics. Survey questions were informed by the Theoretical Domains Framework and purposefully designed to explore barriers and enablers to food and weight management. Caregivers were asked to identify their preferred features in a weight management program for families living with DMD. RESULTS: Fifty-three caregivers completed the survey. Almost half (48%) perceived their son as above healthy weight. Consequences for those children were perceived to be self-consciousness (71%), a negative impact on self-esteem (64%) and movement (57%). Preventing weight gain was a common reason for providing healthy food and healthy eating was a high priority for families. Barriers to that intention included: time constraints, selective food preferences, and insufficient nutrition information. Caregivers preferred an intensive six-week weight management program addressing appetite management and screen time. DISCUSSION: Managing weight is an important issue for caregivers of sons with DMD; yet several barriers exist. Individualized 6 week programs are preferred by caregivers to improve weight management for DMD.

Exploring the long-term sustainability of school-based nutrition and food programs: What works, where and why?

ISSUE ADDRESSED: Most food and nutrition programs cease within 2 years. Understanding the determinants of program sustainability is crucial to maximise output from funding, whilst allowing sufficient time for program benefits to be achieved. This study applied the Consolidated Framework for Implementation Research (CFIR) to map the barriers and enablers of successful long-term implementation of school-based nutrition and food programs. METHODS: Qualitative methods with purposive and snowball sampling were used to recruit experts who were identified as being influential in implementing and sustaining long-term (>2 years) school-based food and nutrition programs. Semi-structured interviews with global experts were conducted, transcribed verbatim and coded deductively (by applying the CFIR constructs) and inductively when required. Thematic analysis informed the development of themes. RESULTS: Interviews were conducted with 11 experts including researchers, government employees, and a consultant of an international agency, from seven countries. Forty-eight deductive codes and eight inductive codes identified six main themes: (1) funding and integrity of its source; (2) political landscape; (3) nutrition policies and their monitoring; (4) involvement of community actors; (5) adaptability of the program and (6) effective program evaluation. Themes related mainly to the 'outer setting' domain of the CFIR. CONCLUSIONS: The CFIR highlighted pertinent factors that influence the successful long-term implementation of school-based food and nutrition programs. SO WHAT?: The findings suggest that to sustain program implementation beyond its initial funding, relationships across government departments, local organisations and communities, need to be nurtured and prioritised from the outset.

Applying the Integrated Sustainability Framework to explore the long-term sustainability of nutrition education programmes in schools: a systematic review.

OBJECTIVE: This review aimed to identify and synthesise the enablers and barriers that influence the long-term (≥ 2 years) sustainment of school-based nutrition programmes. DESIGN: Four databases (PubMed, Cochrane Library, Embase and Scopus) were searched to identify studies reporting on the international literature relating to food and nutrition programmes aimed at school-age (5-14 years) children that had been running for ≥ 2 years (combined intervention and follow-up period). Eligible studies were analysed using the Integrated Sustainability Framework (ISF), which involved deductive coding of programme enablers and barriers. A quality assessment was completed, using the Mixed-Methods Appraisal Tool and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. SETTING: International school-based nutrition programmes. SUBJECTS: Individuals involved with the implementation of school-based nutrition programmes. RESULTS: From the 7366 articles identified, thirteen studies (seven qualitative, five mixed methods and one quantitative descriptive) were included, from which the enablers and barriers of eleven different nutrition-related programmes were analysed. Thirty-four factors across the five domains of the ISF were identified that influenced the sustained implementation of programmes. The most common barrier was a lack of organisational readiness and resources, whereas the most common enabler was having adequate external partnerships and a supportive environment. CONCLUSIONS: These findings have application during the initiation and implementation phases of school-based nutrition programmes. Paying attention to the 'outer contextual factors' of the ISF including the establishment and maintenance of robust relationships across whole of government systems, local institutions and funding bodies are crucial for programme sustainment.

Body composition changes and their relationship with obstructive sleep apnoea symptoms, severity: The Sleeping Well Trial.

BACKGROUND & AIMS: Obstructive sleep apnoea (OSA) and obesity share a complex bi-directional relationship as location of body fat and changes in regional body composition may be more important for OSA improvement than changes in total body weight only. The aim of this study was to evaluate the impact of a 6-month weight loss intervention for adults newly diagnosed with moderate-severe OSA and obesity on regional body composition. The secondary aims evaluated the relationship between changes in OSA symptoms and severity and anthropometry and regional body composition during the first 12-months after commencing CPAP and explored differences in outcomes between males and females. METHODS: Participants (n = 59) received CPAP overnight at home alongside a 6-month modified fasting intervention with 12-months follow up. Regional body composition was measured by Dual X-ray absorptiometry, (DXA) and anthropometry before and after the lifestyle intervention. OSA severity was measured using the apnoea hypopnea index via overnight polysomnography and OSA symptoms were measured using the Epworth Sleepiness scale. RESULTS: Forty-seven adults (74% male) had complete measures available with a mean age of 50.0 y (SD 11.0) and BMI 34.1 kg/m2 (SD 5.0). Following the intervention average fat mass changed by -5.27 kg (5.36), p < 0.001) and visceral adipose tissue (-0.63 kg (0.67), p < 0.001) significantly decreased in males only with a maintenance of fat-free mass (mean -0.41 kg (1.80), p = 0.18). Females (n = 12) had significant decreases in waist circumference (mean -3.36 cm (3.18) p < 0.01), android lean (-0.12 kg (0.04), p < 0.05) and android total mass (-0.28 kg (0.39), p < 0.05) only. Regional body composition changes in males were positively associated with improvements in OSA severity (p < 0.01) but not OSA symptoms. CONCLUSION: Improvements in regional body composition were seen in males only which were related to improvements in OSA severity but not OSA symptoms. Females may exhibit different OSA pathophysiology and may require different treatment approaches. TRIAL REGISTRATION: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369975&isReview=trueAACTRN12616000203459 ACTRN12616000203459.

Participant recruitment for paediatric research using social media: A practical 'how-to' guide for researchers.

AIM: Social media platforms are being increasingly used to support participant recruitment into paediatric health-related research. This study aimed to develop a multi-phase approach for using social media as a recruitment strategy for paediatric research studies. METHODS: The process was informed by the authors' prior experiences recruiting for paediatric obesity-related research studies, expertise in social media marketing and digital participant/ patient recruitment. Reflection on these experiences resulted in the iterative creation of a draft process which was further refined. A narrative literature review using a structured search was conducted to refine and augment the content and finalise the process. RESULTS: A six-phase recruitment approach was developed that includes: (i) plan for social media use as a recruitment strategy, (ii) explore relevant ethical considerations to protect the wellbeing of potentially vulnerable groups and create an ethical management plan, (iii) identify and understand the different target audiences and develop the advertising strategy, (iv) develop and design campaign content, (v) implement, monitor and iteratively refine the recruitment campaign, (vi) evaluate the campaign success. Potential activities and key considerations relevant for paediatric research are presented within each phase. CONCLUSION: Due to the widespread use and diverse characteristics of social media users, social media has the potential to disseminate details of research opportunities to community members who may otherwise not hear about, engage with, and potentially benefit from research participation. Researchers should collaborate with communication experts and target audiences to generate relevant and effective recruitment campaigns. Researchers should implement processes to protect vulnerable audiences' wellbeing at each stage of the process. Recruitment via social media may support wider community participation in research studies designed to improve young people's health.

Investigating the efficacy and feasibility of using a whole-of-diet approach to lower circulating levels of C-reactive protein in postmenopausal women: a mixed methods pilot study.

OBJECTIVE: Chronic inflammation is associated with obesity and is an underlying pathophysiology for cardiovascular disease (CVD) development in postmenopausal women. This study aims to determine feasibility and efficacy of an anti-inflammatory dietary intervention to lower levels of C-reactive protein in weight stable postmenopausal women with abdominal obesity. METHODS: This mixed-methods pilot study used a single arm pre-post design. Thirteen women followed a 4-week anti-inflammatory, dietary intervention, optimizing consumption of healthy fats, low glycemic index wholegrains, and dietary antioxidants. Quantitative outcomes included change in inflammatory and metabolic markers. Focus groups were undertaken and thematically analyzed to explore participants lived experience of following the diet. RESULTS: There was no significant change in plasma high-sensitivity C-reactive, protein. Despite discouraging weight loss, median (Q1-Q3) body weight decreased by -0.7 (-1.3 to 0 kg, P = 0.02). This was accompanied by reductions in plasma insulin (0.90 [-0.05 to 2.20] mmol/L), Homeostatic Model Assessment of Insulin Resistance (0.29 [-0.03 to 0.59]), and low-density lipoprotein:high-density lipoprotein ratio (0.18 [-0.01 to 0.40]) ( P ≤ 0.023 for all). Thematic analysis revealed that postmenopausal women have a desire to improve meaningful markers of health status that do not focus on weight. Women were highly engaged with learning about emerging and innovative nutrition topics, favoring a detailed and comprehensive nutrition education style that challenged their proficient health literacy and cooking skills. CONCLUSIONS: Weight-neutral dietary interventions targeting inflammation can improve metabolic markers and may be a viable strategy for CVD risk reduction in postmenopausal women. To determine effects on inflammatory status, a fully powered and longer-term randomized controlled trial is required.

Development and validation of new predictive equations for the resting metabolic rate of older adults aged ≥65 y.

BACKGROUND: The aging process alters the resting metabolic rate (RMR), but it still accounts for 50%-70% of the total energy needs. The rising proportion of older adults, especially those over 80 y of age, underpins the need for a simple, rapid method to estimate the energy needs of older adults. OBJECTIVES: This research aimed to generate and validate new RMR equations specifically for older adults and to report their performance and accuracy. METHODS: Data were sourced to form an international dataset of adults aged ≥65 y (n = 1686, 38.5% male) where RMR was measured using the reference method of indirect calorimetry. Multiple regression was used to predict RMR from age (y), sex, weight (kg), and height (cm). Double cross-validation in a randomized, sex-stratified, age-matched 50:50 split and leave one out cross-validation were performed. The newly generated prediction equations were compared with the existing commonly used equations. RESULTS: The new prediction equation for males and females aged ≥65 y had an overall improved performance, albeit marginally, when compared with the existing equations. It is described as follows: RMR (kJ/d) = 31.524 × W (kg) + 25.851 × H (cm) - 24.432 × Age (y) + 486.268 × Sex (M = 1, F = 0) + 530.557. Equations stratified by age (65-79.9 y and >80 y) and sex are also provided. The newly created equation estimates RMR within a population mean prediction bias of ∼50 kJ/d (∼1%) for those aged ≥65 y. Accuracy was reduced in adults aged ≥80 y (∼100 kJ/d, ∼2%) but was still within the clinically acceptable range for both males and females. Limits of agreement indicated a poorer performance at an individual level with 1.96-SD limits of approximately ±25%. CONCLUSIONS: The new equations, using simple measures of weight, height, and age, improved the accuracy in the prediction of RMR in populations in clinical practice. However, no equation performs optimally at the individual level.

A Systematic Review Investigating Maternal Nutrition During Pregnancy After Bariatric Surgery.

The aim of this review was to report on maternal diet, micronutrient supplementation, and gestational weight gain (GWG) during pregnancy following bariatric surgery and explore the impact on maternal micronutrient deficiency, offspring growth, and perinatal outcomes. A search in PubMed, CINAHL, EMBASE, and ProQuest in July 2022 returned 23 eligible studies (n = 30-20, 213). Diet was reported in two studies, supplementation in six and GWG in 19 studies. Although many women did not achieve healthy GWG, no consistent link with adverse outcomes was reported. Studies were grades II and III on the National Health and Medical Research Council evidence hierarchy and received a neutral or negative score on the Academy of Nutrition and Dietetics Quality Criteria Checklist, suggesting that methodological limitations impact the reliability of reported findings.

Efficacy of technology-based personalised feedback on diet quality in young Australian adults: results for the advice, ideas and motivation for my eating (Aim4Me) randomised controlled trial.

OBJECTIVE: Web-based dietary interventions could support healthy eating. The Advice, Ideas and Motivation for My Eating (Aim4Me) trial investigated the impact of three levels of personalised web-based dietary feedback on diet quality in young adults. Secondary aims were to investigate participant retention, engagement and satisfaction. DESIGN: Randomised controlled trial. SETTING: Web-based intervention for young adults living in Australia. PARTICIPANTS: 18-24-year-olds recruited across Australia were randomised to Group 1 (control: brief diet quality feedback), Group 2 (comprehensive feedback on nutritional adequacy + website nutrition resources) or Group 3 (30-min dietitian consultation + Group 2 elements). Australian Recommended Food Score (ARFS) was the primary outcome. The ARFS subscales and percentage energy from nutrient-rich foods (secondary outcomes) were analysed at 3, 6 and 12 months using generalised linear mixed models. Engagement was measured with usage statistics and satisfaction with a process evaluation questionnaire. RESULTS: Participants (n 1005, 85 % female, mean age 21·7 ± 2·0 years) were randomised to Group 1 (n 343), Group 2 (n 325) and Group 3 (n 337). Overall, 32 (3 %), 88 (9 %) and 141 (14 %) participants were retained at 3, 6 and 12 months, respectively. Only fifty-two participants (15 % of Group 3) completed the dietitian consultation. No significant group-by-time interactions were observed (P > 0·05). The proportion of participants who visited the thirteen website pages ranged from 0·6 % to 75 %. Half (Group 2 = 53 %, Group 3 = 52 %) of participants who completed the process evaluation (Group 2, n 111; Group 3, n 90) were satisfied with the programme. CONCLUSION: Recruiting and retaining young adults in web-based dietary interventions are challenging. Future research should consider ways to optimise these interventions, including co-design methods.

Total Energy Expenditure in Healthy Ambulatory Older Adults Aged ≥80 Years: A Doubly Labelled Water Study.

INTRODUCTION: The life expectancy of older adults continues to increase; however, knowledge regarding their total energy requirements is lacking. This study aimed to compare the total energy expenditure (TEE) of older adults ≥80 years measured using doubly labelled water (DLW), with estimated TEE. The hypothesis was that the Mifflin, Ikeda, and Livingston equations will more closely estimate energy requirements than the commonly used Schofield equation. METHODS: Resting metabolic rate (RMR) and TEE were measured using the reference methods of indirect calorimetry and DLW, respectively. Bland-Altman plots compared measured RMR and TEE with predicted RMR using equations (Mifflin, Ikeda, Livingston, Schofield) and predicted TEE (predicted RMR × physical activity level). RESULTS: Twenty-one older adults (age range 80.7-90.1 years, BMI 26.1 ± 5.5 kg/m2) were included. The Schofield equation demonstrated the greatest bias from measured RMR, overestimating approximately up to double the mean difference (865 ± 662 kJ/day) compared with the three other equations. The Schofield equation exhibited the greatest bias (overestimation of 641 ± 1,066 kJ/day) compared with measured TEE. The other three equations underestimated TEE, with the least bias from Ikeda (37 ± 1,103 kJ/day), followed by Livingston (251 ± 1,108 kJ/day), and Mifflin (354 ± 1,140 kJ/day). Data are mean ± SD. CONCLUSIONS: In older adults ≥80 years, the Ikeda, Mifflin, and Livingston equations provide closer estimates of TEE than the widely used Schofield equation. The development of nutrition guidelines therefore should consider the utilization of equations which more accurately reflect age-specific requirements.

The Cost-Effectiveness of Adjunctive Lifestyle Interventions for the Management of Cancer: A Systematic Review.

OBJECTIVE: There is a paucity of papers synthesizing the cost-effectiveness (CE) of lifestyle interventions to support cancer patients, and the synthesis papers available have used analytic methods that do not permit easy comparison between studies. We therefore evaluated the CE of adjunctive lifestyle interventions compared with usual care. METHODS: A systematic literature search of Scopus, MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library databases was conducted from database inception until June 2021. Eligible studies were economic evaluations from randomised controlled trials or modelled economic evaluations that recruited subjects with a confirmed diagnosis of cancer and were allocated to a lifestyle intervention as an adjunct or supportive treatment, or usual care. Studies were excluded if there was no cost-effectiveness analysis or if costs were identified but not related back to measures of effectiveness. CE of the included interventions was recalculated, adjusting for key differences (with respect to absolute resource costs and timing) between the broad range of study settings and a common 'target' setting. All CE data were converted into incremental net monetary benefit using a common cost-effectiveness threshold to facilitate comparison. The quality of the studies was evaluated for risk of bias using the ECOBIAS check list. RESULTS: Nine studies were included in our review. Seven studies investigated the benefits of physical exercise in combination with cancer treatment and two studies investigated the combination of exercise and psychosocial counselling alongside cancer treatment. Six studies with an exercise intervention reported larger quality-adjusted life year (QALY) gains compared with usual care and when cost per QALY gained was considered, three of the interventions were cost effective. One of the two interventions combining exercise with psychosocial counselling was cost effective. All studies were considered of good quality but all had some limitations. CONCLUSIONS: The evidence to support the cost effectiveness of lifestyle interventions in patients with cancer is mixed with four of the nine interventions found to be cost effective and two remaining cost effective when uncertainty was taken into account. Sensitivity analysis showed the influence of the CE threshold on the results, highlighting the importance of selecting a CE threshold that is appropriate to the setting. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Registration Number: CRD42020185376.

Transcriptomic Differences Between Monozygotic Adolescent Twins Discordant For Metabolic Syndrome Following Weight Loss: A Case Study.

This case reports peripheral blood mononuclear cell (PBMC) transcriptomic changes in a pair of male monozygotic pediatric twins with metabolic syndrome (MetS) undertaking assisted weight loss. These 14-year-old boys presented with similar baseline biochemistry and body composition. After a 16-week weight-loss intervention, percent body weight loss was similar (Twin A 12%, and Twin B 13%). MetS resolved in Twin A but Twin B maintained elevated triglycerides after weight loss. Analysis of the PBMC transcriptome before and after weight loss revealed very different changes in gene expression including differences in the direction of expression of genes related to immune cell activation. 48.7% of genes that were downregulated in Twin A were upregulated in Twin B. This case highlights a novel approach to report the influence of chronic low-grade inflammation and metabolic dysfunction on the PBMC transcriptome. It explores whether expression of genes related to immune functions may underlie the differences in response to weight loss or whether transcriptomic alterations in immune cells may precede more traditional biomarkers of chronic pro-inflammation. These monozygotic twins present an example of divergence of phenotypic outcomes despite identical genetic background and similar treatment response.

Exploring Impacts of a Nutrition-Focused Massive Open Online Course.

The nutrition education landscape is changing due to advances in technology. Massive Open Online Courses (MOOCs) are an example of new education opportunities, made possible by advances in online learning environments. This research aimed to evaluate a nutrition-focused MOOC, applying Kirkpatrick's theoretical model of learning, to comprehensively describe learners' reactions, knowledge and behaviours. A mixed-methods approach explored learners' experiences of participating in a global nutrition MOOC. Quantitative survey data, using descriptive statistics, measured pre-course nutrition knowledge, post-course satisfaction and learning, and changes to fruit/vegetable intake. Qualitative data from discussion forums and semi-structured interviews were thematically analysed and explored participant experiences and perceived impacts on dietary behaviours and nutrition knowledge. All results were mapped to Kirkpatrick's model. Surveys measuring perceived knowledge, satisfaction, and fruit and vegetable intake were completed by 4941, 1003 and 1090 participants, respectively. Overall reactions to the course were positive. Perceived vegetable intake increased for 62% of participants. Twelve interviews and six hundred and forty-seven forum comments were analysed, identifying eight themes highlighting changes to knowledge and dietary behaviours, and the importance of peer-to-peer learning. All results mapped to Levels 1-3 of Kirkpatrick's model. MOOCs can be an effective platform to communicate evidence-based nutrition information to large, global audiences.