Urban living in healthy Tanzanians is associated with an inflammatory status driven by dietary and metabolic changes.

Sub-Saharan Africa currently experiences an unprecedented wave of urbanization, which has important consequences for health and disease patterns. This study aimed to investigate and integrate the immune and metabolic consequences of rural or urban lifestyles and the role of nutritional changes associated with urban living. In a cohort of 323 healthy Tanzanians, urban as compared to rural living was associated with a pro-inflammatory immune phenotype, both at the transcript and protein levels. We identified different food-derived and endogenous circulating metabolites accounting for these differences. Serum from urban dwellers induced reprogramming of innate immune cells with higher tumor necrosis factor production upon microbial re-stimulation in an in vitro model of trained immunity. These data demonstrate important shifts toward an inflammatory phenotype associated with an urban lifestyle and provide new insights into the underlying dietary and metabolic factors, which may affect disease epidemiology in sub-Sahara African countries.

Aquatic foods to nourish nations.

Despite contributing to healthy diets for billions of people, aquatic foods are often undervalued as a nutritional solution because their diversity is often reduced to the protein and energy value of a single food type ('seafood' or 'fish')1-4. Here we create a cohesive model that unites terrestrial foods with nearly 3,000 taxa of aquatic foods to understand the future impact of aquatic foods on human nutrition. We project two plausible futures to 2030: a baseline scenario with moderate growth in aquatic animal-source food (AASF) production, and a high-production scenario with a 15-million-tonne increased supply of AASFs over the business-as-usual scenario in 2030, driven largely by investment and innovation in aquaculture production. By comparing changes in AASF consumption between the scenarios, we elucidate geographic and demographic vulnerabilities and estimate health impacts from diet-related causes. Globally, we find that a high-production scenario will decrease AASF prices by 26% and increase their consumption, thereby reducing the consumption of red and processed meats that can lead to diet-related non-communicable diseases5,6 while also preventing approximately 166 million cases of inadequate micronutrient intake. This finding provides a broad evidentiary basis for policy makers and development stakeholders to capitalize on the potential of aquatic foods to reduce food and nutrition insecurity and tackle malnutrition in all its forms.

Fasting-mimicking diet and hormone therapy induce breast cancer regression.

Approximately 75% of all breast cancers express the oestrogen and/or progesterone receptors. Endocrine therapy is usually effective in these hormone-receptor-positive tumours, but primary and acquired resistance limits its long-term benefit1,2. Here we show that in mouse models of hormone-receptor-positive breast cancer, periodic fasting or a fasting-mimicking diet3-5 enhances the activity of the endocrine therapeutics tamoxifen and fulvestrant by lowering circulating IGF1, insulin and leptin and by inhibiting AKT-mTOR signalling via upregulation of EGR1 and PTEN. When fulvestrant is combined with palbociclib (a cyclin-dependent kinase 4/6 inhibitor), adding periodic cycles of a fasting-mimicking diet promotes long-lasting tumour regression and reverts acquired resistance to drug treatment. Moreover, both fasting and a fasting-mimicking diet prevent tamoxifen-induced endometrial hyperplasia. In patients with hormone-receptor-positive breast cancer receiving oestrogen therapy, cycles of a fasting-mimicking diet cause metabolic changes analogous to those observed in mice, including reduced levels of insulin, leptin and IGF1, with the last two remaining low for extended periods. In mice, these long-lasting effects are associated with long-term anti-cancer activity. These results support further clinical studies of a fasting-mimicking diet as an adjuvant to oestrogen therapy in hormone-receptor-positive breast cancer.

Forgotten food crops in sub-Saharan Africa for healthy diets in a changing climate.

As climate changes in sub-Saharan Africa (SSA), Africa's "forgotten" food crops offer a wide range of options to diversify major staple production as a key measure toward achieving zero hunger and healthy diets. So far, however, these forgotten food crops have been neglected in SSA's climate-change adaptation strategies. Here, we quantified their capacity to adapt cropping systems of SSA's major staples of maize, rice, cassava, and yams to changing climates for the four subregions of West, Central, East, and Southern Africa. We used climate-niche modeling to explore their potential for crop diversification or the replacement of these major staples by 2070, and assessed the possible effects on micronutrient supply. Our results indicated that approximately 10% of the present production locations of these four major staples in SSA may experience novel climate conditions in 2070, ranging from a high of almost 18% in West Africa to a low of less than 1% in Southern Africa. From an initial candidate panel of 138 African forgotten food crops embracing leafy vegetables, other vegetables, fruits, cereals, pulses, seeds and nuts, and roots and tubers, we selected those that contributed most to covering projected future and contemporary climate conditions of the major staples' production locations. A prioritized shortlist of 58 forgotten food crops, able to complement each other in micronutrient provision, was determined, which covered over 95% of assessed production locations. The integration of these prioritized forgotten food crops in SSA's cropping systems will support the "double-win" of more climate-resilient and nutrient-sensitive food production in the region.

The Potential Effectiveness of Nutrient Declarations and Nutrition and Health Claims for Improving Population Diets.

Nutrition labeling supports healthier diets by aiding purchase decisions and stimulating reformulation. This systematic literature review applied Cochrane methods to synthesize and appraise evidence on the effectiveness of nutrient declarations and nutrition and health claims on diet-related outcomes. The search spanned 11 academic databases, from inception to July 2022. Evidence was synthesized using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) and vote counting. Data were available from 170 studies. Randomized controlled trials (RCTs) suggest that nutrient declarations likely improved consumer understanding of the nutritional quality/content of foods (moderate certainty) and may have improved the healthfulness of choices (low certainty) versus no label. RCT evidence also suggests that claims likely increased consumer perceptions of food healthfulness and increased choice and purchases of labeled foods (both moderate certainty), irrespective of nutritional quality. To improve label understanding and avoid misinterpretation, nutrient declarations may incorporate interpretive elements and claims can apply disqualifying conditions for their usage, on the basis of overall nutritional quality.

The Potential Effectiveness of Front-of-Pack Nutrition Labeling for Improving Population Diets.

Nutrition labeling on the front of food packages can support more healthful purchase decisions and encourage favorable reformulation. This systematic literature review applied Cochrane methods to synthesize and appraise the evidence on the effectiveness of front-of-pack labeling (FOPL) on diet-related outcomes and food reformulation to inform policy recommendations. The search was conducted on 11 academic and gray literature databases, from inception to July 2022. Evidence was synthesized using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation), vote counting, and meta-analyses, where appropriate. Overall, 221 articles were included in the review. The randomized controlled trial evidence suggested that, compared with when no FOPL was present, FOPL likely improved consumer understanding of the nutritional quality/content of foods (moderate certainty of evidence), and the healthfulness of food choices (moderate certainty) and purchases (moderate certainty). Interpretive FOPL had a greater effect on these outcomes compared with noninterpretive systems (moderate certainty). There was inconsistency in the best-performing interpretive FOPL system.

Diet, Pace of Biological Aging, and Risk of Dementia in the Framingham Heart Study.

OBJECTIVE: People who eat healthier diets are less likely to develop dementia, but the biological mechanism of this protection is not well understood. We tested the hypothesis that healthy diet protects against dementia because it slows the pace of biological aging. METHODS: We analyzed Framingham Offspring Cohort data. We included participants ≥60 years-old, free of dementia and having dietary, epigenetic, and follow-up data. We assessed healthy diet as long-term adherence to the Mediterranean-Dash Intervention for Neurodegenerative Delay diet (MIND, over 4 visits spanning 1991-2008). We measured the pace of aging from blood DNA methylation data collected in 2005-2008 using the DunedinPACE epigenetic clock. Incident dementia and mortality were defined using study records compiled from 2005 to 2008 visit through 2018. RESULTS: Of n = 1,644 included participants (mean age 69.6, 54% female), n = 140 developed dementia and n = 471 died over 14 years of follow-up. Greater MIND score was associated with slower DunedinPACE and reduced risks for dementia and mortality. Slower DunedinPACE was associated with reduced risks for dementia and mortality. In mediation analysis, slower DunedinPACE accounted for 27% of the diet-dementia association and 57% of the diet-mortality association. INTERPRETATION: Findings suggest that slower pace of aging mediates part of the relationship of healthy diet with reduced dementia risk. Monitoring pace of aging may inform dementia prevention. However, a large fraction of the diet-dementia association remains unexplained and may reflect direct connections between diet and brain aging that do not overlap other organ systems. Investigation of brain-specific mechanisms in well-designed mediation studies is warranted. ANN NEUROL 2024;95:1069-1079.

Rising rural body-mass index is the main driver of the global obesity epidemic in adults.

Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities1,2. This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity3-6. Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.

Healthy dietary choices involve prefrontal mechanisms associated with long-term reward maximization but not working memory.

Taste and health are critical factors to be considered when choosing foods. Prioritizing healthiness over tastiness requires self-control. It has also been suggested that self-control is guided by cognitive control. We then hypothesized that neural mechanisms underlying healthy food choice are associated with both self-control and cognitive control. Human participants performed a food choice task and a working memory task during functional MRI scanning. Their degree of self-control was assessed behaviorally by the value discount of delayed monetary rewards in intertemporal choice. Prioritizing healthiness in food choice was associated with greater activity in the superior, dorsolateral, and medial prefrontal cortices. Importantly, the prefrontal activity was greater in individuals with smaller delay discounting (i.e. high self-control) who preferred a delayed larger reward to an immediate smaller reward in intertemporal choice. On the other hand, working memory activity did not show a correlation with delay discounting or food choice activity, which was further supported by supplementary results that analyzed data from the Human Connectome Project. Our results suggest that the prefrontal cortex plays a critical role in healthy food choice, which requires self-control, but not working memory, for maximization of reward attainments in a remote future.

Trends in Diet Quality Among U.S. Adults From 1999 to 2020 by Race, Ethnicity, and Socioeconomic Disadvantage.

BACKGROUND: Few data have assessed trends in diet quality among U.S. adults. OBJECTIVE: To evaluate trends in diet quality by race, ethnicity, and socioeconomic disadvantage. DESIGN: Repeated cross-sectional study. SETTING: United States. PARTICIPANTS: Noninstitutionalized adults aged 20 years or older who responded to the 1999-2020 National Health and Nutrition Examination Survey (NHANES). MEASUREMENTS: The proportion of participants meeting the targets of the validated American Heart Association (AHA) 2020 continuous diet score (based on higher intake of fruits, vegetables, whole grains, fish and shellfish, and nuts, seeds, and legumes and lower intake of sugar-sweetened beverages, processed meat, saturated fat, and sodium) and the Healthy Eating Index (HEI)-2015, and energy-adjusted consumption of their components and other individual food groups and nutrients. Poor diet was defined as less than 40% adherence to the AHA score, intermediate as 40% to 79.9% adherence, and ideal as at least 80% adherence. RESULTS: A total of 51 703 adults were included. From 1999 to 2020, the proportion of U.S. adults with poor diet quality decreased from 48.8% to 37.4% (difference, -11.4 percentage points [95% CI, -16.8 to -5.96 percentage points]), the proportion with intermediate quality increased from 50.6% to 61.1% (difference, 10.5 percentage points [CI, 5.20 to 16.1 percentage points]), and the proportion with ideal quality increased from 0.66% to 1.58% (difference, 0.93 percentage points [CI, 0.35 to 1.51 percentage points]) (P for trend < 0.001 for each). Persistent or worsening disparities in diet quality were observed by age, sex, race and ethnicity, education, income, food security, Supplemental Nutrition Assistance Program participation, and health insurance coverage. For example, the proportion of adults with poor diet quality decreased from 47.9% to 33.0% among those with food security (P for trend < 0.001) but did not change (51.3% to 48.2%) among those experiencing food insecurity (P for trend = 0.140) (P for interaction = 0.001). Findings were similar for HEI-2015. LIMITATIONS: Self-reported diet; cross-sectional study design. CONCLUSION: Diet quality among U.S. adults improved modestly between 1999 and 2020, but the proportion with poor diet quality remains high, and dietary disparities persist or are worsening. PRIMARY FUNDING SOURCE: National Institutes of Health.

Randomized 20-year infancy-onset dietary intervention, life-long cardiovascular risk factors and retinal microvasculature.

BACKGROUND AND AIMS: Retinal microvasculature characteristics predict cardiovascular morbidity and mortality. This study investigated associations of lifelong cardiovascular risk factors and effects of dietary intervention on retinal microvasculature in young adulthood. METHODS: The cohort is derived from the longitudinal Special Turku Coronary Risk Factor Intervention Project study. The Special Turku Coronary Risk Factor Intervention Project is a 20-year infancy-onset randomized controlled dietary intervention study with frequent study visits and follow-up extending to age 26 years. The dietary intervention aimed at a heart-healthy diet. Fundus photographs were taken at the 26-year follow-up, and microvascular measures [arteriolar and venular diameters, tortuosity (simple and curvature) and fractal dimensions] were derived (n = 486). Cumulative exposure as the area under the curve for cardiovascular risk factors and dietary components was determined for the longest available time period (e.g. from age 7 months to 26 years). RESULTS: The dietary intervention had a favourable effect on retinal microvasculature resulting in less tortuous arterioles and venules and increased arteriolar fractal dimension in the intervention group when compared with the control group. The intervention effects were found even when controlled for the cumulative cardiovascular risk factors. Reduced lifelong cumulative intake of saturated fats, main target of the intervention, was also associated with less tortuous venules. Several lifelong cumulative risk factors were independently associated with the retinal microvascular measures, e.g. cumulative systolic blood pressure with narrower arterioles. CONCLUSIONS: Infancy-onset 20-year dietary intervention had favourable effects on the retinal microvasculature in young adulthood. Several lifelong cumulative cardiovascular risk factors were independently associated with retinal microvascular structure.

Cardiovascular disease prevention in heterozygous familial hypercholesterolemia: how important is a healthy diet in the era of long-lasting cholesterol-lowering drug therapies?

PURPOSE OF REVIEW: This review aims to provide an in-depth perspective on the importance of diet for cardiovascular disease (CVD) prevention in heterozygous familial hypercholesterolemia (HeFH). RECENT FINDINGS: Even though data on diet and CVD prevention in HeFH are limited, the currently available evidence supports its cholesterol-lowering effect and its favorable association with CVD risk on the long-term. However, qualitative evidence from individuals with HeFH suggests that there is a common perception that diet is useless compared to medication, and this misconception serves as a barrier to healthy eating. On the other hand, evidence also suggests that individuals with HeFH are at higher risk of eating disorders compared with unaffected individuals. Family history of premature death and the chronic nature of the disease would be in cause. SUMMARY: Emphasizing a healthy diet needs to remain at the foundation of CVD prevention in HeFH. Evidence are limited but supportive of the cholesterol-lowering and cardioprotective potential effects of diet. Engaging in conversations about healthy dieting with individuals in HeFH is likely to help prevent misconceptions about diet. Additionally, it could help reduce the risk of eating disorders, which, altogether, is likely to improve overall CVD prevention.

Healthy dietary patterns and risk of prostate cancer in men at high genetic risk.

Prostate cancer has high heritability. Healthy lifestyle has been associated with lower lethal prostate cancer risk among men at increased genetic susceptibility, but the role of healthy dietary patterns remains unknown. We prospectively followed 10,269 genotyped men in the Health Professionals Follow-up Study (1993-2019). Genetic risk was quantified using an established polygenic risk score (PRS). Five dietary patterns were investigated: healthy eating index, Mediterranean, diabetes risk-reducing, hyperinsulinemic and inflammatory diet. Overall and lethal prostate cancer rates (metastatic disease/prostate cancer-specific death) were analyzed using multivariable Cox proportional hazards models. During 26 years of follow-up, 2133 overall and 253 lethal prostate cancer events were documented. In the highest PRS quartile, higher adherence to a diabetes risk-reducing diet was associated with lower rates of overall (top vs. bottom quintile HR [95% CI], 0.74 [0.58-0.94]) and lethal prostate cancer (0.43 [0.21-0.88]). A low insulinemic diet was associated with similar lower rates (overall, 0.76 [0.60-0.95]; lethal, 0.46 [0.23-0.94]). Other dietary patterns showed weaker, but similar associations. In the highest PRS quartile, men with healthy lifestyles based on body weight, physical activity, and low insulinemic diet had a substantially lower rate (0.26 [0.13-0.49]) of lethal prostate cancer compared with men with unhealthy lifestyles, translating to a lifetime risk of 3.4% (95% CI, 2.3%-5.0%) among those with healthy lifestyles and 9.5% (5.3%-16.7%) among those with unhealthy lifestyles. Our findings indicate that lifestyle modifications lowering insulin resistance and chronic hyperinsulinemia could be relevant in preventing aggressive prostate cancer among men genetically predisposed to prostate cancer.

An SMS chatbot digital educational program to increase healthy eating behaviors in adolescence: A multifactorial randomized controlled trial among 7,890 participants in the Danish National Birth Cohort.

BACKGROUND: Few cost-effective strategies to shift dietary habits of populations in a healthier direction have been identified. We examined if participating in a chatbot health education program transmitted by Short Messages Service ("SMS-program") could improve adolescent dietary behaviors and body weight trajectories. We also explored possible added effects of maternal or peer involvement. METHODS AND FINDINGS: We conducted a randomized controlled trial (RCT) among adolescents from the Danish National Birth Cohort (DNBC). Eligible were adolescents who during 2015 to 2016 at age 14 years had completed a questionnaire assessing height, weight, and dietary habits. Two thirds were offered participation in an SMS-program, whereas 1/3 ("non-SMS group") received no offer. The SMS program aimed to improve 3 key dietary intake behaviors: sugar-sweetened beverages (SSBs), fruit and vegetables (FV), and fish. The offered programs had 3 factorially randomized schemes; the aims of these were to test effect of asking the mother or a friend to also participate in the health promotion program, and to test the effect of a 4-week individually tailored SMS program against the full 12-week SMS program targeting all 3 dietary factors. Height and weight and intakes of SSB, FV, and fish were assessed twice by a smartphone-based abbreviated dietary questionnaire completed at 6 months (m) and 18 m follow-up. Main outcome measures were (1) body mass index (BMI) z-score; and (2) an abbreviated Healthy Eating Index (mini-HEI, 1 m window, as mean of z-scores for SSB, FV, and fish). Among the 7,890 randomized adolescents, 5,260 were assigned to any SMS program; 63% (3,338) joined the offered program. Among the 7,890 randomized, 74% (5,853) and 68% (5,370) responded to follow-ups at 6 m and 18 m, respectively. Effects were estimated by intention-to-treat (ITT) analyses and inverse probability weighted per-protocol (IPW-PP) analyses excluding adolescents who did not join the program. Mean (standard deviation (SD)) mini-HEI at baseline, 6 m and 18 m was -0.01 (0.64), 0.01 (0.59), and -0.01 (0.59), respectively. In ITT-analyses, no effects were observed, at any time point, in those who had received any SMS program compared to the non-SMS group, on BMI z-score (6 m: -0.010 [95% confidence interval (CI) -0.035, 0.015]; p = 0.442, 18 m: 0.002 [95% CI -0.029, 0.033]; p = 0.901) or mini-HEI (6 m: 0.016 [95% CI -0.011, 0.043]; p = 0.253, 18m: -0.016 [95% CI -0.045, 0.013]; p = 0.286). In IPW-PP analyses, at 6 m, a small decrease in BMI z-score (-0.030 [95% CI -0.057, -0.003]; p = 0.032) was observed, whereas no significant effect was observed in mini-HEI (0.027 [95% CI -0.002, 0.056]; p = 0.072), among those who had received any SMS program compared to the non-SMS group. At 18 m, no associations were observed (BMI z-score: -0.006 [95% CI -0.039, 0.027]; p = 0.724, and mini-HEI: -0.005 [95% CI -0.036, 0.026]; p = 0.755). The main limitations of the study were that DNBC participants, though derived from the general population, tend to have higher socioeconomic status than average, and that outcome measures were self-reported. CONCLUSIONS: In this study, a chatbot health education program delivered through an SMS program had no effect on dietary habits or weight trajectories in ITT analyses. However, IPW-PP-analyses, based on those 63% who had joined the offered SMS program, suggested modest improvements in weight development at 6 m, which had faded at 18 m. Future research should focus on developing gender-specific messaging programs including "booster" messages to obtain sustained engagement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02809196 https://clinicaltrials.gov/study/NCT02809196.

Improving lifestyle behaviors during chemotherapy for breast cancer: The Lifestyle, Exercise, and Nutrition Early After Diagnosis (LEANer) Trial.

BACKGROUND: Little is known about improving physical activity (PA) and diet during and after chemotherapy for breast cancer. This secondary analysis examines changes in PA and diet quality during a yearlong intervention for patients with breast cancer undergoing chemotherapy and evaluates factors associated with these changes. METHODS: Newly diagnosed patients with breast cancer (N = 173) undergoing chemotherapy were randomized to a year-long nutrition and exercise intervention (n = 87) or usual care (UC, n = 86). Mixed models compared 1-year changes in PA and diet quality via the Healthy Eating Index (HEI)-2015 by study arm. Among the intervention group, baseline factors associated with change in PA and diet were assessed with multivariable linear and logistic regression. RESULTS: At 1 year, compared with UC, the intervention arm increased PA more (mean difference = 136.1 minutes/week; 95% CI, 90.2-182.0), participated in more strength training (56% vs. 15%; p < .001), and had suggestive improvements in HEI-2015 (mean difference = 2.5; 95% CI, -0.3 to 5.3; p = .08). In the intervention arm, lower fatigue was associated with improved PA (p = .04) and higher education was associated with improved HEI-2015 (p = .001) at 1 year. Higher HEI-2015 (p = .04) and married/living with someone (p = .05) were associated with higher odds of participating in strength training at 1 year. CONCLUSIONS: This year-long lifestyle intervention for patients with breast cancer undergoing chemotherapy resulted in increases in PA and suggestive improvements in diet quality. Behavior change was associated with baseline fatigue, diet quality, education, and married/living with someone. Addressing these factors in interventions may improve uptake of lifestyle behaviors in trials during and after chemotherapy.

Reflecting on parental insights into healthy lifestyles: a qualitative study.

BACKGROUND: Children living in the most deprived regions are more than twice as likely as their affluent peers to be obese. One way we can explain the social gradient of health (determined by relative position on the scale of social disadvantage or advantage) is by identifying the barriers and drivers to health that different groups of people experience. This study explored the understanding and perceptions of (and barriers and drivers to) a healthy lifestyle to investigate how commissioned services can better support residents to enable behaviour change in an area of high social deprivation. This community engagement activity was also conducted to inform commissioning decisions in children's public health services. METHODS: We used a qualitative study design with a semi-structured interview schedule. Four focus groups (5-8 participants, n=26) were conducted in an area of high deprivation in northwest England. Parents or carers were invited to attend anonymously by the Public Health Community Engagement Officer (in June 2022). The inclusion criteria were previous attendance on a weight management programme. Data were analysed using thematic analysis. Engagement activities do not require ethics approval. All participants provided written informed consent to take part. No further information was collected about personal characteristics. FINDINGS: The study participants demonstrated an awareness and understanding of factors affecting child and family health and health behaviours: healthy eating, exercise, mental health and emotional wellbeing, family values and attitudes towards a healthy lifestyle, cooking and budgeting, wider social connections, access to open spaces, availability of local activities, costs (including hidden costs), and structural barriers. INTERPRETATION: Using the finding that participants recognise barriers and drivers to behaviour change beyond knowledge and skills, we reflect on why there was no take up for a commissioned intervention that aimed to address childhood obesity in the Lancashire area. These reflections inform arguments for an alternative model of service commission that relies less on established randomised trial evidence base and more on participatory codesign and a place-based approach (working with populations' existing knowledge and skills) and is particularly sensitive to people's own perception of the specific drivers and barriers they experience to behaviour change. Limitations include sampling from an area with low diversity and selection of participants who have previously agreed to uptake a weight management intervention. FUNDING: None.

Implementation of health-promoting retail initiatives in the Healthier Choices in Supermarkets Study-qualitative perspectives from a feasibility study.

BACKGROUND: Improving food environments like supermarkets has the potential to affect customers' health positively. Scholars suggest researchers and retailers collaborate closely on implementing and testing such health-promoting interventions, but knowledge of the implementation of such interventions is limited. We explore the implementation of four health-promoting food retail initiatives selected and developed by a partnership between a research institution, a large retail group, and a non-governmental organisation. METHODS: The four initiatives included downsizing of bags for pick'n' mix sweets and soda bottles at the check-out registers, shelf tags promoting healthier breakfast cereal options, and replacing a complimentary bun with a banana offered to children. The initiatives were implemented for 6 weeks (or longer if the store manager allowed it) in one store in Copenhagen, Denmark. Data were collected through observations, informal interviews with customers, and semi-structured interviews with retailers. We conducted a thematic analysis of transcripts and field notes inspired by process evaluation concepts and included quantitative summaries of selected data. RESULTS: Two out of four initiatives were not implemented as intended. The implementation was delayed due to delivery issues, which also resulted in soda bottles not being downsized as intended. The maintenance of the shelf tags decreased over time. Retailers expressed different levels of acceptability towards the initiatives, with a preference for the complimentary banana for children. This was also the only initiative noticed by customers with both positive and negative responses. Barriers and facilitators of implementation fell into three themes: Health is not the number one priority, general capacity of retailers, and influence of customers and other stakeholders on store operation. CONCLUSIONS: The retailers' interests, priorities, and general capacity influenced the initiative implementation. Retailers' acceptability of the initiatives was mixed despite their involvement in the pre-intervention phase. Our study also suggests that customer responses towards health-promoting initiatives, as well as cooperation with suppliers and manufacturers in the development phase, may be determining to successful implementation. Future studies should explore strategies to facilitate implementation, which can be applied prior to and during the intervention.

Are Dutch adults equally susceptible to nudging and pricing strategies? Secondary analyses of the Supreme Nudge parallel cluster-randomised controlled supermarket trial.

BACKGROUND: Supermarket interventions are promising to promote healthier dietary patterns, but not all individuals may be equally susceptible. We explored whether the effectiveness of nudging and pricing strategies on diet quality differs by psychological and grocery shopping characteristics. METHODS: We used data of the 12-month Supreme Nudge parallel cluster-randomised controlled supermarket trial, testing nudging and pricing strategies to promote healthier diets. Participants were Dutch speaking adults aged 30-80 years and regular shoppers of participating supermarkets (n = 12) in socially disadvantaged neighbourhoods. Data on psychological characteristics (food-related behaviours; price sensitivity; food decision styles; social cognitive factors; self-control) and grocery shopping characteristics (time spent in the supermarket; moment of the day; average supermarket visits; shopping at other retailers; supermarket proximity) were self-reported at baseline. These characteristics were tested for their moderating effects of the intervention on diet quality (scored 0-150) in linear mixed models. RESULTS: We included 162 participants from intervention supermarkets and 199 from control supermarkets (73% female, 58 (± 10.8) years old, 42% highly educated). The interventions had no overall effect on diet quality. Only five out of 23 potential moderators were statistically significant. Yet, stratified analyses of these significant moderators showed no significant effects on diet quality for one of the subgroups and statistically non-significant negative effects for the other. Negative effects were suggested for individuals with lower baseline levels of meal planning (ß - 2.6, 95% CI - 5.9; 0.8), healthy shopping convenience (ß - 3.0, 95% CI - 7.2; 1.3), and healthy food attractiveness (ß - 3.5, 95% CI - 8.3; 1.3), and with higher levels of price consciousness (ß - 2.6, 95% CI - 6.2; 1.0) and weekly supermarket visits (ß - 2.4, 95% CI - 6.8; 1.9). CONCLUSIONS: Adults with varying psychological and grocery shopping characteristics largely seem equally (un)susceptible to nudging and pricing strategies. It might be that certain characteristics lead to adverse effects, but this is not plausible, and the observed negative effects were small and statistically non-significant and may be explained by chance findings. Verification of these findings is needed in real-world trials based on larger sample sizes and with the use of more comprehensive interventions. TRIAL REGISTRATION: Dutch Trial Register ID NL7064, 30th of May, 2018, https://onderzoekmetmensen.nl/en/trial/20990.

The Future of Plant-Based Diets: Aligning Healthy Marketplace Choices with Equitable, Resilient, and Sustainable Food Systems.

The future of plant-based diets is a complex public health issue inextricably linked to planetary health. Shifting the world's population to consume nutrient-rich, plant-based diets is among the most impactful strategies to transition to sustainable food systems to feed 10 billion people by 2050. This review summarizes how international expert bodies define sustainable diets and food systems and describes types of sustainable dietary patterns. It also explores how the type and proportion of plant- versus animal-source foods and alternative proteins relate to sustainable diets to reduce diet-related morbidity and mortality. Thereafter, we synthesize evidence for current challenges and actions needed to achieve plant-based sustainable dietary patterns using a conceptual framework with principles to promote human health, ecological health, social equity, and economic prosperity. We recommend strategies for governments, businesses, and civil society to encourage marketplace choices that lead to plant-rich sustainable diets within healthy, equitable, and resilient agroecological food systems.

Assessing and Monitoring Nutrition Security to Promote Healthy Dietary Intake and Outcomes in the United States.

The US Department of Agriculture's Economic Research Service leads the federal government in data development and research on food security in US households. Nutrition security is an emerging concept that, although closely related, is distinct from food security. No standard conceptualization or measure of nutrition security currently exists. We review the existing research on nutrition security and how it is informed by the more robust literature on food security and diet quality. Based on this review, we propose a conceptual framework for understanding nutrition security and its relationship to food security. We identify two constructs (healthy diets and nutritional status) and multiple subconstructs that form the basis of nutrition security. The proposed framework and corresponding constructs are intended to provide (a) understanding of how nutrition security arises and how it differs from food security, (b) background on why assessment and monitoring of nutrition security is important, and (c) guidance for a research agenda that will further clarify the meaning of nutrition security and its measurement.