Are novel plant-based meat alternatives the healthier choice?

The global market for plant-based meat alternatives (PBMAs) is expanding quickly. In this narrative review, analysis of the most recent scientific literature was achieved to understand the nutritional profile, health implications, and the challenges faced by PBMAs. On the positive side, most PBMAs are good sources of dietary fiber, contain phytochemicals, have comparable levels of iron, and are lower in calories, saturated fat, and cholesterol than meat. However, PBMAs frequently contain anti-nutrients, have less protein, iron, and vitamin B12, are lower in protein quality, and also have higher amounts of sodium. Substituting PBMAs for meats may cause iron, vitamin B12, and less likely protein deficiency for these vulnerable population such as women, older adults, and individuals with disorders. PBMAs fall into the category of ultra-processed foods, indicating a need to develop minimally processed, clean-label products. Replacing red meat with healthy plant-based foods is associated with lower risks of cardiovascular diseases, type 2 diabetes, and total mortality. There is a lack of robust, long-term evidence on the role of PBMAs consumption in health. As the nutrient contents of PBMAs can vary, consumers must read nutrition facts labels and ingredient lists to select a product that best fits their nutritional and health objectives.

"We know what we should be eating, but we don't always do that." How and why people eat the way they do: a qualitative study with rural australians.

BACKGROUND: There is evidence that most people are aware of the importance of healthy eating and have a broad understanding regarding types of food that enhance or detract from health. However, greater health literacy does not always result in healthier eating. Andreasen's Social Marketing Model and Community-Based Social Marketing both posit that, in order to change health behaviours, it is crucial to understand reasons for current behaviours and perceived barriers and benefits to improved behaviours. Limited research has been conducted, however, that explores these issues with general populations. This study aimed to help address this gap in the evidence using a qualitative methodology. METHODS: Three group discussions were conducted with a total of 23 participants: (1) young women aged 18-24 with no children; (2) women aged 35-45 with primary school aged children; and (3) men aged 35-50 living with a partner and with pre- or primary school aged children. The discussions took place in a regional centre of Victoria, Australia. Transcriptions were thematically analysed using an inductive descriptive approach and with reference to a recent integrated framework of food choice that identified five key interrelated determinants: food- internal factors; food- external factors; personal-state factors; cognitive factors; and sociocultural factors. RESULTS: We found that food choice was complex, with all five determinants evident from the discussions. However, the "Social environment" sub-category of "Food-external factors", which included family, work, and social structures, and expectations (or perceived expectations) of family members, colleagues, friends, and others, was particularly prominent. Knowledge that one should practice healthy eating, which falls under the "Cognitive factor" category, while seen as an aspiration by most participants, was often viewed as unrealistic, trumped by the need and/or desire for convenience, a combination of Food-external factor: Social environment and Personal-state factor: Psychological components. CONCLUSIONS: We found that decisions regarding what, when, and how much to eat are seen as heavily influenced by factors outside the control of the individual. It appears, therefore, that a key to improving people's eating behaviours is to make it easy to eat more healthfully, or at least not much harder than eating poorly.

Benchmarking the university campus food environment and exploring student perspectives about food insecurity and healthy eating: a case study from Australia.

OBJECTIVE: To benchmark the university food environment and explore students' experiences with food insecurity and healthy eating in order to inform interventions to improve access and affordability of healthy foods for university students. DESIGN: A food environment audit was conducted on the university campus using the Uni-Food tool from April to May 2022 and was comprised of three main components, university systems and governance, campus facilities and environment, and food retail outlets. A qualitative study design was also used to conduct focus groups and semi-structured interviews with students to explore key themes regarding their experiences with food insecurity and healthy eating. SETTING: Macquarie University, Australia. PARTICIPANTS: For the food environment audit 24 retail outlets on campus and for the qualitative component 29 domestic and international students enrolled at Macquarie University. RESULTS: The university only scored 27% in total for all components in the food environment audit. The results showed the need for better governance and leadership of the food environment. The qualitative component suggested that the main barriers to accessing healthy foods were related to availability, pricing, and knowledge of healthy foods. Future intervention ideas included free fruits and vegetables, food relief, discounts, improved self-catering facilities, education, and increased healthy food outlets. CONCLUSIONS: Improving governance measures related to healthy eating on campus are a core priority to strengthen the food environment and students identified pricing and availability as key issues. These findings will inform effective and feasible interventions to improve food security and healthy eating on campus.

Spatial Barriers to Transforming toward a Healthy Food System in the Noreste of Mexico.

In the past five decades, global food systems have undergone a notable transition, moving from predominantly rural settings to increasingly urban and industrialized environments, largely driven by processes of globalization and supply chain integration. However, this evolution has not adequately addressed equitable access to nutritious diets and food environments, resulting in adverse health outcomes. This study delves into the spatial and non-spatial barriers that impede the adoption of healthy diets in the Noreste of Mexico, particularly focusing on the challenges associated with accessing and cultivating plant-based foods. Through an examination of suitable areas for urban agriculture and an exploration of the socio-cultural factors influencing the adoption of plant-based diets, the research focuses on interventions aimed at promoting healthier and more sustainable eating practices in Monterrey. The findings of the study reveal significant disparities in food access across the Monterrey metropolitan area, with central urban zones exhibiting superior access to fresh foods compared to suburban and peripheral regions. This inequality disproportionately affects marginalized areas characterized by higher poverty rates, exacerbating issues of food insecurity. Nevertheless, traditional dietary practices could offer promising avenues for creating culturally significant and healthier dietary transitions, even amidst the ongoing process of urbanization.

Sociodemographic Trends in Planetary Health Diets among Nutrition Students in Türkiye: Bridging Classroom to Kitchen.

This study aimed to investigate the effects of sociodemographic parameters on healthy and sustainable nutrition in nutrition students. This cross-sectional study was conducted with 601 students. Researchers administered questionnaire forms to gather sociodemographic information such as age, gender, geographical region, residence area, accommodation, BMI, and income level. Participants' 24 h dietary records were used to evaluate Healthy Eating Index-2020 (HEI-2020) and Planetary Health Diet Index (PHDI). The mean PHDI scores of the Marmara (53.4 ± 14.9), Aegean (58.2 ± 18.3), Mediterranean (55.3 ± 15.5), and Black Sea (55.5 ± 15.7) regions, which are the coastal regions of Türkiye, were significantly higher than for the Central Anatolia region (46.7 ± 15.1). The PHDI and HEI-2020 score means of students living in metropolitan cities and rural areas were significantly higher than those living in urban areas (p < 0.05). Being in the 20-25 years age group increased the probability of being in a lower PHDI group (AOR 1.82; 95% CI 1.07:3.12; p = 0.028). While a similar result was found in the 20-25 years age group for HEI-2020, income level and gender did not have a statistically significant effect on these scores. Since students' ages, geographical regions, and residence areas affect PHDI and HEI-2020, it is considered important to take these sociodemographic variables into consideration in guidelines and studies.

Social Media for Nutrition Education-A Randomized Controlled Trial to Promote Fruit and Vegetable Intake in a University Setting: "The University of Valladolid Community Eats Healthy" Study.

Social media- and internet-based interventions are nowadays widely used tools in health interventions. Although evidence of their effectiveness is still low, their applications could be very promising due to their affordability and wide reach. The current paper aims to evaluate the effectiveness of an intervention program, "The University of Valladolid Community Eats Healthy" (UVEH), to increase fruit and vegetable (FV) intake in adults from the University of Valladolid (U. Valladolid) employing three online methodologies. A sample of 211 volunteers was randomly assigned into four groups: virtual campus (VC), Facebook (FB), Instagram (IG), and control. An intervention based on the Theory of Planned Behavior was implemented for seven weeks. Data were collected at the beginning (T0) and the end of the program (T1). The Predimed questionnaire was employed to assess FV intake. Vegetable intake was statistically significantly higher in the VC group (17.4% pre vs. 72.7% post). In the rest of the groups, there was also an increase in intake. Fruit consumption increased slightly only in the VC group (23.9% pre vs. 45.5% post). Participation decreased through the weeks: FB (week 2), IG (week 3), and VC (week 4). Retention was higher in the VC (48%) and control (60%) groups. Internet-based interventions employing interactive platforms such as virtual campus can be effective in enhancing participants' dietary habits in a clinically relevant manner.

The Role of Diet in the Cardiovascular Health of Childhood Cancer Survivors-A Systematic Review.

BACKGROUND: Childhood cancer survivors (CCSs) face an increased risk of cardiovascular disease (CVD). This systematic review aims to provide the first synthesis of observational and interventional studies on the relationship between diet and cardiovascular health in CCSs. METHODS: A comprehensive search was conducted for studies published between 1990 and July 2023 in PubMed, MEDLINE, CINAHL, Child Development & Adolescent Studies, and Cochrane Library. Eligible studies included observational and interventional studies examining the associations or effects of dietary factors on CVD incidence, cardiac dysfunction, or CVD risk factors in CCSs diagnosed before age 25 years. RESULTS: Ten studies met the inclusion criteria (nine observational and one interventional). Collectively, they comprised 3485 CCSs (male, 1734; female, 1751). The outcomes examined across observational studies included characteristics of obesity, diabetes biomarkers, hypertension indicators, dyslipidaemia biomarkers, and metabolic syndrome. The evidence suggested that greater adherence to healthy diets was associated with lower body mass index, blood pressure, glucose, and triglycerides and higher high-density lipoprotein cholesterol. The 12-week lifestyle intervention study in childhood leukaemia survivors found no impact on obesity indicators. CONCLUSION: The review results indicate the potentially protective effects of healthy diets. However, the available research remains preliminary and limited, underscoring the need for more rigorous, adequately powered studies.

What Is Considered Healthy Eating? An Exploratory Study among College Students of Nutrition and Food Science.

In modern industrialized societies, the focus on healthy eating has increased significantly across multiple sectors, including the media, public policy, expert opinion, and public awareness. The aim of this research was to explore the perceptions of healthy eating and the barriers to adopting a healthy diet among undergraduate students in Human Nutrition and Dietetics (HND) and Food Science and Technology (FST) degrees in Spain. An exploratory and descriptive cross-sectional study was conducted using a qualitative and quantitative methodology and convenience sampling. Two focus groups and a questionnaire were utilized (300 participants from all academic years completed the survey). Differences in definitions of healthy eating and perceived barriers were found between genders and students at different stages of training (p < 0.05). In their understanding of healthy eating, the students placed importance on balance, variety, moderation, and individual factors. Although students considered it easy to follow a healthy diet, family's eating habits, time availability, and emotional states were found to be the main barriers to the implementation of healthy practices. The obtained data supports the need to critically address perceptions of healthy eating throughout the training of nutrition and food science professionals. The insights obtained on the perceived barriers highlight the importance of considering both individual and environmental factors.

Ecdysterone and Turkesterone-Compounds with Prominent Potential in Sport and Healthy Nutrition.

The naturally occurring compounds ecdysterone and turkesterone, which are present in plants, including Rhaponticum carthamoides Willd. (Iljin), Spinacia oleracea L., Chenopodium quinoa Willd., and Ajuga turkestanica (Regel) Briq, are widely recognized due to their possible advantages for both general health and athletic performance. The current review investigates the beneficial biological effects of ecdysterone and turkesterone in nutrition, highlighting their roles not only in enhancing athletic performance but also in the management of various health problems. Plant-based diets, associated with various health benefits and environmental sustainability, often include sources rich in phytoecdysteroids. However, the therapeutic potential of phytoecdysteroid-rich extracts extends beyond sports nutrition, with promising applications in treating chronic fatigue, cardiovascular diseases, and neurodegenerative disorders.

Evaluation of the Effect of Parenting Style and Parental Mealtime Actions on the Eating Behavior of Children with Epilepsy.

BACKGROUND: Research on the interaction of parenting style, parents' mealtime behaviors, and children's eating behavior in the presence of chronic disease is limited. This study aimed to investigate the impact of parenting style and parental mealtime actions on the eating behavior of children with epilepsy. METHODS: Thirty-one children with epilepsy, thirty-one healthy children (aged 4-9 years), and their parents were included. The Multidimensional Assessment of Parenting Scale (MAPS), Parent Mealtime Action Scale, Children's Eating Behavior Questionnaire, and Healthy Eating Index (HEI)-2015 were applied. The MAPS, HEI-2015 scores, and body mass index for age Z scores were similar in both groups (p > 0.05). In the epilepsy group, the food approach behavior score was higher, and positive correlations were noted between broadband negative parenting and food approach behavior, and the HEI-2015 score and broadband positive parenting (p < 0.05). Regression analysis showed that broadband negative parenting and snack modeling increased the food approach behavior in the epilepsy group. Owing to the chronic disease, the effects of parent-child interaction on the child's eating behavior in the epilepsy group differed from those of healthy children reported in the literature.

Effect of Sustainably Sourced Protein Consumption on Nutrient Intake and Gut Health in Older Adults: A Systematic Review.

Diet is integral to the healthy ageing process and certain diets can mitigate prolonged and deleterious inflammation. This review aims to assess the impact of diets high in sustainably sourced proteins on nutrient intake, gut, and age-related health in older adults. A systematic search of the literature was conducted on 5 September 2023 across multiple databases and sources. Studies assessing sustainably sourced protein consumption in community dwelling older adults (≥65 years) were included. Risk of bias (RoB) was assessed using 'RoB 2.0' and 'ROBINS-E'. Narrative synthesis was performed due to heterogeneity of studies. Twelve studies involving 12,166 older adults were included. Nine studies (n = 10,391) assessed habitual dietary intake and had some RoB concerns, whilst three studies (n = 1812), two with low and one with high RoB, conducted plant-based dietary interventions. Increased adherence to sustainably sourced diets was associated with improved gut microbial factors (n = 4640), healthier food group intake (n = 2142), and increased fibre and vegetable protein intake (n = 1078). Sustainably sourced diets positively impacted on gut microbiota and healthier intake of food groups, although effects on inflammatory outcomes and health status were inconclusive. Future research should focus on dietary interventions combining sustainable proteins and fibre to evaluate gut barrier function and consider inflammatory and body composition outcomes in older adults.

The design and development of a dashboard for improving sustainable healthy food choices.

Over the last decade, several digital tools have been designed to provide consumers with nutritional and environmental impact information about their food choices post-consumption. Many of these tools lack behavioral change modules, have low user engagement, and ignore inherent environmental nutrition trade-offs to stimulate dietary change. This study presents the design and development of a decision support system to enhance consumer health while meeting sustainability goals from a pre-consumption perspective. The proposed decision support system, Dashboard for Improving Sustainable Healthy (DISH) food choices, employs behavioral features, traffic light labels, and nudges to inform end-users about the nutritional health performance and environmental impact of meals. DISH uses a simple metric that allows end-users to explore the potential minutes of healthy and productive life gained or lost from consuming 100 kcal of a meal. The metric combines the positive or negative nutritional health effects (µ-DALYs) of consuming a meal and environmental damage (endpoint impact expressed in DALYs) on human health. In the DISH application, end-users are rewarded or deducted EnCoins, which represent the number of silver or gold coins lost or gained based on the cost ($) of environmental damage (midpoint impacts) of a meal compared to reference sustainable healthy and unsustainable and unhealthy meal. DISH's gamification module enables end-users to track the potential minutes of healthy and productive life gained/lost and gold or silver rewards or deductions from consuming 100 kcal of a selected meal through cumulative minutes gained or lost and EnCoins. In promoting a sustainable diet culture, the gamification module enables users to create groups and communities where friends and families can track their sustainability performance through meal decisions. The DISH application is currently available online and can be accessed by an end-user through any device. Further pilot studies will focus on testing the technology in partner campus cafeterias.

Factors associated with food label use: focus on healthy aspects of orthorexia and orthorexia nervosa.

PURPOSE: This study aimed to investigate the potential relationships between the use of different section of food label, and healthy and pathological aspects of orthorexia among adults. METHODS: This cross-sectional study was conducted using an online survey (n = 1326). Inclusion criteria were being 19-64 years and graduated from at least primary school. Pregnant and lactating women were excluded. Data were collected using questionnaire including socio-demographic variables, lifestyle factors, body weight and height, frequency of reading different sections of food label ("always", "when buying a food for the first time", "when comparing similar packaged foods", "rarely", "never"), food label literacy, and Teruel Orthorexia Scale. Participants were categorized as nutrition facts panel-users, ingredients list-users or claim-users if they read at least one item from the relevant parts. RESULTS: The proportions of nutrition facts, ingredients list, and claims sections users were 72.3%, 76.3%, and 79.9%, respectively. Both healthy and pathological aspects of orthorexia were associated with reading food labels. The healthy orthorexia had the strongest association with using the ingredients list (OR 1.76, 95% CI 1.41-2.20), whereas the orthorexia nervosa showed the highest association with using nutrition facts panel (OR 1.48, 95% CI 1.20-1.81). While women, physically active participants and those with higher food label literacy were more likely to use all sections of food labels; older age, having children, and chronic disease increased the likelihood of using claims and ingredients list (p < 0.05). Besides, following a diet was associated with higher use of nutrition facts and ingredients list (p < 0.05). CONCLUSIONS: The study demonstrates that food label users have higher orthorexia tendencies compared to non-users. Of the food label sections, healthy orthorexia showed the strongest association with use of the list of ingredients, while pathological orthorexia showed the strongest association with use of the nutrition facts panel. LEVEL OF EVIDENCE: Level V, cross-sectional study.

Diet quality as assessed by the healthy eating index-2020 among different smoking status: an analysis of national health and nutrition examination survey (NHANES) data from 2005 to 2018.

BACKGROUND: Combining smoking with poor eating habits significantly elevates the risk of chronic illnesses and early death. Understanding of how dietary quality shifts post-smoking cessation remains limited. The objective of this study is to examine dietary quality - using Healthy Eating Index (HEI - 2020) and its 13 components, among current, former, and never smokers, and particularly the impact of quitting and the duration of cessation on dietary habits. METHODS: A cross-sectional analysis of 31,569 adults from the National Health and Nutrition Examination Survey (NHANES) 2005-2018 was conducted. Dietary quality was assessed using HEI-2020 scores, which were determined by NIH developed - simple HEI scoring algorithm per person. Smoking status was categorized into current, former, and never smokers, with further subdivisions for current (heavy/light smokers) and former smokers (duration post-cessation). Descriptive analysis and multiple regression models weighted to represent the US population were performed. RESULTS: The current smoking rate was 19.4%, with a higher prevalence in males (22.5%) than females (17.5%). Current smokers reported statistically significantly lower HEI total score than both former and never smokers. Former smokers exhibited HEI scores similar to those of never smokers. The adjusted HEI total scores for current, former, and never smokers were 49.2, 54.0, and 53.3, respectively, with a statistically significant difference (p < 0.001). Moreover, light smokers had better total HEI score than heavy smokers (46.8 vs. 50.8, p < 0.001, respectively), but former and never smokers scored even higher. Quitting smoking immediately improved dietary quality, with former smokers reaching the dietary levels of never smokers within 5-10 years (53.8 vs. 53.3, p > 0.05, respectively). Compared to current smokers, former smokers tended to consume more beneficial foods (e.g., fruits, vegetables, greens and beans, whole grains, proteins, and fatty acids), while also consuming more sodium and less added sugar. CONCLUSIONS: Current smokers, particularly heavy smokers, exhibit poorer dietary habits than former and never smokers. The dietary quality of former smokers aligns with never smokers over time, highlighting the positive impact of smoking cessation on diet. This has implications for reducing chronic disease risks associated with poor diet and smoking.

The association between healthy eating index-2015 with anthropometric, cardiometabolic and hepatic indices among patients with non-alcoholic fatty liver disease.

BACKGROUND: Obesity, cardiovascular diseases, and metabolic disorders are common problems among participants with non-alcoholic fatty liver disease (NAFLD). However, the association between these problems and the healthy eating index-2015 (HEI-2015) remains unknown. Although the HEI-2015 originated from American dietary guidelines, its comprehensive evaluation of diet quality provides valuable insights for various populations, including Iranians. Therefore, the objective of this study was to investigate the association between anthropometric, hepatic, and cardio-metabolic indices with HEI-2015 scores in participants with NAFLD. METHODS: We conducted a cross-sectional analysis of data from the Hoveyzeh Cohort Study, which included adults aged 35 to 70 years between 2016 and 2018. A total of 664 participant with NAFLD (452 females and 212 males) were included in the analysis. The HEI-2015 was assessed using the Food Frequency Questionnaire (FFQ). Various indices, including the body shape index (ABSI), atherogenic index of plasma (AIP), visceral adiposity index (VAI), lipid accumulation product (LAP), cardiometabolic index (CMI), lipoprotein combine index (LCI), AST/ALT ratio, ALD/NAFLD index, and hepatic steatosis index (HSI), were calculated. RESULTS: No significant differences were observed in anthropometric, cardio-metabolic, and hepatic indices across the quartiles of HEI-2015. However, among participants with NAFLD, men had significantly higher AIP and LCI levels, while women had significantly higher BMI, ABSI, VAI, LAP, and CMI levels. Additionally, women with NAFLD exhibited higher AST/ALT and HSI levels but lower ALD/NAFLD levels compared to men with NAFLD. Linear regression analysis among men with NAFLD revealed a significant negative correlation between HEI-2015 score and HSI in both the unadjusted model (ß=-0.131, SE = 0.058, p = 0.024) and the adjusted model for energy intake (ß=-0.129, SE = 0.058, p = 0.028). CONCLUSION: The present study demonstrated a correlation between lower HEI-2015 scores and an increased risk of steatosis in men with NAFLD. Moreover, our findings highlighted gender-related differences in NAFLD and cardio-metabolic disorders.

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.

Perceptions and self-management of a healthy diet among middle-aged adults with risk of stroke in North China: a qualitative exploration.

OBJECTIVE: Although stroke is prevalent among older people, there is a rising incidence among the younger subpopulations, particularly middle-aged adults. A healthy diet is one of the key modifiable factors to primary prevention of stroke among these subpopulations, yet there is limited understanding of the dietary habits among middle agers who have the risk factor(s) but no occurrence of stroke. This study aims to explore the views on perceptions and the self-management of middle-aged adults at risk of stroke on a healthy diet and to identify the enablers and barriers that could inform the future development of dietary interventions. DESIGN: This study used an interpretive descriptive qualitative design, employing semistructured purposive sampling for focus group discussions. Thematic analysis was conducted on the transcribed interviews and field notes, facilitated by NVivo 12.0 Plus software. SETTING: Community settings in Zhengzhou City, Henan Province. PARTICIPANTS: Middle-aged adults (aged 45-59) were identified as at risk of stroke due to the presence of one or more modifiable risk factors. RESULT: A total of seven focus group discussions were audio recorded. Four main themes emerged, which were: (1) cognitive understanding of a healthy diet; (2) dietary practices; (3) knowledge acquisition and (4) barriers to dietary adherence. CONCLUSIONS: The middle-aged adults at risk of stroke were generally aware of the risk and attempted to practise healthy eating. The existing educational programmes on following a healthy diet in the prevention of disease need to be made more comprehensible, accessible and equitable, especially for those from socioeconomically disadvantaged communities.

Interventions to prevent obesity in children aged 12 to 18 years old.

BACKGROUND: Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review. OBJECTIVES: To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was February 2023. SELECTION CRITERIA: Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect. AUTHORS' CONCLUSIONS: The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Interventions to prevent obesity in children aged 5 to 11 years old.

BACKGROUND: Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review. OBJECTIVES: To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was February 2023. SELECTION CRITERIA: Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability. AUTHORS' CONCLUSIONS: The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.