Effects of a lifestyle intervention on cardiovascular risk factors in systemic lupus erythematosus patients: The study "Living well with lupus".

OBJECTIVE: The aim of the present study was to investigate the effects of a lifestyle intervention on cardiometabolic risk factors in patients with systemic lupus erythematosus with a high cardiovascular risk profile. METHODS: This trial was conducted in Sao Paulo, Brazil between August 2020 and March 2023. The patients were randomly assigned to lifestyle intervention or control. The intervention was a 6-month multifaced program focused on behavioral changes through personalized recommendations for increasing physical activity (structured and non-structured) and improving eating aspects. Cardiometabolic risk score (primary outcome), anthropometry and visceral fat, aerobic capacity, blood pressure, inflammatory and oxidative stress markers, and blood flow and endothelial function were assessed before and after the intervention. RESULTS: A total of 80 patients were randomized. Twelve and 6 patients dropped out due to personal reasons in the intervention and control groups, respectively. Average adherence rate for the intervention was 56.9%. Intention-to-treat analysis showed no significant difference between groups in the cardiometabolic risk score (intervention group - Pre: 1.7 ± 3.6; Post: -1.6 ± 4.0; control group - Pre: -1.9 ± 3.6; Post: -2.0 ± 3.8; estimated mean difference between groups at post: -0.4; 95% confidence intervals: -2.7; 1.9; p = 0.96). This finding was confirmed by exploratory, per-protocol analysis. No significant differences were observed between adherents vs. non-adherent participants. Secondary outcomes did not change between groups. CONCLUSION: This 6-month, individualized, lifestyle intervention did not improve cardiovascular risk factors in SLE patients with a high cardiovascular risk profile. TRIAL REGISTRATION: clinicaltrials.gov (NCT04431167).

Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review.

PURPOSE: To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN). METHODS: This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS). RESULTS: Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies. CONCLUSION: All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.

No Associations Between Physical Activity and Immunogenicity in SARS-CoV-2 Seropositive Patients With Autoimmune Rheumatic Diseases Prior to and After Vaccination.

AIM: To investigate the association between physical activity and immunogenicity among SARS-CoV-2 seropositive patients with autoimmune rheumatic diseases prior to and following a 2-dose schedule of CoronaVac (Sinovac inactivated vaccine). METHODS: This was a prospective cohort study within an open-label, single-arm, phase 4 vaccination trial conducted in Sao Paulo, Brazil. In this substudy, only SARS-CoV-2 seropositive patients were included. Immunogenicity was assessed by seroconversion rates of total anti-SARS-CoV-2 S1/S2 immunoglobulin G (IgG), geometric mean titers of anti-S1/S2 IgG, frequency of positive neutralizing antibodies, and neutralizing activity before and after vaccination. Physical activity was assessed through a questionnaire. Model-based analyses were performed controlling for age (<60 or ≥60 y), sex, body mass index (<25, 25-30, and >30 kg/m2), and use of prednisone, immunosuppressants, and biologics. RESULTS: A total of 180 seropositive autoimmune rheumatic disease patients were included. There was no association between physical activity and immunogenicity before and after vaccination. CONCLUSIONS: This study suggests that the positive association between physical activity and greater antibody responses seen in immunocompromised individuals following vaccination is overridden by previous SARS-CoV-2 infection, and does not extend to natural immunity.

Food consumption based on processing level (according to Nova system) during the COVID-19 pandemic among adolescents with immunocompromised conditions: a case-control study.

The COVID-19 pandemic impacts on eating habits among adolescents may be more relevant in pediatric patients with immunocompromised chronic diseases. This case-control study conducted between June and October 2020 aimed to: (i) describe dietary patterns of adolescents with chronic conditions compared to healthy controls and (ii) determine associations between food consumption, health-related quality of life (HRQL) and sleep quality during the COVID-19 pandemic. Participants (184 immunocompromised and 58 healthy adolescents, aged 14.3 [SD 2.5]) responded to HRQL and sleep validated instruments (PedsQL and PSQI) and three 24 h food recalls via online software. Adjusted linear and logistic regressions were used to assess differences in dietary patterns and associations between food consumption (according to Nova classification) and HRQL and sleep quality. Adolescents with gastrohepatic, rheumatic, and kidney diseases had an improved dietary pattern vs. their healthy peers, showing greater consumption of unprocessed and minimally processed foods (unstandardized coefficient (b) = 7.35%[95%CI 1.59; 13.1]; b = 15.10%[95%CI 7.00; 23.1]; and b = 11.2%[95%CI 5.68; 16.8]), and lower consumption of ultraprocessed foods (b = -7.53%[95%CI-12.90; -2.18]; b = -11.4%[95%CI-18.90; -3.94]; b = -10.8%[95%CI-16.00; -5.68]). Consumption of culinary ingredients was associated with reduced psychological HRQL in controls (standardized coefficient (ß) = -0.26[95%CI-0.52; -0.004]), and processed food consumption was associated with improved sleep latency in immunocompromised participants (ß = 0.16[95%CI 0.01; 0.31]). These findings suggest diet quality may play a role in HRQL and sleep quality in this population, and may be relevant for clinical practitioners and policy makers when considering the importance of dietary quality in immunocompromised youths.

Disordered Eating Attitudes and Food Choice Motives Among Individuals Who Follow a Vegan Diet in Brazil.

Importance: It remains controversial whether adhering to a vegan diet may be associated with a higher prevalence of disordered eating. Also, main food choice motives and their association with disordered eating in this population are still unknown. Objective: To determine the association between disordered eating attitudes and food choice motives of individuals who follow a vegan diet. Design, Setting, and Participants: This is a cross-sectional online survey conducted between September 2021 and January 2023. Individuals of both sexes, aged 18 years or older, following a vegan diet for at least 6 months, currently living in Brazil were recruited through advertisements on social media. Exposure: Adherence to a vegan diet and food choice motives. Main Outcomes and Measures: Disordered eating attitudes and food choice motives. Results: Nine hundred seventy-one participants completed the online survey. Median (IQR) age and BMI of participants was 29 (24-36) years and 22.6 (20.3-24.9), respectively, and 800 participants (82.4%) were female. Most participants (908 respondents [94%]) were categorized with the lowest level of disturbed eating attitudes. "Need and hunger," "liking," "health," "habits," and "natural concerns" were the most important food choice motives in this population, while "affect regulation," "social norms," and "social image" were the less important ones. Adjusted models showed that "liking," "need and hunger," and "health" were associated with lower levels of disordered eating attitudes, while "price," "pleasure," "sociability," "traditional eating," "visual appeal," "social norms," "social image," "weight control," and "affect regulation" were associated with higher levels of disordered eating attitudes. Conclusions and Relevance: In this cross-sectional study, as opposed to previous suggestions, levels of disordered eating were very low among vegans, although certain food choice motives were associated with disordered eating attitudes. Understanding the motivations of adhering to diets that may impose restrictions, which include vegan diets, may help tailor interventions focused on promoting healthy eating and preventing or treating disordered eating.

A randomized controlled trial of an intervention promoting physical activity and healthy eating recommendations in systemic lupus erythematosus: the protocol study "Living Well with Lupus".

There is a paucity of studies assessing multidisciplinary interventions focused on tackling physical inactivity/sedentary behavior and poor dietary habits in SLE. The Living well with Lupus (LWWL) is a randomized controlled trial to investigate whether a six-month lifestyle change intervention will improve cardiometabolic risk factors (primary outcome) among systemic lupus erythematosus (SLE) patients with low disease activity (SLEDAI score ≤ 4) and with high cardiovascular risk. As secondary goals, we will evaluate: (1) the intervention's safety, efficacy, and feasibility in promoting lifestyle changes, and (2) the effects of the intervention on secondary outcomes (i.e., clinical parameters, functional capacity, fatigue, psychological aspects, sleep quality and health-related quality of life). Patients will be randomly allocated to either a control (i.e., standard care) or a lifestyle intervention group using a simple randomization (1:1 ratio, blocks of 20). Mixed Model analyses will be conducted for comparing groups following an intention-to-treat approach. A per protocol analysis will also be conducted. This study has the potential to generate new, clinically relevant data able to refine the multidisciplinary management of SLE patients. Protocol version number: NCT04431167 (first version).

Dietary ß-Alanine Intake Assessed by Food Records Does Not Associate With Muscle Carnosine Content in Healthy, Active, Omnivorous Men and Women.

ß-Alanine (BA) is one of the most widely used sport supplements, due to its capacity to improve high-intensity exercise performance by increasing muscle carnosine (MCarn) content, and consequently, the buffering capacity of the muscle. BA is also available in a variety of animal foods, but little is currently known about the influence of dietary BA intake on MCarn. The aim of the current study was to compile a detailed summary of available data on the BA content of commonly consumed foods, and to explore whether associations could be detected between self-reported dietary BA intake and skeletal MCarn in a group of 60 healthy, active, omnivorous men and women. Dietary BA intake was assessed via 3-day food records, and MCarn content assessed by high-performance liquid chromatography. A series of univariate and multivariate linear regression models were used to explore associations between estimated dietary BA and MCarn. No evidence of associations between dietary BA intake and MCarn were identified, with effect sizes close to zero calculated from models accounting for key demographic variables (f2 ≤ 0.02 for all analyses). These findings suggest that capacity to increase MCarn via dietary strategies may be limited, and that supplementation may be required to induce increases of the magnitude required to improve performance.

Physical activity and antibody persistence 6 months after the second dose of CoronaVac in immunocompromised patients.

This prospective cohort study within an open-label, single-arm, phase 4 vaccination trial (clinicaltrials.gov #NCT04754698) aimed to investigate the association between physical activity and persistent anti-SARS-CoV-2 antibodies 6 months after two-dose schedule of CoronaVac in autoimmune rheumatic diseases (ARD) patients (n = 748). Persistent immunogenicity 6 months after the full-course vaccination was assessed using seroconversion rates of total anti-SARS-CoV-2 S1/S2 IgG, geometric mean titers of anti-S1/S2 IgG (GMT), and frequency of positive neutralizing antibodies (NAb). Physical activity was assessed trough questionnaire. Adjusted point estimates from logistic regression models indicated that physically active patients had greater odds of seroconversion rates (OR: 1.5 [95%CI: 1.1 to 2.1]) and NAb positivity (OR: 1.5 [95%CI: 1.0 to 2.1]), and approximately 43% greater GMT (42.8% [95%CI: 11.9 to 82.2]) than inactive ones. In conclusion, among immunocompromised patients, being physically active was associated with an increment in antibody persistence through 6 months after a full-course of an inactivated SARS-CoV-2 vaccine.

Nutritional recommendations for patients undergoing prolonged glucocorticoid therapy.

Glucocorticoid (GC) therapy is a common treatment used in rheumatic and autoimmune diseases, owing to its anti-inflammatory and immunosuppressive effects. However, GC therapy can also induce a number of adverse effects, including muscle and bone loss, hypertension, metabolic perturbations and increased visceral adiposity. We review available evidence in this area and provide nutritional recommendations that might ameliorate these adverse effects. Briefly, optimizing calcium, vitamin D, sodium and protein intake and increasing consumption of unprocessed and minimally processed foods, while decreasing the consumption of ultra-processed foods, might counteract some of the specific challenges faced by these patients. Importantly, we identify a dearth of empirical data on how nutritional intervention might impact health-related outcomes in this population. Further research is required to investigate the clinical and therapeutic efficacy of these theory-based recommendations.

Changes in Eating Habits and Sedentary Behavior During the COVID-19 Pandemic in Adolescents With Chronic Conditions.

Introduction: Among healthy adolescents, school closures and home confinement were shown to increase unhealthier eating habits and sedentary behavior. It remains unknown to which extent the pandemic has impacted the lifestyle of adolescents with chronic conditions. Thus, the aim of this study is to report on the impact of the COVID-19 outbreak on eating habits and sedentary behavior among adolescents with multiple chronic conditions (n = 347) from a tertiary, referral hospital vs. healthy peers. Methods: This observational study was conducted in São Paulo (Brazil) between July and October 2020, period in which a set of social distancing measures to contain the pandemic. Results: The main findings of this study were that adolescents with chronic conditions and health peers showed important changes in eating habits (e.g., more often cooking and eating in front of television than before quarantine). Also, 86.8% of adolescents with chronic conditions and 91.6% of healthy adolescents reported increasing screen time during pandemic. No major differences were observed between patients and controls. Conclusions: Adolescents with chronic conditions and healthy peers exposed to pandemic showed substantial changes in lifestyle, stressing the need for specific care to mitigate poor eating habits and excessive sedentary behavior for patients and healthy adolescents.

Influence of Body Mass Index on Eating Habits and Food Choice Determinants Among Brazilian Women During the COVID-19 Pandemic.

Changes in emotional state due to the COVID-19 pandemic may potentially modify eating habits, which may differ as a function of body mass index (BMI). Using a self-reported, questionnaire-based survey we evaluated Brazilian women during the pandemic for: (i) the influence of BMI on changes in eating habits, food choice determinants, and psychological symptoms; (ii) associations between eating habits, food choice determinants and psychological symptoms. General characteristics, anthropometric data, eating habits before and during the pandemic, food choice determinants and psychological symptoms during the pandemic were collected between June and September, 2020. Participants (n = 1,183) were normal weight (60.4%), overweight (26.2%) and obese (13.4%). A higher frequency of "cooking" (72.3-77.6%, p = 0.004) and "use of delivery service" (29.8-48.8%, p < 0.001) was reported during, in comparison to before the pandemic. Additionally, a higher prevalence of "snacking" (57.1-63.8%, p = 0.005) and "eating at table" (78.5-82.7%, p < 0.001) was reported during the pandemic, while the number of participants reporting "dieting" decreased (28.7-20.4%, p < 0.001). "Health", "natural concerns" and "need and hunger" were less important determinants for participants with overweight/obesity compared to normal weight. Regression analysis indicated that (i) "health", "natural concerns" and "affect regulation"; (ii) "health", "pleasure", "convenience", and "natural concerns"; and (iii) "visual appeal" and "pleasure" were the food choice determinants more associated with eating habits among women with normal weight, overweight, and obesity, respectively. In conclusion, eating habits were modified during the pandemic despite BMI, whereas food choice determinants differed between overweight/obesity and normal weight women.

Poor Eating Habits and Selected Determinants of Food Choice Were Associated With Ultraprocessed Food Consumption in Brazilian Women During the COVID-19 Pandemic.

Background: The aim of this study was to investigate possible associations between food consumption and eating habits and food choice determinants in women during COVID-19 pandemic. Methods: This is a cross-sectional survey conducted in Brazil between June and September, 2020, during which time social distancing measures were in place. Results: Participants (n = 629) were aged 34.0 years and mostly within normal weight according to BMI (60.4%). "Snacking" and "liking" associated with increased energy (ß = 164.27 and ß = 110.24) and carbohydrate intake (ß = 1.97 and ß = 1.80), and with reduced protein intake (ß = -1.54 and ß = -1.18). In contrast, "dieting" and "weight control" associated with reduced energy (ß = -162.57 and ß = -111.49) and carbohydrate intake (ß = -2.78 and ß = -2.07), and with increased protein intake (ß = 3.78 and ß = 1.65). "Dieting" (ß = 7.27), "need and hunger" (ß = 3.34), and "health" (ß = 4.94) associated with an increased consumption of unprocessed and minimally processed foods, whereas "replacing main meals with snacks" (ß = -8.98), "snacking" (ß = -6.92) and binge eating symptoms (ß = -0.34) associated with reduced consumption of foods within this processing level. In contrast, "use of delivery services" (ß = 3.39), "replacing main meals with snacks" (ß = 5.49), "visual appeal" (ß = 2.17), "social norms" (ß = 2.19) and "affect regulation" (ß = 2.01) associated with increased ultraprocessed food consumption. Overall, associations were more frequent and pronounced when analyzing food consumption by processing level rather than by macronutrient intake. Conclusion: Some eating habits and food choice determinants ("snacking," "replacing meals with snacks," "use of delivery services") observed during the COVID-19 pandemic were associated with an unhealthy diet (high energy and carbohydrate consumption, increased ultraprocessed food consumption and reduced unprocessed/minimally processed foods consumption) in Brazilian women.

Efficacy of home-based physical activity interventions in patients with autoimmune rheumatic diseases: A systematic review and meta-analysis.

INTRODUCTION: Physical activity (PA) has been receiving increasing interest in recent years as an adjuvant therapy for autoimmune rheumatic disease (ARDs), but there is scarce information about the efficacy of home-based PA for patients with ARDs. OBJECTIVE: To perform a systematic review and meta-analysis on the efficacy of home-based physical activity (PA) interventions in improving health-related quality of life, functional capacity, pain, and disease activity in patients with ARDs. METHODS: Searches were performed in PubMed, Web of Science, Scopus, Cochrane, CINAHL database and Sport Discus. Trials were considered eligible if they included a home-based physical activity intervention. The population included adults with autoimmune rheumatic diseases (e.g., rheumatoid arthritis, systemic lupus erythematosus, idiopathic inflammatory myopathies, systemic sclerosis and ankylosing spondylitis), comparisons included non-physical activity control or centre-based interventions (i.e., interventions performed on a specialized exercise centre) and the outcomes were quality of life, pain, functional capacity, disease activity and inflammation. RESULTS: Home-based physical activity improved quality of life (p<0.01; g = 0.69; IC95%, 0.61 to 1.07) and functional capacity (p = 0.04; g = - 0.51; IC95%, -0.86; -0.16), and reduced disease activity (p = 0.03; g = - 0.60; IC95%, -1.16; -0.04) and pain (p = 0.01; g = -1.62; IC95%, -2.94 to -0.31) compared to the non-physical activity control condition. Additionally, home-based physical activity interventions were as effective as centre-based interventions for all investigated outcomes. CONCLUSION: Home-based PA is an efficacious strategy to improve disease control and aleviate symptoms in ARD.

"Can A Ballerina Eat Ice Cream?": A Mixed-Method Study on Eating Attitudes and Body Image in Female Ballet Dancers.

Aim: We aimed to explore how a group of classical ballet dancers perceived their eating attitudes and their bodies, with special attention to the potential presence of eating disorders (EDs) symptoms and body image (dis)satisfaction. Methods: A cross-sectional, mixed-method study was conducted on fourteen trained classical ballet dancers (18-30 years old). Their experiences, perceptions, and feelings regarding eating attitudes and body image concerning classical ballet were acquired through qualitative focus groups. The presence of EDs symptoms and perception and (dis)satisfaction with body image was analyzed quantitatively through self-report questionnaires. Results: Participants reported concerning eating attitudes during the focus groups, such as the regular practice of several restrictive popular diets, constant restriction of foods considered "heavy" or "fatty," meal skipping and ignoring signs of hunger, presence of overeating episodes due to stress and anxiety, feeling guilty about breaking their usual diet, classifying foods as "good" and "bad" or "lean" and "fat," and excluding some of those foods from their usual diets. These reports were partially reflected in the questionnaires, with 50% of the ballerinas showing bulimic symptoms indicative of an unusual eating pattern (only two of them with a significant risk index), 7.1% showing symptoms of moderate binge eating, and 14.3% symptoms of EDs in general. Additionally, when considering their bodies in the context of everyday life, participants were satisfied; however, in the "classical ballet" context, they reported feeling dissatisfied with their shape. These findings were in line with results from the Stunkard's Scale, which revealed that 50% of the sample was dissatisfied with their current body shape and 57.1% indicated that their desired body shape was a leaner figure than one they considered healthy. Conclusions: The constant practice of restrictive diets and other weight-loss strategies to achieve a leaner body were associated with symptoms of EDs and body dissatisfaction in this sample. Importantly, the questionnaires used seemed to underestimate the presence of a disordered eating pattern reported by the participants during focus groups. These data could help to inform psychological and nutritional strategies aimed at improving performance, physical and psychological well-being, and quality of life of ballet dancers.

Increased sympathetic and haemodynamic responses to exercise and muscle metaboreflex activation in post-menopausal women with rheumatoid arthritis.

KEY POINTS: Rheumatoid arthritis (RA) patients present exacerbated blood pressure responses to exercise, but little is known regarding the underlying mechanisms involved.  This study assessed autonomic and haemodynamic responses to exercise and to the isolated activation of muscle metaboreflex in post-menopausal women with RA.  Participants with RA showed augmented pressor and sympathetic responses to exercise and to the activation of muscle metaboreflex. These responses were associated with multiple pro- and anti-inflammatory cytokines and with pain.  The results of the present study support the suggestion that an abnormal reflex control of circulation is an important mechanism underlying the exacerbated cardiovascular response to exercise and increased cardiovascular risk in RA. ABSTRACT: Studies have reported abnormal cardiovascular responses to exercise in rheumatoid arthritis (RA) patients, but little is known regarding the underlying mechanisms involved. This study assessed haemodynamic and sympathetic responses to exercise and to the isolated activation of muscle metaboreflex in women diagnosed with RA. Thirty-three post-menopausal women diagnosed with RA and 10 matched controls (CON) participated in this study. Mean arterial pressure (MAP), heart rate (HR) and muscle sympathetic nerve activity (MSNA frequency and incidence) were measured during a protocol of isometric knee extension exercise (3 min, 30% of maximal voluntary contraction), followed by post-exercise ischaemia (PEI). Participants with RA showed greater increases in MAP and MSNA during exercise and PEI than CON (ΔMAPexercise  = 16 ± 11 vs. 9 ± 6 mmHg, P = 0.03; ΔMAPPEI  = 15 ± 10 vs. 5 ± 5 mmHg, P = 0.001; ΔMSNAexercise  = 17 ± 14 vs. 7 ± 9 bursts min-1 , P = 0.04; ΔMSNAPEI  = 14 ± 10 vs. 6 ± 4 bursts min-1 , P = 0.04). Autonomic responses to exercise showed significant (P < 0.05) association with pro- (i.e. IFN-γ, IL-8, MCP-1 and TNFα) and anti-inflammatory (i.e. IL-1ra and IL-10) cytokines and with pain. In conclusion, post-menopausal women with RA showed augmented pressor and sympathetic responses to exercise and to the activation of muscle metaboreflex. These findings provide mechanistic insights that may explain the abnormal cardiovascular responses to exercise in RA.

Ultra-processed food consumption associates with higher cardiovascular risk in rheumatoid arthritis.

To investigate the association between food consumption stratified by processing level and cardiovascular risk factors in rheumatoid arthritis. In this cross-sectional study, 56 patients (age: 62.5 ± 7.9 years, BMI: 28.4 ± 5.1 kg/m2) had food consumption evaluated according to the processing level (e.g., unprocessed or minimally processed foods, processed foods, and ultra-processed foods) and associated with cardiovascular risk factors. The most prevalent food processing level was unprocessed or minimally processed foods (42.6 ± 12.6% of total energy intake [TEI]), followed by processed (24.2 ± 11.9%TEI), ultra-processed (18.1 ± 11.8%TEI), and culinary ingredients (15.1 ± 6.4%TEI). Adjusted regression models showed that higher consumption of ultra-processed foods was positively associated with Framingham risk score (ß = 0.06, CI: 95% 0.001, 0.11, p = 0.045) and glycated hemoglobin (ß = 0.04, CI: 95% 0.01, 0.08, p = 0.021). In contrast, higher consumption of unprocessed or minimally processed foods was associated with lower 10-year risk of developing cardiovascular diseases (ß = -0.05, CI: 95% - 0.09, -0.003, p = 0.021) and LDL (ß = -1.09, CI: 95% - 1.94, -0.24, p = 0.013). Patients with rheumatoid arthritis consuming more ultra-processed foods showed worse metabolic profile, whereas those consuming more unprocessed or minimally processed foods had lower cardiovascular risks. A food pattern characterized by a high ultra-processed food consumption appears to emerge as a novel, modifiable risk factor for cardiovascular diseases in rheumatoid arthritis. Key-Points • Higher ultra-processed food consumption was associated with worse metabolic profile and increased cardiovascular risk, whereas higher unprocessed or minimally processed food consumption was associated with lower 10-year risk of developing cardiovascular diseases. • A food pattern characterized by a high ultra-processed food consumption appears to emerge as a novel, modifiable risk factor for cardiovascular diseases in rheumatoid arthritis.

"Despite being an athlete, I am also a human-being": Male elite gymnasts' reflections on food and body image.

Our aim was to investigate the prevalence of symptoms related to eating disorders, disordered eating and body image perception, and attitudes toward eating in a group of elite male artistic gymnastics. Seventeen athletes took part in this quali-quantitative, cross-sectional study. Presence of eating disorders symptoms, and body image perception and satisfaction were assessed using validated questionnaires. Focus groups were held to discuss their attitudes toward eating and body image perception in more detail. Little to no evidence of symptoms consistent with eating disorders was observed, and this was supported by the qualitative data. However, some concerning practices and attitudes were described. Negative emotional eating cycles appeared prevalent (e.g. feelings of anger, stress and anxiety creating a desire to eat "junk foods", followed by guilt and regret). Body image perception and attitudes toward body weight's influence on performance varied widely. Some athletes expressed a desire to lose weight and believed that this would positively impact their performance, while others believed weight to be irrelevant and focused on feeling strong and vital. Athletes believed their female counterparts experienced far greater pressure to maintain low body weight and described some very concerning practices. We conclude that eating disorders and disordered eating did not appear to be prevalent among these elite male artistic gymnastics. However, some concerning attitudes and practices were observed and should be addressed with nutritional support programmes encompassing psychological and behavioural aspects of eating. These programmes should be extended to support staff and significant others, in addition to athletes.