The global obesity pandemic: shaped by global drivers and local environments

Efficacy of body appreciation training on body image concerns in overweight adolescents

Body image concern is one of the important issues in the field of overweight and the factors of failure in losing weight which is necessary to undergo intervention to increase the efficiency of sports and nutrition programs. This study aimed to analyze the efficacy of body appreciation training on body image concerns in overweight adolescents. It was a semi-experimental method with a pre-test and post-test design with a control group). The research community consisted of overweight girl adolescents who were referred to weight control and weight loss centers in Isfahan City in 2021. From the mentioned society, 30 adolescents were selected by targeted sampling method and assigned to two groups of 15 people, experiment and control. The experimental group received 9 sessions of 90-min body appreciation training. The control group was on the waiting list during this time. The research tool was the body image concern questionnaire of Littleton et al. (2005). Data analysis was done using SPSS-24 software and the covariance analysis method. The results showed that there is a significant difference between the two groups in the variable of concerns related to body image (P < 0.001); Also, the results showed that there is a significant difference between the two groups in the variables of dissatisfaction with appearance and interference in social functioning (P < 0.001). In this way, based on the results of this research, body appreciation training can be used to reduce concerns related to body image in overweight adolescents.

Osteopontin-driven T-cell accumulation and function in adipose tissue and liver promoted insulin resistance and MAFLD

OBJECTIVE

This study investigated the contribution of osteopontin/secreted phosphoprotein 1 (SPP1) to T-cell regulation in initiation of obesity-driven adipose tissue (AT) inflammation and macrophage infiltration and the subsequent impact on insulin resistance (IR) and metabolic-associated fatty liver disease (MAFLD) development.

METHODS

SPP1 and T-cell marker expression was evaluated in AT and liver according to type 2 diabetes and MAFLD in human individuals with obesity. The role of SPP1 on T cells was evaluated in Spp1-knockout mice challenged with a high-fat diet.

RESULTS

In humans with obesity, elevated SPP1 expression in AT was parallel to T-cell marker expression (CD4, CD8A) and IR. Weight loss reversed AT inflammation with decreased SPP1 and CD8A expression. In liver, elevated SPP1 expression correlated with MAFLD severity and hepatic T-cell markers. In mice, although Spp1 deficiency did not impact obesity, it did improve AT IR associated with prevention of proinflammatory T-cell accumulation at the expense of regulatory T cells. Spp1 deficiency also decreased ex vivo helper T cell, subtype 1 (Th1) polarization of AT CD4+ and CD8+ T cells. In addition, Spp1 deficiency significantly reduced obesity-associated liver steatosis and inflammation.

CONCLUSIONS

Current findings highlight a critical role of SPP1 in the initiation of obesity-driven chronic inflammation by regulating accumulation and/or polarization of T cells. Early targeting of SPP1 could be beneficial for IR and MAFLD treatment.

The health and economic impact and cost effectiveness of interventions for the prevention and control of overweight and obesity in Kenya: a stakeholder engaged modelling study

BACKGROUND

The global increase in mean body mass index has resulted in a substantial increase of non-communicable diseases (NCDs), including in many low- and middle-income countries such as Kenya. This paper assesses four interventions for the prevention and control of overweight and obesity in Kenya to determine their potential health and economic impact and cost effectiveness.

METHODS

We reviewed the literature to identify evidence of effect, determine the intervention costs, disease costs and total healthcare costs. We used a proportional multistate life table model to quantify the potential impacts on health conditions and healthcare costs, modelling the 2019 Kenya population over their remaining lifetime. Considering a health system perspective, two interventions were assessed for cost-effectiveness. In addition, we used the Human Capital Approach to estimate productivity gains.

RESULTS

Over the lifetime of the 2019 population, impacts were estimated at 203,266 health-adjusted life years (HALYs) (95% uncertainty interval [UI] 163,752 - 249,621) for a 20% tax on sugar-sweetened beverages, 151,718 HALYs (95% UI 55,257 - 250,412) for mandatory kilojoule menu labelling, 3.7 million HALYs (95% UI 2,661,365-4,789,915) for a change in consumption levels related to supermarket food purchase patterns and 13.1 million HALYs (95% UI 11,404,317 - 15,152,341) for a change in national consumption back to the 1975 average levels of energy intake. This translates to 4, 3, 73 and 261 HALYs per 1,000 persons. Lifetime healthcare cost savings were approximately United States Dollar (USD) 0.14 billion (USD 3 per capita), USD 0.08 billion (USD 2 per capita), USD 1.9 billion (USD 38 per capita) and USD 6.2 billion (USD 124 per capita), respectively. Lifetime productivity gains were approximately USD 1.8 billion, USD 1.2 billion, USD 28 billion and USD 92 billion. Both the 20% tax on sugar sweetened beverages and the mandatory kilojoule menu labelling were assessed for cost effectiveness and found dominant (health promoting and cost-saving).

CONCLUSION

All interventions evaluated yielded substantive health gains and economic benefits and should be considered for implementation in Kenya.

Impact of Sleeve Gastrectomy on Fecal Microbiota in Individuals with Morbid Obesity

BACKGROUND

The intestinal microbiota plays an important role in the etiology of obesity. Sleeve gastrectomy (SG) is a frequently performed and effective therapy for morbid obesity.

OBJECTIVE

To investigate the effect of sleeve gastrectomy on the fecal microbiota of individuals with morbid obesity and to examine whether shifts in microbiota composition are associated with markers of inflammation and intestinal barrier function.

METHODS

Fecal and blood samples of healthy individuals (n = 27) and morbidly obese individuals pre-SG (n = 24), and at 2 months (n = 13) and 6 months post-SG (n = 9) were collected. The 16SrRNA gene was sequenced to assess microbiota composition. Fecal calprotectin, plasma inflammatory markers and intestinal permeability markers (multi-sugar test) were determined.

RESULTS

Fecal microbiota composition between morbidly obese and lean individuals was significantly different. The fecal microbiota composition changed significantly 2 and 6 months post-SG (p = 0.008) compared to pre-SG but not towards a more lean profile. The post-SG microbiota profile was characterized by an increase in facultative anaerobic bacteria, characteristic for the upper gastrointestinal tract. No correlations were found between inflammatory markers, intestinal permeability and microbial profile changes.

CONCLUSIONS

Fecal microbiota composition in morbidly obese individuals changed significantly following SG. This change might be explained by functional changes induced by the SG procedure.

Using System Dynamics to Understand Transnational Corporate Power in Diet-Related Non-communicable Disease Prevention Policy-Making: A Case Study of South Africa

BACKGROUND

Complex interactions between political economy factors and corporate power are increasingly recognized to prevent transformative policy action on non-communicable disease (NCD) prevention. System science offers promising methods for analysing such causal complexity. This study uses qualitative system dynamics methods to map the political economy of diet-related NCD (DR-NCD) prevention policy-making aiming to better understand the policy inertia observed in this area globally.

METHODS

We interviewed 25 key policy actors. We analysed the interviews using purposive text analysis (PTA). We developed individual then combined casual loop diagrams to generate a shared model representing the DR-NCD prevention policy-making system. Key variables/linkages identified from the literature were also included in the model. We validated the model in several steps including through stakeholder validation interviews.

RESULTS

We identified several inter-linked feedback processes related to political economy factors that may entrench different forms of corporate power (instrumental, structural, and discursive) in DR-NCD prevention policy-making in South Africa over time. We also identified a number of feedback processes that have the potential to limit corporate power in this setting.

CONCLUSION

Using complex system methods can be useful for more deeply understanding DR-NCD policy inertia. It is also useful for identifying potential leverage points within the system which may shift the existing power dynamics to facilitate greater political commitment for healthy, equitable, and sustainable food system transformation.

Discounting of Hyper-Palatable Food and Money: Associations with Food Addiction Symptoms

INTRODUCTION

Delay discounting (DD), the tendency to prefer small, immediate rewards over larger, delayed rewards, is associated with health-risk behaviors. The study examined associations between DD for money and hyper-palatable foods (HPF) with food addiction (FA) symptoms among a general population sample.

METHODS

Participants (N = 296) completed an adjusting DD task that consisted of a single-commodity condition with HPF as the reward (HPF now vs. HPF later) and cross-commodity conditions comparing money and HPF (money now vs. HPF later; HPF now vs. money later). The Yale Food Addiction Scale 2.0 was used to assess FA symptoms. Zero-inflated negative binomial regression models tested whether discounting of HPF and money was associated with FA symptoms.

RESULTS

Findings indicated there were no significant associations between DD and FA symptoms in the single-commodity HPF condition (logit: OR = 1.02, p-value = 0.650; count: IRR = 1.04, p-value = 0.515). There were no significant associations among cross-commodity conditions comparing money now vs. HPF later (logit: OR = 0.96, p-value = 0.330; count: IRR = 1.02, p-value = 0.729) or conditions comparing HPF now vs. money later (logit: OR = 1.02, p-value = 0.682; count: IRR = 0.92, p-value = 0.128) and FA symptoms.

CONCLUSIONS

Discounting HPF may not be a key behavioral feature among individuals who endorse FA symptoms.

Emergence of the obesity epidemic preceding the presumed obesogenic transformation of the society

The obesity epidemic, evolving in many countries since the 1970s, has been attributed to the widespread contemporary so-called obesogenic transformation of the societies, but what preceded the epidemic? Using quantile regression, we studied the trends by year of birth in the percentile distribution of body mass index (BMI = weight/height2) of 320,962 Danish school children, born from 1930 to 1976, and of 205,153 Danish young conscripts, born from 1939 to 1959. The overall trend of the percentiles of the BMI distributions were found to be linear across the years of birth. While the percentiles below the 75th were almost stable, those above showed a steadily steeper rise the more extreme the percentile among both school children and young men is. These changes, indicating the emergence of the obesity epidemic, preceded the presumed obesogenic transformation of the society by several decades and imply that other, so far unknown, factors have been involved.

From dearth to excess: the rise of obesity in an ultra-processed food system

More people now have obesity than suffer from starvation thanks to our modern food system. Agriculture was transformed over the 20th century by a variety of technological advancements that relied heavily on fossil fuels. In the United States, government policies and economic incentives led to surplus production of cheap inputs to processed food industries that produced a wide variety of heavily marketed, convenient, rewarding, timesaving, and relatively inexpensive ultra-processed foods. The energy available in the food supply increased by much more than the population needs, albeit with large inequities in nutrition security. While most of the rise in per capita food availability during the late 20th and early 21st centuries in the United States resulted in increased food waste, a variety of mechanisms have been proposed by which changes in the increasingly ultra-processed food environment resulted in excess energy intake disproportionately in people genetically susceptible to obesity. As populations continue to grow, substantial investments in coordinated nutrition and agricultural research are needed to transform our current food system to one that relies less on fossil fuels, preserves biodiversity, ensures environmental health, and provides equitable access to affordable, safe and nutritious food that reduces the prevalence of chronic diet-related diseases like obesity. This article is part of a discussion meeting issue 'Causes of obesity: theories, conjectures and evidence (Part I)'.

Low-Density Lipoprotein Cholesterol Is Associated with Atopic Dermatitis in Korean Adolescents

INTRODUCTION

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases. Several studies have investigated the relationship between obesity and AD prevalence, but the results have been conflicting. This study investigated the association between obesity and AD in Korean adolescents.

METHODS

We used nationally representative data regarding 1,617 Korean adolescents aged 12-18 years, which were obtained from the cross-sectional Korea National Health and Nutrition Examination Survey 2017-2019. Multiple logistic regression analysis (including age, sex, region of residence, number of household members, economic status, lipid profile, and stress level) was used to evaluate the relationships of obesity and abdominal obesity with doctor-diagnosed AD.

RESULTS

Although the results were not statistically significant, obese adolescents were diagnosed with AD (20.8%) more often than non-obese adolescents (20.8% vs. 14.5%, p = 0.055). This tendency was more prominent in male adolescents than in female adolescents, but the finding was not statistically significant. Body mass index and the prevalence of abdominal obesity did not differ between the AD and non-AD groups. Adolescents with AD had significantly higher total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels, compared with adolescents who did not have AD. In the adjusted model, an LDL-C level ≥130 mg/dL was a risk factor for AD (adjusted odds ratio, 1.03; 95% confidence interval, 1.01-1.05).

CONCLUSIONS

A high LDL-C level may be a risk factor for AD. Proper management of dyslipidemia through lifestyle modification may aid in AD prevention and control. Further large-scale prospective studies are needed to assess the associations of AD with obesity and dyslipidemia.

A Review of the Potential Health Benefits of Nigella sativa on Obesity and Its Associated Complications

Obesity has become a worldwide epidemic and its prevalence continues to increase at an alarming rate. It is considered a major risk factor for the development of several comorbidities, including type 2 diabetes, stroke, other cardiovascular diseases and even cancer. Conventional treatments for obesity, such as dietary interventions, exercise and pharmacotherapy, have proven to have limited effectiveness and are often associated with undesirable side effects. Therefore, there is a growing interest in exploring alternative therapeutic approaches. Nigella sativa (NS), a medicinal plant with multiple pharmacological properties, has gained attention due to its potential role in the treatment of obesity and its associated complications. The aim of this review is therefore to assess the effects of NS on obesity and its complications and to provide insights into the underlying mechanisms. From this review, NS appears to play a complementary or supportive role in the treatment of obesity and its complications. However, future studies are needed to verify the efficacy of NS in the treatment of obesity and its complications and to prove its safety so that it can be introduced in patients with obesity.

The effect of breakfast on childhood obesity: a systematic review and meta-analysis

Objective

Previous cohort trials have shown that skipping breakfast increases the risk of obesity or overweight in children. However, this finding remains controversial. Through a meta-analysis, this study systematically evaluated the effect of skipping breakfast on the prevalence of obesity or overweight in children.

Methods

We performed a literature search for studies published until March 19, 2023. using the Cochrane, PubMed, and Embase databases. Based on the inclusion and exclusion criteria, observational studies on the relationship between skipping breakfast and overweight/obesity in children and adolescents were analyzed. Three investigators independently screened the relevant literature, extracted the data, and assessed the risk of bias. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects model was used. The odds ratio (OR) with its 95% confidence interval (CI) was used to indicate the effect size.

Results

A total of 40 retrospective studies with 323,244 children ranging in age from 2 to 20 years were included in this study. The results of this meta-analysis showed that children and adolescents who skipped breakfast had a significantly higher prevalence of obesity or overweight than those who ate breakfast (OR, 1.59; 95% CI, 1.33-1.90; P < 0.001). Skipping breakfast was positively associated with overweight in children and adolescents (OR, 1.37; 95% CI, 1.23-1.54; P < 0.001). Similarly, skipping breakfast was positively associated with obesity in children and adolescents (OR, 1.51; 95% CI, 1.30-1.76; P < 0.001). The effect was also different by sex, with girls being the most affected (OR, 1.47; 95% CI, 1.23-1.76; P < 0.001). There was also a correlation between skipping breakfast and abdominal obesity in children (OR, 0.65; 95% CI, 0.55-0.77; P < 0.001).

Conclusion

This meta-analysis suggested that skipping breakfast is associated with an increased risk of overweight/obesity in children and adolescents. The findings provide support for a possible protective role of breakfast against excessive weight gain in children and adolescents. However, more rigorous study designs with validated and standardized measures of relevant variables are needed.

Childhood caries is associated with poor health and a faster pace of aging by midlife

OBJECTIVES

Childhood caries is associated with poorer self-rated general health in adulthood, but it remains unclear whether that holds for physical health and aging. The aim of this study was to identify whether age-5 caries is associated with (a) biomarkers for poor physical health, and (b) the pace of aging (PoA) by age 45 years.

METHODS

Participants are members of the Dunedin Multidisciplinary Health and Development Study birth cohort. At age 45, 94.1% (n = 938) of those still alive took part. Data on age-5 caries experience and age-45 health biomarkers were collected. The PoA captures age-related decline across the cardiovascular, metabolic, renal, immune, dental and pulmonary systems from age 26 to 45 years. We used (a) generalized estimating equations to examine associations between age-5 caries and poor physical health by age 45 years, and (b) ordinary least squares regression to examine whether age-5 caries was associated with the PoA. Analyses adjusted for sex, perinatal health, childhood SES and childhood IQ.

RESULTS

High caries experience at age-5 was associated with higher risk for some metabolic abnormalities, including BMI ≥30, high waist circumference, and high serum leptin. Those with high caries experience at age-5 were aging at a faster rate by age 45 years than those who had been caries-free.

CONCLUSIONS

Oral health is essential for wellbeing. Poor oral health can be an early signal of a trajectory towards poor health in adulthood. Management for both conditions should be better-integrated; and integrated population-level prevention strategies should be foundational to any health system.

Perspective: A Conceptual Framework for Adaptive Personalized Nutrition Advice Systems (APNASs)

Nearly all approaches to personalized nutrition (PN) use information such as the gene variants of individuals to deliver advice that is more beneficial than a generic "1-size-fits-all" recommendation. Despite great enthusiasm and the increased availability of commercial services, thus far, scientific studies have only revealed small to negligible effects on the efficacy and effectiveness of personalized dietary recommendations, even when using genetic or other individual information. In addition, from a public health perspective, scholars are critical of PN because it primarily targets socially privileged groups rather than the general population, thereby potentially widening health inequality. Therefore, in this perspective, we propose to extend current PN approaches by creating adaptive personalized nutrition advice systems (APNASs) that are tailored to the type and timing of personalized advice for individual needs, capacities, and receptivity in real-life food environments. These systems encompass a broadening of current PN goals (i.e., what should be achieved) to incorporate "individual goal preferences" beyond currently advocated biomedical targets (e.g., making sustainable food choices). Moreover, they cover the "personalization processes of behavior change" by providing in situ, "just-in-time" information in real-life environments (how and when to change), which accounts for individual capacities and constraints (e.g., economic resources). Finally, they are concerned with a "participatory dialog between individuals and experts" (e.g., actual or virtual dieticians, nutritionists, and advisors) when setting goals and deriving measures of adaption. Within this framework, emerging digital nutrition ecosystems enable continuous, real-time monitoring, advice, and support in food environments from exposure to consumption. We present this vision of a novel PN framework along with scenarios and arguments that describe its potential to efficiently address individual and population needs and target groups that would benefit most from its implementation.

The gamification of nutrition labels to encourage healthier food selection in online grocery shopping: A randomized controlled trial

Food purchase choices, one of the main determinants of food consumption, is highly influenced by food environments. Given the surge in online grocery shopping because of the COVID-19 pandemic, interventions in digital environments present more than ever an opportunity to improve the nutritional quality of food purchase choices. One such opportunity can be found in gamification. Participants (n = 1228) shopped for 12 items from a shopping list on a simulated online grocery platform. We randomized them into four groups in a 2 × 2 factorial design: presence vs. absence of gamification, and high vs. low budget. Participants in the gamification groups saw foods with 1 (least nutritious) to 5 (most nutritious) crown icons and a scoreboard with a tally of the number of crowns the participant collected. We estimated ordinary least squares and Poisson regression models to test the impact of the gamification and budget on the nutritional quality of the shopping basket. In the absence of gamification and low budget, participants collected 30.78 (95% CI [30.27; 31.29]) crowns. In the gamification and low budget condition, participants increased the nutritional quality of their shopping basket by collecting more crowns (B = 4.15, 95% CI [3.55; 4.75], p < 0.001). The budget amount ($50 vs. $30) did not alter the final shopping basket (B = 0.45, 95% CI [-0.02; 1.18], p = 0.057), nor moderated the gamification effect. Gamification increased the nutritional quality of the final shopping baskets and nine of 12 shopping list items in this hypothetical experiment. Gamifying nutrition labels may be an effective strategy to improve the nutritional quality of food choices in online grocery stores, but further research is needed.

The Effectiveness of Nutritional Strategies in the Treatment and Management of Obesity: A Systematic Review

Obesity, a condition primarily resulting from positive energy balance, has become a significant global health concern. Numerous studies have demonstrated that obesity is a major risk factor for various illnesses, including different types of cancer, coronary heart disease, sleep apnea, CV stroke, type II diabetes mellitus, etc. To effectively address this issue, prevention and treatment approaches to manage body weight are crucial. There are several evidence-based approaches available for the treatment and management of obesity, taking into account factors such as body mass index classification, individual weight history, and existing comorbidities. To facilitate successful obesity treatment and management, there are pragmatic approaches and tools available, including the reduction of energy density, portion control, and diet quality enhancement. These approaches encompass the use of medications, lifestyle interventions, bariatric surgery, and formula diets. Regardless of the specific method employed, behavior change, reduction of energy intake, and increased energy expenditure are integral components for successful treatment and management of obesity. These measures allow patients to personalize and customize their dietary patterns, leading to effective and sustainable weight reduction. Incorporating physical activities and self-monitoring of individual diets are effective techniques for promoting behavior change in obesity and weight management. The main objective of this systematic review is to evaluate the effectiveness of dietary/nutritional interventions in the treatment and management of obesity through provision of valuable insights into the effectiveness of such nutritional strategies. To attain this, a comprehensive analysis of various dietary approaches and their impacts on weight will be conducted.

Change in the food environment and measured adiposity in adulthood in the Christchurch Health and development birth cohort, Aotearoa, New Zealand: A birth cohort study

This study investigated associations between change in the food environment and change in measured body mass index (BMI) and waist circumference (WC) in the Christchurch Health and Development Study (CHDS) birth cohort. Our findings suggest that cohort members who experienced the greatest proportional change towards better access to fast food outlets had the slightly larger increases in BMI and WC. Contrastingly, cohort members who experienced the greatest proportional change towards shorter distance and better access to supermarkets had slightly smaller increases in BMI and WC. Our findings may help explain the changes in BMI and WC at a population level.

Unhealthy food availability, prominence and promotion in a representative sample of supermarkets in Flanders (Belgium): a detailed assessment

INTRODUCTION

The supermarket food environment is a key setting for potential public health interventions. This study assessed food availability, prominence and promotion in a representative sample of supermarkets in Flanders (Belgium).

METHODS

A sample of 55 supermarkets across five chains and 16 Flemish municipalities was selected in 2022, about 64% in the most deprived socioeconomic areas. Healthiness indicators related to food availability (ratio of cumulative linear shelf length for healthy versus unhealthy foods), prominence (proportion of unhealthy foods at check-outs and end-of-aisle endcaps), and promotion (food marketing on food packages) were measured.

RESULTS

Overall, the average ratio of healthy/unhealthy foods in supermarkets in Flanders was 0.36, meaning that for every 10m of shelf length of unhealthy foods there was 3.6m of healthy foods. There was a large variation in ratio's across supermarket chains. Of all foods available, 97.5% were ultra-processed at the check outs, while 72.2% and 58.5% were ultra-processed at the front and back end-of-aisle end-caps, respectively. Confectionery and sweet biscuits were the food categories with on average the highest number of marketing messages on pack per 10m of shelf length.

CONCLUSION

Supermarket in-store food environments in Flanders were found generally unhealthy, with those located in low income areas having unhealthier in-store food environments than supermarkets located in medium and high income areas. Despite commitments of all large supermarket chains in Flanders to promote and create healthier in-store food environments, our findings indicate that currently consumers are incentivized to buy unhealthy rather than healthy food products.

Body mass index trends and its impact of under and overweight on outcome among PLHIV on antiretroviral treatment in rural Tanzania: A prospective cohort study

INTRODUCTION

Increased body weight is an important risk factor for cardiovascular disease and is increasingly reported as a health problem in people living with HIV (PLHIV). There is limited data from rural sub-Saharan Africa, where malnutrition usually presents with both over- and undernutrition. We aimed to determine the prevalence and risk factors of underweight and overweight/obesity in PLHIV enrolled in a cohort in rural Tanzania before the introduction of integrase inhibitors.

METHODS

This nested study of the prospective Kilombero and Ulanga Antiretroviral Cohort included adults aged ≥19 years initiated on antiretroviral therapy between 01/2013 and 12/2018 with follow-up through 06/2019. Body Mass Index (BMI) was classified as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), or overweight/obese (≥25.0 kg/m2). Stratified piecewise linear mixed models were used to assess the association between baseline characteristics and follow-up BMI. Cox proportional hazard models were used to assess the association between time-updated BMI and death/loss to follow-up (LTFU).

RESULTS

Among 2,129 patients, 22,027 BMI measurements (median 9 measurements: interquartile range 5-15) were analysed. At baseline, 398 (19%) patients were underweight and 356 (17%) were overweight/obese. The majority of patients were female (n = 1249; 59%), and aged 35-44 years (779; 37%). During the first 9 months, for every three additional months on antiretroviral therapy, BMI increased by 2% (95% confidence interval 1-2%, p<0.0001) among patients underweight at baseline and by 0.7% (0.5-0.6%, p<0.0001) among participants with normal BMI. Over a median of 20 months of follow-up, 107 (5%) patients died and 592 (28%) were LTFU. Being underweight was associated with >2 times the hazard of death/LTFU compared to participants with normal BMI.

CONCLUSION

We found a double burden of malnutrition, with underweight being an independent predictor of mortality. Monitoring and measures to address both states of malnutrition among PLHIV should be integrated into routine HIV care.

Bibliometric and Correlation Analysis of Bariatric Surgery Researches in Asia-Pacific from 2000 to 2021

INTRODUCTION

Bariatric surgery has grown in popularity over the past two decades, especially in the Asia-Pacific. Correspondingly, researchers' interest in this field has also increased. This study aims to perform a bibliometric analysis of publications from Asia-Pacific represented by the International Federation for the Surgery of Obesity and Metabolic Disorders Asia-Pacific Chapter (IFSO-APC) and investigate the relevant factors that might affect the publications.

METHODS

The search terms for bariatric surgery were searched in Web of Science focusing on the period 2000-2021. Bibliometric analysis was performed after screening the search results. Univariate and multivariate regression analyses were performed on the number of publications and corresponding indicators obtained from official agencies.

RESULTS

A total of 9,547 publications in IFSO-APC were retrieved, of which China had the largest number with 2,782 publications. Authors and journals with major contributions were listed. The authors' or affiliations' cooperation networks mainly were limited to domestic. "Bariatric surgery" was the most frequent keyword with 2,063 times and also the largest cluster. "Morbid obesity" was the strongest citation bursts. Multivariate analysis found that the number of publications in each country/region was associated with body mass index ≥25 kg/m2, gross domestic product, and total population.

CONCLUSION

Generally, Asia-Pacific represented by IFSO-APC scientific publications on bariatric surgery has grown significantly in the last two decades, but cooperation between countries/regions should be strengthened. "Morbid obesity" is the focus and frontier of research in this field.

Interference of a mammalian circRNA regulates lipid metabolism reprogramming by targeting miR-24-3p/Igf2/PI3K-AKT-mTOR and Igf2bp2/Ucp1 axis

White adipose tissue (WAT) is important for regulating the whole systemic energy homeostasis. Excessive WAT accumulation further contributes to the development of obesity and obesity-related illnesses. More detailed mechanisms for WAT lipid metabolism reprogramming, however, are still elusive. Here, we report the abnormally high expression of a circular RNA (circRNA) mmu_circ_0001874 in the WAT and liver of mice with obesity. mmu_circ_0001874 interference achieved using a specific adeno-associated virus infects target tissues, down-regulating lipid accumulation in the obesity mice WAT, and liver tissues. Mechanistically, miR-24-3p directly interacts with the lipid metabolism effect of mmu_circ_0001874 and participates in adipogenesis and lipid accumulation by targeting Igf2/PI3K-AKT-mTOR axis. Moreover, mmu_circ_0001874 binds to Igf2bp2 to interact with Ucp1, up-regulating Ucp1 translation and increasing thermogenesis to decrease lipid accumulation. In conclusion, our data highlight a physiological role for circRNA in lipid metabolism reprogramming and suggest mmu_circ_0001874/miR-24-3p/Igf2/PI3K-AKT-mTOR and mmu_circ_0001874/Igf2bp2/Ucp1 axis may represent a potential mechanism for controlling lipid accumulation in obesity.

Comprehensive application of a systems approach to obesity prevention: a scoping review of empirical evidence

A systems approach to obesity prevention is increasingly urged. However, confusion exists on what a systems approach entails in practice, and the empirical evidence on this new approach is unclear. This scoping review aimed to identify and synthesise studies/programmes that have comprehensively applied a systems approach to obesity prevention in intervention development, delivery/implementation, and evaluation. By searching international databases and grey literature, only three studies (10 publications) met inclusion criteria, which might be explained partially by suboptimal reporting. No conclusion on the effectiveness of this approach can be drawn yet due to the limited evidence base. We identified common features shared by the included studies, such as measuring ongoing changes, in addition to endpoint outcomes, and supporting capacity building. Some facilitators and barriers to applying a comprehensive systems approach in practice were identified. More well-designed and reported studies are needed, especially from low- and middle-income countries.

A Novel Mobile App for Personalized Dietary Advice Leveraging Persuasive Technology, Computer Vision, and Cloud Computing: Development and Usability Study

BACKGROUND

The Australian Dietary Guidelines (ADG) translate the best available evidence in nutrition into food choice recommendations. However, adherence to the ADG is poor in Australia. Given that following a healthy diet can be a potentially cost-effective strategy for lowering the risk of chronic diseases, there is an urgent need to develop novel technologies for individuals to improve their adherence to the ADG.

OBJECTIVE

This study describes the development process and design of a prototype mobile app for personalized dietary advice based on the ADG for adults in Australia, with the aim of exploring the usability of the prototype. The goal of the prototype was to provide personalized, evidence-based support for self-managing food choices in real time.

METHODS

The guidelines of the design science paradigm were applied to guide the design, development, and evaluation of a progressive web app using Amazon Web Services Elastic Compute Cloud services via iterations. The food layer of the Nutrition Care Process, the strategies of cognitive behavioral theory, and the ADG were translated into prototype features guided by the Persuasive Systems Design model. A gain-framed approach was adopted to promote positive behavior changes. A cross-modal image-to-recipe retrieval model under an Apache 2.0 license was deployed for dietary assessment. A survey using the Mobile Application Rating Scale and semistructured in-depth interviews were conducted to explore the usability of the prototype through convenience sampling (N=15).

RESULTS

The prominent features of the prototype included the use of image-based dietary assessment, food choice tracking with immediate feedback leveraging gamification principles, personal goal setting for food choices, and the provision of recipe ideas and information on the ADG. The overall prototype quality score was "acceptable," with a median of 3.46 (IQR 2.78-3.81) out of 5 points. The median score of the perceived impact of the prototype on healthy eating based on the ADG was 3.83 (IQR 2.75-4.08) out of 5 points. In-depth interviews identified the use of gamification for tracking food choices and innovation in the image-based dietary assessment as the main drivers of the positive user experience of using the prototype.

CONCLUSIONS

A novel evidence-based prototype mobile app was successfully developed by leveraging a cross-disciplinary collaboration. A detailed description of the development process and design of the prototype enhances its transparency and provides detailed insights into its creation. This study provides a valuable example of the development of a novel, evidence-based app for personalized dietary advice on food choices using recent advancements in computer vision. A revised version of this prototype is currently under development.

Double burden of malnutrition and its associated factors among women in low and middle income countries: findings from 52 nationally representative data

BACKGROUND

Double burden of malnutrition (DBM) is an emerging global public health problem. The United Nations member states adopted eradicating all forms of malnutrition as an integral component of the global agenda. However, there is evidence of a high burden of undernutrition among women and rising rates of overweight and obesity, especially in low and middle income countries (LMICs). Therefore, this study aimed to investigate the prevalence and associated factors of underweight, overweight, and obesity among women of reproductive age in LMICs.

METHODS

Data for the study were drawn from a recent 52 Demographic and Health Surveys (DHS) conducted in LMICS. We included a sample of 1,099,187 women of reproductive age. A multilevel multinomial logistic regression model was used to identify factors associated with DBM. Adjusted relative risk ratio (RRR) with a 95% Confidence Interval (CI) was reported to show an association.

RESULTS

The prevalence of underweight, overweight, and obesity in LMICs among women of reproductive age was 15.2% (95% CI: 15.1-15.3), 19.0% (95% CI: 18.9- 19.1), and 9.1% (95% CI: 9.0-9.2), respectively. This study found that women aged 24-34 years, aged ≥ 35 years, with primary, secondary, and above educational level, from wealthy households, using modern contraceptives, exposed to media (radio and television), and with high parity (more than one birth) were more likely to have overweight and obesity and less likely to have underweight. Moreover, the risk of having obesity (RRR = 0.59; 95% CI = 0.58-0.60 and overweight (RRR = 0.78; 95% CI = 0.77-0.79) were lower among rural women, while the risk of being underweight was (RRR = 1.13; 95% CI = 1.11-1.15) higher among rural women compared to urban women.

CONCLUSION

The prevalence of underweight, overweight, and obesity was high among women of reproductive age in LMICs. Underweight, overweight, and obesity are influenced by sociodemographic, socioeconomic, and behavioral-related factors. This study shows that, in order to achieve Sustainable Development Goal 2, a multifaceted intervention approach should be considered to prevent both forms of malnutrition in women of reproductive age. This can be achieved by raising awareness and promoting healthy behaviors such as healthy eating and physical activity, especially among educated women, women from wealthy households, and women exposed to the media.

Impact of obesity on catheter ablation of atrial fibrillation: Patient characteristics, procedural complications, outcomes, and quality of life

INTRODUCTION

Obesity is a well-known risk factor for atrial fibrillation (AF). We aim to evaluate the effect of baseline obesity on procedural complications, AF recurrence, and symptoms following catheter ablation (CA).

METHODS

All consecutive patients undergoing AF ablation (2013-2021) at our center were enrolled in a prospective registry. The study included all consecutive patients with available data on body mass index (BMI). Primary endpoint was AF recurrence based on electrocardiographic documentation. Patients were categorized into five groups according to their baseline BMI. Patients survey at baseline and at follow-up were used to calculate AF symptom severity score (AFSS) as well as AF burden (mean of AF duration score and AF frequency score; scale 0: no AF to 10: continuous and 9 frequencies/durations in between). Patients were scheduled for follow-up visits with 12-lead electrocardiogram at 3, 6, and 12 months after ablation, and every 6 months thereafter.

RESULTS

A total of 5841 patients were included (17% normal weight, 34% overweight, 27% Class I, 13% Class II, and 9% Class III obesity). Major procedural complications were low (1.5%) among all BMI subgroups. At 3 years AF recurrence was the highest in Class III obesity patients (48%) followed by Class II (43%), whereas Class I, normal, and overweight had similar results with lower recurrence (35%). In multivariable analyses, Class III obesity (BMI ≥ 40) was independently associated with increased risk for AF recurrence (hazard ratio, 1.30; confidence interval, 1.06-1.60; p = .01), whereas other groups had similar risk in comparison to normal weight. Baseline AFSS was lowest in normal weight, and highest in Obesity-III, median (interquartile range) 10 (5-16) versus 15 (10-21). In all groups, CA resulted in a significant improvement in their AFSS with a similar magnitude among the groups. At follow-up, AF burden was minimal and did not differ significantly between the groups.

CONCLUSION

AF ablation is safe with a low complication rate across all BMI groups. Morbid obesity (BMI ≥ 40) was significantly associated with reduced AF ablation success. However, ablation resulted in improvement in QoL including reduction of the AFSS, and AF burden regardless of BMI.

Overweight and obesity in adulthood, sociodemographic factors, lifestyle, and the early burden of noncommunicable diseases among Americans: NHANES 2007-2018

OBJECTIVES

To evaluate the association between nutritional status in early adulthood and the burden of noncommunicable diseases (NCDs); To evaluate the influence of sociodemographic factors and lifestyle on the outcomes of BMI kg/m2  ≤24.9, ≥25.0, and ≥30.0; to estimate the population attributable fraction (PAF) to BMI elevated at 25 years old in the burden of NCDs in American adults.

METHODS

We used data from 15 721 American adults participating in the National Health and Nutrition Examination Survey from 2007 to 2018. The Hazard Ratio (HR), Incidence Rate Ratio (IRR), and 95% confidence intervals (CI) were estimated in the proportional risk regression models of Cox (entire population) and Poisson (restricted to non-patients), respectively. The proportionality of the risk between the burden of NCDs and BMI at 25 years old was drawn by the Kaplan-Meier curve, and the PAF was calculated. All analyses were adjusted taking into account the sample weights.

RESULTS

Health disparities (sex, age, race/ethnicity, education, poverty index, and education level), and lifestyle (physical activity, smoking, and alcohol consumption) influenced the current nutritional status. Cumulative survival in overweight and obese groups decreased considerably over time (p < .0001). Being overweight and obese in adulthood may increase the risk of early NCDs (HR: 1.68, 95% CI: 1.54-1.84 and HR: 2.87, 95% CI: 2.56-3.21, respectively). About 22.72% (95% CI: 19.99-25.36, p < .001) of the burden NCDs could have been avoided if overweight at age 25 had been prevented.

CONCLUSIONS

Monitoring weight change from young adulthood can provide a sensitive and useful clinical measure for early detection of adverse trends in NCDs risk.

Impact of front-of-pack nutrition labelling in consumer understanding and use across socio-economic status: A systematic review

An unhealthy diet is a leading contributor to the increasing burden of overweight and obesity. Front-of-pack labelling (FOPL) is being recognized as a policy strategy to promote healthier choices yet there is limited evaluation of FOPL to suggest if it is effective for all population subgroups. This systematic review aimed to assess the impact of FOPL on consumer understanding and usage across socio-economic gradients. Six electronic databases were searched through a systematic search process using key terms for FOPL and socioeconomic status (SES) from 2011 to March 2022 to include studies evaluating the effectiveness of FOPL. A narrative synthesis was conducted and the results were assessed according to the effects of FOPL on consumer awareness, understanding, and usage across SES. The review included 36 articles. In general, people of all SES groups were aware of and more likely to pay attention towards FOPL than the nutrition information panel provided on the back of the package. However, the understanding and usage were relatively poor, particularly in low SES groups. While studies conducted in low SES populations suggest FOPL increased the purchase intention of healthy products, the stratified analysis across SES showed less beneficial effects in low SES individuals. The findings highlight simplified and easy-to-understand FOPLs such as Nutri-score and traffic light labelling are likely to be effective for all populations including low SES groups. Overall, the review suggests FOPLs are more visible than the nutrition information panel and may guide healthier food choices for people of all SES backgrounds. It is unclear whether FOPL influences actual purchasing and food intake as there are insufficient studies comparing the effects among higher and lower SES populations.

Interventions to Address Cardiovascular Risk in Obese Patients: Many Hands Make Light Work

Obesity is a growing public health epidemic worldwide and is implicated in slowing improved life expectancy and increasing cardiovascular (CV) risk; indeed, several obesity-related mechanisms drive structural, functional, humoral, and hemodynamic heart alterations. On the other hand, obesity may indirectly cause CV disease, mediated through different obesity-associated comorbidities. Diet and physical activity are key points in preventing CV disease and reducing CV risk; however, these strategies alone are not always sufficient, so other approaches, such as pharmacological treatments and bariatric surgery, must support them. Moreover, these strategies are associated with improved CV risk factors and effectively reduce the incidence of death and CV events such as myocardial infarction and stroke; consequently, an individualized care plan with a multidisciplinary approach is recommended. More precisely, this review explores several interventions (diet, physical activity, pharmacological and surgical treatments) to address CV risk in obese patients and emphasizes the importance of adherence to treatments.

Mitochondrial metabolic dysfunction and non-alcoholic fatty liver disease: new insights from pathogenic mechanisms to clinically targeted therapy

Metabolic dysfunction-associated fatty liver disease (MAFLD) is among the most widespread metabolic disease globally, and its associated complications including insulin resistance and diabetes have become threatening conditions for human health. Previous studies on non-alcoholic fatty liver disease (NAFLD) were focused on the liver's lipid metabolism. However, growing evidence suggests that mitochondrial metabolism is involved in the pathogenesis of NAFLD to varying degrees in several ways, for instance in cellular division, oxidative stress, autophagy, and mitochondrial quality control. Ultimately, liver function gradually declines as a result of mitochondrial dysfunction. The liver is unable to transfer the excess lipid droplets outside the liver. Therefore, how to regulate hepatic mitochondrial function to treat NAFLD has become the focus of current research. This review provides details about the intrinsic link of NAFLD with mitochondrial metabolism and the mechanisms by which mitochondrial dysfunctions contribute to NAFLD progression. Given the crucial role of mitochondrial metabolism in NAFLD progression, the application potential of multiple mitochondrial function improvement modalities (including physical exercise, diabetic medications, small molecule agonists targeting Sirt3, and mitochondria-specific antioxidants) in the treatment of NAFLD was evaluated hoping to provide new insights into NAFLD treatment.

Visceral adipose tissue and residual cardiovascular risk: a pathological link and new therapeutic options

Obesity is a heterogeneous disease that affects almost one-third of the global population. A clear association has been established between obesity and cardiovascular disease (CVD). However, CVD risk is known to be related more to the local distribution of fat than to total body fat. Visceral adipose tissue (VAT) in particular has a high impact on CVD risk. This manuscript reviews the role of VAT in residual CV risk and the available therapeutic strategies for decreasing residual CV risk related to VAT accumulation. Among the many pathways involved in residual CV risk, obesity and particularly VAT accumulation play a major role by generating low-grade systemic inflammation, which in turn has a high prognostic impact on all-cause mortality and myocardial infarction. In recent years, many therapeutic approaches have been developed to reduce body weight. Orlistat was shown to reduce both weight and VAT but has low tolerability and many drug-drug interactions. Naltrexone-bupropion combination lowers body weight but has frequent side effects and is contraindicated in patients with uncontrolled hypertension. Liraglutide and semaglutide, glucagon-like peptide 1 (GLP-1) agonists, are the latest drugs approved for the treatment of obesity, and both have been shown to induce significant body weight loss. Liraglutide, semaglutide and other GLP-1 agonists also showed a positive effect on CV outcomes in diabetic patients. In addition, liraglutide showed to specifically reduce VAT and inflammatory biomarkers in obese patients without diabetes. GLP-1 agonists are promising compounds to limit inflammation in human visceral adipocytes.

The gap in capacity building on climate, health, and equity in built environment postsecondary education: a mixed-methods study

Institutions of higher education are feeling increasing pressure from both students and the international climate community to offer more courses and joint degrees on the role of the built environment in advancing climate action, population health, and social equity. The built environment plays a leading role in this new, transdisciplinary approach. Thoughtfully designed buildings, neighborhoods, and communities can simultaneously lower per capita greenhouse gas emissions, reduce population exposure to dangerous climate-sensitive extreme weather events, reduce disparities in climate-related health outcomes, and advance social equity goals. This mixed-methods study explored the extent to which post-secondary courses and joint degree programs teach students the research methods and technical skills they will need to design and implement built environment interventions addressing the effects of climate change on population health and social equity. The study found that the number of universities offering courses addressing climate, health, and equity in the built environment grew from 2018 to 2022. The number of joint planning/public health degree programs rose from four in 2005 to 15 in 2022. No joint architecture/public health degree programs were identified. A detailed review of 99 course descriptions from three universities found that 17 courses (roughly 1/5 of the total) covered population health, built environment, and climate change; and, 2/3 of the set (n = 60) covered two out of the three topics. Schools of public health were more likely to offer courses covering all three topics, whereas schools of architecture were more likely to include the building scale in relevant courses. Exposure pathways and social equity/vulnerable populations were the most common methods included in relevant courses. Professors and administrators at institutions identified by the study as "transdisciplinary-ready" reported that accreditation requirements and university rules governing the allocation of student tuition had slowed efforts to offer cross-listed courses. However, faculty in these institutions regularly collaborate informally with their peers - both on transdisciplinary research and by offering guest lectures in each other's courses. The results of this study show that, while universities have made great strides over the past 18 years in beginning to support transdisciplinary research and pedagogy, institutional barriers and gaps in key content areas remain.

The impact of fast food marketing on brand preferences and fast food intake of youth aged 10-17 across six countries

BACKGROUND

Consumption of fast food, which is associated with poor diet, weight gain and the development of noncommunicable diseases, is high amongst youth. Fast food marketing, a modifiable determinant of excess weight and obesity, affects youth's food-related behaviours. This study aimed to examine the relationship between exposure to fast food marketing and the fast food brand preferences and intake amongst youth aged 10-17 across six countries.

METHODS

Data from 9,695 youth respondents living in Australia, Canada, Chile, Mexico, the United Kingdom (UK) and the United States (US) were analyzed from the 2019 International Food Policy Study (IFPS) Youth Survey. Survey measures assessed exposure to fast food marketing and brand-specific marketing, and preference for these brands and fast food intake. Regression models adjusted for age, sex, income adequacy and ethnicity were used to examine the associations.

RESULTS

Exposure to fast food marketing was positively associated with brand preferences and intake consistently across most countries. Overall, preference for McDonald's (OR:1.97; 95% CI:1.52, 2.56), KFC (OR:1.61; 95% CI:1.24, 2.09) and Subway (OR:1.73; 95% CI:1.34, 2.24) were highest when exposed to general fast food marketing ≥ 2x/week compared to never. Preference for McDonald's (OR:2.32; 95% CI:1.92, 2.79), KFC (OR:2.28; 95% CI:1.95, 2.68) and Subway (OR:2.75; 95% CI:2.32, 3.27) were also higher when exposed to marketing for each brand compared to not. Fast food intake was highest in Chile (IRR:1.90; 95% CI:1.45, 2.48), the UK (IRR:1.40; 95% CI:1.20, 1.63), Canada (IRR:1.32; 95% CI:1.19, 1.48), Mexico (IRR:1.26; 95% CI:1.05, 1.53) and the US (IRR:1.21; 95% CI:1.05, 1.41) when exposed to general fast food marketing ≥ 2x/week compared to never and was higher across most countries when exposed to brand-specific marketing compared to not. Respondents classified as ethnic minorities were more likely to report consuming fast food than ethnic majorities, and females were less likely to report consuming fast food than males.

CONCLUSIONS

Exposure to fast food marketing is consistently and positively associated with brand preferences and fast food intake in all six countries. Our results highlight the need for strict government regulation to reduce exposure of unhealthy food marketing to youth in all six countries.

Clinical outcomes and complications of single anastomosis duodenal-ileal bypass with sleeve gastrectomy: A 2-year follow-up study in Bogotá, Colombia

BACKGROUND

The global prevalence of obesity has increased over the past 40 years, and bariatric surgery has proven to be the most effective therapy for long-term weight loss. Its principles are based on modifying the brain-gut axis by altering the gastrointestinal anatomy and affecting the function of gastrointestinal hormones, thereby modifying satiety signals. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) combines both techniques and has become an alternative to gastric bypass and biliopancreatic diversion procedures for treating severe obesity and associated metabolic diseases in selected patients.

AIM

To describe the outcomes and complications of SADI-S.

METHODS

We retrospectively analyzed the data of patients who underwent SADI-S laparoscopically at the Clínica Reina Sofía in Bogotá, Colombia. This study assessed the therapeutic effectiveness of SADI-S in terms of short-term preoperative clinical characteristics, postoperative complications, comorbidities, nutritional defi-ciencies, and intraoperative complications during a 2-year follow-up.

RESULTS

Sixty-one patients with a mean body mass index (BMI) of 50 ± 7.1 kg/m2 underwent laparoscopic SADI-S. The mean operative time and hospital stays were 143.8 ± 42 min and 2.3 ± 0.8 d, respectively. The mean follow-up period was 18 mo, and the mean BMI decreased to 28.5 ± 12.2 kg/m2. The excess BMI loss was 41.8% ± 13.5%, and the weight loss percentage was 81.1% ± 17.0%. Resolution of obesity-related comorbidities, including type 2 diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea, was achieved and defined as complete or partial remission. No intraoperative complications were observed. Short-term complications were observed in four (6.8%) patients. However, larger studies with longer follow-up periods are required to draw definitive conclusions.

CONCLUSION

SADI-S has a low intraoperative and postoperative complication rate and is effective for weight loss and improving obesity-related comorbidities, including hypertension, type 2 diabetes mellitus, dyslipidemia, and sleep apnea syndrome.

Lifestyle habits and obesity indices among male adolescents in Riyadh, Saudi Arabia

Obesity among adolescents is a global health apprehension which requires early prevention. The aim of this study was to determine the association between lifestyle habits including physical activity, sedentary behaviors and eating habits with obesity indices of body mass index (BMI) and waist-to-height ratio (WHtR) among male adolescents in Riyadh, Saudi Arabia. We randomly selected 471 secondary school male adolescents aged 14-18 years. A pre-validated self-reported questionnaire was used to record the data on physical activity level, sedentary behaviors, sleep duration and eating habits. The International Obesity Task Force (IOTF) cutoff values for adolescents under 18 years of age were used to define overweight and obesity. Total energy expenditure was calculated using metabolic equivalent-minutes per week. Anthropometry including weight, height, BMI, waist circumference, waist/height ratio (WHtR), were assessed. 53.7% and 48.4% of the adolescents were overweight/obese and had abdominal obesity; respectively. Those with overweight and obesity or above 50% of WHtR were much less active in terms of METs-min/week from vigorous-intensity sports, sum of all METs-min/week from all vigorous-intensity physical activity, total METs-min/week from all physical activity compared with non-obese adolescents and below 50% of WHtR. The present study identified the lifestyle habits that were associated with obesity and may represent valid targets for the prevention and management of obesity among Saudi adolescents. Knowledge of the factors that contribute to obesity could be used in preventive programs for the control of obesity among adolescents.

Social Network, Food Patterns, Physical Activity and Associations with Overweight and Obesity in Adolescents from a School in Rural Brazil

The objective of this study was to evaluate the social network, food patterns, physical activity, and their associations with overweight/obesity in adolescents from a school in rural Brazil. Students from a rural school in Northeast Brazil (n = 90) completed questionnaires on sociodemographic characteristics, food consumption, physical activity, and a name generator. Social networks were constructed using students' social proximity ties. Principal component analysis was performed to determine food patterns, and logistic models were used to investigate variables associated with overweight/obesity. Most participants were girls (62.9%), and the proportion of overweight/obesity was 30% among adolescents. Students cited 2070 people from their networks (family, friends at school, friends outside of school, and others). Among them, the family had the highest degree of influence (61%) in the network and had the most shared meals with adolescents (47%). Adolescents' perception of their family members' body size as obese, compared to normal or underweight, was prevalent (51%). Adolescents with unhealthy food patterns were 72% more likely to be categorized as overweight/obese, and eigenvector centrality was also associated with overweight/obesity (OR = 5.88, 95% CI = 1.08-32.03). Adolescents presented a social network with strong family influence, in which a high percentage of overweight/obesity was observed. Adolescents with high eigenvector centrality were more likely to be in the overweight/obesity category. Additionally, overweight/obesity was associated with unhealthy food patterns in the family network.

Rebound effects could offset more than half of avoided food loss and waste

Reducing food loss and waste (FLW) could lessen the environmental impacts of food systems and improve food security. However, rebound effects-whereby efficiency improvements cause price decreases and consumption increases-may offset some avoided FLW. Here we model rebounds in food consumption under a scenario of costless FLW reduction. We project that consumption rebound could offset 53-71% of avoided FLW. Such rebounds would imply similar percentage reductions in environmental benefits (carbon emissions, land use, water use) and improvements in food security benefits (increased calorie availability), highlighting a tension between these two objectives. Evidence from energy systems suggests that indirect effects not included in our analysis could further increase rebounds. However, costs of reducing FLW would reduce rebounds. Rebound effects are therefore important to consider in efforts aimed at reducing FLW.

Reversing food preference through multisensory exposure

Experiencing food craving is nearly ubiquitous and has several negative pathological impacts prompting an increase in recent craving-related research. Food cue-reactivity tasks are often used to study craving, but most paradigms ignore the individual food preferences of participants, which could confound the findings. We explored the neuropsychological correlates of food craving preference using psychophysical tasks on human participants considering their individual food preferences in a multisensory food exposure set-up. Participants were grouped into Liked Food Exposure (LFE), Disliked Food Exposure (DFE), and Neutral Control (NEC) based on their preference for sweet and savory items. Participants reported their momentary craving for the displayed food stimuli through the desire scale and bidding scale (willingness to pay) pre and post multisensory exposure. Participants were exposed to food items they either liked or disliked. Our results asserted the effect of the multisensory food exposure showing a statistically significant increase in food craving for DFE participants postexposure to disliked food items. Using computational models and statistical methods, we also show that the desire for food does not necessarily translate to a willingness to pay every time, and instantaneous subjective valuation of food craving is an important parameter for subsequent action. Our results further demonstrate the role of parietal N200 and centro-parietal P300 in reversing food preference and possibly point to the decrease of inhibitory control in up-regulating craving for disliked food.

State-Specific Prevalence of Severe Obesity Among Adults in the US Using Bias Correction of Self-Reported Body Mass Index

INTRODUCTION

Adults with severe obesity are at increased risk for poor metabolic health and may need more intensive clinical and community supports. The prevalence of severe obesity is underestimated from self-reported weight and height data. We examined severe obesity prevalence among US adults by sociodemographic characteristics and by state after adjusting for self-report bias.

METHODS

Using a validated bias-correction method, we adjusted self-reported body mass index (BMI) data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) by using measured data from the National Health and Nutrition Examination Survey. We compared bias-corrected prevalence of severe obesity (BMI ≥40) with self-reported estimates by sociodemographic characteristics and state.

RESULTS

Self-reported BRFSS data significantly underestimated the prevalence of severe obesity compared with bias-corrected estimates. In 2020, 8.8% of adults had severe obesity based on the bias-corrected estimates, whereas 5.3% of adults had severe obesity based on self-reported data. Women had a significantly higher prevalence of bias-corrected severe obesity (11.1%) than men (6.5%). State-level prevalence of bias-corrected severe obesity ranged from 5.5% (Massachusetts) to 13.2% (West Virginia). Based on bias-corrected estimates, 16 states had a prevalence of severe obesity greater than 10%, a level not seen in the self-reported estimates.

CONCLUSION

Self-reported BRFSS data underestimated the overall prevalence of severe obesity by 40% (5.3% vs 8.8%). Accurate state-level estimates of severe obesity can help public health and health care decision makers prioritize and plan to implement effective prevention and treatment strategies for people who are at high risk for poor metabolic health.

BMI and well-being in people of East Asian and European ancestry: a Mendelian randomisation study

Previous studies have linked higher body mass index (BMI) to lower subjective well-being in adult European ancestry populations. However, our understanding of these relationships across different populations is limited. Here, we investigated the association between BMI and well-being in people of (a) East Asian and (b) European ancestry in the China Kadoorie Biobank (CKB) and UK Biobank (UKB), respectively. Mendelian randomisation (MR) methods were used to test the relationship between BMI with (a) health satisfaction and (b) life satisfaction. One-sample MR enabled us to test effects in men and women separately and to test the role of cultural contexts by stratifying our analyses by urban and rural home location in both China and the UK. Further, we implemented a control function method to test the linearity of the BMI-well-being relationship. We found evidence of different associations between BMI and well-being in individuals of East Asian versus European ancestry. For example, a genetically instrumented higher BMI tentatively associated with higher health satisfaction in people of East Asian ancestry, especially in females (ß: 0.041, 95% CI: 0.002, 0.081). In contrast, there was a robust inverse association between higher genetically instrumented BMI and health satisfaction in all European ancestry UKB participants (ß: -0.183, 95% CI: -0.200, -0.165, Pdifference < 1.00E-15). We also showed the importance of considering non-linear relationships in the MR framework by providing evidence of non-linear relationships between BMI and health and life satisfaction. Overall, our study suggests potential setting-specific causality in the relationship between BMI and subjective well-being, with robust differences observed between East Asians and Europeans when considering very similar outcomes. We highlight the importance of (a) considering potential non-linear relationships in causal analyses and (b) testing causal relationships in different populations, as the casual nature of relationships, especially relationships influenced by social processes, may be setting-specific.

The Relationship between the Source of Dietary Animal Fats and Proteins and the Gut Microbiota Condition and Obesity in Humans

The relationship between gut microbiota and obesity is well documented in humans and animal models. Dietary factors can change the intestinal microbiota composition and influence obesity development. However, knowledge of how diet, metabolism, and intestinal microbiota interact and modulate energy metabolism and obesity development is still limited. Epidemiological studies show a link between consuming dietary proteins and fats from specific sources and obesity. Animal studies confirm that proteins and fats of different origins differ in their ability to prevent or induce obesity. Protein sources, such as meat, dairy products, vegetables, pulses, and seafood, vary in their amino acid composition. In addition, the type and level of other factors, such as fatty acids or persistent organic pollutants, vary depending on the source of dietary protein. All these factors can modulate the intestinal microbiota composition and, thus, may influence obesity development. This review summarizes selected evidence of how proteins and fats of different origins affect energy efficiency, obesity development, and intestinal microbiota, linking protein and fat-dependent changes in the intestinal microbiota with obesity.

Change Profiles and Functional Targets of MicroRNAs in Type 2 Diabetes Mellitus Patients with Obesity

BACKGRUOUND

MicroRNAs (miRNAs) exert an essential contribution to obesity and type 2 diabetes mellitus (T2DM). This study aimed to investigate the differences of miRNAs in the presence and absence of T2DM in patients with obesity, as well as before and after bariatric surgery in T2DM patients with obesity. Characterization of the common changes in both was further analyzed.

METHODS

We enrolled 15 patients with obesity but without T2DM and 15 patients with both obesity and T2DM. Their preoperative clinical data and serum samples were collected, as well as 1 month after bariatric surgery. The serum samples were analyzed by miRNA sequencing, and the miRNAs profiles and target genes characteristics were compared.

RESULTS

Patients with T2DM had 16 up-regulated and 32 down-regulated miRNAs compared to patients without T2DM. Improvement in metabolic metrics after bariatric surgery of T2DM patients with obesity was correlated with changes in miRNAs, as evidenced by the upregulation of 20 miRNAs and the downregulation of 30 miRNAs. Analysis of the two miRNAs profiles identified seven intersecting miRNAs that showed opposite changes. The target genes of these seven miRNAs were substantially enriched in terms or pathways associated with T2DM.

CONCLUSION

We determined the expression profiles of miRNAs in the obese population, with and without diabetes, before and after bariatric surgery. The miRNAs that intersected in the two comparisons were discovered. Both the miRNAs discovered and their target genes were closely associated with T2DM, demonstrating that they might be potential targets for the regulation of T2DM.

Effects of a Web-Based Lifestyle Intervention on Weight Loss and Cardiometabolic Risk Factors in Adults With Overweight and Obesity: Randomized Controlled Clinical Trial

BACKGROUND

The high proportion of people with overweight and obesity has become a worldwide problem in recent decades, mainly due to health consequences, such as cardiovascular diseases, neoplasia, and type 2 diabetes mellitus. Regarding effective countermeasures, the digitization of health services offers numerous potentials, which, however, have not yet been sufficiently evaluated. Web-based health programs are becoming increasingly interactive and can provide individuals with effective long-term weight management support.

OBJECTIVE

The purpose of this randomized controlled clinical trial was to evaluate the effectiveness of an interactive web-based weight loss program on anthropometric, cardiometabolic, and behavioral variables and to compare it with a noninteractive web-based weight loss program.

METHODS

The randomized controlled trial included people who were aged between 18 and 65 years (mean 48.92, SD 11.17 years) and had a BMI of 27.5 to 34.9 kg/m² (mean 30.71, SD 2.13 kg/m²). Participants (n=153) were assigned to either (1) an interactive and fully automated web-based health program (intervention) or (2) a noninteractive web-based health program (control). The intervention program focused on dietary energy density and allowed for dietary documentation with appropriate feedback on energy density and nutrients. The control group only received information on weight loss and energy density, but the website did not contain interactive content. Examinations were performed at baseline (t0), at the end of the 12-week intervention (t1), and at 6 months (t2) and 12 months (t3) thereafter. The primary outcome was body weight. The secondary outcomes were cardiometabolic variables as well as dietary and physical activity behaviors. Robust linear mixed models were used to evaluate the primary and secondary outcomes.

RESULTS

The intervention group showed significant improvements in anthropometric variables, such as body weight (P=.004), waist circumference (P=.002), and fat mass (P=.02), compared with the control group over the course of the study. The mean weight loss after the 12-month follow-up was 4.18 kg (4.7%) in the intervention group versus 1.29 kg (1.5%) in the control group compared with the initial weight. The results of the nutritional analysis showed that the energy density concept was significantly better implemented in the intervention group. Significant differences in cardiometabolic variables were not detected between the 2 groups.

CONCLUSIONS

The interactive web-based health program was effective in reducing body weight and improving body composition in adults with overweight and obesity. However, these improvements were not associated with relevant changes in cardiometabolic variables, although it should be noted that the study population was predominantly metabolically healthy.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00020249; https://drks.de/search/en/trial/DRKS00020249.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3390/ijerph19031393.

Exercise and Experiments of Nature

In this article, we highlight the contributions of passive experiments that address important exercise-related questions in integrative physiology and medicine. Passive experiments differ from active experiments in that passive experiments involve limited or no active intervention to generate observations and test hypotheses. Experiments of nature and natural experiments are two types of passive experiments. Experiments of nature include research participants with rare genetic or acquired conditions that facilitate exploration of specific physiological mechanisms. In this way, experiments of nature are parallel to classical "knockout" animal models among human research participants. Natural experiments are gleaned from data sets that allow population-based questions to be addressed. An advantage of both types of passive experiments is that more extreme and/or prolonged exposures to physiological and behavioral stimuli are possible in humans. In this article, we discuss a number of key passive experiments that have generated foundational medical knowledge or mechanistic physiological insights related to exercise. Both natural experiments and experiments of nature will be essential to generate and test hypotheses about the limits of human adaptability to stressors like exercise. © 2023 American Physiological Society. Compr Physiol 13:4879-4907, 2023.

Could Microplastics Be a Driver for Early Onset Colorectal Cancer?

Introduction: The incidence of colorectal cancer in those under 50 years of age (early onset colorectal cancer (EOCRC)) is increasing throughout the world. This has predominantly been an increase in distal colonic and rectal cancers, which are biologically similar to late onset colorectal cancer (LOCRC) but with higher rates of mucinous or signet ring histology, or poorly differentiated cancers. The epidemiology of this change suggests that it is a cohort effect since 1960, and is most likely driven by an environmental cause. We explore the possible role of microplastics as a driver for this change. Review: The development of sporadic colorectal cancer is likely facilitated by the interaction of gut bacteria and the intestinal wall. Normally, a complex layer of luminal mucus provides colonocytes with a level of protection from the effects of these bacteria and their toxins. Plastics were first developed in the early 1900s. After 1945 they became more widely used, with a resultant dramatic increase in plastic pollution and their breakdown to microplastics. Microplastics (MPs) are consumed by humans from an early age and in increasingly large quantities. As MPs pass through the gastrointestinal tract they interact with the normal physiological mechanism of the body, particularly in the colon and rectum, where they may interact with the protective colonic mucus layer. We describe several possible mechanisms of how microplastics may disrupt this mucus layer, thus reducing its protective effect and increasing the likelihood of colorectal cancer. Conclusions: The epidemiology of increase in EOCRC suggests an environmental driver. This increase in EOCRC matches the time sequence in which we could expect to see an effect of rapid increase of MPs in the environment and, as such, we have explored possible mechanisms for this effect. We suggest that it is possible that the MPs damage the barrier integrity of the colonic mucus layer, thus reducing its protective effect. MPs in CRC pathogenesis warrants further investigation. Future directions: Further clarification needs to be sought regarding the interaction between MPs, gut microbiota and the mucus layer. This will need to be modelled in long-term animal studies to better understand how chronic consumption of environmentally-acquired MPs may contribute to an increased risk of colorectal carcinogenesis.

Body mass index does not affect response of rituximab in patients with rheumatoid arthritis: results from the TURKBİO registry

Background/aim

Adipose tissue produces several inflammatory mediators. Thus, obesity affects the disease course and the responses to the antirheumatic agents in inflammatory diseases. The aim of the study was to determine whether the body mass index (BMI) is involved in the response to rituximab in rheumatoid arthritis (RA).

Materials and methods

This multicenter retrospective study included 206 RA patients who received rituximab from the Turkish Biologic (TURKBIO) registry between 2011 and the end of May 2017. Demographic and clinical data including age, sex, disease type, disease duration, and previous or current treatment with disease-modifying antirheumatic drugs (DMARDs) and biological drug durations are stored in the database. Patients with a BMI ≥30 kg/m2 were classified as obese, and patients with a BMI <30 kg/m2 were classified as nonobese. Kaplan-Meier survival analysis was performed to estimate the drug survival. The subgroups were compared using the log-rank test.

Results

The mean BMI of 206 patients included in the study was 27.05 (17.2-43.4) kg/m2. There were 59 (28.6%) patients in the obese group and 147 (71.4%) patients in the nonobese group. The mean age, female percentage, and baseline disease activity score 28 (DAS28) were higher in the obese group than in the nonobese group. However, the ΔDAS28 at both 6 and 12 months were not significantly different between the groups (p = 0.785 and p = 0.512, respectively). Patient pain Visual Analogue Scale (VAS), patient fatigue VAS, and patient global VAS scores were also significantly higher at baseline in the obese group (p = 0.003, p = 0.006, and p = 0.006, respectively). However, no significant difference was found in terms of changes in patient pain VAS, patient fatigue VAS, patient global VAS and physician global VAS scores at 6 and 12 months compared to those at baseline. Rituximab treatment was ongoing for 71.2% of the obese and 63.3% of the nonobese patients (p = 0.279). The median drug survival duration was 77 months in the obese group and 62 months in the nonobese group (p = 0.053). The estimated drug survival rates for rituximab were not statistically significantly different in the obese and nonobese groups. Rituximab-related side effects were also similar between the groups.

Conclusion

In obese and nonobese patients with RA, rituximab treatment exhibits similar side effects and similar long-term efficacy. These results suggest that obesity does not alter drug survival for rituximab and response rates, in RA and rituximab may be a favorable treatment agent in patients with RA and obesity.

State of art on the mechanisms of laparoscopic sleeve gastrectomy in treating type 2 diabetes mellitus

Obesity and type-2 diabetes mellitus (T2DM) are metabolic disorders. Obesity increases the risk of T2DM, and as obesity is becoming increasingly common, more individuals suffer from T2DM, which poses a considerable burden on health systems. Traditionally, pharmaceutical therapy together with lifestyle changes is used to treat obesity and T2DM to decrease the incidence of comorbidities and all-cause mortality and to increase life expectancy. Bariatric surgery is increasingly replacing other forms of treatment of morbid obesity, especially in patients with refractory obesity, owing to its many benefits including good long-term outcomes and almost no weight regain. The bariatric surgery options have markedly changed recently, and laparoscopic sleeve gastrectomy (LSG) is gradually gaining popularity. LSG has become an effective and safe treatment for type-2 diabetes and morbid obesity, with a high cost-benefit ratio. Here, we review the me-chanism associated with LSG treatment of T2DM, and we discuss clinical studies and animal experiments with regard to gastrointestinal hormones, gut microbiota, bile acids, and adipokines to clarify current treatment modalities for patients with obesity and T2DM.

The body mass index is associated with increased temporal variability of functional connectivity in brain reward system

The reward system has been proven to be contributed to the vulnerability of obesity. Previous fMRI studies have shown abnormal functional connectivity of the reward system in obesity. However, most studies were based on static index such as resting-state functional connectivity (FC), ignoring the dynamic changes over time. To investigate the dynamic neural correlates of obesity susceptibility, we used a large, demographically well-characterized sample from the Human Connectome Project (HCP) to determine the relationship of body mass index (BMI) with the temporal variability of FC from integrated multilevel perspectives, i.e., regional and within- and between-network levels. Linear regression analysis was used to investigate the association between BMI and temporal variability of FC, adjusting for covariates of no interest. We found that BMI was positively associated with regional FC variability in reward regions, such as the ventral orbitofrontal cortex and visual regions. At the intra-network level, BMI was positively related to the variability of FC within the limbic network (LN) and default mode network (DMN). At the inter-network level, variability of connectivity of LN with DMN, frontoparietal, sensorimotor, and ventral attention networks showed positive correlations with BMI. These findings provided novel evidence for abnormal dynamic functional interaction between the reward network and the rest of the brain in obesity, suggesting a more unstable state and over-frequent interaction of the reward network and other attention and cognitive networks. These findings, thus, provide novel insight into obesity interventions that need to decrease the dynamic interaction between reward networks and other brain networks through behavioral treatment and neural modulation.

Using patient-reported outcome measures to assess the effectiveness of social media networking programs for people living with overweight and obesity to adopt a healthier lifestyle

Introduction

Overweight, obesity, and their associated health complications have become a major public health issue. Online approaches have been rarely attempted to address the problem. The aim of this study was to evaluate the effectiveness of using social media networking for people living with overweight and obesity to adopt a healthier lifestyle with a three-month multidisciplinary healthcare program. Effectiveness was assessed through questionnaires on patient-related outcome measures (PROMs).

Materials and methods

Two non-profit associations designed the program delivered to people living with overweight and obesity in a closed group via Facebook, the popular social network. The three-month program had three main axes, namely nutrition, psychology, and physical activity. Anthropomorphic data and sociodemographic profiles were collected. Quality of life (QoL) was assessed at the beginning and at the end of the intervention using PROM questionnaires for six different domains, i.e., body image, eating behavior, physical, sexual, social, and psychological functioning.

Results

Six hundred and twenty persons participated in the program; 567 persons consented for the study, and 145 completed the questionnaires entirely. QoL was significantly improved in five out of six domains, i.e., body image, eating behavior, as well as physical, sexual, and psychological functioning. The improvement was valid regardless of age, gender, initial body mass index, person with or without children, educational level (primary versus secondary versus high school), and occupation (employment compared to unemployment or any kind of social assistance). In multivariate analysis, living as a couple was an independent factor correlated to a positive progression in four domains, i.e., body image, eating behavior, as well as physical, and psychological functioning.

Conclusion

This study showed that an online lifestyle intervention might be a promising way of improving the quality of life of people living with overweight or obesity.

National income and macro-economic correlates of the double burden of malnutrition: an ecological study of adult populations in 188 countries over 42 years

BACKGROUND

The double burden of malnutrition (DBM) represents a growing global challenge with adverse health and economic consequences. We aimed to investigate the associative roles of national income (gross domestic product per capita [GDPPC]) and macro-environmental factors on the DBM trends among national adult populations.

METHODS

In this ecological study we assembled extensive historical data on GDPPC from the World Bank World Development Indicators database and population-level DBM data of adults (aged ≥18 years) from the WHO Global Health Observatory database in 188 countries over 42 years (1975-2016). In our analysis, a country was considered to have the DBM in a year when adult overweight (BMI ≥25·0 kg/m²) and underweight (BMI <18·5 kg/m²) prevalence was each 10% or more in that year. We used a Type 2 Tobit model to estimate the association of GDPPC and selected macro-environmental factors (globalisation index, adult literacy rate, female share in the labour force, share of agriculture in the national gross domestic product [GDP], prevalence of undernourishment, and percentage of principal display area mandated to be covered by health warnings on cigarette packaging) with DBM in 122 countries.

FINDINGS

We find a negative association between GDPPC and the likelihood of a country having the DBM. However, conditional on its presence, DBM level exhibits an inverted-U shaped association with GDPPC. We found an upward shift in DBM levels from 1975 to 2016 across countries at the same level of GDPPC. Among the macro-environmental variables, share of females in the labour force and share of agriculture in the national GDP are negatively associated with DBM presence in a country, whereas the prevalence of undernourishment in the population is positively associated. Further, globalisation index, adult literacy rate, share of females in the labour force, and health warnings on cigarette packaging are negatively associated with DBM levels in countries.

INTERPRETATION

DBM level in national adult populations rises with GDPPC until US$11 113 (in 2021 constant dollar terms) and then starts declining. Given their current GDPPC levels, most low-income and middle-income countries are thus unlikely to have a decline in the DBM levels in the near future, ceteris paribus. Those countries will also be expected to experience a higher DBM level at similar levels of national income than were historically experienced by the current high-income countries. Our findings point to a further intensification of the DBM challenge in the near future for the low-income and middle-income countries as they continue to have income growth.

FUNDING

None.

Personal, behavioural and socio-environmental correlates of emerging adults' sustainable food consumption in a cross-sectional analysis

OBJECTIVE

Describe how dietary intake patterns of US young adults align with the EAT-Lancet Planetary Health Diet (PHD) sustainable diet goals and identify personal, behavioural, and socio-environmental correlates of sustainable intake.

DESIGN

Data on past-year dietary intake were captured using a FFQ. The PHD was applied to specific food groups, and a total PHD score was calculated. Linear regression models were used to identify associations between personal, behavioural and socio-environmental factors and PHD scores.

SETTING

This cross-sectional analysis uses data from the second wave of EAT 2010-2018 (Eating and Activity over Time), a population-based longitudinal study recruited in Minnesota.

PARTICIPANTS

Ethnically/racially diverse group of participants (n 1308) with a mean age of 22·1 (sd 2·0) years.

RESULTS

The mean PHD score was 4·1 (sd 1·4) on a scale of 0-14, with 14 representing the most sustainable. On average, participants consumed fewer whole grains, fish, legumes, soya, and nuts than ideal for a sustainable diet, and an excess of eggs, added sugar, and meat. The PHD score was higher for participants with higher socio-economic status (SES) and greater educational attainment. Higher home availability of healthy food (β = 0·24, P < 0·001) and less frequent fast-food consumption (β = -0·26, P < 0·001) were the strongest correlates of PHD scores.

CONCLUSIONS

Results suggest that a high percentage of participants may not be achieving the sustainable diet goals defined by the PHD. Reductions in meat consumption and increases in plant-based foods are necessary to increase the sustainability of US young adults' diets.