Background Sweetened beverage intake may play a role in non-alcoholic fatty liver disease (NAFLD) development, but scientific evidence on their role is limited. This study examined associations between sugar-sweetened beverages (SSB), low/no-calorie beverages (LNCB) and fruit juice (FJ) intakes and NAFLD in four European studies. Methods Data for 42,024 participants of Lifelines Cohort, NQPlus, PREDIMED-Plus and Alpha Omega Cohort were cross-sectionally analysed. NAFLD was assessed using Fatty Liver Index (FLI) (≥60). Restricted cubic spline analyses were used to visualize dose–response associations in Lifelines Cohort. Cox proportional hazard regression analyses with robust variance were performed for associations in individual cohorts; data were pooled using random effects meta-analysis. Models were adjusted for demographic, lifestyle, and other dietary factors. Results Each additional serving of SSB per day was associated with a 7% higher FLI-defined NAFLD prevalence (95%CI 1.03–1.11). For LNCB, restricted cubic spline analysis showed a nonlinear association with FLI-defined NAFLD, with the association getting stronger when consuming ≤1 serving/day and levelling off at higher intake levels. Pooled Cox analysis showed that intake of >2 LNCB servings/week was positively associated with FLI-defined NAFLD (PR 1.38, 95% CI 1.15–1.61; reference: non-consumers). An inverse association was observed for FJ intake of ≤2 servings/week (PR 0.92, 95% CI: 0.88–0.97; reference: non-consumers), but not at higher intake levels. Theoretical replacement of SSB with FJ showed no significant association with FLI-defined NAFLD prevalence (PR 0.97, 95% CI 0.95–1.00), whereas an adverse association was observed when SSB was replaced with LNCB (PR 1.12, 95% CI 1.03–1.21). Conclusions Pooling results of this study showed that SSB and LNCB were positively associated with FLI-defined NAFLD prevalence. Theoretical replacement of SSB with LNCB was associated with higher FLI-defined NAFLD prevalence. An inverse association was observed between moderate intake of FJ and FLI-defined NAFLD. Our results should be interpreted with caution as reverse causality cannot be ruled out.

Results of prospective studies investigating associations between low/no-calorie sweeteners (LNCS) and body weight-related outcomes are inconclusive. We conducted dose–response and theoretical replacement individual patient data meta-analyses using harmonised prospective data to evaluate associations between sugar-sweetened beverage (SSB) consumption, low/no-calorie sweetened beverage (LNCB) consumption, and changes in body weight and waist circumference. Individual participant data were obtained from five European studies, i.e., Lifelines Cohort Study, NQplus study, Alpha Omega Cohort, Predimed-Plus study, and Feel4diabetes study, including 82,719 adults aged 18–89 with follow-up between 1 and 9 years. Consumption of SSB and LNCB was assessed using food-frequency questionnaires. Multiple regression analyses adjusting for major confounders and including substitution models were conducted to quantify associations in individual cohorts; random-effects meta-analyses were performed to pool individual estimates. Overall, pooled results showed weak adverse associations between SSB consumption and changes in body weight (+ 0.02 kg/y, 95

"Nudge" policies are increasingly popular, seeking to modify health-related decisions by affecting response to available options. Thus, critical appraisals of the effectiveness of health-related nudging interventions could help health policy makers in making evidence-based decisions with regards to which of these interventions should be incorporated into policy. The aim of the present effort was to systematically appraise the evidence on nudging interventions on healthy diet and physical activity (PA). A systematic review was performed using Pubmed, Web of Science Core Collection citation index and the Cochrane Controlled Register of Trials (CENTRAL). Interventional studies were included if they quantitatively assessed healthy diet and/or PA interventions that were explicitly related to a nudging context. Methodological assessment was performed using the Cochrane collaboration's risk of bias tool and the Research Triangle Institute item bank. Sixty-four studies were included with varying degrees of bias. Sixty studies investigated healthy diet interventions, three studied PA interventions and one studied interventions pertaining to both. Overall, specific types of interventions such as proximity and presentation alterations can be effective in encouraging people towards the adoption of healthier diet choices, whereas labelling, availability, prompting, functional design and sizing "nudge" interventions provide inconclusive results so far. Nudging interventions improving convenience seem to be effective in encouraging people towards making healthier diet choices, whereas evidence on PA is limited. Further conceptual development and research is needed to optimally determine the type, intensity and circumstances that make nudge-related interventions more effective, particularly regarding PA.

•Las dietas vegetarianas no son necesariamente equivalentes a dietas equilibradas y saludables. Deben incluir una variedad de alimentos saludables a base de alimentos de origen vegetal y paralelamente se reducen las opciones de alimentos menos saludables tales como bebidas azucaradas, néctares de frutas y granos refinados.•Una alimentación vegetariana planificada de manera adecuada es apropiada a todas las etapas del ciclo vital, incluido el embarazo, la lactancia y los primeros años de vida, siempre que se aporten todos los nutrientes que el organismo necesita.•Las dietas vegetarianas estrictas requieren un consejo y un seguimiento cuidadoso y personalizado, haciendo hincapié en el aporte adecuado de determinados nutrientes.•La vitamina B12 es un nutriente que merece una especial atención en aquellos individuos que no consumen ningún tipo de producto animal. Es importante realizar un control analítico frecuente para constatar que las fuentes dietéticas y de suplementos consumidas sean apropiadas para este micronutriente.

Background: Nowadays the food production, supply and consumption chain represent a major cause of ecological pressure on the natural environment, and diet links worldwide human health with environmental sustainability. Food policy, dietary guidelines and food security strategies need to evolve from the limited historical approach, mainly focused on nutrients and health, to a new one considering the environmental, socio-economic and cultural impact-and thus the sustainability-of diets. Objective: To present an updated version of the Mediterranean Diet Pyramid (MDP) to reflect multiple environmental concerns. Methods: We performed a revision and restructuring of the MDP to incorporate more recent findings on the sustainability and environmental impact of the Mediterranean Diet pattern, as well as its associations with nutrition and health. For each level of the MDP we provided a third dimension featuring the corresponding environmental aspects related to it. Conclusions: The new environmental dimension of the MDP enhances food intake recommendations addressing both health and environmental issues. Compared to the previous 2011 version, it emphasizes more strongly a lower consumption of red meat and bovine dairy products, and a higher consumption of legumes and locally grown eco-friendly plant foods as much as possible.

There is a growing recognition that social support can potentially exert consistent or opposing effects in influencing health behaviours. The present paper presents a cross-sectional study, including 2,064 adults from Italy, Spain and Greece, who were participants in a multi-centre randomised controlled trial (C4H study), aiming to examine whether social support is correlated with adherence to a healthy Mediterranean diet and physical activity. Social support data were available for 1,572 participants. The majority of the sample reported emotional support availability (84·5 %), financial support availability (72·6 %) and having one or more close friends (78·2 %). Mediterranean diet adherence was significantly associated with emotional support ( P = 0·009) and social network support ( P = 0·021). No statistically significant associations were found between participant physical activity and the social support aspects studied. In conclusion, emotional and social network support may be associated with increased adherence to the Mediterranean diet. However, further research is needed to evaluate the role of social support in adherence to healthy Mediterranean diet.

Objective: An online intervention to improve fruit and vegetable (FV) intake examines the role of planning, outcome expectancies, self-efficacy and gender. Women are not only expected to eat more FV than men, but they are also expected to be more responsive to nutritional advice and benefit more from treatment.Method: A two-arm digital intervention with 269 men and 395 women (Mage = 41.2, SDage = 11.45; range: 19–66 years) was conducted in Italy, Spain and Greece, followed up at three and six months, comparing a static with a dynamic, feedback-intensive platform.Results: Linear mixed models yielded an increase in FV consumption in both the dynamic and the static intervention arms. In men, outcome expectancies were positively related to follow-up FV intake. Dietary planning interacted with self-efficacy on behavioural outcomes.Conclusion: FV intake increased overall, and being a woman and involvement in planning facilitated behaviour change. Women seemed to be more engaged in the dynamic platform resulting in a higher amount of planning. Initial motivation, as indicated by outcome expectancies, seemed to be beneficial for men. Self-efficacious individuals benefitted from their engagement in planning, but self-efficacy did not compensate for failing to plan.

The burden of malnutrition presents itself in multiple, complex, and connected ways. Malnutrition does not always imply hunger or famine and is manifest in many forms, ranging from hunger to obesity. Core factors leading to malnutrition include excessive intakes, insufficient food consumption, and inadequate utilization of nutrients provided by foods ingested. Undernutrition is a term that comprises stunting, underweight, wasting, and deficiency in essential vitamins and minerals (also called micronutrients). As such, it is the category of malnutrition that represents nutrient deficits. The other form of malnutrition is associated with excessive energy and nutrient intakes (which may also be accompanied by micronutrient deficiencies or suboptimal intakes), leading to obesity and other diet-related noncommunicable diseases. This article focuses on undernutrition and the challenges countries face in dealing with both undernutrition and overnutrition, in essence, the dilemma of overlapping and coexisting forms of malnutrition.

Commonly, health behaviour theories have been applied to single behaviours, giving insights into specific behaviours but providing little knowledge on how individuals pursue an overall healthy lifestyle. In the context of diet and physical activity, we investigated the extent to which cross-behaviour cognitions, namely transfer cognitions and compensatory health beliefs, contribute to single behaviour theory. A total of 767 participants from two European regions (i.e., Germany n  =   351, southern Europe n  =   416) completed online questionnaires on physical activity and healthy dietary behaviour, behaviour-specific cognitions (i.e., self-efficacy, outcome expectancies, risk perception, intention, action planning, action control), as well as cross-behaviour cognitions, namely transfer cognitions and compensatory health beliefs. Nested path models were specified to investigate the importance of cross-behaviour cognitions over and above behaviour-specific predictors of physical activity and healthy nutrition. Across both health behaviours, transfer cognitions were positively associated with intention and self-regulatory strategies. Compensatory health beliefs were negatively associated with intention. Action planning and action control mediated the effect of intentions on behaviour. Cross-behaviour cognitions contribute to single behaviour theory and may explain how individuals regulate more than one health behaviour. What is already known on this subject? What does this study add?

OBJECTIVES:Commonly, health behaviour theories have been applied to single behaviours, giving insights into specific behaviours but providing little knowledge on how individuals pursue an overall healthy lifestyle. In the context of diet and physical activity, we investigated the extent to which cross-behaviour cognitions, namely transfer cognitions and compensatory health beliefs, contribute to single behaviour theory.DESIGN:A total of 767 participants from two European regions (i.e., Germany n = 351, southern Europe n = 416) completed online questionnaires on physical activity and healthy dietary behaviour, behaviour-specific cognitions (i.e., self-efficacy, outcome expectancies, risk perception, intention, action planning, action control), as well as cross-behaviour cognitions, namely transfer cognitions and compensatory health beliefs.METHODS:Nested path models were specified to investigate the importance of cross-behaviour cognitions over and above behaviour-specific predictors of physical activity and healthy nutrition.RESULTS:Across both health behaviours, transfer cognitions were positively associated with intention and self-regulatory strategies. Compensatory health beliefs were negatively associated with intention. Action planning and action control mediated the effect of intentions on behaviour.CONCLUSIONS:Cross-behaviour cognitions contribute to single behaviour theory and may explain how individuals regulate more than one health behaviour. Statement of contribution What is already known on this subject? Cross-behaviour cognitions are related to a healthy lifestyle. Compensatory health beliefs hinder the adoption of a healthy lifestyle. Transfer cognitions encourage the engagement in a healthy lifestyle. What does this study add? Transfer cognitions were positively associated with intentions, action planning, and action control over and above behaviour-specific cognitions. Compensatory health beliefs were related to intentions only. Both facilitating and debilitating cross-behaviour cognitions need to be studied within a unified multiple behaviour research framework.

In 1996, the World Food Summit reaffirmed the inalienable right that each person across the globe has to access safe, adequate and nutritious food. At that time a goal was established to reduce by half the number of undernourished persons worldwide by 2015, in other words the year that we are now commencing. Different countries and organisations considered the necessity of reaching consensus and developing indicators for measuring household food insecurity. The availability of a simple but evidence-based measurement method to identify nutritionally at-risk population groups constitutes an essential instrument for implementing strategies that effectively address relevant key issues.

AbstractObjectiveTo provide the evidence base for targeted nutrition policies to reduce the risk of micronutrient/diet-related diseases among disadvantaged populations in Europe, by focusing on: folate, vitamin B12, Fe, Zn and iodine for intake and status; and vitamin C, vitamin D, Ca, Se and Cu for intake.DesignMEDLINE and Embase databases were searched to collect original studies that: (i) were published from 1990 to 2011; (ii) involved >100 subjects; (iii) had assessed dietary intake at the individual level; and/or (iv) included best practice biomarkers reflecting micronutrient status. We estimated relative differences in mean micronutrient intake and/or status between the lowest and highest socio-economic groups to: (i) evaluate variation in intake and status between socio-economic groups; and (ii) report on data availability.SettingEurope.SubjectsChildren, adults and elderly.ResultsData from eighteen publications originating primarily from Western Europe showed that there is a positive association between indicators of socio-economic status and micronutrient intake and/or status. The largest differences were observed for intake of vitamin C in eleven out of twelve studies (5–47 %) and for vitamin D in total of four studies (4–31 %).ConclusionsThe positive association observed between micronutrient intake and socio-economic status should complement existing evidence on socio-economic inequalities in diet-related diseases among disadvantaged populations in Europe. These findings could provide clues for further research and have implications for public health policy aimed at improving the intake of micronutrients and diet-related diseases.

Background Kawasaki disease (KD) is an acute multisystem vasculitis predominantly affecting the coronary arteries of still unknown etiology. IV gammaglobulin (IVIG) is the standard treatment to reduce the occurrence of coronary artery abnormalities. Methylprednisolone (MP) added to the standard therapy has been shown to provide no additional benefit in the primary therapy of KD but has a role for IVIG-resistant KD. For developing countries, the financial burden of IVIG poses a significant barrier to treatment. The striking immune perturbances in KD is quite similar to other primary systemic vasculitis which are treated with corticosteroids, hence MP may provide some benefit as a primary therapy for KD. In our institution, parents who cannot afford IVIG consented to intravenous MP as an alternative treatment option. Objectives To review the immediate and long term outcome of KD patients treated with IV MP as primary therapy. Methods Retrospective chart review of patients who fulfilled the criteria for the diagnosis of KD and treated with IV pulse MP [30mg/kg/dose (maximum of 1 gm/dose) daily for 3 consecutive days] plus high dose aspirin from January 2006 to December 2010 was done. Results A total of 22 patients were included in the study. There was clinical improvement in all patients with immediate lysis of fever after the first dose of IV MP and significant decrease in CRP levels. Repeat echocardiography done at 8 weeks, 6 months, 1 year and 2 years from the time of diagnosis by a single pediatric cardiologist revealed no coronary artery abnormalities in all patients. No adverse events reported during and after the infusion. Conclusions Methylprednisolone is effective in controlling the systemic manifestations and in preventing coronary aneurysm and safe for patients with KD. It can be an alternative first line treatment for patients who cannot afford IVIG. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3973

This systematic review evaluated micronutrient intake inadequacy of ten micronutrients for adult ethnic minority populations residing in Europe. Pubmed was searched for studies, related references were checked and experts consulted. Ten studies were identified and six were included in the final analysis representing Albanian, Roma, Sub-Saharan African, South Asian and African-Caribbean minority groups. The Estimated Average Requirement cut point was applied to estimate inadequate intake. With the exception of a sub-Saharan African study, of seven micronutrients analysed, inadequate intakes were markedly elevated (> 50 % of the population in most cases) in both genders for folate, vitamin B-12, calcium and iron (the latter in females only). A pressing need exists for intake adequacy studies with sound methodologies addressing ethnic minority groups in Europe. These populations constitute a vulnerable population for inadequate intakes and results substantiate the need for further investigation, interventions and policy measures to reduce their nutritional risk.

The EURopean micronutrient RECommendations Aligned (EURRECA) Network of Excellence explored the process of setting micronutrient recommendations to address the variance in recommendations across Europe. Work centered upon the transparent assessment of nutritional requirements via a series of systematic literature reviews and meta-analyses. In addition, the necessity of assessing nutritional requirements and the policy context of setting micronutrient recommendations was investigated. Findings have been presented in a framework that covers nine activities clustered into four stages: stage one "Defining the problem" describes Activities 1 and 2: "Identifying the nutrition-related health problem" and "Defining the process"; stage two "Monitoring and evaluating" describes Activities 3 and 7: "Establishing appropriate methods," and "Nutrient intake and status of population groups"; stage three "Deriving dietary reference values" describes Activities 4, 5, and 6: "Collating sources of evidence," "Appraisal of the evidence," and "Integrating the evidence"; stage four "Using dietary reference values in policy making" describes Activities 8 and 9: "Identifying policy options," and "Evaluating policy implementation." These activities provide guidance on how to resolve various issues when deriving micronutrient requirements and address the methodological and policy decisions, which may explain the current variation in recommendations across Europe. [Supplementary materials are available for this article. Go to the publisher's online edition of Critical Reviews in Food Science and Nutrition for the following free supplemental files: Additional text, tables, and figures.].