Background:Poor diet is a leading risk factor of non-communicable diseases. Product placement strategies in retail outlets can influence customers' food preferences. The United Kingdom government introduced legislation in October 2022 restricting chain retailers from using location promotions on unhealthy food and drinks. High-quality scientific evidence is needed to inform the inclusion of healthier product placement approaches into these regulations. In the context of Brexit, COVID-19 and the cost-of-living crisis, this study assessed whether positioning an expanded fresh fruit and vegetable section near store entrances in discount supermarkets, which do not routinely market produce this way, improved store sales, household purchasing and diet. Methods and limitations:This natural experiment had a prospective matched controlled cluster design, involving 36 stores (18 intervention and 18 control) across England. The intervention was implemented continuously for 6 months. Control stores were matched on store sales, customer profiles and neighbourhood deprivation. Participants were women, aged 18-60 years, with loyalty cards and were assigned to their primary store (n = 280 intervention and n = 300 control). Weekly store sales and household data from loyalty cards were provided by the collaborating supermarket chain. Dietary quality, household food waste and demographic characteristics were collected through questionnaires. A process evaluation and economic evaluation were completed. Results:Store-level sales of fruit and vegetables were greater in intervention stores than predicted at intervention implementation and 3 and 6 months' follow-up, equivalent to ≈ 2525, ≈ 1940 and ≈ 1450 extra portions per store per week, respectively. Effect sizes were somewhat stronger in stores where the produce section moved forwards more than 14 m. The proportion of households purchasing fruit and vegetables were somewhat protected among intervention compared to control participants after 3 and 6 months. Changes in dietary quality were small but generally in the expected direction for health benefit. Changes in frequency of household fruit and vegetable waste were negligible at 3 months' follow-up but increased at 6 months. The intervention was implemented according to the study protocol, with marked differences in the positioning of fresh fruit and vegetables between intervention and control stores post-intervention implementation. Fresh fruit and vegetable availability increased post intervention in intervention compared with control stores. Interviews with store staff demonstrated that changes in staff attitudes had a positive reinforcing effect on intervention implementation. Assessment of the policy context showed that stakeholders across the food system largely support the United Kingdom government's unhealthy placement ban; some felt it does not go far enough. Future work:This study shows that positioning produce sections near supermarket entrances can improve the nutrition profile of store sales and may improve household purchasing and diet. The United Kingdom Food (Promotion and Placement) Regulations could be refined to require a produce section near supermarket entrances to increase its health impact. Future research should continue to build the evidence for which healthy eating interventions are effective in retail outlets. Further evaluations of real-world supermarket intervention studies using robust scientific study designs are required, alongside process and economic evaluations, to provide evidence for policy intervention to improve retail food environments in the United Kingdom and internationally. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/44/46.

BACKGROUND:Previous product placement trials have been underpowered and limited in outcomes. This study assessed effects of positioning an expanded fruit and vegetable section near entrances on store-level sales, household-level purchasing and waste, and dietary behaviours. METHODS AND FINDINGS:This prospective matched controlled cluster trial (NIHR 17/44/46) involved 36 stores (18 intervention and 18 control) of a discount supermarket chain in England. The study took place between March 2018 and May 2022, and the intervention was implemented for six months. Control stores were matched on store sales, customer profiles and neighbourhood deprivation. Women customers aged 18-60 years, with loyalty cards, who shopped at intervention (n = 280) or control (n = 300) stores agreed to participate. The primary outcome was household purchasing of fresh fruit and vegetables. Secondary outcomes included: i) differences in household purchasing by educational attainment, ii) store sales of fresh fruit and vegetables, iii) dietary quality score for woman, and iv) child aged 2-6 years (if relevant), and v) household fruit and vegetable waste. The proportion of households purchasing fruit and vegetables in intervention compared to control stores was very similar at baseline (-0.1% (95%CI -6.1%, 6.0%)). After 3 months of exposure to the intervention, the proportion was 0.6% (95%CI -5.6%, 6.7%; p = 0.83) and after 6 months the proportion was 3.3% (95%CI -2.5%, 9.2%; p = 0.23). Interrupted time series analyses showed differences in intervention compared to predicted store-level sales of fruit and vegetables were 0.32SDs (95%CI 0.11, 0.53; p = 0.002) at intervention implementation, equivalent to ~2,525 (95% CI 775, 4,115) extra portions per store, per week. The differences were 0.23SDs (95%CI -0.05, 0.52; p = 0.10) at 3 months and 0.18SDs (-0.16, 0.52); p = 0.29) at 6 months post-intervention. Not being able to randomise stores potentially biases the results through unmeasured confounding effects and findings related to intervention dose were not prespecified but determined from process evaluation findings investigating intervention implementation. CONCLUSIONS:This study was conducted during the COVID-19 pandemic and cost-of-living crisis when population level fruit and vegetable sales and intake declined and recruitment to research was challenging. Despite these circumstances, the results of this study show that positioning produce sections near supermarket entrances may improve the nutrition profile of store sales, household purchasing and women's dietary quality. TRIAL REGISTRATION:NCT03573973.

BACKGROUND:Air pollution and diet both affect lung health and may interact. We investigated whether a healthy diet may modify associations between air pollution and lung function in adults. METHODS:Modelled annual-average concentrations of nitrogen dioxide (NO2) and particulate matter with aerodynamic diameters ≤10 μm (PM10) and ≤2.5 μm (PM2.5) were linked to residential address points of 260,982 individuals in the UK Biobank cohort. Averaged air pollution concentrations in the year of spirometry and two years prior to spirometry measurements were used. The healthy diet score (HDS) was calculated based on dietary data collected at baseline. Effect modifications by HDS and individual food components (fruit and vegetables) on the associations of air pollution and lung function were investigated. RESULTS:Participants in the highest HDS group had higher forced expiratory volume in 1-s(FEV1) and forced vital capacity(FVC) than those in the lowest group in both males and females. Interactions between HDS and air pollution were not seen. Suggestive evidence of total fruit intake effect modification on PM2.5-FEV1 was observed in females. Exposure to PM2.5 per 5 μg/m3 increment was associated with reduced FEV1 in the low of -14.4 mL(95%CI: -26.8, -2.2) but not in medium and high fruit intake groups (+2.9 mL(95%CI: -13.8,19.7) and +9.7 mL(95%CI: -4.1,23.6), respectively). A similar pattern was observed for FVC. CONCLUSIONS:We found suggestive evidence that higher consumption of fruit may partially reduce the adverse effects of air pollution on lung function in females. These findings merit investigation to see if they replicate in other cohorts.

Accurately assessing dietary intake in children and adolescents is essential for understanding dietary patterns and informing public health strategies. In Latin America, rapid nutrition transitions and increasing childhood obesity highlight the need for culturally appropriate, validated dietary assessment tools (DATs). However, methodological challenges and limited regional data hinder effective dietary surveillance. This scoping review identified and characterised DATs used among children and adolescents (5-18 years) in Latin America, examining tool types, features, validation and regional coverage. Following Joanna Briggs Institute and PRISMA-ScR guidelines, comprehensive searches were conducted in EMBASE, Web of Science, PubMed, and LILACS (April 2024) in English, Spanish, and Portuguese. Eligible studies included original research developing, validating, or applying DATs in Latin American populations. Of 13,946 records screened, 105 reports met the inclusion criteria. Brazil and Mexico contributed the most studies, while six countries (Paraguay, El Salvador, Nicaragua, Panama, Honduras, and Belize) had none. Forty-three DATs were identified, 77% of which were food frequency questionnaires (FFQs). Half targeted adolescents, 39% children, and 11% both groups. Most were interviewer-administered (58%) and applied in person (49%), with only 19% conducted online, reflecting regional digital limitations. Validation was reported for 70% of tools, primarily against 24 HR. The DAT landscape in Latin America remains dominated by FFQs and traditional administration methods, with limited use of digital platforms. Developing age-appropriate, validated and culturally adapted digital DATs is essential to strengthen dietary surveillance and guide effective nutrition policies across the region.

Traditional methods of measuring diet, mainly FFQ, are not fit for purpose. Diet is complex, with over 150 000 different food items available in UK supermarkets. This review describes the limitations of nutritional assessment methods used in the past. It provides an overview of recent methods using newer technologies, including online tool myfood24. Limitations of dietary assessment methods include recall bias; inability to estimate portion sizes; lack of adaptability across diverse populations; and inadequate food composition data. New tools include mobile apps for real-time intake tracking; use of image-based approaches for portion sizes and food identification; sensor technologies such as smart utensils and bite counters. Online platforms provide an economical approach for large-scale epidemiology. myfood24 is an online tool, developed for research and validated using biomarkers. Having demonstrated success with >250 000 research participants in over 27 countries; myfood24 is also used in healthcare, for student education and other settings. myfood24 focuses on accurate data and ease of participant use. The underlying food composition database curated by nutritionists has fewer missing data and more nutrient variables than standard generic tables. The database includes diet quality and sustainability measures. A new app includes the novel myfood24 Diet Optimization Engine suggesting individual dietary changes to meet nutrition targets. New dietary assessment tools provide more accurate data with deeper insights into dietary behaviour. They need to be used in large epidemiological surveys; for public health population screening and with patients to fully realise their potential.

BACKGROUND:The associations of vegetarian diets with risks for site-specific cancers have not been estimated reliably due to the low number of vegetarians in previous studies. Therefore, the Cancer Risk in Vegetarians Consortium was established. The aim is to describe and compare the baseline characteristics between non-vegetarian and vegetarian diet groups and between the collaborating studies. METHODS:We harmonised individual-level data from 11 prospective cohort studies from Western Europe, North America, South Asia and East Asia. Comparisons of food intakes, sociodemographic and lifestyle factors were made between diet groups and between cohorts using descriptive statistics. RESULTS:2.3 million participants were included; 66% women and 34% men, with mean ages at recruitment of 57 (SD: 7.8) and 57 (8.6) years, respectively. There were 2.1 million meat eaters, 60,903 poultry eaters, 44,780 pescatarians, 81,165 vegetarians, and 14,167 vegans. Food intake differences between the diet groups varied across the cohorts; for example, fruit and vegetable intakes were generally higher in vegetarians than in meat eaters in all the cohorts except in China. BMI was generally lower in vegetarians, particularly vegans, except for the cohorts in India and China. In general, but with some exceptions, vegetarians were also more likely to be highly educated and physically active and less likely to smoke. In the available resurveys, stability of diet groups was high in all the cohorts except in China. CONCLUSIONS:Food intakes and lifestyle factors of both non-vegetarians and vegetarians varied markedly across the individual cohorts, which may be due to differences in both culture and socioeconomic status, as well as differences in questionnaire design. Therefore, care is needed in the interpretation of the impacts of vegetarian diets on cancer risk.

Purpose The first 1000 days of life are critical for long-term health outcomes, and there is increasing concern about the suitability of commercial food products for infants, toddlers, and children. This study evaluates the compliance of UK commercial baby food products with WHO Nutrient and Promotion Profile Model (NPPM) guidelines. Methods Between February and April 2023, data on 469 baby food products marketed for infants and children under 36 months were collected from the online platforms of four major UK supermarkets. Nutritional composition and labelling information were assessed using the NPPM criteria. Quantitative analyses were performed using IBM SPSS, presenting data as means with 95% confidence intervals. Results While 75% of products met the minimum energy content criteria, compliance with total sugar content and protein requirements was 59% and 94%, respectively. Overall, only 45% of products adhered to NPPM nutritional standards. Promotional assessments revealed that no products met the requirements for appropriate nutrient, health, or marketing claims. Furthermore, only 5% of products included adequate statements in support of breastfeeding. Conclusion This study highlights the need for stricter nutritional and promotional standards in the UK baby food industry to foster healthier early dietary habits. Regulatory measures are essential to align commercial baby food products with WHO recommendations, reducing inappropriate claims and improving nutritional quality.

National Health Service England piloted a low-calorie diet programme, delivered through total diet replacement and behaviour change support via 1 : 1, group or digital delivery, to improve type 2 diabetes in adults with excess weight. To coproduce a qualitative and economic evaluation of the National Health Service low-calorie diet pilot, integrated with National Health Service data to provide an enhanced understanding of the long-term cost-effectiveness, implementation, equity and transferability across broad and diverse populations. What are the theoretical principles, behaviour change components, content and mode of delivery of the programme, and is it delivered with fidelity to National Health Service specifications? What are the service provider, user and National Health Service staff experiences of the programme? Do sociodemographics influence programme access, uptake, compliance and success? What aspects of the service work and what do not work, for whom, in what context and why? Can the programme be improved to enhance patient experience and address inequities? What are the programme delivery costs, and policy implications for wide-spread adoption? A mixed-methods study underpinned by a realist-informed approach was delivered across five work packages, involving: semistructured interviews with service users (n = 67), National Health Service staff (n = 55), service providers (n = 9); 13 service provider focus groups; and service user surveys (n = 719). Findings were triangulated with clinical data from the National Health Service England's first cohort analysis (n = 7540). Fifty-five per cent of service users who started total diet replacement completed the programme and lost an average of 10.3 kg; 32% of those with data available to measure remission achieved it. Examination of programme mobilisation identified barriers around referral equality and the impact of COVID-19, while effective cross-stakeholder working and communication were key facilitators. Service delivery and fidelity assessments identified a drift in implementation fidelity, alongside variation in the behaviour change content across providers. Perceived barriers to programme uptake and engagement aligned across service providers and users, resulting in key learning on: the importance of person-centred care, service user support needs, improvements to total diet replacement and the social and cultural impact of the programme. Early National Health Service quantitative analyses suggest some socioeconomic variation in programme uptake, completion and outcomes. Insights from the evaluation and National Health Service data were combined to develop the programme theory and underpinning context, mechanisms and outcomes. These were used to develop a list of recommendations to improve the cultural competency of programme delivery, total diet replacement delivery, peer support and address psychological support needs. Cost-effectiveness analyses using short-term follow-up data indicated there is potential for the programme to be cost-effective, but not cost saving. The National Health Service low-calorie diet can provide a clinically effective and potentially cost-effective programme to support weight loss and glycaemic control in adults with type 2 diabetes. However, this evaluation identified areas for improvement in referral equity, uptake and completion, and fidelity of delivery, which have informed the development of the programme, which has now been rolled out nationally. Ongoing programme monitoring and long-term follow-up are now required. The real-world setting limited some data collection and analysis. Future work will focus on the analysis of long-term clinical and cost-effectiveness, and addressing inequalities. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132075.

The first 1000 days of life are crucial for health, making it essential that foods for infants and young children (FIYC) meet high nutritional standards, as defined by the World Health Organization's (WHO) Nutrient and Promotion Profile Model (NPPM). There is high reliance on commercially available highly processed FIYC for children under 3 years of age, and a growing market. The aim of this study is to analyse the nutrient profiles of FIYC using the WHO NPPM and determine the proportion of products available in Spain suitable for promotion. Data on 830 FIYC available from brands sold by major retailers in Spain were collected. Product nutrient composition and label information were assessed using the WHO NPPM for the European Region. The processed fruit and vegetables were the most common FIYC category, accounting for 46

Objectives: To estimate the association between various indicators of obesity-related health risk and the incidence of rheumatoid arthritis (RA) in a large cohort of women. Methods: The UK Women's Cohort Study is a prospective cohort of 35,372 middle-aged women (aged 35-69 at recruitment) initiated in 1995-1998. Obesity was assessed using body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), categorised according to WHO and NICE guidelines, as well as clothing size. Incident RA cases were identified via Hospital Episode Statistics (HES) linkage up to March 2019. Cox regression models were used to estimate RA risk, adjusting for demographics, reproductive factors, and lifestyle factors. Non-linear associations were examined using restricted cubic splines. Results: Among 27,968 eligible subjects with complete data linkage (625,269 person-years of follow-up), there were 255 incident RA cases. Obesity (≥30.0 kg/m2) was associated with increased RA risk (HR (95% CI) 1.48 (1.02, 2.17), as were abdominal obesity (WC > 88 cm: 1.58 (1.10, 2.27)), WHR ≥ 0.85 (1.56 (1.03, 2.36)), and WHtR ≥ 0.6 (2.25 (1.34, 3.80)). Each 2.5 kg/m2 increase in BMI was associated with a 9% higher risk of RA; each 5 cm increase in WC with 6%; each 0.1 increase in WHR with 20%, and each 0.1 increase in WHtR with 27%. Larger clothing sizes were associated with a greater RA risk: for each onesize increment in blouse size and skirt size, the HRs were 1.13 (95% CI: 1.04, 1.22) and 1.13 (95% CI: 1.05, 1.22), respectively. Notably, skirt size ≥ 20 was associated with a 2.36-fold increased risk of RA. There was evidence of effect modification by weight change and menopausal status in obesity-related RA risk. Conclusions: Our findings suggest that managing obesity and central adiposity in middle-aged women may be associated with the risk of developing RA. WHtR may serve as a practical alternative to BMI in assessing RA risk. Clothing size, particularly skirt size, could provide a simple, cost-effective proxy for identifying at high risk of RA.

Introduction Amyotrophic lateral sclerosis (ALS) is a devastating illness that leads to muscle weakness and death usually within around 3 years of diagnosis. People with ALS (pwALS) often lose weight due to raised energy requirements and symptoms of the disease presenting significant challenges to taking adequate oral diet, with those who lose more weight being at a greater chance of earlier death. There is also some evidence to suggest that a higher calorie diet may benefit the disease course in pwALS, but further research is needed.Methods and analysis Two armed, parallel group, superiority, open labelled, randomised controlled trial, with internal pilot, to assess the effectiveness of an early high calorie diet on functional outcomes in ALS, comprising two treatment arms: (1) standard care, (2) standard care with additional active management using the OptiCALS complex intervention to achieve a high calorie diet (initially randomised 1:1, then 1:2 following a protocol amendment). Using a food first approach, pwALS will be encouraged and supported to follow a diet that meets an individualised calorie target from food before prescribing oral nutritional supplements. 259 pwALS will be recruited from up to 20 ALS centres across the United Kingdom and Ireland and followed up for a period of 12 months. Primary outcome is functional change measured over 12 months, using the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale. Secondary end points include measures of functional health, quality of life, calorie intake and weight, as well as time to gastrostomy and survival. A health economic analysis and process evaluation will also be undertaken. Participant recruitment is expected to complete in September 2025, and participant follow-up is expected to complete in September 2026. The results of this study are expected in March 2027.Ethics and dissemination The trial was approved by Greater Manchester—North West Research Ethics Committee, reference 20/NW/0334 on 8 September 2020. We will publish the study findings in peer-reviewed academic journals and present at local, national and international conferences where possible.Trial registration number ISRCTN30588041.

Background:Many children receive some or all their nutritional intake via a gastrostomy. More parents are using home-blended meals to feed their children, reporting beneficial effects, such as improved gastro-oesophageal reflux and less distress. Aim:To compare safety, outcomes and resource use of those on home-blended diets compared to formula diets. Methods:A mixed-methods study of gastrostomy-fed children. Workstream 1:Qualitative study involving semistructured interviews with parents (n ≈ 20) and young people (n ≈ 2) and focus groups with health professionals (n ≈ 41). Workstream 2:Cohort study; data were collected on 180 children at months 0, 12 and 18 from parents and clinicians using standardised measures. Data included gastrointestinal symptoms, quality of life, sleep (child and parent), dietary intake, anthropometry, healthcare usage, safety outcomes and resource use. Outcomes were compared using propensity scored weighted multiple regression analyses. Results: Workstream 1:Participants believed the type of diet would most likely affect gastrointestinal symptoms, time spent on feeding, sleep and physical health. Workstream 2:Baseline: Children receiving a home-blended diet and those receiving a formula diet were similar in terms of diagnoses and age, but those receiving a home-blended diet were more likely to live in areas of lower deprivation and their parents had higher levels of education. They also had a higher dietary fibre intake and demonstrated significantly better gastrointestinal symptom scores compared to those receiving a formula diet (beta 13.8, p < 0.001). The number of gut infections and tube blockages were similar between the two groups, but stoma site infections were lower in those receiving a home-blended diet. Follow-up: There were 134 (74%) and 105 (58%) children who provided follow-up data at 12 and 18 months. Gastrointestinal symptoms were lower at all time points in the home-blended diet group, but there was no difference in change over time within or between the groups. The nutritional intake of those on a home-blended diet had higher calories/kg and fibre, and both home-blended and formula-fed children have values above the Dietary Reference Values for most micronutrients. Safety outcomes were similar between groups and over time. Total costs to the statutory sector were higher among children who were formula fed, but costs of purchasing special equipment for home-blended food and the total time spent on child care were higher for families with home-blended diet. Conclusion:Findings show that home-blended diets for children who are gastrostomy fed should be seen as a safe alternative to formula feeding for children unless there is a clinical contraindication. Limitations:The target sample for children in workstream 1 was not achieved. The observational study design means unmeasured confounding may still be an issue. Children in this cohort had been on their home-blended diets for different periods of time. A lack of good reference data for nutritional and anthropometric data for disabled children does hinder further interpretation of nutritional adequacy. Future work:Future research on: impact of a home-blended diet on the gut microbiome in children who are gastrostomy fed and equality of access. Children's experiences of living with a gastrostomy, nutritional requirements and quality of life should also be prioritised. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/76/06.

OBJECTIVE:Older adults may require additional support to comprehend written information due to inadequate health literacy, which involves components of cognitive function including reaction time. This study tested the acceptability of web-based reaction time testing in the UK Women's Cohort Study and possible sources of bias. Additionally, it assessed the association between health literacy and reaction time. DESIGN:A cross-sectional analysis was conducted using data from the UK Women's Cohort Study, a prospective cohort study. PARTICIPANTS:The study involved women aged 48-85 without cancer registration who participated in the 2010/2011 follow-up (n=768). SETTING:Postal questionnaires and web-based cognitive function tests were administered in participants' homes. METHODS AND ANALYSIS:Logistic regression identified predictors of volunteering for reaction time testing, used to calculate inverse probability weights for the primary analysis. Associations between health literacy and reaction time were estimated with linear regression models, adjusting for volunteer effects. Poisson regression models assessed associations between health literacy and choice reaction time errors. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome was acceptability of web-based testing (response rate, task distress, task difficulty). Secondary outcomes were sources of volunteer bias and the association between health literacy and reaction time. RESULTS:Web-based testing of cognitive function was attempted by 67% of women (maximum age 80), with little distress or difficulty reported. There was substantive volunteer bias. Women providing data on cognitive function were younger, had higher educational attainment and were higher in self-rated intelligence. Inadequate health literacy was associated with making fewer choice reaction time errors among those providing valid data but was also associated with not providing valid data. Health literacy was not associated with other aspects of reaction time (speed, variability). Additionally, selection bias may have restricted range on study variables, given that 2010/2011 volunteers were younger and more educated compared with those at recruitment in 1995/1998. CONCLUSION:Brief web-based measures of cognitive function in the home are acceptable to women aged 48-80, but there are substantive selection effects and volunteer biases. Additionally, there are potentially vulnerable subgroups who provide poorer quality data.

The aim of this study was to explore the associations between diet quality, socio-demographic measures, smoking, and weight status in a large, cross-sectional cohort of adults living in Yorkshire and Humber, UK. Data from 43, 023 participants aged over 16 years in the Yorkshire Health Survey, 2nd wave (2013-2015) were collected on diet quality, socio-demographic measures, smoking, and weight status. Diet quality was assessed using a brief, validated tool. Associations between these variables were assessed using multiple regression methods. Split-sample cross-validation was utilised to establish model portability. Observed patterns in the sample showed that the greatest substantive differences in diet quality were between females and males (3.94 points; P < 0.001) and non-smokers vs smokers (4.24 points; P < 0.001), with higher diet quality scores observed in females and non-smokers. Deprivation, employment status, age, and weight status categories were also associated with diet quality. Greater diet quality scores were observed in those with lower levels of deprivation, those engaged in sedentary occupations, older people, and those in a healthy weight category. Cross-validation procedures revealed that the model exhibited good transferability properties. Inequalities in patterns of diet quality in the cohort were consistent with those indicated by the findings of other observational studies. The findings indicate population subgroups that are at higher risk of dietary-related ill health due to poor quality diet and provide evidence for the design of targeted national policy and interventions to prevent dietary-related ill health in these groups. The findings support further research exploring inequalities in diet quality in the population.

To provide a systematic and quantitative summary of dietary factors and rheumatoid arthritis (RA) risk. A systematic review and meta-analysis included prospective cohort studies from 2000 to 2024 reporting relative risks (RRs) with 95% confidence intervals (CIs) for RA incidence relating to 32 different dietary exposures. Linear and non-linear dose–response analyses were conducted. Thirty studies were included, involving 2,986,747 participants with 9,677 RA cases. Linear dose–response analysis suggested that each 2-unit per week increase in total alcohol intake was linked to 4% risk reduction (RR (95%-CI), heterogeneity (I2), NutriGrade score: 0.96 (0.94, 0.98), 58%, moderate certainty), and beer consumption was associated with a 10% reduction per 2 units/week increase (0.90 (0.84, 0.97), 0%, very low certainty). Each 2-unit/week increase in total alcohol intake was associated with a 3% decrease in seropositive RA risk (0.97 (0.96, 0.99), 28%, moderate certainty). Increased intakes of fruit (per 80 g/day) and cereals (per 30 g/day) were associated with 5% (0.95 (0.92, 0.99), 57%, moderate certainty) and 3% (0.97 (0.96, 0.99), 20%, moderate certainty) reduced risk, respectively. Conversely, tea consumption showed a 4% increased risk per additional cup/day (1.04 (1.02, 1.05), 0%, moderate certainty). Non-linear associations were observed for total coffee, vegetables, oily fish, and vitamin D supplementation. Data on dietary patterns and specific micronutrients were limited. The findings suggest that moderate alcohol consumption and a higher intake of fruits, oily fish, and cereals are associated with a reduced risk of RA, while tea and coffee may be linked to an increased risk. Optimising dietary intake of certain food components may reduce RA risk, despite moderate-quality evidence.

Promotion of sustainable healthy diets requires comprehensive metrics to assess environmental impact of foods consumed1. Existing food systems are failing to meet the needs of current and future generations, by operating outside several planetary boundaries. Promoting healthy diets from sustainable food systems is central to realizing the 2030 Sustainable Development Goals. Standard food composition tables do not include sustainability metrics. The aim of this work was to add UK focussed sustainability metrics to the food composition table used in myfood24.Greenhouse gas emissions (GHGE), land and water use were added to each food item in the myfood24 UK generic and branded databases. This is recorded as per 100g of product. The values for GHGE2 takes account of factors including production method, land use management, feed used, soil and climate, processing and transport of both the product and aspects of its production e.g., fertiliser and feed. Values were weighted for UK trade statistics to reflect values for the UK food supply. Land use and freshwater withdrawals were also added.Exploration of the sustainability metrics in the myfood24 database by food category show, as expected, that meat (1.5 kg CO2eq, SD 1.4), fish (1.8 kg CO2eq, SD 1.0) and dairy (1.3 kg CO2eq, SD 0.8) plus dried herbs/spices (1.4 kg CO2eq, SD 1.2) have the highest GHGE per 100g. In the meat category, beef and lamb had GHGE ∼3.8 kg CO2eq with pork and chicken having lower values ∼1.0 kg CO2eq. Plant based protein sources had much lower GHGE per 100g, with pulses at 0.3 CO2eq (SD 0.2) and nuts at 0.2 CO2eq (SD 0.2). Land use was by far the highest per 100g for lamb (63 m2year/day, SD 18) with beef next at 8 m2year/day (SD 4). Chocolate (5 m2year/day, SD 2) was the sixth highest food category for land use. Drinks, vegetables, fruit and potatoes had the lowest land use values. Regarding water use, seafood per 100g had high values at 484l/day (SD 167), followed by nuts (218l/day, SD 172), lamb (171l/day, SD 36) and rice (164l/day SD 42). Drinks, potatoes and breads had the lowest land use values per 100g.Through addition of sustainability metrics to food and nutrient composition databases we can measure the impact of food intake in relation to both nutrients and sustainability. This linked data will help us to understand how to adapt our diets to be healthier and better for the planet.

Background and objective: Tools to accurately and efficiently measure dietary intake in Nigeria are lacking. We aimed to develop and assess the usability of a new online dietary assessment tool for Nigeria—myfood24 West Africa. Methods: We developed the myfood24 West Africa database using data from existing food composition tables, packaged foods labels and research articles. The development followed seven steps: identified data sources, selected foods, processed/cleaned the data, calculated the nutrient content of recipes, created and allocated portion sizes, quality-checked the database and developed food accompaniments. To pilot the tool, we recruited 179 university staff in Nigeria using a cross-sectional design. Usability was assessed using a questionnaire that included the System Usability Scale (SUS) and a feedback session. Results: The database included 924 foods, with up to 54 nutrients and 35 portion-size images allocated to foods. Sixty percent of the data were sourced from the 2019 West Africa Food Composition Table, 17% from back-of-pack labels of packaged foods, 14% from the 2017 Nigerian Food Composition Table, 5% from generated recipes and 4% from the published literature. Of the participants, 30% (n = 53) self-recorded their food intake, with a total of 1345 food and drink entries from both self- and interviewer-collected data. The mean SUS score of 74 (95% CI: 68,79) indicated good usability. The feedback showed that the tool was user-friendly, educational and included a variety of local foods. Conclusions: This new tool will enhance the dietary assessment of the Nigerian population. More work will expand coverage to include more foods from the region.