We systematically analysed the literature to assess whether diet and physical activity interventions delivered in high-income countries (HICs) could affect cardio-metabolic biomarkers among women with gestational diabetes mellitus (GDM) in pregnancy. Ten databases and two trial registries were searched from inception until 16/03/2026. Studies were included if they were randomised controlled trials in HICs that allocated women with GDM to diet and/or physical activity interventions, or a control group, and reported outcomes at 12 ± 3 months after the intervention. The review was preregistered in PROSPERO (CRD42024597324; CRD42024518659). We used random effects meta-analyses to pool data. We included 17 studies with 6,535 participants. There was evidence that interventions led to a significant reduction in weight (-0.89 kg (95% CI -1.74, -0.03); I2 = 57.7%), waist circumference (difference -0.79 cm (95% CI -1.45, -0.13); I2 = 0%), and systolic blood pressure (-1.60 mmHg (95% CI -3.16, -0.04), I2 = 72.1%). However, there was no evidence of a significant effect of these interventions on blood lipids, glycaemic outcomes, diastolic blood pressure, or type 2 diabetes incidence. The review highlights the need for high quality research on reducing the risk of long-term cardiometabolic disease among women with a history of GDM in HICs.

Background Obesity increases the complication risk after endometrial cancer surgery. We assessed the feasibility of a preoperative weight loss intervention for women with endometrial cancer and excess weight. Methods In this feasibility randomised trial at nine centres across England, women with a BMI of 28 kg/m2 and higher awaiting curative endometrial cancer surgery were randomly allocated (1:1) to routine care or dietetic support with a low-energy (800 kcal/day, 76 g protein per day) total diet replacement programme between diagnosis and surgery. Criteria for progression to a definitive trial without design changes comprised recruitment (≥72 participants), engagement (≥75% of dietetic telephone appointments attended), adherence (≥60% of intervention participants reaching ≥5% weight loss), and retention (≥85%). Secondary outcomes were complications graded by masked assessors, symptoms, and changes in weight and fat-free mass. All randomly allocated and eligible participants who underwent surgery were analysed in an intention-to-treat approach. Missing data were not imputed. This trial is registered with ISRCTN, ISRCTN13577800, and is closed to recruitment. Findings Between Nov 6, 2023, and Feb 28, 2025, 78 participants were randomly allocated and 72 were analysed (37 in the intervention group and 35 in the routine care group). Participants attended 85% (SD 24) of their dietetic appointments. Retention was 86% (62 participants). The median period from randomisation to surgery was 28 days (IQR 24–36), during which time 16 (44%) participants in the intervention group and four (12%) in the routine care group lost 5% or more of their weight (odds ratio [OR] 6·00 [95% CI 1·75–20·59]). Intervention participants lost a mean of 5·3 kg (SD 4·1) before surgery, 3·5 kg (95% CI 1·8 to 5·1) more than the routine care participants (–1·8 kg [3·0]), with no evidence of between-group difference in fat-free mass (0·8 kg [95% CI –3·2 to 1·6]). A lower proportion of intervention participants had complications than those in routine care (ten [27%] vs 18 [51%], OR 0·35 [0·13–0·93]). No serious adverse events were reported. Interpretation The trial was feasible: the intervention led to meaningful weight loss, had high engagement, and appeared safe. Evidence suggested fewer postoperative complications in the intervention group. A definitive trial is warranted and could benefit from adaptations to enhance weight loss. Funding National Institute for Health and Care Research.

AIMS:To compare postpartum trajectories in body weight and cardiometabolic biomarkers between women with and without GDM, and to explore the moderating effect of progression to type 2 diabetes (T2DM). MATERIALS AND METHODS:We used electronic primary care healthcare records and linked hospital episode records of women who gave birth between 2001 and 2021. Each woman with GDM was matched to four women without GDM based on age at delivery and delivery date (±3 months). We fitted mixed-effects multivariate linear models to map biomarker trajectories and extracted coefficients and 95% confidence intervals (CIs) for each year postpartum. RESULTS:A total of 43 572 women diagnosed with GDM were matched with 174 288 women without GDM in pregnancy. Across the 15-year follow-up, women with GDM weighed more (difference of 5.5 kg [95% CI: 5.3 to 5.7]), had higher HbA1c concentrations (4.4 mmol/mol [95% CI: 4.3 to 4.5]), systolic and diastolic blood pressure (2.6 mmHg [95% CI: 2.4 to 2.7] and 1.7 mmHg [1.6 to 1.8] higher, respectively), and low-density lipoprotein cholesterol (0.08 [95% CI: 0.06 to 0.10]). However, biomarkers increased at a slower rate during the follow-up period among women with GDM, except for HbA1c (increase of 9.3 mmol/mol [95% CI: 8.8 to 9.7] and 2.3 mmol/mol [95% CI: 1.9 to 2.6] in the GDM and non-GDM groups, respectively). Future Progression to type 2 diabetes moderated biomarker trajectories. CONCLUSION:Differences in biomarker trajectories in the early postpartum present an opportunity for early risk stratification and targeted prevention among women with previous GDM.

Objectives To assess the impact of a National Enhanced Service (NES) incentive for weight management that financially rewarded practices for each eligible patient referred to a weight management programme.Design Interrupted time-series analysis to examine the rate of weight management referral and weight management advice.Setting Primary healthcare records from January 2018 to December 2024 in the Oxford Clinical Informatics Digital Hub, covering 8.3 million patients in 1198 primary care clinics around England.Interventions NES payments to practices for weight management were introduced in April 2021.Results The rate of referral increased from 1 referral per 1000 patients per month before the incentive to around 4 referrals per 1000 patients per month afterwards. There was no evidence that the increase differed by age, gender, ethnic group or socioeconomic status. The occurrence of weight management advice was unchanged by the introduction of the NES and was at least three times more common than referral to weight management services.Conclusions The NES was associated with a fourfold increase in referrals to weight management services. However, clinicians are much more likely to offer advice rather than a referral to a weight management programme. There is a clear opportunity to improve outcomes for patients by encouraging greater use of referrals to effective weight management services in place of advice.

Introduction Weight stigma and internalised weight bias are associated with poor mental, social and physical health. Weight-neutral approaches prioritise well-being and sustainable health behaviours. However, the feasibility and acceptability of weight-neutral interventions remain uncertain.Methods and analysis Weight-Neutral Health Intervention (WIN) is an investigator-initiated single-arm feasibility study enrolling 56 adults with body mass index ≥30 kg/m2 in the Capital Region of Denmark. The study investigates a codesigned weight-neutral health intervention. The 6-month intervention comprises 1 preparatory session and 11 group sessions led by trained practitioners, focusing on intuitive eating, body acceptance and self-compassion; optional components include support-network events, up to three individual online sessions and access to ‘size-inclusive yoga’ and ‘body competence’ courses. The primary feasibility outcome is follow-up completion. Recruitment proportion and adherence are secondary feasibility outcomes. These will be assessed using a set of predefined ‘traffic-light’ stop/go progression criteria. Exploratory feasibility outcomes include data completeness for other outcomes and participant engagement with the intervention. Exploratory clinical outcomes include questionnaire data (quality of life, depression, weight bias internalisation, eating behaviours, self-esteem, body image, stress and life satisfaction), clinical measures (weight, heart rate and blood pressure), biomarkers (blood samples and hair cortisol), 7-day actigraphy (physical activity and sleep) and serious adverse events. Qualitative interviews, focus groups and fieldnotes will be used to explore acceptability and contextual factors. If progression criteria are met, the study will inform the design of a pragmatic, multicentre, randomised trial. The exploratory outcomes will inform outcome selection, setting, sample size and procedures.Ethics and dissemination Approved by the Regional Ethics Committee of the Capital Region of Denmark (H-25013213). Results will be disseminated through peer-reviewed publications, conferences and public platforms.Trial registration number NCT06922630.

Background:Excess weight and weight concern among adolescents can lead to adverse physical and psychosocial health consequences. This study aims to examine levels of weight concern, desire for weight support, and their associations in adolescents. Methods:A cross-sectional survey was conducted in 80 English secondary schools as part of the 2023 OxWell Student Survey. Weight concern was measured on a 4-point scale, and desire for weight support with yes/no/I don't know response options. Data was analysed using mixed-effects logistic regression adjusting for gender, year group, ethnicity, and deprivation, with school ID as a random effect. Results:Of 34,245 respondents (aged 11-18 years), 41% reported some level of weight concern, which was more common among older adolescents, those of White ethnicity, and those from deprived backgrounds. Girls, gender non-disclosing, and gender diverse young people were significantly more likely than boys to report weight concern with gender diverse young people having eight times higher odds of weight concern. Thirty percent of young people expressed a desire for weight management support, with modest increases by age but minimal variation by ethnicity or deprivation. Weight concern was strongly associated with desire for support. Conclusion:This study found that weight concern is widespread among UK adolescents, with around one in three expressing a desire for weight management support. These findings reveal a substantial unmet need, as current services targeting only those with overweight or obesity fail to address the broader weight-related distress experienced by many young people.

The industrialization of global food systems has led to dietary changes that harm both health and the environment. If global food systems are to meet the needs of a growing population for healthy, environmentally sustainable, and affordable diets, substantial changes will be required. In this Review, we synthesize growing empirical evidence on the complexity of factors that influence consumer dietary and farmer production choices, especially the roles of public and private entities that shape food environments. We outline promising interventions to help facilitate beneficial global dietary transitions, including research and development for product innovation, regulation of food environments, and food assistance and food-as-medicine programs. Understanding and aligning the motives and incentives of various food system actors is essential to achieve improved health, environment, and equity outcomes.

Evidence suggests we must change both the type of food we consume and the way we produce it, at a transformational scale, to protect population and planetary health and avoid exacerbating existing diet-related health inequalities. We summarise key findings from behaviour change theory and literature, highlighting the need for means, motive and opportunity to enact behaviour change. We evaluate and contrast the implications for interventions aimed at individuals vs. businesses, arguing that policy must shift focus from individual responsibility to systemic change. Past public health interventions have tended to focus on individuals’ motivation, with limited impact, while interventions that target the motivation of businesses, if enacted, would likely garner substantially greater impact. Governments implementing mandatory reporting could provide the foundation to realign the incentives that shape business practices. This would subsequently enable mandatory targets to be introduced on foods sold, providing in turn the necessary conditions — the means and opportunity — for individuals to enact dietary change.

BACKGROUND:Excessive sodium intake is responsible for 3 million deaths a year globally. The UK is one of 64 countries to have a salt reduction program to help reduce the population's sodium intake. It is a voluntary scheme with 108 category-specific salt content targets for the grocery and out-of-home sectors. This study aimed to estimate the potential impact of the 2024 targets on cardiovascular outcomes and health care costs for UK adults. METHODS:Long-term health modeling was based on the adult population in England. Changes in salt intake (g/d), whether the targets were met, were estimated using consumption data from the National Diet and Nutrition Survey 2018/19. Impact on ischemic heart disease and stroke, quality-adjusted life years, and health care costs were estimated using PRIMEtime, a proportional multistate life table model. RESULTS:If the salt reduction targets set for 2024 had been met, then salt intake would have reduced from 6.06 g/d (95% CI, 5.18-6.31) to 4.94 g/d (4.73-5.15), a reduction of 1.12 g/d (1.05-1.20). This would lead to 103 000 (UI, 41 000-161 000) fewer cases of ischemic heart disease and 25 000 (10 000-39 000) fewer cases of stroke over 20 years. A modeled 243 000 (94 000-383 000) quality-adjusted life years would be saved with a net saving of £1.00 billion (£0.35-1.73 billion) to the National Health Service over the remaining lifetime of the adult population. CONCLUSIONS:Reformulation of products to meet the targets could result in substantial reductions in cardiovascular disease without changes in dietary behaviors. Policymakers should consider options to strengthen salt reduction policies, including effective systems for monitoring and enforcement.

Calorie labels may help limit energy intake as part of policy efforts to prevent obesity. However, evidence on their effectiveness is mixed. We hypothesised this variability may relate to differences in responsiveness to labelling by food category, e.g., main meals vs. discretionary items (e.g. snacks). Systematic searches identified randomised field studies of calorie labelling that reported energy purchased (kcal) from targeted food and drink categories (main meals, discretionary foods, soft drinks). A mega-analysis (pooling raw data from multiple studies) used generalised linear mixed models (GLMM) to analyse aggregate study data on total energy (kcal) purchased within each food category per week. Three studies provided data from 22 worksite cafeterias for the mega-analysis. When calorie labels were present (versus absent) energy purchased per transaction for main meals increased (18kcal/transaction; 95%CI: 4,31). There was no evidence of differences in energy purchased per transaction from discretionary foods (-10 kcal/transaction; 95%CI: -24,3), or drinks (-2kcal/transaction; 95%CI: -15,12). Previous studies have reported no or small effects from calorie labels. The findings of this study suggest the impact of calorie labels in worksite cafeterias differs by food category, but there was no clear evidence that labels reduced energy purchased in any of the categories.

In 2021 a Nationally Enhanced Service (NES) incentive for weight management in primary care was rolled out in England. This paid general practices £11.50 for every eligible referral they made to a weight management programme. We explored primary care staff's perceptions, experiences and attitudes toward the NES by conducting 37 semi-structured interviews with General Practitioners (GPs), administrative staff and nurses preceding the introduction of the NES (May to September 2021) and 1 year later following its introduction (September to December 2022). Data were analysed using normalisation process theory. The NES for weight management solidified the position of staff already supportive of referring patients to weight management programmes. For staff less supportive of weight management services, the dissonance between the perceived lack of benefit of services and making referrals to services was reduced with referrals becoming more habitual. Facilitators to implementation included the presence of a coherent national policy; having a 'champion' explain key aspects; and a financial incentive if framed as benefiting the practice at large. Barriers included a perception that primary care has been shouldered with a complex and difficult health crisis; a worry over workload burdens; and inefficient and unclear referral systems. The implementation of the NES was broadly welcomed and accepted by primary care staff. Interviewees expressed concerns around the acceptance of weight management policies in primary care, the provision of training to raise the topic of weight and whether the responsibility of weight management fell with primary care, public health or with the patient.

BackgroundReducing the environmental impact of foods consumed is important for meeting climate goals. We aimed to conduct a randomised controlled trial to test whether ecolabels reduce the environmental impact of food selected in worksite cafeterias, alone or in combination with increased availability of more sustainable meal options.MethodsWorksite cafeterias (n = 96) were randomised to one of three study groups, with 54 included for final analysis. One group was intended to increase the availability of meat-free options, but no change was implemented. Therefore, this group was treated as part of the control, creating two groups: (1) control (no ecolabels) (n = 35), and (2) ecolabels (n = 19). Regression analysis assessed the primary outcome of total environmental impact of hot meals sold over a 6-week period. Secondary outcome analyses explored the individual environmental indicators that composed the total environmental impact score (i.e., greenhouse gas emissions, biodiversity loss, eutrophication, and water scarcity). The mean weekly environmental impact scores of hot meal options over the full 12-week trial period were assessed using hierarchical mixed effects models.ResultsThere was no significant effect of the intervention on the environmental impact scores of meals sold (mean difference between control and intervention sites: -1.4%, 95%CI: -33.6%, + 30.8%). There was no evidence of an effect in mean weekly environmental impact score (-5.4%, 95%CI: -12.6%, + 2.5%), nor in any of the four individual environmental indicators (greenhouse gas emissions: -3.6%, 95%CI: -30.7%, 34.3%; biodiversity loss: 2.0%, 95%CI: -25.8%, 40.2%; eutrophication: -2.4%, 95%CI: -29.3%, 34.7%; water scarcity: -0.4%, 95%CI: -28.7%, 39.1%).ConclusionsEcolabels may not be an effective tool to shift consumer behaviour in worksite cafeterias towards meals with lower environmental impact.Trial registrationThe study was pre-registered prospectively on ISRCTN (https://www.isrctn.com/ISRCTN10268258; 06/01/2022).

Importance:Excess weight increases morbidity risk after colorectal cancer surgery. Objective:To assess the feasibility of a preoperative weight loss intervention. Design, Setting, and Participants:CARE was an assessor-blinded randomized clinical trial performed between March 27, 2023, to August 13, 2024, with a 30-day postoperative follow-up in adults with a body mass index of 28 or greater who were awaiting curative elective colorectal cancer resection at 8 hospitals across England. Intervention:Dietetic support with a low-energy (800 kcal/d, 76 g/d of protein) total diet replacement program between decision to treat and surgery. Main Outcomes and Measures:Progression criteria for a definitive trial included recruitment (≥72 patients), engagement (≥75% of dietetic telephone calls attended), adherence (≥60% of intervention participants achieving ≥5% weight loss), and retention (≥85%). Secondary outcomes included morbidity, symptoms, and changes in weight and fat-free mass. Outcomes were modeled during a 30-year time horizon using cohort simulation. Results:Of the 150 potentially eligible participants approached, 71 eligible randomized participants (mean [SD] age, 64 [8.7] years; 43 [61%] male; mean [SD] body mass index, 35.4 [5.4]) undergoing surgery (36 in the intervention group and 35 in the usual care group) were included in the analysis. Participants were accrued at a rate of 0.57 participants per site per month compared with the anticipated rate of 0.75. Participants attended 85% of their dietetic calls. The median (IQR) period from randomization to surgery was 33 (25-43) days, during which 22 (61%) of the intervention participants and 3 (9%) of the usual care participants lost 5% or more of their weight (odds ratio, 16.8; 95% CI, 4.3-65.3). Intervention participants lost a mean (SD) of 6.1 (3.0) kg before surgery, which was 4.3 kg (95% CI, 2.7 to 5.8 kg) more than the usual care participants. Between-group adjusted change in fat-free mass was 0.1 kg (95% CI, -3.9 to 4.0 kg). There was no evidence of a difference between the 2 group in the proportion of patients with any complications (14 [39%] vs 14 [40%]) or with Clavien-Dindo grade I, II, or III complications. Fecal incontinence (-8.6 points [95% CI, -16.7 to -0.5 points]) and sore skin (-15.9 points (95% CI, -25.3 to -6.6 points]) improved postoperatively in the intervention compared with usual care group. There were no intervention-related serious adverse events. Retention was 100%. In an exploratory observational analysis, participants who lost 3.2% or more of their body weight (above the median loss) had a 50% relative reduction in complications (95% CI, 1%-78%). Modeling indicated that the intervention was cost-effective. Conclusions and Relevance:This randomized clinical trial's intervention of low-energy total diet replacement before colorectal cancer resection was feasible and well tolerated, lacked safety concerns, and was likely cost-effective. The progression criteria were met, but some recruitment challenges need to be addressed. Trial Registration:ISRCTN.org Identifier: ISRCTN39207707.

Background:It is unclear whether weight loss interventions worsen disordered eating in people living with overweight/obesity. We aimed to systematically evaluate the association between weight loss interventions and disordered eating. Methods:Six databases were searched from inception until September 2024. Trials of weight loss interventions in people with overweight/obesity were included if they reported a validated score for disordered eating on either the Eating Disorder Examination Interview or the Eating Disorder Examination Questionnaire pre- and post-intervention. Interventions included behavioural weight loss programmes (BWL) and pharmacotherapy licenced for weight loss, with or without concurrent psychological support, provided for at least 4 weeks. Pooled standardised mean differences (SMD) in scores of disordered eating were calculated using random effects meta-analyses. Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool and the Newcastle-Ottawa scale for randomised and single-arm trials, respectively (PROSPERO ID: CRD42023404792). Findings:Thirty-eight studies with 66 eligible arms (61 interventions: 29 BWL, 11 BWL + pharmacotherapy, 20 BWL + psychological intervention, 1 pharmacotherapy + psychological intervention) and 3364 participants in total were included. The mean weight change was -4.7 kg (95% CI: -5.7, -3.7). Compared with baseline, disordered eating scores improved by -1.47 SMD units (95% CI: -1.67, -1.27, p < 0.001, I2 = 94%) at intervention completion (median of 4 months). Seven randomised trials that directly compared a weight loss intervention to no/minimal intervention reported an improvement of -0.49 SMD units (95% CI, -0.93, -0.04, p = 0.0035, I2 = 73%). Sub-group analyses showed: (a) disordered eating scores improved more in people with an eating disorder at baseline compared with people without high scores, (b) no clear evidence that the association depended upon intervention type, and (c) disordered eating scores improved more in trials rated at low overall RoB. Interpretation:Despite heterogeneity in effect size, weight loss interventions consistently improved disordered eating scores. These findings provide reassurance that weight loss interventions might not worsen disordered eating and may improve it. Funding:Novo Nordisk UK Research Foundation Doctoral Fellowship in Clinical Diabetes.

BACKGROUND:The NHS Path to Remission (PtR) offers a total diet replacement (TDR) programme to help people newly-diagnosed with type 2 diabetes (T2D) lose weight. It is very effective for people who participate, but most eligible people do not take part. AIM:To assess whether offering a range of weight loss programmes can increase uptake of, and persistence with, weight loss and lead to a higher proportion of the population achieving remission of T2D compared with offering PtR only. METHOD:1788 people diagnosed with T2D in the last six years, who are willing to try to lose weight to achieve remission, will be recruited via GP practices and randomised to the NewDAWN service or PtR. Outcomes (weight, height, HbA1c, medications, BP, CVD risk score, PAID, EQ-5D, healthcare resource use) will be assessed at baseline and 12 months, with diabetes remission at 12 months as the primary outcome. An internal pilot assessment will follow 150 participants for 16 weeks to determine whether to progress using pre-specified criteria based on fidelity of programme delivery, adherence to the programme and change in weight. The decision will be reviewed by an external programme steering committee who will also advise on any other considerations they deem material to the likely successful completion of the full trial. A process evaluation will assess fidelity of delivery and collect both staff and participant feedback on the NewDAWN service to improve the effectiveness of implementation. The costs of NewDAWN and lifetime cost-effectiveness of the service will also be determined. ISRCTN Registration: 11090437.

Understanding food purchasing behaviours is complex because people make both choices among goods and volumes of those goods that they choose. We use the novel Multiple Discrete-Continuous Extreme Value (MDCEV) model, capable of handling both aspects of behaviour, on real-world food shopping behaviour data from a clinical trial. We compared the impact of providing general dietary advice, general dietary advice plus personalised shopping advice, or taxation, and combinations thereof, on the amount of saturated fat in consumers’ shopping baskets, using simulation. We used supermarket loyalty card data from a randomized controlled trial of 111 adults with raised cholesterol in Oxfordshire (UK). A Danish fat tax simulation alone is less effective than the tax in combination with dietary and shopping advice. These data illustrate the potential of MDCEV models for these behaviours and, by extension, informing food policies.

BACKGROUND:Psoriasis affects at least 60 million people worldwide, and 80% also live with overweight or obesity. Excess weight increases susceptibility to psoriasis and is associated with more severe disease. OBJECTIVES:To evaluate the impact of weight-loss interventions on psoriasis severity (Psoriasis Area and Severity Index [PASI], PASI50, PASI75, PASI100 [50%/75%/100% reduction in baseline PASI, respectively]) and quality of life (Dermatology Life Quality Index [DLQI]). METHODS:We systematically searched five databases and two trial registries (inception to 03/09/2025). Outcomes were informed by patient focus-group discussions. Randomized controlled trials (RCTs) in adults with psoriasis, comparing any weight-loss intervention versus usual care or a lower-intensity weight-loss intervention, were included. Studies had to report a change in weight and ≥1 psoriasis severity or quality-of-life measure. Random effects meta-analyses were used. RESULTS:Thirteen RCTs (1145 participants) with 14 comparisons were included. Eleven interventions advised dietary changes, of which four included physical activity. Three used weight-loss medications. Across 14 comparisons (n = 1145, mean difference (MD) in weight change: -6.7 kg), weight-loss interventions produced a greater reduction in PASI versus control: MD -2.5 (95%CI: -3.8 to -1.1, I2 = 85.2%). We found a significant effect of weight-loss interventions on the likelihood of achieving PASI75 (RR = 1.6, 95%CI: 1.1-2.2, I2 = 22.6% [based on six comparisons, n = 681, MD in weight change: -7.3 kg]). There was no statistically significant effect of the interventions on the likelihood of achieving PASI50 (RR = 1.5, 95%CI: 0.9-2.4, I2 = 72.8% [based on four comparisons, n = 509, MD in weight change: -4.0 kg]) or PASI100 (RR = 1.6, 95%CI: 0.3-9.7, I2 = 0.0% [based on two comparisons, n = 334, MD in weight change: -5.2 kg]), but both analyses were limited by few studies. Across seven comparisons (n = 364; MD in weight change -7.8 kg), weight-loss interventions were associated with a significant improvement in DLQI compared to control: MD -5.0 (95%CI: -9.7 to -0.3, I2 = 96.0%). CONCLUSIONS:High-certainty evidence suggests weight-loss interventions can improve psoriasis severity and quality of life, and should be considered as part of routine treatment.