Food Reintroduction Research Articles

Biomarkers of dietary intake in faeces of children with Crohn’s disease and their role in disease recurrence following treatment with exclusive enteral nutrition

Abstract Background and aims This study aims to profile biomarkers of dietary intake in faeces of children with Crohn’s disease (CD) and explore their role in disease recurrence following induction treatment with exclusive enteral nutrition. Methods We will profile and quantify biomarkers of dietary intake in 928 banked faecal samples of 116 children with CD collected during the first 30 days of food reintroduction, following successful treatment with exclusive enteral nutrition (EEN), and in spot samples from 53 matched healthy controls. In faecal samples, a wide range of carbohydrates (e.g. galactose, rhamnose, glucose, xylose), polysaccharides (e.g resistant starch) and oligosaccharides (e.g. β-fructans), total nitrogen, as well as nitrogen-containing compounds (e.g. amino acids, dipeptides) will be measured with a combination of 1H-NMR, UHPLC-MS, anion exchange chromatography, the Kjeldahl AOAC method and proprietary kits. Faecal biomarkers of dietary intake will be associated with risk of disease recurrence (indicated by the rapid rise in faecal calprotectin) during the first 30 days of food reintroduction, following successful treatment with EEN. Next, this study will explore whether identified biomarkers of dietary intake in faeces relate with patients’ actual dietary intake, and whether the two datasets complement or supersede each other in prediction of disease recurrence. Last, we will identify common dietary biomarkers of disease recurrence between two distinct cohorts of patients; one which returned to unrestricted diet, post-EEN, and another which followed a novel exclusion diet (CD-TREAT) for the management of CD. Anticipated impact This study has the potential to address one of the most frequently asked questions from patients to healthcare professionals; “What should I eat to control my disease and prevent disease relapse?” Identification of dietary triggers may lead to the development of food reintroduction protocols following EEN completion; hence offering better long-term disease control and improving the quality of life of patients with CD.

Severity trend of recurrence in pediatric Food Protein-Induced Enterocolitis Syndrome (FPIES).

Reintroduction of offending food in pediatric patients affected by Food Protein-Induced Enterocolitis Syndrome (FPIES) is carried out in hospitals with Oral Food Challenge (OFC), which leads to long waiting time and increases the societal burden of medical cost and human resources. The aim of the study is to assess severity trend of acute FPIES adverse reactions over time in the same patient for possible outpatient or home reintroduction of offending food. All children (<18 years-old) with a diagnosis of acute FPIES referred to 2 Italian pediatric allergy clinics were retrospectively enrolled. To determine if home or outpatient clinic reintroduction of trigger food was possible, a risk of severe reactions <5% was arbitrarily considered acceptable. Of the 202 patients enrolled, 23 (11,4%) presented increasing severity from mild-moderate to severe episode. None of the variables analyzed in these patients (sex, age at onset and interval between first and severe episode) had a statistically significant influence on the risk of more severe reactions. Of all patients initially presented mild or moderate episodes, 15.2% and 13.9% later manifested severe episodes over time, respectively. Of patients with cow's milk FPIES started with a mild episode, 5.5% later experienced a severe episode. Performing OFC for acute FPIES is not safe enough at home, because the probability of severe adverse reaction is >5%. However, it could be considered to perform OFC in outpatient clinic in patients with cow's milk FPIES started with a mild episode and if a rapid transfer plan to emergency department is available.

BARRIERS AND ENABLERS OF DIETARY REINTRODUCTION FOLLOWING NEGATIVE ORAL FOOD CHALLENGE: A SCOPING REVIEW.

Following a negative oral food challenge (OFC), it is recommended the individual continues to consume the historical allergen regularly. However, the proportion of families achieving sustained reintroduction, and enablers and barriers for reintroduction, are currently unclear. To understand the frequency and definitions of optimal food reintroduction in children and adolescents following negative OFC, and associated barriers and enablers. We conducted a scoping review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews of four databases (PubMed, Embase, CINAHL, Web of Science) from 2000 until the present. Medical Subject Headings guided our systematic search, and dual screening and extraction were performed. Descriptive analysis was applied to examine key themes aligned with our research questions. In total, 2,270 articles were screened, and 22 studies were included across nine countries. Peanuts were the most studied food (17 studies, 749 OFCs), followed by cow's milk (12 studies, 625 OFCs), hazelnut (4 studies; 361 OFCs) and hen's egg (11 studies; 340 OFCs). What was considered to be successful reintroduction was poorly and inconsistently described. Successful reintroduction (as defined by the authors) ranged from 14% to 86% with failed reintroduction up to 50%. Nineteen studies (86%) examined barriers or enablers of reintroduction. Primary barriers were fear and anxiety, symptoms with reintroduction and aversion to or refusal of the food, while younger age, male gender and guidance from clinicians were commonly reported enablers. The number of families who do not reintroduce foods following OFC remains high, and clinicians need high-quality data to better support families.

Long-term fasting induces a remodelling of fatty acid composition in erythrocyte membranes.

Long-term fasting (LF) activates an adaptative response to switch metabolic fuels from food glucose to lipids stored in adipose tissues. The increase in free fatty acid (FFA) oxidation during fasting triggers health benefits. We questioned if the changes in lipid metabolism during LF could affect lipids in cell membranes in humans. We thus analysed the FA composition in erythrocyte membranes (EM) during 12.6 ± 3.5 days of LF and 1 month after food reintroduction. A total of 98 subjects out of three single-arm interventional studies underwent a medical supervised long-term fasting (12.6 ± 3.5 days) programme. The distribution pattern of 26 FA as well as the HS-Omega-3 Index were assessed in the EM using gas chromatography. Eighteen of 26 FA showed significant changes. Within the group of saturated FA, myristic (14:0) and stearic acid (18:0) decreased while palmitic (16:0) and arachid acid (20:0) increased. While most monounsaturated FA increased, trans fatty acids decreased or remained unchanged. Within the polyunsaturated FA, arachidonic (20:4n6) and docosahexaenoic (22:6n3) acid increased, while linoleic (18:2n6), alpha-linolenic (18:3n3) and eicosapentaenoic acid (20:5n3) decreased. Consequently, the HS-Omega-3 Index increased. 11 out of the 18 FA with significant changes returned to baseline levels 1 month afterwards. Levels of linoleic and alpha-linolenic acid increased over baseline levels. Long-term fasting triggers changes in the FA composition of EM.

Remotely delivered weight management for people with long COVID and overweight: the randomized wait-list-controlled ReDIRECT trial

Long COVID (LC) is a complex multisymptom condition with no known disease-modifying treatments. This wait-list-controlled open-label trial tested whether a remotely delivered structured weight management program could improve respective LC symptoms in people living with overweight. Adults with LC (symptoms >12 weeks) and body mass index >27 kg m−2 (>25 kg m−2 for South Asians) were randomized (n = 234, 1:1) to control (n = 116, usual care) or the remotely delivered structured weight management (n = 118, total diet replacement (850 kcal per day) for 12 weeks, followed by food reintroduction and weight loss maintenance support) via minimization and randomization (80:20) to balance dominant LC symptom, sex, age, ethnicity and postcode-based index of multiple deprivation between groups. The control group received the intervention after 6 months. Participants selected the dominant LC symptom they would most like to improve (fatigue, breathlessness, pain, anxiety/depression or other) as the prespecified respective primary outcome. Individual symptoms were assessed using validated questionnaires and a visual analog scale for those without prespecified scales. At 6 months, the primary outcome improved in the intervention group (change −1.16 (s.d. 1.42), n = 97 analyzed) compared with the control group (change −0.83 (s.d. 1.14), n = 117 analyzed) with a treatment effect of −0.34 (95% confidence interval −0.67 to −0.01), with no excess of serious adverse events. International Standard Randomised Controlled Trial Number Registry registration: ISRCTN12595520.

Changes in intestinal permeability and gut microbiota following diet-induced weight loss in patients with metabolic dysfunction-associated steatohepatitis and liver fibrosis

ABSTRACT Weight loss improves metabolic dysfunction-associated steatohepatitis (MASH). We investigated whether there were associated changes in intestinal permeability, short-chain fatty acids (SCFAs), and gut microbiota, which are implicated in the pathophysiology of MASH. Sixteen adults with MASH, moderate fibrosis, and obesity received a low-energy total diet replacement program for 12 weeks and stepped food re-introduction over the following 12 weeks (ISRCTN12900952). Intestinal permeability, fecal SCFAs, and fecal microbiota were assessed at 0, 12, and 24 weeks. Data were analyzed using mixed-effects linear regression and sparse partial least-squares regression. Fourteen participants completed the trial, lost 15% (95% CI: 11.2–18.6%) of their weight, and 93% had clinically relevant reductions in liver disease severity markers. Serum zonulin concentrations were reduced at both 12 and 24 weeks (152.0 ng/ml, 95% CI: 88.0–217.4, p < 0.001). Each percentage point of weight loss was associated with a 13.2 ng/mL (95% CI: 3.8–22.5, p < 0.001) reduction in zonulin. For every 10 ng/mL reduction in zonulin, there was a 6.8% (95% CI: 3.5%-10.2, p < 0.001) reduction in liver fat. There were reductions in SCFA and alpha diversity evenness as well as increases in beta diversity of the gut microbiota at 12 weeks, but the changes did not persist at 24 weeks. In conclusion, substantial dietary energy restriction is associated with significant improvement in MASH markers alongside reduction in intestinal permeability. Changes in gut microbiota and SCFA were not maintained with sustained reductions in weight and liver fat, suggesting that microbiome modulation may not explain the relationship between weight loss and improvements in MASH.

Food Protein-Induced Allergic Proctocolitis: Real-World Experience from an Italian Cohort.

Background/Objectives: Food protein-induced allergic proctocolitis (FPIAP) is a non-IgE-mediated food allergy, usually presenting as bloody stools in breastfed, well-appearing, and regularly growing infants. The aim of our study was to describe the clinical features of Italian infants affected by FPIAP and their management and natural history in a real-life setting. Methods: A retrospective, observational study was performed at two tertiary pediatric hospitals (Florence and Trieste), including FPIAP-diagnosed infants between 2012 and 2022. Results: Most of the 100 enrolled patients were breastfed (68.0%), and the majority of those who underwent diagnostic tests (n = 51) showed normal hemoglobin and total IgE levels. A maternal elimination diet was performed in 69.0%, mostly for milk only, but 40.6% underwent multiple elimination diets. The remission rate was high both in breastfed infants (76.8%) and in those who received extensively hydrolyzed formula (81.8%). Nine subjects were left on a free diet, but six were lost at follow-up. The median time of complete remission was 30 days (IQR 14-60). Culprit food reintroduction was tolerated at a median age of 8 months (IQR 6-11), in ladder modality (for hen's egg and cow's milk) in 61.7%. Nine patients relapsed (14.3%) upon reintroduction with no associated variables identified at the regression analysis. The relapse rate was slightly higher when trigger food reintroduction was attempted > 12 months (16.7%) versus <12 months (13.0%). Conclusions: In our population, FPIAP had, as expected, a benign evolution. The early reintroduction of the suspect food in a gradual manner for cow's milk and hen's egg leads to good tolerance within the first year in most patients, avoiding unnecessary elimination diets.

Impact of Long-term Fasting on Breath Volatile Sulphur Compounds, Inflammatory Markers and Saliva Microbiota Composition.

Despite substantial evidence supporting the role of resident bacterial communities in therapeutic fasting outcomes, research has primarily focused on gut microbiota, leaving changes in oral microbiota largely unexplored. The clinical significance of oral health changes during fasting is nonetheless underscored by the documented development of halitosis in fasting individuals. However, no scientific studies have comprehensively examined the interplay between salivary microbiota alterations, inflammatory changes in the gingival crevice, and the production of malodorous volatile compounds. We examined volatile sulphur compounds (VSC) in breath during fasting, cytokine levels in the gingival crevice, and oral microbiota composition of the saliva in a single-arm interventional study involving 36 subjects who fasted for 10 ± 3 days. Participants fasted according to Buchinger fasting guidelines. VSC were evaluated every morning before any food or drink intake using the OralChroma gas chromatography device. Saliva and gingival crevicular fluid (GCF) samples were collected at the clinical site before fasting, at the end of fasting, and at the end of food reintroduction. Follow-up saliva samples were sent to the patients after 1 and 3 months. Saliva samples were processed and analysed by targeted sequencing of 16S rRNA gene amplicons, whereas the expression of 6 inflammatory markers in the GCF were analysed using a multiplex fluorescent bead-based immunoassay. The quantification of volatile compounds in the breath demonstrated a statistically significant increase in dimethylsulfide levels during fasting, which corroborates the occurrence of bad breath as a common side effect of fasting. Salivary microbiota profiling showed a shift in microbial composition, including reduction in the levels of Neisseria, Gemella and Porphyromonas spp., concomitant with an increase in the levels of Megasphaera, Dialister, Prevotella, Veillonella, Bifidobacteria, Leptotrichia, Selenomonas, Alloprevotella, and Atopobium. We further demonstrated a reduction in the levels of the pro-inflammatory cytokine interleukin-8 in the GCF. Dimethylsulfide concentrations in the breath increased during fasting, and this was correlated to changes in the oral microbiota. Future studies are needed to illuminate the possible impact of these changes on oral and general health status.

A One-Year Weight Management Program for Difficult-to-Treat Asthma With Obesity: A Randomized Controlled Study

BackgroundObesity-associated asthma results in increased morbidity and mortality. We report one-year asthma outcomes with the Counterweight-Plus weight management programme (CWP) compared to usual care (UC) in a single-centre, randomised, controlled trial in patients with difficult-to-treat asthma and obesity. Research QuestionCan CWP use result in improved asthma control and quality of life compared to UC at one-year in patients with difficult-to-treat asthma and obesity? Study design and methodsWe randomised (1:1 CWP:UC) adults with difficult-to-treat asthma and body mass index ≥30kg/m2. CWP with dietitian support: 12-week total diet replacement phase (850kcal/day low-energy formula); food reintroduction and maintenance phases up to one-year. Outcomes include Asthma Control Questionnaire (ACQ-6), Asthma Quality of Life Questionnaire (AQLQ) and healthcare usage. Minimal clinically important difference (MCID) is 0.5 for ACQ-6 and AQLQ. ResultsOf 36 recruited, 29 attended at 52-weeks: 13 CWP, 16 UC. CWP resulted in greater weight change (median –14kg [IQR –15, –9]) compared to UC (2kg [-7, 8]; p=0.015) at 52-weeks. A greater proportion achieved MCID with CWP vs UC in AQLQ (71% vs 6% respectively; p<0.001). No between-group differences were observed in ACQ-6. Median exacerbation frequency reduced over 52-weeks with CWP from 4 (IQR 2, 5) to 0 (0, 2) (p<0.001), though no between-group difference was observed. 70% of the CWP group lost ≥10% body weight and had improvement in ACQ-6 (mean difference –1.1, 95%CI –1.9, -0.3; p=0.018) and AQLQ (1.2, 95%CI 0.4, 2.1; p=0.011) across 52-weeks. InterpretationUse of a dietitian-supported weight management programme results in sustained weight-loss and is a potential treatment for obesity in asthma. CWP resulted in a higher proportion achieving MCID improvement in AQLQ compared to UC. Within group differences in AQLQ and exacerbation frequency suggest potential with CWP. These encouraging signals justify a larger sample study to further assess asthma-related outcomes.

Reintroduction of oral food in patients with enteral nutritional therapy

Reintroduction of oral food in patients with enteral nutritional therapy

Differing Epithelial and Immunologic Activation Patterns Following Food Reintroduction Reveal Different Transcriptional Profiles in Active Eosinophilic Esophagitis

Differing Epithelial and Immunologic Activation Patterns Following Food Reintroduction Reveal Different Transcriptional Profiles in Active Eosinophilic Esophagitis

Omalizumab reduces anaphylactic reactions and allows food introduction in food-allergic in children with severe asthma: An observational study.

In Europe, Omalizumab (anti-IgE) is indicated for the treatment of moderate to severe asthma, but not for IgE-mediated food allergy (FA). We assessed the impact of Omalizumab on efficacy, safety, and quality of life (FA-QoL) in patients with moderate to severe asthma and who have a history of anaphylaxis to peanut, tree nuts, fish, egg, milk, and/or wheat. Food-allergic children (6-18 years) with moderate to severe asthma underwent oral food challenges (OFCs) to establish the threshold of reaction to the culprit food(s) at baseline (T0) and at 4-month intervals (T1, T2, and T3) during their first year of treatment with Omalizumab. We recorded the number and severity of food-allergic reactions, Asthma Control Test (ACT) scores, FA-QoL, and total IgE levels. In 65 patients allergic to 107 foods, the No Observed Adverse Events Level (NOAEL) at T1 increased: 243- and 488-fold for fresh and baked milk, respectively; 172- and 134-fold for raw and baked egg; 245-fold for hazelnut; 55-fold for peanut; 31-fold for wheat; and 10-fold for fish. Full tolerance was achieved in 66.4% of OFCs at T1, 58.3% at T2, and 75% at T3. Ninety-five foods were liberalized in the diet of 55 patients; the remaining 12 were introduced by 10 patients at least in traces. Throughout the study, 40 out of 65 were able to get a free diet. ACT increased from 17 (Q1-Q3: 15-17) to 23.6 (Q1-Q3: 23-25). The FA-QoL score in children ≤12 years decreased from 4.63 ± 0.74 to 2.02 ± 1.13, and in adolescents from 4.68 ± 0.92 to 1.90 ± 1.50. During Omalizumab therapy, a safe reintroduction of allergenic foods is feasible. ClinicalTrials.gov, NCT06316414.

Differential changes in mast cells with food reintroduction in children with eosinophilic esophagitis.

Intraepithelial mast cells (MCs) are increased in eosinophilic esophagitis (EoE) and reduced with elimination of dietary antigens. Single food reintroduction can identify triggers of eosinophilia; however, the extent to which specific foods trigger intraepithelial mastocytosis remains unknown. We hypothesized that specific foods drive different degrees of MC inflammation. We previously reported a prospective pediatric EoE cohort treated with a 4-food elimination diet (4FED) with removal of soy, egg, wheat, and milk. We retrieved unstained slides in which baseline, 4FED, and post-4FED diet reintroduction time points were available. Slides were stained with tryptase, and intraepithelial MCs were counted. Comparisons were made by stratifying patients by eosinophilia, basal cell hyperplasia (BCH), endoscopic abnormalities, and symptoms. Pearson correlation was assessed for MCs with eosinophilic, endoscopic, and BCH severity; symptoms; and a novel mucosal activity score combining endoscopic and histologic structural severity. Slides were available from 37 patients with at least 1 food reintroduced. MCs were significantly reduced with 4FED. Wheat led to increased intraepithelial MCs in the upper esophagus and with food-induced eosinophilia, while milk led to significantly increased MCs in the upper and lower esophagus and was significantly associated with patients with food-triggered eosinophilia, endoscopic abnormalities, BCH, and symptoms. MCs best correlated with the mucosal activity score during milk reintroduction. In children with EoE, MCs are reduced with 4FED. During milk reintroduction, significant increases in MCs were observed with all metrics of inflammation along with moderate correlation with structural mucosal activity that was not seen with other foods. This suggests that milk exerts unique effects either directly or indirectly on MCs in the esophagus in EoE patients.

Very-low-calorie diet-based intensive lifestyle intervention for remission of type 2 diabetes: Real-world experience in a South Asian population.

Very low-calorie diet (VLCD) can induce weight loss and diabetes remission (DR) amongst people with obesity and recent-onset type 2 diabetes (T2D). We aimed to determine the effectiveness and acceptability of VLCD in achieving DR amongst Sri Lankan adults with T2D. A retrospective analysis was conducted in a diabetes practice where VLCD-based Diabetes Remission Programme (VDRP) was offered for adults (>18 years) with T2D for <3 years and body mass index over 25 kg/m2. VLCD (~800 kcal/day, provided with/without diet replacement formula) was offered for 8-12 weeks, followed by gradual food reintroduction and exercise. DR was defined as HbA1c <6.5% at least 3 months after stopping glucose-lowering medications. A total of 170 participants who enrolled in the VDRP (mean age 38.4 years [±11.1], men 68%, mean baseline HbA1c 86.9 [±18.1] mmol/mol (10.1 [±2.1]%), median duration of T2D 2 years [IQR 1-2]) and 87 (51%) of them followed the programme (attended at least one follow-up visit). Amongst the individuals who followed the VDRP, 40.2% achieved DR (35/87), compared with 2.4% (2/83) amongst those who did not follow the VDRP (aHR 9.3, 95% CI 2.2-16.4, p = 0.002). The proportion achieving normoglycaemia (HbA1c < 6.5%) but continued to take glucose-lowering medication was 20/87 among VDRP followers and 20/85 amongst VDRP non-followers. The commonest reasons for not following the VDRP were too restrictive dietary quantity (92%) and difficulties in finding recommended food items (67%). Majority (79%) would recommend VDRP to others. VDRP is effective in achieving T2D remission amongst Sri Lankan adults with recently diagnosed T2D and obesity. Over half of the participants followed the programme and over 75% would recommend it to others, indicating good acceptability.

HDL cholesterol efflux capacity and cholesterol loading capacity in long-term fasting: Evidence from a prospective, single-arm interventional study in healthy individuals

Background and aimsLong-term fasting (LF) is increasingly emerging as a non-pharmacological approach to modulate risk factors associated with the development of atherosclerotic cardiovascular diseases (ASCVD). However, protection from ASCVD is more tied to the functionality of high-density lipoprotein (HDL) than its plasma levels. Our prospective interventional study focuses on the functional properties of lipoproteins in modulating cholesterol homeostasis on peripheral cells and examines how LF may influence this and lipoprotein subclass composition. For that purpose, we investigated its impact on HDL-cholesterol efflux capacity (CEC), and on serum cholesterol loading capacity (CLC). MethodsForty healthy subjects (50 % females) underwent medically supervised 9-day fasting (250 kcal/day) in a specialised facility. Thirty-two subjects had a follow-up examination after one month of food reintroduction. ResultsLF was well tolerated and increased self-reported energy levels. Fasting reduced triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and HDL cholesterol (HDL-C). Very-low-density lipoprotein cholesterol (VLDL-C) and LDL3-C showed sustained reductions at follow-up. Only HDL-C, specifically HDL2-C levels, increased at follow-up. Total HDL-CEC decreased during LF and increased above baseline at follow-up. Fasting decreased ATP binding cassette (ABC)A1-mediated HDL-CEC whereas ABCG1-mediated HDL-CEC remained unaffected. Aqueous diffusion increased at follow up. LF decreased serum CLC and then returned to baseline levels. ConclusionsLF not only maintains lipoprotein functionality but also contributes to a favorable shift in the atherogenic risk profile, which persists even after food reintroduction. This further emphasizes the importance of considering HDL functionality alongside traditional lipid measurements to understand the potential for non-pharmacological interventions like LF to promote cardiovascular prevention and health. Trial registration numberNCT05031598.

A Novel Machine-Learning Algorithm to Predict the Early Termination of Nutrition Support Team Follow-Up in Hospitalized Adults: A Retrospective Cohort Study.

For hospitalized adults, it is important to initiate the early reintroduction of oral food in accordance with nutrition support team guidelines. The aim of this study was to develop and validate a machine learning-based algorithm that predicts the early termination of medical nutritional therapy (the transition to oral feeding). This retrospective cohort study included consecutive adult patients admitted to the Hacettepe hospital (from 1 January 2018 to 31 December 2022). The outcome of the study was the prediction of an early transition to adequate oral feeding before discharge. The dataset was randomly (70/30) divided into training and test datasets. We used six ML algorithms with multiple features to construct prediction models. ML model performance was measured according to the accuracy, area under the receiver operating characteristic curve, and F1 score. We used the Boruta Method to determine the important features and interpret the selected features. A total of 2298 adult inpatients who were followed by a nutrition support team for medical nutritional therapy were included. Patients received parenteral nutrition (1471/2298, 64.01%), enteral nutrition (717/2298, 31.2%), or supplemental parenteral nutrition (110/2298, 4.79%). The median (interquartile range) Nutritional Risk Screening (NRS-2002) score was 5 (1). Six prediction algorithms were used, and the artificial neural network and elastic net models achieved the greatest area under the ROC in all outcomes (AUC = 0.770). Ranked by z-value, the 10 most important features in predicting an early transition to oral feeding in the artificial neural network and elastic net algorithms were parenteral nutrition, surgical wards, surgical outcomes, enteral nutrition, age, supplemental parenteral nutrition, digestive system diseases, gastrointestinal complications, NRS-2002, and impaired consciousness. We developed machine learning models for the prediction of an early transition to oral feeding before discharge. Overall, there was no discernible superiority among the models. Nevertheless, the artificial neural network and elastic net methods provided the highest AUC values. Since the machine learning model is interpretable, it can enable clinicians to better comprehend the features underlying the outcomes. Our study could support personalized treatment and nutritional follow-up strategies in clinical decision making for the prediction of an early transition to oral feeding in hospitalized adult patients.

Experiences and Acceptability of a Weight Loss Intervention for Diabetes (Diabetes Remission Clinical Trial-DiRECT) in Aotearoa New Zealand: A Qualitative Study within a Pilot Randomised Controlled Trial.

The Diabetes Remission Clinical Trial (DiRECT) demonstrated that substantial weight loss and remission from type 2 diabetes can be achieved with low-energy total diet replacement and behavioural support. However, the acceptability of the DiRECT intervention in diverse populations with strong cultural emphases on food and shared eating remains unclear. We conducted a qualitative study nested within a pilot randomised controlled trial of DiRECT in one Māori (the Indigenous people of New Zealand) primary care provider in Aotearoa New Zealand. Participants with type 2 diabetes or prediabetes, obesity, and a desire to lose weight were randomised to either dietitian-supported usual care or the dietitian-supported DiRECT intervention for twelve months. The DiRECT intervention included three months of total diet replacement, then food reintroduction and supported weight loss maintenance. At three and twelve months, semi-structured interviews explored the acceptability of DiRECT and participants' experiences of each intervention. Interview transcripts from 25 participants (aged 48 ± 10 years, 76% female, 78% Māori or Pacific) at three months and 15 participants at twelve months were analysed. Participants viewed their pre-enrolment selves as unhealthy people with poor eating habits and desired professional weight loss support. For DiRECT participants, the total diet replacement phase was challenging but well-received, due to rapid improvements in weight and health. Food reintroduction and weight loss maintenance each presented unique challenges requiring effective strategies and adaptability. All participants considered individualised and empathetic dietetic support crucial to success. Sociocultural factors influencing success were experienced in both interventions: family and social networks provided support and motivation; however, eating-related norms were identified as challenges. The DiRECT intervention was considered an acceptable approach to weight loss in participants with type 2 diabetes or prediabetes with strong cultural emphases on food and shared eating. Our findings highlight the importance of individualised and culturally relevant behavioural support for effective weight loss and weight loss maintenance.

A refined rodent model of anorexia nervosa: Simulating state‐specific effects of caloric restriction and weight restoration

AbstractCurrent rodent models of anorexia nervosa (AN) often have accelerated weight loss that often do not allow for investigation of physiological ramifications of prolonged low weight status characteristic of AN. The purpose of this project was to refine a rodent model of AN to extend the duration of low weight status and allow for investigation of recovery. Eight‐week‐old female Sprague Dawley rats underwent 50%–60% food restriction for 30 days. Rats were group‐housed except during feeding, where AN rats were individually housed and given up to 2 h to consume food. Control (CON) rats were allowed to consume food ad libitum. To simulate recovery, a separate cohort of animals underwent the same food restriction protocol for 30 days, then rats (AN‐R) were allowed to consume food ad libitum to facilitate weight recovery for an additional 30 days. AN‐R rats were compared to age matched controls (CON‐R). AN rats lost ~15% bodyweight and were ~30% lighter than CON. Compared to CON, AN rats had ~35% lower fat content, ~18% lower bone mineral density, ~22% smaller plantaris muscle mass and ~52% smaller ovaries. Upon reintroduction of food, AN‐R rats achieved comparable bodyweights to CON‐R rats after ~10 days. However, after 30 days of recovery, AN‐R rats still had ~14% lower bone mineral density and ~11% smaller plantaris mass and ~21% smaller ovaries. This refinement of rodent AN results in physiological side effects of AN without reaching excessive weight loss requiring euthanasia. Moreover, some physiological consequences of simulated AN are not resolved with weight restoration.

Re:Mission study. Evaluating the NHS Low Calorie Diet pilot - an overview of service user data collection methods

Introduction: The National Health Service (NHS) Low Calorie Diet (LCD) pilot programme aimed to support people with type 2 diabetes (T2DM) to lose weight, reduce glycaemia and potentially achieve T2DM remission using total diet replacement alongside behaviour change support. The Re:Mission study seeks to provide an enhanced understanding of the long-term cost-effectiveness of the programme and its implementation, equity, transferability and normalisation across broad and diverse populations. This article presents an overview of the methods used in the Re:Mission study. Methods and analysis: A mixed method approach was used to draw together service user insights from across longitudinal and cross-sectional online surveys and semi-structured interviews supported by a modified photovoice technique. Insights were captured from active service users across the three phases of the programme (total diet replacement, food reintroduction and maintenance) in addition to those discharged prematurely. Survey data were analysed using descriptive statistics and qualitative data were thematically analysed and interpreted through a realist informed lens to understand which aspects of the service work and do not work, for whom, in what context and why. Results: Results from the study are presented elsewhere, with recommendations for policy practice and research.

“Trying to make healthy choices”: the challenges of the food reintroduction phase of the NHS Low Calorie Diet Programme pilot for type 2 diabetes

Background: The food reintroduction phase of the NHS Low Calorie Diet (LCD) programme aims to support service users to reintroduce food gradually back into their diet. Understanding experiences of food reintroduction from a broad and diverse range of service users is critical in helping to improve service delivery and commissioning and equity in care. Methods: This was a co-produced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=43) of the NHS LCD Programme were recruited from three delivery models across 21 pilot sites in England. Data were analysed using a thematic approach. Results: The food introduction phase required control and planning that challenged the behaviours of participants. Around a third of participants continued use of Total Diet Replacement products, or considered doing so, for convenience and to maintain calorie control. The coach–service user relationship was important to understanding of session content and translation into behaviour change. Physical activity increased during this phase, which contributed to positive health outcomes. Conclusions: The paper reports insights from the food reintroduction phase of the LCD programme. Key messages include the need for increased frequency of support and the need for tailored and culturally representative education.