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Objective There is substantial variability in the effectiveness of group lifestyle interventions for weight loss. We examined associations between intervention weight loss counselors and participant weight loss and program engagement in a structured lifestyle intervention. Methods Data were from 575 adults (87% female, 51 (12) years, baseline BMI: 32.4 (7.2) kg/m2) in an 11-week structured group lifestyle program. Participants self-enrolled in groups led by 11 weight loss counselors based on meeting times. All weight loss counselors received the same training. Linear mixed models were used to evaluate counselor predictors of participant percent (%) weight loss and program engagement (weight reporting throughout 11 weeks). Results Of the 575 participants, 415 (72%) defined as complete reporters, i.e. reported weight weekly, lost a mean 7.3% weight (range: +3.1% to 16.2%). Participant weight loss differed between weight loss counselors (p = 0.003), and adjusted mean participant weight loss by weight loss counselor ranged from 6% to 9%. Weight loss was greater for weight loss counselors with a graduate degree in nutrition than weight loss counselors with another graduate degree (8.3% versus 6.4%, p = 0.05), but was not different between weight loss counselors with and without graduate degrees. Higher counselor BMI was associated with higher participant weight loss (p = 0.005). Conclusions These results demonstrate the potential for quantitatively important effects of weight loss counselor characteristics on participant success and engagement in structured lifestyle interventions, indicating a need for research in this area.

BACKGROUND Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low. OBJECTIVES We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity. METHODS Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models. RESULTS Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to

Renan Rodrigues,1 Myrna Serapião Dos Santos,1,2 Rachel E Silver,3 Mauro Campos,1,2 Rachel LR Gomes1,2 1Department of Ophthalmology, Federal University of Sao Paulo, Sao Paulo, Brazil; 2Cataract Department, Hospital de Olhos Paulista, Sao Paulo, Brazil; 3Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA Purpose: To evaluate anatomical differences between laser (VICTUS) and manual constructed phacoemulsification incisions.Setting: Study was conducted at the Hospital de Olhos Paulista, Sao Paulo, Brazil.Design: This is a prospective, observational, consecutive nonrandomized cohort.Patients and methods: Sixteen patients (18 eyes) had phacoemulsification surgery, nine eyes had manual incisions and nine eyes had femtosecond incisions. All incisions were performed by the same surgeon. All incisions were evaluated at the 1st and 30th postoperative day with anterior segment optical coherence tomography to evaluate anatomical features. Inclusion criterion was presence of low visual acuity due to cataract. Exclusion criteria were other ocular pathologies, previous trauma, or corneal wound healing disease, as any intra or postoperative complication. Three different corneal specialists analyzed wound architecture features (epithelial or endothelial gap, incision edema, number of planes, Descemet’s detachment, and loss of wound sealing) at both visits. ImageJ (National Institutes of Health) software was also used to analyze anatomical features of incisions.Results: Almost all incisions had edema at the first postoperative day. All femto incisions were triplanar, as intended, unlike manual incisions, which showed two uniplanar incisions (P=0.009). All laser incisions presented partial loss of wound sealing, while five keratome incisions had no loss of wound sealing at the first postoperative day (P=0.03).Conclusion: These findings support the hypothesis that laser constructed incisions are more precisely constructed than manual, although corneal wound healing was similar between the two groups at the 30th postoperative day, with a tendency to a faster anatomical improvement in the keratome group. Keywords: phacoemulsification, cataract, femtosecond laser, optical coherence tomography, cornea&nbsp

Background/aims The Age-Related Eye Disease Study (AREDS) reported the beneficial impact of antioxidant and zinc supplements on the risk of progression to advanced stages of age-related macular degeneration (AMD). We evaluated the role of genetic variants in modifying the relationship between supplementation and progression to advanced AMD. Methods Among 4124 eyes (2317 subjects with a genetic specimen), 882 progressed from no AMD, early or intermediate AMD to overall advanced disease, including geographic atrophy (GA) and neovascular disease (NV) over the course of the clinical trial. Survival analysis using individual eyes as the unit of analysis was used to assess the effect of supplementation on AMD outcomes, with adjustment for demographic, environmental, ocular and genetic covariates. Interaction effects between supplement groups and individual complement factor H (CFH) Y402H and age-related maculopathy susceptibility 2 ( ARMS2 ) genotypes, and composite genetic risk groups combining the number of risk alleles for both loci, were evaluated for their association with progression. Results Among antioxidant and zinc supplement users compared with the placebo group, subjects with a non-risk genotype for CFH (TT) had a lower risk of progression to advanced AMD (HR: 0.55, 95% CI 0.32 to 0.95, p=0.033). No significant treatment effect was apparent among subjects who were homozygous for the CFH risk allele (CC). A protective effect was observed among high-risk ARMS2 (TT) carriers (HR: 0.52, 95% CI 0.33 to 0.82, p=0.005). Similar results were seen for the NV subtype but not GA. Conclusions The effectiveness of antioxidant and zinc supplementation appears to differ by genotype. Further study is needed to determine the biological basis for this interaction. Trial registration number NCT00594672, pre-results.

ObjectiveTo assess the effects of food supplementation on improving working memory and additional measures including cerebral blood flow in children at risk of undernutrition.DesignRandomized controlled trial.Setting10 villages in Guinea-Bissau.Participants1059 children aged 15 months to 7 years; children younger than 4 were the primary population.InterventionsSupervised isocaloric servings (≈1300 kJ, five mornings each week, 23 weeks) of a new food supplement (NEWSUP, high in plant polyphenols and omega 3 fatty acids, within a wide variety and high fortification of micronutrients, and a high protein content), or a fortified blended food (FBF) used in nutrition programs, or a control meal (traditional rice breakfast).Main outcome measurementsThe primary outcome was working memory, a core executive function predicting long term academic achievement. Additional outcomes were hemoglobin concentration, growth, body composition, and index of cerebral blood flow (CBFi). In addition to an intention-to-treat analysis, a predefined per protocol analysis was conducted in children who consumed at least 75% of the supplement (820/925, 89%). The primary outcome was assessed by a multivariable Poisson model; other outcomes were assessed by multivariable linear mixed models.ResultsAmong children younger than 4, randomization to NEWSUP increased working memory compared with the control meal (rate ratio 1.20, 95% confidence interval 1.02 to 1.41, P=0.03), with a larger effect in the per protocol population (1.25, 1.06 to 1.47, P=0.009). NEWSUP also increased hemoglobin concentration among children with anemia (adjusted mean difference 0.65 g/dL, 95% confidence interval 0.23 to 1.07, P=0.003) compared with the control meal, decreased body mass index z score gain (−0.23, −0.43 to −0.02, P=0.03), and increased lean tissue accretion (2.98 cm2, 0.04 to 5.92, P=0.046) with less fat (−5.82 cm2, −11.28 to −0.36, P=0.04) compared with FBF. Additionally, NEWSUP increased CBFi compared with the control meal and FBF in both age groups combined (1.14 mm2/s×10−8, 0.10 to 2.23, P=0.04 for both comparisons). Among children aged 4 and older, NEWSUP had no significant effect on working memory or anemia, but increased lean tissue compared with FBF (4.31 cm2, 0.34 to 8.28, P=0.03).ConclusionsChildhood undernutrition is associated with long term impairment in cognition. Contrary to current understanding, supplementary feeding for 23 weeks could improve executive function, brain health, and nutritional status in vulnerable young children living in low income countries. Further research is needed to optimize nutritional prescriptions for regenerative improvements in cognitive function, and to test effectiveness in other vulnerable groups.Trial registrationClinicalTrials.gov NCT03017209.

OBJECTIVES: Anti-inflammatory diets have been suggested to improve psychological health. This research evaluated the combined effects of consuming an anti-inflammatory diet and caloric restriction (CR) on changes in perceived stress and health-related quality of life in a healthy, non-obese population. METHODS: We conducted a secondary analysis of the publicly available CALERIE data. Participants were randomized to a 2 year CR intervention (n = 143) or an ad libitum Control group (n = 75) and self-selected their dietary intake. An energy-adjusted dietary inflammatory index (DII) was calculated based on 28 components from self-reported food records. Self-reported stress and general health outcomes were measured using validated questionnaires. Linear mixed models were used to assess changes in each outcome from baseline to 12 and 24 months. Models were adjusted for age, sex, baseline outcome measure, change in body fat, and a treatment by DII interaction term. RESULTS: On average, participants were 38.1 ± 7.2 years old with a BMI of 25.1 ± 1.7 kg/m(2). Baseline characteristics, including the DII, stress, and general health, did not differ with randomization. There was no significant association between temporal changes in DII and changes in stress or general health in the CR or Control groups. On average, both groups tended to report higher stress at 12 months; however, there was no difference in perceived stress between groups (adjusted mean difference [MD]: 0.5; 95% confidence interval [CI]: −0.4, 1.5; P = 0.25). There was an improvement in reported general health in the CR group at 12 months (MD: 4.1; 95% CI: 2.2, 6.0; P

OBJECTIVES: Undernutrition is prevalent among young children worldwide and is associated with impaired cognition and reduced educational attainment. We conducted a randomized controlled trial to test the effect of a novel supplementary food (regenerative nutrition for enhanced wellness-cognition; RENEW-C) compared to traditional feeding practices on cognitive function, cerebral blood flow and oxygen metabolism in rural Guinea-Bissau. METHODS: Children aged 15 months to 7 years (n = 1059) were randomized to receive isocaloric quantities of RENEW-C (a highly-fortified cocoa-based bar), a USAID fortified blended food (FBF) or a Control food (rice cooked with oil, replicating a traditional breakfast). The primary outcome was executive function. Secondary outcomes included a cerebral blood flow index (CBF(i)) and cerebral metabolic rate of oxygen (CMRO(2)) measured by Frequency-Domain Near-Infrared Spectroscopy and Diffusion Correlation Spectroscopy (FDNIRS-DCS, MetaOx, ISS Inc.). Six-month changes for RENEW-C and FBF versus Controls were assessed by multivariable linear mixed models adjusted for age, sex, baseline measurement, and study cohort. RESULTS: Improvements in executive function (0.38; 95% CI: 0.10, 0.71; P = 0.02) were observed for RENEW-C compared to Controls in the predefined study focus (children 75% their supplement). There was no significant effect of RENEW-C in children ≥ 4 years. No benefit of the FBF was observed in either age group. In addition, changes in CBF(i) and CMRO(2) in RENEW-C children were greater than in Controls in both ventrolateral prefrontal cortical regions (P = 0.03 and P = 0.04 for left and right, respectively) and greater than FBF in the left ventrolateral (P = 0.05) and left dorsolateral (P = 0.03) prefrontal cortices. CONCLUSIONS: Compared with traditional feeding practices, the RENEW-C supplement consumption was correlated with a marked improvement in executive function among children

Age-related macular degeneration (AMD) is the leading cause of severe vision loss in patients over 50 years of age in industrialized countries.1 Despite its high prevalence, the cause of AMD remains largely unknown. Clinically and histologically, AMD is generally classified as nonexudative or dry AMD, of which geographic atrophy (GA) is the severe form, and exudative or neovascular AMD. Dry AMD progresses more slowly and is characterized by drusen, geographic or focal atrophy of the retinal pigment epithelium (RPE), and photoreceptor dysfunction and degeneration. The advanced exudative form, neovascular AMD, can develop after early and intermediate dry AMD.2 The key feature of the advanced subtype is choroidal neovascularization (CNV), the growth of new blood vessels from the choroid into the region underlying the RPE or extending into the subretinal space. Emerging evidence supports the association between chronic inflammation and AMD. Penfold et al.3 described inflammatory cells (macrophages, lymphocytes, and mast cells) in human AMD choroids. More recent findings suggest a role for immunologic processes in AMD pathogenesis, including recruitment of macrophages,4 involvement of systemic inflammatory processes,5–7 complement activation,8–12 and microglial activation and accumulation.13 Historically, macrophages have been observed at sites of CNV in patients with AMD,14,15 and CD68+ macrophages were detected in rapidly progressive fibrovascular AMD membranes.16 Grossniklaus et al.17 evaluated human CNV and observed that macrophages express proangiogenic vascular endothelial growth factor (VEGF) and suggested that they directly promote CNV.18 Macrophage populations are simplistically divided into phenotypes M1 and M2. Phenotype M1 is proinflammatory and causes tissue injury, whereas M2 phenotype is pro-angiogenic and promotes tissue repair.19 In the laser-induced mouse CNV model with scar, M2 macrophages were recruited to the site of laser injury20,21; however, M1 macrophages were identified in the subretinal space when mice were immunized with carboxyethylpyrrole), an immune response-initiated model of AMD.22,23 Determination of M1 and M2 macrophages in a human is not as straightforward as it is in mouse. In the present study, we chose to localize all macrophages with the monocyte marker ionized calcium-binding adapter molecule 1 (IBA1) and determine if they were activated using an antibody to human leukocyte antigen-antigen D-related (HLA-DR), a subunit of major histocompatibility complex (MHC) class II. The present study aimed to quantify the number, distribution, and activation of choroidal macrophages in choroidal whole mounts from aged control eyes and in eyes from patients with clinically documented early and intermediate AMD, as well as two advanced subtypes, neovascular AMD and GA. The presence of macrophages was related to changes in choriocapillaris (CC) and CNV.

Age-related macular degeneration (AMD) is a multifactorial disease with genetic and environmental factors contributing to risk. Histopathologic changes underlying AMD are not fully understood, particularly the relationship between choriocapillaris (CC) dysfunction and phenotypic variability of this disease.To examine histopathologic changes in the CC of eyes with clinically documented AMD.The study was designed in 2011. Tissues were collected post mortem (2012-2016), and histopathological images were obtained from participants enrolled in AMD studies since 1988. Clinical records and images were collected from participants as standard protocol. Eyes without AMD (n = 4) and eyes with early (n = 9), intermediate (n = 5), and advanced stages of AMD (geographic atrophy, n = 5; neovascular disease, n = 13) were evaluated. Choroidal vasculature was labeled using Ulex europaeus agglutinin lectin and examined using confocal microscopy.A standardized classification system was applied to determine AMD stage. Ocular records and images were reviewed and histopathologic analyses performed. Viability of the choroidal vasculature was analyzed for each AMD stage.All participants were white. Fourteen were male, and 16 were female. The mean age was 90.5 years among AMD patients and 88.5 years among control participants. Submacular CC dropout without retinal pigment eipthelial (RPE) loss was observed in all cases with early stages of AMD. Higher vascular area loss for each AMD stage was observed compared with control participants: 20.5% in early AMD (95% CI, 11.2%-40.2%; P .001), 12.5% in intermediate AMD (95% CI, 2.9%-21.4%; P = .01), 39.0% loss in GA (95% CI, 32.1%-45.4%; P .001), and 38.2% loss in neovascular disease where RPE remained intact (95% CI, 27.7%-47.9%; P .001). Hypercellular, apparent neovascular buds were adjacent to areas of CC loss in 22.2% of eyes with early AMD and 40% of eyes with intermediate AMD.Retinal pigment epithelial atrophy preceded CC loss in geographic atrophy, but CC loss occurred in the absence of RPE atrophy in 2 of 9 eyes with early-stage AMD. Given the cross-sectional nature of this study and the small number of eyes evaluated, definitive conclusions regarding this progression cannot be determined with certainty. We speculate that neovascular buds may be a precursor to neovascular disease. Hypoxic RPE resulting from reduced blood supply might upregulate production of vascular endothelial growth factor, providing the stimulus for neovascular disease.

Background There is growing evidence of the importance of nutrition in age-related macular degeneration (AMD), but few studies have explored associations with folate and B vitamins. No effective therapeutic strategy for geographic atrophy (GA) is available, and prevention could be of great value. Objective We investigated associations between dietary folate, B vitamins, and progression to GA and whether these associations might be modified by genetic susceptibility. Design Among 2525 subjects (4663 eyes) in the Age-Related Eye Disease Study, 405 subjects (528 eyes) progressed to GA over 13 y. Folate and B vitamins were log transformed and calorie adjusted separately for men and women. Ten loci in 7 AMD genes [complement factor H, age-related maculopathy susceptibility 2/high-temperature requirement A serine peptidase 1, complement component 2, complement component 3, complement factor B, collagen type VIII α 1, and RAD51 paralog B] were examined. Survival analysis was used to assess associations between incident GA and dietary intake of folate and B vitamins. Interaction effects between these nutrients and genetic variation on AMD risk were also evaluated. Subjects with at least one eye free of advanced AMD at baseline were included in these analyses. Results There was a reduced risk of progression to GA with increasing intake of thiamin, riboflavin, and folate after adjusting for age, sex, and total energy intake (P-trend = 0.01, 0.03, and 0.001, respectively). After adjustment for demographic, behavioral, ocular, and genetic covariates, trends remained statistically significant for folate (P-trend = 0.007) and were borderline for thiamin (P-trend = 0.05). Riboflavin did not retain statistical significance (P-trend = 0.20). Folate was significantly associated with lower risk of incident GA among subjects homozygous for the complement component 3 (C3) R102G rs2230199 nonrisk genotype (CC) (HR = 0.43; 95% CI: 0.27, 0.70; P = 0.0005) but not subjects carrying the risk allele (G) (P = 0.76). Neither folate nor any B vitamin was significantly associated with neovascular AMD. Conclusions High folate intake was associated with a reduced risk of progression to GA. This relation could be modified by genetic susceptibility, particularly related to the C3 genotype. This trial was registered at clinicaltrials.gov as NCT00594672.

Objective To measure the energy content of frequently ordered meals from full service and fast food restaurants in five countries and compare values with US data. Design Cross sectional survey. Setting 223 meals from 111 randomly selected full service and fast food restaurants serving popular cuisines in Brazil, China, Finland, Ghana, and India were the primary sampling unit; 10 meals from five worksite canteens were also studied in Finland. The observational unit was frequently ordered meals in selected restaurants. Main outcome measure Meal energy content, measured by bomb calorimetry. Results Compared with the US, weighted mean energy of restaurant meals was lower only in China (719 (95% confidence interval 646 to 799) kcal versus 1088 (1002 to 1181) kcal; P2 =0.62, P Conclusion Very high dietary energy content of both full service and fast food restaurant meals is a widespread phenomenon that is probably supporting global obesity and provides a valid intervention target.