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Systematic Review (SR) are foundational to influencing policies and decision-making in healthcare and beyond. SRs thoroughly synthesise primary research on a specific topic while maintaining reproducibility and transparency. However, the rigorous nature of SRs introduces two main challenges: significant time involved and the continuously growing literature, resulting in potential data omission, making most SRs become outmoded even before they are published. As a solution, AI techniques have been leveraged to simplify the SR process, especially the abstract screening phase. Active learning (AL) has emerged as a preferred method among these AI techniques, allowing interactive learning through human input. Several AL software have been proposed for abstract screening. Despite its prowess, how the various parameters involved in AL influence the software's efficacy is still unclear. This research seeks to demystify this by exploring how different AL strategies, such as initial training set, query strategies etc. impact SR automation. Experimental evaluations were conducted on five complex medical SR datasets, and the GLM model was used to interpret the findings statistically. Some AL variables, such as the feature extractor, initial training size, and classifiers, showed notable observations and practical conclusions were drawn within the context of SR and beyond where AL is deployed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background/objectives: Metrics drive diagnosis, and metrics will also drive our response to the challenge of climate change. Recognising how current scientific research defines and uses metrics of the environmental impact of human diets is essential to understand which foods, food groups, or dietary patterns are associated with a higher environmental impact., Methods: This research, aided by artificial intelligence (AI), aimed to search, map, and synthesise current evidence on the commonly used definitions and metrics of the environmental impacts of human diets., Results: We identified 466 studies measuring the environmental impact of diets. Most studies were from North American or European countries (67%), with data mainly from high-income countries (81%). Most studies did not include methods to recall the provenance of the foods consumed. Most (53%) of the studies only used one metric to estimate the environmental impact of human diets, with 82% of the studies using GHGE., Conclusions: Agreement on how the environmental impact of diets is measured and more comprehensive and accurate data on the environmental impact of single foods is essential to better understand what changes in food systems are needed, at a consumer and policy level, to make a well-meaning change towards a more sustainable diet.

Background: Low levels of testosterone cause male hypogonadism, which is associated with sexual dysfunction, tiredness and reduced muscle strength and quality of life. Testosterone replacement therapy is commonly used for ameliorating symptoms of male hypogonadism, but there is uncertainty about the magnitude of its effects and its cardiovascular and cerebrovascular safety., Aims of the Research: The primary aim was to evaluate the safety of testosterone replacement therapy. We also assessed the clinical and cost-effectiveness of testosterone replacement therapy for men with male hypogonadism, and the existing qualitative evidence on men's experience and acceptability of testosterone replacement therapy., Design: Evidence synthesis and individual participant data meta-analysis of effectiveness and safety, qualitative evidence synthesis and model-based cost-utility analysis., Data Sources: Major electronic databases were searched from 1992 to February 2021 and were restricted to English-language publications., Methods: We conducted a systematic review with meta-analysis of individual participant data according to current methodological standards. Evidence was considered from placebo-controlled randomised controlled trials assessing the effects of any formulation of testosterone replacement therapy in men with male hypogonadism. Primary outcomes were mortality and cardiovascular and cerebrovascular events. Data were extracted by one reviewer and cross-checked by a second reviewer. The risk of bias was assessed using the Cochrane Risk of Bias tool. We performed one-stage meta-analyses using the acquired individual participant data and two-stage meta-analyses to integrate the individual participant data with data extracted from eligible studies that did not provide individual participant data. A decision-analytic Markov model was developed to evaluate the cost per quality-adjusted life-years of the use of testosterone replacement therapy in cohorts of patients of different starting ages., Results: We identified 35 trials (5601 randomised participants). Of these, 17 trials (3431 participants) provided individual participant data. There were too few deaths to assess mortality. There was no difference between the testosterone replacement therapy group (120/1601, 7.5%) and placebo group (110/1519, 7.2%) in the incidence of cardiovascular and/or cerebrovascular events (13 studies, odds ratio 1.07, 95% confidence interval 0.81 to 1.42; p  = 0.62). Testosterone replacement therapy improved quality of life and sexual function in almost all patient subgroups. In the testosterone replacement therapy group, serum testosterone was higher while serum cholesterol, triglycerides, haemoglobin and haematocrit were all lower. We identified several themes from five qualitative studies showing how symptoms of low testosterone affect men's lives and their experience of treatment. The cost-effectiveness of testosterone replacement therapy was dependent on whether uncertain effects on all-cause mortality were included in the model, and on the approach used to estimate the health state utility increment associated with testosterone replacement therapy, which might have been driven by improvements in symptoms such as sexual dysfunction and low mood., Limitations: A meaningful evaluation of mortality was hampered by the limited number of defined events. Definition and reporting of cardiovascular and cerebrovascular events and methods for testosterone measurement varied across trials., Conclusions: Our findings do not support a relationship between testosterone replacement therapy and cardiovascular/cerebrovascular events in the short-to-medium term. Testosterone replacement therapy improves sexual function and quality of life without adverse effects on blood pressure, serum lipids or glycaemic markers., Future Work: Rigorous long-term evidence assessing the safety of testosterone replacement therapy and subgroups most benefiting from treatment is needed., Study Registration: The study is registered as PROSPERO CRD42018111005., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/68/01) and is published in full in Health Technology Assessment ; Vol. 28, No. 43. See the NIHR Funding and Awards website for further award information.

Objective: To establish a baseline understanding of whether consuming food with the highest nutritional quality, lowest greenhouse gas emissions (GHGE) and cost differs between different UK demographic and socio-economic population groups., Design: Multiple linear regression models were fitted to evaluate the relationship between predictor socio-demographic variables in this study (i.e. sex, ethnic group, age, BMI and level of deprivation) and the response variables (i.e. consumption of items considered most nutritious, with a low GHGE and price, as a proportion of total items consumed)., Setting: The UK., Participants: 1374 adult (18-65 years) participants from the National Diet and Nutrition Survey latest waves 9-11 (2016-2017 and 2018-2019)., Results: Based on the total energy consumption in a day, the average diet-based GHGE was significantly higher for participants with a higher BMI. Non-white and most deprived participants spent significantly ( P < 0·001) less money per total energy consumption. Participants with a BMI between 18·6 and 39·9 kg/m 2 and those living in the least deprived areas consumed a significantly ( P < 0·001) higher amount of those items considered the most nutritious, with the lowest GHGE and cost per 100 kcal., Conclusions: Consumption of food with the highest nutritional quality, lowest GHGE and cost in the UK varies among those with different socio-demographic characteristics, especially the deprivation level of participants. Our analysis endorses the consideration of environmental sustainability and affordability, in addition to the consideration of nutritional quality from a health perspective, to make current dietary guidelines more encompassing and equitable.

Background: Testosterone replacement therapy is known to improve sexual function in men younger than 40 years with pathological hypogonadism. However, the extent to which testosterone alleviates sexual dysfunction in older men and men with obesity is unclear, despite the fact that testosterone is being increasingly prescribed to these patient populations. We aimed to evaluate whether subgroups of men with low testosterone derive any symptomatic benefit from testosterone treatment., Methods: We did a systematic review and meta-analysis to evaluate characteristics associated with symptomatic benefit of testosterone treatment versus placebo in men aged 18 years and older with a baseline serum total testosterone concentration of less than 12 nmol/L. We searched major electronic databases (MEDLINE, Embase, Science Citation Index, and the Cochrane Central Register of Controlled Trials) and clinical trial registries for reports published in English between Jan 1, 1992, and Aug 27, 2018. Anonymised individual participant data were requested from the investigators of all identified trials. Primary (cardiovascular) outcomes from this analysis have been published previously. In this report, we present the secondary outcomes of sexual function, quality of life, and psychological outcomes at 12 months. We did a one-stage individual participant data meta-analysis with a random-effects linear regression model, and a two-stage meta-analysis integrating individual participant data with aggregated data from studies that did not provide individual participant data. This study is registered with PROSPERO, CRD42018111005., Findings: 9871 citations were identified through database searches. After exclusion of duplicates and publications not meeting inclusion criteria, 225 full texts were assessed for inclusion, of which 109 publications reporting 35 primary studies (with a total 5601 participants) were included. Of these, 17 trials provided individual participant data (3431 participants; median age 67 years [IQR 60-72]; 3281 [97%] of 3380 aged ≥40 years) Compared with placebo, testosterone treatment increased 15-item International Index of Erectile Function (IIEF-15) total score (mean difference 5·52 [95% CI 3·95-7·10]; τ 2 =1·17; n=1412) and IIEF-15 erectile function subscore (2·14 [1·40-2·89]; τ 2 =0·64; n=1436), reaching the minimal clinically important difference for mild erectile dysfunction. These effects were not found to be dependent on participant age, obesity, presence of diabetes, or baseline serum total testosterone. However, absolute IIEF-15 scores reached during testosterone treatment were subject to thresholds in patient age and baseline serum total testosterone. Testosterone significantly improved Aging Males' Symptoms score, and some 12-item or 36-item Short Form Survey quality of life subscores compared with placebo, but it did not significantly improve psychological symptoms (measured by Beck Depression Inventory)., Interpretation: In men aged 40 years or older with baseline serum testosterone of less than 12 nmol/L, short-to-medium-term testosterone treatment could provide clinically meaningful treatment for mild erectile dysfunction, irrespective of patient age, obesity, or degree of low testosterone. However, due to more severe baseline symptoms, the absolute level of sexual function reached during testosterone treatment might be lower in older men and men with obesity., Funding: National Institute for Health and Care Research Health Technology Assessment Programme., Competing Interests: Declaration of interests CNJ reports a research grant from Logixx Pharma. ShB reports research grants from AbbVie and the US NIH; participation on the OKPO Health data safety monitoring board; consulting fees from Aditum, a leadership or fiduciary role from the Endocrine Society; and a patent relating to the diagnosis and treatment of androgen disorders (US patent number 10386375). SSE reports a research grant from AbbVie. MG reports research grants from Otsuka, Bayer, Lilly, Weight Watchers, Novartis, National Health and Medical Research Council (Australia); speaker honoraria from Besins Healthcare, Bayer, and Otsuka; consulting fees from Bayer; and royalties from Walter and Eliza Hall Institute Melbourne Australia. KLH is supported by the National Institute on Aging K23 Career Development Award; reports an unpaid role in the Executive Committee, Kavod Senior Life Board of Directors; and stock or stock options from Medaware Systems. NO reports research grants from Dexcom, Roche Diabetes, Medtronic Diabetes; speaker honoraria from Roche Diabetes; consulting fees from Roche Diabetes and Medtronic Diabetes; payment for expert testimony (Bird and Bird); and a patent issued for an automatic closed loop glucose control system with an adaptive meal bolus calculator. SR reports a research grant from North Staffordshire Medical Institute; and support for meetings or travel from Besins Healthcare. PJS reports a research grant from AbbVie; and payment for expert testimony from Teva. RQ reports speaker honoraria and support for attending meetings or travel from Bayer. SiB reports speaker honoraria from the Obstetrical & Gynaecological Society of Singapore and pharmaceutical companies (Merck and Ferring); a financial role as a non-executive member of NHS Grampian Health Board; and royalties from Cambridge University Press. GBB reports speaker honoraria and consulting fees from Acerus Pharmaceutical. HMT reports speaker honoraria from Besin Healthcare. EmJG reports provision of study materials from Bayer. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objective: To examine whether ready meals and equivalent home-cooked meals differ in nutritional quality indicators, greenhouse gas emissions (GHGE) and cost., Design: We performed a cross-sectional analysis of meal data from the National Diet and Nutrition Survey (NDNS) nutrient databank (2018/19). Additional data on nutrient composition, cost and cooking-related GHGE were calculated and compared between fifty-four ready meals and equivalent home-cooked meals., Setting: The UK., Participants: Not applicable., Results: Ready meals, overall and those that were animal-based, had significantly higher levels of free sugar compared with equivalent home-cooked meals ( P < 0·0001 and P < 0·0004, respectively). Animal-based ready meals had significantly higher levels of GHGE ( P < 0·001), whereas the cost of ready meals, overall, was significantly higher ( P < 0·001), compared with equivalent home-cooked meals. Animal-based meals, whether ready meals or equivalent homemade meals, had significantly higher levels of protein ( P < 0·0001), contained significantly more kilocalories ( P = 0·001), had significantly higher levels of GHGE ( P < 0·0001) and were significantly more expensive ( P < 0·0001), compared with plant-based meals. Overall, plant-based meals home-cooked on the gas or electric stove had the lowest GHGE and cost, whereas animal-based oven-cooked ready meals had the highest levels of GHGE and were most expensive., Conclusions: Ready meals have lower nutritional quality and higher GHGE and are more expensive than equivalent home-cooked meals, especially those meals that are animal-based and prepared in an oven.

Background: Testosterone is the standard treatment for male hypogonadism, but there is uncertainty about its cardiovascular safety due to inconsistent findings. We aimed to provide the most extensive individual participant dataset (IPD) of testosterone trials available, to analyse subtypes of all cardiovascular events observed during treatment, and to investigate the effect of incorporating data from trials that did not provide IPD., Methods: We did a systematic review and meta-analysis of randomised controlled trials including IPD. We searched MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE Epub Ahead of Print, Embase, Science Citation Index, the Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, and Database of Abstracts of Review of Effects for literature from 1992 onwards (date of search, Aug 27, 2018). The following inclusion criteria were applied: (1) men aged 18 years and older with a screening testosterone concentration of 12 nmol/L (350 ng/dL) or less; (2) the intervention of interest was treatment with any testosterone formulation, dose frequency, and route of administration, for a minimum duration of 3 months; (3) a comparator of placebo treatment; and (4) studies assessing the pre-specified primary or secondary outcomes of interest. Details of study design, interventions, participants, and outcome measures were extracted from published articles and anonymised IPD was requested from investigators of all identified trials. Primary outcomes were mortality, cardiovascular, and cerebrovascular events at any time during follow-up. The risk of bias was assessed using the Cochrane Risk of Bias tool. We did a one-stage meta-analysis using IPD, and a two-stage meta-analysis integrating IPD with data from studies not providing IPD. The study is registered with PROSPERO, CRD42018111005., Findings: 9871 citations were identified through database searches and after exclusion of duplicates and of irrelevant citations, 225 study reports were retrieved for full-text screening. 116 studies were subsequently excluded for not meeting the inclusion criteria in terms of study design and characteristics of intervention, and 35 primary studies (5601 participants, mean age 65 years, [SD 11]) reported in 109 peer-reviewed publications were deemed suitable for inclusion. Of these, 17 studies (49%) provided IPD (3431 participants, mean duration 9·5 months) from nine different countries while 18 did not provide IPD data. Risk of bias was judged to be low in most IPD studies (71%). Fewer deaths occurred with testosterone treatment (six [0·4%] of 1621) than placebo (12 [0·8%] of 1537) without significant differences between groups (odds ratio [OR] 0·46 [95% CI 0·17-1·24]; p=0·13). Cardiovascular risk was similar during testosterone treatment (120 [7·5%] of 1601 events) and placebo treatment (110 [7·2%] of 1519 events; OR 1·07 [95% CI 0·81-1·42]; p=0·62). Frequently occurring cardiovascular events included arrhythmia (52 of 166 vs 47 of 176), coronary heart disease (33 of 166 vs 33 of 176), heart failure (22 of 166 vs 28 of 176), and myocardial infarction (10 of 166 vs 16 of 176). Overall, patient age (interaction 0·97 [99% CI 0·92-1·03]; p=0·17), baseline testosterone (interaction 0·97 [0·82-1·15]; p=0·69), smoking status (interaction 1·68 [0·41-6·88]; p=0.35), or diabetes status (interaction 2·08 [0·89-4·82; p=0·025) were not associated with cardiovascular risk., Interpretation: We found no evidence that testosterone increased short-term to medium-term cardiovascular risks in men with hypogonadism, but there is a paucity of data evaluating its long-term safety. Long-term data are needed to fully evaluate the safety of testosterone., Funding: National Institute for Health Research Health Technology Assessment Programme., Competing Interests: CNJ reports research grants from Logixx Pharma. SBhas reports research grants from AbbVie and National Institutes of Health; consulting fees from Aditum; participation on the Data Safety Monitoring board of OKPO; a leadership or fiduciary role in the Endocrine Society; and a patent (free T calculator based on the ensemble allosteric model, reference 20200174026). SSE reports research grants from AbbVie. MG reports research grants from Otsuka, Bayer, Lilly, Weight Watchers, Novartis, National Health and the Medical Research Council Australia; speaker honoraria from Besins Healthcare, Bayer, and Otsuka; consulting fees from Bayer; and Royalties from Walter and Eliza Hall Institute Melbourne Australia. KLH reports research grants from NIA K23 Career Development Award; a leadership or fiduciary role from Kavod Senior Life Board of Directors, Executive Committee; and stock or stock options from Medaware Systems. NO reports research grants from Dexcom, Roche Diabetes, and Medtronic Diabetes; speaker honoraria from Roche Diabetes; consulting fees from Roche Diabetes and Medtronic Diabetes; payment for expert testimony from London law firm Wilmer Hale; and an issued patent for automatic closed loop glucose control with an adaptive meal bolus calculator. SR reports research grants from North Staffordshire Medical Institute and support for attending meetings or travel from Besins Healthcare. PJS reports research grants from Abbvie and payment for expert testimony from Teva. RQ reports speaker honoraria and support for attending meetings or travel from Bayer. SBhat reports speaker honoraria from Obstetrical & Gynaecological Society of Singapore, Merck SMART Masterclass, and Merck FERRING Forum; leadership or fiduciary role at National Health Service Grampian; editorial role (Editor in Chief of Human Reproduction Open, Special Senior Editor of Cochrane Gynaecology and Fertility); membership of NHS Grampian Board; other financial or non-financial interests from Oxford University Press; and Royalties from Cambridge University Press (Royalties for book Reproductive Medicine for the MRCOG, Cambridge University Press). GBB reports speaker honoraria and consulting fees from Acerus Pharmaceutical. HMT reports consulting fees from Besin Healthcare. EJGil reports provision of study materials from Bayer. All other authors declare no competing interests., (© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.)

Objective: Our objective was to determine the extent to which current evidence from long-term randomised controlled trials (RCTs) of weight management is generalisable and applicable to underserved adult groups with obesity (body mass index (BMI) ≥35 kg/m 2 )., Methods: Descriptive analysis of 131 RCTs, published after 1990-May 2017 with ≥1 year of follow-up, included in a systematic review of long-term weight management interventions for adults with BMI ≥35 kg/m 2 (the REBALANCE Project). Studies were identified from MEDLINE, EMBASE, PsychINFO, SCI, CENTRAL and from hand searching. Reporting of trial inclusion and exclusion criteria, trial recruitment strategies, baseline characteristics and outcomes were analysed using a predefined list of characteristics informed by the PROGRESS (Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital)-Plus framework and the UK Equality Act 2010., Results: Few (6.1%) trials reported adapting recruitment to appeal to underserved groups. 10.0% reported culturally adapting their trial materials. Only 6.1% of trials gave any justification for their exclusion criteria, yet over half excluded participation for age or mental health reasons. Just over half (58%) of the trials reported participants' race or ethnicity, and one-fifth reported socioeconomic status. Where outcomes were reported for underserved groups, the most common analysis was by sex (47.3%), followed by race or ethnicity (16.8%). 3.1% of trials reported outcomes according to socioeconomic status., Discussion: Although we were limited by poor trial reporting, our results indicate inadequate representation of people most at risk of obesity. Guidance for considering underserved groups may improve the appropriateness of research and inform greater engagement with health and social care services., Funding: National Institute for Health Research Health Technology Assessment Programme (project number: 15/09/04)., Prospero Registration Number: CRD42016040190., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Food systems are challenged to provide healthy, sustainable and affordable foods. From a consumer perspective, identifying healthy, sustainable and affordable choices based on individual food products rather than diets could promote better shopping choices., Objective: To identify foods and drinks with the highest nutritional quality and lowest greenhouse gas emissions (GHGE) and price. We also assessed how a combination of these indicators (e.g., nutritional quality, GHGE and price) for food categories aligned with current United Kingdom dietary recommendations., Materials and Methods: We performed a secondary analysis of the National Diet and Nutrition Survey (NDNS) nutrient databank year 11 (2018/2019). Spearman correlation coefficients were used to assess the strength of relationships between nutritional quality, environmental impact and/or prices per 100 kcal. In addition, we developed an optimized nutritional quality, GHGE and price score for each food or drink item based on the overall medians for each of these indicators., Results: Median nutritional value was highest for fruit and vegetables, whilst median GHGE and price was lower for starchy carbohydrates, fats and items of which consumption should be limited. The relative proportions of foods considered the most nutritious and with a low GHGE and price in each of the food categories, on a per 100 kcal basis, were comparable to the proportions in the Eatwell Guide, except for the proportion of fruits and vegetables being smaller and the proportion of potatoes, bread, rice, pasta, and other starchy carbohydrates being larger in our analysis., Conclusion: Public health efforts should consider the impact of dietary choices not only in terms of nutritional quality but also in terms of environmental and economic impact. Our food-based analysis shows a large variation in nutritional quality, GHGE and price within and across food categories, which provides consumers with opportunities for "food swaps" that are more nutritious and have lower GHGE and price., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Aceves-Martins, Bates, Craig, Chalmers, Horgan, Boskamp and de Roos.)

Introduction: The coronavirus disease 2019 (COVID-19) led to the worldwide closure of dental practices or reduction of dental services. By the end of April 2020, governments and professional organisations were publishing recommendations or guidance for the reopening/restructuring of dental services. The aim of this study was to assess how dental aerosol-generating procedures (AGPs) were defined in international dental guidelines, what mitigation processes were advised, and whether they were linked to COVID-19 epidemiology., Methods: Electronic searches of a broad range of databases, along with grey literature searches, without language restriction were conducted up to 13 July 2020. Recommendations for the use of face masks and fallow times with patients without COVID-19 were assessed against the deaths per 1 million population in the included countries and country income level using Pearson Chi-squared statistics., Results: Sixty-three guidance documents were included. Most (98%) indicated that AGPs can be performed with patients without COVID-19 with caveats, including advice to restrict AGPs where possible, with 21% only recommending AGPs for dental emergencies. Face masks were recommended by most documents (94%), with 91% also specifying the use of goggles or face shields. Fallow periods for patients without COVID-19 were mentioned in 48% of documents, ranging from 2 to 180 minutes. There were no significant differences in recommendations for face masks or fallow time in patients without COVID-19 by country death rate (P = .463 and P = .901) or World Bank status (P = .504 and P = .835). Most documents recommended procedural or environmental mitigations such as preprocedural mouthwash (82%) and general ventilation (52%). Few documents provided underpinning evidence for their recommendations., Conclusions: While the amount of high-quality direct evidence related to dentistry and COVID-19 remains limited, it is important to be explicit about the considered judgements for recommendations as well as generate new evidence to face this challenge., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Food-based analyses of the healthiness, environmental sustainability and affordability of processed and ultra-processed foods are lacking. This paper aimed to determine how ultra-processed and processed foods compare to fresh and minimally processed foods in relation to nutritional quality, greenhouse gas emissions and cost on the food and food group level. Data from the National Diet and Nutrition Survey nutrient databank year 11 (2018/2019) were used for this analysis. Median and bootstrapped medians of nutritional quality (NRF8.3 index), greenhouse gas emissions (gCO2-equivalents) and cost (in GBP) were compared across processing categories. An optimal score based on the medians was created to identify the most nutritional, sustainable, and affordable options across processing categories. On a per 100 kcal basis, ultra-processed and processed foods had a lower nutritional quality, lower greenhouse gas emissions, and were cheaper than minimally processed foods, regardless of their total fat, salt and/or sugar content. The most nutritious, environmentally friendly, and affordable foods were generally lower in total fat, salt, and sugar, irrespective of processing level. The high variability in greenhouse gas emissions and cost across food groups and processing levels offer opportunities for food swaps representing the healthiest, greenest, and most affordable options.

Background: Adolescents who participate as peer leaders can benefit and acquire competencies from their peer leadership experience., Objectives: To identify the competencies gained by adolescents who participated as peer leaders in a healthy lifestyle study and to determine whether the training characteristics were related to improvement in competencies., Design: The present study was part of the European Youth Tackling Obesity (EYTO) project, a multicentre social marketing intervention involving four European countries., Setting and Participants: Eighteen peer leaders (aged 13-15 years, three or five leaders per country) from disadvantaged neighbourhoods received training in designing and implementing activities for their peers., Measures: The peer leaders' confidence, experience and interest in 11 tasks related to lifelong learning competencies were assessed with questions rated on a colour scale at baseline and at the end of the study., Results: The peer leaders demonstrated improvements in experience, confidence and interest in different tasks, such as research, website or logo design, oral presentations, social media use and collaboration with people from other countries. They increased their confidence in management tasks (p = 0.03) and their confidence and experience in communication tasks (p = 0.01). The peer leaders from Spain and Portugal had greater improvements than those from the other countries., Conclusion: The peer leaders improved their confidence in management tasks and their confidence and experience in communication tasks. Slight differences were detected in improvement in competencies by country, likely due to the differences in the peer training applied. Recommendations for peer leader training are proposed, although these results should be verified with larger sample size., Patient or Public Contribution: The peer leaders contributed to the design and implementation of the training and intervention., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: Acute kidney injury is a serious complication that occurs in the context of an acute critical illness or during a postoperative period. Earlier detection of acute kidney injury may facilitate strategies to preserve renal function, prevent further disease progression and reduce mortality. Acute kidney injury diagnosis relies on a rise in serum creatinine levels and/or fall in urine output; however, creatinine is an imperfect marker of kidney function. There is interest in the performance of novel biomarkers used in conjunction with existing clinical assessment, such as NephroCheck ® (Astute Medical, Inc., San Diego, CA, USA), ARCHITECT ® urine neutrophil gelatinase-associated lipocalin (NGAL) (Abbott Laboratories, Abbott Park, IL, USA), and urine and plasma BioPorto NGAL (BioPorto Diagnostics A/S, Hellerup, Denmark) immunoassays. If reliable, these biomarkers may enable earlier identification of acute kidney injury and enhance management of those with a modifiable disease course., Objective: The objective was to evaluate the role of biomarkers for assessing acute kidney injury in critically ill patients who are considered for admission to critical care., Data Sources: Major electronic databases, conference abstracts and ongoing studies were searched up to June 2019, with no date restrictions. MEDLINE, EMBASE, Health Technology Assessment Database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Web of Science, World Health Organization Global Index Medicus, EU Clinical Trials Register, International Clinical Trials Registry Platform and ClinicalTrials.gov were searched., Review Methods: A systematic review and meta-analysis were conducted to evaluate the performance of novel biomarkers for the detection of acute kidney injury and prediction of other relevant clinical outcomes. Random-effects models were adopted to combine evidence. A decision tree was developed to evaluate costs and quality-adjusted life-years accrued as a result of changes in short-term outcomes (up to 90 days), and a Markov model was used to extrapolate results over a lifetime time horizon., Results: A total of 56 studies (17,967 participants), mainly prospective cohort studies, were selected for inclusion. No studies addressing the clinical impact of the use of biomarkers on patient outcomes, compared with standard care, were identified. The main sources of bias across studies were a lack of information on blinding and the optimal threshold for NGAL. For prediction studies, the reporting of statistical details was limited. Although the meta-analyses results showed the potential ability of these biomarkers to detect and predict acute kidney injury, there were limited data to establish any causal link with longer-term health outcomes and there were considerable clinical differences across studies. Cost-effectiveness results were highly uncertain, largely speculative and should be interpreted with caution in the light of the limited evidence base. To illustrate the current uncertainty, 15 scenario analyses were undertaken. Incremental quality-adjusted life-years were very low across all scenarios, ranging from positive to negative increments. Incremental costs were also small, in general, with some scenarios generating cost savings with tests dominant over standard care (cost savings with quality-adjusted life-year gains). However, other scenarios generated results whereby the candidate tests were more costly with fewer quality-adjusted life-years, and were thus dominated by standard care. Therefore, it was not possible to determine a plausible base-case incremental cost-effectiveness ratio for the tests, compared with standard care., Limitations: Clinical effectiveness and cost-effectiveness results were hampered by the considerable heterogeneity across identified studies. Economic model predictions should also be interpreted cautiously because of the unknown impact of NGAL-guided treatment, and uncertain causal links between changes in acute kidney injury status and changes in health outcomes., Conclusions: Current evidence is insufficient to make a full appraisal of the role and economic value of these biomarkers and to determine whether or not they provide cost-effective improvements in the clinical outcomes of acute kidney injury patients., Future Work: Future studies should evaluate the targeted use of biomarkers among specific patient populations and the clinical impact of their routine use on patient outcomes and management., Study Registration: This study is registered as PROSPERO CRD42019147039., Funding: This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment ; Vol. 26, No. 7. See the NIHR Journals Library website for further project information.

Background: Early and accurate acute kidney injury (AKI) detection may improve patient outcomes and reduce health service costs. This study evaluates the diagnostic accuracy and cost-effectiveness of NephroCheck and NGAL (urine and plasma) biomarker tests used alongside standard care, compared with standard care to detect AKI in hospitalised UK adults., Methods: A 90-day decision tree and lifetime Markov cohort model predicted costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) from a UK NHS perspective. Test accuracy was informed by a meta-analysis of diagnostic accuracy studies. Clinical trial and observational data informed the link between AKI and health outcomes, health state probabilities, costs and utilities. Value of information (VOI) analysis informed future research priorities., Results: Under base case assumptions, the biomarker tests were not cost-effective with ICERs of £105,965 (NephroCheck), £539,041 (NGAL urine BioPorto), £633,846 (NGAL plasma BioPorto) and £725,061 (NGAL urine ARCHITECT) per QALY gained compared to standard care. Results were uncertain, due to limited trial data, with probabilities of cost-effectiveness at £20,000 per QALY ranging from 0 to 99% and 0 to 56% for NephroCheck and NGAL tests respectively. The expected value of perfect information (EVPI) was £66 M, which demonstrated that additional research to resolve decision uncertainty is worthwhile., Conclusions: Current evidence is inadequate to support the cost-effectiveness of general use of biomarker tests. Future research evaluating the clinical and cost-effectiveness of test guided implementation of protective care bundles is necessary. Improving the evidence base around the impact of tests on AKI staging, and of AKI staging on clinical outcomes would have the greatest impact on reducing decision uncertainty., (© 2021. The Author(s).)

Background: Poor retention of participants in randomised trials can lead to missing outcome data which can introduce bias and reduce study power, affecting the generalisability, validity and reliability of results. Many strategies are used to improve retention but few have been formally evaluated., Objectives: To quantify the effect of strategies to improve retention of participants in randomised trials and to investigate if the effect varied by trial setting., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Scopus, PsycINFO, CINAHL, Web of Science Core Collection (SCI-expanded, SSCI, CPSI-S, CPCI-SSH and ESCI) either directly with a specified search strategy or indirectly through the ORRCA database. We also searched the SWAT repository to identify ongoing or recently completed retention trials. We did our most recent searches in January 2020., Selection Criteria: We included eligible randomised or quasi-randomised trials of evaluations of strategies to increase retention that were embedded in 'host' randomised trials from all disease areas and healthcare settings. We excluded studies aiming to increase treatment compliance., Data Collection and Analysis: We extracted data on: the retention strategy being evaluated; location of study; host trial setting; method of randomisation; numbers and proportions in each intervention and comparator group. We used a risk difference (RD) and 95% confidence interval (CI) to estimate the effectiveness of the strategies to improve retention. We assessed heterogeneity between trials. We applied GRADE to determine the certainty of the evidence within each comparison., Main Results: We identified 70 eligible papers that reported data from 81 retention trials. We included 69 studies with more than 100,000 participants in the final meta-analyses, of which 67 studies evaluated interventions aimed at trial participants and two evaluated interventions aimed at trial staff involved in retention. All studies were in health care and most aimed to improve postal questionnaire response. Interventions were categorised into broad comparison groups: Data collection; Participants; Sites and site staff; Central study management; and Study design. These intervention groups consisted of 52 comparisons, none of which were supported by high-certainty evidence as determined by GRADE assessment. There were four comparisons presenting moderate-certainty evidence, three supporting retention (self-sampling kits, monetary reward together with reminder or prenotification and giving a pen at recruitment) and one reducing retention (inclusion of a diary with usual follow-up compared to usual follow-up alone). Of the remaining studies, 20 presented GRADE low-certainty evidence and 28 presented very low-certainty evidence. Our findings do provide a priority list for future replication studies, especially with regard to comparisons that currently rely on a single study., Authors' Conclusions: Most of the interventions we identified aimed to improve retention in the form of postal questionnaire response. There were few evaluations of ways to improve participants returning to trial sites for trial follow-up. None of the comparisons are supported by high-certainty evidence. Comparisons in the review where the evidence certainty could be improved with the addition of well-done studies should be the focus for future evaluations., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objectives: To improve our understanding of the acceptability of behavioural weight management programmes (WMPs) for adults with severe obesity., Design: A systematic review of qualitative evidence., Data Sources: Medline, Embase, PsycINFO, CINAHL, SCI, SSCI and CAB abstracts were searched from 1964 to May 2017., Eligibility Criteria: Papers that contained qualitative data from adults with body mass index (BMI) ≥35 kg/m 2 (and/or the views of providers involved in their care) and considered issues about weight management., Data Extraction and Synthesis: Two reviewers read and systematically extracted data from the included papers which were compared, and contrasted according to emerging issues and themes. Papers were appraised for methodological rigour and theoretical relevance using Toye's proposed criteria for quality in relation to meta-ethnography., Results: 33 papers met our inclusion criteria from seven countries published 2007-2017. Findings were presented from a total of 644 participants and 153 programme providers. Participants described being attracted to programmes that were perceived to be novel or exciting, as well as being endorsed by their healthcare provider. The sense of belonging to a group who shared similar issues, and who had similar physiques and personalities, was particularly important and seemed to foster a strong group identity and related accountability. Group-based activities were enjoyed by many and participants preferred WMPs with more intensive support. However, some described struggling with physical activities (due to a range of physical comorbidities) and not everyone enjoyed group interaction with others (sometimes due to various mental health comorbidities). Although the mean BMI reported across the papers ranged from 36.8 to 44.7 kg/m 2 , no quotes from participants in any of the included papers were linked to specific detail regarding BMI status., Conclusions: Although group-based interventions were favoured, people with severe obesity might be especially vulnerable to physical and mental comorbidities which could inhibit engagement with certain intervention components., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Youth is a dynamic and complex transition period in life where many factors jeopardise its present and future health. Youth involvement enables young people to influence processes and decisions that affect them, leading to changes in themselves and their environment (e.g. peers, services, communities and policies); this strategy could be applied to improve health and prevent diseases. Nonetheless, scientific evidence of involving youth in health-related programmes is scarce. The aim of this paper is to describe youth involvement as a health promotion strategy and to compile practical recommendations for health promoters, researchers and policy-makers interested in successful involvement of young people in health-related programmes. These suggestions aim to encourage a positive working synergy between adults and youth during the development, implementation and evaluation of policies, research and/or health promotion efforts that target adolescents., (© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The cost-effectiveness of childhood obesity prevention interventions is critical for their sustained implementation. This study evaluated the cost-effectiveness of the Educació en Alimentació (EdAl) program, a school-based intervention for reducing obesity., Methods: Total EdAl program implementation costs and per-child costs were estimated. Cost-effectiveness, defined using the incremental cost-effectiveness ratio (ICER), was estimated as the difference between the intervention and control group costs divided by the obesity-related outcome effects for boys (avoided cases of obesity, obesity prevalence, body mass index [BMI], and BMI z-score units) for each group. As a significant difference (4.39%) in the reduction of obesity prevalence between the intervention and control groups was observed for boys in the EdAl program, the data were calculated only for boys., Results: The intervention cost was 24,246.53 € for 1,550 children (15.64 €/child/3 years) or 5.21 €/child/year. The ICERs/boy were 968.66 € to avoid one case of obesity, 3.6 € to reduce the obesity prevalence by 1%, 44.68 € to decrease BMI by one unit, and 65.16 € to reduce the BMI z-score by one unit., Conclusions: The cost of reducing the obesity prevalence in boys by 4.39% was 5.21 €/child/year, half the cost proposed by the Spanish Health Ministry, indicating that the EdAl program is cost-effective.

Background: Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m 2 ] have an increased risk of comorbidities and psychological, social and economic consequences., Objectives: Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment., Data Sources: Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017)., Review Methods: Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m 2 . Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000., Results: A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit., Limitations: Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken., Conclusions: Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends., Future Work: Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions., Study Registration: This study is registered as PROSPERO CRD42016040190., Funding: The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate., Competing Interests: Alison Avenell, Clare Robertson and Graeme MacLennan acknowledge funding from the National Institute for Health Research Health Technology Assessment programme for projects outside this work. Paul Aveyard was an investigator on an investigator-initiated trial funded by Cambridge Weight Plan, and has done half a day’s consultancy for Weight Watchers. These activities led to payments to the University of Oxford for his time but no payments to him personally.

Background: An important challenge of school-based childhood obesity (OB) intervention programs is understanding the maintenance of the effects after cessation of the intervention to overcome the limitations of follow-up studies. The aim of this study is to verify the sustainability of the benefits achieved at a 4-year follow-up of the post-Educació en Alimentació (EDAl) program intervention cessation by assessing the OB-related outcomes and lifestyles of 13- to 15-year-old adolescents., Methods: This paper describes a 4-year follow-up study after the cessation of a school-based randomized controlled intervention in adolescents (n = 349, intervention; n = 154, control) with baseline and 4-year follow-up data from high schools in Reus (intervention group), Salou, Cambrils and Vila-seca (control group). The outcomes are body mass index (BMI), BMI z-score, and OB prevalence according to the World Health Organization and International Obesity Task Force criteria and lifestyle data (obtained from questionnaires)., Results: Compared with the control girls, the intervention girls showed reduced BMI z-scores (-0.33 units, p < 0.01) from baseline (2007) to the 4-year follow-up post-intervention (2014). Compared with the control boys, the intervention boys showed reduced OB prevalence (-7.7%; p = 0.02). Compared with the control boys, more boys in the intervention group (19% increase; p = 0.059) showed ≥4 h/week after-school physical activity (PA). A decrease in the consumption of dairy products, fruits and fish was observed in both groups., Conclusions: At the 4-year post-intervention follow-up of the EdAl program, compared with the control groups, girls had lower BMI z-scores and boys had lower OB prevalence from the intervention. The encouragement in after-school PA was long-lasting and maintained after the cessation of the intervention, whereas healthy food habits must be further reinforced in adolescents., Trial Registration: ISRCTN29247645 .

Introduction: The EYTO-kids (European Youth Tackling Obesity in Adolescents and Children) study aims to increase fruit and/or vegetable consumption and physical activity, decrease sedentary lifestyles, and reduce the intake of sugary drinks and fast food using an innovative methodology based on social marketing and youth involvement., Methods: This study is a pilot school-based cluster randomized controlled 10-month intervention spanning two academic years (2015-2016 and 2016-2017), with eight primary schools and three high schools randomized into and designated the control group and eight primary schools and four high schools designated the intervention group in Reus, Spain. At least 301 younger school peers per group should be included. At the intervention high schools, the adolescent creators (ACs) receive an initial 16-h training session. In total, 26-32 high school ACs (12-14 years) from the four high schools will design and implement four health-promotion activities (1 h/each) for their younger (8-10 years), primary school peers. The control group will not receive any intervention. The outcomes (fruit, vegetable, fast food and sugary drink consumption; physical activity; and sedentary behaviors) of the control and intervention groups will be measured pre- and post-intervention., Conclusion: This study describes a protocol for pilot, peer-led, social marketing and youth-involved intervention, where adolescents design and implement activities for their younger peers to promote healthy lifestyles., Competing Interests: No financial disclosures were reported by the authors of this paper. The authors declare no conflict of interest.

Background: Restaurant-based interventions can be an enjoyable way to encourage healthier eating choices by all members of a family. Thus, the principal aims of this study were a) to promote healthy diets by increasing healthy food offerings and b) to increase the number of foods offered specifically as gluten-free and lactose-free and to inform patrons by including nutritional and allergen information that complies with Regulation 1169/2011 regarding the food served in restaurants, takeaways and snack bars., Methods: A restaurant-based intervention was implemented at 16 food establishments at 2 resorts (the Cambrils Park Resort and Camping Sangulí, Spain, from 2014 to 2015) based on the following 4 components: 1) providing nutritional and allergen analyses of the offered dishes, 2) increasing the number of healthy food choices, 3) identifying menu items associated with allergies and intolerance, and 4) training staff on healthy eating and allergens. Customer satisfaction regarding food aspects was assessed using surveys (10-point scale)., Results: Both resorts significantly increased their offerings of healthy dishes (28.6% to 44.7%; P = 0.003) and desserts with fruit (20% to 51.3%; P = 0.013), thus obtaining the Spanish Government's Mediterranean Diet certification. Additionally, both resorts obtained Catalan Celiac Association certification. Moreover, both resorts significantly increased their percentages of gluten-free dishes (2.1% to 50.5%; P < 0.001) and lactose-free dishes (5.5% to 37.5%; P < 0.001) after the intervention. Customer satisfaction increased (mean ± standard deviation) from 6.9 ± 1.6 to 8.5 ± 1.5 (P < 0.001)., Conclusion: This restaurant-based intervention expanded the number of healthy and allergen-free foods offered in a family-oriented holiday resort environment to encourage healthy food choices, resulting in increased customer satisfaction.

Background: Mexico is a developing country with one of the highest youth obesity rates worldwide; >34% of children and adolescents between 5 and 19 years of age are overweight or obese., Objectives: The current review seeks to compile, describe, and analyze dietary conditions, physical activity, socioeconomic status, and cultural factors that create and exacerbate an obesogenic environment among Mexican youth., Design: A narrative review was performed using PubMed and the Cochrane Library databases, as well as grey literature data from the Mexican government, academics, and statistical reports from nongovernmental organizations, included in electronic formats., Results: The recent socioeconomic and nutritional transition has resulted in reduced healthy meal options at public schools, high rates of sedentary lifestyles among adolescents, lack of open spaces and playgrounds, socioeconomic deprivation, false or misunderstood sociocultural traditional beliefs, misconceptions about health, a high percentage of overweight or obese adults, and low rates of maternal breastfeeding. Some of the factors identified are exacerbating the obesity problem in this population. Current evidence also shows that more policies and health programs are needed for prevention of childhood and adolescent obesity. Mexico presents alarming obesity levels, which need to be curtailed and urgently reversed., Conclusions: The present narrative review presents an overview of dietary, physical activity, societal and cultural preconceptions that are potentially modifiable obesity-promoting factors in Mexican youth. Measures to control these factors need to be implemented in all similar developing countries by governments, policy makers, stakeholders, and health care professionals to tackle obesity in children and young people.

Background: The encouragement of healthy lifestyles for obesity prevention in young people is a public health priority. The European Youth Tackling Obesity (EYTO) project is a multicentric intervention project with participation from the United Kingdom, Portugal, the Czech Republic and Spain. The general aim of the EYTO project is to improve lifestyles, including nutritional habits and physical activity practice, and to prevent obesity in socioeconomically disadvantaged and vulnerable adolescents. The EYTO project works through a peer-led social marketing intervention that is designed and implemented by the adolescents of each participating country. Each country involved in the project acts independently. This paper describes the "Som la Pera" intervention Spanish study that is part of the EYTO project., Methods/design: In Spain, the research team performed a cluster randomised controlled intervention over 2 academic years (2013-2015) in which 2 high-schools were designated as the control group and 2 high-schools were designated as the intervention group, with a minimum of 121 schoolchildren per group. From the intervention group, 5 adolescents with leadership characteristics, called "Adolescent Challenge Creators" (ACCs), were recruited. These 5 ACCs received an initial 4 h training session about social marketing principles and healthy lifestyle theory, followed by 24 sessions (1.30 h/session) divided in two academic years to design and implement activities presented as challenges to encourage healthy lifestyles among their peers, the approximately 180-200 high-school students in the intervention group. During the design of the intervention, it was essential that the ACCs used the 8 social marketing criteria (customer orientation, behaviour, theory, insight, exchange, competition, segmentation and methods mix). The expected primary outcomes from the Spanish intervention will be as follows: increases in the consumption of fruits and vegetables and physical activity practice along with reductions in TV/computer/game console use. The secondary outcomes will be as follows: increased breakfast consumption, engagement with local recreation and reduced obesity prevalence. The outcomes will be measured by the Health Behaviour in School-aged Children Study (HBSC) survey at baseline and at the end of the intervention. In the control group, no intervention was implemented, but the outcome measurements were collected in parallel with the intervention group., Discussion: This study described a new methodology to improve lifestyles and to address adolescent obesity., Trial Registration: ClinicalTrials.gov: NCT02157402. Registered 03 June 2014.

The liver is an important organ with specific functions that influence directly on the nutritional and physiological status of every person. At the presence of any illness or injury in this organ, liver cirrhosis is always its final phase. In this pathology, patients present carbohydrate utilization and storage diminishment, as well as protein and fat catabolism increase. This situation, plus a low ingest and a bad nutrient absorption, results in a high prevalence of malnutrition. Many studies prove the importance of an opportune nutritional treatment in these patients, bringing general benefits and improving their quality of life. It's important to considerate the possible nutritional risks and deficiencies that could appear in the course of the cirrhosis to take opportune actions. The nutritional assessment and treatment is transcendental both in compensated phase (without complications) and in decompensated phase (with complications) of the illness., (Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.)