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In this perspective, we discuss why current mechanistic uncertainty on ultraprocessed foods (UPFs) and health acts as a major challenge to providing informed dietary guidelines and public advice on UPFs. Based on the balance of current evidence, we do not believe it is appropriate to be advising consumers to avoid all UPFs and we await further evidence to inform consumer guidance on the need to limit consumption of specifics foods based on their degree or type of processing.

Abstract Background This study examined the prospective association between financial-related discrimination and psychological well-being related measures and assessed the role of financial-related discrimination in explaining socioeconomic inequalities in psychological well-being related measures. Methods Data of UK older adults (≥ 50 years) from the English Longitudinal Study of Ageing were used (baseline: Wave 5, 2010/2011; n = 8,988). The baseline total non-pension wealth (in tertiles: poorest, middle, richest) was used as a socioeconomic status (SES) measure. Financial-related discrimination at baseline was defined as participants who reported they had been discriminated against due to their financial status. Five psychological well-being related measures (depressive symptoms, enjoyment of life, eudemonic well-being, life satisfaction and loneliness) were examined prospectively across different follow-up periods (Waves 6, 2012/2013, 2-year follow-up; and 7, 2014/2015, 4-year follow-up). Regression models assessed associations between wealth, financial-related discrimination, and follow-up psychological measures, controlling for sociodemographic covariates and baseline psychological measures (for longitudinal associations). Mediation analysis informed how much (%) the association between wealth and psychological well-being related measures was explained by financial-related discrimination. Results Participants from the poorest, but not middle, (vs. richest) wealth groups were more likely to experience financial-related discrimination (OR = 1.97; 95%CI = 1.49, 2.59). The poorest (vs. richest) wealth was also longitudinally associated with increased depressive symptoms and decreased enjoyment of life, eudemonic well-being and life satisfaction in both 2-year and 4-year follow-ups, and increased loneliness at 4-year follow-up. Experiencing financial-related discrimination was longitudinally associated with greater depressive symptoms and loneliness, and lower enjoyment of life across follow-up periods. Findings from mediation analysis indicated that financial-related discrimination explained 3–8% of the longitudinal associations between wealth (poorest vs. richest) and psychological well-being related measures. Conclusions Financial-related discrimination is associated with worse psychological well-being and explains a small proportion of socioeconomic inequalities in psychological well-being.

Abstract Introduction We examined the psychological burden associated with metabolic syndrome (MetSyn). Methods We used comparable longitudinal data of older adults (≥50 years) from the UK (English Longitudinal Study of Aging) and the US (Health and Retirement Study). We defined MetSyn based on biomarker assessments (e.g., blood pressure, impaired glycemic control). Using regression models, we tested a range of individual psychological outcomes (e.g., depressive symptoms) associated with MetSyn. We also examined whether these psychological outcomes may explain or moderate the link between MetSyn and non‐communicable diseases (NCDs). Findings MetSyn was associated cross‐sectionally with a range of psychological outcomes, including depression, anxiety, loneliness, hopelessness, cynical hostility, social strain, negative affect and decreased positive affect, social support and purpose in life. There was no convincing evidence that psychological factors interacted with or explained (mediated) the relationship between MetSyn and increased risk of developing NCD over 10‐year follow‐ups. Conclusions MetSyn and the psychological burden outcomes examined may have independent effects on NCD risk.

Background and objectives On 6 April 2022, the UK government implemented mandatory kilocalorie (kcal) labelling regulations for food and drink products sold in the out-of-home food sector (OHFS) in England. Previous assessments of kcal labelling practices in the UK OHFS found a low prevalence of voluntary implementation and poor compliance with labelling recommendations. This study aimed to examine changes in labelling practices preimplementation versus post implementation of mandatory labelling regulations in 2022.Methods In August–December 2021 (preimplementation) and August–November 2022 (post implementation), large OHFS businesses (250 or more employees) subject to labelling regulations were visited. At two time points, a researcher visited the same 117 food outlets (belonging to 90 unique businesses) across four local authorities in England. Outlets were rated for compliance with government regulations for whether kcal labelling was provided at any or all point of choice, provided for all eligible food and drink items, provided per portion for sharing items, if labelling was clear and legible and if kcal reference information was displayed.Results There was a significant increase (21% preimplementation vs 80% post implementation, OR=40.98 (95% CI 8.08 to 207.74), p

Abstract Background We test a novel ‘weight scarring’ hypothesis which suggests that past obesity is associated with impairments in current psychological well-being and this increases risk of negative physical health outcomes associated with obesity. Across two nationally representative studies, we tested whether past obesity is associated with current psychological outcomes and whether these psychological outcomes explain the association between past obesity and subsequent early mortality. Methods Data were from the National Health and Nutrition Examination Survey (NHANES) (n = 29,047) and the Health and Retirement Study (HRS) (n = 11,998). Past obesity was defined based on maximum lifetime weight in NHANES and the highest weight from past study waves in the HRS. Across both studies, current depressive symptoms were analysed. A set of 10 additional well-being measures were combined to produce an ‘index of impaired well-being’ in HRS. Subsequent all-cause mortality was examined using National Deaths Index records in NHANES and household interviews in HRS. Linear or logistic regression, Cox proportional hazard regression, and causal mediation models were used. Results We found that past obesity was associated with greater current depressive symptoms after controlling for current weight status and in analyses limited to those who were no longer classified as having obesity in NHANES (β = 0.17; 95% CI: 0.13, 0.22) and HRS (β = 0.20; 95% CI: 0.08, 0.31). In HRS, past obesity was also associated with a range of current negative psychological outcomes, including an index of impaired psychological well-being (β = 0.16; 95% CI: 0.05, 0.27). Past obesity was associated with a higher risk of early mortality in both NHANES and HRS (HR = 1.31; 95% CI: 1.16, 1.48 and HR = 1.34; 95% CI: 1.20, 1.50, respectively). Depressive symptoms explained 6% (95% CI: 0.01, 0.10) and 5% (95% CI: 0.01, 0.09) of the association between past obesity and premature mortality in NHANES and HRS, respectively. Impaired psychological well-being partly mediated the association between past obesity and premature mortality by 10% (95% CI: 0.04, 0.16) in HRS. Conclusions Our findings suggest that there may be a psychological legacy of past obesity that is associated with raised mortality risk. Ensuring people with obesity receive psychological support even after experiencing weight loss may be important.

Abstract Objective: To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups. Design: Cross-sectional data from the International Food Policy Study (IFPS) online survey. Setting: IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019. Participants: Adults aged 18–99; n 19 393. Results: Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy. Conclusions: Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small.

Abstract Objectives In 2021 the UK government announced a new obesity policy requiring large out‐of‐home food outlets to provide mandatory in‐store calorie labeling on food and drink items. Public acceptability and engagement with obesity policies could influence the level of impact on wider public health particularly with population‐level policies such as calorie labeling. This study aimed to examine public responses and awareness of the policy using social media (Twitter) comments and Google trends data. Methods This study examined responses to social media posts on Twitter (tweets) from the UK Department of Health and Social Care detailing the policy, implementation date and post‐implementation information about the policy's enforcement. The sentiments of the tweets were coded and the number of likes and replies extracted. This study utilized google trends to examine public awareness of the policy by extracting weekly relative search volume for relevant phrases such as “calorie labeling.” Results From the 276 replies/quote‐tweet extracted, the majority expressed a negative sentiment toward the policy (N = 197/71.4%). There were fewer tweets expressing a positive sentiment (N = 25/8.7%) and a neutral/no sentiment (N = 54/19.6%). There was no difference in the number of “likes” or retweets between tweets expressing positive or negative sentiments. Five themes were identified expressing negative sentiments (most common being negative impacts on eating disorders). Google trends data revealed increased searches for “calorie labels/labeling” during the week of the policy enforcement compared to previous weeks in the last 5 years but no significant differences in searches for specific menu calorie labeling. Conclusions This analysis revealed negative sentiment toward and increased searching of calorie labeling information during the announcement and implementation of the 2021 mandatory calorie labeling policy in England. A greater understanding of public responses to calorie labeling policies may help tailor future policies and public communication strategies.

Abstract Background Mandatory calorie labelling in the out-of-home food sector was introduced in England in 2022, and menu pricing strategies that ensure cost is equivalent to portion size (proportional pricing) have been proposed as a policy to reduce obesity. Food delivery app-based platforms now contribute significantly to diet, and evidence suggests that those at a socioeconomic disadvantage may have greater exposure to unhealthy options on these platforms. However, public health policies to improve nutritional quality of food ordered from food delivery apps has received limited examination. Objective This experimental study assessed the impact of calorie labelling and proportional pricing on item and meal size selection, calories ordered, and money spent when selecting food and drinks from three outlet types on a virtual delivery app. Methods UK adult participants (N = 1126, 49% female), stratified by gender and education level completed an online study where they ordered items from three branded food and beverage outlets (coffee shop, sandwich outlet, fast food outlet) using a virtual delivery app. Participants were presented food and beverage options with vs. without calorie labels and with value (larger portions are proportionally cheaper) vs. proportional pricing. Results Calorie labelling did not influence portion size selection for any outlets, but significantly reduced calories ordered from the coffee shop (-18.95kcals, 95% CI -33.07 to -4.84) and fast food outlet (-54.19kcals, 95% CI -86.04 to -22.33). Proportional pricing reduced the likelihood of choosing a larger beverage from the coffee shop (OR = 0.58, 95% CI 0.45 to 0.75), but was associated with increased calories ordered from the fast food outlet (51.25kcals, 95% CI 19.59 to 82.90). No consistent interactions were observed with participant characteristics, suggesting that effects of calorie labelling and pricing on outcomes were similar across sociodemographic groups. Conclusions Calorie labelling on food delivery platforms may effectively reduce calories ordered. Proportional pricing may be useful in prompting consumers to select smaller portion sizes, although further research in real-world settings will now be valuable.

Background: Ultra-processed food (UPF) is currently not included in most countries’ dietary guidance. However, there may be growing public interest and consumer avoidance of UPF due to media reporting of studies on the negative health outcomes associated with UPFs. Methods: We surveyed 2386 UK adults (M age = 45 years, 50% female) during February–April 2024. Participants completed measures on awareness of the term UPF, whether the UPF status of foods affects their dietary decision-making, and confidence in identifying UPFs. Participants categorised a list of 10 foods (5 UPFs and 5 non-UPFs) as UPF vs. not, before rating whether information about studies linking UPF to worse health impacts on their negative affect and acts as a deterrent to consuming UPFs. Results: Most participants (73%) were aware of the term UPF and 58% reported that their food choices are determined by whether they believe a food is ultra-processed or not. Participants with the highest income and education levels were most likely to report both being aware of, and, avoiding consuming UPFs. Most participants could not accurately categorise whether foods were UPFs. Some sociodemographic groups (e.g., higher education levels) were more likely to accurately categorise UPFs but were also more likely to incorrectly believe that non-UPFs were UPFs. Participants tended to report that UPF-health risk information increases negative affect and acts as a deterrent to consuming UPFs. Conclusions: In this study, a large number of UK adults reported avoiding consuming UPFs. This was particularly pronounced among those with the highest education and income levels.

Objective: The objective of this study was to assess procedure markup (charge-to-cost ratio) across lung resection procedures and examine variability by geographic region. Methods: Provider-level data for common lung resection operations was obtained from the 2015 to 2020 Medicare Provider Utilization and Payment Data datasets using Healthcare Common Procedure Coding System codes. Procedures studied included wedge resection; video-assisted thoracoscopic surgery; and open lobectomy, segmentectomy, and mediastinal and regional lymphadenectomy. Procedure markup ratio and coefficient of variation (CoV) was assessed and compared across procedure, region, and provider. The CoV, a measure of dispersion defined as the ratio of the SD to the mean, was likewise compared across procedure and region. Results: Median markup ratio across all procedures was 3.56 (interquartile range, 2.87-4.59) with right skew (mean, 4.13). Median markup ratio was 3.59 for lymphadenectomy (CoV, 0.51), 3.13 for open lobectomy (CoV, 0.45), 3.55 for video-assisted thoracoscopic surgery lobectomy (CoV, 0.59), 3.77 for segmentectomy (CoV, 0.74), and 3.80 for wedge resection (CoV, 0.67). Increased beneficiaries, services, and Healthcare Common Procedure Coding System score (total) were associated with a decreased markup ratio (P

Abstract Background Regulations mandating kilocalorie (kcal) labelling for large businesses in the out-of-home food sector (OHFS) came into force on 6th April 2022 as a policy to reduce obesity in England. To provide indicators of potential reach and impact, kcal labelling practices were studied in the OHFS, and customer purchasing and consumption behaviours prior to implementation of the mandatory kcal labelling policy in England. Methods From August-December 2021, large OHFS businesses subject to the kcal labelling regulations were visited prior to regulations coming into force on 6th April 2022. 3308 customers were recruited from 330 outlets and collected survey information on the number of kcal purchased and consumed by customers, customers’ knowledge of the kcal content of their purchases, and customers noticing and use of kcal labelling. In a subset of 117 outlets, data was collected on nine recommended kcal labelling practices. Results The average number of kcals purchased (1013 kcal, SD = 632 kcal) was high with 69% of purchases exceeding the recommendation of a maximum of 600 kcal per meal. Participants underestimated the energy content of their purchased meals by on average 253 kcal (SD = 644 kcals). In outlets providing kcal labelling in which customer survey data was collected, a minority of customers reported noticing (21%) or using (20%) kcal labelling. Out of the 117 outlets assessed for kcal labelling practices, 24 (21%) provided any in-store kcal labelling. None of the outlets met all nine aspects of recommended labelling practices. Conclusions Prior to implementation of 2022 kcal labelling policy, the majority of sampled OHFS large business outlets in England did not provide kcal labelling. Few customers noticed or used the labels and on average customers purchased and consumed substantially more energy than recommended in public health guidelines. The findings suggest that reliance on voluntary action for kcal labelling implementation failed to produce widespread, consistent, and adequate kcal labelling practices.

Abstract Objective: To assess associations between self-reported advertising exposure to foods high in fats, salt and sugar and household purchases of energy, nutrients and specific product categories. Design: A cross-sectional design was used. Advertising exposure data were gathered using a questionnaire administered to the main shopper of each household, and purchase data from supermarkets and other stores for these households were accessed for a 4-week period during February 2019. Setting: Households in London and the North of England. Participants: Representative households (N 1289) from the Kantar Fast Moving Consumer Goods Panel. Main shoppers were predominantly female (71 %), with a mean age of 54 years (±13). Results: Linear regression models identified that exposure to foods high in fats, salt and sugar advertising through traditional mediums (including broadcast and print), but not digital, transport, recreational or functional mediums, was associated with greater purchases of energy (9779 kcal; 95 % CI 3515, 16 043), protein (416 g; 95 % CI 161, 671), carbohydrate (1164 g; 95 % CI 368, 1886) and sugar (514 g; 95 % CI 187, 841). Generalised linear models showed that individuals who reported exposure to sugary drink advertising were more likely to purchase sugary drinks (1·16; 95 % CI 2·94, 4·99) but did not purchase more energy or nutrients from sugary drinks. There was no evidence of associations between exposure to advertising for sugary cereals or sweet snacks and purchases from these categories. Conclusions: There was a strong influence of traditional advertising and sugar-sweetened beverage advertising on household food and drink purchases, thus supporting the need for advertising restrictions across traditional formats and for sugary drinks specifically.

A primary aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysms caused by erosion of the aortic wall into the vena cava. It is more frequently observed in the setting of ruptured abdominal aortic aneurysms and presents a unique challenge for vascular surgeons. Both open and endovascular techniques exist, with the main differences being perioperative mortality and recurrence rates. We present a case of an ACF diagnosed intraoperatively, which persisted after endovascular aneurysm repair in conjunction with a type II endoleak. We applied a unique staged, triple endovascular approach to close the ACF via caval and aortic exclusion of inflow and outflow vessels.

Employing the full arsenal of therapeutics to treat brain tumors is limited by the relative impermeability of the blood–brain and blood–tumor barriers. In physiologic states, the blood–brain barrier serves a protective role by passively and actively excluding neurotoxic compounds; however, this functionality limits the penetrance of therapeutics into the tumor microenvironment. Focused ultrasound technology provides a method for overcoming the blood–brain and blood–tumor barriers through ultrasound frequency to transiently permeabilize or disrupt these barriers. Concomitant delivery of therapeutics has allowed for previously impermeable agents to reach the tumor microenvironment. This review details the advances in focused ultrasound in both preclinical models and clinical studies, with a focus on its safety profile. We then turn towards future directions in focused ultrasound-mediated therapies for brain tumors.

Abstract Background Reducing portion sizes of commercially available foods could be an effective public health strategy to reduce population energy intake, but recent research suggests that the effect portion size has on energy intake may differ based on socioeconomic position (SEP). Objective We tested whether the effect of reducing food portion sizes on daily energy intake differed based on SEP. Methods Participants were served either smaller or larger portions of food at lunch and evening meals (N = 50; Study 1) and breakfast, lunch and evening meals (N = 46; Study 2) in the laboratory on two separate days, in repeated-measures designs. The primary outcome was total daily energy intake (kcal). Participant recruitment was stratified by primary indicators of SEP; highest educational qualification (Study 1) and subjective social status (Study 2), and randomisation to the order portion sizes were served was stratified by SEP. Secondary indicators of SEP in both studies included household income, self-reported childhood financial hardship and a measure accounting for total years in education. Results In both studies, smaller (vs larger) meal portions led to a reduction in daily energy intake (ps

Abstract Alcohol is calorie dense, but unlike food products, alcoholic drinks tend to be exempt from nutritional labelling laws that require energy content information to be displayed on packaging or at point of purchase. This review provides a perspective on the likely efficacy of alcoholic drink energy labelling as a public health policy to reduce obesity and discusses key questions to be addressed by future research. First, the contribution that alcohol makes to population level daily energy intake and obesity is outlined. Next, consumer need for alcohol energy labelling and the potential impacts on both consumer and industry behavior are discussed. Pathways and mechanisms by which energy labelling of alcoholic drinks could reduce obesity are considered, as well as possible unintended consequences of alcoholic drink energy labelling. Would widespread energy labelling of alcoholic drinks reduce obesity? The unclear effect that alcohol has on population level obesity, the modest contribution calories from alcohol make to daily energy intake and limited impact nutritional labelling policies tend to have on behavior, suggest alcohol energy labelling may have limited impact on population obesity prevalence as a standalone policy. However, there are a number of questions that will need to be answered by future research to make definitive conclusions on the potential for alcohol energy labelling policies to reduce obesity.

Abstract Background There are well documented socioeconomic disparities in diet quality and obesity. Menu energy labelling is a public health policy designed to improve diet and reduce obesity. However, it is unclear whether the impact energy labelling has on consumer behaviour is socially equitable or differs based on socioeconomic position (SEP). Methods Systematic review and meta-analysis of experimental (between-subjects) and pre-post implementation field studies examining the impact of menu energy labelling on energy content of food and/or drink selections in higher vs. lower SEP groups. Results Seventeen studies were eligible for inclusion. Meta-analyses of 13 experimental studies that predominantly examined hypothetical food and drink choices showed that energy labelling tended to be associated with a small reduction in energy content of selections that did not differ based on participant SEP (X2(1) = 0.26, p = .610). Effect estimates for higher SEP SMD = 0.067 [95% CI: -0.092 to 0.226] and lower SEP SMD = 0.115 [95% CI: -0.006 to 0.237] were similar. A meta-analysis of 3 pre-post implementation studies of energy labelling in the real world showed that the effect energy labelling had on consumer behaviour did not significantly differ based on SEP (X2(1) = 0.22, p = .636). In higher SEP the effect was SMD = 0.032 [95% CI: -0.053 to 0.117] and in lower SEP the effect was SMD = -0.005 [95% CI: -0.051 to 0.041]. Conclusions Overall there was no convincing evidence that the effect energy labelling has on consumer behaviour significantly differs based on SEP. Further research examining multiple indicators of SEP and quantifying the long-term effects of energy labelling on consumer behaviour in real-world settings is now required. Review registration Registered on PROSPERO (CRD42022312532) and OSF ( https://doi.org/10.17605/OSF.IO/W7RDB ).

Abstract Background There is convincing evidence that unhealthy food marketing is extensive on television and in digital media, uses powerful persuasive techniques, and impacts dietary choices and consumption, particularly in children. It is less clear whether this is also the case for outdoor food marketing. This review (i) identifies common criteria used to define outdoor food marketing, (ii) summarises research methodologies used, (iii) identifies available evidence on the exposure, power (i.e. persuasive creative strategies within marketing) and impact of outdoor food marketing on behaviour and health and (iv) identifies knowledge gaps and directions for future research. Methods A systematic search was conducted of Medline (Ovid), Scopus, Science Direct, Proquest, PsycINFO, CINAHL, PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and a number of grey literature sources. Titles and abstracts were screened by one researcher. Relevant full texts were independently checked by two researchers against eligibility criteria. Results Fifty-three studies were conducted across twenty-one countries. The majority of studies (n = 39) were conducted in high-income countries. All measured the extent of exposure to outdoor food marketing, twelve also assessed power and three measured impact on behavioural or health outcomes. Criteria used to define outdoor food marketing and methodologies adopted were highly variable across studies. Almost a quarter of advertisements across all studies were for food (mean of 22.1%) and the majority of advertised foods were unhealthy (mean of 63%). The evidence on differences in exposure by SES is heterogenous, which makes it difficult to draw conclusions, however the research suggests that ethnic minority groups have a higher likelihood of exposure to food marketing outdoors. The most frequent persuasive creative strategies were premium offers and use of characters. There was limited evidence on the relationship between exposure to outdoor food marketing and eating behaviour or health outcomes. Conclusions This review highlights the extent of unhealthy outdoor food marketing globally and the powerful methods used within this marketing. There is a need for consistency in defining and measuring outdoor food marketing to enable comparison across time and place. Future research should attempt to measure direct impacts on behaviour and health.

BackgroundIt is unclear whether heavy alcohol use and associated hangover symptoms changed as a result of the COVID-19 pandemic. Due to a lack of available accurate and nonretrospective self-reported data, it is difficult to directly assess hangover symptoms during the COVID-19 pandemic. ObjectiveThis study aimed to examine whether alcohol-induced hangover-related internet searches (eg, “how to cure a hangover?”) increased, decreased, or remained the same in England before versus during the COVID-19 pandemic (2020-2021) and during periods of national lockdown. Secondary aims were to examine if hangover-related internet searches in England differed compared to a country that did not impose similar COVID-19 lockdown restrictions. MethodsUsing historical data from Google Trends for England, we compared the relative search volume (RSV) of hangover-related searches in the years before (2016-2019) versus during the COVID-19 pandemic (2020-2021), as well as in periods of national lockdown versus the same periods in 2016-2019. We also compared the RSV of hangover-related searches during the same time frames in a European country that did not introduce national COVID-19 lockdowns at the beginning of the pandemic (Sweden). Hangover-related search terms were identified through consultation with a panel of alcohol researchers and a sample from the general public. Statistical analyses were preregistered prior to data collection. ResultsThere was no overall significant difference in the RSV of hangover-related terms in England during 2016-2019 versus 2020-2021 (P=.10; robust d=0.02, 95% CI 0.00-0.03). However, during national lockdowns, searches for hangover-related terms were lower, particularly during the first national lockdown in England (P

Abstract Background Dietary energy density is thought to be a contributor to obesity, but the extent to which different magnitudes and types of reductions to food energy density decreases daily energy intake is unclear. The primary objective was to systematically review and meta-analyse experimental studies that have examined the effect that manipulating energy density of food has on total daily energy intake. Secondary objectives were to examine moderators of the effect that altering energy density has on daily energy intake and effects on body weight. Methods A systematic review and multi-level meta-analysis of studies on human participants that used an experimental design to manipulate the energy density of foods served and measured energy intake for a minimum of 1 day. Results Thirty-one eligible studies sampling both children (n = 4) and adults (n = 27) contributed 90 effects comparing the effect of higher vs. lower energy density of served food on daily energy intake to the primary meta-analysis. Lower energy density of food was associated with a large decrease in daily energy intake (SMD = − 1.002 [95% CI: − 0.745 to − 1.266]). Findings were consistent across studies that did vs. did not manipulate macronutrient content to vary energy density. The relation between decreasing energy density and daily energy intake tended to be strong and linear, whereby compensation for decreases to energy density of foods (i.e. by eating more at other meals) was minimal. Meta-analysis of (n = 5) studies indicated that serving lower energy dense food tended to be associated with greater weight loss than serving higher energy dense food, but this difference was not significant (− 0.7 kg difference in weight change, 95% CIs: − 1.34, 0.04). Conclusions Decreasing the energy density of food can substantially reduce daily energy intake and may therefore be an effective public health approach to reducing population level energy intake. Trial registration Registered on PROSPERO ( CRD42020223973 ).

The Eating Disorders In weight-related Therapy (EDIT) Collaboration brings together data from randomised controlled trials of behavioural weight management interventions to identify individual participant risk factors and intervention strategies that contribute to eating disorder risk. We present a protocol for a systematic review and individual participant data (IPD) meta-analysis which aims to identify participants at risk of developing eating disorders, or related symptoms, during or after weight management interventions conducted in adolescents or adults with overweight or obesity. We systematically searched four databases up to March 2022 and clinical trials registries to May 2022 to identify randomised controlled trials of weight management interventions conducted in adolescents or adults with overweight or obesity that measured eating disorder risk at pre- and post-intervention or follow-up. Authors from eligible trials have been invited to share their deidentified IPD. Two IPD meta-analyses will be conducted. The first IPD meta-analysis aims to examine participant level factors associated with a change in eating disorder scores during and following a weight management intervention. To do this we will examine baseline variables that predict change in eating disorder risk within intervention arms. The second IPD meta-analysis aims to assess whether there are participant level factors that predict whether participation in an intervention is more or less likely than no intervention to lead to a change in eating disorder risk. To do this, we will examine if there are differences in predictors of eating disorder risk between intervention and no-treatment control arms. The primary outcome will be a standardised mean difference in global eating disorder score from baseline to immediately post-intervention and at 6- and 12- months follow-up. Identifying participant level risk factors predicting eating disorder risk will inform screening and monitoring protocols to allow early identification and intervention for those at risk.

Objective: Esophagectomy remains the mainstay of treatment for nonmetastatic esophageal cancer. The optimal technique for anastomosis after esophagectomy remains unknown. The purpose of this systematic meta-analysis is to combine the available high-quality evidence to provide esophageal surgeons with an evidence base for their decision making. Methods: A systematic search of multiple databases was conducted to find randomized controlled trials of esophageal anastomotic techniques. A meta-analysis of the pooled data was conducted. Results: A total of 19 studies with 2123 patients were included in the meta-analysis. The pooled analysis revealed a 102% higher incidence of anastomotic leak after hand-sewn anastomosis compared with stapled anastomosis (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.48-2.75). Anastomotic stricture rate was also 31% higher with hand-sewn anastomosis (OR, 1.31; 95% CI, 1.00-1.7). Thirty-day mortality did not show statistical difference favoring one anastomosis technique to another (OR, 0.68; 95% CI, 0.45-1.04). None of anastomotic leak rate, anastomotic stricture rate, or 30-day overall survival differed between anastomotic techniques in studies with only thoracic anastomoses. In cervical position hand-sewn anastomosis was associated with higher rate of anastomotic leak (OR, 2.02; 95% CI, 1.33-3.05) and stricture (OR, 1.77; 95% CI, 1.15-2.72), but no difference in 30-day mortality. Conclusions: This meta-analysis showed a signal of higher rate of leak and stricture in hand-sewn anastomoses, but sensitivity analyses did not show a consistent outcome, so these results should be interpreted with caution.

We present a case of refractory cystitis after BK-virus associated hemorrhagic cystitis following bone marrow transplantation requiring cystectomy in a 17-year-old female with genetically confirmed dyskeratosis congenita, a telomere disorder characterized by early bone marrow failure. She presented with a contracted, small bladder with intense urinary symptoms non-responsive to conservative therapy and requiring opioids for pain control. Cystectomy is a rare, final surgical treatment for benign bladder conditions, especially among younger patients, and she experienced successful resolution of symptoms and cessation of chronic opioids post-intervention.

Abstract Background There are a range of interventions designed to promote healthier food choices in full-service restaurants. However, it is unclear how these interventions affect dietary choices in people of lower and higher socioeconomic position (SEP). Methods A total of 2091 US participants recruited online completed Study 1 (n = 1001) and Study 2 (n = 1090). Recruitment was stratified by participant highest education level, resulting in higher SEP and lower SEP groups. In a between-subjects design, participants made hypothetical food choices (main dish, plus optional sides and desserts) from six restaurants menus in the absence vs. presence of menu energy labelling and from menus with baseline (10%) vs. increased availability (50%) of lower energy main dishes. Data were collected and analysed in 2019. Two studies were conducted in order to examine replicability and generalisability of findings across different restaurant menu types. Results Across both studies, increasing the availability of lower energy main menu options decreased the average energy content of the ordered main dish (− 129 kcal, 95% CI [− 139; − 119]) and total energy ordered (− 117 kcal, 95% CI [− 138; − 95]) in both higher and lower SEP participants. Energy labelling significantly reduced the energy content of ordered main dishes in higher SEP participants (− 41 kcal, 95% CI [− 54; − 29]), but not lower SEP participants (− 5 kcal, 95% CI [− 22; 11]). However, energy labelling reduced total energy ordered (− 83 kcal, 95% CI [− 105; − 60]) irrespective of SEP. Conclusions In two virtual experiments, increasing the availability of lower energy restaurant main menu options impacted on main menu dish choice and decreased total energy ordered irrespective of SEP. Energy labelling had a less pronounced effect on total energy ordered and had a larger impact on the energy content of main menu dish choice in higher as opposed to lower SEP participants. Trial registration Clinicaltrials.gov NCT04336540 retrospectively registered (7 April, 2020).

Summary Background The COVID‐19 crisis is likely to have had wide‐ranging consequences on lifestyle behaviours and may have affected weight management. The objective of the present study was to examine perceptions of how weight‐related lifestyle changed in social lockdown among UK adults compared with before the emergence of the COVID‐19 crisis. Methods As part of an online cross‐sectional survey conducted during social lockdown in the United Kingdom, 723 UK adults reported on the extent to which their eating (healthiness of diet, frequency of bingeing on food), physical activity, sleep and alcohol consumption had changed since the emergence of the COVID‐19 crisis and completed measures of current psychological well‐being. Results Although both improvements and declines in weight gain protective behaviours were reported, 79% of participants reported a decline in one or more weight gain protective behaviours. Both participants with a diagnosis of psychiatric illness or obesity (body mass index [BMI] ≥ 30) were most likely to report declines in weight gain protective behaviours and show an overall profile of weight management behaviours worsening. Participants experiencing high levels of stress also reported reductions in more weight gain protective behaviours. Conclusions Lifestyle behaviours associated with weight gain are likely to have been affected by the COVID‐19 crisis. Reductions to the perceived frequency by which people engage in behaviours usually associated with successful weight management appear to be common, and people living with obesity and mental health problems may be at increased risk.

BackgroundPeoples' sexual behaviors have changed during the period of enforced COVID-19 social distancing, in some cases, to cope with negative feelings during lockdown. Research on coping using sex is relatively restricted to samples of men with a history of sexual offending, and it is unknown whether coping using sex is associated with health-related behaviors and mental health in the general population.AimWe examined if coping using sex before and during lockdown was associated with adverse outcomes (i.e., self-perceived reduction in health-related behaviors and mental health) in a community sample.HypothesesWe hypothesized that participants who reported greater use of sex to cope in the weeks preceding lockdown would show a greater decline in health-related behaviors and mental health during lockdown. Furthermore, that changes in coping using sex resulting from lockdown would account for further variance in the worsening of health-related behaviors and mental health.MethodsParticipants were UK residents, aged 18–60 years, and fluent in English. 789 participants completed an online survey, providing demographic information, self-reported social distancing, loneliness, and coping using sex over a 14-day period during lockdown, and retrospectively preceding lockdown.OutcomesParticipants reported perceived changes in health-related behaviors and mental health symptomatology during lockdown compared to before the pandemic. They also self-reported levels of stress, anxiety and depression during lockdown.ResultsGreater coping using sex prior to lockdown predicted positive change in health-related behaviors, for example, higher scores were associated with participants reporting having exercised and slept more. It was also associated with higher trait levels of anxiety, stress and depression during lockdown. Changes in coping using sex from before to during lockdown did not predict perceived changes in health related behaviors or mental health symptomatology.ConclusionsOverall, greater coping using sex prior to lockdown was associated with worse mental health symptomatology during lockdown (anxiety, depression and stress), however, it was also associated with perceived positive change in health-related behaviors compared with before lockdown. This suggests that coping using sex may be associated with negative emotional reactions during lockdown, but may also be linked with positive change in health-promoting behaviors.

Summary The obesity crisis is one of the largest public health challenges of the 21st century. Population‐level adiposity has increased dramatically in recent times, and people not recognizing that they have overweight or obesity is now common. It has been widely assumed that not recognizing oneself as having overweight is detrimental to weight management and long‐term health. Here, diverse research is reviewed that converges on the counterintuitive conclusion that not recognizing oneself as having overweight is actually associated with more favourable physical and mental health outcomes than recognizing oneself as having overweight. Drawing on existing models in social psychology and weight stigma research, an explanatory model of the health effects of self‐perception of overweight is outlined. This model proposes that self‐perception of overweight triggers social rejection concerns and the internalization of weight stigma, which in turn induce psychological distress and negatively impact health‐promoting lifestyle behaviours. How self‐perception of overweight may in part explain progression from overweight to obesity, and the public health implications of self‐perception of overweight and obesity are also discussed.

Abstract Background Smaller portions may help to reduce energy intake. However, there may be a limit to the magnitude of the portion size reduction that can be made before consumers respond by increasing intake of other food immediately or at later meals. We tested the theoretical prediction that reductions to portion size would result in a significant reduction to daily energy intake when the resulting portion was visually perceived as ‘normal’ in size, but that a reduction resulting in a ‘smaller than normal’ portion size would cause immediate or later additional eating. Methods Over three 5-day periods, daily energy intake was measured in a controlled laboratory study using a randomized crossover design (N = 30). The served portion size of the main meal component of lunch and dinner was manipulated in three conditions: ‘large-normal’ (747 kcal), ‘small-normal’ (543 kcal), and ‘smaller than normal’ (339 kcal). Perceived ‘normality’ of portion sizes was determined by two pilot studies. Ad libitum daily energy intake from all meals and snacks was measured. Results Daily energy intake in the ‘large-normal’ condition was 2543 kcals. Daily energy intake was significantly lower in the ‘small-normal’ portion size condition (mean difference − 95 kcal/d, 95% CI [− 184, − 6], p = .04); and was also significantly lower in the ‘smaller than normal’ than the ‘small-normal’ condition (mean difference − 210 kcal/d, 95% CI [− 309, − 111], p

Abstract Background Food consumed outside of the home is often high in energy and population level interventions that reduce energy intake of people from both lower and higher socioeconomic position (SEP) are needed. There is a lack of evidence on the effectiveness and SEP equity of structural-based (e.g. increasing availability of lower energy options) and information provision (e.g. menu energy labelling) interventions on food choice. Methods Across two online experiments, participants of lower and higher SEP made meal choices in a novel virtual fast-food restaurant. To be eligible to take part, participants were required to be UK residents, aged 18 or above, fluent in English, have access to a computer with an internet connection and have no dietary restrictions. Participants were randomized to one of four conditions in a 2 × 2 between-subjects design: menu energy labelling present vs. absent and increased availability of lower energy options (75% of menu options lower energy) vs. baseline availability (25% of menu options lower energy). Participants also completed measures of executive function and food choice motives. Results The analysis of pooled data from both studies (n = 1743) showed that increasing the availability of lower energy options resulted in participants ordering meals with significantly less energy on average (− 71 kcal, p

Abstract Background Eating out is now common and food served out of the home is often of low nutritional quality. Kilocalorie (kcal) labelling of food and drink products sold in restaurant chains in the US is now mandatory, although in store kcal labelling practices among major UK restaurant and takeaway chains have not been examined. Methods During August 2018, we contacted, visited the website and/or retail outlets of major eating out and takeaway food chains in the UK, including full-service and fast-food restaurants, cafes and coffee shops, some of which had previously made a voluntary pledge to provide kcal labelling. We examined the proportion of chains providing kcal information to customers at point of choice in store and the extent to which kcal information provision adhered to labelling recommendations. We also examined the proportion of chains that did not have point of choice kcal labelling but were able to provide kcal information on request. The study protocol was pre-registered on the Open Science Framework. Results Of the 104 eligible chains, only a small minority (18 chains, 17%) provided in store kcal labelling. Of those that did, provision of kcal information tended not to adhere to recommended labelling practices. Of the 16 eligible chains that had previously committed to a voluntary public health pledge to provide point of choice kcal labelling, labelling did not meet recommendations and 4 (25%) did not provide kcal labelling. Of the 86 chains that did not provide kcal labelling in store, kcal information was available on request from 43 (50%) chains. Conclusions It is rare for eating out and takeaway chains in the UK to provide point of choice kcal labelling and when labelling is provided it does not adhere to recommended labelling practices. Chains that previously volunteered to provide kcal labelling as part of an industry and public health partnership do so inadequately. Voluntary policies have not resulted in adequate kcal labelling in the UK eating out of home sector.

Abstract Background Laboratory studies suggest that eating more ‘attentively’ (e.g. attending to food being eaten and recalling eating episodes) can reduce food intake among participants with both healthy weight and overweight. The aim of this trial was to assess whether a smartphone application that encourages a more attentive eating style reduces energy intake and promotes weight loss. Methods In an open-label, single centre, parallel groups, individually randomised controlled trial, 107 adults with overweight/obesity in Merseyside, UK used an attentive eating smartphone application along with standard dietary advice (intervention group) or standard dietary advice only (control group) for 8 weeks. The primary outcomes were change in body weight at 8 weeks and energy intake at 4 and 8 weeks. Additional outcomes included self-reported eating behaviours measured at 8 weeks. Differences between groups were assessed with linear regression (adjusted) using multiple imputation for missing data. Study protocol registered prospectively at (https://doi.org/10.17605/osf.io/btzhw). Results There was no significant difference between the intervention and control group in weight lost at 8 weeks, or change in self-reported 24 h or objective taste-test energy intake at 4 or 8 weeks. Mean weight loss in the intervention group (n = 53) was 1.2 kg and 1.1 kg in the control group (n = 54), adjusted difference of − 0.10 (− 1.6 to 1.3) kg. Self-reported eating behaviours at 8 weeks also did not differ across groups. The intervention was largely used as intended and a per protocol analysis confined to participants in the intervention group that used the attentive eating smartphone application regularly and as intended also showed no effect on energy intake or weight loss. Conclusions A smartphone based attentive eating intervention and standard dietary advice did not result in reduced energy intake or greater weight loss at 4 or 8 week follow-up than standard dietary advice alone. Trial registration ClinicalTrials.gov, NCT03602001. Registered retrospectively on 26th July 2018. Prospectively registered on the Open Science Framework on 11th August 2017.

Abstract Background In an era when obesity prevalence is high throughout much of the world, there is a correspondingly pervasive and strong culture of weight stigma. For example, representative studies show that some forms of weight discrimination are more prevalent even than discrimination based on race or ethnicity. Discussion In this Opinion article, we review compelling evidence that weight stigma is harmful to health, over and above objective body mass index. Weight stigma is prospectively related to heightened mortality and other chronic diseases and conditions. Most ironically, it actually begets heightened risk of obesity through multiple obesogenic pathways. Weight stigma is particularly prevalent and detrimental in healthcare settings, with documented high levels of ‘anti-fat’ bias in healthcare providers, patients with obesity receiving poorer care and having worse outcomes, and medical students with obesity reporting high levels of alcohol and substance use to cope with internalized weight stigma. In terms of solutions, the most effective and ethical approaches should be aimed at changing the behaviors and attitudes of those who stigmatize, rather than towards the targets of weight stigma. Medical training must address weight bias, training healthcare professionals about how it is perpetuated and on its potentially harmful effects on their patients. Conclusion Weight stigma is likely to drive weight gain and poor health and thus should be eradicated. This effort can begin by training compassionate and knowledgeable healthcare providers who will deliver better care and ultimately lessen the negative effects of weight stigma.

Abstract Background There is concern that the body size of fashion store mannequins are too thin and promote unrealistic body ideals. To date there has been no systematic examination of the size of high street fashion store mannequins. Methods We surveyed national fashion retailers located on the high street of two English cities. The body size of ‘male’ and ‘female’ mannequins was assessed by two blinded research assistants using visual rating scales. Results The average female mannequin body size was representative of a very underweight woman and 100% of female mannequins represented an underweight body size. The average male mannequin body size was significantly larger than the average female mannequin body size. Only 8% of male mannequins represented an underweight body size. Conclusions The body size of mannequins used to advertise female fashion is unrealistic and would be considered medically unhealthy in humans.

Reducing the energy density (ED) of product selections made during online supermarket food shopping has potential to decrease energy intake. Yet it is unclear which types of intervention are likely to be most effective and equitable. We recruited 899 UK adults of lower and higher socioeconomic position (SEP) who completed a shopping task in an online experimental supermarket. Participants were randomised in a 2 × 2 between-subjects design to test the effects of two interventions on the ED of shopping basket selections: labelling lower-ED products as healthier choices and increasing the relative availability of lower-ED products within a range (referred to as proportion). Labelling of lower-ED products resulted in a small but significant decrease (−4.2 kcal/100 g, 95% CIs −7.8 to −0.6) in the ED of the shopping basket. Increasing the proportion of lower-ED products significantly decreased the ED of the shopping basket (−17 kcal/100 g, 95% CIs −21 to −14). There was no evidence that the effect of either intervention was moderated by SEP. Thus, both types of intervention decreased the ED of foods selected in an online experimental supermarket. There was no evidence that the effectiveness of either intervention differed in people of lower vs. higher SEP.

Acute alcohol administration can lead to a loss of control over drinking. Several models argue that this 'alcohol priming effect' is mediated by the effect of alcohol on inhibitory control. Alternatively, beliefs about how alcohol affects behavioural regulation may also underlie alcohol priming and alcohol-induced inhibitory impairments. Here two studies examine the extent to which the alcohol priming effect and inhibitory impairments are moderated by beliefs regarding the effects of alcohol on the ability to control behaviour. In study 1, following a priming drink (placebo or .5g/kg of alcohol), participants were provided with bogus feedback regarding their performance on a measure of inhibitory control (stop-signal task; SST) suggesting that they had high or average self-control. However, the bogus feedback manipulation was not successful. In study 2, before a SST, participants were exposed to a neutral or experimental message suggesting acute doses of alcohol reduce the urge to drink and consumed a priming drink and this manipulation was successful. In both studies craving was assessed throughout and a bogus taste test which measured ad libitum drinking was completed. Results suggest no effect of beliefs on craving or ad lib consumption within either study. However, within study 2, participants exposed to the experimental message displayed evidence of alcohol-induced impairments of inhibitory control, while those exposed to the neutral message did not. These findings do not suggest beliefs about the effects of alcohol moderate the alcohol priming effect but do suggest beliefs may, in part, underlie the effect of alcohol on inhibitory control.

Background. To date, there have been no published investigations on the cause of acetabular debonding, a rare failure phenomenon in metal-on-metal hip resurfacing where the acetabular porous coating delaminates from the implant while remaining well fixed to the pelvic bone. Purposes. This study aims to summarize the current understanding of acetabular debonding and to investigate the discrepancy in rate of debonding between two implant systems. Patients and Methods. To elucidate potential causes of debonding, we retrospectively analyzed a single-surgeon cohort of 839 hip resurfacing cases. Specifically, we compared rate of debonding and manufacturing processes between two implant systems. Results. Group 1 experienced significantly more cases of debonding than Group 2 cases (4.0% versus 0.0%, p value

Portion sizes of commercially available foods have increased, and there is evidence that exposure to portion sizes recalibrates what is perceived as ‘normal’ and subsequently, how much food is selected and consumed. The present study aims to explore the role of social (descriptive and injunctive) and personal portion size norms in this effect. Across two experiments, participants were either visually exposed to (Study 1, N = 329) or actually served (Study 2, N = 132) a smaller or larger than normal food portion. After 24 h, participants reported their intended consumption (Study 1) or served themselves and consumed (Study 2) a portion of that food and reported perceived portion size norms. In Study 1, visual exposure to portion size did not significantly affect intended consumption and perceived portion size norms. In Study 2, participants consumed a smaller portion of food when they were served a smaller rather than a larger portion the previous day, which was mediated by perceived descriptive and injunctive social (but not personal) portion size norms. Results suggest that being served (but not mere visual exposure to) smaller (relative to larger) portions changes perceived social norms about portion size and this may reduce future consumption of that food.

It is well established that the satiety providing effects of food can influence meal size and a disparate area of research suggests that memory regarding recent eating informs food intake. Here we examined whether remembered meal satisfaction (encompassing memory for meal liking and satiety) can be manipulated in the laboratory and whether this influences later food intake. Participants (N = 128, body mass index mean = 23.46kg/m2, standard deviation = 4.70) consumed a fixed lunch and then rehearsed the satisfying or dissatisfying aspects of the meal, or a neutral experience (control), in order to manipulate memory for meal satisfaction. Three hours later participants completed a bogus taste-test to measure food intake and meal memory measures. There was no evidence that memory for general satisfaction with the meal was affected by the rehearsal condition. However, in the dissatisfying rehearsal condition, participants remembered being less satisfied with the satiety-providing effects of the lunch meal than in the satisfying and neutral rehearsal conditions. Snack food consumption did not differ across conditions and there was a small negative correlation between how satiating participants remembered their earlier meal to be and later snack food intake (r = −0.16, p = 0.07). The present study did not produce evidence that memory relating to meal satiety affects later food intake but further research is warranted.

Social factors are known to influence food intake and choice. However, whether social influence acts on evaluations of food and drink liking has not been studied. Across two studies, we tested whether leading a participant to believe that other people do not like a food affects food liking evaluations. In Study 1, we exposed participants to social normative information suggesting a) that an in-group disliked orange juice, b) that an out-group disliked orange juice or c) that an in-group were neutral about orange juice. We then examined how much participants believed they liked orange juice. In Study 2, participants consumed a snack food before being led to believe that two previous participants had also eaten the food and either disliked or quite liked it. We asked participants to rate how much they had enjoyed eating the snack food. Across both studies, social influence was observed, as underlined by decreases in liking evaluations. In Study 1, beliefs about liking were only influenced by social normative information when the norm was expressed by an in-group. In Study 2, exposure to others' accounts of a negative experience with a food decreased evaluated liking of the recent consumption experience. These results suggest that social influence can act upon food liking evaluations.