Background Epidemiologic evidence is sparse on the effect of dietary behaviors and diet quality on body mass index (BMI) that may be important drivers of the obesity epidemic. Objective This study investigated the relationships of frequency of eating and time of intake to energy density, nutrient quality and BMI using data from the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP) including 2,696 men and women aged 40-59 from the United States and the United Kingdom. Design INTERMAP is a cross-sectional investigation with four 24-hour dietary recalls and BMI measurements conducted between 1996 and 1999. Consumption of solid foods was aggregated into eating occasion. Nutrient density is expressed using the Nutrient Rich Food (NRF 9.3) index. The ratio of evening/morning energy intake was calculated; mean values of four visits were used. Statistical analyses performed Characteristics across eating occasion categories are presented as adjusted mean with corresponding 95% confidence interval. Multiple linear regression models were used to examine associations of eating occasions, ratio of evening/morning energy intake, dietary energy density, and NRF 9.3 index with BMI. Results Compared to participants with < 4 eating occasions/24-hours, those with ≥ 6 eating occasions/24-hours had lower mean: BMI: 27.3 vs. 29.0 kg/m2; total energy intake: 2,129 vs. 2,472 kcal/24-hours; dietary energy density: 1.5 vs. 2.1 kcal/g; and higher NRF 9.3 index: 34.3 vs. 28.1. In multiple regression analyses, higher evening intake relative to morning intake was directly associated with BMI; however this did not influence the relationship between eating frequency and BMI. Conclusions Our results suggest that a larger number of small meals may be associated with improved diet quality and lower BMI. This may have implications for behavioral approaches to controlling the obesity epidemic.

Background Negative lifestyle behaviors are associated with an increased risk of adverse outcomes from coronavirus disease (COVID-19). This study aimed to assess lifestyle changes affecting weight, sleep, mental health, physical activity, and dietary habits prospectively from before COVID-19 to during lockdown. Methods A total of 297 Saudi women, aged 19–30 years (mean age, 20.7 ± 1.4 years), were interviewed at two time points, before and during the quarantine. The data collected included anthropometrics, sociodemographic data, clinical history, food frequency questionnaire responses, Pittsburgh Sleep Quality Index scores, Global Physical Activity Questionnaire (GPAQ) responses, and Perceived Stress Scale measures. In addition, during quarantine, COVID-19 and nutrition-related information and Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9 scores were collected. Multivariate multinomial logistic regression analysis was used to examine the indicators of weight gain and loss from before COVID-19 (baseline) until during lockdown. Results Although approximately half of the participants did not report a weight change, 30% revealed weight loss and 18%, weight gain. The variables associated with increased weight gain were self-quarantine since COVID-19 started (OR: 5.17, 95% CI: 1.57–17.01, p = 0.007), age (OR: 1.53, 1.03–2.28, p = 0.04), and stress at baseline and during lockdown (OR: 1.15, 1.03–1.29, p = 0.01; OR: 1.10, 1.01–1.19, p = 0.03, respectively). The variables associated with a reduced risk of weight gain were the GPAQ score during lockdown (OR: 0.16, 0.04–0.66, p = 0.01), coffee consumption (OR: 0.36, 0.19–0.67, p = 0.01), and total sleep time (OR: 0.70, 0.51–0.97, p = 0.03). Conclusion While most young Saudi women experienced no weight change during the COVID-19 lockdown, one-third lost weight and a significant proportion gained weight. Factors associated with weight, such as stress, sleep hours, physical activity, and coffee consumption, highlight the need to carefully consider those at risk during future circumstances that may require lockdowns. These factors could also aid in implementing policies for future lockdowns and support those most at risk of gaining weight.

Healthy dietary habits are the cornerstone of cardiovascular disease (CVD) prevention. Numerous researchers have developed diet quality indices to help evaluate and compare diet quality across and within various populations. The availability of these new indices raises questions regarding the best selection relevant to a given population. In this perspective, we critically evaluate a priori–defined dietary indices commonly applied in epidemiological studies of CVD risk and mortality. A systematic literature search identified 59 observational studies that applied a priori–defined diet quality indices to CVD risk factors and/or CVD incidence and/or CVD mortality. Among 31 different indices, these scores were categorized as follows: 1) those based on country-specific dietary patterns, 2) those adapted from distinct dietary guidelines, and 3) novel scores specific to key diet-related factors associated with CVD risk. The strengths and limitations of these indices are described according to index components, calculation methods, and the application of these indices to different population groups. Also, the importance of identifying methodological challenges faced by researchers when applying an index are considered, such as selection and weighting of food groups within a score, since food groups are not necessarily equivalent in their associations with CVD. The lack of absolute cutoff values, emphasis on increasing healthy food without limiting unhealthy food intake, and absence of validation of scores with biomarkers or other objective diet assessment methods further complicate decisions regarding the best indices to use. Future research should address these limitations, consider cross-cultural and other differences between population groups, and identify translational challenges inherent in attempting to apply a relevant diet quality index for use in CVD prevention at a population level.

Background In recent years, the use of mobile phone weight-management apps has increased significantly. Weight-management apps have been found effective in promoting health and managing weight. However, data on user perception and on barriers to app usage are scarce. Objective This study aimed to investigate the use of weight-management apps and barriers to use as well as reasons for discontinuing use in a sample of mobile phone users in Saudi Arabia. Methods Mobile phone users aged 18 years and above from the general public in Saudi Arabia completed a Web-based survey. The survey included questions on weight-management app usage patterns, user perceptions concerning weight management, efficacy of weight-management apps, and reasons for discontinuing use. Participants were classified into normal weight (body mass index [BMI]: 18.5 to 24.9 kg/m 2 ) and overweight or obese (BMI: ≥25.0 kg/m 2 ). Results The survey included 1191 participants; 513 of them used weight-management apps. More overweight or obese respondents used these apps compared with normal weight respondents (319/513, 62.2% vs 194/513, 37.8%, respectively). App features that overweight or obese users were most interested in were mainly the possibility to be monitored by a specialist and barcode identification of calorie content, whereas normal weight users mostly preferred availability of nutrition information of food items. Reasons for discontinuing use among overweight or obese respondents were mainly that monitoring by a specialist was not offered (80/236, 33.9%) and the app was not in the local language (48/236, 20.3%). Among normal weight users, the main reason for noncontinuance was the app language (45/144, 31.3%) and difficulty of use (30/144, 20.8%). Conclusions To better address the needs of both normal weight and overweight or obese adults, improved app designs that offer monitoring by a specialist are needed. Developers may consider ways of overcoming barriers to use, such as language, by developing local language apps, which can improve the efficacy of such apps and help spread their use.

Prospective cohort studies have shown inverse associations between fibre intake and CVD, possibly mediated by blood pressure (BP). However, little is known about the impact of types of fibre on BP. We examined cross-sectional associations with BP of total, insoluble and soluble fibre intakes. Data were used from the INTERnational study on MAcro/micronutrients and blood Pressure (INTERMAP) study, including 2195 men and women aged between 40 and 59 years from the USA. During four visits, eight BP, four 24 h dietary recalls and two 24 h urine samples were collected. Linear regression models adjusted for lifestyle and dietary confounders to estimate BP differences per 2 SD higher intakes of total and individual types of fibre were calculated. After multivariable adjustment, total fibre intake higher by 6·8 g/4184 kJ (6·8 g/1000 kcal) was associated with a 1·69 mmHg lower systolic blood pressure (SBP; 95 % CI −2·97, −0·41) and attenuated to −1·01 mmHg (95 % CI −2·35, 0·34) after adjustment for urinary K. Insoluble fibre intake higher by 4·6 g/4184 kJ (4·6 g/1000 kcal) was associated with a 1·81 mmHg lower SBP (95 % CI −3·65, 0·04), additionally adjusted for soluble fibre and urinary K excretion, whereas soluble fibre was not associated with BP. Raw fruit was the main source of total and insoluble fibre, followed by whole grains and vegetables. In conclusion, higher intakes of fibre, especially insoluble, may contribute to lower BP, independent of nutrients associated with higher intakes of fibre-rich foods.Key words: Dietary fibre: Insoluble fibre: Soluble fibre: Blood pressure High blood pressure (BP) is a major independent risk factor for CVD (1) . Meta-analyses of prospective cohort studies have shown that higher intake of total dietary fibre is associated with a lower risk of fatal and non-fatal coronary events (2,3) . Reported cross-sectional findings of total fibre intake and BP, however, were inconsistent: some showed inverse associations (4)(5)(6) , whereas others observed no association (7,8) . The limited available prospective cohort studies found inverse relations between total fibre intake and BP rise (9) , or risk of hypertension (4,5) . Methodological limitations of these studies include validity of dietary assessment methods (4)(5)(6)8) , absent or limited adjustment for dietary and other lifestyle confounders (6,8,10) , substitution of fibre supplements rather than dietary fibre sources (11,12) and inadequate frequency of BP measurement (6)(7)(8) . Meta-analyses of randomised controlled intervention studies showed that fibre supplementation (average dose, 11·5 g/d) did not significantly reduce BP (11,12) , but significant BP-lowering effects were found in hypertensive participants (12) . It has been suggested that the mechanism by which higher dietary fibre intakes may lower BP is attributed to enhanced insulin sensitivity that may improve endothelial function and other CVD risk factors (11) . The potential effect of insoluble fibre on BP has been less thoroughly investigated. Soluble fibre ma...

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Enteral nutrition (EN) is considered the first feeding route for critically ill patients. However, adverse effects such as gastrointestinal complications limit its optimal provision, leading to inadequate energy and protein intake. We compared the clinical outcomes of supplemental parenteral nutrition added to EN (SPN + EN) and EN alone in critically ill adults. Electronic databases restricted to full-text randomized controlled trials available in the English language and published from January 1990 to January 2019 were searched. The risk of bias was evaluated using the Jadad scale, and the meta-analysis was conducted using the MedCalc software. A total of five studies were eligible for inclusion in the systematic review and meta-analysis. Compared to EN alone, SPN + EN decreased the risk of nosocomial infections (relative risk (RR) = 0.733, p = 0.032) and intensive care unit (ICU) mortality (RR = 0.569, p = 0.030). No significant differences were observed between SPN + EN and EN in the length of hospital stay, hospital mortality, length of ICU stay, and duration of mechanical ventilation. In conclusion, when enteral feeding fails to fulfill the energy requirements in critically ill adult patients, SPN may be beneficial as it helps in decreasing nosocomial infections and ICU mortality, in addition to increasing energy and protein intakes with no negative effects on other clinical outcomes.

Background Effective management of the spread of a novel infectious disease, such as the COVID-19 virus can be achieved through influencing people’s behavior to adopt preventive measures. The public’s perceptions and attitudes towards the virus, governmental guidance and preventive measures were unknown in Saudi Arabia. Objectives 1) investigate the public perception of COVID-19, anxiety level, the COVID-19 information sources sought, adoption of preventive measures, and ability and willingness to self-isolate during and post-lockdown periods of the COVID-19 pandemic in Saudi Arabia; 2) investigate socio-demographic factors associated with adoption of preventive measures against COVID-19 and self-isolation practices. Method Between April 22nd and June 21st 2020, Saudi adults aged ≥18 years voluntarily completed a self-administered web-based cross-sectional survey, distributed through social media (WhatsApp) and emails to representatives in education, health, business, and social sectors across all Saudi Arabian regions. The survey included questions on anxiety level, COVID-19 risk perceptions and adoption of preventive measures. Weighted percentages, Pearson’s chi-square tests, and multiple logistic regression were applied to evaluate associations between these factors and socio-demographic variables. Results A total of 2393 respondents completed the survey. A majority (74%) were worried about the COVID-19 outbreak and of those, 27% reported that it was likely that they would be infected with COVID-19; 16% believed it would be life-threatening or severe. However, only 11% of respondents reported high anxiety level. Adoption of hygiene practices and social distancing were lower among older (> 65 years) compared to younger (18–24 years) respondents (OR: 0.06; 95% CI: 0.01, 0.28 and OR 0.06; 95% CI: 0.01, 0.27 respectively). High percentages of respondents reported being able to (88%) and were willing to (82%) self-isolate. Those with the lowest gross household income and those with at least one flu symptom were less able and willing to self-isolate. A significant increase in levels of anxiety, perceived effectiveness of social distancing and hygiene practices was reported in the post-lockdown compared to during the lockdown. Conclusions The study reported high levels of adoption of preventive measures, willingness and perceived ability to self-isolate during the early phase of the pandemic. Vulnerable groups such as the elderly, and those with low socio-economic status reported lower adoption of preventive measures or ability and willingness to self-isolate. Tailored public health messages and interventions are needed to achieve high adherence to these preventive measures in these groups.