Adhering to the Mediterranean diet (MD) and physical activity (PA) public health guidelines have independently been linked to health benefits in adults. These behaviours form essential components of the traditional Mediterranean lifestyle. However, their combined effect on metabolic risk has not been systematically assessed. This systematic review with meta-analysis (PROSPERO; CRD42017073958) aimed to examine, for the first time, the combined effect of promoting the MD and PA compared with no treatment, treatment with MD or PA alone, or a different dietary and/or PA treatment, and estimate its magnitude on metabolic risk factors. Medline, Embase, CINAHL and Web of Science were systematically searched until March 2018 for English language controlled interventions reporting the combined effects of the MD and PA on one or multiple metabolic risk factors in adults. Two researchers independently conducted data extraction and risk of bias assessment using a rigorous methodology. Reporting followed PRISMA guidelines. Quality of reporting and risk of bias were assessed using the CONSORT guidelines and the Cochrane Collaboration’s tool, respectively. Data from 12 articles reporting 11 randomised controlled trials (n = 1684) were included in the qualitative synthesis; across them, risk of bias was considered low, unclear and high for 42%, 25% and 33% of domains, respectively. Between-study heterogeneity ranged from 44% (triglycerides) to 98% (insulin and high density lipoprotein cholesterol (HDL)-cholesterol). Compared to a control condition, there was strong evidence (p < 0.001) of a beneficial effect of promoting the MD and PA on body weight (−3.68 kg, 95% CI (confidence intervals) −5.48, −1.89), body mass index (−0.64 kg/m², 95% CI −1.10, −0.18), waist circumference (−1.62 cm, 95% CI −2.58, −0.66), systolic (−0.83 mmHg, 95% CI −1.57, −0.09) and diastolic blood pressure (−1.96 mmHg, 95% CI −2.57, −1.35), HOMA-IR index (−0.90, 95% CI −1.22, −0.58), blood glucose (−7.32 mg/dL, 95% CI −9.82, −4.82), triglycerides (−18.47 mg/dL, 95% CI −20.13, −16.80), total cholesterol (−6.30 mg/dL, 95% CI −9.59, −3.02) and HDL-cholesterol (+3.99 mg/dL, 95% CI 1.22, 6.77). There was no evidence of an effect on insulin concentrations. The data presented here provide systematically identified evidence that concurrently promoting the MD and PA is likely to provide an opportunity for metabolic risk reduction. However, due to the high degree of heterogeneity, most likely due to the variation in control group treatment, and the small number of included studies, findings from the pooled analysis should be interpreted with caution. These findings also highlight the need for high quality randomised controlled trials examining the combined effect of the MD and PA on metabolic risk.

Oral processing behaviours (OPBs) have been repeatedly associated with energy intake and appetite in younger adults; however, in older adults, these associations remain poorly understood. Older adults often experience ageing-related physiological decline, which can affect food oral manipulation and intake. This study investigated individual variations in OPBs and their association with energy intake and appetite in healthy older adults. Eighty-eight participants (44 males, mean age 73.7 SD 5.3 years) attended one visit after an overnight fast. A fixed-portion breakfast was provided and consumed in full, while consumption was video-recorded to quantify OPBs (chews, bites, swallows, chews per bite, bite size, eating rate, meal duration). Self-reported appetite was assessed using visual analogue scales (VAS). Meal energy intake was measured using an ad libitum lunch. A weighed food diary was used for the rest of the day to record food and drink intake. Generally, eating rate was negatively correlated with OPBs frequency and duration (p < 0.001). OPBs differed between genders and eating rate subgroups. From the postprandial self-reported appetite ratings, in faster compared to slower eaters, "prospective intake" was rated higher, indicating greater perceived appetite. Faster eating rate at the ad libitum meal was significantly and independently associated with greater energy intake (p < 0.001), when accounting for age, gender, BMI, lunch liking and pre-lunch appetite ratings. This study highlights the link between eating rate and energy intake in older adults and provides insights for future interventions, especially when energy intake needs to be increased in frail older adults.

Eating behaviours among older adults can be affected by age-associated oral physiological changes. This may influence nutritional intake, liking and acceptance of foods, increasing malnutrition risk. To better understand age-associated changes to textural perception, a systematic review was designed to evaluate the factors that affect the perception of food texture among older adults, and the impact this has on food liking and intake. Electronic searches were conducted in three databases (Pubmed, WebofScience, Scopus), yielding 12,216 articles. The 2020 PRISMA guidelines were used to screen all articles; these were assessed in three stages, by title, abstract and full text. Subsequently, PECO (population, exposure, comparison, outcome) guidelines were applied to assess study eligibility. 13 articles were included in the final review, all of which were of sufficient quality. A wide range of methodologies and outcomes were identified, leading to the discussion of findings in three categories; (i) oral manipulation and processing of food types within the oral cavity, (ii) age-associated changes to the physical properties of this cavity, and (iii) psychological factors that influence food choice and acceptance. A combination of these factors facilitate textural manipulation and perception in older adults, which were shown to significantly drive product acceptance and intake. Whereas several perceptual and physiological changes that occur with aging are unavoidable, recognising the heterogenous nature of older adults will lead to a better understanding of the oral capabilities and sensory-specific needs of this population, and could be used to improve food acceptance, nutritional intake and reduce the risk of malnutrition.

SARS-CoV-2 infection (COVID-19) is associated with malnutrition risk in hospitalised individuals. COVID-19 and malnutrition studies in large European cohorts are limited, and post-discharge dietary characteristics are understudied. This study aimed to assess the rates of and risk factors for ≥10% weight loss in inpatients with COVID-19, and the need for post-discharge dietetic support and the General Practitioner (GP) prescription of oral nutritional supplements, during the first COVID-19 wave in a large teaching hospital in the UK. Hospitalised adult patients admitted between March and June 2020 with a confirmed COVID-19 diagnosis were included in this retrospective cohort study. Demographic, anthropometric, clinical, biochemical, and nutritional parameters associated with ≥10% weight loss and post-discharge characteristics were described. Logistic regression models were used to identify risk factors for ≥10% weight loss and post-discharge requirements for ongoing dietetic input and oral nutritional supplement prescription. From the total 288 patients analysed (40% females, 72 years median age), 19% lost ≥ 10% of their admission weight. The length of hospital stay was a significant risk factor for ≥10% weight loss in multivariable analysis (OR 1.22; 95% CI 1.08–1.38; p = 0.001). In addition, ≥10% weight loss was positively associated with higher admission weight and malnutrition screening scores, dysphagia, ICU admission, and artificial nutrition needs. The need for more than one dietetic input after discharge was associated with older age and ≥10% weight loss during admission. A large proportion of patients admitted to the hospital with COVID-19 experienced significant weight loss during admission. Longer hospital stay is a risk factor for ≥10% weight loss, independent of disease severity, reinforcing the importance of repeated malnutrition screening and timely referral to dietetics.

Older adults often experience deterioration in oral health and oral-related abilities, with tooth loss, impaired masticatory performance, alterations to salivary flow and composition all being common. Additionally, other ageing-related physiological changes happen, including delayed gastric emptying and higher postprandial glycemic responses. The interaction between oral-related factors and metabolic responses has been researched in younger adults, but not in older age groups. This study aimed to explore oral performance measures (OPMs) and oral processing behaviours (OPBs) and their associations with gastric emptying (GE) and postprandial glucose and insulin responses in adults aged ≥65 years. Participants attended one visit after an overnight fast and were provided with a fixed-portion breakfast, which they were asked to consume in full. Eating behaviours were coded to quantify OPBs (including chewing and eating rate). OPMs (salivary flow rate, salivary alpha-amylase, bolus saliva uptake and masticatory performance) and questionnaire data were collected. Over three postprandial hours, GE was measured using labelled breath samples, and glucose and insulin responses were measured in capillary blood samples. Increased bolus salivary uptake was associated with greater masticatory performance, greater stimulated salivary flow rate and a slower eating rate. Greater masticatory performance was related to faster GE times. Faster eating rates and reduced chewing were associated with lower early postprandial glucose responses (up to peak glucose (45 min)); however, they were not associated with postprandial insulin responses or GE. This research highlights the significant, complex associations between oral performance, oral processing behaviours and postprandial metabolism in older adults.