Patients with major depression exhibit circadian disturbance of sleep and mood, and when they are discharged from inpatient wards, this disturbance poses a risk of relapse. We developed a circadian reinforcement therapy (CRT) intervention to facilitate the transition from the inpatient ward to the home for these patients. CRT focuses on increasing the zeitgeber strength for the circadian clock through social contact, physical activity, diet, daylight exposure, and sleep timing.In this study, we aimed to prevent the worsening of depression after discharge by using CRT, supported by an electronic self-monitoring system, to advance and stabilize sleep and improve mood. The primary outcome, which was assessed by a blinded rater, was the change in the Hamilton Depression Rating Scale scores from baseline to the end point.Participants were contacted while in the inpatient ward and randomized 1:1 to the CRT or the treatment-as-usual (TAU) group. For 4 weeks, participants in both groups electronically self-monitored their daily mood, physical activity, sleep, and medication using the Monsenso Daybuilder (MDB) system. The MDB allowed investigators and participants to simultaneously view a graphical display of registrations. An investigator phoned all participants weekly to coinspect data entry. In the CRT group, participants were additionally phoned between the scheduled calls if specific predefined trigger points for mood and sleep were observed during the daily inspection. Participants in the CRT group were provided with specialized CRT psychoeducation sessions immediately after inclusion, focusing on increasing the zeitgeber input to the circadian system; a PowerPoint presentation was presented; paper-based informative materials and leaflets were reviewed with the participants; and the CRT principles were used during all telephone consultations. In the TAU group, phone calls focused on data entry in the MDB system. When discharged, all patients were treated at a specialized affective disorders service.P=.04) than those in the TAU group. The self-monitored MDB data showed significantly improved evening mood (P=.02) and sleep quality (P=.04), earlier sleep onset (P=.009), and longer sleep duration (P=.005) in the CRT group than in the TAU group. The day-to-day variability of the daily and evening mood, sleep offset, sleep onset, and sleep quality were significantly lower in the CRT group  than in the TAU group. The user evaluation was positive for the CRT method and the MDB system.Overall, 103 participants were included. Participants in the CRT group had a significantly larger reduction in Hamilton Depression Scale score (We found significantly lower depression levels and improved sleep quality in the CRT group than in the TAU group. We also found significantly lower day-to-day variability in daily sleep, mood parameters, and activity parameters in the CRT group than in the TAU group. The delivery of the CRT intervention should be further refined and tested.ClinicalTrials.gov NCT02679768; https://clinicaltrials.gov/study/NCT02679768RR2-10.1186/s12888-019-2101-z Patients with major depression exhibit various circadian rhythmic abnormalities. These include day-to-day instability, drifting of the sleep-wake cycle -3, diurnFor patients with a major depressive episode, the transition from an inpatient psychiatric ward to an outpatient status poses a risk of relapse, readmission, suicide attempts, and suicide ,14,15. TP<.001), and this drift was associated with a significant worsening of mood (P=.03). Another evident result of that study was that both mood and sleep were very unstable on a day-to-day basis. The usability of Daybuilder was very high, with a System Usability Score (SUS) of 86.2 (SD 9.7).To deliver timely help, researchers have made attempts to monitor patients’ daily condition throughout this transition to catch signs of deterioration and provide immediate intervention. We previously tested an electronic system (Daybuilder ) using dA newer randomized controlled trial in patients with major depression used the Monsenso system, a smartphone-based electronic monitoring system . Using tIt is debatable whether electronic monitoring per se has a positive or negative impact on patients with affective disorders ,19. For Relevant literature showed that technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for anxiety and mood disorders , and theThis study aimed to combine a newly developed intervention, Circadian Reinforcement Therapy (CRT) , with daThe electronic system used in this study is a slightly updated version of the Daybuilder electronic system used in our previous study . The updThis study aimed to prevent the worsening of depression in patients with a major depressive episode after discharge from inpatient psychiatric wards . We hypoThis study was designed as a 4-week, randomized, controlled, single-blinded, parallel-group trial, with a balanced allocation rate (1:1) to either the CRT or the treatment-as-usual (TAU) group.The procedure of this study was described in a published study protocol . We deveParticipants who aged ≥18 years and had a diagnosis of a major depressive episode, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition , were elAll the patients who were referred from the psychiatric inpatient wards at the Mental Health Center Copenhagen for follow-up at the Intensive Affective Outpatient Service (IAOS) were consecutively asked to participate in the study. The IAOS exclusively receives patients with depression immediately after discharge from inpatient psychiatric wards . We aimeUsing a computer-generated random list without stratification, we randomized the patients to either the group using the CRT intervention as an add-on to the ongoing IAOS treatment or the group receiving only the IAOS treatment (TAU). Treatment at the IAOS included individual consultations with psychiatrists, supporting sessions with specially trained psychiatric nurses, group psychoeducation including some sleep hygiene advice (but no information on circadian-related components), physiotherapy, and pharmacological treatment.All participants in both the groups used the MDB self-monitoring system to assess daily mood, sleep, activity, and medication compliance ,30. In achrono diary  slides, where the principles of CRT were explained. The presentation was supplemented with paper-based informative material and leaflets. This specialized psychoeducation was intended to provide participants with knowledge on ways to strengthen time signals to their circadian system using temporally structured and higher levels of exposure to zeitgeber elements, such as daylight, exercise, regular meals, and social contact ,31-33. Cno diary  was usedOnce a week, an investigator phoned or met participants at the IAOS, and together, they examined the self-assessment data from the last week through the graphical display in the MDB system and discussed possible solutions using the elements in the CRT method. In addition, MDB data entries from participants in the CRT group were monitored by the investigators on all weekdays, and predetermined triggers elicited additional phone calls to participants. The trigger points were sudden mood drops, changes in sleep timing, reduced medication compliance, low data entry compliance, and negative text messages . CRT priCRT methods were used in all phone calls in the CRT group to help stabilize mood, sleep, and activity by recalling CRT elements that could strengthen zeitgeber signals. For example, an observed drift to late sleep onset would elicit advice on morning daylight exposure, morning exercise, avoiding late-night light exposure, late-night exercise, and late meals. Likewise, unstable sleep patterns would elicit advice on more regular sleep schedules and examine the underlying reasons for deviations .During the planned weekly phone calls, the investigator also evaluated and discussed (1) experience with the MDB system, (2) suicidal ideation, (3) side effects of medications, (4) worsening of depression and plan for action, and (5) compliance with data entry.Patients in the TAU group also received weekly telephone calls, and these talks only covered the items (1) to (5) that are mentioned in the previous paragraph for the CRT group. See the published study protocol for more details .17)  13.8%-18%) in the CRT group and 21.3% (CL 19.1%-23.4%) in the TAU group . This indicates a higher level of activity in the morning type (higher MEQ scores).The baseline values of the steps registered from the Fitbit bracelet were 5221 (SE 630) and 6514 (SE 715) steps in the CRT and TAU groups, respectively. We found no difference in the estimated mean end point number of daily reported steps between the 2 groups, with 9195 (SE 764) and 9151 (SE 737) steps in the CRT and TAU groups, respectively, but showed a significant increase in activity from baseline. In the model, the MEQ was significant (P<.001), no difference between groups for depression_morning scores with 1.42/1.49, significantly lower values for depression_evening scores with 1.45/1.94 (P<.001), significantly lower values for sleep onset with 0.85/1.24 (P<.001), significantly lower values for sleep offset with 1.03/1.45 (P<.001), significantly lower values for sleep quality scores with 1.69/2.15, and significantly lower values for the number of steps with 10,674,014/14,054,624 (P<.001).When comparing the day-to-day variability of MDB data between the CRT and the TAU groups, we found significantly lower values for depression_daily scores with 1.22/1.56 (P=.95). The items with the lowest scores were item 4 , with a mean score of 3.8 (SD 1.5), and item 7 (“I would imagine that most people would learn to use this system very quickly”), with a score of only 1.9 (SD 1.6).The mean SUS score was 62.8 (SD 15.2) and 63.3 (SD 16.6) in the CRT and TAU groups, respectively  of the participants in the CRT group, with a mean number of 1.8 (SD 1.1) calls in the 4-week period per participant. The rules for entries in the MDB that triggered a phone call and the percentage of participants eliciting a specific trigger by MDB entry are shown in P<.001). With regard to the CRT-specific questions, there was a high percentage of positive statements for all questions, with 92% (36/39) recommending the use of the MDB system.In total, 852 text messages were logged by the participants in the CRT group in the “sleep-wake cycle” text option in the MDB, corresponding to 70.18% (852/1214) of the days. The content of these comments included the CRT elements that the participants had used to strengthen zeitgebers and stabilize the sleep-wake cycle: “went for a walk in the sun,” “doing training,” “visiting friends,” and “keep regular eating hours.” These comments were discussed during the weekly phone calls. The daily compliance with medication was 99.8% (1369/1372) in the CRT group and 96% (1398/1456) in the TAU group. The results of the end point evaluation questions are shown in We found a significantly larger reduction in the end point Hamilton score, better evening mood, earlier sleep onset, longer sleep duration, better sleep quality, fewer naps, and lower day-to-day variation in sleep and mood in the CRT group than in the TAU group. Furthermore, a statistically significant interaction was found between TDV1 and the groups (CRT and TAU): the longer the TDV1, the lesser the difference between the Hamilton scores in the 2 groups. This supports the intention of this study to include participants as early as possible. Finally, the MEQ scores showed that the morning types had better sleep quality, earlier sleep onset, and sleep offset.The observed phase advance of sleep in the CRT group compared with the TAU group and the reduced day-to-day variation of sleep were treatment goals and expected through the known impact of zeitgebers on the circadian system, including the sleep-wake cycle. Fewer naps in the CRT group were expected because of psychoeducational advice to limit naps. The significantly earlier timing of naps in the TAU group could be caused by lower sleep quality and shorter sleep duration in this group, resulting in more daytime sleepiness and thus an earlier need for naps.MEQ associations with sleep timing and quality were also expected, whereas the influence of the morning type on activity is probably a new finding.Regarding day-to-day variability, our results are in line with our earlier results using sleep time stabilization and bright light, both of which also enhance zeitgeber strength .The intended early inclusion of patients was difficult, with only 56% (55/98) of patients included 8 days after discharge. This delayed inclusion was caused not only by the COVID-19–related restrictions, which made visits to the inpatient wards impossible or difficult but also by the earlier discharge dates than expected in many cases. Thus, in future studies in this field, the implementation of CRT should preferably use a research coordinator located permanently in the inpatient ward to include patients as early as possible and provide psychoeducation sessions before discharge. This might be done in a group session to optimize the use of resources and facilitate group dynamics in learning. If implemented, CRT could also be incorporated into standard psychoeducation in the ward and thus be provided before discharge.Another finding in the study was that the participants at discharge still had a significant level of depression, as well as cognitive dysfunction, probably making it difficult for them to acquire new information . This waThe presence of cognitive dysfunction makes it important to refine both psychoeducation and electronic monitoring systems. Compliance with the MDB system was acceptable but might still have caused some frustration.The structured questions in the end point evaluation showed that the patients felt that the CRT intervention was helpful; thus, the results from the study show that CRT could be used in the management of depression. However, a subset of patients also gave a negative statement regarding the management of the MDB system, and 4 patients dropped out because they felt that it was stressful or burdensome to participate in the CRT group.Overall, 45% (22/49) of the participants in the CRT group were phoned once or more between weekly scheduled calls due to trigger alerts in the MDB system. This shows that the trigger systems worked, and the evaluation questions regarding phone calls showed that participants appreciated this feature. This might have had a positive influence on the outcomes of the CRT groups and should be included when implementing the system.Refinement of CRT methods could include video presentations, podcasts, group sessions, peer involvement, and an electronic monitoring system designed as a smartphone app. CRT should be co-designed with users within the framework of a complex intervention ,50.Knowledge of how nonphotic zeitgebers influence the circadian system, sleep, and mood work and how they should be administered is still very rudimentary and should be incorporated into CRT refinement. For example, different types of exercise  and their timing and the nutritional components in diet and timing of diet will most likely have different impacts on the circadian system, sleep, and mood .One of the challenges in conducting randomized controlled trials in this patient group is obtaining sufficient, preferably daily, and precise data from the participants without fatiguing them too much. The development of wearable devices is a possible solution for collecting certain data types. We still await an easy-to-use and dependable method to measure sleep and circadian rhythms. The current candidates are ear electroencephalography that are currently being tested , 24-hour17 scores compared with those that were evaluated at the end point, indicating that the sample available for analyses was probably not biased because of these dropouts. We did not have any data on daylight exposure, which would have provided an indication of the signal to the circadian system in the 2 groups, and whether it differed. In future studies, an activity tracker with a light sensor can be used.The sample size was smaller than planned, resulting in less robust findings and limited generalizability. Participants could not be blinded to their allocation to the CRT and the TAU groups, which might have induced an unknown bias in the outcomes. Information on physical comorbidity and types and dosages of medications was not collected, and we cannot rule out an imbalance of these characteristics between groups that could have induced an unknown effect on some of the outcomes. The COVID-19–related restrictions caused difficulty in performing the procedures, and we believe that this might have impaired the implementation of the CRT method. The MDB system might have caused some inconvenience for some patients; nevertheless, their end point evaluation of the system was positive. The 15 patients who did not attend the end point assessment did not deviate substantially in their baseline HAM-DCRT delivered in combination with the MDB system showed a moderate add-on antidepressant effect, the magnitude of which was dependent on the time of inclusion after discharge. Furthermore, we found a sleep phase advancing effect, improvement in sleep quality and evening mood, and a significant reduction in day-to-day variability of mood and sleep. The structured questions from the end point evaluations supported these findings. However, the usability of the MDB system was low for 2 specific items and should be improved. There is thus room for improvement with better electronic systems, timely inclusion, and updated CRT content.


High levels of staphylococcal colonization, including predominantly coagulase-negative staphylococci and S. aureus in the nasopharyngeal sample, were present in both groups. The reduced number of Gram-negative rods colonized in the cases studied was seen in samples from the NPW group, particularly with Enterobacterales, and anaerobic Cutibacterium spp. were isolated only in the PW group (p < 0.05). Moreover, a higher carriage rate of Enterobacter aerogenes colonization was statistically significant (p < 0.05) and correlated with the NPW group. Pregnancy may disturb the composition of the NPM represented by commensals and opportunistic bacteria and promote yeast colonization as compared to nonpregnant women.The aim of the study was to compare the prevalence of the nasopharyngeal carriage of culturable microorganisms in the microbiota of asymptomatic women with a physiological pregnancy (PW) and nonpregnant women (NPW). Nasopharyngeal swabs were collected from 53 PW and 30 NPW to detect bacterial and fungal colonization. Isolates were identified using the culture method and the MALDI-TOF MS technique. The nasopharyngeal microbiota (NPM) partially differed between PW and NPW. These differences in the frequency of nasopharyngeal colonization between the PW and NPW groups were not statistically significant ( The human nasopharynx is an appropriate environment for the life of various types of microorganisms, mainly bacteria, that may inhabit its cavity as the microbiota. Pregnancy is a special state that induces a number of changes in the maternal body. It is associated with major changes in hormonal regulation, metabolism, immunodeficiency, and physiological status ,2,3,4,5.The opportunistic microorganisms with their dual features of commensalism and pathogenicity are the reason why these bacteria and fungi are defined as pathobionts . Their aEighty-three asymptomatic female participants were enrolled in this study between December 2017 and September 2019 to determine the effect of pregnancy on nasopharyngeal colonization, mainly with aerobically growing bacteria, and the prevalence of opportunistic pathogens. The participants were divided into two groups: 53 pregnant women (PW group) and 30 non-pregnant women (NPW group—control group). The PW group with a physiological course of pregnancy between the 5th and 40th week of gestation, whose average age was 29.68 ± 4.63 (with a range from 19 to 41 years), was diagnosed at the Department of Obstetrics and Perinatology, Medical University of Lublin, Poland. In the NPW group, the mean age was 31.47 ± 8.64 years (with a range from 22 to 45 years).After an accurate clinical data collection, the study inclusion and exclusion criteria were applied to the PW and NPW groups. The inclusion criteria in the PW group were: (a) singleton pregnancy, (b) absence of chronic disease, (c) absence of autoimmune disease, and (d) absence of infection. The exclusion criteria in the PW group were: (a) multiple pregnancy, (b) presence of chronic disease , (c) presence of autoimmune disease , (d) presence of inherited thrombophilia, (e) presence of pregnancy-associated disease , (f) presence of adverse pregnancy outcomes in the patient’s history , and (g) presence of any type of infection. Inclusion criteria in the NPW group were a good health without autoimmune and chronic diseases and the absence of infection. None of them were treated with anticoagulants and antimicrobials. All of the participants signed an informed consent to participate in the study and completed the questionnaire. The protocol was approved by the institutional review board . In order to protect the confidentiality of the cases, no information that could identify PW and NPW women was included in the case record form.A total of 83 nasopharyngeal samples were collected from both groups. Patients were advised not to eat, suck sweets, use any antimicrobials or other oral or nasal medications, or smoke cigarettes (e-cigarettes) for at least 2–3 h prior to the nasopharyngeal swab collection. Samples were collected using sterile cotton swabs with Amies medium . In the PW group, samples were collected at the Department of the Obstetrics and Perinatology, Medical University of Lublin within 2–4 h of the patient’s admission and then transferred to the Department of Pharmaceutical Microbiology, Medical University of Lublin. In the NPW group, the samples were collected at the Department of Pharmaceutical Microbiology, Medical University of Lublin by medical microbiology specialists.Haemophilus chocolate agar , Wilkins Chalgren agar supplemented with sheep blood , and Sabouraud dextrose agar  supplemented with chloramphenicol (for yeasts). After inoculation, the media were incubated at a temperature of 35 °C under aerobic conditions for up to 2–3 days for facultatively anaerobic bacteria and yeasts, under aerobic conditions with an elevated 5% CO2 concentration for microaerophilic bacteria, and for 4–6 days with the GENbag anaer atmosphere generator  for anaerobic bacteria. After incubation, morphologically distinct colonies growing on the agar media were selected and cultured on the agar media for bacteria and fungi. Isolates were classified according to phenotypic characteristics, including the growth morphology , biochemical properties and Gram staining. Subsequently, isolates were identified according to Bucka-Kolendo et al. [g, 5 min). The supernatant was removed, and the microbial pellet was suspended in 40 µL of 70% formic acid . After vortexing, 40 µL of acetonitrile  was added, and the sample was centrifuged . For identification, 1 µL of protein extract was applied to the MALDI target plate and overlaid with the same volume of α-cyano-4-hydroxycinnamic acid (HCCA) solution . The mass spectra obtained for each isolate were processed using the MALDI Biotyper 3.1 database, Build (66) .The components of the nasopharyngeal microbiota were first detected and identified using the culture method. A microbial examination of the samples was performed by inoculation onto agar media routinely used for the selective growth of microorganisms. Bacteria were cultured and isolated on appropriate nonselective media such as blood agar with 5% sheep blood for aerobic bacteria, o et al.  for bacto et al.  for yeast-test or ANOVA ) or their nonparametric counterparts  were used to analyze the quantitative variables presented in groups. The choice of tests and the normal distribution of continuous variables were assessed using the Shapiro–Wilk test. The calculations were carried out in the statistical environment of R version 3.6.0, PSPP, and MS Office 2019. The values of the parameters are presented as minimum, maximum, and median values. Statistical significance was set at p < 0.05. Statistical analyses were performed by the company E-Statystyka (statystyka@e-statystyka.com.pl) .A test sample with a group size of 53 (PW group) and 30 (NPW group) women, respectively, will reliably (with a probability greater than 0.9 for the test power) detect effect sizes d ≥ 0.747, using a two-sided detection criterion that allows a maximum Type I error rate of α = 0.05. Variables expressed at the ordinal or nominal level were analyzed using chi-square tests. When the conditions for using the chi-square test were not met, Fisher’s exact test was used. Parametric tests . From one to six different species (median of two species) were isolated from each sample in both the PW and NPW groups (p > 0.05) differentiate the carriage of microbes, including bacterial groups and phenotypes , in the nasopharynx of each case in the PW and NPW groups  or by bacteria and yeasts together (2 women). In the majority of cases, a uniform growth of bacterial colonies was observed, and sometimes, some bacteria appeared in predominant numbers. The differences in the frequency of colonization of the nasopharynx by different species of bacteria and fungi in the PW group compared to the NPW group were not statistically significant (W groups . As showW groups .p = 0.463). Notably, 48/53 (90.6%) vs. 27/30 (90.0%) cases in the PW and NPW groups, respectively, were colonized with different species of staphylococci. A number of cases colonized with Gram-negative bacteria belonging to the order Enterobacterales  was observed both in the PW group  and in the NPW group   and Corynebacterium pseudodiphtheriticum in both samples.Bacteria belonging to facultative anaerobes were mainly found in the nasopharyngeal samples of both PW and NPW groups . Gram-po, 20.0%) . Fungi bEnterobacteriaceae colonization in the nasopharyngeal cavity . The remaining variables, including exposure to tobacco smoke, were not statistically significant predictors of the occurrence of these bacteria.The woman’s age was an important predictor of the occurrence of Gram-negative rods l cavity . SupplemS. epidermidis and coagulase-positive (CoPS) S. aureus were the most abundant genera in the nasopharynx of the PW group  and the NPW group . The remaining CoNS Staphylococcus species were rarely isolated in both groups of patients.As shown in Enterobacter aerogenes (family Enterobacteriacae) colonization between the PW group  and the NPW group  was statistically significant (p = 0.019). No statistically significant relationship (p > 0.05) was observed between the pregnancy and the colonization of other bacterial and fungal species and their groups, genera, families, or orders.According to Staphylococcus species were isolated from each case in the PW group and from one to three of them in the NPW group  of the nasopharyngeal samples. One to five PW group .n = 83) whether factors such as age, health status, place of residence, and exposure to tobacco smoke (active or passive) could be important predictors and adequately explain the probability of occurrence of the nasopharyngeal colonization with specific groups of bacteria and yeasts in the entire study sample (p < 0.05) difference in colonization was observed with women positive for anaerobically grown Gram-positive bacilli of Cutibacterium spp. (formerly Propionibacterium spp.) or aerobically grown Gram-negative rods of the Enterobacteriaceae family in both groups (Cutibacterium spp. (R2 = 0.36) and Enterobacteriaceae (R2 = 0.17) colonization, respectively. The results for other groups of microorganisms were not statistically significant (p > 0.05).It was also investigated in a total number of cases (y sample . The stah groups . The prep > 0.05) of the occurrence of colonization by specific groups, families, genera or order, and species of bacteria and fungi.In the PW group, the gestational age and CRP level were not important predictors , other individual factors, such as age, may have a partial effect on the composition of the nasopharyngeal microbiota.Our research showed that the nasopharyngeal microbiota of healthy patients varied according to pregnancy, without reaching statistical significance. The highest microbial species richness was associated with the pregnant group, although no statistical significance was achieved. In some cases, including It has been documented that estrogen and progesterone during pregnancy can influence the gut and oral microbiota and create conditions for opportunistic infections ,21,22,31Staphylococcus, Streptococcus  and Corynebacterium, and Staphylococcus species, including coagulase-positive (CoPS) S. aureus and the diverse group of coagulase negative staphylococci (CoNS), were frequently isolated as the PW and NPW groups of nasopharyngeal colonizers. The heterogeneous group of coagulase-negative staphylococci have historically been classified as nonpathogenic bacteria and are less frequently involved in clinically manifest infections [S. epidermidis and S. haemolyticus as the most important species [S. epidermidis and other CoNS have become one of the most important causes of nosocomial infections in recent years [Streptococcus was found to be the most abundant, followed by Staphylococcus spp. [Streptococcus (GAS) infections are known to be a major cause of maternal and infant mortality worldwide. According to known data sources, GAS colonization of the genital tract and sepsis-related maternal or infant mortality or morbidity are major problems [Staphylococcus spp. is predominant in the nose and nasopharynx of 1.5-month-old infants [S. aureus are associated with increasing rates of antibiotic resistance and limited therapeutic options.The differences in the composition of the nasopharyngeal microbiota of pregnant women compared to nonpregnant women have been reported during our research. According to our results, the microbial composition in the nasopharynx during pregnancy was dominated by members of the genera fections ,35. Nowa species ,36,37,38 species ,40. S. ent years ,42. In tnt years , in whiccus spp. . In contproblems . It is a infants . MoreoveS. aureus has long been known to cause a wide range of infections, from mild to fatal [S. aureus during the third trimester of pregnancy or at the time of delivery were more likely to have infants carrying these bacteria. In addition, S. aureus colonization (including MRSA—methicillin resistant strains) was extremely common in this cohort of mother–infant pairs. Infants born to mothers with S. aureus were more likely to be colonized, and early postnatal acquisition appeared to be a very important and primary mechanism. In addition to this, strains of this pathogenic species often cause infections by releasing toxins, with some proteins as virulence factors, including coagulase [S. aureus.to fatal . Accordito fatal , mothersoagulase . Among tKocuria, which belongs to the family Micrococcaceae which also includes morphologically similar Staphylococcus and Micrococcus species [Kocuria rhizophila infection caused sepsis and acute pancreatitis in a six-year-old boy [K. rhizophila was described as a pathogenic factor only in the immunocompromised patients [Kocuria species show an increasing trend and include, e.g., urinary tract infections, catheter-associated bacteremia, keratitis, native valve endocarditis, peritonitis, descending necrotizing mediastinitis, brain abscess, and meningitis [Many studies have investigated the differences in various oral microorganisms in pregnant women as compared to nonpregnant women ,48,49. T species ,51. Thes-old boy  and a th-old boy . K. rhizpatients ,53. Currningitis .Cutibacterium spp. (formerly Propionibacterium) or aerobically grown Gram-negative rods of the Enterobacteriaceae family was statistically significant (p < 0.05). The Cutibacterium species are nonsporulating bacilli and belong to the skin coryneform commensal group, the most studied species being C. acnes and C. avidum [As was shown in our study, the difference in the colonization of the PW and NPW groups with anaerobically grown Gram-positive bacilli of . avidum . However. avidum ,57,58,59Enterobacteriaceae (including two Klebsiella species). In contrast, the presence of E. aerogenes was important and statistically significant (p < 0.05) only in the control group (NPW). Most authors refer to bacteria from the Enterobacteriaceae family, as they are mainly found in the gastrointestinal tract. Their presence as colonizers in our study may indicate potential risks for pregnant women. As shown by other authors, Gram-negative bacteria, mainly catalase-positive and oxidase-negative members of the Enterobacteriaceae family, are opportunistic pathogens responsible for the majority of nosocomial infections [Enterobacterales order with representative bacteria from the family Enterobacteriaceae , Erwiniaceae (Pantoea spp.), and Morganellaceae (Proteus spp.). Based on the results of the protein profiles, the presence of two Klebsiella species was detected, including K. variicola. This bacterium is known to cause severe bloodstream infections, to produce hypervirulent strains, and to exhibit multidrug resistance [Pseudomonadaceae (including P. aeruginosa) as one of the most abundant genera in the PW group, which is consistent with other findings [Rhodotorula yeasts were also identified only in the PW group, but this was not statistically significant. These yeasts were also found to co-occur with staphylococci. There are few publications available describing the contribution of Rhodotorula fungi to the upper respiratory tract microbiota. Recent mycobiome studies, for example, found a higher fungal diversity in caries-free children, with the most abundant taxa being Rhodotorula mucilaginosa [Based on our data, only in the PW group were the most common genera among the Gram-negative bacteria fections . The prefections , in our sistance . We founfindings ,63 and ifindings . In our laginosa . Reportslaginosa ,66 may sPantoea agglomerans was found in only two women in the PW group. These bacteria can colonize the human body mainly through wound infection with plant and food material [P. agglomerans etiology may be an exposure of patients to medical devices or fluids contaminated with this bacterium during their hospitalization. Furthermore, the reason for a clinical infection or nosocomial sepsis with a P. agglomerans etiology may be the exposure of often immunocompromised patients to medical equipment or fluids contaminated with this bacterium [Lactobacillus, Bifidobacterium, Streptococcus, and Escherichia coli has been found to change during pregnancy [In our study, material . One reaacterium . In addiregnancy ,68. Furtregnancy . The comThere were no statistically significant differences between opportunistic bacterial and yeast colonization according to exposure to tobacco smoke or the place of residence. We had a small group of women in both pregnant and nonpregnant groups who were active or passive smokers and nonsmokers. This problem should be investigated in the next study. Tobacco smoke contains toxic substances that accumulate at various sites and induce changes in human health and environmental conditions . AccordiPrevotellaceae family.To our knowledge, this is the first study on the nasopharyngeal microbiota of healthy and uninfected women during pregnancy compared to nonpregnant women in good health. A similar issue was addressed by Crovetto et al. . Their rp = 0.0006) and second (p < 0.0001) trimesters. Circulating high-sensitivity CRP (hs-CRP) is a widely accepted marker of chronic low-grade systemic inflammation [Many studies have shown that pregnancy induces changes and differences in the gut microbiota , especially in late pregnancy and rarely from the first to the third trimester ,69,70,71ammation , and it ammation , colorecammation , and comammation . Fink etammation  demonstrA number of limitations have made us unable to answer questions about the effect of pregnancy, its trimester, and some parameters that are often higher in pregnant women  on the composition and changes of the nasopharyngeal microbiota and the occurrence of various microorganisms in the nasopharynx during the course of a physiological pregnancy. The differences can be related to relatively a small number of pregnant and nonpregnant women groups, different populations, pets, place of residence, and different parameters which require several studies. Among these limitations, the relatively small specimen size did not allow us to draw proper conclusions from various subgroup comparisons; additionally, as there were no data on the upper respiratory tract microbiota during pregnancy, it was not possible to discern if differences were due only to the pregnancy itself. For this reason, future investigations are warranted to compare these and many more data and their effect on nasopharyngeal microbiota composition and differences among pregnant and nonpregnant women of the same age and health status.Staphylococcus aureus and coagulase-negative staphylococci, as well as Cutibacterium spp. and Enterobacterales colonization. The data may suggest that pregnancy can promote the differentiation of microorganisms in the nasal cavity and facilitate the colonization of opportunistic bacteria and yeasts, which requires confirmation with a larger study in a much larger group of patients, both pregnant and nonpregnant. Chronic diseases, including metabolic diseases , pharmacotherapy used, frequency of infections of various types, physical activity, contact with animals, place of residence, and a number of other endo- and exogenous factors, including stress, should be taken into account. Further studies are needed to clarify the relationship between risk factors , levels of selected diagnostic parameters  and the composition of the respiratory microbiota in pregnant women. In our opinion, the presence of specific groups of microorganisms in the respiratory microbiota has no direct clinical significance in healthy individuals. However, changes that occur, for example, during pregnancy or childbirth may be associated with the risk of opportunistic infections, including those associated with a change in the localization of microorganisms. One of the causes of many chronic and recurrent diseases and their associated risks is the disruption of the microbiota in different parts of the human body. Due to the paucity of literature on this subject, we do not know the full consequences of the presence of certain commensal microorganisms in the microbiota, the disturbances in the qualitative–quantitative composition, and the possible consequences for the mother and the newborn. The prevalence and characteristics of opportunistic pathogens can help in the prevention and treatment of infectious diseases. In our opinion, the idea and the methodological design show promising potential, and it is an important question because of the potential for diagnostic and therapeutic applications that could be derived. This is all the more reason why we believe that knowledge on this subject, especially in the case of pregnant women who undergo many changes, e.g., hormonal changes, is very important and is part of the new trends in health care and personalized medicine.This study demonstrated the differences in the composition of the nasopharyngeal microbiota in pregnant and nonpregnant women, with a particular emphasis on


Food neophobia is an aversion to eating or a reluctance to try unfamiliar or new foods. From an evolutionary perspective, this behaviour may minimise the risk of consuming foods that are harmful to health. However, such aversion causes food monotony, which may result in nutritional deficiencies. This study aimed to assess the prevalence of feeding problems among Polish children aged 2–7 years using the Montreal Children’s Hospital Feeding Scale and to investigate the correlation between age, gender, mode of feeding in infancy, including complementary feeding, and the prevalence of feeding difficulties in the study group of children. Material and method: The study group consisted of 585 children: 299 boys (51.11%) and 286 girls (48.89%). The study was conducted using a questionnaire-based method, with an indirect survey technique using a web-based form (CAWI). The research tool used was the Montreal Children’s Hospital-Pediatric Feeding Program. Results: Groups with the lowest risk feeding problems, risk 0, comprised 445 children (76.06%); group 1, middle difficulties, 59 children (10.08%); group 2, moderate difficulties, 40 children (6.84%); and group 3, most difficulties, 40 children (7.01%). The mean MCH-FS score for the entire study group was calculated and was 37.29 points ± 12.02; for 2 year olds, 35.69 points; for 3 year olds, 37.41 points; for 4 year olds, 38.31 points; for 5 year olds, 38.46 points; for 6 year olds, 37.95 points; and for 7 year olds, 36.06 points. The mean value of the MCH-FS scale for girls was 37.44 points, and for boys, 37.32 points. None of the above parameters correlated with the risk of feeding problems, including age, except with a non-significative tendency to be higher in the youngest age. Conclusion: Breast milk feeding and the time of complementary feeding (CF) in the study group did not influence the risk of feeding problems. Using the full BLW method during CF can protect the child against the occurrence of feeding problems such a food selectivity or picky eating in the future. In our study, children with difficulties during CF, mainly the vomiting reflex, were more likely to develop feeding problems such as food neophobia. Based on our study, we did not observe a correlation between age, gender, and the occurrence of feeding problems, and there was only a non-significant tendency to be higher in the youngest age. However, further research needs to be undertaken to assess how such behaviour affects subsequent feeding difficulties. Food neophobia is an aversion to eating or a reluctance to try unfamiliar or new foods ,2. From One theory of the prevalence of food neophobia is that in early human history, it was beneficial because it helped children avoid potential food hazards, including poisonous foods such as berries or spoiled meat. The ability to detect and avoid unfamiliar foods ensured that children only consumed safe, familiar foods they could trust. This innate preference for familiar foods was significant in the evolutionary pathway because it benefited the species’ survival ,4. However, the exact aetiology of food neophobia still needs to be determined, and its expression varies with age . During In addition to evolutionary factors, environmental factors may also influence food neophobia in children. Parents and caregivers may inadvertently reinforce a child’s reluctance to try new foods by offering only familiar foods or expressing negative attitudes towards unfamiliar foods. This can lead to a vicious circle in which children become increasingly reluctant to try new foods, which can further limit the variety of foods they eat ,11,12,13In addition, taste and texture preferences may play a role in food neophobia. Children may be more sensitive to bitter tastes or prefer sweet foods ,15,16, mBabies fed with modified milk tend to become accustomed to the constant and specific taste of milk formula, consequently showing less tolerance or even aversion to new foods and tastes ,20,21,22Food neophobia is a complex phenomenon influenced by many factors, including evolutionary and environmental factors, taste preferences, and cultural norms. Understanding these factors can help parents and carers encourage children to try new foods and develop a more varied and balanced diet. Most studies of food neophobia have examined the prevalence of neophobia in different age groups rather than each year. This has led to broad peak estimates, and whether food neophobia differs between children aged 2 to 7 years remains unclear. Therefore, this study aimed to assess the prevalence of feeding problems among Polish children aged 2–7 years using the Montreal Children’s Hospital Feeding Scale and to investigate the correlation between age, gender, mode of feeding in infancy, including complementary feeding, and the prevalence of feeding difficulties in the study group of children. The study was conducted using a questionnaire-based method, with an indirect survey technique using a web-based form (CAWI). The questionnaire was made available to mothers of children in randomly selected nurseries and kindergartens in Poland through closed groups on instant messaging systems designed for communication between parents and educational institutions and on parent association groups in individual cities and regions in Poland. All survey participants were informed about the purpose of the study, the voluntary nature of their participation, and the preservation of their anonymity, and were asked to accept the data-sharing rules. Adults (mothers of preschool and nursery-aged children) took part in the study. The study period covered the months of January to March 2023.In verifying the study group of parents, it was observed that only one father completed the survey questionnaire; mothers completed the other questionnaires. Therefore, only mothers qualified for the study of feeding children during the period of dietary expansion and feeding during the nursery and preschool period, as they are the ones who are most often at home with their children during the complementary feeding period or in contact with an educational institution such as a nursery/preschool and are responsible for feeding children during this period. The survey was conducted using the CAWI method, so the sample selection was utterly random (according to the adopted inclusion and exclusion criteria of the survey).Mothers taking part in the study gave their informed consent to participate, and the questionnaire was only made available when approval to participate in this study was obtained. The criteria for group selection included the fact that respondents were of legal age, had at least one child of nursery or preschool age, and had no formal knowledge of the behavioural determinants of nutrition . Inclusion criteria for the study proper were: being the mother/legal guardian of a child aged between 2 and 7 years, consent to participate in the study, and correct and complete completion of the questionnaire. The criteria for exclusion from the study were: lack of consent to participate in the study; incorrectly completed questionnaire, including non-response to questions; child’s age below 2 years and above 7 years; and the presence of a disease determining the method of feeding, e.g., food allergies and intolerances, autism spectrum disorders. After consideration of the inclusion and exclusion criteria, 585 pairs of mothers and their children were included in the final analysis.The study was conducted according to the Declaration of Helsinki and the Act on the Profession of Physicians and Dentists. A positive opinion of the Bioethics Committee operating at the Medical University of Silesia in Katowice was obtained to conduct the research “Dietary neophobia among infants and children” (BNW/NWN/0052/KB/34/23).The research tool was an anonymous survey questionnaire consisting of 5 parts. The first part concerned the parent/guardian and their child; it included data such as age and sex of the parent/guardian, place of residence, education of the parent/guardian, sex of the child, information on delivery, current weight and height, and food intolerances and allergies. Based on the child’s current age, weight, length/height using centile grids, and 3 SD BMI for girls and boys aged 0–3 years, the WHO standard body weight of children in terms of underweight, average weight, overweight, and obesity was assessed; for children aged 3–7 years, the developmental norms for girls/boys aged 3–18 years according to OLAF and OLAF studies ,28 were According to the Polish law issued by the Polish Ministry of Health, the child health booklet contains standardised information on the child, including the prenatal period; birth; health status after birth; patronage visits; preventive examinations, including dental examinations; history of infectious diseases, allergies, and anaphylactic reactions; radiological procedures; provision of medical devices; exemption from sports activities; and other information relevant to the assessment of the child’s normal development from birth, including measurements of weight, length/growth up to adult. All entries in the above document are made by medical staff, including a doctor, midwife, nurse, or other medical professional. This information is entered into the health booklet after providing the health service. If this is not possible, it is completed at the next visit based on the individual’s internal records .The next part of the questionnaire focused on the mode of feeding during infancy, taking into account breast milk feeding, exclusive breastfeeding, length of breastfeeding, and the timing and method of CF . In our study, we used the application of the baby-led weaning (BLW) method during complementary feeding. According to the definition of the BLW method, we considered that the child ate completely or mostly independently, so they ate using the BLW method; or the child was occasionally spoon-fed by an adult—approximately 10% feeding, 90% on their own, and also ate using the BLW method.The third part concerned the child’s current diet, including the use of cutlery, food preferences, taste senses, feeding behaviour, and occurrence of food selectivity. The questionnaire was developed based on current dietary recommendations for the group of the youngest children and the method of diet expansion developed by PTGHiŻD  based onThe last part of the questionnaire concerned the prevalence of feeding problems. The research tool used was The Montreal Children’s Hospital-Pediatric Feeding Program ,33. The The Montreal Children’s Hospital-Pediatric Feeding Program (MCH-FS) is related to feeding a child from 6 months (receiving a pureed diet) to 6 years of age. It includes questions such as: How would you rate your child’s meal pattern? How concerned are you about your child’s meal pattern? How do you assess your child’s appetite (feeling of hunger)? At what point during a meal does your child start refusing to eat? How long do your child’s meals last (in minutes)? How do you assess your child’s behaviour during mealtimes? Does your child choke, gag, spit, or vomit at certain foods? Does your child hold food in the mouth without swallowing? Do you have to walk behind your child or distract him/her  to get him/her to eat? Do you have to force your child to eat or drink? How do you assess your child’s chewing (or sucking) skills? How do you assess your child’s growth ? How does feeding your child affect your relationship with your child? How does feeding your child affect your family relationships? ,33. The MCH-FS consists of 14 items covering the following feeding characteristics: oral motility, sensory, and appetite. Other items address mothers’ concerns about feeding, mealtime behaviour, strategies mothers use, and the family’s reaction to the child’s feeding . A 7-poiThe programs used to analyse the collected data were Microsoft Office Word and Microsoft Office Excel. Statistical analysis was performed using Statistica v. 13.3 software . The measured data were characterised by mean and standard deviation (X ± SD), and the range of minimum and maximum values obtained in the study group of children was determined. Statistical tests were used to analyse the variables for statistical inference. The study group of children was divided into 4 subgroups based on the calculation of the MCH-FS scale score: group 0, no risk; group 1, moderate difficulties; group 2, moderate difficulties; and group 3, most difficulties. Bivariate tables were used to compare the group of children in the four groups: 0, no risk; 1, middle difficulties; 2, moderate difficulties; 3, most difficulties, for r non-parametric characteristics Pearson’s chi-squared test was used. p ≤ 0.05. The level of statistical significance adopted in the study was set at Characteristics of the Study Groupp = 0.988), place of residence (p = 0.755), weight (p = 0.755), and age (p = 0.764) was analysed. None of the above parameters correlated with the risk of feeding problems, including age, except for a non-significative tendency to be higher in the youngest age.The study group consisted of 585 children: 299 boys (51.11%) and 286 girls (48.89%). Most of the children in the study came from cities with more than 100,000 inhabitants, i.e., 212 children (36.24). In terms of body weight, 404 children (69.06%) were of average weight, 139 children (23.76%) were underweight, 31 children (5.30%) were overweight, and 11 (1.88%) were obese. The study included children aged between 2 and 7 years of age, including 130 two year olds (22.22%), 134 three year olds (22.91%), 91 four year olds (15.56%), 80 five year olds (13.68%), 82 six year olds (14.02%), and 68 seven year olds (11.62%) . ThroughHowever, it can be seen in the results that the prevalence of feeding problems is lowest in 2 year olds (84.61%), and the level then increases in children aged 7 years.The mean MCH-FS score for the entire study group was calculated and was 37.29 points ± 12.02; for 2 year olds, it was 35.69 points; for 3 year olds, 37.41 points; for 4 year olds, 38.31 points; for 5 year olds, 38.46 points; for 6 year olds, 37.95 points; and for 7 year olds, 36.06 points. The mean value of the MCH-FS scale for girls was 37.44 points, and for boys, 37.32 points. Age and gender differences were not statistically significant. p = 0.242), the length of exclusive breast milk feeding (p = 0.296), and the time of initiation of complementary feeding (p = 0.899) did not correlate with the risk of feeding problems.By definition, “exclusive breastfeeding” means not giving modified milk to the baby; the baby consumes only breast milk. Both the length of breast milk feeding (p = 0.010). The administration of puree with lumps did not correlate with the risk of feeding problems (p = 0.240). The study also included the baby-led weaning (BLW) method, which involves child-controlled feeding. It is based on the omission of the spoon-feeding stage by the parents/carers and the feeding of pulpy foods (purees). When the baby can sit up unaided (approx. 6–7 months of age), various solid foods are given in such a form that they can be easily grasped with the hand  [p = 0.026), in contrast to children fed traditionally with a spoon. The study also assessed the difficulties in introducing new foods into the child’s diet. Children who experienced difficulties during CF were more likely to be at risk of feeding problems (p < 0.001)  .p = 0.001). In contrast, spitting food out of the mouth (p = 0.085), gagging (p = 0.244), choking (p = 0.590), and choking and needing medical attention (p = 0.121) did not correlate with the risk of feeding problems. p < 0.001) and (p < 0.001).Among the children surveyed, the consumption of foods with specific tastes was assessed. In the surveyed group, most children consume products with different flavours (90.43%). A total of 4.44% of the children surveyed consume products with selected flavours .p < 0.001, V Cramer = 0.274), spitting food out of the mouth , playing with food , and burying cutlery in food  correlated positively with the occurrence of feeding problem risk. Choking did not correlate with feeding problems  (The study assessed current problems related to children’s eating patterns. Both the vomiting reflex ( 0.0810) . There is no precise formal definition of picky eating, although it is generally accepted that it includes the rejection or restriction of familiar and unfamiliar foods, and thus includes an element of neophobia; these factors are associated with feeding problems in children ,31. The A high prevalence of food neophobia and pickiness has been reported previously among children aged 3 to 7 years in a study by Hafsrad G. et al. . An exceIn diagnosing feeding difficulties, including pickiness and feeding neophobia, the Montreal Children’s Hospital Feeding Scale (MCH-FS) may be applicable ,37. The Feeding problem, selective eating, and food neophobia can lead to deficiencies in some essential nutrients, especially vitamins and minerals . ChildreThe results of the Di Nucci study showed a low intake of foods typical of the Mediterranean model, such as fruit, vegetables, and legumes, and conversely, a high intake of foods typical of the Western dietary model, such as sweets, sugary drinks, and red meat .Food neophobia tends to occur with highly recommended and health-promoting foods such as fruit, vegetables, and legumes, which taste bitter or sour. Lower intake also occurs in the group of animal products, such as fish . ChildreSome studies indicate that neophobic children are less likely to meet the recommended intake standards, especially the need for vitamin E . In addiNutritional neophobia is highly relevant to the concept of metabolic programming, especially in the nutritional aspect, which is understood as the long-term or lifelong effect of a stimulus or signal affecting the structures or functions of the organism during a critical period of development. It has been shown that the occurrence of factors such as malnutrition, or nutrient deficiency or excess, during so-called critical periods can reprogram the metabolism, leading to irreversible consequences. The first 1000 days of a child’s life is when the metabolism is programmed, and many of the physiological processes responsible for appetite control and energy regulation are fixed. During the first three years of a child’s life, there is less activity of enzymes produced in the liver, which is responsible for the metabolism of harmful compounds. The immature kidneys do not yet excrete toxins efficiently. The child’s diet should include, above all, products rich in vitamins A, D, C, and B. Micronutrients such as zinc, selenium, iron, and copper should also be present. Polyunsaturated fatty acids, including DHA, cod liver oil, probiotics, and prebiotics, are also essential to the diet ,47,48,49The origin of food neophobia can be traced back to evolution when a neophobic attitude protected children from eating potentially contaminated food . Humans,Although food neophobia is genetically determined, environmental factors that underlie individual differences in taste preferences can also influence its occurrence . GeneticFood preferences are highly variable, resulting in a reluctance to eat new foods, and those less accepted may be reduced in the child. This is influenced by several factors, including the diet during pregnancy and lactation  or the mp = 0.242), the length of exclusive breast milk feeding (p = 0.296), and the time of initiation of complementary feeding (p = 0.899) did not correlate with the risk of feeding problems. The Øverby study found no significant association between feeding problems and any breastfeeding nor a significant correlation between exclusive breastfeeding [In our study, the length of breast milk feeding (tfeeding . Maier’stfeeding .p = 0.026), unlike children fed traditionally with a spoon. It should be emphasised that we assessed the full use of the BLW method in the present analysis. The mixed BLW method (50% adult feeding and 50% self-feeding) already indicated a higher risk of feeding problems. Since our study was not aimed at verifying the BLW method as a superior method, we believe that the study should be extended in this respect to fully assess in which aspect the BLW method helps avoid the occurrence of feeding problems.There are not many studies linking the method of dietary expansion and the occurrence of feeding problems. In our study, we verified the use of the BLW method by assessing the estimated percentage of spoon-feeding during CF. The children we included in the group of children who were fully fed using the BLW method were labelled as entirely or mostly independent eaters, and children who were occasionally spoon-fed by an adult (approximately 10% adult feeding 90% independent) (full-BLW). Children using the complete BLW method in CF did not show a risk of feeding problems (p = 0.001), whereas spitting food out of the mouth (p = 0.085), gagging (p = 0.244), choking (p = 0.590), and choking and needing medical intervention (p = 0.121) did not directly affect the risk of developing feeding problems at a later stage of development.Other factors also influenced the course of feeding problems. In a study by An M. et al., the main factors were urging the child to eat with a firm refusal on the child’s part, unpleasant emotions during mealtimes , and high levels of neophobia in the mother . SimilarThe high prevalence of feeding problems between the ages of 2 and 6 years may also be because children tend to behave assertively and try to become independent from their parents. Therefore, refusing certain foods is a way of asserting their authority and presence. Another reason for this higher figure may be that older children are influenced by their peers and family, making them more likely to accept new foods ,56.The factors influencing food neophobia and feeding problems vary widely. On the one hand, it is a natural developmental stage; on the other hand, some factors may influence the perpetuation of inappropriate behaviour . TherefoBreast milk feeding and the time of CF in the study group did not influence the risk of feeding problems.Using the full BLW method during CF can protect the child against the occurrence of feeding problems, such a food selectivity or picky eating, in the future.In our study, children with difficulties during CF, mainly the vomiting reflex, were more likely to develop feeding problem such as food neophobia.In our study, we did not observe a correlation between age, gender, and the occurrence of feeding problems; there was only a non-significant tendency to be higher in the youngest age.However, further research needs to be undertaken to assess how such behaviour affects subsequent feeding difficulties.The following conclusions can be drawn from this study: The results of our study should be interpreted with its limitations in mind. The study should expect some risk of error due to the greater interest of study participants in their children’s diets.Our study was a retrospective study, which may influence the occurrence of the false memory effect, especially in the group of mothers of older children, particularly 4–7 year olds, regarding the details of CF and infancy.Additionally, the survey was conducted using the CAWI method, which is repeatedly criticised for lacking insight into the data collection process. However, it is worth noting that this type of data collection is widely accepted and convenient for collecting large amounts of information in groups that are often difficult to reach.The MCH-FS tool was not developed primarily for screening and diagnosing neophobia; however, using the questions in this questionnaire, we believe that many of the questions and answers provided can be a tool for initial screening of food neophobia.The advantage of the study is the size of the group; to date, most studies on food neophobia among children have been conducted on smaller groups of subjects. It is also worth mentioning that very few studies have been conducted on this topic, especially in Poland, and the above study is also currently being continued. In addition, to date, no cross-sectional study has examined the relationship between the use of the BLW method and difficulties during CF and the CF method, and the occurrence of food neophobia in the preschool age group.


Schizophrenia is a serious mental disease that brings not only serious burdens to patients and their families but also serious challenges to society. More research is needed to find better drugs to treat schizophrenia. This meta-analysis investigated the efficacy and safety of sodium nitroprusside in the treatment of schizophrenia.Randomized controlled trials comparing the efficacy and safety of sodium nitroprusside in the treatment of schizophrenia were searched via English and Chinese databases. The outcomes, including the Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS), were recorded. RevMan 5.3 was used for the meta-analysis.A total of six randomized controlled trials (174 patients) were included. The overall quality of the included studies was good. No statistically significant benefit of sodium nitroprusside over placebo was found when combined PANSS total and BPRS-18 . Except for PANSS positive , there was no significant difference in the scale score after sodium nitroprusside treatment compared with the control group in PANSS total , PANSS general , and PANSS negative . The results of the sensitivity analysis excluding the study with clinical heterogeneity showed that sodium nitroprusside had no statistical benefit for the score of PANSS positive . Moreover, there was also no significant difference in the BPRS-18 .We conservatively believe that sodium nitroprusside does not alleviate the symptoms of schizophrenia compared with placebo. The subjects tolerated sodium nitroprusside well. Our findings provide a new idea for researchers to explore and solve the drug treatment of schizophrenia. Schizophrenia is a serious mental disease with disorders in perception, thinking, emotion, and behavior that bring not only serious burdens to patients and their families but also serious challenges to society . The aveWhether it is a positive or negative symptom of schizophrenia, there are different evaluations of the efficacy of nondrug therapy, and drug therapy is still the main treatment . To dateSodium nitroprusside, a nitric oxide donor, is being investigated as a potential antipsychotic drug. The occurrence of schizophrenia is related to dysfunction of the N-methyl-D-aspartate receptor, and the expression level of nitric oxide is decreased , 9. In aJAMA Psychiatry  and Chinese databases  using the keywords “sodium nitroprusside” and “schizophrenia.” The specific search strategy was listed in our previously published protocol . The finCochrane Handbook for Systematic Reviews of Interventions. The outcomes, including the Positive and Negative Syndrome Scale (PANSS) and Brief Psychiatric Rating Scale (BPRS), were synthesized by RevMan 5.3 (Cochrane Collaboration). The test level was set at two-sided α = 0.05. Depending on the heterogeneity of the studies, we used either random- or fixed-effects models. Subgroup analysis and sensitivity analysis were performed.The same two investigators (XF and SW) independently extracted the data, and the third investigator (JL) participated in the discussion of conflicting data. The quality and risk of bias of the randomized controlled trials were evaluated according to the bias risk assessment tool of the n = 174)  , 14–17 wn = 174) . Figure The basic characteristics of the included studies are shown in 2 = 77%), so further subgroup analysis and sensitivity analysis were carried out.We combined the PANSS total and BPRS-18 scores in 6 trials, and we did not find that sodium nitroprusside had a statistically significant benefit over placebo  . HoweverExcept for PANSS positive , there was no significant difference in the scale score after sodium nitroprusside treatment compared with the control group in PANSS total , PANSS general , and PANSS negative  –D.The study of Hallak et al.  led to sThree trials involving 60 patients were included, with 30 patients in the nitroprusside group and 30 patients in the placebo group. The combined results showed that there was no significant difference in BPRS-18  . In the In terms of safety, no serious adverse events were reported except for muscle spasms, asymptomatic hypotension, and venipuncture pain in some subjects. Most of the adverse events were relieved spontaneously during the intervention. Only one patient withdrew from the trial because of hypotension, and this patient’s data were not included in the final statistics .Schizophrenia is an important public health problem, and finding drugs to treat its symptoms, especially negative symptoms, would be very beneficial to improve the quality of life of patients and reduce the burden on society. Schizophrenia is difficult to cure and requires long-term medication. The efficacy, safety, and tolerability of drugs are important factors in drug treatment. Sodium nitroprusside is a rapid, reliable, and easy-to-adjust antihypertensive drug that releases nitric oxide to directly relax arterioles and veins and is safe in clinical practice.Sodium nitroprusside can eliminate the behavioral effect of phencyclidine and theoretically prevent the progression of mental symptoms . A previMore importantly, some clinical studies have reported its efficacy in the treatment of schizophrenia, which is the main reason for our meta-analysis , 23. TheAt present, there are many scales for the evaluation of mental illness worldwide, but there are certain requirements for the selection of scales because of the complex symptoms of schizophrenia . The PANAlthough we obtained a negative result in our study, this is more common in single-center studies than in multicenter trials. In the process of drug development, the probability of positive results in small single-center trials is higher than that in large-scale trials conducted in multiple centers . SlightlThere are some limitations in our study. Some studies did not introduce random and distribution hiding methods, which may have the possibility of bias. In addition, the included studies were only indexed journal articles that had been published and could be retrieved, which may have resulted in publication bias.In summary, our findings provide a new idea for researchers to explore and solve the drug treatment of schizophrenia. We conservatively believe that sodium nitroprusside does not alleviate the symptoms of schizophrenia compared with placebo. Additionally, the subjects tolerated sodium nitroprusside well. Necessarily, we hope that follow-up studies can provide more and higher quality clinical evidence.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.XF: Data curation, Formal analysis, Methodology, Resources, Writing – original draft, Writing – review & editing. JL: Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. SW: Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. JW: Project administration, Resources, Writing – original draft, Writing – review & editing. CG: Writing – review & editing. RQ: Writing – review & editing. YG: Conceptualization, Project administration, Supervision, Writing – review & editing. YH: Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing.


In both developed and developing countries, non-alcoholic fatty liver disease (NAFLD) has lately risen to the top of the list of chronic liver illnesses. Although there is no permanent cure, early management, diagnosis, and treatment might lessen its effects. The purpose of conducting the current study is to compare the effects of beetroot juice and the Mediterranean diet on the lipid profile, level of liver enzymes, and liver sonography in patients with NAFLD.p < 0.05 is the statistical significance level.In this randomized controlled trial, 180 people with a mean age of (45.19 ± 14.94) years participated. Participants ranged in age from 19 to 73. The mean weight before intervention was (82.46 ± 5.97) kg, while the mean weight after intervention was roughly (77.88 ± 6.26) kg. The trial lasted for 12 weeks. The participants were split into four groups: control, a Mediterranean diet with beet juice (BJ + MeD), Mediterranean diet alone (MeD), and beetroot juice (BJ). The Mediterranean diet included fruits, vegetables, fish, poultry, and other lean meats (without skin), sources of omega-3 fatty acids, nuts, and legumes. Beetroot juice had 250 mg of beetroot. Data analysis was done using SPSS software (version 26.0). p = 0.001). Also, high-density lipoprotein (HDL) significantly increased in the BJ + MeD, BJ, and MeD groups (p = 0.001), while decreasing in the Control group (p = 0.001).Following the intervention, Serum Bilirubin, alkaline phosphatase (ALP), alanine transaminase (ALT), serum cholesterol (CHOL), triglyceride (TG), and low-density lipoprotein (LDL) levels were significantly decreased in the BJ + MeD, BJ, and MeD groups (The research findings indicate a significant reduction in hepatic steatosis among the groups receiving beetroot juice (BJ) and beetroot juice combined with the Mediterranean diet (BJ + MeD). This suggests that beetroot juice holds potential as an effective treatment for non-alcoholic fatty liver disease (NAFLD) in adults. Furthermore, the combination of beetroot juice with the Mediterranean diet showed enhanced efficacy in addressing NAFLD.Clinical trial registration:ClinicalTrials.gov, identifier NCT05909631. Non-alcoholic fatty liver disease (NAFLD) has recently become the most common chronic liver disease in both industrialized and developing countries . It is cRecently, there has been an increase in interest in the efficacy of specific dietary components in the management of NAFLD, such as beetroot supplementation and the Mediterranean diet (MeD). Beetroot, which is high in bioactive compounds such as betaine, nitrates, and antioxidants, is one such supplement that has received attention for its potential health benefits . And alsAccording to research, the Mediterranean diet is good for several health outcomes, including liver function. Studies show that the MIND diet may improve liver health and reduce the risk of NAFLD .Due to the continuous increase in the prevalence of NAFLD and its related risk factors in recent decades, the prevalence of unhealthy dietary patterns that follow them, we aimed to compare the effects of beetroot juice and the Mediterranean diet on lipid profile, level of liver enzymes and the liver sonography in patients with NAFLD.ClinicalTrials.gov: (NCT05909631). Informed consent had been obtained from all participants before the start of the study and was approved by Sulaimany Polytechnic University, Kalar Technical College ethics committee, and the consent process was documented in their medical records.This Randomized Control Trial was conducted in Kalar City, Kurdistan region, Iraq. The Ethics Committee of Sulaimani Polytechnic University, Kalar technical college approved the study. It was also registered in All methods were carried out by relevant guidelines and regulations. All methods were carried out by relevant guidelines and regulations. This study was conducted by the Declaration of Helsinki.Patients with NAFLD were identified and enrolled for this research at the PAR hospital in the Kurdistan Region of Iraq. Based on eligibility requirements, the participants were chosen by purposive sampling. Patients had to be between the ages of 19 and 73, and they had to have NAFLD as their main diagnosis. For a NAFLD diagnosis, ultrasound proof of fatty liver (stage I or above) and an elevated level of liver enzymes were required. An experienced radiologist did the ultrasonography. The grade of fatty liver was determined based on hepatic parenchymal brightness by ultrasound, and established methods were used to test the liver’s biochemical profile .n = 45) and three groups for the intervention group: n = 45 for beetroot juice plus Mediterranean diet (BJ + MeD), beetroot juice (BJ), and Mediterranean diet (MeD) via simple randomization. Then, the sequence of groups was drawn up by coin tossing.The following factors were used as exclusion criteria: a history of diseases like cardiovascular, liver, chronic hepatitis C, and kidney disease; supplement use within the previous 6 months; hormone therapy; use of drugs like amiodarone, methotrexate, and corticosteroids; cases of starvation or inadequate nutrition; pregnancy; metabolic disorders like Wilson disease and glycogen storage disease; a history of liver irradiation; and a refusal to continue the study protocol. We selected 180 participants for this study because they all met the requirements for inclusion. Finally, eligible participants were divided equally into four groups; a control group , respectively .in vitro digestion, yet found in the highest ratio in beetroot gel than other conformations including beetroot juice . Using the Modified Nutritionist IV Software, the calorie, macronutrient, micronutrient, and water intakes were calculated .To control adherence to the MeD, patients complete a 24 h recall (weekly consumption data). Patients were also followed up every week by telephone to be aware of possible side effects and to ensure the use of beetroot juice.250 mL of concentrated beetroot juice, 250 mL of a placebo (red carmoisine food color and a little quantity of a sweetener diluted in water), and beetroot juice were given to participants in the BJ groups and BJ + MeD groups . This was carried out in the morning, 30 min before breakfast, and on an empty stomach.FLI was first presented by Bedogni et al. in 2006 with thirteen variables , four of which remained as predictors in the equation , 23.According to the area under the receiver operator characteristic curve (AUROC), the FLI’s fatty liver detection accuracy was 0.83 (95% CI: 0.825 to 0.842). The FLI scores are between 0 and 100. Thus, with a high degree of diagnostic accuracy, FLI scores of 30 and 60 indicated the absence or presence of fatty liver, respectively .The BEACK Questionnaire was used to assess the degree of physical activity among the patients  at the sAfter fasting for 10–12 h, 10 mL of whole blood was drawn from each participant at the beginning and end of the study. After centrifuging the samples, the serum was extracted. The serum was kept at −80°C for upcoming experiments. The levels of All biochemical investigations including liver function tests , lipid profile tests (serum triglyceride (TG), cholesterol (Chol), cholesterol LDL and cholesterol HDL), and the grade of fatty liver were also assessed. Hence, COBASE C111 fully automated analyzer was used for analysis.The ultrasound examination was performed by two experienced radiologists with more than 15 years of experience in the field. The machines used for the scanning were the GE Logiq7 and Philips HD11, both equipped with a 2–5 MHz curved probe.The diagnosis of fatty liver was based on parenchymal brightness, liver-to-kidney contrast, bright vessel walls, gallbladder wall definition, and diaphragmatic definition .The fatty disease was graded and labeled as mild, moderate, or severe, or grades 0 to 3  based on the degree of parenchymal brightness.Grade 0 : the liver and renal cortex are of similar echogenicity (genicity .Grade 1 (mild): slight diffuse increase in the fine echoes of liver parenchyma with appreciable periportal and diaphragmatic echogenicity (genicity .Grade 2 (moderate): moderately diffuse increase in fine echoes of the liver parenchyma obscuring periportal echogenicity, but diaphragmatic echogenicity is still appreciable.Grade 3 (severe): marked increase in fine echoes of liver parenchyma with poor or no visualization of the intrahepatic vessel borders, diaphragm, and posterior portion of the right lobe of the liver.When the discrepancy between the grades of fatty liver developed between the two radiologists, the final decision was made by consensus.t-test and one-way analysis of variance (ANOVA) were applied to determine differences between continuous variables. Statistical significance was considered when p < 0.05 was used.SPSS software (version 26.0) was used to analyze the data, also data were presented as means and standard deviations for continuous variables and frequencies, and Categorical data were expressed as counts and percentages. The Kolmogorov–Smirnov test and histogram were applied to ensure the normal distribution of variables. Chi-square was used for the sociodemographic characteristics of the subjects and differences between qualitative. Paired n = 45). According to the following chart in A total of 180 participants of different ages were enrolled in the current study and were randomly assigned to one of the four groups . Further, a comparison of the intergroup revealed that at the end of the current study, the T.S.B. in groups BJ + MED (p < 0.001), and BJ (p < 0.001) in comparison with the beginning of the study, had decreased significantly. Furthermore, no significant differences in serum AST levels were found between the intervened groups and the control group at the end of the study, whereas the intergroup comparison for serum AST levels revealed that at the end of the current study, the amount of serum AST in the BJ (p.001) and MED (p < 0.001) groups was significantly lower than at the start of the study. In the case of ALT, there is a significant decrease in the concentration of ALT in the intervened groups as compared with that of the control group (p < 0.001). Further, a comparison of the intergroup data revealed that the concentration of serum ALT at the end of the study was significantly lower in the MED (p < 0.001) and BJ + MED (p < 0.001) groups. Finally, the results for serum ALP concentration showed that the concentration of serum ALP at the end of the study in the intervention groups was significantly lower in comparison with that of the control group. Besides, the intergroup comparison for serum ALP at the beginning and end of the study revealed a significant decrease in serum ALP concentration in the BJ + MED (p < 0.001) and BJ (p < 0.001) groups at the end of the current study.p < 0.001). Further, the intragroup comparison revealed that at the end of the current study, the concentrations of serum TG in the BJ + MED (p < 0.001), MED (p < 0.001), and BJ (p < 0.001) groups were significantly decreased in comparison with the beginning of sample collection. Further, serum cholesterol concentrations in the intervention groups were significantly reduced in comparison with those of the control group (p < 0.001). In addition, the intergroup comparison revealed that serum cholesterol concentrations in the BJ + MED (p < 0.001), MED (p < 0.001), and BJ (p < 0.001) groups had been significantly reduced at the end of the current study. Besides, the concentration of serum LDL in the intervention groups was significantly decreased at the end of the study as compared with that of the control group (p < 0.001), and the intragroup comparison revealed that the concentration of serum LDL in all four groups was significantly reduced at the end of the study (p < 0.001). Finally, there were significant differences in serum HDL concentration between the intervention groups and the control group at the end of the study. However, as shown in the intragroup comparison, we notice that the concentration of serum HDL in the BJ + MED (p < 0.001), MED (p < 0.001), and BJ (p < 0.001) groups was significantly increased in The assessment of the lipid profile at the end of the study was as follows: the results for serum TG concentration in the intervention groups were significantly reduced in comparison with that of the control group (p < 0.001) while no significant differences were reported in other variables: total cereal, fermented dairy, and fruits (p < 0.001) were reported within groups regarding total cereal, low-fat dairy, and MUFA/SFA in the control group, fermented dairy legumes, nuts, and seeds; low-fat dairy, red and processed meats, poultry, fish; and fruits in the BJ + Med, group; and red and processed meats, fish, and MUFA/SFA in the MeD group, while only MUFA/SFA was reported as a significant variable in the BJ group. According to daily energy intake, at the beginning of the study, the highest daily energy intake was for the BJ + Med group , and the lowest was the control group . At the end of the study, there was a change in the daily energy intake of all groups, with the greatest amount of change in the BJ + Med group.Structural and cross-sectional questionnaires were carried out for all groups regarding the baseline at the end of the intervention for Mediterranean diet components. Significant differences were reported between groups in variables within vegetables, legumes, nuts and seeds, low-fat dairy, red and processed meats, poultry and fish, and MUFA/SFA . Flavonoids, dietary nitrate, and Saponin are the three main components of beetroot . Saponin2; 95% CI − 2.38 to −0.09 kg/m2), weight   .p = 0.018)  concentrations. In the current study, serum TG levels were significantly affected. Furthermore, the intergroup comparison revealed that at the end of the study, serum TG concentrations in the BJ + MeD, MeD, and BJ groups were significantly lower than at the start of sample collection within daily feed intake. Besides, serum cholesterol concentrations in the intervention groups were significantly lower than in the control group. A cohort study by Baratta et al. revealed that adherence to MeD had a preventive effect on NAFLD  . Kaliora= 0.018) .A 2022 published review found that drinking beetroot juice for 4 weeks significantly reduced serum TG concentrations in healthy adults . In a coCombining beetroot juice and the Mediterranean diet may have even greater effects on lipid profiles. A 2020 study published in the Journal of Functional Foods found that combining beetroot juice and the Mediterranean diet for 12 weeks significantly reduced serum TG concentrations in overweight and obese adults . Sigh etHence, our finding showed that the bilirubin level in participants in the intervention groups was considerably lower than in the control groups. Additionally, the total bilirubin level in groups BJ + MeD and BJ had considerably decreased. Several studies have found that beetroot juice can improve liver enzyme levels in people with liver disease. For example, a 2017 study published in the World Journal of Gastroenterology found that drinking beetroot juice for 12 weeks significantly reduced levels of liver enzymes in people with non-alcoholic fatty liver disease .Moreover, there were no discernible differences in serum AST levels between the baseline and end of the intervention in the BJ + MeD group. However, an intragroup comparison of AST showed that the amounts of AST in the BJ and MeD groups had significantly decreased from the study’s start to the end. When compared to the control group, the percentage of ALT in the intervention groups significantly decreased.Beta vulgaris extract effect on the liver of diabetic rats and found that the level of ALT, AST, and ALP significantly reduced in the intervened group, as compared to the placebo or control group.Integration of BJ the key liver disease biomarkers, AST and ALP, was considerably reduced in the NAFLD patients’ treatment regimen compared to the standard of care. Because NAFLD patients have greater degrees of fibrosis and increased AST , a possiOn NAFLD, MeD, which primarily consists of higher intakes of fruits, vegetables, whole-grain cereals, plant-based proteins (legumes and nuts), micronutrients like potassium, calcium, and vitamin C, dietary fiber, omega-3 fatty acids, and monounsaturated fatty acids, as well as polyphenols and other antioxidant agents, has been linked to several beneficial outcomes . CurrentConsuming a healthy diet that contains sufficient amounts of vegetables and fruits (about 400 g/day) prevents the incidence of non-communicable diseases . BecauseThe main finding of the current study was a significant reduction in liver steatosis in BJ and BJ + MeD groups. It was also observed that this reduction in hepatic steatosis in the group members receiving Beetroot juice was increasingly more significant than that in the Mediterranean diet group. The results of this study were supported by Srivastava et al. (2019) . And theFinally, based on the comparison between the intervention groups in this study, it was concluded that beetroot juice (BJ group) is more effective than the Mediterranean diet (MeD group) in the treatment of NAFLD. By contrast, taking the Mediterranean diet (MeD group) and beetroot juice (BJ group) together (BJ + MeD group) is even more effective than taking either beetroot juice or the Mediterranean diet alone. The strength of the current study is that it is the first to estimate the effect of two intervened groups alone and together on the NAFLD. However, there are some limitations, such as the lack of complete adherence to a diet by some participants.Red beetroot stands out as one of the most nutritionally dense foods found in the plant kingdom, containing a wealth of essential nutrients such as vitamins, minerals, phenols, carotenoids, nitrate, ascorbic acids, and betalains. Notably, both beetroot juice and the Mediterranean diet have demonstrated promising advantages for liver well-being. Nevertheless, additional research is necessary to comprehensively grasp their impact on liver enzyme levels and liver sonography. Future studies must examine any potential adverse effects that may arise from the consumption of beetroot juice.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Kalar technical college ethic commite. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.HF designed the study and analyzed the data. HF, SR, SM, SA-J, and AA prepared the draft of the manuscript. All authors contributed to the article and approved the submitted version.This research was supported by Garmian Polytechnic University.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


One of the underlying mechanisms of aging is chronic inflammation, which has been closely associated with daily diet. Phenotypic age (PhenoAge) has been used as an index to track the aging process before diseases show clinical symptoms. The present study aimed to explore the association between the dietary inflammatory index (DII) and PhenoAge.In total, 9,275 adults aged 20 years old and over in the National Health and Nutrition Examination Survey were involved in this study. Dietary patterns were classified as pro-inflammatory or anti-inflammatory according to the DII. PhenoAge was regarded as a continuous variable, and linear regression was used to explore its association with dietary inflammation. Stratified analyses by sex, age, race, physical exercise, smoking status, drinking status, and body mass index were used to test the sensitivity of these associations.interaction<0.001). The strength of the association between a pro-inflammatory diet and PhenoAge was stronger as age increased.The median value of PhenoAge was 38.60 years and 39.76 years for the participants with anti-inflammatory and pro-inflammatory diets, respectively. A pro-inflammatory diet was positively associated with PhenoAge , compared with participants who had an anti-inflammatory diet. There was an interaction between dietary inflammation and age for PhenoAge (pA pro-inflammatory diet was associated with a higher PhenoAge, and the association was strongest in the elderly. We recommended reducing dietary inflammation to delay phenotypic aging, especially for the elderly. According to a 2019 report from the United Nations, 9% of people in the world are over 65 years of age, and by 2050 this number will rise to 16% ,4. NotewChronic inflammation is a significant risk factor for morbidity and mortality in the elderly and a common molecular pathway for most age-related diseases . It has However, no studies have explored the association between DII and PhenoAge, especially for different age groups. In this study, we aimed to explore the association between dietary inflammation and aging via DII and PhenoAge in adults based on the National Health and Nutrition Examination Survey (NHANES), and we attempted to quantify the effect of a pro-inflammatory diet on aging. Furthermore, our results might provide a reference for specifying measurements for aging prevention.The NHANES is an ongoing cross-sectional survey that enrolls randomly selected participants for a comprehensive health screening every 2 years to generate a nationally representative sample . A totalThe PhenoAge calculation was proposed by Liu et al.  as a marWhereWe used the revised version of the DII calculation developed by Shivappa et al. , and the2), overweight (25.0≤ BMI< 30.0 kg/m2), and obese (BMI ≥ 30.0 kg/m2) [Body mass index (BMI) groups were defined into 3 categories: underweight and healthy weight (BMI < 25.0 kg/m0 kg/m2) . The phy0 kg/m2)  and divi0 kg/m2) . The NHA0 kg/m2) . MoreoveThe mean and standard error (SE) were used to describe continuous variables, and the unweighted frequency and weighted percentage were used to describe categorical variables. Multivariate linear regression was used to evaluate the associations between dietary inflammation and PhenoAge with adjustments. Sensitivity analyses were conducted via stratified analyses, and p-values for interaction between dietary inflammation and each stratified variable were also tested. All statistical analyses were conducted using SPSS version 24.0  and R version 4.1.0 , and the packages “forestplot”  and “surThe institutional review board approved the protocols of the NHANES of the National Center for Health Statistics, Centers for Disease Control and Prevention. Written informed consent was obtained from each participant before participation in this study. The responsible committee of the Ethics Committee of the National Center for Health Statistics Research Ethics Review Board has approved the research protocol .We conducted univariate linear regression to test the relationships of variables with PhenoAge in adults, as shown in interaction< 0.001). The association between a pro-inflammatory diet and PhenoAge was stronger as age increased. Moreover, we did not observe statistically significant interactions of dietary inflammation with sex, race, physical exercise, smoking status, drinking status, or BMI group on PhenoAge.As shown in the forest plot in In this study, we investigated the association between dietary inflammation and PhenoAge, and we found that a pro-inflammatory diet was significantly associated with a higher PhenoAge. Additionally, an interaction was found between a pro-inflammatory diet and age, with the strongest association between a pro-inflammatory diet and PhenoAge found in the elderly.No previous cohort or cross-sectional study has examined the relationship between the DII and PhenoAge. Our study was the first to do so, to the best of our knowledge. PhenoAge has been proven to be more than a measure of disease or morbidity; instead, it may be a marker that tracks the effect of aging before diseases become clinically evident . MeanwhiAging is a ubiquitous and complex phenomenon, and epidemiological evidence has indicated that elevated inflammatory biomarkers, including CRP and interleukin (IL)-6 could reflect a mild inflammatory state associated with many aging phenotypes . “InflamDiet is an important and potentially easily modifiable risk factor for chronic disease . There hMoreover, dietary inflammation has been found to be positively associated with cognitive impairment, frailty, cardiometabolic risk, and other age-related diseases in previous studies ,15,39. IThere are some strengths and weaknesses of current research. As for the advantages, firstly, it was the first study focused on the DII and PhenoAge, which are combined indicators of dietary inflammation and aging, respectively. Secondly, our study could provide evidence to support preventing aging from a dietary perspective. Thirdly, our study was based on the NHANES, a nationally representative survey. As for the weaknesses, firstly, this was a cross-sectional study and might not enable robust causal inferences. Secondly, the study population was from the United States, and the conclusions may not be generalized to other populations. Thirdly, the 24-hour recall diet data may have been subject to recall bias. Furthermore, we need to expand the cohort study’s sample size to explore in-depth associations between dietary inflammation and PhenoAge and how dietary inflammation affects aging in the general population. Finally, the age of participants was slightly lower than the age of non-participants, which may have caused selection bias; thus, the PhenoAge may have been underestimated. However, we performed a sensitivity analysis to reanalyze the imputed data, and consistent findings were obtained.https://www.cdc.gov/nchs/nhanes/. Information from NHANES is made available through an extensive series of publications and articles in scientific and technical journals. For data users and researchers throughout the world, survey data are available on the Internet and on easy-to-use CD-ROMs.The data that support the findings of this study are openly available at