The open birth interval is the time since a woman's last birth. It reflects not only desire for contraception and child health services but also freedom for outside activities, employment, and personal autonomy. It merits attention from policy makers, program managers, and service providers. The open birth interval is the time since a woman's last birth. It reflects not only desire for contraception and child health services but also freedom for outside activities, employment, and personal autonomy. It merits attention from policy makers, program managers, and service providers. Every woman who has ever given birth has a most recent birth, and she now stands at some point removed from it, in an “open interval.” Some women go on to another pregnancy and birth, but some never do, remaining permanently in the open interval. This interval is entirely different from the well-known “closed interval,” which pertains only to the time between 2 births in the past. The open interval can be determined from a simple question: “How long has it been since your last birth?” Recent national surveys can provide a current snapshot, and changes through time can be detected by reference to earlier surveys.Currently, how are women distributed by the age of their youngest child?How does this distribution vary over time, by region, and by fertility levels?How does the open interval distribution relate to personal characteristics  and to reproductive health variables ?How do these variables change within the first year after birth and in each ensuing year for the age of the youngest child?Has the declining percentage of women having children been offset by the overall increasing number of women, leading to a higher absolute number of women needing pregnancy and child care services?What are the likely policy and program applications of information on numbers and trends in the age of the youngest child?What are the implications of the age of the youngest child for women's roles, their freedom to pursue activities other than those related to pregnancy and child care, their participation in the labor force, and their empowerment?We undertook research on the open interval, with the expectation that it holds promise for a deeper understanding of reproductive behavior, women's status, and demographic processes. This study was exploratory in nature, rather than an investigation of a specific hypothesis. It required assembling the first general body of empirical information on interval lengths, and it included the following research questions:In this commentary, we discuss our findings for these questions and show how the open interval distribution, based upon a single question in national surveys, can usefully augment other information for analytic and management purposes.,Literature on the open interval is primarily composed of highly technical modeling work, starting in the mid-1960s, with publications by Sheps et al. in 1967Very little empirical information has been available on actual open intervals until now.However, for 4 countries—Ethiopia, Kenya, Tanzania, and Zimbabwe—a notable analysis of past survey trends incorporates both closed and open intervals, using technical methods to combine data to estimate both time trends and determinants.An early Taiwan survey in the 1960s that included the open interval showed that it explained socioeconomic variations in fertility levels at ages 30–39 better than past closed intervals. That survey further showed that contraceptive practice had helped extend the intervals.One experimental study included the open interval as a predictor of contraceptive adoption.One section below concerns the first year after birth, termed the “extended postpartum period, defined as the first year after birth.” There is an extensive literature on women's needs and behavior in that year, but here we refer to only selected sources, as explained in that section, for postpartum programs offered at or soon after women give birth.This study uses 232 Demographic and Health Surveys (DHS) conducted from 1985 onward in 74 countries, of which 56 have multiple surveys. The focus throughout is on the time since the woman's last birth, for currently married/in union women of reproductive age (15–44 or 15–49 depending on the survey). The analyses below pertain only to married women who have had at least 1 birth, although for brevity we refer simply to women. The inclusion of unmarried women would have complicated this first examination of open intervals across many countries. Countries are weighted equally in all averages presented below.The focus throughout is on currently married/in union women of reproductive age and the time since the women's last birth.The key DHS variable in our study is the time elapsed since the most recent birth, and we use this period as an approximation for the age of the woman's youngest child. In doing so, we neglect errors due to nonreporting of a most recent birth when the child died, in which case the youngest child is from an earlier birth. For example, if the latest birth was 10 years ago but the child died, the woman may be reporting a birth that occurred 12 years ago.Pregnant women are usually included with the women closest to birth . Pregnant women represent 9% of all married women, on average, or 31% of those within the first-year category. The actual measurement of the open interval is subject to errors, as with misdating of births and with births omitted due to infant deaths; also, the data on current pregnancies omit early, unrecognized conceptions. We assume here that the error components are minor for our purposes, are constant for trend estimates, or both. Unmet need, referring basically to women not using any method but who are still fecund and wish to avoid pregnancy, has been defined technically with variations, but as used in this article, it follows the standard DHS definition. The various alternatives that have been suggestedStata 15 and R software were used to access the individual survey files and tabulate the data. The analytic methods included tabulations across countries and over time, with selected summary measures and regression techniques.We use 2 figures to illustrate first, the character of the open interval distribution, and second, to show how the distribution differs by country and over time. These figures use 1- or 5-year intervals up to 15 years .In Further, such demands can change over time, as illustrated by the trends in Bangladesh . The perChanges in open birth intervals have clear implications for planning with regard to supplies, types of clinic loads, personnel decisions, and budgets.On average over all 74 countries, a remarkable one-fourth of women are pregnant or in the first year after birth and another fourth are clustered in their second or third year. The other half are spread thinly, at declining percentages, over the ensuing years, albeit with a peak of 8% in the final interval, which represents women whose youngest child is aged 15 or older .Supplement 1 documents the variation around the average figures, by country and by region. Among regions, the proportion of women who are pregnant or have an infant is as low as 10% in Europe/West Asia and as high as 36% in West/Central sub-Saharan Africa. Among countries, the proportion is 15% or less in India, Bangladesh, Vietnam, Indonesia, and Nepal, as well as in Kazakhstan and Turkey, and in most countries listed in Europe/West Asia. The highest percentages are in the 2 sub-Saharan regions, exceeding 40% in Chad, the Democratic Republic of the Congo, and Niger. The range represented by the various countries—from 10% to over 40%—implies a great deal about the variation in the daily activities and personal options for the women involved, given how much women's lives can change when they no longer have the care of very young children.The greatest regional contrast is between sub-Saharan Africa (38 countries) and other regions (36 countries), as depicted in As contraceptive use has increased over the years, more women are going longer without a next birth. In our data set, 56 countries had multiple surveys, and a comparison of the earliest and latest survey in each country (average 17.3-year gap) shows a drop from 32.7% to 26.5% of women in the first interval (pregnant or in the first year after birth) and an increase from 26.1% to 31.3% in the final interval of over 5 years (data not shown). The intermediate intervals are consistent with that transition, with an initial decline and a subsequent increase. These changes modify the circumstances of many women as they are freed from the care of children in their early years of life. An additional view of the lengthening intervals over time in these countries is provided in the section labeled “A Simple Model Captures the Open Interval Distribution.”Rapid changes occur in women's lives as their youngest child ages. Rapid changes occur in women's lives as their youngest child ages.After pregnancy, women reporting amenorrhea are prominent in the first year, but that proportion declines rapidly. Afterward, contraceptive use increases, and it remains important in all intervals (women who are both amenorrheic and using a method are counted as users). Women are also divided into those who have an unmet need (and again by whether they intend to use contraception in the future or not) and those without unmet need (and whether they intend to use contraception in the future).Total unmet need (sum of the first 2 bars below contraception for both those intending to use and not intending to use) grows substantially across the intervals. Total intention to use (first and third bars below contraception) is less than total unmet need, but it remains at a near constant level after the first year until shrinking in the final interval. Notably, the largest of the 4 subgroups pertains to women classified with unmet need who say they do not intend to use a method, which underscores the importance of watching trends for intention to use regardless of unmet need.Infecundity in We do not show the systematic shift across the intervals from unmet need for spacing to unmet need for limiting. As noted in the Methods section, alternative definitions of unmet need have been proposed, but we are constrained by the available data to using the standard DHS definition. In the early intervals after birth, the need for spacing births dominates, but the 2 needs are about equal by the third year. Afterward, the need for limiting takes precedence. In the final interval, unmet need for spacing is nearly zero. This finding carries administrative implications for commodity requirements and budgetary adjustments.Next, Supplement 2 provides for each region a set of changes across the intervals for pregnancy, contraceptive use, unmet need crossed by intention to use, and infecundity.proportion of women in each interval were using contraception, intending to use, or having an unmet need. Now we ask a different question: how are all contraceptive users distributed across the intervals; how are those women with an intention to use distributed; and how are women with an unmet need distributed  or wanted the current pregnancy/last birth to occur at a later time (unmet need for spacing). Otherwise, they are regarded as having no unmet need.We found that of all women with unmet need, 14.5% were currently pregnant. Another 23% fell within the first year after birth and 19.9% in the second year. These 3 groups accounted for 57.4% of all unmet need. This percentage creates a division of roughly half the unmet need being in the very early intervals for mothers with a child below age 2 and the other half among those with older children.The need for spacing as opposed to limiting shifts systematically with longer intervals after birth. For currently pregnant women, the ratio is 19.7% for those wanting to space births against 9.2% who want to limit births. That ratio reverses sharply to 6.1% vs. 29.0% in the final interval. These shifts and differences among married women contain significant information for the mix of needed services.The need for spacing as opposed to limiting shifts systematically with longer intervals after birth.A woman's own declared intention to use or not to use a contraceptive method has advantages over the unmet need estimate, which is a statistical construct based on several variables. The 2 measures overlap only partly; some women classified with unmet need do not intend to use, and some women who intend to use do not have unmet need.Over half of those who intend to use a method are in the early intervals, being either pregnant or in the first year after birth. Among those already using a method, 13.9% are in the first year, nearly 47% are within the first 3 years, and a third are in the final interval, a fairly wide spread. The distribution for those not intending to use, with half in the final interval, reflects a mix: some are not interested, some lack access to services, some are already menopausal/infecund, and some have other reasons.Examining the contraceptive method mix in more detail is always useful because it changes in important ways as the youngest child ages. As Thus, women tend to adjust their choice of methods as they and their youngest child age. Although the specific pattern may vary across regions and by personal characteristics, trend information on the open interval can provide useful information for each country regarding changing method preferences. Finally, the pattern pertains to current users, not annual adoptions. The percentage using sterilization reflects an accumulation of past adoptions; that is true to a lesser extent for the IUD and implant. On the other hand, current use of all spacing methods reflects adoptions in the recent past.Supplement 3). By age, the older women are, the longer the time that has elapsed since the latest birth. Women aged 15–19 cluster as either pregnant or in the first year, while women aged 45–49 are nearly absent in all intervals except the last one. By number of living children, the pattern mirrors that for age. The shift in the interval since the last birth is perfectly regular: more recent for women with 1 child to more distant for those with 4 or more. By residence, the differences are not large, but they run in the expected direction: rural women with their higher fertility rates fall within the more recent intervals, with more recent births. Finally, by wealth quintiles, the contrasts are entirely regular: the poorer the women, the more likely they are pregnant or have an infant in arms. Among the wealthiest women, the youngest child is older than in any other group. It should be noted that the measure of wealth is defined by the household in which the woman lives.Systematic changes occur across the open intervals according to personal characteristics because they correlate broadly with reproductive health needs . Total contraceptive use rose from 40% in 1986 to 70% and higher after 2000, while the total fertility rate fell from 4.1 to about 2.5 in the same years.These cases show that managers must track numbers, not just percentages, as they change through time. Numbers may grow within all intervals, but not proportionately. Instead, as fertility and pregnancy rates decline they may grow much less in the early intervals.The open interval offers its own advantages compared with the familiar ones of the total fertility rate (TFR), the general fertility rate (GFR), and the age-specific fertility rates (ASFR). These rates commonly pertain to births over the previous 3 to 5 years, as in the DHS reports, but the open interval as a survey snapshot can reflect the current state due to both recent births and the behavior over many past years that produced the older children.Further, changes in the open interval and in the other rates behave somewhat differently as annual births occur. More births elevate the GFR and TFR, but they affect the open interval distribution mainly only at the start, where the births are located. A burst in the fertility rate tends to increase women in the first interval, but other parts of the distribution can change if births start coming more than usually from women located in the later intervals. In addition, if more women than usual in the final interval age out, that can modify the distribution. In general, however, the shape of the distribution is relatively stable.Closed intervals, as valuable as they are, omit much reproductive behavior. Many women are actively avoiding pregnancy and birth and will never have another. Most women who have gone 5 years without a birth tend not to have another; 84% of closed intervals are less than 5 years long .A very close correlation exists between the open interval and the usual fertility rates. For the 74 countries in the current study, the correlations are 0.93 to 0.97 between the GFR or TFR and such open interval measures as the percentage of women who are within the first year after birth, or equally, the percentages within 2 years, or 3, 4, or 5 years after birth . Those cGiven this close association between the open interval and the TFR or GFR, the single question on when the last birth occurred provides an added picture of fertility behavior, one that has its own advantages and is free of the multiple questions needed to calculate the TFR and GFR.The single question on when the last birth occurred can provide an added picture of fertility.Finally, the average level of the TFR is clearly associated with the open interval. Countries averaging a TFR below 3 have well over half (56%) of married women with the youngest child over age 5. At the other extreme, countries averaging TFRs over 5 have only a fifth (20%) in that bracket. In between the parallels are exact .a and b in a power equation, are discussed in Supplement 4 and the values of the parameters are provided for all surveys in the 74 countries. Supplement 4 also shows how the shape of the open interval distribution can change over time; illustrated by Rwanda, which has had a strong anti-natalist national policy with vigorous implementation. On average, between 1992 and 2005, 44% of married women were either pregnant or in the first year after birth; that fell to a remarkable 30% in the 2010 and 2014 surveys.The shape of the open interval distribution is remarkably similar across countries. Because the pattern is nearly universal, a model with just 2 parameters captures the level and the sharpness of the decline in numbers of women as the intervals since the last birth become longer. These 2 parameters, labeled Upon release from child care, women have more options for activities outside of the home. They can explore or widen roles other than pregnancy—different ones from the homebound duties tied to motherhood. Some of the new options are economic in nature, and one way to examine these changes is by the degree of women's participation in the labor force. We used data from the International Labor Organization on women's participation in the labor force to compare the rate of their participation to the proportion of women whose youngest child is over age 5. The results are based on a fixed effects analysis, which controls for spurious cross-country correlations. For example, compared with other regions, Asian countries tend to have both longer intervals since the last birth, suggesting greater female freedom, and lower rates of labor force participation, running counter to the relative levels in other regions. But within individual countries, the association is generally positive between the open interval and female participation in the labor force.The parallel trends of female participation in the labor force and the age of the youngest child are shown in In general, the balance of home roles and outside roles changes as the youngest child ages. Women can engage more in formal employment and small business ventures, with more personal income and enhanced power within the family. They can be out in the greater world, with enhanced freedom of movement, seeking job training and further education and making wider social connections. Such changes tend to enhance both gender equity and female empowerment.As the youngest child ages, women gain more opportunities and a greater role in economic development.The development process can also be hastened by greater female equity in these respects. The World Bank notes that… gender equality is a core development objective in its own right. But greater gender equality is also smart economics, enhancing productivity and improving other development outcomes. It urges closing of gender gaps in access to economic opportunities, earnings, and productivity.Further, the World Bank asks for a reduction of gaps in human capital, specifically those that address female mortality and education. It notes thatIn nearly every country today, women face barriers to fully participate in the work force and earn as much as men. Because of this, women account for only 38 percent of their country's human capital wealth, defined as the value of the future earnings of their adult citizens—versus 62 percent for men. In low income and lower-middle income countries, women account for just a third or less of human capital wealth.R2 values 0.40 and 0.48, respectively). All 3 are in turn related to the prevailing fertility rates (not shown) since lower fertility is associated with high GDP per capita and also with the 2 measures of child care. Overall, the associations in the figure are consistent with a link between faster national development and the percentage of women free from early child care.The development process and the roles of women are intertwined in many respects, including the extent of their involvement in childbearing. To explore this relationship, we examined the association between GDP (gross domestic product) per capita and the percentages of women either pregnant or with an infant (up to 1 year old). The relationships across the 74 counties in our analysis appear in These issues are intertwined. Reductions in child care encourage labor force participation, which in turn often leads women to postpone or avoid a next birth. Women can bring advantages to the economy and can hasten the development process, which then tends to enlarge job opportunities for more women to enter selected occupations. The results of these processes can serve to advance women's empowerment.Each part of the open interval distribution tells a story that programs can benefit from. Changes in the proportions of women who are pregnant or have recently given birth signal necessary modifications in the allocation of the services needed. These pertain especially to maternity care, postpartum services, and early contraceptive offerings. But equally, attention to the numbers in the intermediate and later intervals can clarify the likely need, or market, for the changing mix of contraception shown above between short-acting and long-acting methods.Each part of the open interval distribution tells a story that programs can benefit from.Absolute numbers within the various intervals are important for planning, as are rapid changes in method mix from one survey to the next in particular intervals, as they have been in sub-Saharan Africa toward the implant and injectable.Asking about the age of the youngest child is useful for service staff who provide family planning. Counselors and fieldworkers may already ask about the age of the woman's youngest child, but that information is not captured in the usual service statistics systems that are fed upward for management purposes. It is available only in surveys at national and lower levels. Where not already systematically done in client contacts, establishing the youngest child's age provides a springboard to ask about intentions for spacing or limiting in counseling about contraceptive methods, and it affords an opportunity to enquire about key health services for the child such as immunization.In rural and peri-urban settlements, where many women lack easy access to services, workers should pay particular attention to women with very young children because they are the most likely to have early, unplanned pregnancies. All outreach activities should recognize that a woman's need for, readiness for, and interest in contraceptive use is tied closely to the age of her youngest child.,The “extended postpartum period,” the first year after birth, has been of particular interest since the 1960s.Meanwhile, attention continues to be focused on “best practices” for the implementation of these programs, as in a review by Cleland et al.In general, program implementation can only gain by knowledge of where women are within the open interval distribution and how the distribution has changed since the previous survey. Both proportions and numbers need attention, especially since the absolute numbers of women in the population diminish sharply in the later intervals due to aging, and because progressively more women are infecund or already using contraception. The largest absolute numbers of women are in the early and intermediate intervals.Program implementation benefits by knowledge of where women are within the open interval distribution and how the distribution has changed over time.After the postpartum period, attention must go to the middle and later intervals. Over 60% of unmet need for family planning and over 40% of intention to use contraception fall beyond 1 year postpartum, as shown in The survey data show that substantial percentages of women want to postpone a next pregnancy for 2 years or longer, so even for those who wish to space rather than limit, the reversible long-acting methods have a role to play, especially given their low failure and discontinuation rates. Van Lith et al.Ministries of health have additional channels to broaden access to contraceptive assistance. While family planning efforts have focused on integration with immunization services for children, little attention has been paid to linkages with curative health services for them. Unlike immunization, curative treatments continue throughout childhood at a variety of clinics for such ailments as diarrhea, pneumonia, injuries, and infections. The mothers rather than the fathers usually accompany children needing attention, and finding creative ways to link family planning to these services deserves fresh thinking, especially given current emphases on primary health care. For the mothers, the growth of cancer screenings is an additional service of interest.The simple question “How long has it been since your last birth?” differentiates women in a fundamental manner, by the age of their youngest child. Easily available over time in national surveys, the open birth interval shows movement through the stages of reproductive behavior, it informs fertility analyses, and it offers guidelines for national action programs. In addition, it relates to women's movement into the labor force and to policies for women's empowerment.The open birth interval shows movement through reproductive stages, informs fertility analyses, and offers guidelines for national action programs.Supplement 4 captures these changes and allows for estimates across countries and over time.For the first time, a large body of empirical information on the open birth interval has been assembled and analyzed. This study shows that the distribution has a characteristic shape, with a substantial proportion of women near a birth or expecting one soon, then declining proportions through 15 years and beyond. While this characteristic shape is present everywhere, the relative proportions between the first year and the later years varies a great deal, from countries with very low fertility and therefore few women either pregnant or in the first year after birth, to countries with high fertility rates and therefore many women who are pregnant or in the first year after birth. The simple model presented in The age of a woman's youngest child carries important implications for her freedom of action, and it varies greatly across regions. In sub-Saharan Africa at one extreme, and in the European/West Asia countries at the other, women are preoccupied to greater and lesser degrees with pregnancy and childrearing. Correspondingly, they vary in the ages at which they are able to pursue other roles. Much of that is captured in the distribution of delays since the latest birth, as women's circumstances fundamentally change as their youngest child moves from infancy to childhood to school and finally departs from the home. In between, the needed health and social services evolve in character.For public programs devoted to reproductive health, the distribution of women along the axis of their youngest child, and the absolute numbers within each of the early intervals, are basic for planning. Information by year within the open interval is unique; it gives insights not present in averages and overall estimates.Policy makers should examine open birth interval data in making economic development policy. They should recognize that providing voluntary family planning services not only benefits individual women but also advances overall economic development. Considerations of social policy and equity for women can only benefit from information on the proportions of women preoccupied with childbearing and the extent to which women can enter the labor force. Those estimates and the changes from one survey to the next are relevant to advocacy efforts to reduce barriers to equal earnings and opportunities for the advancement of girls and women.We recommend that national planners for reproductive health programs and social policy examine each new survey for the open birth interval distribution and its correlates, in light of changes since the previous surveys. This information will augment other bodies of information currently in use to strengthen both the planning and the implementation of national programs.


The phenomenology of Eating Disorders (ED) relates with altered functioning of the Autonomic Nervous System (ANS). The lack of agreement in what comes to the direction and significance of such alterations is possibly due to the variability in the ED spectrum. As the stress response system is an integral part of the ANS, we propose to investigate ANS tonic variations and phasic activations in response to stressors. We hypothesize that, while using stress as a test probe, characteristic ANS dysregulations in ED may be found when considering several physiological signals measured over time, and weighted by the individual psychological profiles. In this article we describe a novel methodological approach to investigate this hypothesis with the aim of providing further clarification on the ED spectrum conceptualization. The proposed methodology has been designed to be easily integrated in clinical practice and, eventually, in daily life. The population under observation includes both patients in treatment for ED, and matched controls. The study session has the duration of 1 day, including: (1) the administration of a stress task in a controlled environment and (2) naturalistic data collection. The stress task is designed to elicit both mentally and physically driven ANS activation. The naturalistic component intends to illustrate the psychophysiology in everyday life. We use wearable devices to continuously and non-invasively measure bio-signals related to ANS functioning. This information is complemented with psychometric information from validated stress and ED scales and ecological momentary assessments. The protocol has received ethical approval and has been implemented in practice, currently accounting for 37 patients (out of 120) and 16 controls (out of 60). Ongoing work focus on the definition and implementation of a data processing pipeline to quantitatively test our hypothesis, both standard statistical methods and more exploratory machine learning approaches will be considered. Anorexia Nervosa (AN) and Bulimia Nervosa (BN) constitute the official ED diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)The official guidelines for classification of psychiatric pathologies are described in the DSM  appointed as potentially valid dimensional constructs underlying psychopathology  baseline observations, e.g., at rest or respecting to slow tonic variations; (2) task induced, e.g., in reaction to a stressor. In summary, most studies point out the existence of baseline ANS dysregulations, that are transversal to AN and BN , or both, is out of our scope.Our work aims at bridging some of the research gaps found in the literature, namely: (1) the full ED spectrum has only punctually been studied using the same psychophysiological protocol ?Can the four most prominent ED classes  be identified based on autonomic signals?Based on a data driven approach, relying both on psychological descriptors and ANS signals, can we establish a multiparameter model of the ED spectrum  that describes psychopathological state?In the following sections we will present the experimental design  , discuss the limitations of our approach and suggest possibilities for further development (section Discussion).Toward studying the ANS in ED we devised an experiment that would allow us to capture both tonic and phasic ANS activation using the following conditions: (1) at rest in the lab; (2) in response to a stressor in the lab; and (3) in naturalistic conditions, where both rest and stress situations may occur. During the day of the study participants are administered a stress task in a controlled environment, and afterwards they continue freely with their routines for the rest of the day. Measurements of autonomic physiology using wearable sensors are pervasive throughout the day, and EMA on stress, feelings and activities take place every hour.The detailed methodology is described in the next sections. The protocol was approved by the Medical Ethical Committee of U. Z. Leuven (Belgium), and the study has been running ever since February 2018, with an amendment accepted on January 2019 toward extending the number of centers where subjects are recruited.The study sample is composed of a group of ED patients  and a group of healthy subjects (control group). Detailed admission criteria for each group are displayed in The clinical group includes patients  receiving treatment for their ED at a medical unit in Belgium. In the treatment context, all patients, including the ones admitted at the hospital, have free time for rest or social interactions, and can leave the treatment facilities. Mealtimes are fixed in the inpatient and day hospital situations. To pinpoint characteristic features of ED only subjects in treatment are considered, when there is irrefutable need for clinical attention. To gather information on the psychopathology across the ED spectrum, we include patients with strict diagnoses , but also those falling within EDNOS. These classifications are primarily provided by the clinician. Since we intend to focus on characteristic ED traits and its comorbidities, we exclude subjects with coexistent health issues not directly connected to the core features of ED, such as somatic chronical illness with current impact in daily life or need for continued medication, and acute illness. Knowing from epidemiological studies that women are the major group in ED  the Chillband  is a wrist worn sensing device that captures SC, skin temperature and acceleration , at sampIn the clinical group, the clinician responsible for the patient fills in a form with clinical information, including the treatment program , days since admission, age, height, weight at start of treatment, weight on the day of the study session, diagnose according to clinical evaluation, symptomatology, and current medication. In the case of ambulant patients, if the clinician cannot be reached, the form is filled in by the researcher based on the patient report.Four standardized psychometric tools are employed in this study to model the participants' psychology: the MINI 5.0, a diagnostic interview; the EDI3 , a self-report to assess ED psychopathology; the DEBQ, a self-report to assess general eating style, and behaviors; and the PSS10, a self-report on stress. These tools have been highly validated and are widely used in trials. Ecological Momentary Assessment is a psychometric method intended at overcoming the limitations of retrospective self-reports, that rely on recollection of past events and may be biased. This is accomplished by regularly assessing the individuals' state with short questions, providing a close to real time assessment in a naturalist setting , idiosyncratic stimulus , ED specific stimulus (food cues test), physical stimulus , baseline, and recovery rest phases . It takeYou have to speak faster; Please, continue; Don't give up; You can continue. Performances are not evaluated during the task. At the beginning and end of the task, participants rate their stress levels and feelings toward food on a short self-report that includes questions 12–18 of the diary  to appropriately annotate the sensor data according to the successive activities. Instructions on the activities related to each task module are provided on screen and vocalized by the researcher. The start of the experiment consists of a calibration procedure for subsequent alignment of signals across sensors. It consists of five sets of downward/upward torso movements, conducted while seating, and keeping both hands on top of the sensor on the chest. Relaxing sounds are reproduced during baseline and recovery phases, to calm the participant before and after each stimulus. The researcher keeps a neutral posture, and is allowed only standard interactions during the stimulus, such as he diary . The bloAt the end of the study day the participants must return the wearable devices and the diary. The participant is debriefed and if the diary contains at least eight reports, the participant receives a 10€ voucher for online shopping, as an appreciation for the participation.Power analysis estimation was performed to back up the study decisions in what comes to the size of the study sample. Toward this end we considered some simplifications and assumptions:We focus only on processing autonomic signals .All autonomic signals will be analyzed toward extracting parameters to describe the ANS function .Each participant will be treated as an observation, represented by a set of parameters .We assume a Gaussian distribution for all parameters.When comparing clinical and control groups only matched participants will be considered, hence in this situation both groups will have the same number of individuals.Gender, BMI, and Age are controlled by design, and activities during the stress task are typified.The clinical group has four ED subgroups and the control group has no subgroups.Both clinical and control group include a varied set of individuals, we assume these groups to present comparable parameter dispersion. When considering clinical subgroups, the dispersion of parameter values per group should be lower  except for EDNOS, which should have similar dispersion as the overall clinical group.We drafted four analysis methodologies in accordance to the research questions proposed in the introduction section, and hereafter, we present the respective power calculations:During the stress task, the autonomic parameters from the clinical group differ from those of the control group. Toward evaluating the statistical significance of each parameter to differentiate across groups  a t-test for two samples is considered. The nominal variable is being a patient , and the measurement variable is one of the autonomic parameters . We target high magnitude differences across groups , using During an ambulant condition, the autonomic parameters from the clinical group differ from those of the control group. We use the same formulation as in the previous hypothesis, assuming a t-test for two samples. Since data collected in uncontrolled conditions is prone to artifacts, this may affect the signal physiological content and increase the data variance. Therefore, we expect to find less sharp differences, hence we set a lower effect size in this case. We target medium magnitude differences across groups , using Patient groups  present different autonomic parameters. We expect to find differences across patient groups based on autonomic signals throughout the full collection. If we assume the symptomatologic classification to have a parallel on physiology, then we expect to be able to find four distinct groups in the data, i.e., AN, BN, BED, and EDNOS. In this context we can use a one-way ANOVA test to verify the statistical significance of differences across groups. Targeting high magnitude differences , using As for the fourth research question, related to data driven clustering and classification of ED patients, both unsupervised and supervised machine learning techniques will be used and compared. The diagnostic classes  will be considered as labels for the supervised methods. Power calculation for this analysis was omitted given its exploratory character.In summary, to attain statistically relevant findings from this study we require at least 55 ED participants and respective controls to test hypothesis 1 and 2, and 116 ED participants to test hypothesis 3. The number of possible participants is highly variable, but we envision that in average two new clinical participants will be available on a weekly basis, and one new healthy match will be found. Considering that the time limit for the study is 60 weeks (15 months) related to project constraints, we will be able to include 120 ED participants and 60 controls. This scenario agrees with the numbers from the power analysis.The data acquired in this study is stored and managed using Research Electronic Data Capture (REDCap) (Harris et al., A preliminary procedure for data analysis includes the generation of a set of annotations to contextualize the sensor data . Namely,Quality of the data, in particular for the ambulant recording, is evaluated both via visual inspection and via automatic methods (Jones and Lederman, via calculation of appropriate physiological parameters (e.g., HR and HRV (Task Force of The European Society of Cardiology and The North American, Tonic and phasic components of the ANS activation are accounted The laboratory data will be analyzed separately toward generating a numerical rating (Guo et al., While ED are mainly studied according to their psychological dimension, we proposed a new approach in which we intend to explore ED relation to ANS dysfunctions. To this end we designed a comprehensive protocol and successfully implemented it in a study in which we include physiological parameters from ECG, SC, and skin temperature. Participants are studied during the period of 1 day, with the expectation that longitudinal data can provide further insights than cross-sectional data. Recordings take place both in a lab session that calibrate individual physiological responses to different stressors, as well as in ambulatory, allowing participants to do the activities of their choice while the electrophysiological measurements are stored. At the time this article was written, we had collected data on 37 clinical subjects and 16 controls. Ongoing work focus on the implementation of a complete processing pipeline for data analysis and on the quantitative validation of our hypothesis using the collected dataset.While the study design presents advantages over a cross-sectional one, because it includes continuous recording over about 8 h, the collection time can be still considered limited. While 1 day of data is enough to test our hypothesis, we cannot exclude punctual factors, not representative of the day to day life of the individual. In future research, conversion of the paper diary into an app and synchronized sensors data streaming directly to a cloud infrastructure, will reduce experimental burdens both for the participants and for the researchers allowing also for longer data collection period and even for easier implementation in clinical practice.In what comes to physiological sensing, new non-invasive wearables methods have been recently developed that can be used in future trials to complement or substitute the current devices, for example multi-sensor wrist devicesWith the stress task presented we tried to assess broad set of test situations, nonetheless other variables could have been studied depending on the need to answer specific questions, e.g., emotion perception could be assessed in response to pictures from the International Affective Picture System (Joos et al., In the clinical context the evolution assessment of psychiatric patients relies mainly on self-reports and clinical observation. Information gaps between sparse appointments–when there is no hospital admission—are often bridged based on the patient reports, a recollection exercise that can be affected by momentary altered mental states. In ED, BMI is routinely measured to verify if weight goals are achieved, while cardiovascular assessment and blood analysis may be requested when the physical state of the patient is dubious. In these circumstances, most information gathered about the patient is sparse and subjective, often collected in a non-standardized way. In this backdrop, there is a recognized need for methodological enhancements in the field of mental health management. Nevertheless, in the past decades no major developments have been registered.Recently mental health management sprouted attention outside medical and human sciences. This followed the technological developments that led to miniaturization of wireless sensing platforms, enhanced remote communications, increased computational power, and their broad availability to end users. The resulting enhanced possibilities for data collection and processing became an enabling factor for continuous follow-up and multifactorial analysis—seemingly matching the challenges of mental health management. Currently, there is a crescent interest and openness of the psychiatric research community to technology aided mental health management. Nonetheless, the topic is still highly enfolded in speculation and ethical concerns, and solid outcomes need to arise before the clinical community is convinced to adopt new technologies as an integral part of their methods.If our hypothesis holds, we can further the understanding of psychopathology across ED and help establishing a dimensional biologically oriented nosology. For design reasons our study focuses on the treatment phase, when the patient has already reached the healthcare system. Which is nonetheless, a valid phase to introduce aiding technologies, namely, to help determining the patient psychopathological state, and track it during follow-up, toward modulating the treatment at each step.This study was carried out in accordance with the recommendations of the Commissie Medische Ethiek, UZ Leuven and in accordance to the Belgian law of 7 of May 2004 with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Commissie Medische Ethiek, UZ Leuven.NS-C, EV, and GS: conceptualization and investigation. NS-C, EV, CV, and WD: project administration. EV and CV: supervision. NS-C, GS, EV, CV, and WD: writing original draft, review, and editing.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.


The legislation regarding pig housing systems states that environmental enrichment needs to be provided for group-housed pigs. Moreover, the materials used for improving animal housing are categorised as optimal, suboptimal, and of marginal interest. Straw has been considered as the optimal solution for pig housing, however there are some limitations in using it in a large amount. Therefore, other materials, objects, and toys have been used as enrichment in pig maintenance. Understanding how various enrichments influence animal welfare seems to be an important key to elaborating the best methods of improvement. This review presents new literature references regarding environmental enrichment for suckling piglets, weaning piglets, and fattening pigs.Good husbandry conditions on farms is of key importance for assuring animal welfare. One of the most important legal documents regulating the rules of maintaining pigs is the Directive 2008/120/EC, which states that group-housed pigs should have access to litter or other materials that provide exploration and occupation. Released in 2016, the Commission Recommendation (EU) 2016/336 on the application of the Council Directive 2008/120/EC characterizes the various categories of materials that may be used to improve animal welfare. According to the document, straw is considered as an optimal material for pig housing, however, materials categorized as suboptimal  and materials of marginal interest  are often used in practice and scientific research. As such, the aim of this paper is to review and systematize the current state of knowledge on the topic of the impact of environmental enrichment on pig welfare. This article raises mainly issues, such as the effectiveness of the use of various enrichment on the reduction of undesirable behavior—tail biting; aggression; and stereotypies at the pre-weaning, post-weaning, and fattening stage of pig production. In recent years, there has been a growing interest from consumers into food production. Taking into consideration products of animal origin, it may be stated that the public debate is focused not only on the good quality of such products. Currently, a great deal of attention has also been paid to maintaining good husbandry conditions on farms. Animal welfare qualities have been known for many years ,2. This One of the most important legal documents providing the minimum standards for pigs is the Directive 2008/120/EC . This leIn 2016, the Commission Recommendation (EU) 2016/336 on the application of the Council Directive 2008/120/EC laying down the minimum standards for the protection of pigs regarding the measures needed to reduce the need for tail-docking was released . As the In spite of the fact that straw is considered as the optimal material for pig housing improvement , in slatted floor systems, it is not easy to introduce it, as it may lead to blocking the manure system . HoweverThe aim of this paper is to review and systematize the current state of knowledge on the topic of the impact of environmental enrichment on pig welfare. This review covers the issues of using the various materials to improve the housing of different pig groups, piglets pre- and post-weaning, and fattening pigs. In this review, the latest scientific literature has been included, mainly concerning the effect of enrichment materials on the reduction of undesirable behavior, such as tail biting, aggression, and stereotypies. Animal welfare has been a scientific concept for many years . It can The occurrence of undesirable behavior may be considered as an indicator of poor welfare ,17. In aBesides behavioral indicators, physiological measures are very commonly used to assess animal welfare. Physiological indicators of animal welfare, which are often used in animal studies, are measurements of stress hormones . ImpropeA wide range of behavioural methods used together with, preferably, non-invasive biomarkers, is of key importance for the reliable assessment of animal welfare.When discussing animal well-being concepts, it must also be stated that animals have strong motivational systems to meet their essential needs. These include basic needs for eating and drinking, but also for exploring the surroundings and expressing their natural behavior ,33. RootPlay may be considered as a luxury behavior, and thus as a positive indicator of welfare ,16. It iTail biting is a huge problem for both the economic and welfare aspects of pig production. Taylor et al.  identifiAn increase in aggressive behavior is often observed during mixing, as this is generally considered a stressful procedure, when the individuals of different herds are placed together in one pen. The social hierarchy must be established, so it is often linked with fighting and aggression . Only afAnother form of behavior observed mainly in weaned piglets, especially in those weaned earlier, is the belly nosing phenomenon characterized by the rhythmical rubbing of a piglet’s snout on the other individual’s belly . WidowskThere has been some evidence of how stereotypic behavior is induced in farm, laboratory, and wild animals kept in a barren environment ,56,57. SIn animal models, it has also been shown that environmental enrichment for the prevention of stereotypies is linked with a higher level of neuronal metabolic activity and dendritic morphology (more dendritic spines) in the motor areas of the brain . Taking The first idea for enriching the environment was proposed for laboratory animals in the 1940s . Since tTaking into consideration the fact that pigs may lose attention towards the object within a few days , it is oIt seems that in spite of the fact that many years have passed since the Council Directive 2008/120/EU was introduced, there are still some experiments carried out using objects and materials not admitted by this legal EU Act, showing some positive effect on pigs’ behavior. However, the earlier results obtained by Scott et al.  and ZwicThe review of the literature included in the report of Ernst et al.  covers tThe effects of environmental improvement have been studied in pre- and post-weaning piglets. It seems that providing the enrichment in early, neonatal housing conditions may lead to better social behavior at later stages of the pig’s life ,77,78. AThe effect of straw provision at an early stage may be effective in the reduction of nosing and tail biting . Access Positive indicators of animal welfare may also be observed when materials other than straw are provided. As mentioned previously, belly nosing has a multifactor origin, and generally may be considered as an indicator of poor welfare in weaned piglets . PreviouFurther effects of environmental enrichment provided in the neonatal period were shown in some studies ,81,82,83Actinobacilllus pleuropneumoniae co-infection at a later stage of their lives.It is well known that chronic stress has an immunosuppressive effect . Taking In turn, Telkänranta et al.  reportedBrajon et al.  found thAs has been well documented in previous studies, the sudden limitation of enrichments may cause an increase in harmful social behavior ,87. ThisAromas in pigs’ surroundings may be a factor causing positive stimulation, which has been proven in some studies ,88,89. IOther environmental enrichment than that mentioned previously was tested by Winfield et al. . The autWeaned piglets experience multiple stressors while they are subjected to nutritional and social changes . The litTaking into consideration the environmental enrichment of growing and finishing pigs, a larger space seems to be a key factor for providing animal comfort. In the study of Cornale et al. , the fae2 space for pigs heavier than 150 kg seems to be insufficient. Moreover, the directive states that before carrying out tail docking, other measures should be taken in order to prevent tail-biting and other vices, taking into account environment and stocking densities. For this reason, inadequate environmental conditions or management systems must be changed. It is worth adding that the fattening heavy pigs used for specific productions require the provision of more space than the minimum legal requirements. These situations may be seen when pigs reach 180–190 kg of body weight, and when the fattening process is long . The CouThe genetic background is also a significant factor of tail biting occurrence . This waSome positive aspects of the prevalence of mild damage to the tail and ear biting reduction were found in the Telkänranta et al.  study, bContinued high interest in straw investigation was found in the study of Scott et al. , when thThe effect of the enrichment on stress response in finishing pigs was tested in Casal et al.’s  and NannThe above-mentioned findings ,93,94 weOne of the main findings of this study was the increase of animal activity, even when only the material classified by the EU Recommendation as being of marginal interest is provided. The animals of the control group which had no access to a “toy” remained for the majority of time inactive. Based on this and other results presented in this section, regardless of fact that harmful behavior still occurred in the pigs kept with access to enrichment, it may be stated that the increase of animal activity and interest in an enrichment object is very valuable from an animal welfare perspective. Moreover, Scott et al.  pointed Similarly, as in Based on the various research results presented in the review, it may be stated that the enrichments provided for young and fattening pigs have many benefits with regard to animal welfare. Generally, it may be concluded that access to even a small amount of substrate and objects increases targeted activity. As it has currently been proven, enrichment given at the neonatal stage (farrowing pen) improves manipulating skills, and may also lead to better social behavior performed at later stages of the animal’s life. The main effects of enrichment may be seen through a reduction of attention paid to other individuals in the pen. This also includes the pigs’ interest in performing tail chewing, biting, or belly nosing. However, the results of a reduction in these harmful behaviors through the provision of enrichments is inconclusive. Despite the fact that studies have confirmed the advantages of using different kinds of enrichments at the same time, some results have also shown that only the use of materials that are considered to be of marginal interest (according to Commission Recommendation (EU) 2016/336) brought about the desired effect on the pigs’ behavior. It can be misleading for farmers, because it is strongly highlighted in the recommendation that “materials of marginal interest—materials providing a distraction for pigs, which should not be considered as fulfilling their essential needs, and therefore optimal or suboptimal materials should also be provided”. Moreover, some authors found a positive impact of materials, such as newspaper or PCV pipes, with protruding tubes. As such, it remains an open question whether these enrichments could be considered as completely safe for animal health; similarly for hard wood, whose chewing may also result in injury.It is not possible and it makes no sense to change the European legislation regulating the types of environmental enrichment materials and their features. The current EU regulations are based on research results and represent the results of the European Union scientific projects. It should always be taken into account that tail biting and ear biting have a multifactorial origin, which is often difficult to determine. Tail-docking should be an absolute last resort (in some of the EU countries it is forbidden), so looking for alternative possible ways in terms of scientific and practical activities to stop and prevent tail biting should be essential . Making changes in the pigs’ environment, such as reducing stocking density and introducing optimal environmental enrichment solutions based on the scientific evaluation of their efficiency, should lead to the situation in which the procedure of tail-docking would be performed as little as possible, or not at all.


Surveying the landscape of the educational experience of medical physicists, there are many relatively recent accomplishments, and our educational organizations have been active promoting some necessary improvements. Maintenance of Certification became a reality in the early years of this century. The requirement to complete a residency program to sit for the American Board of Radiology (ABR) certification examinations is a reality as of 2014. The Commission on Accreditation of Medical Physics Education Programs (CAMPEP) has accredited over 50 academic programs, over 100 residency programs in therapy physics and over 25 residency programs in imaging physics. The majority of these programs were first accredited in this decade. Additionally, the American Association of Physicists in Medicine (AAPM) Education Council and the Society of Directors of Academic Medical Physics Programs have been active promoting medical physics education, encouraging quality, providing for coordination between education programs and establishing best practices in medical physics education. The AAPM has hundreds of Councils, Committees, Subcommittees, Task Groups and Working groups, all involved in some aspects of the evolving nature of technology, clinical practice, and the knowledge base of our profession.Even with all of this activity, however, keeping up with changes in the field and providing for contemporary education is a daunting task and challenging to do well. Continuing education is absolutely necessary in this profession. If we fail to keep up, our practice skills can become obsolete in a few years. So as a profession, we face two challenges in education: how do we bring students up to a baseline level of practice in our academic and residency programs, and how do we maintain a level of practice proficiency? This editorial discusses one aspect of the first challenge.JACMP and Medical Physics. An argument easy to make is that an advanced structured course in both radiation oncology and imaging physics of one semester each would be not only desirable, but perhaps essential for the training of the next generation of medical physicists. But what would such a course look like?Respecting CAMPEP academic programs, there is only one full structured course required in radiation oncology physics (at the level of the Khan or Hendee text) and one required in imaging physics (at the level of Bushberg). These courses, usually one semester each, can do little more than provide the most basic of introduction to the science of the field. Thus, a growing knowledge gap exists between the material in these courses and the information published each month in our scholarly journals, the We envision the second course in therapy physics to be site/disease based and would focus on integrating the technology with the clinical challenges we face each day. As an example, consider prostate cancer. Three or four lectures would include the cancer biology and progression, staging and scoring, treatment approaches, planning and optimization algorithm details, Image Guided Radiation Therapy (IGRT), outcomes, and avenues for research. Other disease sites, including Central Nervous System (CNS), Gynocology (GYN), brain, lung, head and neck, and others would follow similarly. An advanced course in imaging physics would deal with specific sites , using the latest insights into use of advanced techniques such as molecular imaging, dual‐energy imaging, image registration, artificial intelligence, computer‐aided diagnosis and other emerging technologies.The justification for such courses is that this is the type of work therapy and imaging physicists face every day. It is our calling to solve imaging problems for specific disease sites and to assure knowledgeable and precise clinical practice respecting therapy interventions. Yet so often, entry‐level medical physicists are less prepared than they could be to undertake these challenges.JACMP would be an ideal place to publish such articles since the journal is open access and the author retains ownership of the copyright. There would therefore be no restriction on the use in an educational setting as the articles are free to access and use. These review articles would be peer reviewed and would form the basis for the second advanced course in therapy or imaging physics.The basis for these advanced courses would include, among other references, a series of review articles published in a public forum. The JACMP has an established category to publish Education Articles, we are issuing a call for the community to volunteer its time to create and publish Education Review Articles as described. To avoid duplication of effort, please email the Editor and volunteer your article for a therapy or imaging site along with a timetable for submission. We believe these articles will be very valuable to the community and essential to prepare medical physics students and residents for clinical practice.Since the


Background: Dietary behavior encompasses many aspects, terms for which are used inconsistently across different disciplines and research traditions. This hampers communication and comparison across disciplines and impedes the development of a cumulative science. We describe the conceptual analysis of the fuzzy umbrella concept “dietary behavior” and present the development of an interdisciplinary taxonomy of dietary behavior.Methods: A four-phase multi-method approach was employed. Input was provided by 76 scholars involved in an international research project focusing on the determinants of dietary behavior. Input was collected from the scholars via an online mind mapping procedure. After structuring, condensing, and categorizing this input into a compact taxonomy, the result was presented to all scholars, discussed extensively, and adapted. A second revision round was then conducted among a core working group.Results: A total of 145 distinct entries were made in the original mind mapping procedure. The subsequent steps allowed us to reduce and condense the taxonomy into a final product consisting of 34 terms organized into three main categories: Food Choice, Eating Behavior, and Dietary Intake/Nutrition. In a live discussion session attended by 50 of the scholars involved in the development of the taxonomy, it was judged to adequately reflect their input and to be a valid and useful starting point for interdisciplinary understanding and collaboration.Conclusion: The current taxonomy can be used as a tool to facilitate understanding and cooperation between different disciplines investigating dietary behavior, which may contribute to a more successful approach to tackling the complex public health challenges faced by the field. The taxonomy need not be viewed as a final product, but can continue to grow in depth and width as additional experts provide their input. As of yCrucially, however, “dietary behavior” and related terms such as “diet”, “nutrition”, “dietary intake”, “eating behavior”, “eating habits”, and “food choice” are fuzzy umbrella concepts, which are used inconsistently across different disciplines and research traditions, and which often include a multitude of qualitatively different outcomes lumped together. These outcomes cover all aspects related to dietary behavior from foraging to ingestion and range from the intake of single nutrients to patterns of entire diets, from disordered eating to eating habits, from food preferences to food preparation. Moreover, while standardized classifications of certain aspects of dietary behavior exist within single disciplines  to facioutcome of its determining factors. It should be noted that, of course, from the perspective of more upstream health consequences , dietary behavior in turn would be considered as the cause or determinant. For the purposes of the DEDIPAC project, however, dietary behavior was thus considered as the outcome of certain determinants, and the framework that is presented here was conceptualized as such.The current article describes the conceptual analysis of the fuzzy umbrella concept “dietary behavior” and related concepts conducted within an interdisciplinary, international workgroup of researchers that was formed in the context of the European research network and knowledge hub Determinants of Diet and Physical Activity . What all members shared was a research focus on diet and/or diet-related aspects, such as nutrition-related non-communicable diseases. The workgroup was managed and led by two of the authors (FMS and BR), and followed previous examples of successful multidisciplinary academic cooperation in the field of obesity-related behaviors  graphically depicts the working process and the development of the taxonomy throughout the different phases. The ethics committee of the University of Konstanz decided that this project falls outside the range of projects requiring an IRB statement (decision IRB17KN9_001).The conceptual analysis and taxonomy development were conducted using a four-phase multi-method approach. The first, second, and fourth phases occurred de-centralized , while the third phase was centralized, with the workgroup members assembled at one location at one specific time. A flowchart , as well as a categorical structure between different text boxes . It was also possible to indicate relations (by means of arrows) between text boxes that are not otherwise connected in the hierarchical or categorical structure. While contributing their ideas, workgroup members were thus automatically required to also consider the categorical and hierarchical structure of the concepts they listed. Communication was possible within the program itself via comments, such that different workgroup members could discuss and resolve areas of disagreement in real time.In the first phase, an online mind mapping  tool calSeveral guidelines for the nomination phase were provided by the workgroup leaders. First, each partner was given a unique color and symbol in the program, so that it was possible to keep track of partners’ contributions. Partners were encouraged to also indicate their name when providing input, to ensure that everybody knew who contributed which input, from which scientific background, facilitating effective discussion about potential areas of disagreement. Second, partners were informed that nomination of outcomes was possible both based on scientific evidence  as well as on expert knowledge and experience , in order to arrive at the most complete and comprehensive mind map possible. Third, partners were asked never to delete anything from the mind map, but to communicate disagreement with existing input via comments instead. The mind map was made available to all partners involved in the workgroup to review and edit for one month, after which the final mind map was downloaded and stored.In phase 2, the outcomes entered in the mind map were reduced, combined, and categorized into a compact taxonomy by the workgroup leaders (BR and FMS). All decisions made were recorded and discussed with the larger working group in a later live discussion session . The workgroup leaders first merged entries that were clearly referring to the same outcome. In case there was any doubt about whether two entries referred to the exact same outcome, both were retained, to be further discussed in a later phase. Second, the workgroup leaders determined whether each entry indeed specified a distinct diet-related outcome. Entries that did not meet this criterion were not retained . The remaining valid and unique entries were then scrutinized with regard to content and position in the categorical structure. Entries were structured systematically, grouping conceptually related outcomes together. In Phase 1, workgroup members disagreed on multiple issues . In these cases, the workgroup leaders made decisions based on majority opinion (which could be deduced from the accompanying comments in the mind map program) and, whenever possible, checked these decisions against the available evidence in the literature. When no clear majority opinion or best evidence-based option was evident, the issue was noted down to be put forward to further discussion in the next phase. The entries in the resulting categorization of outcomes were then scrutinized more closely for level of detail . The decision was made not to include outcomes related to individual food items or nutrients, in order to keep the taxonomy compact, condensed, and consistent with our focus on research targeting overall human dietary behavior.In the third phase, the reduced and condensed taxonomy was presented to all workgroup members during a live DEDIPAC project meeting. The taxonomy was displayed on a large screen and suggested changes to the taxonomy were processed on-screen in real time, so that workgroup members could see the effects of each potential change and evaluate its desirability. In a first discussion round, the categorization issues remaining from the previous phase were discussed by the moderators (FMS and BR) and resolved. In a second discussion round, workgroup members were able to provide any remaining comments or suggestions, which were then discussed amongst all members until resolved. All occurring disagreements could be resolved through mutual discussion, such that the final product was agreed upon. The end product of this phase was a further reduced, “pre-final” taxonomy approved by all of the workgroup members who were present.In the fourth phase, the “pre-final” taxonomy was thoroughly discussed once more by the core workgroup and, where necessary, edited. Finally, the workgroup leaders compared the final taxonomy to the original mind map, so as to ensure that the input provided by the workgroup members in phase 1 was correctly and exhaustively represented in the taxonomy. After concluding that this was the case, the resulting taxonomy was finalized as the end product of the work process. The terms in the final taxonomy were then defined by the core workgroup. Definitions were based on the working definitions of the terms used within the entire working group during the project period, and checked by the workgroup leaders against the commonly accepted terms in the literature.A total of 43 unique contributors provided input on the mind map. Unique contributors in some cases collected and summarized inputs from multiple colleagues in their research group, meaning that the mind map contains input of substantially more than 43 workgroup members. The final mind map (available from the authors) consisted of a total of 145 entries that all represented, according to the members of the workgroup, different diet-related outcomes. The entries differed to a large extent with regard to their level of detail; both high-order  as well as much more specific, lower-order  outcomes were mentioned. Importantly, the mind map process organically gave rise to a logical and concise main categorization of the terms: the workgroup members grouped most of the text boxes into three main parts, which at the end of the entry period were found to represent three meaningfully different categories. These three categories  will be further described in the section “final taxonomy”. Some entries were not included in one of these three main parts of the mind map, but rather entered as isolated terms.n = 4, e.g., “diet diversity” into “diversity of dietary pattern”). In addition, the workgroup leaders added seven entries  which they felt were missing from the mind map, leading to a total of 43 entries. All of these decisions were recorded and extensively discussed with the entire working group during the live discussion session (Phase 3).In the second phase, six entries were removed because they overlapped . Furthermore, as the ultimate target of the working group was the development of a framework of determinants, several members misinterpreted the purpose of the mind map, and thought that the purpose was to collect both dietary behavior-related outcomes as well as potential determinants of these outcomes. A total of 98 entries specified determinants of dietary behavior  rather than dietary behavior-related outcomes themselves, and were removed again for that reason [determinant collection occurred at a later stage during the working process and is described elsewhere ]. In somUsing the three-legged structure of the original mind map as a guideline, the 43 entries were organized into a concise taxonomy with a maximum of four hierarchical levels. Placement of the entries within the taxonomy was based on the suggestions by the workgroup members in the online mind map. Comments in the online mind map program showed that members disagreed about the best placement within the taxonomy in several cases . Again, in these cases the workgroup leaders made decisions based on majority opinion and evidence from the relevant literature; when this was not possible the issue was noted down to be further discussed in the next phase.This 43-entry taxonomy was used as the starting point for the discussion during the live meeting. About 50 workgroup members were present at the live meeting. The process of reducing, combining and categorizing the terms of the mind map by the workgroup leaders was presented and extensively discussed. Areas of disagreement that the workgroup leaders noted in Phase 2 were given extensive attention in the live session and discussed until they could be resolved through consensus. The live discussion session resulted in the removal of further 12 entries because the workgroup members considered these entries too detailed . The workgroup members further agreed on adding six other entries  which they considered to be missing from the previous version, and to rephrase four more of the original entries . Beyond these alterations, the taxonomy drawn up by the workgroup leaders was approved by the working group. The partners also agreed upon the main three-category structure  that had already emerged from their preliminary organization in the original mind map. Together, these changes meant that the second version of the taxonomy consisted of 37 entries. Importantly, all workgroup members present at the live meeting (stemming from diverse research disciplines and from various countries) confirmed that the outcomes they typically focused on in their line of work were adequately represented in the taxonomy.Figure 2. A table of definitions of the terms in the final taxonomy was then created (see Table 2), based on the working definitions of the terms used within the entire working group during the project period. The workgroup leaders checked these working definitions against the commonly accepted terms in the literature.A thorough discussion in the core workgroup led to the decision to remove three lower-level entries that were relevant only to a very specific target population , so as to ensure that all terms in the taxonomy were applicable to the entire lifespan. This was discussed with and approved by the workgroup members who had originally included these entries in the mind map. This resulted in a taxonomy including 34 entries. The core workgroup also rearranged the lower-level order of some terms within the three main categories to arrive at the most logical representation; this did not change the content of the taxonomy in any way. The core workgroup members discussed this change within the subgroups to ensure that all workgroup members agreed with this change. Finally, the workgroup leaders compared the resulting taxonomy with the original input by the workgroup members and were able to conclude that the taxonomy represented the workgroup members’ original input. The process was therefore considered to be successfully concluded and the taxonomy was finalized. The final taxonomy is depicted in Food Choice, represents behaviors and other factors occurring before food actually reaches the mouth. This category is further broken down into seven distinct outcomes: preferences, share of income spent on food, willingness-to-pay, frequency of purchase, product purchase, food preparation, and intentions. The second main category, Eating Behavior, encompasses all the outcomes related to the actual act of consumption. This category is further broken down into six distinct outcomes : eating habits, eating occasions, portions, dieting, disordered eating symptoms, and neophobia/pickiness/fussiness. Finally, the third main category, Dietary Intake/Nutrition, includes all outcomes that break down the content of what exactly is being consumed. This category consists of four main outcomes : dietary pattern, meal pattern, food intake, and food components.The three main categories in the final taxonomy represent wholly different aspects of diet and dietary behavior. Taken together, these three categories are a concise yet holistic representation of the range outcomes under the umbrella concept of “dietary behavior”, including outcomes relating to the beginning of the eating process , all the way through to terms regarding constituents of the food that has been ingested. Broadly put, the first main category, named Figure 2).A conceptual analysis of the fuzzy umbrella concept “dietary behavior” was carried out in an interdisciplinary, international workgroup of researchers, and resulted in the development of a taxonomy of diet-related outcomes. The taxonomy was developed with the aims of demonstrating the breadth of outcomes grouped under the broad umbrella concept “dietary behavior”, and categorizing these outcomes in a concise consensus structure. Having such a taxonomy in place can help interdisciplinary understanding and knowledge exchange, thereby facilitating cross-disciplinary research. Starting from a mind mapping approach and ending in a live consensus meeting, diet-related outcomes were grouped into three main categories: food choice, eating behavior, and dietary intake/nutrition. Each category was further broken down into more specific outcomes, with the final taxonomy consisting of 34 terms medical field, the important benefits of developing and employing standardized taxonomies  has been advocated for decades and remains an important agenda topic e.g., . In the assessment in empirical research (constructs included in the umbrella term dietary intake and nutrition (the second leg of the taxonomy). By combining a standardized inventory of the different aspects of dietary behavior with a standardized inventory of the ways to assess these aspects, empirical research in the area of nutrition can be more easily compared and pooled. Arguably the most extensive effort to date in the field of nutrition stems from the ENPADASI research project . By referencing the taxonomy and determining one’s figurative “location” on the taxonomy, mutual understanding was enhanced. The potential benefits of the taxonomy extend beyond the scope of this single research project, however, to the general field of diet-related research and the substantial challenge of diet-related health problems faced in public health (such as the obesity epidemic). As an example of manner in which the taxonomy can facilitate efforts to compare and synthesize research results, we come back to the issues (presented in the introduction) of one and the same term being used to represent different things across disciplines and researchers and conversely, of one concept being referred to with various different terms . These suggestions will be appraised for validity and plausibility by the core working group, and the taxonomy can be updated in an event-based manner. Visitors can also provide general feedback on the taxonomy. The taxonomy is also disseminated through presentation at scientific conferences  but, importantly, is also available online on an openly accessible website (see footnote 3), which also hosts the framework of determinants of dietary behavior developed in conjunction with this taxonomy within the DEDIPAC project. This website also provides the possibility for discussion and comments where experts can suggest additions and changes to the DONE framework and the taxonomy.Somewhat related to the previous issue, the working group was an exclusively European group, and also predominantly a north-western European group, and its findings should be placed in this context. Nevertheless, the working group included researchers from a wide range of European countries. These countries differ substantially and, crucially, predictably, with respect to socio-cultural, socio-economic, and socio-demographic characteristics. Comparing findings from the different countries could provide some indications as to how results might be extrapolated to other Western countries that were not part of the working group, though of course such extrapolation should be further examined and empirically tested for validity. Moreover, our findings cannot be readily applied to non-Western cultures as such countries were not part of the current working group.determinants of dietary behavior, and (b) to predominantly cover dietary behavior outcomes applicable to the general population, across the entire lifespan. The taxonomy may therefore need to be adjusted and expanded in order to meet also the needs of researchers interested in the more upstream pathway of dietary behavior as the exposure factor for various health consequences. Moreover, similar expansions in both depth and width may be necessary to accommodate also more detailed dietary behaviors relevant for specific populations . Crucially, because the taxonomy is not considered finite but rather is suggested as a starting point that can be improved upon, such changes can indeed be realized when deemed necessary or useful by other researchers in the field.Another limitation is the fact that the taxonomy was developed (a) with a specific purpose in mind; ultimately, the taxonomy was developed to facilitate research on the Within a large group of researchers, from different European countries and with varying academic backgrounds, we conducted a conceptual analysis of the fuzzy umbrella concept “dietary behavior”, and developed a taxonomy of outcomes attributed to this fuzzy concept. This taxonomy demonstrates the extent of variation that exists within the field of diet, and succeeds in categorizing this variation into a concise structure. We propose that the taxonomy can be put to good use in promoting understanding, knowledge exchange, and data sharing between disciplines and countries, all of which are crucial components of a new, more holistic, and more successful approach to tackling the complex challenges faced by the field.BR and FMS conceptualized the analysis and development of the taxonomy, devised the methodology, and drafted the manuscript. FMS created the first version of the taxonomy. BR, JA, HB, RE, SI, EK, NL, MM, PM, MS-M, DV, and SH contributed to the revision of the taxonomy. JA, HB, RE, SI, EK, NL, MM, PM, MS-M, DV, and SH critically reviewed and edited the manuscript. All authors were involved in the mind mapping procedure and approved submission of the manuscript in its current form.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.The reviewer CL and handling Editor declared their shared affiliation.