At age 20 weeks, after a dual‐energy X‐ray absorptiometry (DXA) scan, 12 of the rats on each diet underwent ovariectomy (OVX) and the remaining rats were left intact. Twelve of the intact rats in each diet group were culled at age 26 weeks (short‐term cohort). The remaining rats were culled at age 48 weeks (long‐term cohort). Rats were DXA scanned before cull, then various fat pads were dissected. The results revealed that HF/HS rats and OVX rats dramatically increased body weight and fat deposition in correlation with leptin. In the long‐term cohort, vertebral spine BMD rapidly declined after OVX. At termination, the OVX rats had decreased plasma bone turnover markers of CTX‐1 and TRAP when compared with sham rats. Significantly higher BMD was found in OVX rats fed the HF/HS diet compared with ND, but this difference was not recapitulated in intact rats. BMD of right femur was significantly increased 5% to 10% by GSM in the short‐term cohort. The data demonstrated that obesity can be beneficial by increasing BMD in OVX rats, and this may extrapolate to postmenopausal women as adipocyte‐produced estrogen may slightly compensate for the reduction in ovarian hormones. Finally, the data showed that GSM may be beneficial to bone health by increasing BMD accrual. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.Obesity is considered to impair long‐term health by disturbing multiple physiological functions. However, it remains a controversial issue as to whether obesity has beneficial or detrimental effects on bone health in postmenopausal women. The aims of this study were to investigate the relationships between obesity and bone mineral density (BMD) under conditions of ovarian hormone deficiency in an animal model and to evaluate the potential health benefits of Greenshell mussel (GSM) on bone health. A total of 144 adult female Sprague–Dawley rats were fed from age 12 weeks on one of four diets (normal [ND]; ND + GSM; high fat/high sugar [HF/HS]; HF/HS + GSM;  Osteoporosis is a disease of aging, and it shares a complex relationship with obesity. It used to be considered that obesity had a positive effect on osteoporosis based on a positive correlation between bone mineral density (BMD) and body mass index (BMI) and evidence from computed tomography showing that obese people have higher BMD in cortical and trabecular bone as well as increased trabecular bone at the distal radius and tibia. Further support from a meta‐analysis study showed that low BMI correlated with hip fracture risk with obese adults having lower risk of hip fracture. Despite strong evidence of increased BMD in obese adults, the incidence of bone fracture is increased in obese children.) Further, there is an increased fracture risk in obese people at the proximal humerus, upper legs, and ankles, particularly in postmenopausal women. However, the fracture risk in these bone sites might be attributed to impairment of muscular function causing instability of movement in obesity. Although obesity in older adults is accepted as being at least partly protective against osteoporosis, it is also clearly a risk factor for other chronic disorders, such as osteoarthritis, diabetes, cardiovascular disease, and metabolic syndrome. These contradictions in the benefits versus detriments of obesity have given rise to the term “obesity paradox,.”The incidence of obesity has increased worldwide in the last five decades.1 It h This notion is evidenced by the fact that bone marrow of obese mice has more adipocyte infiltration. However, the increase of mechanical loading on bone in obesity can inhibit apoptosis and increase proliferation of osteoblasts and osteocytes by activation of the Wnt/β‐catenin signaling pathways. This could result in an increase in bone formation.Homeostasis of bone is the equilibrium between bone formation supported by osteoblasts and bone remodeling driven by osteoclasts. From a perspective of cell origin, adipogenesis bias could threaten bone formation and result in bone loss because adipocytes and osteoblasts share a common precursor mesenchymal stem cell in bone marrow.16 Thi Strong evidence supports the role of leptin in increasing BMD. Stephan and colleagues demonstrated that leptin administration resulted in an increase in femoral bone length, bone mineral content, and BMD in leptin‐deficient mice (ob/ob mice). Injection of leptin mitigated cancellous and trabecular bone loss in ovariectomized rats. However, other studies suggest that the effect of leptin on the central nervous system was different from its effect on peripheral tissues, resulting in the reduction of BMD. Moreover, leptin indirectly activates osteoclastogenesis by activating macrophages to produce pro‐inflammatory cytokines. These cytokines in turn increase receptor activator of NF‐κB ligand (RANKL) expression in osteoblasts, which directly activates the process of osteoclast differentiation and subsequent bone resorption. Finally, adipocytes in large numbers, as occurs in obesity, can themselves increase the pro‐inflammatory cytokines TNF‐α, IL6, IL1β, IFN‐γ, MIP‐1, GRO‐α, and RANTES.Another controversial factor is leptin, an adipokine secreted from adipocytes, which is significantly increased in the blood of obese people. On one hand, leptin has osteogenic effects by increasing osteoblastogenesis and suppressing adipocytic differentiation in human marrow stromal cells.22 Str whereas circulating 25‐hydroxyvitamin D levels are low in obese people. This evidence supports a correlation between bone loss and obesity in postmenopausal women. However, an increase in adiposity has a benefit on estrogen replacement because aromatase in adipocytes has the ability to produce estrogen as an alternative source for postmenopausal women. The controversy remains a highly debated subject and is unlikely to reach a consensus in clinical research. The current study addressed the issues described above by using an obese rat model compounded with the multiple challenges  and followed serial stages of the life cycles in order to further understand the changes in BMD in the context of obesity, postmenopause, and aging.The relationship between obesity and BMD is further complicated under postmenopausal circumstances. Estrogen deficiency is associated with not only fat deposition but also bone loss, leading to osteoporosis. In addition to the lack of estrogen causing calcium loss from bone, parathyroid levels are elevated correlating with body weight in obese menopausal women,31 whe and to have beneficial anti‐inflammatory and anti‐arthritis effects. Omega‐3 fatty acids have been shown to protect against osteoporosis, although there is no published information to date regarding any potential benefits of GSM on bone health. The current study assessed whether GSM could benefit bone health by increasing BMD in growing rats or reducing bone loss in ovariectomized rats under either normal or obese conditions. The findings from this study combined with additional studies using a rat model as a tool for preclinical studies assessing the effect of GSM on obesity‐related disorders may clarify some of the ambiguities in the BMD‐obesity relationship and as well as in the obesity paradox.Supplements containing components of Greenshell mussel (GSM) have been widely reported to be a rich source of omega‐3 fatty acids35 and22.1Flash‐dried powder from whole GSM meat was produced by Sanford Ltd  using standard manufacturing processes and assessed for proximate composition in a commercial testing laboratory . To measure the stability of the diets, samples from each of the experimental diets used in the study were collected and frozen after mixing with mussel powder and the nutritive value analyzed according to the Association of Official Analytical Chemists (AOAC) methods for crude protein (AOAC 981.10), total fat (AOAC 948.15), moisture at 105°C (AOAC 950.46), and ash (AOAC 920.153). Carbohydrate content was determined by calculation . An aliquot of the total lipid extract from the GSM powder was transmethylated in methanol/chloroform/hydrochloric acid  for 1 hour at 100°C. After the addition of water, the mixture was extracted three times with hexane/chloroform  to obtain fatty acid methyl esters (FAME). Samples were made up to 1 mL with an internal injection standard (19:0 FAME) and analyzed by gas chromatography mass spectrometry (GC‐MS) according to AOAC 963.22.2.2A total of 144 female Sprague–Dawley rats aged 12 weeks were obtained from the Small Animal Production Unit at Massey University , randomized into groups, and fed test diets for 14 weeks  or 36 weeks  after a 1‐week acclimatization period. Animals were maintained in conventional systems and singly housed in plastic “shoebox” cages with high‐top wire lids, using heat‐treated aspen wood shavings as bedding. The rat rooms were kept at 22 ± 1°C, 45% to 55% humidity, and a 12‐hour light/dark cycle. The numbers of rats per test group were selected calculating a power (1‐β) of 0.8 and a type 1 error rate (α) of 5% for the key parameter of BMD using data from our research group's previous rat studies. All aspects of the study were approved by Massey University Animal Ethic Committee .Normal versus high‐fat/high‐sugar diets were used to allow comparisons between normal‐weight and obese rats groups that these diets generated. Each base diet type  was obtained as a single batch, packaged in vacuum‐sealed plastic pouches, and used within 9 months of receipt. Diets were stored frozen until needed. All diets were designed to contain 15% protein as is standard for AIN‐93M. The proportion of GSM was selected on the assumption that, extrapolated to the human diet, one meal out of each three meals per day would source the protein from GSM; therefore, for the rat diets, one‐third of the protein was sourced from GSM for the GSM‐containing diets. After thawing a pouch in the refrigerator, diets designed to incorporate GSM had GSM powder added in a ratio of one part GSM/nine parts base diet. Diets were then stored refrigerated during the week of use. Subsamples of each diet were taken periodically for further chemical analysis.normal control diet (ND) containing 5% total fat (from soy oil), 5% sucrose, and 15% total protein (from casein);normal control diet supplemented with GSM (ND + GSM) containing 5% total fat (84% from soy oil/16% from GSM), 5% sucrose, and 15% total protein (66% from casein/33% from GSM);high‐fat/high‐sugar diet (HFHS) containing 30% total fat (50% from soy oil/50% from lard), 30% sucrose, and 15% total protein (from casein);high‐fat/high‐sugar diet supplemented with GSM (HFHS + GSM) containing 30% total fat (49% from soy oil/49% from lard/1% from GSM), 30% sucrose, and 15% total protein (66% from casein/33% from GSM).Each day, uneaten diet from each individual feeder was weighed and discarded, and feeders were cleaned and filled with new food, which was weighed and recorded to measure food intake. The test diets, designed to meet or exceed all AIN‐93M requirements, were:2.3DXA whole‐body and regional scans to generate BMD and fat mass/lean mass data in the short‐term cohort were performed at baseline (age 12 weeks) and after 8 and 14 weeks on the experimental diets (age 20 and 26 weeks). The long‐term cohort schedule was similar to the short‐term cohort but with an additional scan after 36 weeks on the experimental diets (age 48 weeks). For both cohorts, after the baseline DXA scan, rats were randomized into diet groups, ensuring that there were no significant differences between groups in basal body weight and no significant differences in lumbar spine and whole‐body bone mineral densities. Rats in the long‐term cohort were further randomized into surgical groups within their diet groups, with randomization again based on eliminating significant differences in body weight and BMD. BMD was evaluated with a Hologic Discovery, a bone densitometer . Quality‐control checks were performed before scanning the animals, and the acceptance of coefficient of variance was 0.98 to 1.01. Rats were positioned supine with right angles between the spine and femurs. All scans used a high‐resolution mode.Anesthesia and DXA scans were carried out as described previously.39 BMD2.4At the end of each cohort, all rats were subjected to euthanasia by undergoing deep anesthesia followed by exsanguination. Samples including different fat pads  were dissected and weighed.In the long‐term cohort, at the age of 20 weeks, half of each group (12 of 24 rats) underwent ovariectomy and the other half a sham surgery as described previously.39At t2.5 were purchased from Sigma‐Aldrich . Leptin was measured using Quantikine Kits . CTX‐I assay kits were obtained from Cloud‐Clone Corp. . Samples were performed in duplicate, and reactions were measured using a microplate reader At the end of the study, anesthetized rats underwent cardiac puncture. Blood was drawn and collected in EDTA‐anticoagulant tubes. Plasma was separated by centrifugation at 2500 rpm  and kept at −80°C until analysis. All analytes were measured using ELISA kits except for tartrate‐resistant acid phosphatase (TRAP), for which individual chemical reagents for a chromogenic assay performed as published elsewhere40 wer2.6t test was used to identify statistically significant differences in fat pad weights between the short‐term rats and the sham rats in the long‐term cohort or the sham rats and OVX rats. Data from serial DXA scans were analyzed by repeated measure method composed of three effects: diet (ND/HFHS), GSM (yes/no), and surgical procedure . Pearson correlation was used to evaluate relationships between body composition and BMD. Bone markers in blood collected from the rats at termination were analyzed by two‐way ANOVA. Statistical analysis was performed using IBM  statistic software version 25, and differences were considered significant at p < 0.05.Body weight, feed intake, and fat pads were analyzed by one‐way ANOVA followed by the least significant difference test. Student's 33.1Protein was equivalent in all diets Table , {TBL 1}3.2p = 0.911). The rate of mean BW gain in the following periods (T1 to T3) declined consecutively, especially in intact rats on the normal control diet (ND), whereas BW gain in the OVX rats increased immediately after the surgical procedure (T2) before returning to the rate of gain observed in T1.Time 0 (T0) designates the period of growing rats on standard chow from age 4 to 12 weeks, during which the rate of body weight (BW) gain of almost 3 g/d was similar across all groups in the long‐term cohort . For the last period of the study (T3), voluntary food consumption rate by OVX rats reduced to a similar rate as sham rats, but their BW gain continued to be higher than sham rats and subsequently OVX rats had higher BW at the end of the study, especially those fed HFHS. The OVX procedure increased total final BW by 24% and 18%, respectively, in rats fed ND and HFHS compared with their sham counterparts (p < 0.001), but only 14% and 7%, respectively, in rats fed ND + GSM and HFHS+GSM, suggesting that regardless of diet type, the inclusion of GSM partially mitigated the weight gain caused by OVX, although this did not reach statistical significance.During the first 8 weeks on the experimental diets before surgery (T1), rats fed HFHS consumed 20% less food by weight than those fed ND but had a 12% higher kilojoule intake due to the HFHS diets being more energy‐dense  but showed no correlation with any BMD scans. Then BMD data were segregated into each group and correlation curves of BMD against BW or plasma leptin were depicted  and CTX‐I (p = 0.036)  Fig. . {FIG7} 4Our study showed that GSM supplementation increased BMD of the right femur, especially in rats in the short‐term cohort. The statistically significant difference of this data is consistent even after adjusting BMD with BW. However, the effect was very mild (only 5% differences when compared with non‐GSM diet), inconsistent with comparative BMD in other body sites, and transient as this effect disappeared at the same time (T2) and the later time (T3) in the long‐term cohort. It is possible that with this very small effect size, a larger sample size would be needed to reveal a consistent result. On the other hand, it might be irrelevant to expect more than a minor change of BMD in physiologically normal rats as body homeostasis regulates the optimal levels of minerals in bone. Any values undergoing extreme changes may represent pathological stages rather than a beneficial effect. Another explanation is that a higher dose of bioactives may be required for efficacy; the dosage levels on a per‐kg body weight basis would have been reduced as food intake did not proportionally increase with increased body weight. and reached the reported therapeutic doses of GSM in animal studies, although these studies did not specifically assess bone health. Thus, it would be predicted that the daily intake in the current study would at least maintain the effective dose of DHA and EPA for anti‐inflammation in the rats. However, as individual lipids were not tested in this study, the bioactive factor(s) cannot be definitively identified. It is also noted that GSM diets contained more ash, and therefore it is possible that the beneficial effects of GSM included additive or synergistic effects between lipids, proteins and peptides, and/or minerals such as calcium.In addition, the bioactives in GSM may not be potent enough to prevent severe bone loss from OVX. Our results seem to support the benefit of omega‐3 rather than omega‐6 because the composition of the diets supplemented with GSM contained DHA and EPA, whereas these omega‐3 fatty acids were not present in the GSM‐free diets. Arachidonic acid is an omega‐6 fatty acid and was not present in any of the diet formulas. The total amount of DHA and EPA in ND + GSM was approximately 2 g/100 g. As the average daily feed intake of the rats was 20 g and the mean BW was 500 g, each rat would have received the combination of DHA and EPA at a dose of 800 mg/kg BW. This dose level is higher than the daily dosage recommended for humans41 andFeeding rats with HFHS induced obesity, even though these animals consumed a lower volume of food because they had a higher overall energy intake due to the HFHS diet being energy‐dense. This resulted in a greater rate of weight gain per day. Weight gain and BW increased in accordance with both feed intake and energy intake in all groups except the sham rats on ND + GSM. Although those rats consumed less food than their paired diet group and even though the GSM diets provided slightly lower energy source  the rats' BW still increased significantly. Similar results were also found in other animal studies and corresponding human studies in which postmenopausal women increased their food intake and weight a few years after the onset of menopause, alterations in metabolism that likely can be attributed to hormonal changes.There was no significant change in the feed intake in all sham rats throughout the study. OVX rats, however, increased their food intake after the surgical procedure for a short period; within 2 months, their consumption rate reduced to these rats' baseline intake and matched the same level as sham animals. The modified food intake in OVX rats had significant effects on their weight gain and increased body weight. This main effect resulted in OVX rats being the most obese in the study; the brief period of increased food intake is likely due to the fact that ovarian hormones have direct effects on adipose tissues and indirect effect on regulation of feed intake and energy expenditure via hypothalamus.43 Sim There was a significant increase of interscapular brown fat due to feeding HFHS diet, but this effect was not present in OVX rats. This conflicting data may not be due to the sole effect of estrogen deficiency but rather combined effects of the hormone and HFHS diet resulting in severely impaired insulin sensitivity, which was revealed by significantly increased HbA1c in the OVX rats fed HFHS diet in our previous report and which influenced brown fat mass. Similar results of decreased brown fat mass were also revealed in obese male rats with insulin resistance. Moreover, insulin‐deprived animal models and insulin knockout rodents model demonstrated a decrease in brown fat mass.Fat mass was the source of BW gain in the older rats as can be found in the consecutive increase of percent change of body fat mass by DXA scans. Also, all main white fat pads harvested during necropsy  significantly increased from 6‐month‐old rats to 12‐month‐old rats. Inguinal fat, which is subcutaneous fat situated around groin and inguinal regions, was present as only a half of that perigonadal fat mass. In contrast to white fat, brown fat, a type of adipocyte responsible for utilizing energy expense through non‐shivering thermogenesis, has an inverse relationship with body mass index in human.47 The reporting a short‐term increase of body lean mass in women after menopause and a shift of fat distribution from leg‐groin area to the upper part of body and abdominal cavity. There was an interaction effect of diet and surgical procedure that could possibly explain the different effects of OVX on the significant increase of fat mass only in ND groups but not HFHS groups at T3. Body fat tended to increase in sham rats but reduced in OVX rats when adding GSM into the diets, although these differences did not reach statistical significance when compared by one‐way ANOVA method within the same time. In contrast, body lean mass increased and reached the peak at the middle age of the animals, then declined at the older age.As expected, HFHS and OVX obviously showed cumulative effects on the expansion of these fat pads; therefore, the OVX rats on HFHS accumulated more fat tissue compared with the other groups. Interestingly, the inguinal fat pad, a type of subcutaneous fat composed of mixed functional (white and brown) adipocytes in OVX rats accelerated its expansion more pronounced than retroperitoneal and perigonadal fat pad, which are visceral fat composed of white adipocytes. This revealed that OVX influenced shifting the course of fat accumulation from visceral fat to inguinal fat. OVX did not only influence fat deposition but also significantly increased lean mass in a short period of time after surgery. It is possible that the observed increase in feed intake directly after ovariectomy supported an increase in body lean mass through increased protein intake. More importantly, the instant loss of estrogen due to ovariectomy would result in a higher androgen/estrogen ratio. The relative increase in androgens could enhance body lean mass and also influence the shift of fat distribution. This finding corroborates with Morita and colleagues51 repLoss of BMD in OVX rats was observed consistently in the lumbar spine and femur scans. However, the whole‐body scan, which is less accurate for detecting bone loss in obese subjects with high body fat compared with the other scans, did not show reduced BMD at the end of the study in OVX rats. Thus using the whole‐body scan to interpret the relationship between body composition and BMD in the context of the obesity paradox may be inappropriate. This discrepancy might be due to the fact that our study scanned the whole femur, which is composed of more cortical bone rather than cancellous bone in the femoral head and pelvic part of the total hip region. However, the same study also recommended using spinal BMD for monitoring treatment. At around 6 months after OVX, estrogen deficiency could cause bone fragility in the lumbar spine as the BMD was lower than the baseline. The OVX rats fed HFHS lost BMD less than those fed ND in lumbar spine and right femur scans, indicating the benefit of obesity on reducing loss of BMD in OVX rats. It has been posited that the expansion of adipocytes in obesity may have an advantage on bone in postmenopausal women by being an alternative source of estrogen. Unfortunately, estrogen levels were not measured in this study and thus this cannot be confirmed, and a significant positive correlation between fat mass and BMD was not observed.The other DXA scans revealed that the deposition of calcium in the femur, the long bone, takes precedence over the lumbar spine in rats as percent change of BMD in femur were higher compared with lumbar spine. Even though most bone sites showed significant bone loss in response to ovariectomy, the lumbar spine is the most sensitive bone site to detect the early bone loss in OVX rats. This finding seems to be different from the study of human trials indicating the total hip is the most reliable site for detecting osteoporosis or predicting hip fracture.52 Thi However, our study found that the bone turnover markers TRAP and CTX‐I declined in the OVX rats. It is possible that adding HSHF diet in OVX rats could aggravate hyperglycemia and insulin resistance in rats as mentioned before, resulting in the reduction of bone metabolism. This finding corroborates with evidence in human with type 2 diabetes who have reduced bone remodeling markers such as procollagen type 1 N‐terminal propeptide, osteocalcin, alkaline phosphatase, and CTX‐I. In addition, hyperglycemia mice induced by high‐fat diet showed reduced biomechanical strength of trabecular and cortical bone with reduced expression of osteocalcin, as which the finding supported bone loss in hyperglycemia mice due to decreased bone formation (osteoblast function). Therefore, decreased bone metabolism is probably the underlying mechanism driving the reduction of BMD in our OVX rats. This finding reveals the fact that there may be different subtypes of osteoporosis in postmenopausal women based on the severity of metabolic conditions and, therefore, the specific therapeutic approach should be considered for those subtypes.Bone health depends on the balance of bone metabolism, which is functioned by osteoblasts and osteoclasts. Many lines of evidence show that bone turnover rate (osteoclast function) increases after ovariectomy and results in bone loss.54 HowTo explore some aspects of the complex relationship between obesity and bone and whether obesity has any benefit on BMD, relevant parameters of all rats at the endpoint data were pooled and correlation analysis was done. The data generally showed that it was not BW and fat mass but only lean mass that had a high correlation with BMD, although we observed significant correlations between fat mass and lean mass as well as between BW and fat mass and BW and lean mass. These findings demonstrate the complexity of defining “obesity” and might raise the question of whether BW needs to be adjusted for in correlation with BMD in obese populations as these subjects are likely to have increased fat mass proportionally higher than lean mass.High levels of fat mass correlated with increased leptin production in the rats, which in turn was highly correlated with BW and fat mass, but leptin still failed to show a correlation with BMD. The data were stratified into groups and the correlations were reevaluated. Surprisingly, a highly positive correlation of BW and BMD in ND/sham rats was detected in all bone site scans and a similar result was found in the correlation with leptin. Therefore, in our model, increased BW and leptin correlated with an observed positive influence on BMD within the normal weight range. We hypothesize that there are likely to be causal relationships between some of these parameters, but this has not yet been demonstrated.) Attainment of peak bone mass depends on a variety of nutritional and endocrine factors.) Many studies have reported the benefits of polyunsaturated fat (PUFA) consumption; however, omega‐3 and omega‐6 are debated in context of anti‐inflammation and bone health.) The increase in BMD theoretically is related to increased calcium deposition in the bone matrix and this might be due to the capability of enhanced calcium absorption in duodenum by DHA and EPA.)Many findings in this animal study correspond with the evidence in postmenopausal women. In women, bone growth during childhood and adolescence contributes to the achievement of peak bone mass, resulting in bone strength of later life.lammation61 and and higher concentration of high‐density lipoprotein cholesterol, producing lower pro‐inflammatory cytokines than visceral fat,) whereas abdominal fat has detrimental effects associated with insulin sensitivity similar to visceral fat. A rat's subcutaneous fat, on the other hand is divided into cranial and caudal parts, which are interscapular fat and inguinal fat, respectively. Both fat pads have common type of beige adipocytes and different from white adipocytes of visceral fat. In postmenopausal women, preferential site of fat deposition is shifted from subcutaneous fat depot to visceral fat depot  regardless of age,) but this study showed that OVX rats increased inguinal fat mass more pronounced than visceral fat when compared with sham rats and, probably, total subcutaneous fat may be greater than visceral fat in OVX rats. Furthermore, women reach the peak of bone mass at the hip by approximately 20 years old followed by a decline, whereas rats are sexually mature by 2.5 months of age but bone growth still occurs until 10 months of age. BMD at all bone sites measured in the sham rats in this study increased over time; hence, the data may not extrapolate to human bone loss in advancing age. However, bone growth in this rat model provided an opportunity to investigate the effect of GSM on enhancement of calcium acquisition in bone.However, some discrepancies between rodents and humans were evident in this study or have been reported elsewhere. For instance, women have two main parts of subcutaneous fat, all located at the lower part of the body, which is gluteofemoral and abdominal fat depot. Gluteofemoral fat in women has been considered as a healthy fat associated with lower triglycerides64 andIn conclusion, our data have partially unraveled the ambiguity of the obesity paradox identified in humans and enabled inference with human bone health by establishing correlations between a number of parameters. First, increased body weight appears to enhance BMD to some extent as long as the weight gain is associated with an increase in lean mass. High fat mass in general was not beneficial to bone density in these rats, although it has been reported to have some advantages of increased bone mass in postmenopausal women. Moreover, consumption of GSM was correlated with increased acquisition of BMD in younger rats but has no effect on increased BMD in ovarian hormone deficiency.HST has a conflict of interest as she is employed by Sanford Limited, which is a mussel producer and exporter. All other authors state that they have no conflicts of interest.5https://publons.com/publon/10.1002/jbm4.10571.The peer review history for this article is available at Appendix S1. Supporting informationClick here for additional data file.


Daniel Hyer and Dr. Bin Cai to join us for this debate.As several major non‐inferiority phase 3 clinical trial studies published their promising results,Parallel to this opinion is Dr. Daniel Hyer. Dr. Hyer received his PhD in Medical Physics from the University of Florida in 2010 and was certified by the American Board of Radiology in 2013. Dr. Hyer is currently an Associate Professor and the Director of Clinical Physics at the University of Iowa. His research interests include MRI‐guided radiotherapy and proton beam therapy. On the latter topic, Dr. Hyer currently holds a National Cancer Institute grant for the development of a proton collimator. Clinically, he is the technical director of the Elekta Unity program at the University of Iowa and has been involved with the project since 2017.Opposed to this opinion is Dr. Bin Cai. Dr. Cai is Associate Professor and Director of Advanced Physics Service in the Department of Radiation Oncology at the University of Texas Southwestern Medical Center. Dr. Cai received his Ph.D. in Physics from Ohio University and completed his medical physics residency training at Washington University School of Medicine. Dr. Cai stayed as a faculty member for  6 years at Washington University after residency. In 2021, he joined UT Southwestern to help develop the adaptive radiotherapy program as well as to lead the implementation of biology‐guided radiotherapy. Dr. Cai is one of the key team members that led the clinical implementation of the world's first MRgART platform. Later he also led the clinical development and implementation of the first CBCT‐guided online adaptations in the United States. Therefore Dr. Cai has extensive and balanced experience on both CTgART and MRgART platforms.22.1The primary goal of online ART is to enable clinicians to develop treatment plans that account for daily anatomical changes of both targets and surrounding normal tissues. Each specific clinical indication has its own set of challenges, and to address these varied issues, clinicians need tools. My esteemed colleague in this debate will be forced to argue that the enormous variety of clinical challenges can entirely or mostly be managed with one tool: a non‐contrast on‐board (CB) CT. I maintain that the way forward for our field is to build not on a single imaging modality, but on a toolset that can be modified to visualize essentially any tissue in the body. This toolset, represented by MR‐Linacs, are equipped with a library of imaging sequences to visualize and enhance a variety of tissues in the body. More importantly, we are currently only scratching the surface of the potential variety of MRI sequences that may have clinical utility in the field of radiotherapy. The non‐contrast on‐board (CB) CTs have and will continue to play an important role in radiotherapy, but the future of online adaptive radiotherapy is the MR toolset.To inform us on what the future of adaptive radiotherapy holds, I believe it is important to consider the historic use of CT in radiotherapy. CT was adopted to provide clinicians with a 3D image to visualize targets and organs at risk that has (1) accurate spatial integrity and (2) density information necessary for dose calculations. If we consider these two features in the context of modern MR scanners, we find that the historical challenges to using MR for these two goals have been addressed: spatial distortion concerns have been managed 10 > 70 Gy) had significant improvements in 2‐year overall survival compared with patients who received a standard treatment regimen in the same trial. Pancreatic dose escalation to this level is likely not possible without the use of MRI‐guided adaptive therapy to delineate the surrounding organs at risk and manage motion in real‐time.The soft‐tissue contrast afforded by MRI has proven critical in numerous clinical cases in our department, but I would like to highlight one especially exciting trial which suggests an increase in 2‐year overall survival for inoperable pancreatic cancer with the use of an MR‐Linac.From a technical standpoint, on‐board MRI not only provides high‐quality 3D images, but also enables continuous 2D cine imaging of the patient during treatment with no extraneous radiation dose. MR‐Cine during daily treatment allows for respiratory gating based on nearly real‐time tumor images rather than the use of a surrogate such as implanted fiducials, as is often required for x‐ray‐guided radiotherapy. This is a notable breakthrough for the treatment of moving targets and has the potential to reduce margins as the uncertainties associated with respiratory gating are greatly mitigated when the user has the ability to track the actual tumor while also visualizing adjacent organs at risk. In the future, it is expected that MRI‐based treatment systems will advance beyond gating for moving targets, and toward MLC tracking based on these cine images—this is something that x‐ray imaging will only be able to do with fiducial implants for targets outside of the lung.The final area where MRI holds an advantage over (CB) CT‐based online adaptive therapy is in the growing field of quantitative imaging. There is still much work to do in this area, however, promising data are emerging for tumor response evaluation using MR sequences such as diffusion‐weighted imaging,I can comfortably concede that non‐contrast on‐board (CB) CT will continue to be the mainstay with respect to image‐guided radiation therapy—not all situations warrant adaptive therapy. However, for the more technically and clinically challenging scenario of online adaptive therapy, we will need and want the full panoply of tools that MR imaging brings.2.2With on‐board MR or X‐ray imaging system, both MR‐guided and CT‐guided online adaptive radiotherapy (MRgART and CTgART) have been implemented clinically by early adopters. Such plan adaption compensates for daily anatomy changes or set up uncertainties, therefore, enables target dose hypofractionation and/or escalation while maintaining low toxicities to organs at risk (OARs). The first commercial MRgART platform, using Co‐60 sources, was deployed to the clinic back in 2014,First, the implementation of MRgART requires significant initial investment in treatment vault construction, MRgART machine with custom‐designed hardware accessories or tools, as well as extra staffing with MR imaging experience. Special consideration should be given to treatment vault design for MRgART machine, including, for example, RF shielding, quench pipe design, MR zoning, etc. all of which add extra cost in addition to regular radiotherapy machine shielding. The treatment unit itself is also expensive, higher than the cost of an MRI scanner and a linac combined.Second, the MRgART introduces new risks due to MR hazards and uncertainties due to MR imaging used, thus demands re‐consideration in treatment strategies and even requires re‐designing of regular clinical workflow. Special staff training is required in order to understand MR hazards and emergency procedures with magnetic field presents. Patient MR screening now is mandatory and patient status needs to be closely monitored/rescreened for each fraction. Radiotherapy planning should take into account uncertainties and complexity resulting from the use of MR imaging, including imaging distortion, potential MR‐CT multi‐modality imaging registration errors, electron return effects, electron density mapping uncertainties, as well as dose calculation accuracy due to presence of MR field. Consequently, regular planning and delivery workflow might need to be redesigned to accommodate these concerns.Moreover, long treatment and potential MR hazards’ limit the patient throughput for MRgART machines. It has been reported that a long treatment time slot is required for MRgART.CT imaging, on the other hand, is a widely applied technology in radiation oncology practice and has been routinely used for many disease sites. Recent development of CTgART enables online adaptation with high‐quality FBCT or CBCT. CTgART offers several distinct benefits over MRgART. The above‐mentioned MR‐specific cost and concerns are largely eliminated. The integrated artificial intelligence (AI)‐assisted automatic segmentation and treatment planning process have greatly streamlined the ART workflow and improved overall treatment efficiency. Reasonable adaptive treatment time has been reported for the Varian Ethos platform, which allows potential high patient throughput with ART.To conclude, as more centers adopt this less complex and more cost‐effective online adaption platform, the future mainstream for online adaptive radiotherapy will be using on‐board CT rather than on‐board MR images.33.1Dr. Cai has argued against the future of MRI‐guided adaptive radiotherapy based on three main points: high capital cost, complex workflows, and low patient throughput. These arguments can be associated with nearly any new technology and are relevant for the present but not the future. I will counter each of these points in my rebuttal.The capital costs associated with an MRI‐guided adaptive radiotherapy program include both construction and equipment costs. With respect to construction, it has been shown many times, including at our own center, that an MR‐linac can fit within the footprint of a standard linac vault. Some centers may require substantial work to receive these state‐of‐the‐art machines; but, from a historical perspective, these are one‐time costs that traditional radiotherapy departments will need to address in order to modernize. New radiotherapy departments will be constructed in a way to anticipate and accommodate MR‐linacs. While I will concede that the equipment costs will always be greater for a combined MRI and linear accelerator, this is only one part of the cost equation. In order to provide commensurate care achievable on an MR‐linac, clinics with only (CB) CT‐equipped devices will need to insert fiducials, beacons, spacers, etc. to address inadequacies in soft‐tissue imaging. The incremental costs associated with these devices will arguably exceed the upfront capital expenditures of an MR‐linac when summed over the decade or more in which they are used.Dr. Cai's second argument is that MRI‐based workflows are more complex. I will agree that clinical workflows for adaptive radiotherapy are certainly more complex than an image‐guided radiotherapy (IGRT) workflow, but I do not believe that the choice of imaging modality makes a significant impact on the complexity of the workflow. The specific complexities that Dr. Cai mentions have all been addressed with modern MR‐linacs. Specifically, dose calculation algorithms used in MR workflows are based on well benchmarked Monte Carlo models which alleviate dosimetric concerns and image distortion is less than 1.1 mm in a 40 cm diameter spherical volume emanating from isocenter on the Elekta Unity.The final point that Dr. Cai makes is that the throughput of MR adaptive radiotherapy is lower than that of CT adaptive radiotherapy. While I agree that in its current form, adaptive radiotherapy is less efficient than traditional IGRT approaches, I do not believe the selection of imaging modality makes a significant impact on throughput. Given the same software tools for registration, contouring, and treatment planning, the only time difference between CT and MR‐based adaptive radiotherapy is in the image acquisition. A standard MR image acquisition for a pelvis treatment at our site is 2 minutes. A similar pelvis CBCT acquisition can be up to 1‐minute in length, meaning that the difference between imaging time with on‐board MRI and on‐board (CB) CT treatments is on the order of 1 minute. When considering the entire treatment, the imaging time is only a small fraction of the entire process. Furthermore, it is reasonable to expect that segmentation, which is one of the most time‐consuming steps in the online adaptive process, will be more fully automated in the future on MR‐linacs because of the superior image quality.In conclusion, my colleague argues that the strength of a CT‐guided approach is in its simplicity and low cost. This, however, is a view of the present challenges of MR guidance. Armed with a comprehensive set of MR sequences and techniques, I am confident that for many of our most challenging clinical problems, we will develop simpler and more cost‐effective approaches using the MR toolset than using the single imaging modality of (CB) CT. I look forward to a future where MR is the mainstay for adaptive radiotherapy.3.2I appreciate Dr. Hyer's effort to introduce and discuss several advantages of MR imaging and its application in MRgART. I do agree that, as mentioned in my opening statement, MR images provide superior soft‐tissue contrast which is critical for accurate delineation of target and OARs of some treatment sites, that is, abdomen. I also agree it is hard to believe a single tool set or ART modality can resolve all challenging scenarios for every treatment site, therefore, in my opinion, both MRgART and CTgART will remain as powerful treatment approaches when implementing online ART. However, the debate topic here is which modality will be the future mainstream ART platform. I believe to serve as a mainstream platform, it should provide effective, efficient, and robust ART solutions for the majority of treatment sites, and also be easy to adopt by a wide range of clinical settings, from large academic cancer centers with great resources to small or standalone clinics with limited resources. As described previously, the MRgART poses more challenges in clinical implementation, which inevitably limits its wide adoptions particularly for centers with limited resources but large patient volume.Indeed, superior MR imaging sequences can be deployed on MR‐Linacs for clear soft‐tissue visualization. However, the distinct benefits of these advanced imaging tools might be limited or specific to certain anatomical sites.From a technical point of view, Dr. Hyers mentioned several limitations on MR imaging: for example, image distortion, registration errors, and uncertainties in electron density mapping, and briefly argued that all limitations have been addressed. It is true that many research efforts have been put into these areas and potential solutions have been proposed. However, none of these solutions completely eliminate the uncertainties or errors for every treatment site. For example, the MR‐only workflow is promising but it is still new to the community. It definitely requires extra efforts in terms of validation and quality assurance. Many early adopters utilize their in‐house solutions on synthetic CT generation which requires high proficiency in programming; several commercial solutions are now available but often remain as a black box to the treatment team, therefore, require extra validation effort and extra precaution when used in a clinic.Note that both commercial and research development of CT or CBCT technologies for the CTgART strategy have NOT reached their maturity yet. With new breakthroughs on X‐ray tube and detector design, improvement in imaging reconstruction algorithm as well as utilization of AI tools, there is no doubt that the image quality and integrity of (CB) CT imaging modality will be further improved. In addition, CT/CBCT imaging with contrast is still an option. As the entire field is going through this paradigm shift to hypo‐fractionation and ultra‐ hypofractionation, it is feasible to give contrast for a limited number of fractions during image acquisition for on‐board CT or CBCT to aid target delineation. Contrast CT or CBCT images will further extend the clinical utility of CTgART to cover more treatment sites, even those demanding superior soft‐tissue contrast.CONFLICT OF INTEREST.Daniel Hyer is the beneficiary of intellectual property licensed to Ion Beam Applications and provides consulting services for Elekta.


Transgender (trans) men in sub‐Saharan Africa are a hidden and vulnerable population who may engage in sex work due to socio‐economic exclusion and lack of alternative employment opportunities. Little is known about HIV and sexually transmitted infection (STI) risk among trans men in this setting. We conducted a multi‐method study to characterize HIV/STI risk among trans men in Uganda.Between January and October 2020, we enrolled 50 trans men into a cross‐sectional study through snowball sampling. Data were collected on socio‐demographic characteristics, sexual practices and depression. We conducted 20 qualitative interviews to explore: (1) descriptions of sexual practices that could increase HIV/STI exposure; (2) experiences of accessing public healthcare facilities; (3) perceptions of HIV or STI testing; (4) HIV and STI service delivery; and (5) drug and alcohol use. We used an inductive content analytic approach centring on descriptive category development to analyse the data.The median age was 25 years (interquartile range 23–28). The prevalence of HIV, syphilis and hepatitis B was 4%, 6% and 8%, respectively. We observed multiple levels of intersecting individual, interpersonal and structural stigmas. (1) Trans men reported transphobic rape motivated by interpersonal stigma that was psychologically traumatizing to the survivor. The resultant stigma and shame hindered healthcare access. (2) Structural stigma and economic vulnerability led to sex work, which increased the risk of HIV and other STIs. Sex work stigma further compounded vulnerability. (3) Individualized stigma led to fear of disclosure of gender identity and HIV status. Concealment was used as a form of stigma management. (4) Multiple levels of stigma hampered access to healthcare services. Preference for trans‐friendly care was motivated by stigma avoidance in public facilities. Overall, the lived experiences of trans men highlight the intertwined relationship between stigma and sexual health.In this sample from Uganda, trans men experienced stigma at multiple levels, highlighting the need for gender‐sensitive healthcare delivery. Stigma reduction interventions, including provider training, non‐discrimination policies, support groups and stigma counselling, could strengthen uptake and utilization of prevention services by this marginalized population. EmerginOther HIV risk factors centre around sex work and sexually transmitted infections (STIs) among trans men. Sex work is common; 13% of trans men in the United States report engaging in sex work, similar to proportions of trans women . Trans mTrans men have been largely ignored in HIV and STI research globally , 22, 23,22.1We conducted a cross‐sectional study among trans men in Uganda from January to October 2020. The study was conducted at the Makerere University Infectious Diseases Institute research clinic in Kasangati, Uganda. Since 2018, five HIV prevention research studies among trans women and trans men have been implemented at the research facility, which is easily accessible by public transportation . The resWe asked about gender identity using a two‐step approach: (1) assessment of sex assignment at birth and (2) current self‐reported gender identity . Inclusi2.2Prior to study initiation, research staff received gender sensitivity training, including from trans men peer educators . QuantitWe invited a purposively sampled subset of participants with a range of relevant life experiences  to take part in a single in‐person qualitative interview after administration of the quantitative survey, usually at the same clinic visit. Interview topics included: (1) descriptions of sexual practices that may increase HIV/STI exposure, including sex work; (2) experiences of accessing public healthcare facilities; (3) perceptions of HIV or STI testing; (4) perspectives on how HIV and STI services should be provided to trans men; and (5) drug and alcohol use. Interviews were about 1 hour long, were conducted by trained cisgender women and men proficient in Luganda  and English and took place at the study clinic in a private place where conversations could not be overheard. Interviews were audio‐recorded with permission, transcribed and translated into English by the interviewer. We performed quality checks for each transcript to identify and correct errors. Participants were compensated with UGX 30,000 ($8.16) in accordance with local research ethics committee guidance.® HBsAg rapid test; Healgan Scientific, Houston, TX, USA) and pregnancy  according to national guidelines . All participants provided written informed consent in English or Luganda. The study received ethical approval from the Makerere University School of Public Health , Uganda National Council for Science and Technology (SS 4467) and MassGeneral Brigham Human Research Committee (protocol 2017P001951).Participants received point‐of‐care testing for HIV and syphilis , hepatitis B virus (HBV)  to organize the coding process. On completion of the coding process, we used queries to sort the data and identify concepts corresponding to stigma experiences. Content categories were developed from emerging themes. Each category consists of a descriptive label, elaborative text and interview quotes illustrating the concept. Categories are described in the Qualitative Results, below. The primary themes identified in the data are represented in these categories; saturation was achieved. We used the Consolidated Criteria for Reporting Qualitative Studies checklist for reporting study findings  23–28) and the median duration of education was 13 years of schooling (IQR 12–15)  had ever used hormone therapy of which six were current users who obtained hormones online (50%), on the black market (17%) or through a healthcare provider (17%). Most  planned to take hormones in the future. The proportion testing positive for HIV, syphilis and HBV was 4%, 6% and 8%, respectively.3.2We present four content categories representing the results of the qualitative analysis. Each category describes a different way in which stigma was experienced by trans men in Uganda Figure . The fir3.3“I got HIV through rape. It is something that I have [not] gotten over because I have never talked about it. At times medicine becomes difficult for me because of the thoughts I get about that incident…for someone who has been raped…there is so much in me that has been damaged since I identify myself as a man. While you will say it happens to every woman, but it is more damaging to me” (age 32).Trans men in this qualitative sample experienced sexual violence, or the threat of it. They were raped by cisgender men “who want to prove a point that you are not a man; you should be a woman.” Transphobic rape was perpetrated to allegedly “correct” gender identity and “teach” trans men how to be cisgender women. The shame and internalized stigma associated with rape made it difficult to talk about being sexually assaulted. The psychological trauma of rape was particularly corrosive to trans male identity. Trans men living with HIV reported that it was difficult to adhere to HIV treatment because taking pills reminded the survivor how they acquired HIV.“When I was 13, I was sent to the market in the evening…and when I was coming back, I was raped. I went back home, and I told my grandparent, ‘I have been raped and blood is coming out of me’. She did not care and only told me, ‘You climb so many trees, you ride bicycles like men, it's good you have been raped’. I cannot forget that statement and it hurt so much that they did not care. I was tortured psychologically. I was in pain, and I even started rotting as I had not got treatment…my grandmother had refused to take me to the hospital because I behave in a certain way and that I am possessed by the devil” (age 30).Participants reported that sexual assault was dismissed by family members who prioritized adherence to societal norms over individual self‐expression, and perceived gender non‐conformity as a spiritual problem. The lack of empathy from loved ones following sexual assault further traumatized rape survivors. They were also denied access to post‐rape care services, which compromised their mental and sexual health and perpetuated stigma.3.4You will not get a job where your identity card reads a ‘she’ and they call you a ‘he’.” It was also experienced after getting employed –– “Once they got to know [who] I was, I would lose the job.” Economic vulnerability resulting from lack of employment opportunities and limited educational attainment led trans men into selling sex for survival, which exposed them to the risk of HIV and other STIs. Stigma affected trans men economically, through financial pressure to make ends meet, and socially through the clandestine nature of sex work, which was not disclosed to intimate partners. Poverty, enacted stigma and transgender inequality contributed to engagement in sex work and susceptibility to HIV.“Some of us have multiple partners and most HIV risks are a result of [our] socio‐economic setup. We are doing sex work because many of us have not finished school so we do not have jobs and the best thing we can do is survive which is through sex work and we are in relationships with people who expect us to take care of them. You find someone doing sex work with a man and they are not telling their partner and there are risks involved because they are having sex with a man for money. They are having sex with their partner for intimacy, and they are not mentioning that they are actually having sex for money outside the relationship” (age 32).Structural stigma enacted through employer discrimination was experienced before getting a job –– ““Me to sleep with my boss when he is giving me two hundred thousand shillings [$56.20] and it can help me solve my problem, at the end of the day, what am I losing? I do it. You don't think of HIV and other diseases. You think about them after solving your problem” (age 29).Avoiding HIV infection was not an immediate priority for participants if exchanging sex for money helped to solve pressing financial problems. A hidden population with limited employment opportunities had to find ways to survive economically. The end was perceived to justify the means.3.5“That myth that trans men cannot get HIV is common because people believe that the risk of getting HIV is low since vaginal sex is not penetrative. That myth of them not being at risk of getting HIV stops them from testing for HIV, and you do not want to be the only trans man that is HIV positive! It is already too much work [to be] a trans person. People are afraid of knowing of their status…the stigma is still much” (age 25).Despite these sexual practices, trans men alluded to the common belief that they were not at risk of HIV infection because of non‐penetrative consensual sex with cisgender women. HIV stigma coupled with the stigma of being transgender was perceived to hinder the uptake of HIV testing services and status disclosure.“When I was arrested [at a club party], I told [my friend] that you know what, ‘My mum is going to get to know that am a gay’. She told me that, ‘You just tell your mum point blank that you are a trans man’. I told her that I cannot tell her such things. She will instead hang me. She insisted that I should tell her… I got my phone and called her while crying. I told her that the truth is, ‘I fall in love with fellow women, but I ask for your forgiveness. That is what I feel like I want’. She was like, ‘You know what, you are not going to stay here. You might spoil my other children. Don't come back here to spoil my children because I gave birth to girl children only’. I got my belongings and left. She told me goodbye. Up to now, we don't communicate” (age 21).Trans men preferred to conceal their identity because “trans stigma that is out there” led to fear of disclosure. Disclosure of gender identity to family members was fraught with difficulty and risked ostracization. It was occasioned by significant events like arrest and incarceration, which necessitated notifying next of kin. Such disclosure had significant consequences, like being asked to leave the family home after “coming out of the closet,” because of stigma based on gender identity.3.6“How is the public going to look at me? Yeah, I have just entered [a] public hospital; people are staring, people are looking. People want to ask questions so that uncomfortable [feeling] is what I don't want. The trans community is still, there is still that reluctance of going there [health facility]. I think most of them now prefer when a [transgender] organization has a drop‐in center (DIC). They feel a sense of belonging. I know I will be safe there. No one will ask these personal questions so I will gladly want a DIC not a health facility” (age 27).Trans men avoided public health facilities for fear of how they would be perceived and treated by healthcare workers, preferring instead to receive healthcare from trans‐friendly facilities, such as drop‐in centres. These service delivery points offer walk‐in services, are staffed by members of key populations or friendly healthcare providers and are safe spaces where trans men felt comfortable knowing they would not be asked uncomfortable personal questions.“Trans men [are] not going to tell you that [they] had a sexual encounter with this person but then it ended up as rape. They usually never want to open up and say those things to any health facilities or providers. So, there is going to be that barrier of he has raped me and how do I go for screening? What has he given to me? Probably he had a few infections. I just come in secrecy; I confide in [someone] in the [trans] community that has access to these services. I will not tell them what is wrong, I will just tell them…help me get a [HIV] testing kit and some PEP [post‐exposure prophylaxis]” (age 27).Healthcare stigma made it particularly difficult to seek care in facilities where they worried about being stigmatized and where it would be difficult to explain that a man had been sexually assaulted. It was difficult for trans men to articulate their vulnerability to healthcare providers. Survivors of sexual violence preferred instead to ask trusted people within the trans community for help with accessing testing and treatment services.4In this multi‐method study of young trans men in Uganda, stigma was experienced at individual, interpersonal and structural levels. Rape motivated by transphobic beliefs resulted in poor mental health and internalized stigma among rape survivors exacerbating HIV/STI vulnerability. Structural stigma enacted through employment discrimination, limited opportunities for gainful employment and resulted in sexual risk practices and engagement in sex work. Anticipated stigma resulted in fear of disclosure of gender identity and HIV status, poor uptake of HIV services and healthcare avoidance. Overall, stigma operated at multiple intersecting levels to negatively impact health.Trans men in our study experienced rape that was motivated by transphobic beliefs –– enacted forms of stigma, including physical and sexual violence, due to an individual's gender identity or expression . Sexual Structural stigma –– cultural and societal norms, policies and laws that limit opportunities and resources available to stigmatized people –– reduces trans men's access to formal employment and financial services; lack of alternative opportunities drives trans men into sex work, which increases their vulnerability to HIV and other STIs , 49. TraBoth internalized stigma (negative beliefs a person holds about themselves and their identity) and anticipated stigma (concerns about reactions or behaviours of others were their stigmatized identity to become known) can influence behaviour . In thisHealthcare stigma operates at interpersonal and structural levels and is rooted in the ways that society negatively views trans men . Lack ofWe found that HIV prevalence in our study of trans men was lower than that reported among cisgender women in the 2017 Uganda Population‐Based HIV Impact Survey (7.6%) . HIV preOur study strengths include the successful enrolment of a novel sample of trans men who are largely hidden and invisible to HIV programming and research in sub‐Saharan Africa. Our study adds to the knowledge base of HIV and STI risk and stigma experiences of trans men in sub‐Saharan Africa. The limitations of this exploratory work include the cross‐sectional design. Non‐random sampling may have led to the selection of trans men with greater HIV/STI vulnerability. The inability to determine temporal relationships between outcomes and risk factors limited the analysis of behavioural correlates of HIV/STI infection. We had limited funding for broader STI testing and did not test for other curable STIs. The small sample size may not be representative of trans men in Uganda. Our results, obtained from one research clinic, are not generalizable but may inform programmatic delivery of sexual health services for this population in Uganda and potentially other African settings. Nevertheless, our study contributes to a scarce body of literature on stigma and HIV vulnerability among trans men in sub‐Saharan Africa.5Our findings underscore the urgent need for trans men to access safe and friendly comprehensive HIV/STI services that are tailored to their specific needs. This need is underscored in settings where HIV and other STIs are concentrated among key populations, unemployment is rife, sex work is illegal and healthcare access is limited. Trans men exposed to sexual violence should be provided with gender sensitive and respectful survivor‐centred support, and access to justice and legal redress. Multi‐level interventions are needed to address trans stigma at individual, interpersonal and structural levels and improve health outcomes.AM reports a grant from Gilead Sciences, Inc outside the submitted work, and was an advisor to ViiV Healthcare. JEH is a consultant for Merck. JMB works for Gilead Sciences, Inc. but was faculty at the University of Washington, Seattle, USA at the time of the study.AM, JEH and NCW conceptualized the manuscript. MSN conducted the statistical analyses. VK, BK, AN, JM and CCT conducted qualitative interviews and transcription. MAW, TRM, JEH and AM supervised qualitative data collection and study implementation. AM and VK coded the data. AM wrote the first draft along with JEH. ACT, TRM, JEH, MAW, JMB and NCW reviewed drafts and provided substantial edits. All authors read and approved the final version.This work was supported through research grants from the United States National Institutes of Health (grants K43 TW010695 and AI027757 [AM] and K24 mentor award MH114732 [JEH]). Study data were collected using REDCap, funded through grants UL1 TR002319, KL2 TR002317 and TL1 TR002318 from the National Center for Advancing Translational Sciences. This paper represents the opinions of the authors and does not necessarily represent the official views of the National Institutes of Health.


Childhood undernutrition includes wasting (weight‐for‐height z‐score (WHZ) < ‐2SD), stunting (height‐for‐age z‐score (HAZ) < ‐2SD), underweight (weight‐for‐age z‐score (WAZ) < ‐2SD) and micronutrient deficiencies or insufficiencies (WHO 2017a). The current World Health Organization (WHO) guidelines subsume these entities into the blanket term of childhood malnutrition which is broadly categorized into acute and chronic malnutrition. Acute malnutrition is further classified on the basis of severity into moderate acute malnutrition (MAM) (WHZ between ‐3 and ‐2) and severe acute malnutrition (SAM) (WHZ < ‐3 and mid‐upper arm circumference (MUAC) < 115 mm) whereas chronic malnutrition occurs due to long‐term insufficient intake of nutrients and a complex interplay of intergenerational and environmental factors and results in stunting (UNICEF 2009). In 2017, an estimated 155 million children under five years of age were stunted and 52 million were wasted (Development Initiatives 2017). Around 45% of death among children under five years of age is associated with undernutrition (WHO 2017a). Asia and Africa still share the greatest burden of malnutrition with more than half of all stunted children and two third of all wasted children under five years of age living in Asia and over one third stunted children and a quarter of wasted children living in Africa (UNICEF 2017).Ruel 2013).Childhood malnutrition is a major public health concern since it is associated with significant morbidity and mortality (WHO 2017). The consequences of malnutrition among infants and children can be short‐term like morbidity, mortality and disability or long‐term including impaired cognitive development, increased risk of disease due to either concurrent infections or metabolic disorders and sub optimal economic productivity . UndernuThe existing WHO guidelines for the management malnutrition among children suggests the following (WHO 2013):1. Early identification of children with SAM in the community through active community screening by trained community health workers and community members. Community health workers should measure the MUAC of infants and children under five years of age and examine them for bilateral pitting oedema.2. Assessment of nutrition status in primary health‐care facilities and hospitals through routine health facility screening. Health‐care workers should assess the MUAC or the WHZ status of infants and children under five years of age and also examine them for bilateral oedema.3. Children who are identified as having SAM should first be assessed with a full clinical examination to confirm whether they have medical complications and whether they have an appetite. Children who have appetite and are clinically well and alert should be treated as outpatients and can be managed with ready‐to‐use therapeutic food (RUTF) in amounts adjusted to their weight, to provide recommended energy intakes for recovery.4. Children with uncomplicated SAM, not requiring to be admitted and who are managed as outpatients, should be given a course of oral antibiotics such as amoxicillin while children who are undernourished but who do not have SAM should not routinely receive antibiotics unless they show signs of clinical infection. Children admitted with SAM and with no apparent signs of infection and no complications should be given an oral antibiotic.5. Children who have medical complications, severe oedema (+++), or poor appetite, or present with one or more Integrated Management of Childhood Illness danger signs should be treated as inpatients. Children admitted with SAM and complications such as septic shock, hypoglycaemia, hypothermia, skin infections, or respiratory or urinary tract infections, or who appear lethargic or sickly, should be given parenteral antibiotics. Children with SAM who are admitted to hospital can be transferred to outpatient care when their medical complications, including oedema, are resolving and they have good appetite, and are clinically well and alert. The decision to transfer children from inpatient to outpatient care should be determined by their clinical condition and not on the basis of specific anthropometric outcomes. Children with SAM who are discharged from treatment programmes should be periodically monitored to avoid a relapse.6. F‐75 and F‐100 are formula diets used for the management of children with SAM in inpatient care. F‐75  is used during the initial phase of treatment, while F‐100  is used during the rehabilitation phase. Children with SAM cannot tolerate high amounts of protein and fat and hence they are supplemented with F‐75 initially; as soon as the child is stabilized on F‐75, F‐100 is used as a “catch‐up” formula. Children with SAM who present with either acute or persistent diarrhoea, can be given RUTF in the same way as children without diarrhoea, whether they are being managed as inpatients or outpatients.7. Children with SAM should receive the daily recommended nutrient intake of vitamin A throughout the treatment period. Children with SAM should be provided with about 5000 IU vitamin A daily, either as an integral part of therapeutic foods or as part of a multi‐micronutrient formulation.According to these guidelines, children with complicated SAM are managed as inpatients in three phases; stabilization phase which includes fluid management for severe dehydration, correction of hypothermia, hypoglycaemia and micronutrient deficiencies and the use of antibiotics for complications; rehabilitation phase which includes increased nutrient and energy intake through therapeutic or fortified foods as well continued electrolyte and micronutrient management. Following recovery, caregivers are given appropriate nutritional training to avoid similar recurrences and instructed on the importance of sensory stimulation in children for continued emotional and physical development (Ashworth 2003). SAM among children under six months of age is increasingly being associated with higher mortality than in older infants and children (WHO 2013). The WHO guideline suggests that in infants who are under six months of age with SAM should receive the same general medical care as infants with SAM who are six months of age or older with increased focus on establishing, or re‐establishing, effective exclusive breastfeeding by the mother or other caregiver (WHO 2013).In this review, we will assess the effectiveness of various community‐based and facility based strategies to identify and manage MAM and SAM; including the community based screening, identification management of SAM and MAM, relative effectiveness of RUTF for SAM and RUSF for MAM, effectiveness of prophylactic use of antibiotic to manage uncomplicated SAM and the effectiveness of vitamin A supplementation to manage children with acute malnutrition.Childhood malnutrition results in long‐term disability through cognitive impairment, delayed motor growth, poor physical performance, low‐birth weight of future offspring, behavioural issues and poor academic performance as well as sub‐optimal productivity in adulthood . The ComAlcoba 2013; Undernutrition  has been associated with infectious diseases and children with SAM may be more susceptible to infection . CurrentKarakochuk 2012). Supplementary foods are considered an effective strategy in the treatment and management of malnutrition either at home, facility or rehabilitation centre (Visser 2013). Supplementation promotes recovery by increasing nutrient absorption, thus improving growth and promoting development especially in the first 1000 days of life which is critical to cognitive function , there is uncertainty around the most effective methods to treat malnutrition in young children . The exi1. Assessing the strategies to improve active community screening and routine health‐facility screening, and investigating barriers to service access and uptake, to enhance treatment coverage.2. Assessing the clinical effect and cost effectiveness of giving oral antibiotics to children and infants with SAM who do not require inpatient management in non‐HIV settings.3. Assessing the adverse effects of giving broad‐spectrum antibiotics to infants and children with SAM without complications.4. Assessing the efficacy and effectiveness of different ready to use supplementary food (RUSF) and RUTF that comply with WHO specifications and are made from different ingredients in different regions of the world  and the comparative effectiveness of RUTF, RUSF and F‐100 for recovery of children with MAM and SAM.5. Assessing the efficacy of daily low‐dose vitamin A supplementation compared to single high‐dose vitamin A in the treatment of children with SAM and the most effective way to improve and sustain the vitamin A status of children with SAM after discharge from treatment.Lenters 2013). Existing reviews on management of acute malnutrition are either focused on specific population groups; specific interventions ; or there is discrepancy in the definition of undernutrition and types of therapeutic or supplementary foods ((Manary 2012). But there is a need to comprehensively review the evidence for the management of SAM and MAM according to the current WHO protocol using facility‐ and community‐based approaches as well as the effectiveness of RUTF, RUSF, prophylactic antibiotic use and vitamin A supplementation. Therefore, the aim of this systematic review is to analyse and update the evidence on the effectiveness of recommended interventions and to assess the program and/or guidelines that have been adapted to manage children with acute malnutrition to provide a comprehensive and updated review.The above research gaps from the WHO guidelines have not been the topic of a comprehensive systematic review. However, there are a few existing reviews evaluating some interventions separately. The objectives of this review are as follows:1. To evaluate the effectiveness of community‐based strategies such as community‐based mobilization, screening, follow‐up, counselling and education to improve screening, identification and management of SAM and MAM.2. To evaluate the effectiveness of facility‐based strategies such as facility based screening, management and periodic follow‐up to improve screening and management of SAM and MAM.3. To evaluate the effectiveness and relative effectiveness of various RUTF and RUSF for the management of SAM and MAM.4. To evaluate the effectiveness of prophylactic use of antibiotic to manage uncomplicated SAM.5. To evaluate the effectiveness of various doses of vitamin A supplements to manage children with SAM and MAM.We will include the following study designs that allow for causal inference. We will include study designs other than RCTs to include large‐scale programme evaluations, which assess the efficacy and/or effectiveness of interventions:We will include the following study designs:► Randomized controlled trials (RCTs), where participants were randomly assigned, individually or in clusters, to intervention and comparison groups. Cross‐over designs will be eligible for inclusion.► Quasi‐experimental designs, which include:▷ Natural experiments: studies where non‐random assignment is determined by factors that are out of the control of the investigator. One common type includes allocation based on exogenous geographical variation.▷ Controlled before‐after studies (CBA), in which measures were taken of an experimental group and a comparable control group both before and after the intervention. We also require that appropriate methods were used to control for confounding, such as statistical matching  or regression adjustment .▷ Regression discontinuity designs; here, allocation to intervention/control is based upon a cut‐off score.▷ Interrupted time series (ITS) studies, in which outcomes were measured in the intervention group at least three time points before the intervention and after the intervention.We will include studies targeting children under five years of age with MAM and SAM in low‐ and middle‐income countries. Studies including both eligible and non‐eligible participants will only be included if the results for the eligible participant subgroup is separately provided in the study. We will use the following definition of MAM and SAM by WHO (WHO 2013):► SAM: weight for‐ height z‐score (WHZ) < ‐3 SD, weight‐for‐height (WFH) < 70% of the median National Center for Health Statistics (NCHS) or WHO reference or mid‐upper arm circumference (MUAC) < 115mm or oedema. Complicated SAM: SAM cases without appetite and/or with medical complications. Uncomplicated SAM: SAM children with successful standard appetite test, without fever, clinical infections, or complications.► MAM: weight‐for‐height z‐score (WHZ) between ‐2 and ‐3 standard deviations (SD), WFH equal to 70‐80% of the NCHS or WHO reference median or mid‐upper arm circumference (MUAC) of 115‐125mm.We will exclude studies conducted on HIV populations specifically.The following interventions will be considered and compared against the suggested comparison groups separately:► Community based strategies to screen, identify and manage SAM and MAM compared to standard care  versus no active surveillance; training of CHWs for community based screening versus no training; community based management with RUTF versus standard care practices).► Facility based strategies to screen and manage uncomplicated SAM according to the WHO protocol compared to other standards of care .► Community based management of children with uncomplicated SAM as outpatients with RUTF compared to standard diet, fortified blended flours (FBFs) or other locally produced foods► RUSF for MAM compared to standard diet, or FBF or other locally produced foods.► Prophylactic use of antibiotics in children with uncomplicated SAM compared to no antibiotics.► Vitamin A supplementation in the management of SAM and MAM with various doses and frequency of administration.We will not use the outcomes listed below as criteria for including studies but rather as a list of the outcomes of interest. We will use denominators for the outcomes according to the intention to treat analysis to avoid misleading results. We will subgroup outcomes reported at different time points as specified under the ‘Subgroup analysis and investigation of heterogeneity’.Primary outcomes► Recovery rate .► Weight gain (measured as grams/kg/day).► Relapse (measured as the proportion of children who re‐enrolled after they had recovered).► Mortality .► Case fatality rates .Secondary outcomes► Height gain► MUAC gain► Time to recover (measured as length of time between admission and discharge).► Stunting (defined as below minus two standard deviations from median height for age of reference population).► Wasting (defined as below minus two standard deviations from median weight for height of reference population).► Underweight (defined as below minus two standard deviations from median weight for age of reference population).► Infection incidence .► Adverse effects .► Costs and cost effectivenessWe will attempt to standardise the effect sizes from the included studies and report the outcomes at the longest follow‐up reported.We will include studies conducted in community or facility based settings in low and middle income countries as defined by the World Bank criteria.indmed.nic.in/indmed.html and WHO Global Health Index. We will also search the WHO International Clinical Trials Registry Platform ; ClinicalTrials.gov and Epistemonikos (https://www.epistemonikos.org)/. We will not restrict our searches by date, language or publication status.We will search the following databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; World Health Organization regional databases; The Campbell Library; MEDLINE (PubMed); Embase; CINAHL; Web of Science; POPLINE; CAB abstracts and Global Health; PAHO; IndMED  to include data from large‐scale programme evaluations, which assess the efficacy and/or effectiveness of interventions. One potentially eligible study is Dubrey 2008 which is a randomised, unblinded, superiority‐controlled trial. The study setting is a therapeutic feeding centre in Khartoum, Sudan. The study participants included children aged 6–59 months with SAM. The study compared once daily intramuscular injection administration with ceftriaxone for two days with oral amoxicillin twice daily for five days among children with SAM. The outcomes reported by the trial included weight gain, SAM recovery rate and case fatality ratio between the two groups.Another potentially eligible study is Before initiating the synthesis (detailed below), we will ensure that all articles reporting on the same study are appropriately linked. To ensure independence and appropriate combination of outcome constructs, syntheses will be conducted according to the type of interventions specified above. If multi‐arm studies are included, intervention groups will be combined or separated into different forest plots, and we will ensure that there is no double counting of participants. If an outcome is reported in several different metrics, we will perform unit conversions in order to pool the data. We do anticipate differences in the types of literature and we will ensure that any analysis will take possible sources of dependency into account by grouping papers into studies and ensuring that no double counting of evidence takes place when synthesizing across studies.Two reviewers will independently assess relevant studies by screening the titles and abstracts for inclusion. The selected studies will undergo full text evaluation and will be added based on predefined eligibility criteria. Disagreements about appropriateness of the inclusion of studies will be resolved by discussion between all review authors. Studies that meet the inclusion criteria on full text screening but upon further investigation become ineligible will appear in a ‘characteristics of excluded studies' table, along with the reasons for their exclusion. We will also attempt to contact the study authors regarding eligibility for studies where eligibility is unclear.Two review authors will independently extract data on a predefined and pre‐tested data extraction sheet. We will extract the following information, where available, from relevant studies and any discrepancies will be resolved by group discussion.Study Method:► Study dates► Location ► Study design► Method of recruitment► Study context and settingsParticipants:► Sample size► Age► Gender► Socioeconomic status► Inclusion and exclusion criteriaIntervention:► Micronutrients and vitamin A supplementation (doses and timing)► Antibiotics (type and doses)► Community based screening and management of malnutrition ► Facility based screening and management of malnutrition► Type of RUTF► Type of supplementary feedingComparison group:► No intervention or placebo or standard practice or other treatment.► Type of supplementary food Outcomes► Primary and secondary outcomes, as outlined in the types of outcome measure section. We will use denominators for the outcomes according to the intention to treat analysis to avoid misleading resultsQuality Assessment► On all Cochrane ‘Risk of bias’ assessment tool indicatorsTwo review authors will independently assess methodological quality of studies using and any disagreements will be resolved by discussion among all review authors. The Cochrane ‘Risk of bias’ assessment tool  will be 1. Selection bias 2. Performance bias (blinding of participants and personnel assessment)3. Detection bias (blinding of outcome assessment)4. Attrition bias (incomplete outcome data)5. Reporting bias (selective reporting)6. Other biasFor non‐randomised studies, we will use the Cochrane Effective Practice and Organisation of Care (EPOC) guidelines based on the following criteria (EPOC 2017). We will rate each of the following components as either ‘low risk’, ‘high risk’ or ‘unclear risk’ and provide justifications for the judgements:1. Baseline outcome measurements similar2. Baseline characteristics similar3. Incomplete outcome data4. Knowledge of the allocated interventions adequately prevented during study (refers to blinding of participants and personnel and blinding of outcome assessment)5. Protection against contamination6. Selective outcome reporting7. Other risks of bias For interrupted time series studies, the following criteria from EPOC will be considered (EPOC 2017). We will rate each of the following components as either ‘low risk’, ‘high risk’ or ‘unclear risk’ and provide justifications for the judgements:1. Intervention independent of other changes2. Shape of intervention effect pre‐specified3. Intervention unlikely to affect data collection4. Knowledge of the allocated interventions adequately prevented during study (refers to the blinding of outcome assessment)5. Incomplete outcome data6. Selective outcome reporting7. Other risks of bias We will separately analyse the dichotomous and continuous outcomes. For dichotomous outcomes, we will present the results as summary risk ratios (RRs) with 95% confidence intervals (CI). We will combine incidence data as risk ratios (events per child) and rate ratios (events per child year) because of their similar interpretation and scale. We will present continuous outcome data as either a mean difference (MD), if outcomes have been measured on the same scale, or a standardized mean difference (SMD), if outcomes have been measured on different scales, with 95% CI. If outcomes are reported at multiple time points in the included studies, we will report the outcomes at the last reported time period, unless other time point points are relevant for the subgroup analysis. For studies reporting outcomes at multiple time points, we will report the last outcome reported at last follow‐up. We will conduct subgroup analysis for outcomes reported at different time periods.We will conduct separate meta‐analysis for different study designs and for subcategories of interventions and outcomes. For cluster RCTs, if we will contact trial authors for an estimate of the intra‐cluster correlation coefficient (ICC) if the clustering effect is not accounted for in the analysis, if we are unable to contact the trial author we will then calculate an interclass correlation coefficient based on the other studies in the review and use the variance inflation factor to adjust the standard errors appropriately. Subsequently, effect sizes and standard errors will be meta‐analysed by using the generic inverse method in RevMan 5 (RevMan 2014) If there are multiple papers that describe the same trial, these will be combined and coded as a single study. For trials that include multiple intervention arms, we will select one pair (intervention and control) that satisfy the inclusion criteria of the review and exclude the rest. If > 2 intervention groups meet the eligibility criteria, then these groups will be combined into a single pair‐wise comparison group and data will be disaggregated into corresponding subgroups, or these arms will be separated into different forest plots to ensure that there is no double counting of participants. Multiple outcome estimates within the same study will be analysed separately.We will report the missing data or dropouts along with the reasons. We will contact the study authors if the missing data is not accounted for or the reasons for dropping out are unclear. If authors have accounted for missing data (i.e. multiple imputations), we will use the adjusted data within our analysis.2, I2 and significance of the Chi‐square test; we will also assess heterogeneity visually using forest plots. Based on prior theory and clinical knowledge, we expect clinical and methodological heterogeneity in effect sizes in this literature. Therefore, we will attempt to explain any observed statistical heterogeneity using subgroup analysis .Statistical heterogeneity will be assessed using TauIf the number of studies is sufficient (> 10), we will use a funnel plot to visually inspect for publication bias. In addition, we will perform Egger's test to determine funnel plot asymmetry.Statistical analysis will be carried out separately for each intervention using Review Manager 5.3 (RevMan 2014). Separate meta‐analyses will be conducted for each type of intervention and comparison group and study design. Where analysis has not been ideal in the original papers, we would attempt to reconstruct if the data presented allows us to. Considering the expected heterogeneity in interventions, comparisons, outcomes and settings within the included studies, we will use random‐effects meta‐analyses. Where meta‐analysis is deemed inappropriate due to substantial statistical or clinical heterogeneity between studies, the findings of the included studies will be summarized in narrative form. In cases where we include multiple groups from one study, we will combine all relevant experimental intervention groups of the study into a single group, and combine all relevant control intervention groups into a single control group or include each pair‐wise comparison separately, but with shared intervention groups divided out approximately evenly among the comparisons to avoid double counts .We will set out the main findings of the review for the primary outcomes in ‘Summary of findings’ tables prepared via the GRADE approach  with GRAThere are five criteria that can downgrade evidence for RCTs and quasi‐RCTs. [GRADE 2004]:► Risk of bias in individual studies► Indirectness of evidence► Unexplained heterogeneity or inconsistency of results► Imprecision of results► High probably of publication biasThere are three criteria that can upgrade the evidence for quasi‐experimental studies with no serious methodological limitations. [GRADE 2004]:► Large magnitude of effect► Presence of a dose response relationships► Effect of plausible residual confoundingDepending on data availability, we will conduct exploratory subgroup analyses for the following subgroups:► Age ► Duration of intervention (short‐term (< 3 months), medium‐term (3‐6 months), and long‐term (6‐12 months))► Various formulations of supplementary foods► Setting ► Vitamin A supplementation dosage (different doses)► Different antibiotics► Equity (low income and disadvantaged groups versus relatively high income groups)We will use the Chi2 test to assess subgroup differences.We will conduct sensitivity analysis based on the risk of bias of the included studies by restricting the analysis to studies with low risk of bias for sequence generation, allocation concealment and blinding of participants to determine whether the removal of studies with high risk of bias impacts the estimates.We do not plan to include qualitative research.Lead review author: The lead author is the person who develops and co‐ordinates the review team, discusses and assigns roles for individual members of the review team, liaises with the editorial base and takes responsibility for the on‐going updates of the review.► Content: Jai K Das, Rehana A Salam, Zulfiqar A Bhutta► Systematic review methods: Jai K Das, Rehana A Salam, Marwah Saeed, Hasana Bilal► Statistical analysis: Jai K Das, Rehana A Salam► Information retrieval: Rehana A Salam, Marwah Saeed, Hasana BilalFunding for this review came from a grant from the Bill & Melinda Gates Foundation to theCentre for Global Child Health at The Hospital for Sick Children (Grant No. OPP1137750)The authors are not aware of any conflicts of interest arising from financial or researcher interestsApproximate date for submission of the systematic review: March 2019.The corresponding author, will be responsible for any forthcoming updates to the review.By completing this form, you accept responsibility for preparing, maintaining and updating the review in accordance with Campbell Collaboration policy. 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Some journals, however, have restrictions that preclude publication of findings that have been, or will be, reported elsewhere and authors considering publication in such a journal should be aware of possible conflict with publication of the monograph version in Campbell Systematic Reviews. Publication in a journal after publication or in press status in Campbell Systematic Reviews should acknowledge the Campbell version and include a citation to it. Note that systematic reviews published in Campbell Systematic Reviews and co‐registered with Cochrane may have additional requirements or restrictions for co‐publication. Review authors accept responsibility for meeting any co‐publication requirements.I understand the commitment required to undertake a Campbell review, and agree to publish in the Campbell Library. Signed on behalf of the authors: