A Modern Flexitarian Dietary Intervention Incorporating Web-Based Nutrition Education in Healthy Young Adults: Protocol for a Randomized Controlled Trial

Background The trend of flexitarian eating patterns is on the rise, with young adults among the biggest adopters claiming health and environmental reasons to reduce red meat intake. Nutrient-dense meat and animal products are often the lynchpin of these diets, even when consumed only occasionally and in moderate amounts. Red meat provides forms and concentrations of essential proteins, lipids, and micronutrients that are scarce in exclusively vegetarian regimens. Objective The aim of this study is to consider the effects of moderate consumption of lean red meat as part of an otherwise vegetarian balanced diet and its impact on biomarkers of sustained health and well-being. Methods A cohort of healthy, young (20-34 years old, n=80) male and female participants will take part in a 2-arm, parallel randomized controlled trial (RCT) for a duration of 12 weeks, with a 3-month posttrial follow-up. The trial will commence with a 2-week assessment period followed by allocation to the intervention arms. The intervention will include the consumption of red meat or meat alternatives 3 times per week for 10 weeks. Blood samples of the participants will be collected to measure changes in erythrocyte fatty acid distribution, circulating amino acids, neurotransmitters, markers of mineral status, and inflammatory markers. Questionnaires to assess well-being and mental health will be undertaken every 2 weeks. Body composition, physical function, and blood parameters will be assessed at allocation (t0), week 5 into the intervention (t5), and post intervention (t10). Results The protocol has been developed using the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) checklist and the outcomes will be reported in accordance with the CONSORT (Consolidated Standards of Reporting Trials) guidelines. The trial was approved by the New Zealand Ministry of Health’s Health and Disability Ethics Committees (protocol 20/STH/157). The results of this study will be communicated via publication. Conclusions To our knowledge, this is the first RCT investigating the overarching health consequences of consuming pasture-fed red meat or no meat as part of a healthy diet. Trial Registration ClinicalTrials.gov NCT04869163; https://clinicaltrials.gov/ct2/show/NCT04869163 International Registered Report Identifier (IRRID) PRR1-10.2196/30909


1a-i) Identify the mode of delivery in the title
Identify the mode of delivery. Preferably use "web-based" and/or "mobile" and/or "electronic game" in the title. Avoid ambiguous terms like "online", "virtual", "interactive". Use "Internet-based" only if Intervention includes non-web-based Internet components (e.g. email), use "computer-based" or "electronic" only if offline products are used. Use "virtual" only in the context of "virtual reality" (3-D worlds). Use "online" only in the context of "online support groups". Complement or substitute product names with broader terms for the class of products (such as "mobile" or "smart phone" instead of "iphone"), especially if the application runs on different platforms.
Does your paper address subitem 1a-i? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study 1a-ii) Non-web-based components or important co-interventions in title Mention non-web-based components or important co-interventions in title, if any (e.g., "with telephone support").
Does your paper address subitem 1a-ii?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the title states that it is a "Modern Flexitarian Dietary Intervention". The food delivery and web-based nutrition education are the features of this intervention.

1a-iii) Primary condition or target group in the title
Mention primary condition or target group in the title, if any (e.g., "for children with Type I Diabetes") Example: A Web-based and Mobile Intervention with Telephone Support for Children with Type I Diabetes: Randomized Controlled Trial Does your paper address subitem 1a-iii? * Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the title states that the target group are "Healthy Young Adults" Mention key features/functionalities/components of the intervention and comparator in the abstract. If possible, also mention theories and principles used for designing the site. Keep in mind the needs of systematic reviewers and indexers by including important synonyms. (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-i? * Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Key features of the intervention are described ("The intervention will include the consumption of red meat or meat-alternatives three times per week for 10 weeks"). The abstract does not describe key features of the EHealth methodology, as this is a tool used to support the dietary intervention.

1b-ii) Level of human involvement in the METHODS section of the ABSTRACT
Clarify the level of human involvement in the abstract, e.g., use phrases like "fully automated" vs. "therapist/nurse/care provider/physician-assisted" (mention number and expertise of providers involved, if any). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) subitem not at all important 1 2 3 4 5 essential Does your paper address subitem 1b-ii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant to our study, as EHealth is used to support the dietary intervention. Therefore, there is insufficient scope in the abstract to provide this type of detail for the EHealth intervention.
1b-iii) Open vs. closed, web-based (self-assessment) vs. face-to-face assessments in the METHODS section of the ABSTRACT Mention how participants were recruited (online vs. offline), e.g., from an open access website or from a clinic or a closed online user group (closed usergroup trial), and clarify if this was a purely web-based trial, or there were face-to-face components (as part of the intervention or for assessment). Clearly say if outcomes were self-assessed through questionnaires (as common in web-based trials). Note: In traditional offline trials, an open trial (open-label trial) is a type of clinical trial in which both the researchers and participants know which treatment is being administered. To avoid confusion, use "blinded" or "unblinded" to indicated the level of blinding instead of "open", as "open" in web-based trials usually refers to "open access" (i.e. participants can self-enrol). (Note: Only report in the abstract what the main paper is reporting. If this information is missing from the main body of text, consider adding it) Does your paper address subitem 1b-iii?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant to our study, as EHealth is used to support the dietary intervention. Therefore, there is insufficient scope in the abstract to provide this type of detail for the EHealth intervention. Does your paper address subitem 1b-iv?
Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not applicable to this manuscript, as this is a research protocol paper and data has not been generated. Rather, we state that "The protocol has been developed using the SPIRIT checklist (Standard Protocol Items: Recommendations for Interventional Trials) and the outcomes will be reported following the CONSORT ( Does your paper address subitem 1b-v? Copy and paste relevant sections from the manuscript abstract (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not applicable to this manuscript, as this is a research protocol paper and data has not been generated. Rather, we state that "To our knowledge this is the first randomised controlled trial (RCT) investigating the overarching health consequences of consuming pasture fed red meat or no meat, as part of a healthy diet"

2a-i) Problem and the type of system/solution
Describe the problem and the type of system/solution that is object of the study: intended as stand-alone intervention vs. incorporated in broader health care program? Intended for a particular patient population? Goals of the intervention, e.g., being more cost-effective to other interventions, replace or complement other solutions? (Note: Details about the intervention are provided in "Methods" under 5) Does your paper address subitem 2a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This item is not applicable to our study, as EHealth is used to support the dietary intervention rather than being the primary intervention of interest. Does your paper address subitem 2a-ii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This item is not applicable to our study, as EHealth is used to support the dietary intervention rather than being the primary intervention of interest.
Does your paper address CONSORT subitem 2b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states that "We will measure changes in markers of nutritional status and indices of longer-term health and mental wellbeing, with the hypothesis that lean red meat will confer benefits related to the presence, concentration, and bioavailability of nutrients typically not matched in vegetarian analogues" Does your paper address CONSORT subitem 3a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, in the methods it is stated that the study is a parallel-randomized controlled trial and that participants are randomly allocated with a 1:1 ratio.
Does your paper address CONSORT subitem 3b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant to our study, as changes to methods have not been made since submitting the research protocol.

3b-i) Bug fixes, Downtimes, Content Changes
Bug fixes, Downtimes, Content Changes: ehealth systems are often dynamic systems. A description of changes to methods therefore also includes important changes made on the intervention or comparator during the trial (e.g., major bug fixes or changes in the functionality or content) (5-iii) and other "unexpected events" that may have influenced study design such as staff changes, system failures/downtimes, etc. [2].
Does your paper address subitem 3b-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We do not feel that this item is relevant to the methods of our study, given that we are using Facebook as a platform for the delivery of web-based nutrition education. Does your paper address CONSORT subitem 4a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states "All participants are required to be omnivores who in the last 2 months consumed at least 2-3 meals per week containing meat of any description (red or white fleshed meat, including fish). They must be willing to consume both red meat and meat-analogues for the purposes of the trial. Those with chronic health conditions, obesity (BMI ≥ 30 kg/m2), hyperlipidaemia, disordered eating patterns, history of anosmia and ageusia (issues with smell and taste), use of medications (except for occasional NSAIDs and antihistamines), or recreational drugs, or who smoke tobacco will be excluded from participating. Potential participants who use dietary supplements were asked to abstain for the month prior to the study beginning. Participants must own a mobile phone with a camera, and be proficient with using Facebook and Facebook Messenger. Women must confirm they are not pregnant, nor intending to become pregnant during the trial"

4a-i) Computer / Internet literacy
Computer / Internet literacy is often an implicit "de facto" eligibility criterion -this should be explicitly clarified.
Does your paper address subitem 4a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "Participants must own a mobile phone with a camera, and be proficient with using Facebook and Facebook Messenger" 4a-ii) Open vs. closed, web-based vs. face-to-face assessments: Open vs. closed, web-based vs. face-to-face assessments: Mention how participants were recruited (online vs. offline), e.g., from an open access website or from a clinic, and clarify if this was a purely webbased trial, or there were face-to-face components (as part of the intervention or for assessment), i.e., to what degree got the study team to know the participant. In online-only trials, clarify if participants were quasi-anonymous and whether having multiple identities was possible or whether technical or logistical measures (e.g., cookies, email confirmation, phone calls) were used to detect/prevent these.
Does your paper address subitem 4a-ii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states that "Recruitment will be advertised with posters placed around the University of Auckland and using social media websites and tools", which as a combination of online and offline recruitment. The manuscript also clarifies that participants will be required to complete assessments with both online and face-to-face components.

4a-iii) Information giving during recruitment
Information given during recruitment. Specify how participants were briefed for recruitment and in the informed consent procedures (e.g., publish the informed consent documentation as appendix, see also item X26), as this information may have an effect on user self-selection, user expectation and may also bias results. Does your paper address subitem 4a-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "Potential participants will meet with researchers responsible for recruitment in person, where eligibility will be confirmed, and details of the study will be discussed with opportunity for questions to be clarified. At this in-person screening visit participants will provide written informed consent (Appendix 3)". Please note that the project title differs to that of the current manuscript, as the manuscript title has been updated to better align with JMIR guidelines.
Does your paper address CONSORT subitem 4b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states that "Participants will visit the University of Auckland Clinical Research Centre and a blood testing facility in Auckland on three occasions" 4b-i) Report if outcomes were (self-)assessed through online questionnaires Clearly report if outcomes were (self-)assessed through online questionnaires (as common in web-based trials) or otherwise. 5) The interventions for each group with sufficient details to allow replication, including how and when they were actually administered Does your paper address subitem 4b-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states that "All participants will complete the suite of mental health questionnaires on up to 7 occasions either online or in person, which takes approximately 15 minutes".

4b-ii) Report how institutional affiliations are displayed
Report how institutional affiliations are displayed to potential participants [on ehealth media], as affiliations with prestigious hospitals or universities may affect volunteer rates, use, and reactions with regards to an intervention.(Not a required item -describe only if this may bias results) Does your paper address subitem 4b-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Institutional affiliations are displayed to participants on their informed consent form, please see Appendix 3. Does your paper address subitem 5-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We do not feel this item is relevant to our research, as Facebook and Facebook Messenger are used as the software to deliver nutrition education. It can also be seen in Appendix 2 that no author has employee, intellectual, or financial conflict with Facebook.

5-ii) Describe the history/development process
Describe the history/development process of the application and previous formative evaluations (e.g., focus groups, usability testing), as these will have an impact on adoption/use rates and help with interpreting results.

Does your paper address subitem 5-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We do not feel this item is relevant to our research, as Facebook and Facebook Messenger are used as the software to deliver nutrition education, which the researchers play no role in developing or evaluating.

5-iii) Revisions and updating
Revisions and updating. Clearly mention the date and/or version number of the application/intervention (and comparator, if applicable) evaluated, or describe whether the intervention underwent major changes during the evaluation process, or whether the development and/or content was "frozen" during the trial. Describe dynamic components such as news feeds or changing content which may have an impact on the replicability of the intervention (for unexpected events see item 3b).

Does your paper address subitem 5-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We do not feel this item is applicable to our research, as Facebook and Facebook Messenger are used as the software to deliver nutrition education, which this information is not relevant for. Further, this is a protocol paper and if any major changes were to occur this would be discussed in a paper reporting on outcomes of the trial.

5-iv) Quality assurance methods
Provide information on quality assurance methods to ensure accuracy and quality of information provided [1], if applicable.
Does your paper address subitem 5-iv?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Regarding the nutrition education delivered to participants, the manuscript states "The nutrition package was developed and reviewed by expert Registered Dietitians in the team, who are appropriately placed to ensure the accuracy and quality of information provided" -v) Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing flowcharts of the algorithms used Ensure replicability by publishing the source code, and/or providing screenshots/screen-capture video, and/or providing flowcharts of the algorithms used. Replicability (i.e., other researchers should in principle be able to replicate the study) is a hallmark of scientific reporting.

Does your paper address subitem 5-v?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant to the manuscript, as source code or algorithms have not been employed in the protocol paper. However, this could be published in any paper reporting on outcomes of this trial.

5-vi) Digital preservation
Digital preservation: Provide the URL of the application, but as the intervention is likely to change or disappear over the course of the years; also make sure the intervention is archived (Internet Archive, webcitation.org, and/or publishing the source code or screenshots/videos alongside the article). As pages behind login screens cannot be archived, consider creating demo pages which are accessible without login.

Does your paper address subitem 5-vi?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We will attempt to archive the intervention at webcitation.org, however the platform does not appear to be accepting new archiving requests.

5-vii) Access
Access: Describe how participants accessed the application, in what setting/context, if they had to pay (or were paid) or not, whether they had to be a member of specific group. If known, describe how participants obtained "access to the platform and Internet" [1]. To ensure access for editors/reviewers/readers, consider to provide a "backdoor" login account or demo mode for reviewers/readers to explore the application (also important for archiving purposes, see vi).
Does your paper address subitem 5-vii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states "Each team will have a private Facebook page and messenger chat which will be utilised to deliver evidence-based nutritional information and meal ideas". Details are not provided on how participants accessed the application, as this is not relevant for an app like Facebook which is widely available and utilised. Does your paper address subitem 5-viii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states that "We have designed an online nutrition education package specifically for young adults, following a literature review and focus group needs assessments. The Nine Principles framework, incorporating behavioural theory and usercentred design, was used to guide its development. The aim of the package is to (i) support young adults' adoption and maintenance of healthy dietary behaviours, such as those outlined in the Eating and Activity Guidelines for New Zealand Adults, and (ii) support adherence to respective dietary arms. Each team will have a private Facebook page and messenger chat which will be utilised to deliver evidence-based nutritional information and meal ideas. Behaviour change techniques employed include goal setting, demonstrating the behaviour, and setting graded tasks. The nutrition package content and delivery will be standardised across arms to encourage consistency in the adoption of a healthy dietary behaviours".

5-ix) Describe use parameters
Describe use parameters (e.g., intended "doses" and optimal timing for use). Clarify what instructions or recommendations were given to the user, e.g., regarding timing, frequency, heaviness of use, if any, or was the intervention used ad libitum.
Does your paper address subitem 5-ix?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, regarding the nutrition education via a web-pased platform, the manuscript states ". Participants will only be prompted to engage with nutrition education by way of notifications through Facebook and Facebook messenger as posts are made according to a predetermined schedule". Regarding the dietary intervention, it is stated that "Household units will receive regular deliveries of either red meat or vegetarian analogues sufficient for three evening meals per week. The quantity of meat will provide 350-500 g cooked weight per person per week" and that "household units will receive a weekly vegetarian meal kit delivery (Woop Ltd., New Zealand) containing complete ingredients and recipe cards for cooking 3 evening meals which will be matched across all participants".

5-x) Clarify the level of human involvement
Clarify the level of human involvement (care providers or health professionals, also technical assistance) in the e-intervention or as co-intervention (detail number and expertise of professionals involved, if any, as well as "type of assistance offered, the timing and frequency of the support, how it is initiated, and the medium by which the assistance is delivered". It may be necessary to distinguish between the level of human involvement required for the trial, and the level of human involvement required for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
Does your paper address subitem 5-x?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, it is stated that " Two members of the research team will be responsible for participant recruitment, clinic visit assessments, and nutrition education delivery, participants will also be in contact with technical staff at the blood testing facility."

5-xi) Report any prompts/reminders used
Report any prompts/reminders used: Clarify if there were prompts (letters, emails, phone calls, SMS) to use the application, what triggered them, frequency etc. It may be necessary to distinguish between the level of prompts/reminders required for the trial, and the level of prompts/reminders for a routine application outside of a RCT setting (discuss under item 21 -generalizability).
Does your paper address subitem 5-xi? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states " Participants will only be prompted to engage with nutrition education by way of notifications through Facebook and Facebook messenger according to a pre-determined schedule." Does your paper address subitem 5-xii? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The primary intervention in this research is following a red meat or a vegetarian diet for 10 weeks. The EHealth intervention is used to support behaviour change towards healthy eating in the context of this intervention. No other co-interventions beyond the EHealth intervention described are used to support behaviour change in this research. Does your paper address CONSORT subitem 6a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript provides complete details of primary and secondary outcomes. The primary outcome is "Change in concentrations of polyunsaturated fatty acids ( The manuscript states that "Participants will visit the University of Auckland Clinical Research Centre andor a blood testing facility in Auckland on three occasions: at allocation baseline (t0), midway through intervention at week 5 (t5) and at the end of intervention at week 10 (t10)" and "All participants will complete the suite of mental health questionnaires on up to 7 occasions either online or in person".
Methods for measurement are clearly outlined in the manuscript: "Dietary intake: At the completion of the intervention the manual data entry into the Easy Diet Diary will be analysed through FoodWorks Professional (Xyris Pty Ltd), which aligns with the New Zealand food composition database (New Zealand FOODfilesTM 2018). This will allow for analysis of the nutritional composition of participant's diets during the intervention, and for insight into the dietary behaviours of participants'. In addition, the Otago Food Frequency Questionnaire-Short Form will be used at t-2, t5¬, t10, and t22. It has been validated in New Zealand to assess overall nutrient intake over a 3-month period. y y p g All participants will wear a Huawei Band 4 Pro fitness wristband for the duration of the study. The device has an accelerometer and optical heartbeat detector that will be set to continuous monitoring, and a sleep tracker which will be enabled. Participants will be asked to download the Huawei Health smartphone application (Huawei Device Co., Ltd) preintervention. At t5 and t10 clinic visits, weekly average number of steps and sleep duration will be collected for the previous 5 weeks from this app.
Body composition Body weight and height will be measured at each laboratory visits. Additionally, full body composition will be analysed using Dual X ray Absorptiometry (DEXA) at t0 and t10. Each DEXA scan is 6-9 minutes long, and measures percent body fat, percent body lean mass and bone mineral density.
Muscle strength Grip strength will be assessed with a handheld dynamometer at three laboratory visits.
Blood erythrocyte, plasma and serum analyses Whole blood samples will coagulate at room temperature for 15 minutes prior to centrifugation and separating the serum, which will be stored at -80°C until analysis. Erythrocytes and plasma from whole blood containing anticoagulant will be harvested and stored at −80°C until analysis. In erythrocytes, fatty acid composition will be analysed by the fatty acid methyl esters (FAME) assay as previously described and by lipidomics, as previously described. In plasma, glucose and cholesterol (total, LDL, HDL) and triglycerides will be measured using a Roche Cobas c311 by enzymatic colorimetric assay and insulin will be measured using Roche E411 autoanalyser by an electrochemiluminescence immunoassay. Free amino acids and one-carbon metabolites will be analysed using ultra performance liquid chromatography (UPLC) according to previously published methods . Fat-soluble vitamin extraction procedures and analysis will follow an LC-MS method. Neurotransmitters and related compounds will be measured by mass spectroscopy. These include phenylethyl amine, 3,4-dihydroxyphenylalanine, dopamine, 3-methoxytyramine, 3,4dihydroxyphenylacetic acid, homovanillic acid, norepinephrine, 3,4-dihydroxyphenylglycol, 3methoxy-4-hydroxyphenylglycol, normetanephrine, epinephrine, metanephrine, vanillylmandelic acid, tryptophan, kynurenine, 5-hydroxytryptophan, serotonin, 5hydroxyindoleacetic acid, alpha-aminobutyric acid, gamma-aminobutyric acid. The methodology utilises a MS probe and stable isotope coding LC-MS method developed by AgResearch and has been optimised for plasma samples. The method aligns with published protocol data. Inflammatory markers will be analysed using the Invitrogen Inflammation 20-Plex Human ProcartaPlex™ Panel (catalogue number: EPX200-12185-901). Briefly, 25 µL of plasma and internal controls are incubated with magnetic beads prior to a series of wash steps. 25 μL of detection antibody will be added and incubated for 30 min before 50 μL of Streptavidin-PE is added. The 96-well plate is analysed using Bio-Plex® 200 system (BioRad) with inflammatory markers being measured in pg/mL. Serum iron status biomarkers (iron, unbound iron capacity, ferritin, transferrin, soluble transferrin receptor), and whole blood haemoglobin will be analysed using a Roche Cobas c311 by enzymatic colorimetric assay. Serum zinc concentration will be analysed using a commercial fluorometric probe kit (Ab176725, Abcam). Self-Efficacy and End of Intervention questionnaires The Self-Efficacy questionnaire will be distributed at eligibility screening. The questionnaire asks participants to indicate their levels of confidence with adherence to healthy eating behaviours, adherence to the flexitarian or vegetarian food patterns and cooking skills. The End of Intervention questionnaire will include closed and open-ended questions regarding the satisfaction, ease of compliance and likelihood of continuing the food pattern in the future. Adverse events Psychological assessments will be monitored by a psychology scientist and those who raise concerns will be referred to counselling services, with participant permission. Serious adverse events will be reported to the Health and Disability Ethics Committee." 6a-i) Online questionnaires: describe if they were validated for online use and apply CHERRIES items to describe how the questionnaires were designed/deployed If outcomes were obtained through online questionnaires, describe if they were validated for online use and apply CHERRIES items to describe how the questionnaires were designed/deployed [9].
Does your paper address subitem 6a-i?

Copy and paste relevant sections from manuscript text
We do not feel this item is relevant to the current research. The online questionnaires are validated and widely-used questionnaires, selected by an expert in the field. We have not developed or adapted the questionnaires used in any way. The CHERRIES items appear to be more applicable for E-surveys, whereas the questionnaires used in the current research are employed both in person and between clinic visits and therefore do not influence sample selection. Further, this appears to be more applicable to a manuscript reporting on results rather than the current protocol.

6a-ii) Describe whether and how "use" (including intensity of use/dosage) was defined/measured/monitored
Describe whether and how "use" (including intensity of use/dosage) was defined/measured/monitored (logins, logfile analysis, etc.). Use/adoption metrics are important process outcomes that should be reported in any ehealth trial. subitem not at all important 1 2 3 4 5 essential 6b) Any changes to trial outcomes after the trial commenced, with reasons Does your paper address subitem 6a-ii?
Copy and paste relevant sections from manuscript text Yes, the manuscript states "EHealth use will be monitored according to participant's having viewed messages in the Facebook messenger chat, and engagement will be monitored according to their "likes" and comments on Facebook messages and posts." 6a-iii) Describe whether, how, and when qualitative feedback from participants was obtained Describe whether, how, and when qualitative feedback from participants was obtained (e.g., through emails, feedback forms, interviews, focus groups).

Does your paper address subitem 6a-iii?
Copy and paste relevant sections from manuscript text Yes, the manuscript states "The End of Intervention questionnaire will include closed and open-ended questions regarding the satisfaction, ease of compliance and likelihood of continuing the food pattern in the future".
Does your paper address CONSORT subitem 6b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant to the current manuscript, as no changes have been made from the current protocol.

Does your paper address subitem 7a-i?
Copy and paste relevant sections from manuscript title (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "The primary biomarker for calculation of the sample size is the concentrations of LCn3 in erythrocyte membranes, and a sample size of 63 will provide sufficient power to detect changes in fatty acids that may occur due to the intervention.
Published data indicate a change of 3.01 /L (±1.1 µg/mL) in erythrocyte fatty acid composition (20:5) following a two-week dietary intervention and crossover meat trial in young adults . The Cohen effect size of 0.2 (small) of the variability in erythrocyte fatty acids was used to consider the smallest worthwhile effect . To allow for dropouts, a total of 80 participants will be recruited." Does your paper address CONSORT subitem 7b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant to the current manuscript which is a protocol paper. 8a) Method used to generate the random allocation sequence NPT: When applicable, how care providers were allocated to each trial group 8b) Type of randomisation; details of any restriction (such as blocking and block size) 9) Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), describing any steps taken to conceal the sequence until interventions were assigned Does your paper address CONSORT subitem 8a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The manuscript states "The 80 participants (self-organised as 40 couples/household units) will be randomised evenly to the vegetarian or flexitarian arm, with a random allocation sequence (1:1 ratio) generated through www.random.org".
Does your paper address CONSORT subitem 8b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "The 80 participants (self-organised as 40 couples/household units) will be randomised evenly to the vegetarian or flexitarian arm, with a random allocation sequence (1:1 ratio) generated through www.random.org" 10) Who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions 11a) If done, who was blinded after assignment to interventions (for example, participants, care providers, those assessing outcomes) and how NPT: Whether or not administering co-interventions were blinded to group assignment subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 9? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "Researchers responsible for participant recruitment will be blinded to allocation until participants begin their two-week lead in period. Due to the nature/form of the food provided, participants will not be blinded to their intervention though will not be aware of this until the intervention begins" Does your paper address CONSORT subitem 10? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "Researchers responsible for participant recruitment will be blinded to allocation until participants begin their two-week lead in period. Due to the nature/form of the food provided, participants will not be blinded to their intervention though will not be aware of this until the intervention begins" 11a-i) Specify who was blinded, and who wasn't Specify who was blinded, and who wasn't. Usually, in web-based trials it is not possible to blind the participants [1, 3] (this should be clearly acknowledged), but it may be possible to blind outcome assessors, those doing data analysis or those administering co-interventions (if any). Does your paper address subitem 11a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "Researchers responsible for participant recruitment will be blinded to allocation until participants begin their two-week lead in period. Due to the nature/form of the food provided, participants will not be blinded to their intervention though will not be aware of this until the intervention begins" 11a-ii) Discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator" Informed consent procedures (4a-ii) can create biases and certain expectations -discuss e.g., whether participants knew which intervention was the "intervention of interest" and which one was the "comparator".
Does your paper address subitem 11a-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "Due to the nature/form of the food provided, participants will not be blinded to their intervention though will not be aware of this until the intervention begins" Does your paper address CONSORT subitem 11b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "Yes, the manuscript states "Researchers responsible for participant recruitment will be blinded to allocation until participants begin their two-week lead in period. Due to the nature/form of the food provided, participants will not be blinded to their intervention though will not be aware of this until the intervention begins". The manuscript includes a table showing nutrient differences/similarities between the intervention.
Does your paper address CONSORT subitem 12a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be included in manuscripts reporting on outcomes from the trial.

12a-i) Imputation techniques to deal with attrition / missing values
Imputation techniques to deal with attrition / missing values: Not all participants will use the intervention/comparator as intended and attrition is typically high in ehealth trials. Specify how participants who did not use the application or dropped out from the trial were treated in the statistical analysis (a complete case analysis is strongly discouraged, and simple imputation techniques such as LOCF may also be problematic [4]). Does your paper address subitem 12a-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be included in manuscripts reporting on outcomes from the trial.
Does your paper address CONSORT subitem 12b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be included in manuscripts reporting on outcomes from the trial. Does your paper address subitem X26-i?

X26-i) Comment on ethics committee approval
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "The trial was approved by the New Zealand Ministry of Health's Health and Disability Ethics Committees (20/STH/157). The investigators will ensure that this study is conducted in accordance with the principles of the Declaration of Helsinki, with relevant institutional regulations".

x26-ii) Outline informed consent procedures
Outline informed consent procedures e.g., if consent was obtained offline or online (how? Checkbox, etc.?), and what information was provided (see 4a-ii). See [6] for some items to be included in informed consent documents.

Does your paper address subitem X26-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "At this in-person screening visit participants will provide written informed consent (Appendix 3)."

X26-iii) Safety and security procedures
Safety and security procedures, incl. privacy considerations, and any steps taken to reduce the likelihood or detection of harm (e.g., education and training, availability of a hotline) RESULTS 13a) For each group, the numbers of participants who were randomly assigned, received intended treatment, and were analysed for the primary outcome NPT: The number of care providers or centers performing the intervention in each group and the number of patients treated by each care provider in each center 13b) For each group, losses and exclusions after randomisation, together with reasons Does your paper address subitem X26-iii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study We do not feel there is any potential safety/security procedures that are relevant to the study, as such procedures are already performed by Facebook when participants sign up for use. Of note, we anticipate that all participants will already be using Facebook (this being a source of social media recruitment), rather than requiring participants to sign up to an unknown app. The manuscript states that "Team members will engage virtually through social media, which was explained to participants during recruitment".
Does your paper address CONSORT subitem 13a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be included in manuscripts reporting on outcomes from the trial.

14a) Dates defining the periods of recruitment and follow-up
Does your paper address CONSORT subitem 13b? (NOTE: Preferably, this is shown in a CONSORT flow diagram) * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

13b-i) Attrition diagram
Strongly recommended: An attrition diagram (e.g., proportion of participants still logging in or using the intervention/comparator in each group plotted over time, similar to a survival curve) or other figures or tables demonstrating usage/dose/engagement.

Does your paper address subitem 13b-i?
Copy and paste relevant sections from the manuscript or cite the figure number if applicable (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.
Does your paper address CONSORT subitem 14a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial. 14a-i) Indicate if critical "secular events" fell into the study period Indicate if critical "secular events" fell into the study period, e.g., significant changes in Internet resources available or "changes in computer hardware or Internet delivery resources" Does your paper address subitem 14a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.
Does your paper address CONSORT subitem 14b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial. analysis and whether the analysis was by original assigned groups Does your paper address CONSORT subitem 15? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

15-i) Report demographics associated with digital divide issues
In ehealth trials it is particularly important to report demographics associated with digital divide issues, such as age, education, gender, social-economic status, computer/Internet/ehealth literacy of the participants, if known.

Does your paper address subitem 15-i? *
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial. 16-i) Report multiple "denominators" and provide definitions Report multiple "denominators" and provide definitions: Report N's (and effect sizes) "across a range of study participation [and use] thresholds" [1], e.g., N exposed, N consented, N used more than x times, N used more than y weeks, N participants "used" the intervention/comparator at specific pre-defined time points of interest (in absolute and relative numbers per group). Always clearly define "use" of the intervention.
Does your paper address subitem 16-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

16-ii) Primary analysis should be intent-to-treat
Primary analysis should be intent-to-treat, secondary analyses could include comparing only "users", with the appropriate caveats that this is no longer a randomized sample (see 18-i).

Does your paper address subitem 16-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial. subitem not at all important 1 2 3 4 5 essential 17b) For binary outcomes, presentation of both absolute and relative effect sizes is recommended Does your paper address CONSORT subitem 17a? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.
17a-i) Presentation of process outcomes such as metrics of use and intensity of use In addition to primary/secondary (clinical) outcomes, the presentation of process outcomes such as metrics of use and intensity of use (dose, exposure) and their operational definitions is critical. This does not only refer to metrics of attrition (13-b) (often a binary variable), but also to more continuous exposure metrics such as "average session length". These must be accompanied by a technical description how a metric like a "session" is defined (e.g., timeout after idle time) [1] (report under item 6a).
Does your paper address subitem 17a-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial. Does your paper address CONSORT subitem 17b? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.
Does your paper address CONSORT subitem 18? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

18-i) Subgroup analysis of comparing only users
A subgroup analysis of comparing only users is not uncommon in ehealth trials, but if done, it must be stressed that this is a self-selected sample and no longer an unbiased sample from a randomized trial (see 16-iii).

Does your paper address subitem 18-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, and is unlikely to be considered in manuscripts reporting on outcomes as all participants in the trial will be using the Ehealth intervention in support of their dietary intervention. Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

19-i) Include privacy breaches, technical problems
Include privacy breaches, technical problems. This does not only include physical "harm" to participants, but also incidents such as perceived or real privacy breaches [1], technical problems, and other unexpected/unintended incidents. "Unintended effects" also includes unintended positive effects [2].

Does your paper address subitem 19-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial. Does your paper address subitem 19-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

22-i)
Restate study questions and summarize the answers suggested by the data, starting with primary outcomes and process outcomes (use) Restate study questions and summarize the answers suggested by the data, starting with primary outcomes and process outcomes (use). Does your paper address subitem 22-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

22-ii) Highlight unanswered new questions, suggest future research
Highlight unanswered new questions, suggest future research.

Does your paper address subitem 22-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.

20-i) Typical limitations in ehealth trials
Typical limitations in ehealth trials: Participants in ehealth trials are rarely blinded. Ehealth trials often look at a multiplicity of outcomes, increasing risk for a Type I error. Discuss biases due to non-use of the intervention/usability issues, biases through informed consent procedures, unexpected events. Does your paper address subitem 20-i? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study The typical limitations suggested are not relevant for the current protocol. We do however state in a limitations section that "Using a free living, mixed meal approach has its advantages in real life applicability of study findings, but may hinder the clarity in outcomes.
A key aim was to compare the health effects of red meat and alternatives in combination with a healthy diet, using a clearly planned nutrition-education and adherence strategy. However, we acknowledge that compliance is voluntary and the degree to which participants comply will impact the outcomes. To address this, daily food intake will be assessed using imaged based or mobile phone app technology and stop-go strategies in place to best support the participants in adhering to the dietary intervention and provide confidence in participant compliance"

21-i) Generalizability to other populations
Generalizability to other populations: In particular, discuss generalizability to a general Internet population, outside of a RCT setting, and general patient population, including applicability of the study results for other organizations Does your paper address subitem 21-i?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial. Discuss if there were elements in the RCT that would be different in a routine application setting (e.g., prompts/reminders, more human involvement, training sessions or other co-interventions) and what impact the omission of these elements could have on use, adoption, or outcomes if the intervention is applied outside of a RCT setting.

Does your paper address subitem 21-ii?
Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This is not relevant for the current protocol, but will be considered in manuscripts reporting on outcomes from the trial.
Does your paper address CONSORT subitem 23? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "The trial is registered with ClinicalTrial.gov and the unique identifier is NCT04869163." subitem not at all important 1 2 3 4 5 essential Does your paper address CONSORT subitem 24? * Cite a Multimedia Appendix, other reference, or copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study This item is not relevant, as this manuscript is the full trial protocol.
Does your paper address CONSORT subitem 25? * Copy and paste relevant sections from the manuscript (include quotes in quotation marks "like this" to indicate direct quotes from your manuscript), or elaborate on this item by providing additional information not in the ms, or briefly explain why the item is not applicable/relevant for your study Yes, the manuscript states "This research is funded by the Meat Industry Association Innovation Limited (a subsidiary of the New Zealand Meat Industry Association), Beef + Lamb New Zealand Incorporated and the New Zealand Ministry of Business, Innovation and Employment. National Science Challenge-High Value Nutrition have funded the laboratory analysis of inflammatory biomarkers. The funders are not involved in the collection, analysis and interpretation of data, in the writing of reports, or in the decision to submit manuscripts for publication."

X27-i) State the relation of the study team towards the system being evaluated
In addition to the usual declaration of interests (financial or otherwise), also state the relation of the study team towards the system being evaluated, i.e., state if the authors/evaluators are distinct from or identical with the developers/sponsors of the intervention.