High-Dose Vitamin D Supplementation Interferes with Cholesterol Absorption and Affects Circulating Cholesterol Levels in Overweight/Obese Postmenopausal Women (OR14-01)
Nirupa R. Matthan,1 Huicui Meng,2 Sue Shapses,3 Stephen H. Schneider,4 and Alice H. Lichtenstein1
1Tufts University, MA; 2Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, MA: 3Rutgers University, NJ; and 4Rutgers-Robert Wood Johnson Hospital, NJ
Objective: Data on the relationship between vitamin D and cardiovascular disease risk is inconsistent. This may be because of unaccounted-for variability among individuals at the intestinal level. We assessed whether high-dose vitamin D3 supplementation alters in vivo cholesterol homeostasis (absorption and synthesis) and subsequently circulating plasma 25-hydroxyvitamin D [25(OH)D] and total cholesterol (TC) concentrations, and whether these responses are modified in individuals with inherently high versus low cholesterol absorption rates (hyper- and hypoabsorbers).
Methods: Archived serum aliquots from a randomized double-blind controlled trial designed to determine the effect of 1-y supplementation with 600, 2000 or 4000 IU daily of vitamin D on bone parameters in overweight or obese (body mass index, 30.2 ± 3.8 kg/m2) post-menopausal women (n = 12–16/group; 58 ± 6 y; screening 25(OH)D < 30 ng/mL; not taking lipid-lowering medication) were analyzed for markers of cholesterol absorption (campesterol, β-sitosterol) and synthesis (squalene, desmosterol, lathosterol) by gas chromatography. Participants were classified as hypo- or hyper-responders based on serum campesterol concentrations below or above the median value (9.6 µmol/L) at baseline. Results were merged with available data for serum 25(OH)D and TC concentrations.
Results: The 4000 IU dose resulted in significantly lower serum campesterol (–16%), β-sitosterol (–11%) and TC (–4%) concentrations compared with the baseline, as well as the lower doses. Interestingly, hyperabsorbers had a trend toward lower 25(OH)D concentrations (35 vs. 42 ng/mL, P = 0.09) and less reduction in TC (–2% vs. –7%, P < 0.05) than hypoabsorbers to 4000 IU vitamin D supplementation. Markers of cholesterol synthesis remained unchanged at all doses and among hypo- and hyperabsorbers.
Conclusions: Chronic high-dose vitamin D supplementation interferes with cholesterol absorption, without a compensatory increase in synthesis, thus resulting in lower TC concentrations. This pleotropic effect of vitamin D supplementation was diminished in hyper- compared with hypoabsorbers. This may be because of diminished bioavailability of the nutrient secondary to competition with cholesterol at the level of intestinal transport proteins, thereby attenuating potential beneficial effects of supplementation in cholesterol hyperabsorbers.
Funding Sources
USDA 1950-51,000-072-02S.
Almonds Improve Glycemic Status in Chinese Patients with Better Controlled Type 2 Diabetes (OR14-02)
C-Y Oliver Chen,1 Jen-Fang Liu,2 and Chiao-Ming Chen3
1Tufts University, MA; 2Chang Gung University of Science and Technology, Republic of China; and 3Shih-Chien University, Republic of China
Objective: Almonds can decrease the glycemic index of co-consumed foods, and are a good source of oleic acid, α-tocopherol, riboflavin, manganese, copper magnesium, molydenum, and phosphorus. Our previous 4-wk controlled feeding study with Chinese patients with type 2 diabetes mellitus (T2DM) and mild hypercholesterolemia showed that almonds (∼60 g/d) added
to replace 20% of the calories of a National Cholesterol Education Program step II diet (NCEP II) improved glycemic control, lipid profile, oxidative stress status, and inflammation compared with the NCEP II. Thus, we conducted a longer clinical trial to examine the effect of almonds on cardiometabolic risk factors in Chinese patients with T2DM.
Methods: Forty T2DM patients were enrolled and randomly assigned to receive NCEP II or almond diet (ALM) for 12 wk after a 2-wk run-in period. ALM was prepared by incorporating almonds to replace 20% of the daily calories. Meals were provided to study subjects during 2 dietary intervention phases. Four blood and urine samples were collected from each subject at the beginning and end of each intervention phase for the assessment of biomarkers of glucoregulation, lipid profile, inflammation, and oxidative stress.
Results: ALM had a better overall nutritional quality than NCEP II as ALM increased monounsaturated fatty acid, fiber, Mg, and α-tocopherol intakes. Neither ALM nor NCEP II improved the glycemic status as the primary study outcome and other cardiovascular disease risk factors. Serum high-sensitivity C-reactive protein was below 0.5 mg/dL in all measurements and was not affected by the diets. While the preintervention nitric oxide (NO) value was comparable between the 2 diets, ALM significantly decreased serum NO by 30% compared with NCEP II. Among 27 of 33 patients with baseline glycated hemoglobin (HbA1c) of ≤8%, ALM decreased postinterventional fasting serum glucose and HbA1c by 5.9% (7.01% vs. 7.23%) and 3.0% (129 vs. 137 mg/dL), respectively, compared with that of NCEP II (P = 0.01 and 0.04). In the same subgroup, total and LDL cholesterol concentrations (170 and 98 mg/dL at baseline) were not changed by both diets.
Conclusions: These results suggest almonds incorporated into healthful diets can improve the glycemic status of diabetic patients with better glycemic control.
Funding Sources
Almond Board of California and USDA.
Long-Term Function and Body Composition Outcomes in Older Adults Completing a Protein-Enhanced Obesity Intervention (OR14-03)
Marshall G Miller,1 Kathryn Porter Starr,2 Jamie Rincker,3 Shelley McDonald,3 Richard J Sloane,3 Carl Pieper,3 Leah M Solomon,4 and Connie W. Bales2
1Duke University, NC; 2Duke University School of Medicine, Durham VA Medical Center, NC; 3Duke University School of Medicine, NC; and 4Meredith College, NC
Objective: During aging, obesity increasingly limits function and elevates morbidity and mortality risk. Treatments to reduce obesity in older adults are complicated by a relatively limited treatment window and potential loss of lean mass. Recent research shows that weight loss interventions with higher protein intakes (≥30 g/meal) can effectively reduce body weight while improving physical function among older adults. However, it is important that weight loss interventions provide lasting benefits in order to be justified in this population.
Methods: Long-term changes to physical function (short physical performance battery; SPPB), body composition, and quality of life were evaluated among 30 obese older adults (age ≥ 60 y; BMI ≥ 30; SPPB 4–10) completing a 6-mo weight loss intervention with either the recommended intake of protein (RDA 0.8 g/kg/d; n = 9; Control) or higher protein (1.2 g/kg/d) balanced (≥30 g/meal) throughout the day (Protein; n = 21). Completers of the interventions were not asked to continue their respective diets, but were invited to return 12 mo later for assessment.
Results: Both Control and Protein reduced body weights during the intervention, but the weight had been regained 12 mo later. Likewise, function by SPPB had regressed at follow-up. However, group comparison at 12 mo showed that the Protein group tended (P < 0.07) to retain a better SPPB score relative to Controls. Additionally, within-group analysis for Protein showed that improvements over baseline for functional measures, including SPPB, a 6-min walk test, and 30-s chair stands, remained significant (P < 0.05) at follow-up. Body weight was still lower at follow-up than at baseline for Protein (–4.6 ± 6.2 kg, P < 0.01), whereas the Control group weight was no longer different from baseline (–3.8 ± 5.3 kg, P = 0.11). The same pattern was found for fat mass, which was still significantly lower than baseline (P < 0.01) in the Protein group only. Lean mass, although not significantly altered during the intervention, had decreased for both groups at follow-up (P < 0.05).
Conclusions: These findings support further study of balanced higher-protein weight-loss regimens for obese older adults and suggest a potential “legacy” benefit, particularly for physical function, that is retained for at least 1 y after the intervention is discontinued.
Funding Sources
This study was funded by the Beef Checkoff, and received additional support from the National Institutes of Health (T32-AG000029) and the US Department of Veterans Affairs Rehabilitation Research and Development Service Program (CDA-2/IK2 RX002348).
Artificial Sweetened Beverages and Liver Function Scores among Women with Prior Gestational Diabetes (OR14-04)
Stefanie N. Hinkle,1 Stefanie Hinkle,2 Shristi Rawal,3 Anne Ahrendt Bjerregaard,4 Thor Halldorsson,4 Sjurdur Olsen,4 Mengying Li,2 Sylvia H. Ley,5 Jing Wu,6 Yeyi Zhu,7 Liwei Chen,8 and Cuilin Zhang1
1National Institutes of Health; 2NICHD; 3Rutgers University, NJ; 4SSI; 5Harvard University, MA; 6Glotech; 7Kaiser Permanente, NC; and 8Clemson University, SC
Objective: Artificial sweetened beverage (ASB) intake is a modifiable lifestyle factor that has been put forward as an alternative to sugar-sweetened beverages, but complete understanding of the metabolic effects of ASB is lacking. We aimed to examine associations of ASB intake and liver function among women at high risk with prior gestational diabetes (GDM).
Method: We included 566 women from the Danish National Birth Cohort (1996–2002) with GDM during their index pregnancy who had completed a clinical examination 9–16 y later for the Diabetes & Women's Health Study (2012–2014). Liver function assays included alanine aminotransferase, aspartate aminotransferase, and γ-glutamyltransferase (GGT) measured in fasting blood collected at the clinical examination. Calculated liver function scores included fatty liver index (FLI), hepatic steatosis index (HSI), and nonalcoholic fatty liver disease-liver fat score (NAFLD-LFS). A food frequency questionnaire on the past year's habitual intake was completed at the clinical examination. We estimated adjusted percentage differences in log-transformed enzyme concentrations and RRs for elevated scores according to clinical cutpoints by ASB quartile (Q). To investigate potential reverse causality, we limited the analysis to “metabolically healthier” women without obesity, diabetes or prediabetes, or elevated triglycerides at follow-up.
Results: At follow-up, 43.5%, 54.6%, and 36.6% of women had elevated FLI (≥60), HSI (≥36), and NAFLD-LFS (>−0.64), respectively. Adjusted GGT concentrations increased with higher ASB intake [Q4, ∼1.4 servings/d, vs. Q1, none: 21.1% (95% CI 3.7–41.4), P-trend = 0.02]; this was attenuated with adjustment for body mass index. Higher ASB intake was associated with increased risk for elevated liver scores. Among “metabolically healthier” women at follow-up (n = 211), 9.5%, 12.9%, and 5.7% of women had elevated FLI, HSI, and NAFLD-LFS, respectively; higher ASB intake (Q4 vs. Q1) was associated with increased GGT [27.6% (0.2–62.6)], and elevated FLI [RR = 9.7 (1.5–62.0); P-trend < 0.001] and HSI [RR = 5.1 (1.6,16.4); P-trend = 0.008].
Conclusions: In women with prior GDM, the past year's ASB intake was associated with increased risk for elevated liver scores, reflecting abnormal liver function.
Supporting Images/Graphs
FIGURE OR14-04-1.
Association between quartiles of artificial sweetened beverage intake in the past year and elevated liver function scoring indices among women with a history of gestational diabetes (n = 566).
Funding Sources
This work was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health [Contract Nos.: HHSN275201000020C, HHSN275201500003C, HHSN275201300026I, and HSN275201100002I]. The Nurses’ Health Study II cohort is supported by the National Institutes of Health [grant UM1 CA176726]. Financial support for the Danish component was received from March of Dimes Birth Defects Foundation [grants 6-FY-96-0240, 6-FY97-0553, 6-FY97-0521, and 6-FY00-407], Innovation Fund Denmark [grants 09-06,7124 and 11-115,923, “Centre for Fetal Programming”], the Health Foundation [grant 11/263-96], the Heart Foundation [grant 96-2-4-83-22,450], the EU (grant FP7-289,346-EarlyNutrition), and the Danish Diabetes Academy supported by the Novo Nordisk Foundation.
The Modulation of Pro-fibrogenic Gene Expression by Various Fatty Acids in Hepatic Stellate Cells (OR14-05)
Siqi Hu, Minkyung Bae, Young-Ki Park, and Ji-Young Lee
University of Connecticut
Objective: Activated hepatic stellate cells (HSCs) play a crucial role in the accumulation of extracellular matrix proteins during the development of liver fibrosis. The objective of this study was to determine the effects of various fatty acids (FAs) on the regulation of fibrogenic gene expression in activated HSCs.
Methods: Fatty acids, including palmitic acide (PA), oleic acid (OA), linoleic acid (LA), alpha linolenic acid (ALA), and eicosapentaenoic acid (EPA), were delivered into cell culture medium by complexation with bovine serum albumin (BSA) at a BSA to FA molar ratio of 1:2.5.
The cytotoxicity of the FAs was determined in LX-2 cells, a human HSC cell line, at 0–100 μM concentrations. LX-2 cells and primary human HSCs were treated with BSA or an FA (50 μM) for 24 h, followed by activation using transforming growth factor beta 1 (TGFβ1; 4 ng/ml) for another 24 h.
Results: All fatty acids showed moderate cytotoxicity at 50 and 100 μM, with OA being the least cytotoxic. TGFβ1 treatment significantly induced the expression of pro-fibrogenic genes, e.g., alpha-smooth muscle actin (α-SMA) and collagen type I alpha 1 chain (Colα1), in LX-2. Upon the stimulation of TGFβ1, PA and EPA treatments significantly decreased α-SMA mRNA amounts; and PA, ALA, and EPA significantly downregulated Colα1 mRNA in LX-2 cells. In contrast, OA significantly increased mRNA amounts of α-SMA and Colα1 induced by TGFβ1. Consistent with the findings in LX-2 cells, PA, LA, ALA, and EPA treatments significantly decreased α-SMA mRNA amounts in primary human HSCs. Interestingly, however, only LA and EPA markedly attenuated TGFβ1-induced α-SMA and Colα1 protein concentrations in LX-2 cells.
Conclusions: Transcriptional and post-transcriptional regulation of pro-fibrogenic gene expression by FAs is likely to exist in HSCs. Only polyunsaturated fatty acids (PUFAs), e.g., LA and EPA, suppressed mRNA and protein expression of pro-fibrogenic genes in HSCs, which may contribute to their anti-fibrogenic effects reported in the literature. Further studies on the transcriptional and post-transcriptional regulation of pro-fibrogenic genes by fatty acids are necessary to elucidate mechanisms by which PUFAs exert anti-fibrogenic properties in HSCs.
Funding Sources
Funding sources: USDA Hatch CONS00972; USDA Multi-State Hatch CONS00916.
Changes in Glucose Regulation and Dietary Intake in Women with Polycystic Ovary Syndrome: a Pulse-Based Diet versus the Therapeutic Lifestyle Changes Diet (OR14-06)
Maryam Kazemi, Laura McBreairty, Donna R Chizen, Roger A Pierson, Philip D Chilibeck, and Gordon Zello
University of Saskatchewan, Canada
Background: The optimal balance of diet composition to improve glycemic control in women with polycystic ovary syndrome (PCOS) is poorly elucidated.
Objective: The aim of this study was to compare the effects of a pulse-based diet (low–glycemic index diet, including split peas, beans, lentils, and chickpeas) with the National Cholesterol Education Program Therapeutic Lifestyle Changes (TLC) diet on glycemic response and dietary intake of women with PCOS.
Methods: Glucose response and dietary intake were assessed in women randomly assigned to one of the 2 diets without caloric restriction in a controlled, prospective clinical intervention using standard oral glucose tolerance tests (OGTT) and serial 24-h dietary recalls. Ninety-five women with PCOS (18–35 y) enrolled in a 16-wk lifestyle changes program; 30 women assigned to the pulse-based diet group and 31 women in the TLC diet group completed the study. Women in both groups participated in an aerobic exercise program.
Results: Women in the pulse-based and TLC diet groups exhibited a decreased total (–99.9 vs. –73.0 mg dL- min–1) and incremental (–11.7 vs. –14.4 mg dL- min–1) area under the curve for glucose response to OGTT (P < 0.01). Both the pulse-based (2273 vs. 1707 kcal) and TLC diet (2211 vs. 1654 kcal) groups voluntarily reduced their average daily energy intake from the baseline (P < 0.001). Dietary cholesterol intake decreased, expressed as change from baseline, in the pulse-based diet group compared with the TLC diet group (–228.8 vs. 3.2 mg/d, respectively; P < 0.001). Dietary intakes, expressed as change from baseline, increased for fiber (10.5 vs. 0.0 g/d; P < 0.01), folate (259.5 vs. –48.9 µg/d; P < 0.001), magnesium (73.1 vs. –8.0 mg/d; P < 0.05), and iron (1.9 vs. –8.6 mg/d; P < 0.05) in the pulse-based diet group compared with the TLC diet group. The pulse-based diet group tended toward a greater decrease in the change of trans fat intake from baseline than the TLC diet group (–0.9 vs. –0.1 g/d; P = 0.06).
Conclusions: Both diets, without calorie restriction, in combination with aerobic exercise, decreased the glucose response to OGTT. Although women in both groups reduced their energy intake, the pulse-based diet was more effective than the TLC diet in improving the overall diet quality in women with PCOS.
Funding Sources
Supported by Agriculture and Agri-Food Canada, Saskatchewan Pulse Growers, the Canada Foundation for Innovation, and Saskatchewan Health Research Foundation.
Dietary Fiber Supplementation Effect on Symptoms and Esophageal Function in Non-erosive GERD Patients with Low Dietary Fiber Intake (OR14-07)
Vasily Isakov, Sergey Morozov, Mariya Konovalova, and Vasily Isakov
Federal Research Center of Nutrition and Biotechnology
Objective: Epidemiologic data has shown a negative correlation between heartburn frequency and amount of dietary fiber consumed. However, no interventional study had been performed to prove a clinically beneficial effect of dietary fibers in gastroesophageal reflux disease (GERD) patients. The aim of this study was to investigate the effect of dietary fiber on symptoms and esophageal function testing parameters in nonerosive GERD (NERD) patients.
Methods: Thirty-six NERD patients were examined using a food frequency questionnaire and those with <20 g/d dietary fibre intake underwent high-resolution esophageal manometry and 24-h esophageal pH-impedance. A language-specific GERD-Q questionnaire was used to assess the symptoms. Repeated examinations were performed after 10 d of usual diet supplemented with 15.0 g psyllium/d. Complete data of 30 NERD patients were available for the final analysis. The Wilcoxon matched-pairs test was used to assess changes in patients’ symptoms, GERD-Q score, results of high-resolution esophageal manometry, and 24-h esophageal pH-impedance studies (Statistica 10, StatSoft Inc.).
Results: After the course of treatment, a decrease in the proportion of patients experiencing heartburn was found (93.3% at baseline vs. 40% at the end of the study, P < 0.001), as was a decrease in GERD-Q score (M ± m: 10.9 ± 1.7 vs. 6.0 ± 2.3, P < 0.001). The minimal resting lower esophageal sphincter (LES) pressure increased from 5.41 ± 10.1 to 11.3 ± 9.4 (P = 0.023), but no change in residual LES pressure or mean resting pressure was found. The total number of gastroesophageal refluxes (GERs) decreased from 67.9 ± 17.7 to 42.4 ± 13.5 (P < 0.001), predominantly by acid and weak acid types of GERs. No significant change in mean esophageal pH and percentage of time at pH < 4 was registered. The maximal reflux time decreased from 10.6 ± 12.0 to 5.3 ± 3.7 min (P = 0.017).
Conclusions: Supplementation of diet with 5.0 g of psyllium 3 times a day in NERD patients led to a significant increase in minimal esophageal resting pressure and decreases in number of gastroesophageal refluxes and frequency of heartburn per week.
Supporting Images/Graphs
FIGURE OR14-07-1 .
Design of the study.
FIGURE OR14-07-2.
Patients allocation chart.
FIGURE OR14-07-3.
Proportion of patients experiencing heartburn at baseline and at the end of the treatment. EOT - end of treatment period.
FIGURE OR14-07-4.
Mean GERD-Q score at baseline and at the end of treatment (EOT) period.
TABLE OR14-07-1.
Effect of fiber supplementation on esophageal function testing in NERD patients with low dietary fiber intake.
Funding Sources
Federal Agency of Scientific Organizations of Russia, Applied research work 0529-2014-0033 “Development of technologies of diagnostics of functional disorders of the gastrointestinal tract and methods of their nutritional and pharmacological correction.”
Results of the Bacteriophage for Gastrointestinal Health (PHAGE) Study (OR14-08)
Taylor C Wallace,1 Tiffany Weir,2 Hallie Febvre,2 Natalie Goodwin,2 Mindy Gindin,2 Eli Finer,2
1George Mason University, VA; and 2Colorado State University
Objective: Bacteriophages are viruses that do not infect humans, but target specific bacteria. Because they are safe for humans and can selectively combat specific microorganisms, they are being examined for their potential to help restore balance to the microbiota.
Methods: The Bacteriophage for Gastrointestinal Health (PHAGE) Study is the first randomized, double-blind, placebo-controlled crossover trial designed to investigate the ability of 4 bacteriophages (LH01-Myoviridae, LL5-Siphoviridae, T4D-Myoviridae, and LL12-Myoviridae) to modulate the microbiome and reduce gastrointestinal distress in healthy individuals. Secondary outcomes include local and systemic inflammatory markers [e.g., secretory immunoglobulin A (sIgA), tumor necrosis factor-α, interleukin-6 (IL-6)] and plasma lipid profiles. Individuals not diagnosed with disorders but who reported significant gastrointestinal distress were enrolled into the study. Participants were assigned to either the placebo or treatment group for the first 4-wk, followed by a 2-wk washout period and an additional 4-wk on the opposite treatment. Outcome measures included evaluating shifts in the microbiota using 16S rRNA sequencing and targeted quantitative polymerase chain reaction, self-assessment of gastrointestinal distress, fecal calprotectin and sIgA, fecal short-chain fatty acids and triglycerides, high-sensitivity C-reactive protein, 13 circulating cytokines and inflammatory mediators, plasma lipid profiles, and metabolic safety markers. Thirty-two participants completed the study.
Results: The treatment was well tolerated, with no adverse events or differences in metabolic safety markers detected. Bacteriophage treatment resulted in significant decreases in IL-4, often associated with allergic response, but no other inflammatory markers. There was also a trend toward decreased total and LDL cholesterol with bacteriophage consumption; however, the significance of this would need to be determined in a larger, more clinically relevant population.
Conclusions: There were no major perturbations to the microbiota as indicated by alpha and beta diversity measures, suggesting that bacteriophage consumption is selective and does not globally disrupt the microbiota. Changes in differential abundance of several key bacterial species, including reductions in OTUs most closely mapping to the pathogen Clostridium perfringens, were observed.
Funding Sources
Funding for this study was provided through an unrestricted educational grant from Deerland Enzymes.
Timing of Gastrostomy Placement and Nutritional Status in Patients with Recessive Dystrophic Epidermolysis Bullosa (P14-001)
Syeda Anum, Kerri Gosselin, and Karen Wiss
University of Massachusetts Medical School
Background: Recessive dystrophic epidermolysis bullosa (RDEB) is an inherited disease that causes cutaneous and mucosal erosions at sites of friction and frequently leads to poor growth. Patients often require a gastrostomy tube to supplement caloric intake and improve nutrition. However, the optimal timing for gastrostomy placement is unknown.
Methods: We performed a retrospective review of 6 patients with RDEB to assess growth parameters before and after gastrostomy placement.
Results: The median age of gastrostomy was 10.7 y (range 3.7–21 y). The mean weight-for age z score prior to gastrostomy placement was –2.3, which improved to –1.8 after placement (P = 0.07). The mean height-for-age z scores did not change significantly with gastrostomy placement (P = 0.45). Patients were followed for a mean of 18 mo (range 11–26 mo) following gastrostomy placement.
Conclusions: Gastrostomy placement led to improved weight for age in our small RDEB cohort. Further research into the timing of gastrostomy placement in the setting of RDEB is needed.
Funding Sources
N/A.
Fatty Liver Index Responsiveness to a 10-wk Lifestyle Modification Program with Supervised Physical Exercises and Dietary Counselling (P14-003)
Roberto C Burini,1 Hugo Kano,2 Layene Barros,2 Caroline NM Nunes,2 Mariana Nakagaki,3 and Bruce Krystal4
1Sao Paulo State University-Botucatu Medical School, Brazil; 2UNESP Medical School, Brazil; 3UEL/UEM Physical Exercise School, Brazil; and 4BWH-Department of Medicine, Harvard Medical School, MA
Methods: Baseline data of 1030 subjects from a dynamic cohort study (2005–2017 data) were analyzed cross-sectionally. Analysis included medical, dietary [24-h food intake questionnaire and healthy eating index (HEI) calculation], physical activity, anthropometry, and plasma biochemistry. An algorithm based on body mass index, waist circumference, triglycerides, and γ-glutamyltransferase was previously used to develop the “fatty liver index” (FLI), which varies between 0 and 100, with an FLI of ≥60 associated with nonalcoholic fatty liver disease (NAFLD). Longitudinal analyses were undertaken using data from 583 subjects submitted to a 10-wk LiSM intervention, with daily supervised mixed physical exercises (5 times per week, 80 min per session, 60–80% VO2 max) and dietary counseling. FLI values were split into quartiles for comparison with covariables. SAS version 9.2 was used to complete an ANOVA and to evaluate the FLI quartiles (Q1–Q4). Tukey's post hoc test was applied, with the significance level set at p84.8.
Results: The top quartile of FLI was predominantly male, with lower schooling, lower income, lower physical activity, and inadequate HEI (98.8%). FLI was positively correlated with total energy intake and its fat and carbohydrate (CHO) components; FLI was negatively correlated with fiber, fruit, and legume intake. Multiple regression analysis revealed that an increased FLI is associated with a higher intake of fats (except MUFA) and refined CHOs (cereal and sugar), and a higher Na/K ratio in the diet. Biochemically, FLI was influenced by altered LDL and HDL cholesterol, homeostasis model assessment of insulin resistance (glucose and insulin), high-sensitivity C-reactive protein (hs-CRP) and malondialdehyde. After LiSM, 95 subjects had reduced the >60 (M0) FLI to hs-CRP and malondialdehyde as the main factors for positive responsiveness of FLI to LiSM.
Conclusions: In a low socioeconomic, low physical activity population, FLI, an index reflective of NAFLD risk, was associated with a low-quality diet replete with high-energy dense/manufactured foods along with insulin resistance, proinflammatory, and elevated oxidative stress. Responsiveness to LiSM was associated with a decrease in processed-refined foods and a reduced inflammatory-oxidative state.
Funding Sources
Brazilian foundations CNPq and CAPES.
Impact of Fish Oil Supplementation on Adolescents with Acne Vulgaris: A Randomized Clinical Trial (P14-004)
Felipe de Souza Cardoso,1 Ana Maria Mósca de Cerqueira,2 and Maria das Graças Tavares-Do-Carmo3
1Federal University of Rio de Janeiro and Bezerra de Araújo College, Brazil; 2Jesus Municipal Hospital, Brazil; and 3Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Brazil
Objective: The aim of this study was to evaluate the effects of fish oil supplementation on the clinical, nutritional, biochemical, and hormonal parameters of adolescents with acne vulgaris.
Methods: A randomized, placebo-controlled, double-blind clinical trial was undertaken with 10 adolescent male volunteers, diagnosed with moderate to severe acne vulgaris, who attended the dermatologic clinic of the Jesus Hospital, Rio de Janeiro, Brazil. The volunteers were divided into 2 groups: fish oil (700 mg of docosahexaenoic acid in 1000 mg of total oil per day) or mineral oil as placebo. The variables analyzed before and after 2 mo of treatment were fasting glucose, fasting insulin, homeostasis model assessment of insulin resistance (HOMA-IR), 25(OH) cholecalciferol, tumor necrosis factor alpha, C-reactive protein, and severity scale of acne vulgaris. Student's t test was considered for statistical significance at P < 0.05.
Results: The parameters measured indicated statistically significant differences between fish oil and placebo group after 2 mo of intervention. The data are indicated as mean ± SD and variation between the end and baseline of the treatment (Δ) for the test and placebos groups, respectively: magnesium (1.77 ± 0201 mg/dL, Δ: 0.4 mg/dL; 1.72 ± 0.23 mg/dL, Δ: 0.0 mg/dL), fructosamine (219 ± 55.89 mmol/L, Δ: –100.14 mmol/L; 277.33 ± 73.96 mmol/L, Δ: 29.66 mmol/L), fasting blood glucose (84.71 ± 3729 mg/dL, Δ: –3.86 mg/dL; 92.33 ± 2.52 mg/dL, Δ: 7.33 mg/dL), HOMA-IR (1.20 ± 0530, Δ: –0,22; 4.7 ± 5.62, Δ: 0.58), 25(OH) cholecalciferol (31.96 ± 4577 ng/mL, Δ: –5.5 ng/mL; 29.20 ± 8.01 ng/mL, Δ: 3.37 ng/mL), severity scale of acne vulgaris (16 ± 8145, Δ: –12.43; 34.33 ± 5.51, Δ: 0.66), tumor necrosis factor alpha (6.43 ± 0864 pg/mL, Δ: –0.87 pg/mL; 11.03 ± 3.35 pg/mL, Δ: 0.46 pg/mL), and C-reactive protein (0.42 ± 0186 mg/L, Δ: –0,36 mg/L; 2.9 ± 2.35 mg/L, Δ: 1,63 mg/L).
Conclusions: The study shows that omega-3 fatty acids could be used as adjuvant treatment for adolescent patients with acne, improving clinical, nutritional, biochemical and hormonal parameters involved in the pathogenesis of the disease.
Funding Sources
Federal University of Rio de Janeiro and Jesus Municipal Hospital.
Micronutrients as Biomarkers for Assessment of Nutritional Status in Acne Vulgaris after Supplementation with Fish Oil: A Randomized Clinical Trial (P14-005)
Felipe de Souza Cardoso,1 Ana Maria Mósca de Cerqueira,2 and Maria das Graças Tavares-Do-Carmo1
1Federal University of Rio de Janeiro and Bezerra de Araújo College, Brazil; and 2Jesus Municipal Hospital, Brazil
Objective: The aim of this study was to evaluate the effects of fish oil supplementation on micronutrients in the blood involved in the pathogenesis of acne vulgaris in adolescents.
Methods: A randomized, placebo-controlled, double-blind clinical trial was undertaken with 10 adolescent male volunteers, diagnosed with moderate to severe acne vulgaris, who attended the dermatologic clinic of the Jesus Hospital, Rio de Janeiro, Brazil. The volunteers were divided into 2 groups: fish oil (700 mg of docosahexaenoic acid in 1000 mg of total oil per day) or mineral oil as placebo. The following variables were analyzed before and after 2 mo of treatment: cobalamin, zinc, retinol, homocysteine, subjective evaluation, and severity scale of acne vulgaris. Student's t test was considered for statistical significance at P < 0.05.
Results: The parameters measured indicated statistically significant differences between the fish oil and placebo group after 2 mo of intervention. The data are indicated as mean ± SD and variation between the end and baseline of the treatment (Δ) for the test and placebos groups, respectively: cobalamin (430.86 ± 79.43 pg/mL, Δ: 45.72 pg/mL; 351 ± 40.04 pg/mL, Δ: –19.33 pg/mL), zinc (84.70 ± 7989 mg/dL, Δ: 13.94 mg/dL; 78.37 ± 2.57 mg/dL, Δ: –1,66 mg/dL), retinol (55.43 ± 7934 mg/dL, Δ: 8.72 mg/dL; 45.03 ± 2.00 mg/dL, Δ: 1.76 mg/dL), homocysteine (7.54 ± 0969 mmol/L, Δ: –2.87 mmol/L; 8.43 ± 2.00 mmol/L, Δ: –1.94 mmol/L), subjective evaluation (5.43 ± 1134, Δ: –4.57; 8.33 ± 0.58, Δ: –1.67), and severity scale of acne vulgaris (16 ± 8145, Δ: –12.43; 34.33 ± 5,51, Δ: 0.66). No severe adverse effect was reported.
Conclusions: The study indicates that after supplementation with fish oil and improvement of acne lesions, there are possible changes between the micronutrients of the blood. These may be involved in the pathogenesis of acne vulgaris, contributing to the current clinical treatments of the disease.
Funding Sources
Federal University of Rio de Janeiro and Jesus Municipal Hospital.
Nutritional Status and Clinical Outcomes in Hospital: The Importance of Nutritional Healthcare Policies in Practice (P14-006)
Harrison David Edward Carter, Celia Laur, Glenys Jones, Minha Rajput-Ray, and Sumantra Ray
Need for Nutrition Education/Innovation Programme
Objective: The aim of this study was to examine the current state of play in hospital nutritional care and the usefulness of policy and practice guidance in driving improvements in: 1) screening for malnutrition; and 2) skills and awareness of the health care workforce.
Methods: A MEDLINE search of peer-reviewed literature was conducted (via Ovid). The policy and practice guidance search and synthesis used the National Institute for Care and Clinical Excellence (NICE) quality statement and the British Association of Parenteral and Enteral Nutrition standards as reference points.
Results: The search of the peer-reviewed literature captured 19 relevant papers, and a review of the policy and practice guidance captured 51 policy papers. A number of different screening tools, ranging from locally introduced, condition-specific nutritional screening criteria to the Malnutrition Universal Screening Tool, were used. Screening practices were variable, with the reported proportion screened ranging from 68% to 87%. In instances where the NICE guidance was followed, patients were more likely to be screened on admission. Assessment and management knowledge amongst medical students and doctors was poor. Doctors scored consistently lower when compared with dieticians. Surgeons’ nutrition care abilities were understudied, despite the fact that poor nutritional status leads to
FIGURE P14-006-1.
Flow diagram of systematic literature search including exclusion criteria.
TABLE P14-006-1.
Relevant bodies identified as having an interest in malnutrition.
adverse surgical outcomes. Postgraduate training programs were not addressing deficiencies in nutrition knowledge, indicating that nutrition knowledge and understanding was only gained from the undergraduate course and subsequent self-directed learning.
Conclusions: Educational standards need to be devised across the continuum of undergraduate and postgraduate education and form part of mandatory training across the health services. The delivery of nutrition curricula should be studied to determine the effectiveness of methods and content. Work in Canada as part of the Integrated Nutrition Pathway for Acute Care is an example of the type of evidence-based pathway that is much needed for health care professionals to guide their nutrition management. A current Medical Nutrition International project being rolled out over 2018/19 provides an opportunity to develop and test a bespoke medical nutrition education model within the UK.
Supporting Images/Graphs
TLR4 Promotes Fibrosis in Nonalcoholic Liver Disease (P14-007)
J Matias Caviglia
Columbia University, NY
Objective: In nonalcoholic liver disease (NAFLD), fibrosis is the most important predictor of outcome. In patients with advanced fibrosis, liver-related mortality increases ∼40-fold. Our aims were: 1) to establish a mouse model of NAFLD that included nonalcoholic steatohepatitis (NASH), including fibrosis; and 2) to study the role of TLR4 in the development of fibrosis in NASH. Hypothesis: Blocking TLR4 signaling decreases fibrosis in NASH.
Methods: 1) We developed a model of NASH with fibrosis by feeding hyperphagic mice a diet high in fat and fructose (HFF): we fed Ay male mice with a Western diet and a drinking solution containing fructose and glucose as an equivalent of high-fructose corn syrup. After 16 wk, we evaluated the liver for the development of NAFLD, in particular, fibrosis. 2) To study the role of TLR4 in liver fibrosis, we used the previously described model to compare TLR4 null and TLR4 wild-type mice.
Results: 1) Ay mice fed the HFF diet developed obesity, hepatomegaly, and NASH, characterized by factors including steatosis, hepatocellular injury (ballooning), inflammation, and fibrosis. 2) TLR4 null mice also developed NASH, but had less fibrosis than TLR4 wild-type mice, as assessed by Sirius Red staining and quantification, and mRNA expression of the fibrosis markers Col1a1 and Timp1.
Conclusions: 1) The Ay-HFF model accurately replicates NASH with fibrosis in a physiologic model that includes obesity and does not require a diet with trans fats or large amounts of cholesterol. 2) In NASH, TLR4 promotes fibrosis and thus constitutes a potential therapeutic target.
Funding Sources
K22 CA178098R03 DK101863R01 CA200597R01 CA190844.
Text Messaging Intervention on Cardiovascular Disease Risk Perception among Type 2 Diabetes Patients (P14-008)
Weiwen Chai1 and Martha Nepper2
1University of Nebraska-Lincoln; and 2Nebraska Methodist Health System
Objective: The aim of this study was to examine the effects of text messaging intervention on cardiovascular disease (CVD) risk perception and dietary intake among adults with type 2 diabetes using a quasi-experimental design.
Methods: Thirty-five type 2 diabetes patients (aged ≥30 y) were recruited to the intervention group and 35 to the control group. The intervention group received 3 text messages weekly, consisting of nutrition education and diabetes self-management information and skills, for 12 wk. The control group did not receive text messages. Participants in both intervention and control groups completed self-report surveys on CVD risk perception and 24-h dietary recall at baseline and 12-wk follow-up (after the intervention was concluded). Data collection for the control group started 2 mo later than for the intervention group.
Results: The intervention and control groups had similar characteristics at baseline (Ps > 0.05). In the intervention group, CVD awareness scores on surveyed items improved in the expected direction, with significant improvement in scores of having concern of CVD in lifetime (pre: 1.45 ± 0.97; post: 1.79 ± 0.93, P = 0.025). The CVD awareness scores decreased in the control group, with significant decreases in scores of having concern of CVD in the next 5 y (pre: 1.52 ± 0.75, post: 1.10 ± 0.76; P = 0.047) and of having concern of having CVD compared with other people of one's age and gender (pre: 2.10 ± 0.63, post: 1.62 ± 0.87; P = 0.021). Additionally, the percentage of calorie intake from carbohydrate decreased from 47.1% at baseline to 40.3% at the 12-wk follow-up for the intervention group (P = 0.026).
Conclusions: A 12-wk text messaging intervention may help diabetes patients increase their awareness of CVD risk.
Funding Sources
This research was supported by the University of Nebraska-Lincoln Layman faculty seed grant.
Almonds Improve Vitamin E Status and Cardiometabolic Risk Factors in Overweight or Obese Korean Adults (P14-009)
C-Y Oliver Chen,1 Hana Jung,2 Jeffrey Blumberg,1 and Ho-Kyung Kwak2
1Tufts University, MA; and 2Korea National Open University
Objective: Almonds improve many cardiometabolic risk factors in diverse ethnic populations, but these benefits have never been tested in Koreans. Thus, we aimed to examine the impact of almonds consumed as a snack within the context of a typical Korean diet on cardiometabolic risk factors in overweight or obese Korean adults.
Methods: We conducted a randomized, crossover trial in a free-living setting with a 2-wk run-in period, two 4-wk intervention phases, and a 2-wk washout period between interventions. Eighty-four overweight or obese adults (11 M/73 F; 52.4 ± 0.6 y; 25.4 ± 0.2 kg/m2) consumed either 56 g of almonds or isocaloric cookies daily for 4 wk.
Results: The mean percentage daily energy intake at baseline was 64.8%, 21.3%, and 14.9% from carbohydrate, fat, and protein, respectively. Compared with the values from the prealmond phase, the addition of almonds to the habitual diet of the subjects decreased carbohydrate energy to 55.0%, increased fat to 32.0%, and maintained protein at 14.7%. Furthermore, the almonds increased the intake of MUFA by 192.3%, PUFA by 84.5%, vitamin E by 102.7%, and dietary fiber by 11.8%. The almonds increased the total caloric intake by 210 kcal/d, but did not alter the body weight, waist circumference, or body composition. As compared with the changes during the cookie phase, the almonds decreased total cholesterol, LDL cholesterol, and non-HDL cholesterol by 5.5%, 4.6%, and 6.4%, respectively (P ≤ 0.05). The almonds increased plasma α-tocopherol by 8.5% (P ≤ 0.05) from the corresponding baseline and tended to increase its value compared with the cookies (P = 0.055). Neither the almonds nor the cookies altered plasma protein carbonyls, malondialdehyde, or oxidized LDL. The almonds decreased the postintervention serum interleukin-10 (IL-10) concentration by 22.2% compared with the cookies (P ≤ 0.05) and tended to reduce intercellular adhesion molecule-1, IL-1β, and IL-6.
Conclusions: Consumption of 56 g of almonds per day as a snack favorably modified the typical Korean diet by increasing MUFA, PUFA, vitamin E, and dietary fiber intakes and decreasing the percentage energy intake from carbohydrates. Almonds also enhanced plasma α-tocopherol status and decreased total cholesterol and LDL cholesterol in overweight or obese Koreans. Thus, including almonds as a snack in the typical Korean diet can help healthy overweight or obese adults improve their nutritional status and reduce their risk for cardiometabolic diseases.
Funding Sources
Almond Board of California and USDA.
Tomato Powder Attenuated Nonalcoholic Fatty Liver Disease Independent of Sirtuin 1 Activity in Mice (P14-010)
Junrui Cheng,1 Chun Liu,1 Kang-quan Hu,1 Andrew Greenberg,1 Dayong Wu,1 Lynne Ausman,1 Michael W. McBurney,2 and Xiang-dong Wang1
1Tufts University, MA; and 2University of Ottawa, Canada
Background: Mammalian sirtuin 1 (SIRT1), a highly conserved NAD+-dependent protein deacetylase, has been identified as a key regulator of energy homeostasis and lipid metabolism. Epidemiologic studies have reported that high consumption of tomato and tomato products is associated with low risk for the progression of nonalcoholic fatty liver disease (NAFLD), a risk factor of hepatocellular carcinoma (HCC). We have recently shown that the supplementation of tomato powder (TP, as a whole food approach) increased hepatic expression of SIRT1 and inhibited high fat diet (HFD) induced NAFLD development. However, whether the TP inhibition of NAFLD and HCC is dependent on SIRT1 activity remains unknown.
Objective: The objective of this study was to determine whether TP inhibition of NAFLD and HCC is dependent on SIRT1 activity.
Methods: Mutated mice with ablation in catalytic activity of SIRT1 (MT) and their corresponding wild-type littermates (WT) were injected with the carcinogen diethylnitrosamine at 2 wk of age, then fed an HFD (60% calories from fat) with or without TP feeding (WT, n = 18; WT + TP, n = 16; MT, n = 13; MT + TP, n = 15) for 34 wk.
Results: Dietary TP significantly reduced the liver pathologic steatosis score in both WT and MT mice, but through different molecular mechanisms: in WT mice, the protective effect of TP was associated with increased SIRT1 protein expression and activity, and with decreased hepatic fatty acid binding protein 1 expression and long chain fatty acid uptake. In MT mice, however, TP decreased hepatic fatty acid synthesis by inactivating hepatic acetyl-CoA carboxylase mediated by AMPK phosphorylation, independent of SIRT1 activity. Although we did not detect significant pathologic inflammatory lesions in either WT or MT mice, TP lowered il-6 mRNA expression in mesenteric adipose tissue and IL-6 concentration in both plasma and liver in MT mice, whereas in WT mice, dietary TP decreased caspase-1 mediated IL-1β maturation. Neither the ablation of SIRT1 activity nor TP supplementation altered HCC incidence or tumor number in either WT or MT mice. This could be because of the lack of inflammation as a target of TP protection or limited efficacy in ameliorating HCC development in this mouse model.
Conclusions: The present study demonstrated that dietary TP supplementation, independent of SIRT1 activity, can ameliorate HFD-induced NAFLD and inflammatory responses, but not affect carcinogen-induced HCC development.
Supporting Images/Graphs
FIGURE P14-010-1.
Funding Sources
USDA/NIFA (2015-67,017-23,141) and USDA/ARS (58-1950-51,000-074S).
A Dietary Intervention Comparison of Healthy Young Adults and Those with Metabolic Syndrome (P14-011)
Rashel L Clark,1 Olivia Kinkade,1 Michelle Cesa,1 Timothy Waanders,1 Mason D Arbogast,1 Ida Holaskova,1 Pamela J Murray,1 Marianne Downes,1 Joseph W McFadden,2 Christopher F Cuff,1 Ivan M Olfert,1 Sarah Colby,3 and Melissa D Olfert1
1West Virginia University; 2Cornell University, NY; and 3University of Tennessee Knoxville
Objective: The objective of this study was to determine if young adults with metabolic syndrome (MetS) have different dietary habits than healthy young adults.
Methods: The 8-wk nutrition intervention was completed in 2 cohorts, with an “at risk” cohort and a MetS cohort. Subjects were educated on MyPlate guidelines and counseled weekly by a nutrition specialist. Anthropometrics, complete blood panel, arterial stiffness, and a stool sample were taken at baseline and postintervention. Each week, diet logs and food receipts were collected for compliance. A repeated measures ANOVA test was used to compare differences over the 8-wk study between the 2 cohorts. A matched pairs t test was used to examine preintervention to postintervention clinical differences.
Results: Thirty-six young adults enrolled in the healthy “at risk” cohort (C1) and 17 in the MetS cohort (C2). However, because of lack
of compliance, 8 individuals were eliminated from the analysis, giving n = 30 in C1 and n = 15 in C2. No significant changes were seen in physical activity, stress, or sleep. Dietary differences between the 2 cohorts yielded significant differences in percentage protein (P = 0.012), fiber (P = 0.003), and empty calories (P = 0.038). Percentage protein and fiber intake were higher in C1 both pre- and postintervention. Empty calories actually started slightly higher in C1, but decreased to a lower value at the end of the intervention in C1 (997.6 ± 948.1 and 441.6 ± 240.1 calories in C1 vs. 964.3 ± 689.4 and 627.1 ± 449.8 calories in C2). Fruit and vegetable intake had a group by diet interaction (P = 0.043), with C1 maintaining a higher fruit and vegetable intake at both pre- and postintervention (2.5 ± 2.0 and 5.2 ± 2.4 cups/d, respectively), whereas C1 intake was 1.7 ± 1.5 and 4.6 ± 1.5 cups/d, respectively.
Conclusions: The dietary intake in both cohorts improved with the 8-wk free-living dietary intervention. However, young adults with MetS had lower overall dietary quality compared with the healthy cohort both before and after the intervention, suggesting that those with MetS and with a lower diet quality beginning the intervention may require longer dietary interventions to yield similar dietary improvements to result in better metabolic health.
Funding Sources
USDA Agriculture and Food Research Initiative Grant 2014-67,001-21,851-A2101, West Virginia Clinical Translational Science Institute (NIH P30 GM103488), and West Virginia University Experimental Station Hatch (WVA00627 and WVA00641).
Feasibility and Acceptability of Three Technology-Supported Behavioral Interventions in Hemodialysis Patients with Persistent Hyperphosphatemia (P14-012)
Margaret A. Curran,1 Mary Lou Pompeii,1 David St-Jules,1 Lu Hu,1 Kathleen Woolf,2 and Mary Ann Sevick1
1New York University Langone Health; and 2New York University Steinhardt
Objective: Hyperphosphatemia is a major cause of complications in hemodialysis (HD) patients. Dietary phosphorus restriction and phosphorus binders are effective in lowering phosphorus concentrations, but hyperphosphatemia persists, due in part to treatment nonadherence. Our study examined the feasibility and acceptability of using mobile technology to deliver 3 phosphorus management interventions of varying intensity in HD patients with hyperphosphatemia.
Methods: A total of 28 participants were randomized to one of 3 groups: 1) education (EDU) (n = 10), 2) education plus self-monitoring (SM) (n = 9), and 3) education and self-monitoring plus social cognitive theory (SCT)-based counseling (COMBINED) (n = 9). Education sessions consisted of 4 short videos shown weekly. An iPad was given to SM and COMBINED participants to record their dietary intakes in MyNetDiary. The COMBINED group also received SCT-based videos. Intervention activities ceased at 12 wk, but the SM and COMBINED groups were encouraged to self-monitor for 24 wk. Participant's satisfaction was assessed by two 5-point Likert-scale surveys at 24 wk.
Results: Six participants were lost to follow-up and were not included in the analysis. The sample was predominantly white (46.4%) or African American (42.9%) and male (75%), aged 62.2 ± 13 y (mean ± SD). The proportion of participants who logged at least one meal a week during the 12-wk intervention and 12-wk postintervention was 65% and 28%, respectively. The SM and COMBINED groups did not exhibit a significant difference in self-monitoring adherence. Participants reported (agree or strongly agree): receiving enough training in using the iPad (88%), ease in using the iPad's touch screen (94%), convenience of using the iPad away from home (81%), and desire to continue using the iPad to monitor health (63%). Technology-based self-monitoring helped them understand how to change their diet (69%), keep track of nutrition (81%), and stay motivated (63%).
Conclusions: Technology-based behavioral intervention and self-monitoring are feasible and acceptable in an HD population, but adherence declines following active intervention withdrawal. Additional research is needed to determine the level of contact required to sustain engagement, and to evaluate technology-based interventions in this population.
Funding Sources
The behavioral management of phosphorus in hemodialysis study was supported by the following grant: NIH-R21-DK105437-01.
Patient Reported Outcomes of the Health Benefits of Fasting: A Historical Perspective (P14-013)
William Troy Donahoo
University of Florida
Objective: Fasting has received attention recently as a medical treatment with a multitude of reported benefits: cardiometabolic, cognitive/neuronal, cancer, and longevity. Fasting as a medical intervention is not new. In 1911, Upton Sinclair published “The Fasting Cure”, wherein he reported the first ever review of patient reported outcomes (PROs) following fasting. The aim of this study was to compile the actual PROs published to gain an historical perspective and better understand potential benefits and limitations of fasting in humans.
Methods: In his book, Sinclair accumulated PROs following fasting. Where possible, we abstracted demographic data, disease state, fast duration, and effects from accounts of individually reported data from letters written to Sinclair for this analysis.
Results: Sinclair summarized the PROs of 277 total fasts lasting an average of 6 d (90 ≥ 5 d, 51 ≥ 10 d, 6 ≥ 30 d) and stated that of 117 reported fasts in 109 people, 100 reported benefit. From our review, 36 patients with PROs presented who had data that could be abstracted. Their age was 46.5 ± 16 y (mean ± SD; n = 8, range 28–80 y) and 57% were male (n = 30). There were 66 separate PROs described, 30% of which involved gastrointestinal, 13% neuropsychiatric, 12% infectious disease, 12% general health, and <10% each other organ systems. There were 35 separate fasts with a reported duration, the mean length being 14.8 ± 11.5 d (range 2–50 d). In these PROs, 95% reported a benefit. There was also one death reported, but it is uncertain if this was related to fasting. Specific conditions and comparison with Sinclair's report are described in detail.
Conclusions: Over a century ago, medical benefits of therapeutic fasting were reported for a variety of diseases. Despite significant limitations, including the state of medicine, as a true diagnosis could rarely be made, self-reported results, and the possibility of “publication bias” such that only positive cases were included or submitted, it is exciting to see that current interest in fasting is similar to that in the past, and it will be interesting to see if science is able to verify the purported benefits.
Funding Sources
University of Florida Department of Medicine internal funding.
Dietary Intake and Cardiovascular Risk Factors: An Update of the Healthy Eating Index in Hemodialysis Patients (P14-014)
Van Tuyen Duong,1 Tuyen Duong,1 I-Hsin Tseng,1 Te-Chih Wong,2 Chien-Tien Su,1 Hsi-Hsien Chen,3 Tzen-Wen Chen,1 Tso-Hsiao Chen,4 Yung-Ho Hsu,5 Sheng-Jeng Peng,6 Ko-Lin Kuo,7 Hsiang-Chung Liu,8 En-Tsu Lin,9 and Shwu-Huey Yang1
1Taipei Medical University, Republic of China; 2Chinese Culture University, Republic of China; 3Taipei Medical University Hospital, Republic of China; 4Taipei Medical University-Wan Fang Hospital, Republic of China; 5Taipei Medical University-Shuang Ho Hospital, Republic of China; 6Cathay General Hospital, Republic of China; 7Taipei Tzu-Chi Hospital, Republic of China; 8Wei Gong Memorial Hospital, Republic of China; and 9Lotung Poh-Ai Hospital, Republic of China
Objectives: The objectives of this study were to modify the hemodialysis eating index (m-HDEI), aligning it with the Healthy Eating Index released by the USDA; and to investigate the associations of the m-HDEI with cardiovascular disease (CVD) risks in hemodialysis (HD) patients.
Methods: In the clinical cross-sectional study, we recruited 492 HD patients, aged ≥20 y, from 7 hospital-based dialysis centers in Taiwan between 2013 and 2017. Dietitians assessed dietary intake using 3-d dietary records. Traditional and nontraditional CVD risks were evaluated using patient chart reviews and laboratory examinations. The m-HDEI scoring criteria were calculated from the diet quantity and quality recommended per energy requirement level, found in the Daily Food Guide in Taiwan and the Kidney Disease Outcomes Quality Initiative guidelines. We used regression models to examine the associations and conducted subgroup analysis for age and history of CVD.
Results: In the sample, 61.8% of patients were aged <65 y, 56.3% were men, and 66.1% did not have CVD. The m-HDEI consisted of 5 diet quantity items [fruit, vegetable, grains, high protein food (HPF), oil] and 3 diet quality items [high biological value protein (HBV), fish, processed red meat]. The scores of the components ranged from a minimum of 0 to a maximum of 10, 15, or 20, and m-HDEI score ranged from 0 to 100. A higher fruit score was associated with reduced high systolic blood pressure and hypoalbuminemia; a higher grain score was associated with lower high LDL cholesterol; and a higher oil score was linked to lower hyperkalemia in patients without CVD. A higher vegetable score was associated with lower hyperhomocysteinemia and inflammation in patients <65 y old. A higher HPF score was associated with lower hypercalcemia in patients <65 y old, and with lower hypophosphate and inflammation in both subgroups. A higher HBV score was associated with lower low HDL cholesterol in patients <65 y old, and with lower high intact parathyroid hormone in both subgroups. A higher seafood/fish score was linked to a lower prevalence of high LDL cholesterol, whereas a higher score of (or less consumption of) processed meat was associated with a reduced high diastolic blood pressure in both subgroups.
Conclusions: The m-HDEI is valid and reliable. Dietary intake was mainly associated with CVD risks in patients aged <65 y and without CVD. Early nutritional interventions might contribute to the prevention of CVD in HD patients.
Funding Sources
The research was supported by the Ministry of Science and Technology in Taiwan (NSC 102-2320-B-038-026, MOST 105-2320-B-038-033-MY3).
Dietary Changes in a Diabetes Prevention Program among People with Prediabetes—The D-CLIP Trial (P14-015)
Christopher N Ford,1 Mary Beth Weber,1 Lisa R Staimez,1 Ranjit M Anjana,3 Karthikeyan Lakshmi,3 Viswanathan Mohan,3 and KM Venkat Narayan2
1Rollins School of Public Health and 2Emory Global Diabetes Research Center, Emory University, GA; and 3Madras Diabetes Research Foundaion & Dr Mohan's Diabetes Specialties Centre, India
Background: Diabetes prevention trials promoting a low-fat diet have been less successful in South Asian compared with other populations, which may be because of the pre-existing low fat intake. This study evaluated the impact of a diabetes prevention intervention on diet and risk of diabetes in Asian Indians.
Methods: Data were included from the Diabetes Community Lifestyle Improvement Program, a randomized control trial and translational study of the Diabetes Prevention Program. Overweight Asian Indian adults (20–65 y) with prediabetes were randomized to receive standard treatment (control; n = 283) or the 6-mo intervention (n = 295), which included structured education and support to reduce intakes of fat (to <30% of total energy) and total calories. Diet was measured at baseline, 6, 12, and 24 mo using a food-frequency questionnaire, and incident diabetes was determined using fasting plasma glucose and 2-h plasma glucose from an oral glucose tolerance test. Random-effects linear regression was used to evaluate intervention-related changes in intakes of foods and nutrients. Cox proportional hazards were used to compare 1-y hazards of diabetes in the intervention and control groups, with and without adjustment for intervention-related dietary changes.
Results: The sample included 485 respondents (control, n = 240; intervention, n = 245), who consumed an average of 27.7% of total energy from fat at baseline. At 6 mo, there were no changes in relative intakes of fat, carbohydrates, or protein. However, the intervention was associated with decreased intakes of total energy (–185.6 kcal/d; 95% CI: –353.6, –17.5 kcal/d) and refined cereals (–7.2 g/1000 kcal; 95% CI: –12.7, –1.7 g/1000 kcal), and increased intake of fruits and vegetables (33.4 g/1000 kcal; 95% CI: 16.0, 50.8 g/1000 kcal). Those in the intervention group were half as likely (HR: 0.49; 95% CI: 0.24, 0.94) to develop diabetes at 1 y. The hazard ratio was significantly attenuated (12.2%; P = 0.015) after adjusting for intakes of fruits and vegetables.
Conclusions: Pre-existing low fat intake in Asian Indians may delimit the impact of diabetes prevention trials that emphasize a low-fat diet. Interventions that promote increased intake of fruits and vegetables and decreased intakes of refined grains and total calories may be more likely to prevent diabetes in Asian Indians.
Funding Sources
This project is supported by a BRiDGES grant from the International Diabetes Federation (LT07-115). BRiDGES, an International Diabetes Federation project, is supported by an educational grant from Lilly Diabetes. Additional support was provided by the Global Health Institute at Emory University. CNF received funding from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under Award Number R21DL105891. MBW received funding from 2 National Institute of Diabetes and Digestive and Kidney Diseases T32 grants (5T3-2DK-0,07298-33 and T32-DK-0,07734-16). LRS received funding from the Human Health Molecules to Humankind program funded by the Burroughs Wellcome Fund grant (BWF 1,008,188).
Body Composition Changes of Children with Congenital Heart Disease during the Perioperative Period (P14-016)
Li Hong and Liqing Xie
Shanghai Childrens Medical Center, China
Objective: Children with congenital heart disease (CHD) are at high risk for malnutrition, and the body composition changes obtained through bioelectrical impedance analysis (BIA) could be a sensitive index for the nutritional evaluation of CHD children during the perioperative period.
Methods: Seventy-five children with CHD (37 male, 38 female, mean ± SD age 4.53 ± 1.69 y) were enrolled in the study. Their body composition and phase angle (PA) were measured via BIA 1 d before, 1 d after, and 7 d after open heart surgery. Seventy-five gender- and age-matched health controls were also recruited.
Results: The PA 1 d after surgery was significantly lower than that 1 d before surgery and returned to the preoperative level 7 d after surgery. However, a repeated-measures ANOVA showed that the changes in the body weight, fat mass, free-fat mass, and body cell mass over time were not significant, whereas the changes in the PA over time were significant. The repeated-measures ANOVA indicated that changes in the total body water, edema index, and intracellular water over time were not significant, but the changes in the extracellular water were significantly.
Conclusions: The PA might be a sensitive index for the nutritional evaluation of CHD children during the perioperative period. The conditional implementation of BIA has been proposed for the accurate evaluation of the nutritional status of CHD children, which would allow individualized nutritional support and thus improvement of the nutritional conditions and clinical outcomes of CHD children.
Lack of Peroxisome Proliferator-Activated Receptor alpha Exacerbates NAFLD in High Fat–Fed Mice Treated with Decaffeinated Green Tea Extract (P14-017)
Weslie Khoo, Jeffrey Peters, and Joshua D Lambert
Penn State University
Objective: Nonalcoholic fatty liver disease (NAFLD) is a growing health problem. There is growing evidence that green tea extract (GTE) can mitigate NAFLD in laboratory models. To determine the importance of peroxisome proliferator-activated receptor alpha (PPARα) as a mediator of GTE, we compared the NAFLD preventive effect of GTE in high fat–fed wild-type (WT) and PPARα-null (KO) mice.
Methods: Female WT and KO mice (starting body weight 16.4–27.9 g) were fed either a high-fat diet (HF, 60% energy from fat) or a HF diet supplemented with decaffeinated green tea extract (7.7 g GTE/kg) for 12 wk. Blood glucose concentrations and hepatic triglycerides were analyzed biochemically. Hepatic lipidosis was quantified by histologic analysis.
Results: Overall, WT mice had a significantly higher body mass compared with KO mice (P < 0.01). GTE treatment was well tolerated by WT mice, but resulted in 25% mortality in KO mice. GTE-treated KO mice were lethargic and some had noticeably sluggish responses to touch. GTE treatment caused a greater reduction in visceral fat mass in KO mice than in WT mice, but led to higher fasting blood glucose concentrations in KO mice (P < 0.05). Markers of fatty liver disease (liver weight, lipidosis) were more pronounced in KO mice than in WT mice (P < 0.05). As expected, GTE decreased hepatic lipidosis in HF-fed WT mice. Unexpectedly, GTE supplementation increased hepatic lipidosis in HF-fed KO mice. These data suggest that in the absence of PPARα, GTE treatment can exacerbate NAFLD rather than improve it. Studies are ongoing to further characterize the extent of hepatoxicity caused by GTE in HF-fed KO mice.
Conclusions: Taken together, our preliminary study represents the first study to show that in the absence of PPARα, GTE exacerbates, rather than mitigates, HF diet-induced NAFLD in mice. These effects may be related to the role that PPARα plays in antioxidant response and the reported potential for GTE to induce oxidative stress. Further studies are needed to better understand how differences in PPARα can influence hepatic response to sensitivity to GTE in the context of NAFLD.
Funding Sources
NIH AT004678 and USDA Hatch Project No. 4565 (to JDL).
Oral Supplementation of Pueraria lobata and Rehmannia glutinosa Improve Postmenopausal Bone Status: Studies in Rats and in Humans (P14-018)
Eun Ok Lee, Oran Kwon, and Yeni Lim
Ewha Womans University, South Korea
Objective: During menopause, bone metabolism shifts to a status characterized by high turnover and an imbalance between bone formation and bone resorption. The use of hormone therapy increases the risk of several serious diseases in postmenopausal women. Therefore, alternative natural resources, like Pueraria lobata and Rehmannia glutinosa (PR), are in great demand. P. lobata is an important source of puerain and R. glutinosa contains catalpol. The aim of this study was to investigate the effects of PR on estrogen deficiency–related bone loss in ovariectomized rats and in postmenopausal women.
Methods: For the animal study, 8-wk-old female Sprague-Dawley rats were randomly divided into 5 groups (n = 10 per group): sham-operated with low-fat diet (LFD) control (SLVS), ovariectomized (OVX) with LFD control (OLVS), OVX with high-fat diet (HFD) (OHVS), OVX with HFD + PR (400 mg kg–1 d–1 by mouth, OHPS), and OVX with HFD + 17β-estradiol (0.5 mg kg–1 d–1 by mouth, OHES). After oral administration for each diet for 8 wk, bone microarchitecture, bone turnover markers, and osteoclastic and resorptive gene markers in the bone were measured. The human study was a double-blinded, randomized, placebo-controlled study of 63 postmenopausal women, who were assigned to either a placebo or PR group for 12 wk. We analyzed exogenous metabolites in their plasma and bone turnover markers in their plasma or urine.
Results: In the animal study, the PR supplement had increased bone mineral density, improved trabecular microarchitecture, and suppressed bone turnover rate. Consistent with the animal study, C- and N-terminal telopeptide concentrations were decreased in the PR group in the human study. Furthermore, the plasma puerarin and daidzin response was higher in the PR group than in the placebo group.
Conclusions: These findings suggest that the PR supplementation may have the potential to preserve bone loss in postmenopausal women by suppressing bone turnover.
Dietary Changes in Recently Diagnosed Breast Cancer Patients after a Personalized Food-Based Nutrition Intervention Program (P14-019)
Ana T Limon-Miro,1 Veronica Lopez-Teros,2 Mauro Valencia,2 Graciela Caire-Juvera,3 Bertha Pacheco-Moreno,3 and Humberto Astiazaran-Garcia3
1Centro de Investigacion en Alimentacion y Desarrollo (CIAD), Mexico; 2University of Sonora, Mexico; and 3Research Center for Food and Development, Mexico
Objective: The objective of this study was to analyze the dietary modifications of recently diagnosed breast cancer patients under treatment after 6 mo of a personalized food-based nutrition intervention program (NIP).
Methods: Dietary intakes at baseline and 6 mo after a personalized food-based NIP were compared using 24-h recall as a tool for dietary assessment. Individual diet plans and recommendations for this therapy were based on the patient's nutritional status, dietary habits, schedule, activities, and cultural preferences. Total energy expenditure was estimated using an algorithm based on body weight, age, and sex for the Mexican population and, when appropriate, a caloric restriction (500–1000 kcal/d) was considered. Macronutrient intake was distributed as follows: <30% fat per day (mainly mono- and polyunsaturated fatty acids), ∼55% carbohydrates per day (principally whole grains, legumes and fruits), and 1.5 g kg–1 d–1 of protein to avoid sarcopenic obesity, which is frequent among this population group. Garlic and cruciferous vegetables were encouraged, as well as 5–9 servings of fruits and vegetables per day, throughout the intervention. The NIP was based on the meal-equivalent menu method adapted from the Mexican Food Equivalent System. Patients’ follow-up was every 2 wk, and a different diet menu was provided in each session by a specialized nutritionist, excluding any food supplements.
Results: Nineteen women recently diagnosed with breast cancer completed the 6-mo personalized NIP. Participants increased their dietary fiber intake from 30 g/d at baseline to 33 g/d at the endline (an increase of 3 g/d; P = 0.03), calcium from 447 to 1201 mg/d (754 mg/d; P = 0.01), folate from 282 to 513 mg/d (231 mg/d; P = 0.008), zinc from 6 to 10 mg/d (4 mg/d; P = 0.02), cholesterol from 196 to 370 mg/d (174 mg/d; P = 0.05), and vitamin E from 5 to 9 mg/d (4 mg/d; P = 0.001), respectively.
Conclusions: This 6-mo personalized NIP, based on a nutrient-specific diet for breast cancer patients, produced significant increases in the consumption of dietary fiber, calcium, zinc, cholesterol, vitamin E, and folate, suggesting that an appropriate food-based intervention therapy could improve the nutritional status of patients with this type of cancer.
Funding Sources
Supported by a fellowship from the National Research and Technology Council, Mexico (for ATL-M).
Prebiotic and Probiotic Treatment of Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-analysis (P14-020)
Brett R Loman,1 Diego Hernández-Saavedra,2 Ruopeng An,2 and R Scott Rector3,4
1Center for Microbial Pathogenesis, Nationwide Children's Hospital, Columbus, OH; 2University of Illinois at Urbana-Champaign; 3University of Missouri, Columbia; and 4Harry S Truman Memorial Veterans Medical Center, Columbia, MO
Background: Nonalcoholic fatty liver disease (NAFLD) is a highly prevalent and underdiagnosed comorbidity of many chronic diseases that is associated with altered intestinal bacterial communities. This has prompted research into alternative treatments aimed at modulating intestinal microbiota. Given the novelty of these treatments, scarce evidence exists assessing their effectiveness in clinical populations.
Objective: The objective of this study was to systematically review and quantitatively synthesize evidence on prebiotic, probiotic, and synbiotic therapies for patients with NAFLD in randomized, controlled trials.
Methods: PRISMA guidelines ensured the transparent reporting of evidence. PICOS criteria defined the research question for the systematic review. A systematic keyword search in PubMed and EMBASE identified 25 studies: 9 assessed prebiotic, 11 assessed probiotic, and 7 assessed symbiotic therapies. Basic population characteristics, the primary variables aspartate aminotransferase and alanine aminotransferase (utilized for NAFLD diagnosis), and the secondary variables body mass index (BMI), γ-glutamyltransferase (GGT), tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), total cholesterol, HDL cholesterol, LDL cholesterol, and TAG, were extracted; pooled effect sizes of these variables were calculated via meta-analysis. No publication bias was identified using Begg's and Egger's tests, or Cochrane Bias Assessment tool.
Results: Meta-analysis indicated that microbial therapies significantly reduced BMI [–0.37 kg/m2 (–0.46, –0.28)], hepatic enzymes [alanine aminotransferase –6.9 U/L (–9.4, –4.3), aspartate aminotransferase –4.6 U/L (–6.6, –2.7), GGT –7.9 U/L (–11.4, –4.4)], inflammation [TNF-α –2.0 ng/mL (–4.7, 0.61); but not CRP –0.74 mg/L (–1.9, 0.37)], serum cholesterol [–10.1 mg/dL (–13.6, –6.6)], LDL cholesterol [–4.5 mg/dL (–8.9, –0.17)], HDL cholesterol [–4.4 mg/dL (–7.1, –1.6)], and triglycerides [–10.1 mg/dL (–18.0, –2.3)]. Subgroup analysis by treatment category indicated similar effects of prebiotics and probiotics on BMI, liver enzymes, and HDL, but not the effects on total cholesterol and LDL cholesterol.
Conclusions: This meta-analysis supports the potential use of microbial therapies in the treatment of NAFLD and sheds light on their potential mode of action. Further research into these treatments should consider the limitations of biomarkers currently utilized for the diagnosis and progression of NAFLD, in addition to the inherent challenges of personalized microbial-based therapies.
Funding Sources
Salary support for RSR was provided by VA-Merit GrantI01BX003271-01.
Effectiveness of the NEWSTART Lifestyle Program to Reverse Hypertension (P14-021)
Maximino Alfredo Mejia,1 Albert Sanchez,2 S Christine Chung,1 Gerald W Shavlik,2 Francisco Ramirez,2 Randall Bivens,2 Sherine Brown-Fraser,1 and Roger D Gallant2
1Andrews University, MI; and 2Weimar Institute, CA
Background: Hypertension is the most common clinical condition in primary care within the US whose primary treatment is antihypertensive medications. A systolic blood pressure (SBP) of <120 mm Hg can be achieved with intensive medications along with increased incidence of serious side effects. Thus, some consumers prefer lifestyle approaches to reduce hypertension. Lifestyle interventions targeting multiple lifestyle factors concurrently appear to be more effective than those targeting a single factor.
Objective: The purpose of this study was to assess the effectiveness of the NEWSTART Lifestyle program to reduce SBP.
Methods: The NEWSTART Lifestyle targets multiple factors to reduce hypertension, including nutrition (vegan diet), exercise, water, temperance, fresh air, rest, and trust in divine power. We evaluated retrospective data from a pretest-posttest intervention of 117 hypertensive subjects who were drawn from 173 consecutive clients that had participated in the NEWSTART program for a 16-d period during 2014. The baseline age and body mass index of the subjects (mean ± SD) were 66.5 ± 11.4 y and 31.6 ± 6.6 kg/m2, respectively. Compared with the baseline SBP (138 ± 21 mm Hg), the SBP was significantly reduced by day 16 (119 ± 28 mm Hg) (P < 0.001); a drop of 19 mm Hg or 14%. Half of the subjects achieved a desirable blood pressure of <120 mm Hg. This reduction of systolic blood pressure was consistent in all subjects irrespective of gender, body weight, use or nonuse of antihypertensive medications, and presence or absence of diabetes or dyslipidemias such as hypercholesterolemia, hypertriglyceridemia, or low HDL cholesterol. The intake of antihypertensive medications was also significantly decreased. The NEWSTART Lifestyle program was effective in achieving a significant reduction in systolic blood pressure. This lifestyle intervention should be retested with a larger population for a longer period of time to assess its long-term effectiveness, clinical significance, and relevance to plant-based nutrition research.
Funding Sources
N/A.
Nutrition Assessment and Interventions for Patients with Cystic Fibrosis: An Evidence Scoping Review (P14-022)
Mary Rozga and Deepa Handu
Academy of Nutrition and Dietetics, IL
Objective: The objective of this study was to identify and describe the range and characteristics of existing literature examining nutrition care for patients with cystic fibrosis (CF) in order to determine the need for and scope of a systematic review (SR) and evidence-based practice guidelines (EBPG) in this area.
Methods: A literature search was conducted using PubMed, CINAHL, and the Cochrane systematic review databases for articles examining the validity and/or reliability of nutrition assessment methods and the effect of nutrition interventions on nutrition-related outcomes in CF patients. All types of articles published between 1997 and June 2017 were eligible. The studies included were mapped in order to determine trends in literature availability. Two content advisors provided guidance and reviewed findings to ensure applicability in the context of CF nutrition practice.
Results: Following iterative title and full-text screening, 143 articles were identified. Of these, 10 were identified as guidelines (2 were recent comprehensive nutrition care guidelines for CF); 33 were nutrition assessment articles; 84 were intervention trials; and 20 were SRs. Most of the intervention studies identified were included in current SRs. However, there were no current SRs or EBPGs addressing the efficacy of medical nutrition therapy (MNT) provided by a dietitian on relevant outcomes. Additionally, whereas many trials examined the effect of nutrition supplementation (micronutrient and macronutrient) in CF patients, there were no trials identified that examined the effect of prolonged intake of dietary patterns on nutrition-related outcomes in CF patients. Finally, there was no synthesized information regarding the validity and reliability of assessment methods or tools for the CF population specifically.
Conclusions: This scoping review indicates that there is a need for evidence-based guidance regarding valid and reliable methods for nutrition assessment, including for nutritional status and body composition, and complex interventions, such as MNT and dietary patterns, to inform the nutrition care process for patients with CF.
Funding Sources
Evidence Analysis Library, Academy of Nutrition and Dietetics.
Malnutrition Diagnosis in Hospitalized Patients and Outcomes (P14-023)
Nestor Alejandro Sainz Rueda,1 Nestor Sainz Rueda,1 Lorraine Young,1,2,3 and Dong W Kim3
1Boston Medical Center, MA; 2Boston University Medical Center, MA; and 3Boston University School of Medicine, MA
Objective: Previous studies have demonstrated that malnutrition is associated with increased length of stay, higher 30-d readmission rates, and increased mortality among hospitalized patients. The Academy of Nutrition and Dietetics (AND) and the American Society for Parenteral and Enteral Nutrition (ASPEN) have categorized the etiology-based malnutrition diagnosis by inflammatory status and severity. The objective of this study is to compare hospital outcomes between subtypes of malnutrition.
Methods: The study was a retrospective chart review comparing documented malnutrition within subcategories admitted to the Boston Medical Center between 1 March 2016 and 28 February 2017. Eligible subjects were inpatients identified by registered dietitians on routine evaluation as having malnutrition based on AND/ASPEN criteria. The primary outcomes studied were: number of patients readmitted within 30 d, length of stay, number of patients with length of stay >7 d, overall mortality in 10 mo, and mortality within 90 d.
Results: A total of 1543 patients were diagnosed with malnutrition. Their average age was 63.7 y and 56.4% were men. Six distinct categories were analyzed using malnutrition severity and inflammatory status. Severe malnutrition and chronic disease–related malnutrition represented 57.8% and 69.1% of the patients, respectively. The overall mortality rate was 18.7%, mortality within 90 d was 12.4%, 20.8% had a length of stay >7 d, and 15.2% of the malnourished patients were readmitted within 30 d. There was significantly greater mortality within 90 d in the severely malnourished patients compared with those diagnosed with moderate malnutrition (9.7% vs. 14.5%, P = 0.0049), and the overall mortality was greater in the group with chronic malnutrition (15.1% vs. 20.9%, P = 0.0105).
TABLE P14-023-1.
Demographic and outcomes based on malnutrition severity levels.
TABLE P14-023-2.
Demographic and outcomes based on the context of illness duration.
Conclusions: To the best of our knowledge, this is the first study which compares clinical outcomes among severe and acute versus chronic types of malnutrition. Both severity and chronicity of malnutrition are associated with poor clinical outcomes in hospitalized patients. These results suggest that this subgroup of malnourished patients may benefit most from focused nutrition interventions in the hospital as well as after discharge.
Funding Sources
Department.
Dietary Supplement with Amino Acids and Chromium Picolinate Decreases Postprandial Glucose: A Meta-analysis of Controlled Trials (P14-024)
Azat Samigullin,1 Kristina Anderson,2 Lovisa Heyman-Lindén,2 Rickard Öste,2 Per Humpert,3 and Elin Östman2
1starScience GmbH; 2Aventure AB, Lund, Sweden; and 3Stoffwechselzentrum Rhein-Pfalz
Objective: Water containing amino acids (AA) and chromium picolinate (CrPic) has been shown to improve postprandial glucose in healthy individuals in controlled trials. To substantiate results and explore subgroups of individuals in which these effects are pronounced, a pooled analysis of 3 studies was performed.
Methods: Data from randomized, placebo-controlled, 1) single and 2) double-blinded studies were pooled to include 82 lean and overweight [body mass index (BMI) < 30 kg/m²] healthy individuals. Twenty-three subjects were studied in the US, 23 in Canada, and 36 in Sweden. Participants received a test breakfast meal containing 46–50 g of available carbohydrates and 7–14 g of protein. The test product was the commercially available Good Idea water or a late prototype. Good Idea contains 2.6 g of AA (Leu, Ile, Val, Lys, Thr) and 250 µg of CrPic, as well as carbonation and flavoring. The placebo drink was identical with respect to water, carbonation, and flavoring. Subjects consumed 350 ml of Good Idea or placebo starting 3 min prior to the meal. Glucose and insulin responses were measured and incremental areas under the curve (iAUC) were calculated up to 3 h after a meal and compared using a paired t test. This analysis focuses on 2 h iAUC values.
Results: Good Idea reduced the iAUC for glucose by 28% (43.0 ± 37.7 vs. 59.4 ± 50.4 mmol × min/l, P = 0.002) and the maximum blood glucose by 5% (6.0 ± 0.8 vs. 6.3 ± 0.9 mmol/l, P < 0.001), which were both significant. Significant correlations of change in iAUC glucose with BMI (R = 0.34 P < 0.01) and age (R = 0.26 P < 0.05) were found. Women had a more pronounced glucose reduction (33%; n = 42; P = 0.01), whereas the reduction in men was 22% (n = 40; P = 0.10). The insulin curves with GoodIdea shifted somewhat to the left, yet maximum insulin and the insulin iAUCs were not significantly different between groups.
Conclusions: This meta-analysis shows the potential of Good Idea to reduce postprandial glucose after a carbohydrate-rich meal. There seem to be influences of age, BMI, and gender on this effect that will have to be further investigated. In addition, it needs to be clarified whether regular consumption of Good Idea may favorably influence surrogate markers of metabolic disease and overall caloric intake, or even reduce the risk of developing diabetes.
Funding Sources
Glucanova AB.
Supporting Images/Graphs
FIGURE P14-024-1.
Vitamin D Status in Canadian Children and Adolescents with Sickle Cell Disease (P14-025)
Kaitlyn Samson,1 Heather McCartney,2 Suzanne M Vercauteren,2 John K Wu,2 and Crystal D Karakochuk1
1University of British Columbia, Canada; and 2BC Children's Hospital, Canada
Background: Sickle cell disease (SCD) is an inherited disorder caused by a mutation (rs334) in the HBB gene encoding hemoglobin. Polymerization causes sickle-shaped erythrocytes, resulting in anemia, increased erythropoiesis and RBC turnover, and other complications. Individuals with SCD are at risk of vitamin D deficiency because of increased erythropoiesis, inadequate dietary intakes, and lower UV production of vitamin D by the skin (as SCD is common in individuals of African-origin).
Objective: We aimed to assess serum 25-hydroxyvitamin D [25(OH)D] concentration (as a biomarker of vitamin D status), estimate deficiency prevalence, and investigate factors associated with 25(OH)D in children and adolescents with SCD attending BC Children's Hospital in Vancouver, Canada.
Methods: We conducted a retrospective chart review of SCD clinic patients (2–19 y) over a 5-y period (2012–2017). Data was available for n = 45 patients with n = 142 25(OH)D measurements, assessed using an immunoassay. Other relevant data were recorded, including age, season of blood collection, and prescribed supplements. Linear regression was used to determine associations between 25(OH)D concentration and numerous predictor variables.
Results: Overall, the mean ± SD 25(OH)D concentration was 79 ± 36 nmol/L; the prevalence of low 25(OH)D concentrations (< 30, < 40, and < 75 nmol/L) was 5%, 17%, and 50%, respectively. All individuals were recommended vitamin D supplements (between 500 and 1000 IU/d); however, adherence rates were not known. Mean 25(OH)D concentrations measured in July–September were higher [by 28 nmol/L (95% CI: 16–40 nmol/L), P < 0.001] than in January–March. Vitamin D deficiency rates varied widely by season: based on 25(OH)D < 30 nmol/L, the prevalence was 0% in October–December and 6% in January–March; based on < 40 nmol/L, prevalence was 0% in October–December and 26% in January–March.
Conclusions: In a population of purportedly vitamin D–supplemented children and adolescents with SCD, the prevalence of vitamin D deficiency fluctuated from 0% to 26%, depending on the season of blood collection. The season of blood collection should be considered when measuring and interpreting 25(OH)D concentrations and comparing values over time.
Funding Sources
University of British Columbia's Work Learn Program.
Agreement between Subjective Global Assessment and the American Society for Parenteral and Enteral Nutrition/Academy of Nutrition and Dietetics Malnutrition Framework in Identifying Malnutrition among Adults on Maintenance Hemodialysis (P14-026)
Emily Schwartz,1 Rebecca Brody,2 J. Scott Parrott,2 Emily Peters,2 and Laura Byham-Gray2
1Touchpoint; and 2School of Health Professions’ Department of Nutritional Sciences at Rutgers University, NJ
Objective: Malnutrition is associated with negative outcomes for adults on maintenance hemodialysis (MHD). Subjective global assessment (SGA) is commonly used for the nutritional assessment of those on MHD, though a gold standard for malnutrition identification in this population has not been identified. The American Society for Parenteral and Enteral Nutrition (ASPEN) and the Academy of Nutrition and Dietetics (Academy) have proposed a malnutrition diagnostic framework; however, there is no published research on its use with patients on MHD. The aim of this study was to determine the level of agreement between the SGA and the ASPEN/Academy framework (AAF) in identifying malnutrition among adults on MHD.
Methods: This study was a secondary analysis of an existing dataset from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Development and Validation of a Predictive Energy Equation in Hemodialysis study. Participants were evaluated retrospectively using surrogate markers for the AAF. SGA scores were compared with the framework results for all participants to determine the level of agreement in malnutrition identification. Participants were adults (n = 80) on MHD who participated in the Newark, NJ arm of the NIDDK study.
Results: The majority of the study participants were Black/African American (n = 65, 81.3%) and non-Hispanic (n = 62, 77.5%), and were predominantly male (n = 44, 55.0%). The mean ± SD age of the study participants was 56.9 ± 9.9 y. Malnutrition prevalence identified by the AAF was 25% (n = 20), compared with 78.8% (n = 63) identified by the SGA. A κ of 0.131 indicated slight agreement between the AAF and the SGA. The most commonly reported malnutrition framework characteristic was reduced functional capacity (n = 41, 51.3%), whereas the “disease state/comorbidities” category had the highest number of scores within the malnutrition range (scores of 1–5) on the SGA (n = 75, 93.8%).
Conclusions: There was a difference in malnutrition prevalence identified by the 2 tools. Future prospective trials comparing the AAF to the SGA, as well as to clinical outcomes, will provide more data regarding how the framework identifies malnutrition.
Funding Sources
None.
Exploring the Differences between Early and Traditional Diet Advancement in Postoperative Feeding Outcomes in Patients with an Ileostomy or Colostomy (P14-027)
Sabrina N Toledano,1 Joachim Sackey,2 Kate Willcutts,3 James Parrott,2 Jennifer Tomesko,2 Ahmed Al-Mazrou,1 Pokala Kiran,1 and Rebecca Brody2
1NewYork-Presbyterian/Columbia University Medical Center; 2School of Health Professions’ Department of Nutritional Sciences at Rutgers University, NJ; and 3University of Virginia Health System
Objective: The objective of this study was to assess the differences in postoperative feeding outcomes when comparing early and traditional diet advancement in patients who had an ileostomy or colostomy creation. We hypothesized that patients who receive early diet advancement would pass flatus and produce their first ostomy output earlier than patients who receive traditional diet advancement.
Methods: At a US tertiary care hospital, data from patients who underwent a new ileostomy or colostomy creation from 1 June 2013 to 30 April 2017 were extracted from a prospectively maintained institutional outcomes database. Patients who received early diet advancement (postoperative days 0 and 1) were compared with traditional diet advancement (postoperative day 2 and later) for demographics, preoperative risk factors (body mass index, primary diagnosis), and operative features (surgical approach, type of ostomy). The postoperative feeding outcomes included time to first flatus and first ostomy output. Mann-Whitney U tests determined bivariate differences in postoperative feeding outcomes between the diet advancement groups. Poisson regression was used to adjust for unequal baseline characteristics.
Results: Data from 255 patients were included; 204 (80.0%) received early diet advancement and 51 (20.0%) had traditional diet advancement. The mean age was 56.5 y (total sample), with slightly more males (52.5%) than females (47.5%). Cancer was the most frequently reported primary diagnosis (42.4%), with no difference between the groups. Time to first flatus and time to first ostomy output were significantly shorter in the early compared with the traditional diet advancement group (median difference 1 d for both flatus and ostomy output).
Conclusions: Early diet advancement is associated with earlier return of flatus and first ostomy output compared with traditional diet advancement after the creation of an ileostomy or colostomy.
Funding Sources
N/A.
Hepatocytes (CWSV1) with CRISPR-dCas9 Deletion of the Betaine Homocysteine Methyltransferase (Bhmt) Gene Exhibit a Hepatocellular Carcinoma Phenotype (P14-028)
Isis Trujillo, Stephen Orena, Walter B Friday, and Steven H Zeisel
University of North Carolina at Chapel Hill
Background: One-carbon metabolism, including folate and methionine cycles, is considered a central pathway for adequate methylation and redox maintenance, among other functions. Specifically, in the methionine cycle, betaine homocysteine methyl transferase (BHMT) generates approximately half the methionine necessary for the S-adenosylmethonine synthesis needed for DNA and histone methylation. Our research group has demonstrated that deletion of Bhmt in mice is associated with spontaneous development of hepatocellular carcinomas (HCC). We also demonstrated that this event is in part mediated through the downregulation of IQ motif–containing GTPase activating protein 2 (Iqgap2) and Proteinase-Activated Receptor 3 (F2rl2) genes.
Objectives: We hypothesize that deletion of Bhmt causes endoplasmic reticulum stress, triggering changes in metabolites, and gene and protein expression resulting in HCC.
Methods: To gain insight into the potential mechanism, we created Bhmt knockout CWSV1 hepatic cells via the CRISPR-dCas9 system (Bhmt-KO).
Results: Our preliminary results show that Bhmt-KO cells exhibit upregulation of fibroblast growth factor 21 gene (Fgf21), downregulation of Iqgap2 and F2rl2 genes, and anchorage-independent growth in agar, which correlates strongly with tumorigenicity.
Conclusions: These results mimic the phenotype observed in Bhmt knockout mouse liver. Since our in vitro cell model mimics the in vivo findings, studies are ongoing to determine the metabolic, protein, and gene expression changes that lead to HCC in our Bhmt-KO cells. We propose that Bhmt deletion disrupts metabolic homeostasis, leading to changes in gene expression and thereby causing HCC.
Funding Sources
This work was funded by grants from the NIH (DK115380, DK056350).
Supporting Images/Graphs
FIGURE P14-028-1.
FIGURE P14-028-2.
FIGURE P14-028-3.
lqgap2 and F2rl2 genes are differentially expressed in WT and KO in CWSV1 cells.
Copper Supplementation in Drinking Water Reverses Dietary Iron Overload-Induced Anemia and Cardiac Hypertrophy in Mice (P14-030)
Tao Wang,1 Ping Xiang,2 Jung-Heun Ha,3 Caglar Doguer,3 Xiaoyu Wang,3 Shireen Flores,3 Y James Kang,1 and James Collins3
1Sichuan University, China; 2Nanjing University, China; and 3University of Florida
Objective: Our previous studies showed that feeding of mice and rats with a high-iron (0.88% carbonyl iron) diet led to impaired growth, severe anemia, tissue copper depletion, and cardiac hypertrophy. Interestingly, these physiologic perturbations were prevented by adding extra Cu to the high-Fe diet, proving that they were the consequence of severe Cu deficiency. Whether these pathophysiologic changes could be reversed by Cu treatment, however, is unknown. The current study was thus undertaken to test the hypothesis that Cu supplementation of dietary Fe-overloaded mice could restore the systemic Cu status, and reverse the anemia and cardiac hypertrophy.
Methods and Results: Weanling, male C57BL/6 mice were fed AIN-93G-based diets containing adequate (∼8 ppm) Cu in combination with adequate (∼80 ppm) or high (∼8000 ppm) Fe for 4 wk. The mice were then given 20 mg/L Cu (as CuSO4) in drinking water for another 3 wk. Subsequently, the Fe- and Cu-related phenotype of the mice was assessed. Mice fed the high-Fe diet showed a significant growth impairment and systemic Cu deficiency, accompanied by severe anemia, decreased serum ceruloplamine (Cp) activity, and cardiac hypertrophy. Cu replenishment via drinking water corrected the deficits in hemoglobin, hematocrit, and serum Cp concentrations, restored tissue Cu status, and reversed cardiac hypertrophy. It was further found that high-Fe feeding significantly impaired intestinal Cu absorption and disturbed Cu tissue distribution.
Conclusions: This study demonstrates that high Fe consumption blocks intestinal Cu absorption, leading to a systemic Cu deficiency which resulted in severe anemia and cardiac hypertrophy in mice. Cu supplementation corrects these physiologic perturbations associated with high Fe consumption. These observations have important implications for investigators that utilize the dietary iron overload model in that high-Fe feeding should probably be accompanied by Cu supplementation to prevent these noted physiologic perturbations that are not directly related to tissue Fe accumulation. Moreover, this study has provided further evidence of physiologically relevant Fe-Cu interactions in mammals.
Funding Sources
Supported by NIH grant 1R01 DK074867 (to JFC).
Supporting Images/Graphs
FIGURE P14-030-1.
Consumption of a HFe diet by weanling, male mice causes notable pathological outcomes in only 2 weeks.
FIGURE P14-030-2.
High-iron diet feeding induces severe systemic copper deficiency, decreases serum Cp activity, and eventually caused cardiac hypertrophy after 4 weeks.
FIGURE P14-030-3.
Copper supplementation reverses the anemia associated with dietary iron loading in weanling, male mice.
FIGURE P14-030-4.
High-iron diet feeding induces severe systemic copper deficiency, decreases serum Cp activity, and eventually caused cardiac hypertrophy after 4 weeks.
FIGURE P14-030-5.
Copper supplementation reverses the anemia associated with dietary iron loading in weanling, male mice.
A Branched-Chain Amino Acid Supplement Enriched with Isoleucine Improves Glucose and Insulin Sensitivity in College-Age Males but not in Females (P14-031)
Thomas A Wilson, Michael Dellogono, and Lyra Clark
University of Massachusetts Lowell
Objective: The purpose of this study was to examine how branched-chain amino acids (BCAAs) enriched with isoleucine would influence glucose tolerance following a meal compared with the standard ratio of 2:1:1 (leucine:isoleucine:valine).
Methods: We recruited healthy male (n = 13) and female (n = 5) participants, and asked them to fast for 12 h before a fasting blood collection. The subjects then consumed a breakfast containing 113 g of carbohydrates, 8 g of protein, 1.5 g of fat, and BCAA powder in the 2:1:1 ratio (Control) or BCAA powder enriched with isoleucine (2:6:1; Isoleucine) added to orange juice. We collected blood samples at 30, 60, 90, and 120 min after the meal.
Results: No differences were observed for changes in serum glucose or insulin response between the Control and Isoleucine groups when examining all the subjects together. However, when comparing each gender, males had significantly lower serum glucose with Isoleucine at 60 and 90 min compared with Control, whereas females had significantly higher serum glucose with Isoleucine at 30 and 90 min
compared with Control. Also, males with Isoleucine had significantly lower serum glucose at 90 min and insulin at all time points compared with females with Isoleucine.
Conclusions: Our study indicates a significant difference in the way genders respond to BCAA supplementation, as isoleucine may improve glucose tolerance and insulin response in males but not in females.
Funding Sources
University of Massachusetts Lowell Seed Grant.
Transcriptomic Analysis Reveals the Differential Expression of Hepatic Genes in C57BL/6 Mice with Long-Term Feeding of a High-Fat Diet (P14-032)
Huawei Zeng,1 Kate Larson,1 Wen-Hsing Cheng,3 and Reza Hakkak4
1USDA/ARS, Grand Forks Human Nutrition Research Center, ND; 2Mississippi State University; 3University of Arkansas for Medical Sciences; and 4Arkansas Children Research Institute
Objective: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the Western countries. In mice, high-fat (HF) diets induce obesity and are linked to NAFLD. However, the mechanistic pathogenesis of NAFLD at the molecular level remains to be characterized. We tested the hypothesis that HF feeding increases the differential expression of hepatic genes.
Methods: Male C57BL/6 mice, 4 wk old (n = 15 per group), were fed an HF (45% energy) diet or a low-fat (LF) (10% energy) diet for 21 wk. We used biochemical, immunohistologic, and RNA sequencing approaches to determine the differential expression of hepatic genes and fatty liver status.
Results: At the end of the study, body weight and fat percentage in the HF group were 0.23- and 0.41-fold greater than the LF group, respectively. These changes were associated with significant increases in lipid droplets, inflammatory cell infiltration, and inducible nitric oxide synthase in the livers of the HF group. With the use of RNA sequencing, transcriptomic analysis revealed that mRNA amounts of 79 hepatic genes were altered more than 8-fold in the HF group compared with the LF group. Many of the genes upregulated by the HF diet are involved in amino acid, glucose, and lipid metabolism, the nucleotide catabolic process, protein synthesis, degradation of ketone bodies, and selenium metabolism. On the other hand, downregulated genes are involved in phosphorylation/catabolic processes, G protein receptor, Hedgehog, mitogen-activated protein kinase (MAPK), cell cycle, and tumor suppressor signaling pathways. For example, upregulation of nicotinamide N-methyltransferase (Nnmt) and selenoprotein P (Selenop) is involved in diet-induced obesity and type 2 diabetes, and downregulation of inositol polyphosphate 4 phosphatase A (Inpp4a) reduces immune responses. Changes in the protein concentrations of Nnmt and Selenop, and the Inpp4a gene were confirmed.
Conclusions: Results from RNA sequencing analysis identify a differential mRNA profiling of 79 hepatic genes which are involved in protein phosphorylation, signal transduction, and energy metabolism in the livers of mice fed the HF diet.
Funding Sources
USDA/ARS, CRIS project (3062-51,000-050-00D).
Inhibition of Soluble Epoxide Hydrolase Attenuates Nonalcoholic Fatty Liver Disease Induced by a High-Fat Diet (P14-033)
Jianan Zhang, Jianan Zhang, Weicang Wang, Haixia Yang, katherine Sanidad, Elvira Sukamtoh, Guodong Zhang
University of Massachusetts
Objective: Nonalcoholic fatty liver disease (NAFLD) is a blatantly visible health problem and the prevalence is increasing globally. It is of critical importance to identify a new target to reduce the risks of NAFLD and associated diseases.
Results: Here, we report that the expression of soluble epoxide hydrolase (sEH) is increased in liver tissues of a high-fat diet–induced NAFLD model; in addition, inhibition of sEH attenuates high-fat diet–induced NAFLD, suggesting that sEH could be a novel therapeutic target of NAFLD. C57BL/6 male mice (6 wk of age) were maintained with 1) a control diet (10 kcal% fat), 2) a high-fat diet (60 kcal% fat), or 3) a high-fat diet with the oral administration of an sEH inhibitor (TPPU) for 8 wk. We found that the expression of sEH in the high-fat diet group was dramatically increased in liver. The inhibition of sEH attenuated the accumulation of triglycerides in liver and plasma significantly, induced the accumulation of fat in the liver (Oil Red O staining and H&E histology staining), and reduced the expression of pro-inflammatory genes (Mcp-1 and Tnf-α) in the liver. Regarding the mechanisms, we found that inhibition of sEH can suppress the gene expression of Srebf1, Ppar-γ, Cd36, and Dgat2, which play critical roles in lipid synthesis in liver, and increases the expression of Ppar-α, which regulates β-oxidation of fatty acid in liver.
Conclusions: These results suggest that inhibition of sEH could be a promising way to attenuate NAFLD, suppressing fat accumulation and inflammation in liver.
Effects of Nutritional Intervention on Plasma Protein Concentration of Patients with Ovarian Hyperstimulation Syndrome after Occyte Retrieval (P14-034)
Tiantian Zhang, Ling Geng, Huanhuan Zhang, Xiaoyan Zou, Mingxia Geng, Lin Lin, Qian Wang, and Guangyuan Liu
Reproduction Hospital Affiliated to Shandong University, China
Objective: The objective of this study was to study the effects of nutrition intervention on plasma protein concentration of patients with ovarian hyperstimulation syndrome (OHSS) after oocyte retrieval.
Method: A total of 105 OHSS patients (mean ± SD age 29.20 ± 3.56 y, range 21–40 y) after oocyte retrieval in our hospital were selected, and were randomly divided into an intervention group (67 cases) and a control group (38 cases). The control group was treated with routine clinical treatment and care for 10 d. The intervention group was treated with a high-protein diet (120 g/d) on the basis of the treatment for the control group for 10 d. The general clinical data and plasma protein concentration were compared between the 2 groups.
Results: The level of energy and protein intake per day in the intervention group was higher than the control group (energy intake: 1679.69 ± 317.44 kcal/d vs. 1180.09 ± 246.63 kcal/d, P < 0.05; protein intake: 81.38 ± 17.36 g/d vs. 40.04 ± 7.65 g/d, P < 0.01; ratio of protein energy: 19.01 ± 2.17% vs. 13.11 ± 3.05%, P < 0.05). The decrease of total protein and albumin concentrations was slower in the intervention group than in the control group (P < 0.05). At the beginning of the intervention, there was no difference between the 2 groups in protein concentration (P > 0.05). The concentration of plasma protein reduced significantly from day 3 after oocyte retrieval (P < 0.05). The range of the fall in concentration of plasma total protein and albumin in the control group was significantly larger during days 7 to 9 (P < 0.05). The concentration of plasma total protein and albumin of the intervention group was higher than that of the control group on days 7 and 9 after oocyte retrieval (P < 0.05).
Conclusions: The nutritional intervention can relieve the decrease in plasma protein concentration and promote the recovery of patients with OHSS.
Supporting Images/Graphs
TABLE P14-034-1.
Baseline information (x ± s).
TABLE P14-034-2.
Dietary energy and protein intakes and BMI (x ± s).
TABLE P14-034-3.
The concentration of plasma total protein and albumin (x ± s).