Associations of metabolic, inflammatory and oxidative stress markers with total morbidity and multi-morbidity in a large cohort of older German adults

The association of a low-inflammatory diet with the trajectory of multimorbidity: a large community-based longitudinal study

BACKGROUND

A proinflammatory diet has been associated with a risk of individual chronic diseases, however, evidence on the association between inflammatory dietary patterns and the trajectory of chronic disease multimorbidity is sparse.

OBJECTIVES

We aimed to investigate the associations of a low-inflammatory diet with the multimorbidity trajectory.

METHODS

Within the UK Biobank, 102,424 chronic disease-free participants (mean age 54.7 ± 7.9 y, 54.8% female) were followed up to detect multimorbidity trajectory (annual change in the number of 59 chronic diseases). Baseline inflammatory diet index (IDI) and empirical dietary inflammatory pattern (EDIP) were separately calculated from the weighted sum of 32 posteriori-derived (15 anti-inflammatory) and 18 prior-defined (9 anti-inflammatory) food groups, and tertiled as low-, moderate-, and high-inflammatory diet. Data were analyzed using linear mixed effects model, Cox model, and Laplace regression with adjustment for potential confounders.

RESULTS

During the follow-up (median 10.23 y), 15,672 and 35,801 participants developed 1 and 2+ chronic conditions, respectively. Adherence to a low-inflammatory diet was associated with decreased multimorbidity risk (hazard ratio [HRIDI] = 0.84, 95% confidence interval [CI]: 0.81, 0.86; HREDIP = 0.91, 95% CI: 0.89, 0.94) and a slower multimorbidity accumulation (βIDI = -0.033, 95% CI: -0.036, -0.029; βEDIP = -0.006, 95% CI: -0.010, -0.003) compared with a high-inflammatory diet, especially in participants aged > 60 y (βIDI = -0.051, 95% CI: -0.059, -0.042; βEDIP = -0.020, 95% CI: -0.029, -0.012; both P-interactions < 0.05). The 50th percentile difference (95% CI) of chronic disease-free survival time was prolonged by 0.81 (0.64, 0.97) and 0.49 (0.34, 0.64) y for participants with a low IDI and EDIP, respectively. Higher IDI and EDIP were associated with the development of 4 and 3 multimorbidity clusters (especially for cardiometabolic diseases), respectively.

CONCLUSIONS

A low-inflammatory diet is associated with a lower risk and slower accumulation of multimorbidity (especially in participants aged > 60 y). A low-inflammatory diet may prolong chronic disease-free survival time.

The Dietary Inflammatory Index and Its Associations with Biomarkers of Nutrients with Antioxidant Potential, a Biomarker of Inflammation and Multiple Long-Term Conditions

We aimed to validate the Dietary Inflammatory Index (DII®) and assess the cross-sectional associations between the DII® and multiple long-term conditions (MLTCs) and biomarker concentrations and MLTCs using data from the European Prospective Investigation into Cancer (EPIC-Norfolk) study (11,113 men and 13,408 women). The development of MLTCs is associated with low-grade chronic inflammation, and ten self-reported conditions were selected for our MLTC score. Data from a validated FFQ were used to calculate energy-adjusted DII® scores. High-sensitivity C-reactive protein (hs-CRP) and circulating vitamins A, C, E, β-carotene and magnesium were available. Micronutrient biomarker concentrations were significantly lower as the diet became more pro-inflammatory (p-trend < 0.001), and hs-CRP concentrations were significantly higher in men (p-trend = 0.006). A lower DII® (anti-inflammatory) score was associated with 12-40% higher odds of MLTCs. Lower concentrations of vitamin C and higher concentrations of hs-CRP were associated with higher odds of MLTCs. The majority of the associations in our study between MLTCs, nutritional biomarkers, hs-CRP and the DII® were as expected, indicating that the DII® score has criterion validity. Despite this, a more anti-inflammatory diet was associated with higher odds of MLTCs, which was unexpected. Future studies are required to better understand the associations between MLTCs and the DII®.

Gender-specific factors associated with case complexity in middle-aged and older adults-Evidence from a large population-based study

OBJECTIVES

To investigate gender-specific factors associated with case complexity in a population-based sample of middle-aged and older adults using a holistic approach to complexity.

METHODS

Data were derived from the 8-year follow-up home visits of the ESTHER study-a German population-based study in middle-aged and older adults. Cross-sectional analyses were conducted for 2932 persons (aged 57-84). Complexity was assessed by the well-established INTERMED for the elderly interview, which uses a holistic approach to the definition of case complexity. The association between various bio-psycho-social variables and case complexity was analyzed using gender-specific logistic regression models, adjusted for sociodemographic factors (age, marital status, education).

RESULTS

Prevalence of complexity was 8.3% with significantly higher prevalence in female (10.6%) compared to male (5.8%) participants (p < 0.001). Variables associated with increased odds for complexity in both, women and men were: being divorced (odds ratio [OR] women: 1.86, 95% CI 1.05-3.30; OR men: 3.19, 1.25-8.12), higher total somatic morbidity (women: 1.08, 1.04-1.12; men: 1.06, 1.02-1.11), higher depression severity (women: 1.34, 1.28-1.40; men: 1.35, 1.27-1.44), and higher loneliness scores (women: 1.19, 1.05-1.36; men: 1.23, 1.03-1.47). Women (but not men) with obesity (Body mass index [BMI] ≥30) had higher odds (1.79, 1.11-2.89) for being complex compared to those with a BMI <25. High oxidative stress measured by derivatives of reactive oxygen metabolites in serum was associated with 2.02 (1.09-3.74) higher odds for complexity only in men.

CONCLUSIONS

This study provides epidemiological evidence on gender differences in prevalence and factors associated with case complexity in middle-aged and older adults. Moreover, this study adds to the holistic understanding of complexity by identifying novel variables linked to complexity among middle-aged and older individuals. These factors include loneliness for both genders, and high oxidative stress for men. These findings should be confirmed in future longitudinal studies.

Association Between Speech Reception Threshold in Noise and Multimorbidity: The UK Biobank Study

OBJECTIVE

To investigate the association between hearing function, as approached with the functional auditory capacity, and multimorbidity.

STUDY DESIGN

Cross-sectional study.

SETTING

The UK Biobank was established from 2006 to 2010 in the United Kingdom. This cross-sectional analysis included 165,524 participants who provided baseline information on hearing function.

METHODS

Functional auditory capacity was measured with a digit triplet test. Three categories were defined according to the speech reception threshold in noise (SRTn): normal (SRTn < -5.5 dB signal-to-noise ratio [SNR]), insufficient (SRTn ≥ -5.5 to ≤ -3.5 dB SNR) and poor hearing function (SRTn > -3.5 dB SNR). To define multimorbidity, 9 chronic diseases were considered, including chronic obstructive pulmonary disease, dementia, Parkinson's disease, stroke, cancer, depression, osteoarthritis, coronary heart disease, and diabetes; multimorbidity was defined as the coexistence of 2 or more in the same individual. Analyses were conducted using logistic models adjusted for relevant confounders.

RESULTS

Among the study participants, 54.5% were women, and the mean (range) age was 56.7 (39-72) years. The prevalence of insufficient and poor hearing function and multimorbidity was 13% and 13.2%, respectively. In comparison with having a normal SRTn, the odds ratio (95% confidence interval) of multimorbidity associated with insufficient SRTn was 1.13 (1.08-1.18), and with poor SRTn was 1.25 (1.14-1.37).

CONCLUSION

Insufficient and poor hearing function was associated with multimorbidity. This association suggests common biological pathways for many of the considered morbidities.

Association of cardiovascular health using Life's Essential 8 with noncommunicable disease multimorbidity

Cardiovascular health (CVH) is closely associated with various noncommunicable diseases (NCDs) and comorbidity; however, the influence of CVH on NCD multimorbidity was not fully elucidated. We aimed to examine the association between CVH using Life's Essential 8 (LE8) and NCD multimorbidity among adults, males, and females in the United States, conducting a cross-sectional analysis using data involving 24,445 participants from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2018. LE8 was categorized into low, moderate, and high CVH groups. Multivariate logistic regressions and restricted cubic spline regressions were used to estimate the association between LE8 and NCD multimorbidity. Overall, 6162 participants had NCD multimorbidity, of which 1168 (43.5%), 4343 (25.9%), and 651 (13.4%) had low, moderate, and high CVH, separately. After multivariable adjustment, LE8 was negatively associated with NCD multimorbidity among adults (odds ratio (OR) for per 1 standard deviation (SD) increase in LE8 and 95% confidence interval (CI), 0.67 (0.64, 0.69)), and the top 3 NCDs associated with CVH were emphysema, congestive heart failure, stroke, and the dose-response relationships between LE8 and NCD multimorbidity were observed among adults (overall P < 0.001). Similar patterns were also identified among males and females. Higher CVH measured by the LE8 score was associated with lower odds of NCD multimorbidity among adults, males, and females.

Efficacy of Comedy on Health-Related Quality of Life and Oxidative Stress in Cancer Survivors

INTRODUCTION

Cancer survivors have reduced health-related quality of life (HRQOL) due to impaired daily functioning. In addition, daily stress leads to worsening oxidative stress. The purpose of this study is to investigate the efficacy of laughter therapy on HRQOL and oxidative stress in cancer survivors.

METHODS

This before-and-after study asked cancer survivors to watch a 15-minute or longer comedy video over a four-week period to assess the Functional Assessment of Cancer Therapy-General (FACT-G), EuroQOL 5 dimension 3-level (EQ-5D-3L), Hospital Anxiety and Depression Scale (HADS), biological Antioxidant Potential (BAP), Reactive Oxygen Metabolites-derived compounds (d-ROMs), Oxidative Stress Index (OSI), and the antioxidant/oxidative stress ratio.

RESULTS

The nonparametric Friedman test showed significant increases from baseline in FACT-G and EQ-VAS scores and significant decreases in HADS-Anxiety and HADS-Depression scores. Post hoc analyses showed that these items commonly differed significantly at baseline versus three and four weeks after Bonferroni correction. T-test results in the biological analysis revealed small and moderate effects with significant differences in BAP (p < 0.01, d = 0.49), OSI (p = 0.03, d = 0.33), and BAP/d-ROMs (p < 0.01, d = 0.51).

CONCLUSION

These results suggest that daily comedy viewing may be an effective intervention to improve quality of life and antioxidant capacity in cancer survivors. Considering its safety, convenience, and low cost, it should be considered a high-value intervention for cancer survivors.

Normal and Pathological NRF2 Signalling in the Central Nervous System

The nuclear factor erythroid 2-related factor 2 (NRF2) was originally described as a master regulator of antioxidant cellular response, but in the time since, numerous important biological functions linked to cell survival, cellular detoxification, metabolism, autophagy, proteostasis, inflammation, immunity, and differentiation have been attributed to this pleiotropic transcription factor that regulates hundreds of genes. After 40 years of in-depth research and key discoveries, NRF2 is now at the center of a vast regulatory network, revealing NRF2 signalling as increasingly complex. It is widely recognized that reactive oxygen species (ROS) play a key role in human physiological and pathological processes such as ageing, obesity, diabetes, cancer, and neurodegenerative diseases. The high oxygen consumption associated with high levels of free iron and oxidizable unsaturated lipids make the brain particularly vulnerable to oxidative stress. A good stability of NRF2 activity is thus crucial to maintain the redox balance and therefore brain homeostasis. In this review, we have gathered recent data about the contribution of the NRF2 pathway in the healthy brain as well as during metabolic diseases, cancer, ageing, and ageing-related neurodegenerative diseases. We also discuss promising therapeutic strategies and the need for better understanding of cell-type-specific functions of NRF2 in these different fields.

Multimorbidity

Multimorbidity (two or more coexisting conditions in an individual) is a growing global challenge with substantial effects on individuals, carers and society. Multimorbidity occurs a decade earlier in socioeconomically deprived communities and is associated with premature death, poorer function and quality of life and increased health-care utilization. Mechanisms underlying the development of multimorbidity are complex, interrelated and multilevel, but are related to ageing and underlying biological mechanisms and broader determinants of health such as socioeconomic deprivation. Little is known about prevention of multimorbidity, but focusing on psychosocial and behavioural factors, particularly population level interventions and structural changes, is likely to be beneficial. Most clinical practice guidelines and health-care training and delivery focus on single diseases, leading to care that is sometimes inadequate and potentially harmful. Multimorbidity requires person-centred care, prioritizing what matters most to the individual and the individual's carers, ensuring care that is effectively coordinated and minimally disruptive, and aligns with the patient's values. Interventions are likely to be complex and multifaceted. Although an increasing number of studies have examined multimorbidity interventions, there is still limited evidence to support any approach. Greater investment in multimorbidity research and training along with reconfiguration of health care supporting the management of multimorbidity is urgently needed.

Prognostic stratification of older patients with multivessel coronary artery disease treated with percutaneous transluminal coronary angioplasty based on clinical and biochemical measures: protocol for a prospective cohort study

INTRODUCTION

The incidence of acute coronary syndrome is rising in step with the growth of life expectancy. An increase in the age of patients with coronary artery disease has been related to in-hospital mortality, which has seen an upsurge over a short period of time. However, there is no consensus about the percutaneous coronary angioplasty strategy to follow for older patients with multivessel coronary artery disease (MVCAD). Complete revascularisation (CR) or incomplete revascularisation (ICR) strategy depends on prognosis but this has not yet been accurately described because of geriatric conditions and comorbidities. The aim of this study is to evaluate changes of clinical and biochemical parameters in older patients with MVCAD undergoing revascularisation and to establish a prognostic stratification model for CR and ICR.

METHODS AND ANALYSIS

This observational, longitudinal, prospective study will include 150 patients with MVCAD and subsequent revascularisation who attend the Hospital Universitario Virgen de la Victoria (Málaga, Spain). Because of the dropout rates, 180 patients will be recruited at the beginning. Sociodemographic characteristics, clinical and angiographic parameters, and biochemical variables, such as cardiovascular, metabolic, inflammatory, stress oxidative biomarkers, will be collected in the admission for coronary revascularisation and three follow-ups at 6, 12 and 18 months. Statistical analyses will be conducted with these data using CR and ICR as the primary exposure variable. Relevant explanatory variables will be selected from a predictive model for their inclusion in a prognostic stratification model. The primary outcome measures will be major adverse cardiovascular events.

ETHICS AND DISSEMINATION

Protocols and patient information have been approved by the regional research ethics committee (CEIm Provincial de Málaga-PEIBA (PI0131/2020). The results will be disseminated in international peer-reviewed journals, presented at conferences in Cardiology and Gerontology, and sent to participants, medical and health service managers, clinicians and other researchers.

Oxidative stress in elderly population: A prevention screening study

Background

Aging is a multifactorial phenomenon, characterized by a progressive decline in the efficiency of biochemical and physiological processes and an increased susceptibility to disease. There is increasing evidence that aging and age‐related disease are correlated with an oxidative stress (OS) condition. The latter is characterized by an imbalance between reactive species (RS), in particular reactive oxygen species (ROS) and antioxidant reserve.

Objectives

The aim of this study is to evaluate the two main markers of oxidative stress, plasmatic peroxide concentration (through d‐ROMs FAST test, derivates‐Reactive Oxygen Metabolites) and plasmatic antioxidant power measured by iron‐reducing power (PAT test, Plasma Antioxidant Test) in 290 apparently healthy volunteers over 60, and their possible correlation with age and gender.

Materials and methods

Human capillary blood samples from healthy volunteers were used in this observational study for the evaluation of the markers of OS.

Results

The data obtained broadly demonstrate that the majority of elderly people display an OS condition characterized by increased levels of peroxides and a slight reduction in antioxidant reserve.

Conclusions

Seniors have a greater propensity to develop a condition of oxidative stress, and therefore it is important to associate the monitoring of oxidative stress markers and, if necessary, antioxidant supplementation, with a healthy lifestyle.

Effects of resistance exercise training on redox homeostasis in older adults. A systematic review and meta-analysis

BACKGROUND

Resistance exercise training (RET) has proven effective at reducing the risk of chronic disease in older populations, and it appears to regulate redox homeostasis.

AIMS

To determine the effects of RET on redox homeostasis in older people.

STUDY DESIGN

A systematic review and meta-analysis of randomized clinical trials identified by searching MEDLINE, Web of Science, EMBASE, Sportdiscus, LILACS, CENTRAL and CINAHL. We included studies of subjects aged 65 years or older, with or without pathologies, and including RET metrics with quantified molecular oxidation and antioxidant capacity outcomes.

RESULTS

Fifteen studies were included in this review. Agreement between reviewers reached a kappa value of 0.725. There were a total of 614 participants, with an average age of 68.1 years. Five (for molecular oxidation markers) and three (for antioxidant capacity markers) studies included data that quantified the effects of RET on homeostasis redox. The results of the meta-analysis showed that there were no differences in the molecular oxidation markers (SMD = -0.26; 95% CI = -0.57 to 0.05; P = 0.10; I2 = 0%) and antioxidant capacity markers (SMD = 0.53; 95% CI = -0.20 to 1.26; P = 0.16; I2 = 71.5%) in healthy older people after a RET of 8-24 weeks compared to non-intervention.

CONCLUSIONS

Based on a small number of studies of low methodological quality, this systematic review with meta-analysis suggests that RET is not effective at reducing molecular oxidation markers in healthy older people. More research is needed on the effects of RET on redox homeostasis in older people.

PROSPERO REGISTRATION NUMBER

CRD42019121529.

The associations of plant-based protein intake with all-cause and cardiovascular mortality in patients on peritoneal dialysis

BACKGROUND AND AIMS

Plant-based protein intake is associated with all-cause and/or cardiovascular disease (CVD) mortality in general population, but such data are scarce in dialysis patients. Thus, we examined the associations of plant-based protein-total protein ratio with all-cause and CVD mortality in patients on peritoneal dialysis (PD).

METHODS AND RESULTS

The study enrolled 884 incident patients who started PD between October 2002 and August 2014. All demographic and laboratory data were recorded at baseline. Repeated measurements for laboratory and nutrition parameters were recorded at regular intervals and thus calculated as time-averaged values. Multivariable Cox regression models were used to estimate the hazard ratio (HR) of plant-based protein-total protein ratio and mortality based on baseline and time-averaged covariates, respectively. There were 437 (49%) patients died during a mean follow-up period of 45 months, of which 178 (40.8%) were due to CVD. Each 10% in increase in time-averaged plant-based protein-total protein ratio was associated with a reduction of 71% (95% CI, 90%-14%) and 89% (95% CI, 98%-29%) for all-cause and CVD mortality, respectively. Based on examination on interactive effects, we further found both baseline and time-averaged plant-based protein-total protein ratio were inversely associated with all-cause and CVD mortality in the subgroups of female, age ≥60 years, and albumin >35 g/L.

CONCLUSIONS

The present study suggested that a diet with a higher plant-based protein-total protein ratio is associated with lower all-cause and CVD mortality in PD patients, and is more significant in female and elderly patients, and those without hypoalbuminemia.

Association of Arterial Hypertension with Hepatobiliary Pathology: The Occurrence of Comorbidity and Features of Metabolic Processes

Comorbidity of hypertension and hepatobiliary pathology has negative medical and social consequences, including an increase in the indicators of hospital admissions, disability and mortality.

OBJECTIVE

The aim was to study the occurrence of hypertension combined with hepatobiliary diseases depending on social status, gender and age in 2003-2017 and their influence on indicators of metabolic processes in patients with a therapeutic profile.

METHODS

A cross-sectional study using the inpatients' medical record database of the clinic of Federal Research Centre for Basic and Translational Medicine (Novosibirsk, Russia), which collects demographics, diagnoses (using ICD-10 codes), procedures and examinations of all inpatients from 2003-2017 was conducted. The incidence of comorbidity of hypertension and hepatobiliary pathology depending on age, gender and social status, based on the analysis of 13496 medical records was examined. A comparative analysis of biochemical parameters characterizing the main types of metabolism (lipid, protein, carbohydrate and purine) was carried out in 3 groups of patients: with hypertension; with hepatobiliary pathology, and with a combined pathology.

RESULTS

During the years 2003-2005, there was the greatest frequency of this comorbidity in workers, in women, in the age group 60 years and older. In 2009-2017, the highest incidence was observed in the male administrative staff. In patients with this comorbidity, more pronounced changes in carbohydrate, protein, lipid and purine metabolism were found in comparison with groups of patients with isolated diseases.

CONCLUSION

The results highlight the need to improve the system of prevention and treatment of comorbidity taking into account sex, age, occupation and features of metabolism.

Physiological markers and multimorbidity: A systematic review

Background:

Multimorbidity is the co-occurrence of two or more diseases in the same individual. One method to identify this condition at an early stage is the use of specific markers for various combinations of morbidities. Nonetheless, evidence related to physiological markers in multimorbidity is limited.

Objective:

The aim was to perform a systematic review to identify physiological markers associated with multimorbidity.

Design:

Articles available on PubMed, Register of Controlled Trials, Academic Search Premier, CINAHL, Scopus, SocINDEX, Web of Science, LILACS, and SciELO, from their inception to May 2018, were systematically searched and reviewed. The project was registered in PROSPERO under the number CRD42017055522.

Results:

The systematic search identified 922 papers. After evaluation, 18 articles were included in the full review reporting at least one physiological marker in coexisting diseases or which are strongly associated with the presence of multimorbidity in the future. Only five of these studies examined multimorbidity in general, identifying five physiological markers associated with multimorbidity, namely, dehydroepiandrosterone sulfate (DHEAS), interleukin 6 (IL-6), C-reactive protein (CRP), lipoprotein (Lp), and cystatin C (Cyst-C).

Conclusions:

There is a paucity of studies related to physiological markers in multimorbidity. DHEAS, IL-6, CRP, Lp, and Cyst-C could be the initial focus for further investigation of physiological markers related to multimorbidity.

Current Psychosomatic Practice

Psychosomatic research has advanced over the past decades in dealing with complex biopsychosocial phenomena and may provide new effective modalities of patient care. Among psychosocial variables affecting individual vulnerability, course, and outcome of any medical disease, the role of chronic stress (allostatic load/overload) has emerged as a crucial factor. Assessment strategies include the Diagnostic Criteria for Psychosomatic Research. They are presented here in an updated version based on insights derived from studies carried out so far and encompass allostatic overload, type A behavior, alexithymia, the spectrum of maladaptive illness behavior, demoralization, irritable mood, and somatic symptoms secondary to a psychiatric disorder. Macroanalysis is a helpful tool for identifying the relationships between biological and psychosocial variables and the individual targets for medical intervention. The personalized and holistic approach to the patient includes integration of medical and psychological therapies in all phases of illness. In this respect, the development of a new psychotherapeutic modality, Well-Being Therapy, seems to be promising. The growth of subspecialties, such as psychooncology and psychodermatology, drives towards the multidisciplinary organization of health care to overcome artificial boundaries. There have been major transformations in health care needs in the past decades. From psychosomatic medicine, a land of innovative hypotheses and trends, many indications for changes in the current practice of medicine are now at hand. The aim of this critical review is to outline current and potential clinical applications of psychosomatic methods.

Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population based cohort study

Objective To determine the association of different types of meat intake and meat associated compounds with overall and cause specific mortality.Design Population based cohort study.Setting Baseline dietary data of the NIH-AARP Diet and Health Study (prospective cohort of the general population from six states and two metropolitan areas in the US) and 16 year follow-up data until 31 December 2011.Participants 536 969 AARP members aged 50-71 at baseline.Exposures Intake of total meat, processed and unprocessed red meat (beef, lamb, and pork) and white meat (poultry and fish), heme iron, and nitrate/nitrite from processed meat based on dietary questionnaire. Adjusted Cox proportional hazards regression models were used with the lowest fifth of calorie adjusted intakes as reference categories.Main outcome measure Mortality from any cause during follow-up.Results An increased risk of all cause mortality (hazard ratio for highest versus lowest fifth 1.26, 95% confidence interval 1.23 to 1.29) and death due to nine different causes associated with red meat intake was observed. Both processed and unprocessed red meat intakes were associated with all cause and cause specific mortality. Heme iron and processed meat nitrate/nitrite were independently associated with increased risk of all cause and cause specific mortality. Mediation models estimated that the increased mortality associated with processed red meat was influenced by nitrate intake (37.0-72.0%) and to a lesser degree by heme iron (20.9-24.1%). When the total meat intake was constant, the highest fifth of white meat intake was associated with a 25% reduction in risk of all cause mortality compared with the lowest intake level. Almost all causes of death showed an inverse association with white meat intake.Conclusions The results show increased risks of all cause mortality and death due to nine different causes associated with both processed and unprocessed red meat, accounted for, in part, by heme iron and nitrate/nitrite from processed meat. They also show reduced risks associated with substituting white meat, particularly unprocessed white meat.