Dietary Reference Values for choline

Choline in Pediatric Nutrition: Assessing Formula, Fortifiers and Supplements Across Age Groups and Clinical Indications

Background: Sufficient choline supply is essential for tissue functions via phosphatidylcholine and sphingomyelin within membranes and secretions like bile, lipoproteins and surfactant, and in one-carbon metabolism via betaine. Choline requirements are linked to age and genetics, folate and cobalamin via betaine, and arachidonic (ARA) and docosahexaenoic (DHA) acid transport via the phosphatidylcholine moiety of lipoproteins. Groups at risk of choline deficiency include preterm infants, children with cystic fibrosis (CF) and patients dependent on parenteral nutrition. Fortifiers, formula and supplements may differently impact their choline supply. Objective: To evaluate added amounts of choline, folate, cobalamin, ARA and DHA in fortifiers, supplements and formula used in pediatric care from product files. Methods: Nutrient contents from commonly used products, categorized by age and patient groups, were obtained from public sources. Data are shown as medians and interquartile ranges. Results: 105 nutritional products including fortifiers, formula and products for special indications were analyzed. Choline concentrations were comparable in preterm and term infant formulas (≤6 months) (31.9 [27.6-33.3] vs. 33.3 [30.8-35.2] mg/100 kcal). Products for toddlers, and patients with CF, kidney or Crohn's disease showed Choline levels from 0 to 39 mg/100 kcal. Several products contain milk components and lecithin-based emulsifiers potentially increasing choline content beyond indicated amounts. Conclusions: Choline addition is standardized in formula for term and preterm infants up to 6 months, but not in other products. Choline content may be higher in several products due to non-declared sources. The potential impact of insufficient choline supply in patients at risk for choline deficiency suggests the need for biochemical analysis of products.

Vitamin D supplementation in critically ill patients: a meta-analysis

Background

Vitamin D is commonly used in clinical practice, while its clinical significance in critically ill patients remains controversial. Therefore, we aimed to perform a systemic review and meta-analysis to investigate the effect of vitamin D on this patient population.

Methods

We searched for randomized controlled trials (RCTs) in PubMed, Embase, and the Cochrane Library databases from inception until August 15, 2024. Studies evaluating critically ill adult patients who received vitamin D compared to controls were included. The primary outcome was short-term mortality. We used the Cochrane risk of bias tool and GRADE system to evaluate the study quality and evidence. Secondary outcomes were changes in serum 25-hydroxyvitamin D levels, mechanical ventilation (MV) duration, and length of stay (LOS) in the ICU or hospital. We also conducted meta-regression, subgroup analyses, and trial sequential analysis (TSA) to explore the potential heterogeneity among the included trials.

Results

Nineteen RCTs with 2,754 patients were eligible. Overall, vitamin D significantly increased serum 25-hydroxyvitamin D levels and significantly reduced the short-term mortality (risk ratio [RR] = 0.83; 95%CI, 0.70-0.98; p = 0.03, I 2 = 13%), duration of MV (MD = -2.96 days; 95% CI, -5.39 to -0.52; I 2 = 77%; p = 0.02) and ICU LOS (MD = -2.66 days; 95% CI, -4.04 to -1.29, I 2 = 70%; p = 0.0001) but not hospital LOS (MD = -0.48 days; 95% CI, -2.37 to 1.40; I 2 = 31%; p = 0.61). The meta-regression analysis revealed that the proportion of MV (MV%) accounted for the source of heterogeneity, and the subgroup analyses based on MV% suggested that the MV group was more likely to benefit from vitamin D applications than the partly MV group in all the predefined outcomes (all p values<0.05). TSA for short-term mortality suggested that more data is required to confirm our main conclusion.

Conclusion

Vitamin D supplementation increased serum 25-hydroxyvitamin D levels and significantly benefited critically ill patients, especially those with MV.

Systematic review registration

https://inplasy.com/inplasy-2022-10-0074/, INPLASY2022100074.

Choline in Pregnancy and Lactation: Essential Knowledge for Clinical Practice

BACKGROUND/OBJECTIVES

In 1998 choline was identified as an essential nutrient by the United States Institute of Medicine. Choline is known primarily for its roles in neurotransmitter production, cell membrane formation, and methyl and lipid metabolism. Since this discovery the relevance of choline to maternal, fetal, and infant health has been studied intensively. This narrative review provides a coherent update of the latest evidence for field clinicians and healthcare professionals.

METHODS

A PubMed/ScienceDirect search for human clinical evidence restricted to meta-analysis and systematic/review publications from the last 10 years was undertaken.

RESULTS

Meta-analysis and review publications highlight the importance of choline in supporting maternal health and fetal development during pregnancy by showing promising roles for choline in relation to neurological development, brain and liver function, reduced neural tube defect risk, and adverse pregnancy outcome risk. However, there are clear present-day gaps between habitual choline intakes and intake recommendations with the majority of pregnant and lactating women not meeting adequate intake recommendations for choline. This gap is anticipated to widen given transitions towards plant-based diets which tend to be lower in choline.

CONCLUSIONS

Alongside folic acid recommendations, choline supplementation should be considered in dietary recommendations by clinicians during crucial life stages such as pregnancy and lactation when physiological demands for this critical nutrient substantially increase.

[Legislative clarifications on the article "2024 Positioning of the SEEDO Dietary Guidelines"]

Introduction

Effects of choline alfoscerate on cognitive function and quality of life in type 2 diabetes: A double-blind, randomized, placebo-controlled trial

AIMS

This study evaluated the effects of choline alfoscerate on cognitive function and quality of life in T2DM patients with mild cognitive decrements.

MATERIALS AND METHODS

In a double-blind, randomized, placebo-controlled trial, we recruited 36 individuals with T2DM and mild cognitive impairment which was assessed by the Mini-Mental State Examination (MMSE) score of 25-28, and randomly assigned them to receive either 1200 mg/day of choline alfoscerate or a placebo. Four additional questionnaires-the 36-Item Short Form Survey, the modified Informant Questionnaire on Cognitive Decline in the Elderly, the Korean version of Activities of Daily Living, and the Patient Health Questionnaire-were investigated at 6 and 12 months and analysed via mixed-effects models for repeated measures.

RESULTS

The mean age of study participants was 71.8 ± 5.3 years and 69.4% women. Six-month treatment with choline alfoscerate resulted in a non-significant increase in the MMSE score from 26.2 ± 1.3 to 26.9 ± 2.0, whereas the placebo group showed a non-significant decline from 26.6 ± 1.3 to 25.9 ± 2.3, resulting in a mean difference of +1.4 between the two groups (p = 0.059). At 12 months, the mean difference increased to +1.7 with statistical significance (p < 0.001). Physical health, as measured by the SF-36 survey, was significantly better in the choline alfoscerate group than in the placebo group.

CONCLUSIONS

Choline alfoscerate 1200 mg once daily treatment showed marginal improvement in cognitive function in T2DM patients with mild cognitive impairment at 6 months but leading to significance at 12 months compared to placebo, suggesting its potential as an adjunct therapy for managing early cognitive decline.

Low Plasma Choline, High Trimethylamine Oxide, and Altered Phosphatidylcholine Subspecies Are Prevalent in Cystic Fibrosis Patients with Pancreatic Insufficiency

BACKGROUND

Exocrine pancreatic insufficiency in cystic fibrosis (CF) increases fecal choline losses, but the postnatal course of plasma choline and its metabolites in these patients is unknown. While choline homeostasis is crucial for cellular, bile, and lipoprotein metabolism, via phosphatidylcholine (PC) and via betaine as a methyl donor, choline deficiency is associated with impaired lung and liver function, including hepatic steatosis.

OBJECTIVE

The goal of our study was to evaluate the plasma levels of choline, betaine, trimethylamine oxide (TMAO), PC, and PC subclasses in CF patients from infancy to adulthood and compare those with exocrine pancreatic insufficiency (EPI) to those with pancreatic sufficiency (EPS).

METHODS

Retrospective analysis of target parameters in plasma samples (July 2015-November 2023) of CF patients (0.64-24.6 years) with tandem mass spectrometry.

RESULTS

A total of 477 samples from 162 CF patients were analyzed. In CF patients with EPI (N = 148), plasma choline and betaine concentrations were lower and decreased with age compared to EPS patients showing normal values. TMAO concentrations, indicating intestinal choline degradation by bacterial colonization, were frequently elevated in EPI from infancy onwards, and inversely related to plasma choline and betaine levels. PC-containing linoleic acid levels were lower in EPI, but arachidonic and docosahexaenoic acid content was similar in both patient groups.

CONCLUSION

CF patients with EPI are at risk of choline and betaine deficiency compared to exocrine pancreas-sufficient CF patients. Elevated TMAO concentrations in EPI patients indicate increased bacterial colonization leading to choline degradation before absorption. These findings indicate that laboratory testing of choline, betaine, and TMAO as well as clinical trials on choline supplementation are warranted in CF patients.

Prospective Study of Urinary Stone Formation in Pediatric Patients with Acquired Brain Injury: A Focus on Incidence and Analysis of Risk Factors

Background/Objectives: Little is known about the factors linked with nutrition, infections, and physical activity, which may influence urinary stone formation in patients with acquired brain injury. Previous studies have demonstrated that enteral nutrition mixtures rich in sodium and poor in calcium may promote stone formation in pediatric patients, but a confirmation study is lacking. Moreover, the occurrence of urinary stones and heterotopic ossifications has not been studied regarding incidence. We thus conducted a prospective observational study in an unselected pediatric population with acquired brain injury, to estimate the incidence of urinary stones and heterotopic ossifications and analyze the associated factors. Methods: Prospective observational study: We recruited all patients with enteral nutrition consecutively admitted to our brain injury rehabilitation unit during a 5-year time-frame. We collected clinical data regarding nutrition, infections, blood and urine exams performed, neurological examinations, and physical examinations. Results: The prospective design allowed us to observe that no patient developed heterotopic ossifications, while urinary stones were found in 12.5% of patients and gravel in 14.6%. Factors associated with stone formation were having a worse subacute GCS, having done intense physical activity before injury, receiving bladder catheterizations, having a higher urine pH, and having higher blood potassium levels. The composition of the enteral nutrition did not influence stone formation, although the nutrition mixtures contained levels of vitamin C and proteins considerably higher than the recommended reference ranges. Conclusions: We have provided an observation of the incidence of urolithiasis in pediatric patients in rehabilitation, which was lacking from the literature. Enteral nutrition, at the amounts received by the patients studied herein, does not seem to have a role in stone formation. We identified a set of risk factors that can be useful for clinicians to pinpoint patients at an increased risk of developing stones.

Serum choline, leptin and interleukin-6 levels in fibromyalgia syndrome-induced pain: a case-control study

BACKGROUND

Fibromyalgia Syndrome (FMS) predominantly affects middle-aged women, characterized by musculoskeletal pain, fatigue, and cognitive issues. Choline, an endogenous molecule, may influence FMS due to its analgesic and anti-inflammatory properties. This study compared choline, leptin, and interleukin-6 (IL-6) levels in FMS patients and controls and examining their association with pain severity.

METHODS

Volunteers with FMS were clinically diagnosed at a Physical Medicine and Rehabilitation Department. The control group included pain-free volunteers. Pain severity was gauged using a numeric scale, dietary choline intake through a questionnaire. Serum choline, leptin and (interleukin)IL-6 levels were measured from fasting blood samples of volunteers with enzyme-linked immunosorbent assays (ELISA).

RESULTS

All FMS patients (n = 38) and healthy volunteers (n = 38) were female. Pain score in patients with FMS was 7.6 ± 0.2. Dietary choline intake was lower in patients with FMS than the controls (p = 0.036). Serum choline and leptin levels were lower in the FMS group compared to control (p = 0.03). Serum IL-6 levels were higher in the FMS group than in the control (p < 0.001). There was weak positive correlation between IL-6 levels and pain scores and there were no correlation between leptin levels and pain scores in FMS.

CONCLUSIONS

This research highlights FMS's complex nature, involving neurochemical, immunological, and nutritional factors. It suggests the significance of choline's anti-inflammatory effect, leptin's metabolic function, and IL-6's role in FMS pathology. The results suggest that reduced dietary choline might influence serum choline, leptin, and IL-6 levels, potentially impacting FMS-related pain. This points to the potential of supplementary choline intake in FMS management.

TRIAL REGISTRATION

Not applicable (Non-interventional study).

Baseline Vitamin D Levels on Quality of Life and Pain Perception Among Patients with Chronic Pain with Long-Term Prescription Opioid Use: A Prospective Study

Objectives: To investigate the correlation between baseline serum concentrations of 25-hydroxyvitamin D (25-OHD) and quality of life (QoL), as well as pain perception in patients with chronic pain with long-term prescription opioid usage before opioid detoxification. Methods: We prospectively studied 45 patients with chronic pain with long-term prescription opioid usage who were selected for elective detoxification. Baseline serum 25-OHD levels were measured prior to detoxification, classifying patients as either vitamin D deficient (<75 nmol/L) or sufficient (≥75 nmol/L). QoL was assessed using the SF-36v2TM questionnaire, while pain levels were assessed using Visual Analogue Scale (VAS) scores before treatment. Results: Mean pain scores before detoxification of the patients with sufficient baseline 25-OHD levels vs. those with deficient levels were, respectively, 6.06 ± 2.32 vs. 6.86 ± 2.10 (normalized scores 1.22 ± 0.571 vs. 0.950 ± 0.632; p = 0.164). The analysis of SF-36v2™ questionnaire scores revealed minimal variation between groups (35.00 ± 14.198 vs. 34.97 ± 13.52), indicating no significant association between Vitamin D levels and QoL (p = 0.913). Conclusions: The analysis of baseline 25-OHD levels in relation to QoL assessments and pain scores did not reveal a statistically significant association, indicating that variations in baseline vitamin D levels may not substantially impact QoL or pain perception. Further studies may help determine how to assess and optimize vitamin D levels in patients with chronic pain on long-term prescription opioids.

International expert consensus on micronutrient supplement use during the early life course

BACKGROUND

Growing evidence demonstrates that maternal nutrition is crucial for the health of the mother-to-be, and early life course of the offspring. However, for most micronutrients, guidelines are inconsistent. This Delphi study aimed to investigate the level of expert consensus on maternal nutrition and micronutrient needs during preconception, pregnancy and lactation.

METHODS

We conducted a two-round web-based Delphi survey on various topics including general approaches to diet and supplement use, and existing guidelines. For the periods of preconception, pregnancy and lactation, questions focused on the importance and strength of evidence for supplement use with the following micronutrients for low- and high-risk populations: folic acid, choline, iodine, magnesium, calcium, iron, selenium, docosahexaenoic acid (DHA), and vitamins B1, B2, B6, B12, D and K.

RESULTS

Thirty-five experts participated in the panel, who were healthcare professionals (HCPs), researchers and joint HCP-researchers with expertise in nutrition, gynaecology and/or obstetrics. Panellists reached consensus on the importance of diet and dietary supplement use during pregnancy and agreed on the lack of clarity and consistency in current guidelines, and the need for education in these areas for HCPs, pregnant people and the general population. For general low-risk populations, there was consensus on the importance of supplement use with iron and vitamin D from preconception through lactation, with folic acid and iodine from preconception through the second and third trimesters, respectively, with DHA from the first trimester through lactation and with calcium during lactation. Panellists agreed that the evidence for supplement use with each of these micronutrients during these phases to improve outcomes and/or foetal development is strong, except for vitamin D (preconception), DHA (first trimester), and iron (both periods). There was also consensus that supplement use advice should be tailored for people following vegan/vegetarian diets, restricted diets due to food intolerances, obesity, polycystic ovary syndrome, diabetes mellitus, and previous nutrition-related pregnancy complications.

CONCLUSION

The findings revealed robust consensus on various aspects of maternal nutrition, including the need for education, the lack of consistency in current guidelines on supplement use, the importance of supplement use across specific phases of pregnancy and the at-risk groups requiring tailored approaches.

Cellular and organismal function of choline metabolism

Choline is an essential micronutrient critical for cellular and organismal homeostasis. As a core component of phospholipids and sphingolipids, it is indispensable for membrane architecture and function. Additionally, choline is a precursor for acetylcholine, a key neurotransmitter, and betaine, a methyl donor important for epigenetic regulation. Consistent with its pleiotropic role in cellular physiology, choline metabolism contributes to numerous developmental and physiological processes in the brain, liver, kidney, lung and immune system, and both choline deficiency and excess are implicated in human disease. Mutations in the genes encoding choline metabolism proteins lead to inborn errors of metabolism, which manifest in diverse clinical pathologies. While the identities of many enzymes involved in choline metabolism were identified decades ago, only recently has the field begun to understand the diverse mechanisms by which choline availability is regulated and fuelled via metabolite transport/recycling and nutrient acquisition. This review provides a comprehensive overview of choline metabolism, emphasizing emerging concepts and their implications for human health and disease.

Vitamin D-Do Diet Recommendations for Health Remain Strong?

How will the scientific community and authoritative bodies define future nutritional requirements for vitamin D? At the International Symposium on Nutritional Aspects of Musculoskeletal Health, the authors debated the strength of current evidence for setting vitamin D intake recommendations from diet: the positive side of the strength of the evidence (PRO) suggests there is a physiological requirement for vitamin D and the opposing view (CON) that in light of negative results from large, recent trials, particularly those with fractures and bone health outcomes, we are left rudderless. Should we provide recommendations based on empiric treatment of vitamin D for most groups and conditions? It is becoming increasingly evident that vitamin D plays a role in many physiological functions and processes associated with long-term human health; however, to what extent are these benefits apparent beyond what is needed for adequate nutritional status, measured as serum 25-hydroxyvitamin D levels, for active calcium absorption? The meeting attendees voted for the PRO vs. CON position at the end of the session.

Toward Supplementation Guidelines for Vegan Complementary Feeding

Previously published recommendations for vegetarian (including vegan) diets for children have highlighted the need for vitamin B12 supplementation. Increased attention to several other key nutrients (including iodine, vitamin D, calcium, and iron) has also been recommended. However, an overview focusing on supplementation guidelines, specifically for vegan infants, has not been published, and a potential requirement for iodine and/or selenium supplementation in (some) vegan infants has not been discussed. Vegan complementary feeding should be supplemented (particularly with 5 μg/day of vitamin B12 and 10 μg/day of vitamin D). Iodine should be supplemented (up to 110 μg/day) if the intake of breast milk and infant formula is low, and selenium supplementation (5 μg/day) should be considered in regions with low soil selenium levels. Caution is required to avoid excessive intakes of iodine and particularly selenium. Supplements for vegan infants are on the market, and observational studies are urgently needed to assess the nutrient intake (including supplements) and status in vegan infants.

Dietary Omega-3 PUFA Intake in Patients with Chronic Kidney Disease: The Association with Vitamin D Deficiency, Intima-Media Thickness and Blood Pressure

Background/Objectives: Numerous risk factors associated with development of cardiovascular disease (CVD) have been unfavorably altered in patients with chronic kidney disease (CKD). Low omega-3 polyunsaturated fatty acid (PUFA) intake and vitamin D deficiency are potential cardiometabolic risk factors in patients with CKD. The aim of this study was to evaluate dietary intake and status of omega-3 PUFA and vitamin D in pre-dialysis and hemodialysis patients and to examine the association of dietary α-linolenic acid (ALA) and fish consumption with blood pressure and carotid intima-media thickness (C-IMT), representing a non-invasive marker of atherosclerosis in CKD patients. Methods: All 77 selected patients (36 pre-dialysis, 41 on hemodialysis) underwent standardized clinical, nutritional, and laboratory assessments. Repeated 24 h recalls were performed to assess dietary intake. The fatty acid profile was determined by gas-liquid chromatography. Results: Inadequate vitamin D intake and vitamin D status were found in 95% of patients. PUFA profiles did not differ between hemodialysis and pre-dialysis participants. Dietary intake of ALA was negatively correlated with systolic blood pressure (SBP) (p = 0.013), C-IMT (p = 0.002), serum CRP (p = 0.044), iPTH (p = 0.01), and 25(OH)D3 (p = 0.006). ALA intake of more than 0.23 g daily was linked with lower SBP (p = 0.001), serum 25(OH)D3 (p = 0.004), and C-IMT (p = 0.002). Conclusions: This study contributes to a better understanding of the relationship between dietary ALA intake and C-IMT in CKD. The results of this study could emphasize the significant role of the high prevalence of vitamin D deficiency and inadequate omega-3 PUFA intake and status regarding CVD health in CKD patients.

Impact of Vitamin D Status and Nutrition on the Occurrence of Long Bone Fractures Due to Falls in Elderly Subjects in the Vojvodina Region of Serbia

Bone fractures are a significant public health issue among elderly subjects. This study examines the impact of diet and vitamin D status on the risk of long bone fractures due to falls in elderly subjects in Vojvodina, Serbia. Conducted at the University Clinical Center of Vojvodina in autumn/winter 2022-2023, the study included 210 subjects >65 years: 105 (F: 80/M: 15) with long bone fractures due to falls and 105 (F: 80/M: 15) controls. Groups were similar regarding age and BMI. Dietary intakes (by two 24-h recalls) and serum vitamin D levels were analyzed. The fracture group had a significantly lower median daily vitamin D intake (1.4 μg/day vs. 5.8 μg/day), intake of calcium, energy, proteins, fats, fibers, dairy products, eggs, fish, edible fats/oils, and a higher intake of sweets (p < 0.001 for all). Serum vitamin D levels were significantly lower in the fracture group (40.0 nmol/L vs. 76.0 nmol/L, p < 0.001). Logistic regression identified serum vitamin D as the most important protective factor against fractures, and ROC curve analysis indicated that serum vitamin D levels > 50.5 nmol/L decreased fracture risk. Nutritional improvements (increased intake of vitamin D and protein sources such as fish, eggs, and dairy), increased sun exposure, and routine vitamin D supplementation during winter are advised.

Dietary choline intake in European and non-european populations: current status and future trends-a narrative review

BACKGROUND

Choline is a nutrient necessary for the proper functioning of the body with a multidimensional impact on human health. However, comprehensive studies evaluating the dietary intake of choline are limited. The aim of this narrative review is to analyze current trends in choline intake in European and non-European populations. The secondary aim was to discuss possible future choline trends.

METHODS

The search strategy involved a systematic approach to identifying relevant literature that met specific inclusion criteria. Observational studies and randomized clinical trials were searched for in PubMed and Scopus databases from January 2016 to April 2024. This review includes the characteristics of study groups, sample sizes, methods used to assess choline intake and time period, databases used to determine intake, choline intakes, and the main sources of choline in the diet. The review considered all population groups for which information on choline intake was collected.

RESULTS

In most studies performed in Europe after 2015 choline intake did not exceed 80% of the AI standard value. The mean choline intake for adults in different European countries were 310 mg/day, while the highest value was reported for Polish men at 519 mg/day. In non-European countries, mean choline intakes were 293 mg/day and above. The main reported sources of choline in the diet are products of animal origin, mainly eggs and meat. The available data describing the potential intake of these products in the EU in the future predict an increase in egg intake by another 8% compared to 2008-2019 and a decrease in meat intake by about 2 kg per capita from 2018 to 2030.

CONCLUSIONS

In the last decade, choline intake among adults has been insufficient, both in Europe and outside it. In each population group, including pregnant women, choline intake has been lower than recommended. Future choline intake may depend on trends in meat and egg consumption, but also on the rapidly growing market of plant-based products. However, the possible changes in the intake of the main sources of choline may lead to either no change or a slight increase in overall choline intake.

Evidence and Perspectives for Choline Supplementation during Parenteral Nutrition-A Narrative Review

Choline is an essential nutrient, with high requirements during fetal and postnatal growth. Tissue concentrations of total choline are tightly regulated, requiring an increase in its pool size proportional to growth. Phosphatidylcholine and sphingomyelin, containing a choline headgroup, are constitutive membrane phospholipids, accounting for >85% of total choline, indicating that choline requirements are particularly high during growth. Daily phosphatidylcholine secretion via bile for lipid digestion and very low-density lipoproteins for plasma transport of arachidonic and docosahexaenoic acid to other organs exceed 50% of its hepatic pool. Moreover, phosphatidylcholine is required for converting pro-apoptotic ceramides to sphingomyelin, while choline is the source of betaine as a methyl donor for creatine synthesis, DNA methylation/repair and kidney function. Interrupted choline supply, as during current total parenteral nutrition (TPN), causes a rapid drop in plasma choline concentration and accumulating deficit. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) defined choline as critical to all infants requiring TPN, claiming its inclusion in parenteral feeding regimes. We performed a systematic literature search in Pubmed with the terms "choline" and "parenteral nutrition", resulting in 47 relevant publications. Their results, together with cross-references, are discussed. While studies on parenteral choline administration in neonates and older children are lacking, preclinical and observational studies, as well as small randomized controlled trials in adults, suggest choline deficiency as a major contributor to acute and chronic TPN-associated liver disease, and the safety and efficacy of parenteral choline administration for its prevention. Hence, we call for choline formulations suitable to be added to TPN solutions and clinical trials to study their efficacy, particularly in growing children including preterm infants.

Biomarker Candidates of Habitual Food Intake in a Swedish Cohort of Pregnant and Lactating Women and Their Infants

Circulating food metabolites could improve dietary assessments by complementing traditional methods. Here, biomarker candidates of food intake were identified in plasma samples from pregnancy (gestational week 29, N = 579), delivery (mothers, N = 532; infants, N = 348), and four months postpartum (mothers, N = 477; breastfed infants, N = 193) and associated to food intake assessed with semi-quantitative food frequency questionnaires. Families from the Swedish birth cohort Nutritional impact on Immunological maturation during Childhood in relation to the Environment (NICE) were included. Samples were analyzed using untargeted liquid chromatography-mass spectrometry (LC-MS)-based metabolomics. Both exposure and outcome were standardized, and relationships were investigated using a linear regression analysis. The intake of fruits and berries and fruit juice were both positively related to proline betaine levels during pregnancy (fruits and berries, β = 0.23, FDR < 0.001; fruit juice, β = 0.27, FDR < 0.001), at delivery (fruit juice, infants: β = 0.19, FDR = 0.028), and postpartum (fruits and berries, mothers: β = 0.27, FDR < 0.001, infants: β = 0.29, FDR < 0.001; fruit juice, mothers: β = 0.37, FDR < 0.001). Lutein levels were positively related to vegetable intake during pregnancy (β = 0.23, FDR < 0.001) and delivery (mothers: β = 0.24, FDR < 0.001; newborns: β = 0.18, FDR = 0.014) and CMPF with fatty fish intake postpartum (mothers: β = 0.20, FDR < 0.001). No clear relationships were observed with the expected food sources of the remaining metabolites (acetylcarnitine, choline, indole-3-lactic acid, pipecolic acid). Our study suggests that plasma lutein could be useful as a more general food group intake biomarker for vegetables and fruits during pregnancy and delivery. Also, our results suggest the application of proline betaine as an intake biomarker of citrus fruit during gestation and lactation.

Associations of dietary choline and betaine with all-cause mortality: a prospective study in a large Swedish cohort

PURPOSE

Investigate the association between choline and betaine intake and all-cause mortality in a large Swedish cohort.

METHODS

Women (52,246) and men (50,485) attending the Västerbotten Intervention Programme 1990-2016 were included. Cox proportional hazard regression models adjusted for energy intake, age, BMI, smoking, education, and physical activity were used to estimate mortality risk according to betaine, total choline, phosphatidylcholine, glycerophosphocholine, phosphocholine, sphingomyelin, and free choline intakes [continuous (per 50 mg increase) and in quintiles].

RESULTS

During a median follow-up of 16 years, 3088 and 4214 deaths were registered in women and men, respectively. Total choline intake was not associated with all-cause mortality in women (HR 1.01; 95% CI 0.97, 1.06; P = 0.61) or men (HR 1.01; 95% CI 0.98, 1.04; P = 0.54). Betaine intake was associated with decreased risk of all-cause mortality in women (HR 0.95; 95% CI 0.91, 0.98; P < 0.01) but not in men. Intake of free choline was negatively associated with risk of all-cause mortality in women (HR 0.98; 95% CI 0.96, 1.00; P = 0.01). No other associations were found between intake of the different choline compounds and all-cause mortality. In women aged ≥ 55 years, phosphatidylcholine intake was positively associated with all-cause mortality. In men with higher folate intake, total choline intake was positively associated with all-cause mortality.

CONCLUSION

Overall, our results do not support that intake of total choline is associated with all-cause mortality. However, some associations were modified by age and with higher folate intake dependent on sex. Higher intake of betaine was associated with lower risk of all-cause mortality in women.

Vitamin D Status and Reference Intervals Measured by Liquid Chromatography-Tandem Mass Spectrometry for the Early Adulthood to Geriatric Ages in a South Korean Population during 2017-2022

This study aimed to describe the latest 25-hydroxyvitamin D (25(OH)D) status of the South Korean population aged ≥ 20 years using 25(OH)D concentrations measured by liquid chromatography-tandem mass spectrometry and to determine the factors associated with total 25(OH)D concentrations. This cross-sectional, retrospective study consecutively selected 119,335 subjects with a median age of 57 (20-101) years who underwent health checkups among 13 Korean cities during 2017-2022. The total 25(OH)D concentration was 54.5 ± 24.0 nmol/L (mean ± SD). The 7.6%, 47.5%, and 82.9% of participants had 25(OH)D less than 25, 50, and 75 nmol/L, respectively. The prevalence of 25(OH)D deficiency (<25 nmol/L) was higher in females than in males (8.9% vs. 6.1%) and varied between age groups, decreasing in older subjects. Those aged 20-29 years had the highest prevalence of 25(OH)D deficiency (23.0% in females and 20.1% in males), which also varied between cities. In the adjusted model, female sex, older age, summer and autumn seasons, lower body mass index (<25 kg/m2), and lower high-sensitivity C-reactive protein concentration (<1 mg/L) were associated with higher total 25(OH)D concentrations. This study could provide an exact understanding of the status of vitamin D and help devise strategies to prevent vitamin D deficiency among the Korean population.

Eggs - a scoping review for Nordic Nutrition Recommendations 2023

Cardiovascular diseases (CVD), type 2 diabetes (T2D), and cancer are a significant public health burden in the Nordic and Baltic countries. High intake of eggs, mainly due to its high cholesterol content, has been suggested to have adverse health effects. The purpose of this scoping review is to describe the evidence related to the impact of egg intake on health. A literature search identified 38 systematic reviews and meta-analyses on egg consumption in relation to health outcomes published between 2011 and 30 April 2022. Overall, current evidence from systematic reviews of randomized clinical trials indicates that higher egg intake may increase serum total cholesterol concentration and the ratio of low-density lipoprotein to high-density lipoprotein cholesterol, but with substantial heterogeneity in the response. However, recent evidence from observational studies does not provide strong support for a detrimental role of moderate egg consumption (up to one egg/day) on the risk of CVD, especially in the European studies. The overall evidence from observational studies indicates that egg consumption is not associated with increased risk of mortality or T2D in European study populations. There is also little support for a role of egg consumption in cancer development, although a weak association with higher risk of certain cancers has been found in some studies, mainly case-control studies. Again, no associations with cancer risk have been observed in European studies. Systematic reviews and meta-analyses of egg consumption in relation to other health-related outcomes are scarce. There are also limited data available on the associations between the consumption of more than one egg/day and risk of diseases. Based on the available evidence, one egg/day is unlikely to adversely affect overall disease risk.

A Narrative Review on Maternal Choline Intake and Liver Function of the Fetus and the Infant; Implications for Research, Policy, and Practice

Dietary choline is needed to maintain normal health, including normal liver function in adults. Fatty liver induced by a choline-deficient diet has been consistently observed in human and animal studies. The effect of insufficient choline intake on hepatic fat accumulation is specific and reversible when choline is added to the diet. Choline requirements are higher in women during pregnancy and lactation than in young non-pregnant women. We reviewed the evidence on whether choline derived from the maternal diet is necessary for maintaining normal liver function in the fetus and breastfed infants. Studies have shown that choline from the maternal diet is actively transferred to the placenta, fetal liver, and human milk. This maternal-to-child gradient can cause depletion of maternal choline stores and increase the susceptibility of the mother to fatty liver. Removing choline from the diet of pregnant rats causes fatty liver both in the mother and the fetus. The severity of fatty liver in the offspring was found to correspond to the severity of fatty liver in the respective mothers and to the duration of feeding the choline-deficient diet to the mother. The contribution of maternal choline intake in normal liver function of the offspring can be explained by the role of phosphatidylcholine in lipid transport and as a component of cell membranes and the function of choline as a methyl donor that enables synthesis of phosphatidylcholine in the liver. Additional evidence is needed on the effect of choline intake during pregnancy and lactation on health outcomes in the fetus and infant. Most pregnant and lactating women are currently not achieving the adequate intake level of choline through the diet. Therefore, public health policies are needed to ensure sufficient choline intake through adding choline to maternal multivitamin supplements.

Choline - a scoping review for Nordic Nutrition Recommendations 2023

Choline is an essential nutrient with metabolic roles as a methyl donor in one carbon metabolism and as a precursor for membrane phospholipids and the neurotransmitter acetylcholine. Choline content is particularly high in liver, eggs, and wheat germ, although it is present in a variety of foods. The main dietary sources of choline in the Nordic and Baltic countries are meat, dairy, eggs, and grain. A diet that is devoid of choline causes liver and muscle dysfunction within 3 weeks. Choline requirements are higher during pregnancy and lactation than in non-pregnant women. Although no randomized controlled trials are available, observational studies in human, supported by coherence from interventional studies with neurodevelopmental outcomes and experimental studies in animals, strongly suggest that sufficient intake of choline during pregnancy is necessary for normal brain development and function in the child. Observational studies suggested that adequate intake of choline could have positive effects on cognitive function in older people. However, prospective data are lacking, and no intervention studies are available in the elderly.

Advancing nutrition science to meet evolving global health needs

Populations in crisis!A global overview of health challenges and policy efforts within the scope of current nutrition issues, from persistent forms of undernutrition, including micronutrient deficiency, to diet-related chronic diseases. Nutrition science has evolved from a therapeutic and prevention emphasis to include a focus on diets and food systems. Working and consensus definitions are needed, as well as guidance related to healthy diets and the emerging issues that require further research and consensus building. Between nutrient deficiency and chronic disease, nutrition has evolved from focusing exclusively on the extremes of overt nutrient deficiency and chronic disease prevention, to equipping bodies with the ability to cope with physiologic, metabolic, and psychological stress. Just what is 'optimal nutrition', is that a valid public health goal, and what terminology is being provided by the nutrition science community? Nutrition research on 'healthspan', resilience, and intrinsic capacity may provide evidence to support optimal nutrition. Finally, experts provide views on ongoing challenges of achieving consensus or acceptance of the various definitions and interventions for health promotion, and how these can inform government health policies.Nutrition topics that receive particular focus in these proceedings include choline, NAD-replenishment in neurodegenerative diseases, and xanthophyll carotenoids. Choline is a crucial nutrient essential for cellular metabolism, requiring consumption from foods or supplements due to inadequate endogenous synthesis. Maternal choline intake is vital for fetal and infant development to prevent neural tube defects. Neurodegenerative diseases pose a growing health challenge, lacking effective therapies. Nutrition, including NAD-replenishing nutrients, might aid prevention. Emerging research indicates xanthophyll carotenoids enhance vision and cognition, potentially impacting age-related diseases.

Whey Protein Dietary Supplements: Metal Exposure Assessment and Risk Characterization

Protein supplements (PS) are trendy foods, especially those made from whey. In addition to providing protein, these products are a source of metals, providing essential elements (Na, K, Mg, Ca, Mo, Mn, Fe, Co, Cu, and Zn) and other potentially toxic elements (Al, B, Sr, V Ba, and Ni). In this study, 47 whey PS samples were analyzed for mineral elements by ICP-OES, and their dietary exposures were assessed for three consumption scenarios. Elements found in higher concentrations were K (4689.10 mg/kg) and Ca (3811.27 mg/kg). The intake of 30 g PS (average recommended amount/day) provides about 20% of the established reference value (NRI) for Cr (18.30% for men and 25.63% for women) and Mo (26.99%). In a high daily consumption scenario (100 g PS/day) and when the maximum concentrations are considered, Cr, Zn, Fe, Mo, and Mg dietary intakes of these metals exceed the daily recommended intakes and could pose a risk. The daily intake of 30, 60, and 100 g of whey PS for 25 years does not pose a health risk since the hazard index (HI) is less than one in these consumption scenarios, and the essential elements contributing most to HI are Co, followed by Mo and Cr. It is recommended to improve the information to the consumers of these new products. Furthermore, to help in the management and prevention of these potential health risks, it would be advisable to improve the regulation of these dietary supplements and their labeling.

Nutritional, bioactive components and health properties of the milpa triad system seeds (corn, common bean and pumpkin)

The milpa system is a biocultural polyculture technique. Heritage of Mesoamerican civilizations that offers a wide variety of plants for food purposes. Corn, common beans, and pumpkins are the main crops in this agroecosystem, which are important for people's nutritional and food security. Moreover, milpa system seeds have great potential for preventing and ameliorating noncommunicable diseases, such as obesity, dyslipidemia, type 2 diabetes, among others. This work reviews and analyzes the nutritional and health benefits of milpa system seeds assessed by recent preclinical and clinical trials. Milpa seeds protein quality, vitamins and minerals, and phytochemical composition are also reviewed. Evidence suggests that regular consumption of milpa seeds combination could exert complementing effect to control nutritional deficiencies. Moreover, the combination of phytochemicals and nutritional components of the milpa seed could potentialize their individual health benefits. Milpa system seeds could be considered functional foods to fight nutritional deficiencies and prevent and control noncommunicable diseases.

Dietary Energy and Nutrient Intake of Healthy Pre-School Children in Hungary

Diet in the early years of life may influence the development of chronic diseases later on. The aim of the present study was to investigate the dietary intake of 2- to 6-year-old Hungarian children. In 2013 and subsequently in 2016, cross-sectional surveys were conducted among parents of healthy children attending kindergarten in Hungary. We used a three-day food diary to record quantitative data of all the nutrients consumed by the children on two working days and one weekend day. The dietary intakes were compared to both the Hungarian recommended dietary allowances and the European Food Safety Authority recommendations. The nutritional data of altogether 186 children in 2013 and 556 children in 2016 were analyzed. The total energy and carbohydrate intake was appropriate. We observed high sugar intake in every fifth child. Protein, fat and cholesterol intake, as well as the intake of sodium, potassium and phosphorus, were high. The consumption of calcium and vitamin D was low. Water consumption was not satisfying. The present results underline the need for interventions starting early in life in order to ameliorate nutrient intake during childhood, possibly impacting long-term health outcomes.

The Role of Choline in Neurodevelopmental Disorders-A Narrative Review Focusing on ASC, ADHD and Dyslexia

Neurodevelopmental disorders appear to be rising in prevalence, according to the recent Global Burden of Disease Study. This rise is likely to be multi-factorial, but the role of certain nutrients known to facilitate neurodevelopment should be considered. One possible contributing factor could be attributed to deficits in choline intake, particularly during key stages of neurodevelopment, which includes the first 1000 days of life and childhood. Choline, a key micronutrient, is crucial for optimal neurodevelopment and brain functioning of offspring. The present narrative review discusses the main research, describing the effect of choline in neurodevelopmental disorders, to better understand its role in the etiology and management of these disorders. In terms of findings, low choline intakes and reduced or altered choline status have been reported in relevant population subgroups: pregnancy (in utero), children with autism spectrum disorders, people with attention deficit hyperactivity disorder and those with dyslexia. In conclusion, an optimal choline provision may offer some neuronal protection in early life and help to mitigate some cognitive effects in later life attributed to neurodevelopmental conditions. Research indicates that choline may act as a modifiable risk factor for certain neurodevelopmental conditions. Ongoing research is needed to unravel the mechanisms and explanations.

Eggs: Healthy or Risky? A Review of Evidence from High Quality Studies on Hen's Eggs

Hen's eggs (from Gallus gallus domesticus) provide choline, folate, vitamin D, iodine, B vitamins and high-quality protein and are no longer viewed by national bodies as a risk factor for hypercholesterolaemia and cardiovascular disease (CVD). Yet, questions remain about the benefits and risks of eating eggs regularly. This review evaluates recent high-quality evidence from randomised controlled trials (RCT) and meta-analyses of observational studies and considers new areas of interest, such as weight management, protein metabolism, allergy risk and sustainability. In several RCT, eggs increased muscle protein synthesis and lowered fat mass, which could support optimal body composition. Eggs within a meal improved satiety, which could translate into lower energy intakes, although more RCT are needed. In observational studies, higher egg consumption was associated with a null effect or a modest reduced risk of CVD. For type 2 diabetes (T2D) incidence and risk of CVD in people with T2D, there were inconsistencies between observational and RCT data, with the former noting positive associations and the latter seeing no effect of higher egg intake on markers of T2D and CVD. Sustainability metrics suggest that eggs have the lowest planetary impact amongst animal proteins. To lower allergy risk, earlier introduction of eggs into weaning diets is warranted. In conclusion, the balance of evidence points to eggs being a nutritious food suggesting there are broad health benefits from including eggs in the diet at intakes higher than that currently consumed by European populations.

Different choline supplement metabolism in adults using deuterium labelling

BACKGROUND

Choline deficiency leads to pathologies particularly of the liver, brain and lung. Adequate supply is important for preterm infants and patients with cystic fibrosis. We analysed the assimilation of four different enterally administered deuterium-labelled (D9-) choline supplements in adults.

METHODS

Prospective randomised cross-over study (11/2020-1/2022) in six healthy men, receiving four single doses of 2.7 mg/kg D9-choline equivalent each in the form of D9-choline chloride, D9-phosphorylcholine, D9-alpha-glycerophosphocholine (D9-GPC) or D9-1-palmitoyl-2-oleoyl-glycero-3-phosphoryl-choline (D9-POPC), in randomised order 6 weeks apart. Plasma was obtained at baseline (t = - 0.1 h) and at 0.5 h to 7d after intake. Concentrations of D9-choline and its D9-labelled metabolites were analysed by tandem mass spectrometry. Results are shown as median and interquartile range.

RESULTS

Maximum D9-choline and D9-betaine concentrations were reached latest after D9-POPC administration versus other components. D9-POPC and D9-phosphorylcholine resulted in lower D9-trimethylamine (D9-TMAO) formation. The AUCs (0-7d) of plasma D9-PC concentration showed highest values after administration of D9-POPC. D9-POPC appeared in plasma after fatty acid remodelling, predominantly as D9-1-palmitoyl-2-linoleyl-PC (D9-PLPC), confirming cleavage to 1-palmitoyl-lyso-D9-PC and re-acylation with linoleic acid as the most prominent alimentary unsaturated fatty acid.

CONCLUSION

There was a delayed increase in plasma D9-choline and D9-betaine after D9-POPC administration, with no differences in AUC over time. D9-POPC resulted in a higher AUC of D9-PC and virtually absent D9-TMAO levels. D9-POPC is remodelled according to enterocytic fatty acid availability. D9-POPC seems best suited as choline supplement to increase plasma PC concentrations, with PC as a carrier of choline and targeted fatty acid supply as required by organs. This study was registered at Deutsches Register Klinischer Studien (DRKS) (German Register for Clinical Studies), DRKS00020498, 22.01.2020.

STUDY REGISTRATION

This study was registered at Deutsches Register Klinischer Studien (DRKS) (German Register for Clinical Studies), DRKS00020498.

Hydration and Nephrolithiasis in Pediatric Populations: Specificities and Current Recommendations

Renal lithiasis is less frequent in children than in adults; in pediatrics, lithiasis may be caused by genetic abnormalities, infections, and complex uropathies, but the association of urological and metabolic abnormalities is not uncommon. The aim of this study is to provide a synthesis of nephrolithiasis in children and to emphasize the role of hydration in its treatment. As an etiology is reported in 50% of cases, with a genetic origin in 10 to 20%, it is proposed to systematically perform a complete metabolic assessment after the first stone in a child. Recent data in the field reported increased incidence of pediatric urolithiasis notably for calcium oxalate stones. These changes in the epidemiology of stone components may be attributable to metabolic and environmental factors, where hydration seems to play a crucial role. In case of pediatric urolithiasis, whatever its cause, it is of utmost importance to increase water intake around 2 to 3 L/m² per day on average. The objective is to obtain a urine density less than 1010 on a dipstick or below 300 mOsm/L, especially with the first morning urine. Some genetic diseases may even require a more active 24 h over-hydration, e.g., primary hyperoxaluria and cystinuria; in such cases naso-gastric tubes or G-tubes may be proposed. Tap water is adapted for children with urolithiasis, with limited ecological impact and low economical cost. For children with low calcium intake, the use of calcium-rich mineral waters may be discussed in some peculiar cases, even in case of urolithiasis. In contrast, sugar-sweetened beverages are not recommended. In conclusion, even if parents and patients sometimes have the feeling that physicians do not propose "fancy" therapeutic drugs, hydration and nutrition remain cornerstones of the management of pediatric urolithiasis.

Nutritional Genomics in Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is a common chronic condition associated with genetic and environmental factors in which fat abnormally accumulates in the liver. NAFLD is epidemiologically associated with obesity, type 2 diabetes, and dyslipidemia. Environmental factors, such as physical inactivity and an unbalanced diet, interact with genetic factors, such as epigenetic mechanisms and polymorphisms for the genesis and development of the condition. Different genetic polymorphisms seem to be involved in this context, including variants in PNPLA3, TM6SF2, PEMT, and CHDH genes, playing a role in the disease's susceptibility, development, and severity. From carbohydrate intake and weight loss to omega-3 supplementation and caloric restriction, different dietary and nutritional factors appear to be involved in controlling the onset and progression of NAFLD conditions influencing metabolism, gene, and protein expression. The polygenic risk score represents a sum of trait-associated alleles carried by an individual and seems to be associated with NAFLD outcomes depending on the dietary context. Understanding the exact extent to which lifestyle interventions and genetic predispositions can play a role in the prevention and management of NAFLD can be crucial for the establishment of a personalized and integrative approach to patients.

An exploratory study on the effect of choline and folate deficiency on levels of vascularization proteins and transcription factors in first trimester trophoblast HTR-8/SVneo cells

AIMS

We studied the effect of choline and folate deficiencies on levels of predetermined placental proteins during early development.

METHODS

We incubated HTR-8/SVneo cells under choline and folate deficiency conditions and measured levels of some placental proteins using ELISA methods.

RESULTS

Concentrations of LRP2 protein in cell lysates were higher in cells incubated in choline and folate deficient media compared to the control media (mean [SD] = 2.95 [1.30] vs. 1.65 [0.27] ng/mg protein, p = 0.004). The levels of LRP2 protein in lysates of cells incubated in choline and folate deficient media were significantly higher than the concentrations in lysates of cells incubated in choline deficient but folate sufficient media (1.96 [0.28] ng/mg protein) or those incubated in choline sufficient but folate deficient media (1.77 [0.24] ng/mg protein) (p < 0.05 for both). The cellular levels of CDX2 protein were significantly higher in cells incubated in choline and folate deficient media compared to the control media (1.78 [0.60] vs. 0.99 [0.42] pg/mg protein, p = 0.002); and compared to CDX2 levels in cells incubated in choline deficient but folate sufficient media (0.87 [0.13] pg/mg protein, p < 0.001) or in choline sufficient but folate deficient media (0.96 [0.16] pg/mg protein, p < 0.001). The levels of sFLT-1 and IGF1 in culture media and that of EOMES in HTR-8/SVneo cell lysates remained unchanged under all deficiency conditions.

DISCUSSION

LRP2 and CDX2 are likely to be molecular targets for early choline and folate deficiencies in human trophoblast cells. The results should be confirmed in animal models and in other models of placental cells.

Inadequate Choline Intake in Pregnant Women in Germany

Choline is an essential nutrient that is involved in various developmental processes during pregnancy. While the general adequate choline intake (AI) for adults has been set at 400 mg/day by the European Food Safety Authority (EFSA), an AI of 480 mg/day has been derived for pregnant women. To date, the choline intake of pregnant women in Germany has not been investigated yet. Therefore, in this survey, the total choline intake from dietary and supplementary sources in pregnant women was estimated using an online questionnaire. A total of 516 pregnant women participated in the survey, of which 283 met the inclusion criteria (13 to 41 weeks of gestational age, 19−45 years). 224 (79%) of the participants followed an omnivorous diet, 59 (21%) were vegetarian or vegan. Median choline intake was 260.4 (±141.4) mg/day, and only 19 women (7%) achieved the adequate choline intake. The median choline intake of omnivores was significantly higher than that of vegetarians/vegans (269.5 ± 141.5 mg/day vs. 205.2 ± 101.2 mg/day; p < 0.0001). 5% (13/283) of pregnant women took choline-containing dietary supplements. In these women, dietary supplements provided 19% of the total choline intake. Due to the importance of choline for the developmental processes during pregnancy, the study results prove the urgent need for an improved choline supply for pregnant women.

Vitamin B-6 and riboflavin, their metabolic interaction, and relationship with MTHFR genotype in adults aged 18-102 years

BACKGROUND

The generation of the active form of vitamin B-6, pyridoxal 5'-phosphate (PLP), in tissues is dependent upon riboflavin as flavin mononucleotide, but whether this interaction is important for maintaining vitamin B-6 status is unclear.

OBJECTIVE

To investigate vitamin B-6 and riboflavin status, their metabolic interaction, and relationship with methylenetetrahydrofolate reductase (MTHFR) genotype in adulthood.

METHODS

Data from 5612 adults aged 18-102 y were drawn from the Irish National Adult Nutrition Survey (NANS; population-based sample) and the Trinity-Ulster Department of Agriculture (TUDA) and Genovit cohorts (volunteer samples). Plasma PLP and erythrocyte glutathione reductase activation coefficient (EGRac), as a functional indicator of riboflavin, were determined.

RESULTS

Older (≥65 y) compared with younger (<65 y) adults had significantly lower PLP concentrations (P < 0.001). A stepwise decrease in plasma PLP was observed across riboflavin categories, from optimal (EGRac ≤1.26), to suboptimal (EGRac: 1.27-1.39), to deficient (EGRac ≥1.40) status, an effect most pronounced in older adults (mean ± SEM: 76.4 ± 0.9 vs 65.0 ± 1.1 vs 55.4 ± 1.2 nmol/L; P < 0.001). In individuals with the variant MTHFR 677TT genotype combined with riboflavin deficiency, compared with non-TT (CC/CT) genotype participants with sufficient riboflavin, we observed PLP concentrations of 52.1 ± 2.9 compared with 76.8 ±0.7 nmol/L (P < 0.001). In participants with available dietary data (i.e., NANS cohort, n = 936), PLP was associated with vitamin B-6 intake (nonstandardized regression coefficient β: 2.49; 95% CI 1.75, 3.24; P < 0.001), supplement use (β: 81.72; 95% CI: 66.01, 97.43; P < 0.001), fortified food (β: 12.49; 95% CI: 2.08, 22.91; P = 0.019), and EGRac (β: -65.81; 95% CI: -99.08, -32.54; P < 0.001), along with BMI (β: -1.81; 95% CI: -3.31, -0.30; P = 0.019).

CONCLUSIONS

These results are consistent with the known metabolic dependency of PLP on flavin mononucleotide (FMN) and suggest that riboflavin may be the limiting nutrient for maintaining vitamin B-6 status, particularly in individuals with the MTHFR 677TT genotype. Randomized trials are necessary to investigate the PLP response to riboflavin intervention within the dietary range. The TUDA study and the NANS are registered at www.ClinicalTrials.gov as NCT02664584 (27 January 2016) and NCT03374748 (15 December 2017), respectively.Clinical Trial Registry details: Trinity-Ulster-Department of Agriculture (TUDA) study, ClinicalTrials.gov no. NCT02664584 (January 27th 2016); National Adult Nutrition Survey (NANS), ClinicalTrials.gov no. NCT03374748 (December 15th 2017).

Estimated Choline Intakes and Dietary Sources of Choline in Pregnant Australian Women

(1) Background: Despite the postulated importance of choline during pregnancy, little is known about the choline intake of Australians during pregnancy. In this study, we estimated dietary intakes of choline in early and late pregnancy, compared those intakes to recommendations, and investigated food sources of choline in a group of pregnant women in Australia. (2) Methods: 103 pregnant women enrolled in a randomized controlled trial. In early pregnancy (12−16 weeks gestation) and late pregnancy (36 weeks gestation), women completed a food frequency questionnaire designed to assess dietary intake over the previous month. (3) Results: Choline intakes and sources were similar in early and late pregnancy. Median choline intake in early pregnancy was 362 mg/day. Of the women, 39% and 25% had choline intakes above the Australian National Health and Medical Research Council (NHMRC) adequate intake (AI) of >440 mg/day and the European Food Safety Authority (EFSA) AI of >480 mg/day for choline in pregnancy, respectively. Eggs, red meat, nuts, legumes, and dairy accounted for 50% of choline intake, with eggs being the most significant contributor at 17%. (4) Conclusions: Few pregnant women in our study met the AI recommended by the NHMRC and EFSA. In Australia, choline intake in pregnancy may need to be improved, but further work to define choline requirements in pregnancy is required.

Milk polar lipids composition and functionality: a systematic review

Polar lipids including glycerophospholipids and sphingophospholipids are important nutrients and milk is a major source, particularly for infants. This systematic review describes the human and bovine milk polar lipid composition, structural organization, sources for formulation, and physiological functionality. A total of 2840 records were retrieved through Scopus, 378 were included. Bovine milk is a good source of polar lipids, where yield and composition are highly dependent on the choice of dairy streams and processing. In milk, polar lipids are organized in the milk fat globule membrane as a tri-layer encapsulating triglyceride. The overall polar lipid concentration in human milk is dependent on many factors including lactational stage and maternal diet. Here, reasonable ranges were determined where possible. Similar for bovine milk, where differences in milk lipid concentration proved the largest factor determining variation. The role of milk polar lipids in human health has been demonstrated in several areas and critical review indicated that brain, immune and effects on lipid metabolism are best substantiated areas. Moreover, insights related to the milk fat globule membrane structure-function relation as well as superior activity of milk derived polar lipid compared to plant-derived sources are emerging areas of interest regarding future research and food innovations.

Dietary Supplements for Weight Management: A Narrative Review of Safety and Metabolic Health Benefits

Dietary supplements for weight management include myriad ingredients with thermogenic, lipotropic, satiety, and other metabolic effects. Recently, the safety of this product category has been questioned. In this review, we summarize the safety evidence as well as relevant clinical findings on weight management and metabolic effects of six representative dietary supplement ingredients: caffeine, green tea extract (GTE), green coffee bean extract (GCBE), choline, glucomannan, and capsaicinoids and capsinoids. Of these, caffeine, GTE (specifically epigallocatechin gallate [EGCG]), and choline have recommended intake limits, which appear not to be exceeded when used according to manufacturers’ instructions. Serious adverse events from supplements with these ingredients are rare and typically involve unusually high intakes. As with any dietary component, the potential for gastrointestinal intolerance, as well as possible interactions with concomitant medications/supplements exist, and the health status of the consumer should be considered when consuming these components. Most of the ingredients reviewed also improved markers of metabolic health, such as glucose, lipids, and blood pressure, although the data are limited for some. In summary, weight management supplements containing caffeine, GTE, GCBE, choline, glucomannan, and capsaicinoids and capsinoids are generally safe when taken as directed and demonstrate metabolic health benefits for overweight and obese people.

25-Hydroxyvitamin D reference percentiles and the role of their determinants among European children and adolescents

BACKGROUND/OBJECTIVES

To provide age- and sex-specific percentile curves of serum 25-hydroxyvitamin D (25(OH)D) by determinants from 3-<15 year-old European children, and to analyse how modifiable determinants influence 25(OH)D.

SUBJECTS/METHODS

Serum samples were collected from children of eight European countries participating in the multicenter IDEFICS/I.Family cohort studies. Serum 25(OH)D concentrations were analysed in a central lab by a chemiluminescence assay and the values from 2171 children (N = 3606 measurements) were used to estimate percentile curves using the generalized additive model for location, scale and shape. The association of 25(OH)D with time spent outdoors was investigated considering sex, age, country, parental education, BMI z score, UV radiation, and dietary vitamin D in regressions models.

RESULTS

The age- and sex-specific 5th and 95th percentiles of 25(OH)D ranged from 16.5 to 73.3 and 20.8 to 79.3 nmol/l in girls and boys, respectively. A total of 63% had deficient (<50 nmol/l), 33% insufficient (50-<75 nmol/l) and 3% sufficient (≥75 nmol/l) levels. 25(OH)D increased with increasing UV radiation, time spent outdoors, and vitamin D intake and slightly decreased with increasing BMI z score and age. The odds ratio (OR) for a non-deficient 25(OH)D status (reference category: deficient status) by one additional hour spent outdoors was 1.21, 95% CI [1.12-1.31], i.e., children who spent one more hour per day outdoors than other children had a 21% higher chance of a non-deficient than a deficient status.

CONCLUSION

A majority of children suffer from deficient 25(OH)D. UV radiation, outdoor time, and dietary vitamin D are important determinants of 25(OH)D.

Vitamin D Status Among Children With Juvenile Idiopathic Arthritis: A Multicenter Prospective, Non-randomized, Comparative Study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a chronic autoimmune disease characterized by destructive and inflammatory damage to the joints. The aim in this study was to compare vitamin D levels between children and adolescents, 1-18 years of age, with juvenile idiopathic arthritis (JIA) and a health control group of peers. We considered effects of endogenous, exogenous, and genetic factors on measured differences in vitamin D levels among children with JIA.

METHODS

Our findings are based on a study sample of 150 patients with various variants of JIA and 277 healthy children. The blood level of vitamin D was assessed by calcidiol level. The following factors were included in our analysis: age and sex; level of insolation in three regions of country (center, south, north); assessment of dietary intake of vitamin D; effect of prophylactic doses of cholecalciferol; a relationship between the TaqI, FokI, and BsmI polymorphisms of the VDR gene and serum 25(OH)D concentration.

RESULTS

We identified a high frequency of low vitamin D among children with JIA, prevalence of 66%, with the medial level of vitamin D being within the range of "insufficient" vitamin D. We also show that the dietary intake of vitamin D by children with JIA is well below expected norms, and that prophylactic doses of vitamin D supplementation (cholecalciferol) at a dose of 500-1,000 IU/day and 1,500-2,000 IU/day do not meet the vitamin D needs of children with JIA. Of importance, we show that vitamin D levels among children with JIA are not affected by clinical therapies to manage the disease nor by the present of VDR genetic variants.

CONCLUSION

Prophylactic administration of cholecalciferol and season of year play a determining role in the development of vitamin D deficiency and insufficiency.

Choline intake and associations with egg and dairy consumption among pregnant women attending a high-risk antenatal clinic in South Africa: the NuEMI study

BACKGROUND

The importance of adequate choline intake during pregnancy has been well documented, but low intake is common. Total choline intake, main food sources of choline, as well as associations between choline intake and egg and dairy consumption were determined in a sample of pregnant women attending the high-risk antenatal clinic at a regional hospital in Bloemfontein, South Africa.

METHODS

A cross-sectional study design was used. Trained fieldworkers collected dietary intake data using a validated quantified food frequency questionnaire (QFFQ), after which all food items were matched to foods in the USDA Database for the Choline Content of Common Foods (Release 2) to quantify choline intake. Logistic regression with backward selection (p < 0.05) was used to determine whether egg and dairy consumption were independently associated with a choline intake below the adequate intake (AI) level.

RESULTS

The median daily intake of choline was 275 mg (interquartile range 185 mg - 387 mg) (N = 681). Most participants (84.7%) consumed less than the AI of 450 mg/day for choline. Meat and meat products, cereals, eggs and dairy contributed mostly to choline intake. Food items that contributed most to choline intake included full-cream milk, maize porridge, brown bread, deep-fried potatoes and deep-fried dough (vetkoek). A choline intake below the AI was significantly associated with lower egg and dairy intakes (p < 0.0001 and p = 0.0002 respectively).

CONCLUSION

Most pregnant women in the current study had choline intakes below the AI. It is recommended that public health messaging targeted at pregnant women promote the consumption of foods that can significantly contribute to choline intake, such as eggs and dairy.

Bone Health in School Age Children: Effects of Nutritional Intake on Outcomes

The maximum rate of bone mass accumulation is during early adolescence. As such, a focus on optimizing mineral nutrition in school age children, defined here as approximately 5 to 15 years of age, is crucial to minimize the risk of bone loss that occurs later in life leading to osteoporosis and fractures. Optimizing bone mass in this age group requires attention to an overall healthy diet including adequate calcium, phosphorus, magnesium, and vitamin D. Special concerns may exist related to children who follow a restricted diet such as a vegan diet, those with intolerance or allergies to dairy, and those with chronic health conditions including young adolescents with eating disorders. Public policy messages should focus on positive aspects of bone health nutrition in this age group and avoid overly specific statements about the exact amounts of foods needed for healthy bones. In this regard, dietary recommendations for minerals vary between North America and Europe and these are higher than the values that may be necessary in other parts of the world. The management of many children with chronic illnesses includes the use of medications that may affect their bone mineral metabolism. Routine lab testing for bone mineral metabolism including the serum 25-hydroxyvitamin D level is not indicated, but is valuable for at-risk children, especially those with chronic illnesses.

Understanding Choline Bioavailability and Utilization: First Step Toward Personalizing Choline Nutrition

Choline is an essential macronutrient involved in neurotransmitter synthesis, cell-membrane signaling, lipid transport, and methyl-group metabolism. Nevertheless, the vast majority are not meeting the recommended intake requirement. Choline deficiency is linked to nonalcoholic fatty liver disease, skeletal muscle atrophy, and neurodegenerative diseases. The conversion of dietary choline to trimethylamine by gut microbiota is known for its association with atherosclerosis and may contribute to choline deficiency. Choline-utilizing bacteria constitutes less than 1% of the gut community and is modulated by lifestyle interventions such as dietary patterns, antibiotics, and probiotics. In addition, choline utilization is also affected by genetic factors, further complicating the impact of choline on health. This review overviews the complex interplay between dietary intakes of choline, gut microbiota and genetic factors, and the subsequent impact on health. Understanding of gut microbiota metabolism of choline substrates and interindividual variability is warranted in the development of personalized choline nutrition.

Dietary Intake Adequacy and Food Sources of Nutrients Involved in the Methionine-Methylation Cycle in Women of Childbearing Age from the ANIBES Spanish Population

Growing evidence confirms choline as a critical perinatal nutrient. However, intake levels of choline and betaine among the Spanish fertile population remain unknown. Given their role in one-carbon metabolism with potential epigenetic effects, the aim of the present study was to evaluate the dietary intakes, their adequacy to existing guidelines and the main food sources together with other micronutrients involved in the methylation-methionine cycle (vitamin B6, folates and vitamin B12) in women of childbearing age. The ANIBES study, a cross-sectional study of a representative sample of women of childbearing age (18-45 years, n = 641) resident in Spain, was used. The sample was divided into younger women (18-30 years, n = 251) and older women (31-45 years, n = 390). Dietary intake was assessed by a three-day dietary record by using a tablet device. Total median intakes for the total sample were 303.9 mg/d for choline; 122.6 mg/d for betaine; 1.3 mg/d for vitamin B6; 140.8 μg/d for folates, and 3.8 μg/d for vitamin B12. The older subgroup showed significantly higher choline (p < 0.05), betaine (p < 0.001) and folates (p < 0.05) intakes than younger women. Main food sources for the whole sample were meat and meat products for choline (28.3%), vitamin B6 (25.7%) and vitamin B12 (22.8%); cereals and derivatives (79.9%) for betaine; vegetables (20.0%) for folates. Overall intake adequacy was only observed for vitamin B12, with a very limited number of participants showing adequate intakes for all the other micronutrients. These results illustrate there is a relevant need to raise awareness about optimizing the status of the methionine cycle-related vitamins and cofactors in this potentially vulnerable population.

Vitamin D Status and Its Correlation With Anthropometric and Biochemical Indicators of Cardiometabolic Risk in Serbian Underground Coal Miners in 2016

The status of vitamin D in underground working coal miners and its association with their cardiometabolic health is rarely studied. This study aimed to examine vitamin D (VitD) status in Serbian underground coal miners and to correlate it with anthropometric and laboratory indicators of cardiometabolic risk. Nutritional data (food frequency questionnaire, FFQ, and two times repeated 24 h recall), anthropometric data (including segmental analysis by bio-impedance analyzer TANITA BC-545N), arterial tension, and biochemical and hematological data of 103 coal miners (aged 22-63 years) were correlated with their late summer (early September) serum 25 (OH)D levels (measured by HPLC). 68.9% of the studied coal miners were overweight/obese, and 48.5% had metabolic syndrome. Their mean VitD nutritional intakes were low: 5.3 ± 3.8 μg/day (FFQ) and 4.9 ± 8 μg/day (24 h recalls), but their mean serum 25 (OH)D levels were surprisingly high (143.7 ± 41.4 nmol/L). Only 2.9% of the coal miners had 25(OH)D levels lower than 75 nmol/L (indicating an insufficient/deficient status), while 63.2% had values above 125 nmol/L (upper optimal limit), and even 10.7% had values above 200 nmol/L. There were no statistical differences in 25 (OH)D levels in the coal miners with or without metabolic syndrome (or overweight/obesity). Interestingly, 25(OH)D levels had significant positive correlations with body mass index (BMI), fat mass (FM), fat mass percentage (FM%), limbs FM%, serum triglycerides, GGT, AST, ALT, and ALT/AST ratio, and had significant negative correlations with serum HDL-cholesterol and age. All these correlations were lost after corrections for age, FM, FM%, and legs FM%. In Serbian coal miners, high levels of early September VitD levels were observed, indicating sufficient non-working-hour sun exposure during the summer period. Furthermore, the unexpected positive correlations of VitD levels with anthropometric and biochemical parameters indicative of obesity, metabolic syndrome, and fatty liver disease were found. More research is needed on the VitD status of coal miners (particularly in the winter period) and its relationship with their cardiometabolic status.

[Quantification, dietary intake adequacy, and food sources of nutrients involved in the methionine-methylation cycle (choline, betaine, folate, vitamin B6 and vitamin B12) in pregnant women in Spain]

OBJECTIVE

a quantification of dietary intakes of the micronutrients involved in the methylation-methionine cycle (choline, betaine, folate, vitamins B6 and B12) in a representative sample of pregnant women in Spain; assessment of intake adequacy to available official recommendations; and analysis of their main food sources.

MATERIAL AND METHODS

the median intake of each micronutrient was established using food consumption data reported in the National Dietary Survey of adults, the elderly, and pregnant women (ENALIA-2) (n = 133). For folate, vitamin B6 and vitamin B12 intake, nutritional composition data from the Spanish Food Composition Tables were used, whereas for choline and betaine, which are not included in European food composition databases, the National Nutrient Database for Standard Reference of the United States Department of Agriculture (USDA) was considered. Intake adequacy was estimated in accordance with the recommendations of the main Spanish, European, and US guidelines.

RESULTS

mean daily intakes observed were 271.1 mg/day of choline; 142.5 mg/day of betaine; 182.8 μg/day of folate; 1.4 mg/day of vitamin B6; and 4.5 μg/day of vitamin B12. Intake adequacy levels were insufficient for choline (< 60.2 %) and folate (< 30.5 %); close to adequacy for vitamin B6 (> 71.6 %); and fully adequate only in the case of vitamin B12 (> 101.1 %). It is not possible to draw any conclusions regarding betaine intake in the absence of established recommendations. Main food sources included foods of animal origin for choline and vitamin B12 (71.8 % and 97.4 %, respectively); cereals and derivatives for betaine (85.3 %); vegetables (27.5 %) together with cereals and derivatives (18.6 %) for folate; and meats and derivatives (26.6 %) followed by vegetables (17.9 %) for vitamin B6.

CONCLUSIONS

these findings are clearly indicative of the need to improve the intake and nutritional status of these components, which are of great nutritional interest for the health of pregnant women and, consequently, of their offspring. Consequent to the degree of adequacy observed, it seems necessary and urgent to employ not only dietary improvement strategies and the use of fortified foods, but also nutritional supplements with an individualized approach.

The dietary management of potassium in children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Dyskalemias are often seen in children with chronic kidney disease (CKD). While hyperkalemia is common, with an increasing prevalence as glomerular filtration rate declines, hypokalemia may also occur, particularly in children with renal tubular disorders and those on intensive dialysis regimens. Dietary assessment and adjustment of potassium intake is critically important in children with CKD as hyperkalemia can be life-threatening. Manipulation of dietary potassium can be challenging as it may affect the intake of other nutrients and reduce palatability. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, has developed clinical practice recommendations (CPRs) for the dietary management of potassium in children with CKD stages 2-5 and on dialysis (CKD2-5D). We describe the assessment of dietary potassium intake, requirements for potassium in healthy children, and the dietary management of hypo- and hyperkalemia in children with CKD2-5D. Common potassium containing foods are described and approaches to adjusting potassium intake that can be incorporated into everyday practice discussed. Given the poor quality of evidence available, a Delphi survey was conducted to seek consensus from international experts. Statements with a low grade or those that are opinion-based must be carefully considered and adapted to individual patient needs, based on the clinical judgment of the treating physician and dietitian. These CPRs will be regularly audited and updated by the PRNT.

NADES-based surfactant-free microemulsions for solubilization and extraction of curcumin from Curcuma Longa

A choline chloride + lactic acid (1:1) natural deep eutectic solvent (NADES) is used as an adjuvant to ethanol/triacetin mixtures to solubilize and extract curcumin from Curcuma Longa. The obtained NADES/ethanol/triacetin mixtures are homogeneous, transparent and of low viscosity even in the absence of water. Dynamic light scattering revealed significant nanostructures, typical of surfactant-free microemulsions. A twofold increase of curcumin solubility and remarkable extraction power (yield of ~90%) can be achieved in the ternary system including the NADES, although curcumin is hydrophobic and the used NADES are very polar. Due to the elevated solubility of curcumin, more extraction cycles can be made than in the previously published aqueous systems with the same amount of solution. As a result, less solvent is required to achieve the same extraction yield.

'An Apple a Day'?: Psychiatrists, Psychologists and Psychotherapists Report Poor Literacy for Nutritional Medicine: International Survey Spanning 52 Countries

Nutritional interventions have beneficial effects on certain psychiatric disorder symptomatology and common physical health comorbidities. However, studies evaluating nutritional literacy in mental health professionals (MHP) are scarce. This study aimed to assess the across 52 countries. Surveys were distributed via colleagues and professional societies. Data were collected regarding self-reported general nutrition knowledge, nutrition education, learning opportunities, and the tendency to recommend food supplements or prescribe specific diets in clinical practice. In total, 1056 subjects participated in the study: 354 psychiatrists, 511 psychologists, 44 psychotherapists, and 147 MHPs in-training. All participants believed the diet quality of individuals with mental disorders was poorer compared to the general population (p < 0.001). The majority of the psychiatrists (74.2%) and psychologists (66.3%) reported having no training in nutrition. Nevertheless, many of them used nutrition approaches, with 58.6% recommending supplements and 43.8% recommending specific diet strategies to their patients. Only 0.8% of participants rated their education regarding nutrition as 'very good.' Almost all (92.9%) stated they would like to expand their knowledge regarding 'Nutritional Psychiatry.' There is an urgent need to integrate nutrition education into MHP training, ideally in collaboration with nutrition experts to achieve best practice care.