Options for basing Dietary Reference Intakes (DRIs) on chronic disease endpoints: report from a joint US-/Canadian-sponsored working group

Dietary fat quality, plasma atherogenic lipoproteins, and atherosclerotic cardiovascular disease: An overview of the rationale for dietary recommendations for fat intake

The scientific evidence supporting the current dietary recommendations for fat quality keeps accumulating; however, a paradoxical distrust has taken root among many researchers, clinicians, and in parts of the general public. One explanation for this distrust may relate to an incomplete overview of the totality of the evidence for the link between fat quality as a dietary exposure, and health outcomes such as atherosclerotic cardiovascular disease (ASCVD). Therefore, the main aim of the present narrative review was to provide a comprehensive overview of the rationale for dietary recommendations for fat intake, limiting our discussion to ASCVD as outcome. Herein, we provide a core framework - a causal model - that can help us understand the evidence that has accumulated to date, and that can help us understand new evidence that may become available in the future. The causal model for fat quality and ASCVD is comprised of three key research questions (RQs), each of which determine which scientific methods are most appropriate to use, and thereby which lines of evidence that should feed into the causal model. First, we discuss the link between low-density lipoprotein (LDL) particles and ASCVD (RQ1); we draw especially on evidence from genetic studies, randomized controlled trials (RCTs), epidemiology, and mechanistic studies. Second, we explain the link between dietary fat quality and LDL particles (RQ2); we draw especially on metabolic ward studies, controlled trials (randomized and non-randomized), and mechanistic studies. Third, we explain the link between dietary fat quality, LDL particles, and ASCVD (RQ3); we draw especially on RCTs in animals and humans, epidemiology, population-based changes, and experiments of nature. Additionally, the distrust over dietary recommendations for fat quality may partly relate to an unclear understanding of the scientific method, especially as applied in nutrition research, including the process of developing dietary guidelines. We therefore also aimed to clarify this process. We discuss how we assess causality in nutrition research, and how we progress from scientific evidence to providing dietary recommendations.

The science of micronutrients in clinical practice - Report on the ESPEN symposium

BACKGROUND & AIMS

The European Society for Clinical Nutrition and Metabolism published its first clinical guidelines for use of micronutrients (MNs) in 2022. A two-day web symposium was organized in November 2022 discussing how to apply the guidelines in clinical practice. The present paper reports the main findings of this symposium.

METHODS

Current evidence was discussed, the first day being devoted to clarifying the biology underlying the guidelines, especially regarding the definition of deficiency, the impact of inflammation, and the roles in antioxidant defences and immunity. The second day focused on clinical situations with high prevalence of MN depletion and deficiency.

RESULTS

The importance of the determination of MN status in patients at risk and diagnosis of deficiencies is still insufficiently perceived, considering the essential role of MNs in immune and antioxidant defences. Epidemiological data show that deficiencies of several MNs (iron, iodine, vitamin D) are a global problem that affects human health and well-being including immune responses such as to vaccination. Clinical conditions frequently associated with MN deficiencies were discussed including cancer, obesity with impact of bariatric surgery, diseases of the gastrointestinal tract, critical illness, and aging. In all these conditions, MN deficiency is associated with worsening of outcomes. The recurrent problem of shortage of MN products, but also lack of individual MN-products is a worldwide problem.

CONCLUSION

Despite important progress in epidemiology and clinical nutrition, numerous gaps in practice persist. MN depletion and deficiency are frequently insufficiently searched for in clinical conditions, leading to inadequate treatment. The symposium concluded that more research and continued education are required to improve patient outcome.

Sweetness preference and its impact on energy intake and body weight - a review of evidence

In the last few years, several approaches have been postulated for tackling the global increase in overweight and obesity rates, including different dietary macronutrient compositions or the timing of meals. Recently, taste modulation has come into focus as a possible approach for influencing dietary behavior. The perception of sweet taste is innate and an evolutionary protection mechanism to prevent primates from eating poisonous plants. It is hypothesized that this innate sweetness preference could be modulated by dietary sweetness, including sweet foods and beverages, which results in a learned sweetness preference that affects energy intake and body weight. However, this hypothesis is not supported by unanimous scientific evidence. This review provides an update of the current literature, regarding the modulation of sweetness preference as a possible new approach in the prevention of overweight and obesity. In general, results from observation as well as interventional studies in all age groups are heterogeneous. The majority showed no effect of dietary sweetness modulation on sweetness preference, energy intake or anthropometric measures. Therefore, the modulation of sweetness preference due to diet, foods or beverages is still a hypothesis and not scientifically proven. However, due to the lack of data, more research is necessary.

The impact of wavelength on acute non-visual responses to light: A systematic review and meta-analysis

Light is detected in the eye by three classes of photoreceptors (rods, cones, and intrinsically photosensitive retinal ganglion cells (ipRGCs)) that are each optimized for a specific function and express a particular light-detecting photopigment. The significant role of short-wavelength light and ipRGCs in improving alertness has been well-established; however, few reviews have been undertaken to assess the other wavelengths' effects regarding timing and intensity. This study aims to evaluate the impact of different narrowband light wavelengths on subjective and objective alertness among the 36 studies included in this systematic review, 17 of which were meta-analyzed. Short-wavelength light (∼460-480 nm) significantly improves subjective alertness, cognitive function, and neurological brain activities at night, even for a sustained period (∼6h) (for λmax: 470/475 nm, 0.4 < |Hedges's g| < 0.6, p < 0.05), but except early morning, it almost does not show this effect during the day when melatonin level is lowest. Long-wavelength light (∼600-640 nm) has little effect at night, but significantly increases several measures of alertness at lower irradiance during the daytime (∼1h), particularly when there is homeostatic sleep drive (for λmax: ∼630 nm, 0.5 < |Hedges's g| < 0.8, p < 0.05). The results further suggest that melanopic illuminance may not always be sufficient to measure the alerting effect of light.

Occupational exposure to cosmetic talc and mesothelioma in barbers, hairdressers, and cosmetologists: A systematic review of the epidemiology

Inhalation exposure to cosmetic talc has generated much scientific debate regarding its potential as a risk factor for mesothelioma, a rare, but fatal cancer. Barbers, hairdressers, and cosmetologists have regularly used cosmetic talc-containing products, but the collective epidemiological evidence for mesothelioma in these occupations has yet to be described. As such, we conducted a systematic review of PubMed and the National Institute for Occupational Safety and Health's (NIOSH) Numbered Publications list to identify original epidemiological literature reporting measures of association between these occupations and incidence of or death from mesothelioma. Literature screening was performed independently twice, the results of which were summarized and tabulated and underwent a review for their accuracy. A total of 12 studies met our inclusion criteria, including three cohort, six case-control, and three proportionate mortality/registration studies. The data from these studies were collected in 13 European and North American countries, spanning more than 50 years. We supplemented this review with queries of occupational mortality databases that are managed by the Washington State Department of Health and NIOSH for 26 U.S. states. Most findings were null and if statistically significant, nearly all showed an inverse relationship, indicative of a protective effect of these occupations on mesothelioma risk. Overall, the epidemiological evidence does not support an increased risk of mesothelioma for these occupations. This research fills an important data gap on the etiology of mesothelioma in barbers, hairdressers, and cosmetologists, and provides a benchmark for those with comparatively less exposure, such as non-occupational users of similar cosmetic talc-containing products.

What's in the mind's eye of individuals with bipolar disorders: an exploration of the content and characteristics of mental images in different thymic phases

BACKGROUND

Mental imagery, or 'seeing with the mind's eye' (Kosslyn et al. ), provokes strong emotional responses (Ji et al., ). To date, there is a lack of data on the content and clinical characteristics (e.g. vividness, likelihood, emotional effects) of spontaneous mental images (MI) in people with bipolar disorder (BD) according to their thymic states.

AIM

The current study sought to assess the characteristics associated with the contents of MI in people with BD.

METHOD

Forty-two euthymic individuals diagnosed with BD (American Psychiatric Association, ) were asked to self-report their MI during depression, (hypo)mania and euthymia. Participants also rated levels of vividness, likelihood and emotional activation related to MI (i.e. valence, arousal, type of emotion).

RESULTS

The contents of the MI revealed phenomenological aspects of BD. Different themes were associated with each thymic phase. In (hypo)mania and in euthymia, the mental images were assessed as being as vivid as probable (p>.05). (Hypo)manic and euthymic-related MI activated more pleasure than displeasure (p<.001) and were mainly associated with joy. In depression, MI were assessed as more vivid than likely (p<.05). In depression, MI activated more displeasure than pleasure (p<.0001) and induced mainly sadness.

DISCUSSION

Overall, a congruence between the contents of images and the three thymic phases was found. The content of the MI was related to self-reported emotional effects that were congruent with the thymic phases concerned. The results add new clinical information for the use of imagery-based cognitive therapy in individuals with BD.

Precision Nutrition: The Hype Is Exceeding the Science and Evidentiary Standards Needed to Inform Public Health Recommendations for Prevention of Chronic Disease

As dietary guidance for populations shifts from preventing deficiency disorders to chronic disease risk reduction, the biology supporting such guidance becomes more complex due to the multifactorial risk profile of disease and inherent population heterogeneity in the diet-disease relationship. Diet is a primary driver of chronic disease risk, and population-based guidance should account for individual responses. Cascading effects on evidentiary standards for population-based guidance are not straightforward. Precision remains a consideration for dietary guidance to prevent deficiency through the identification of population subgroups with unique nutritional needs. Reducing chronic disease through diet requires greater precision in (a) establishing essential nutrient needs throughout the life cycle in both health and disease; (b) considering effects of nutrients and other food substances on metabolic, immunological, inflammatory, and other physiological responses supporting healthy aging; and (c) considering healthy eating behaviors. Herein we provide a template for guiding population-based eating recommendations for reducing chronic diseases in heterogenous populations.

Tolerable Upper Intake Level for Individual Amino Acids in Humans: A Narrative Review of Recent Clinical Studies

Individual amino acids are widely popular as supplements because of various perceived and real health benefits. However, currently, there are no recommendations set by national health agencies for tolerable upper intake levels (UL) for amino acids because of a lack of well-conducted human dose-response trials. In the past decade, under the initiative of the International Council on Amino Acid Science, a nonprofit organization, a series of UL human clinical studies were conducted. The goal of this narrative review is to summarize the studies on 6 essential amino acids (leucine, tryptophan, methionine, lysine, histidine, and phenylalanine), 2 nonessential amino acids (arginine and serine), and 2 nonproteinogenic amino acids (ornithine and citrulline) and provide the first set of ULs. A brief background of the concept of the DRI framework of UL, the concept of UL for amino acids, and a perspective of the results are also provided. The data suggest that in relatively healthy adult individuals, the tested amino acids are well tolerated, and ULs, or the no-observed-adverse-effect-level (NOAEL), lowest-observed-adverse-effect-level (LOAEL), can be determined. The ULs were for leucine-young (35 g/d), tryptophan (4.5 g/d), and leucine-elderly (30 g/d); NOAEL and LOAEL for methionine at 3.2 and 6.4 g/d, respectively; NOAEL for arginine (30 g/d); NOAEL and LOAEL for lysine at 6 and 7.5 g/d, respectively; NOAEL and LOAEL for histidine at 8 and 12 g/d, respectively; and NOAEL for phenylalanine (12 g/d), serine (12 g/d), ornithine (12 g/d) and citrulline (24 g/d). This first set of human UL data are hoped to help national and international agencies set safety standards for supplemental amino acids.

Foundational Nutrition: Implications for Human Health

Human nutrition, and what can be considered "ideal" nutrition, is a complex, multi-faceted topic which many researchers and practitioners deliberate. While some attest that basic human nutrition is relatively understood, it is undeniable that a global nutritional problem persists. Many countries struggle with malnutrition or caloric deficits, while others encounter difficulties with caloric overconsumption and micronutrient deficiencies. A multitude of factors contribute to this global problem. Limitations to the current scope of the recommended daily allowances (RDAs) and dietary reference intakes (DRIs), changes in soil quality, and reductions in nutrient density are just a few of these factors. In this article, we propose a new, working approach towards human nutrition designated "Foundational Nutrition". This nutritional lens combines a whole food approach in conjunction with micronutrients and other nutrients critical for optimal human health with special consideration given to the human gut microbiome and overall gut health. Together, this a synergistic approach which addresses vital components in nutrition that enhances the bioavailability of nutrients and to potentiate a bioactive effect.

Measuring the intake of dietary bioactives: Pitfalls and how to avoid them

Bioactives are food constituents that, while not essential to human life, can affect health. Thus, there is increased interest in developing dietary recommendations for bioactives. Such recommendations require detailed information about the long-term association between habitual intake and health at population scale, and these can only be provided by large-scale observational studies. Nutritional epidemiology relies on the accurate estimation of intake, but currently used methods, commonly based on a 2-step process involving self-reports and food composition tables, are fraught with significant challenges and are unable to estimate the systemic presence of bioactives. Intake assessments based on nutritional biomarkers can provide an advanced alternative, but there are a number of pitfalls that need to be addressed in order to obtain reliable data on intake. Using flavan-3-ols as a case study, we highlight here key challenges and how they may be avoided. Taken together, we believe that the approaches outlined in this review can be applied to a wide range of food constituents, and doing so will improve assessments of the dietary intake of bioactives.

Health and nutrition beyond essential nutrients: The evolution of the bioactives concept for human health

Our food supply contains a range of essential and non-essential food components. There are substantial epidemiologic findings and additional clinical data to support the health benefits for some non-essential food components - these compounds are often referred to as bioactives. While there is a well-established process in place to make science-based dietary recommendations for essential nutrients, this is not the case for bioactive food components. This manuscript reviews the evolution of the RDAs and the transition to a DRI framework for establishing requirements for essential nutrients. Then, the potential of development of public health recommendations for bioactives will be explored and the benefits and challenges of making recommendations will be presented. The scientific support for case studies for lutein and flavan-3-ols, will be made. Finally, suggestions for frameworks that might be considered by authoritative policy-making bodies when evaluating the efficacy and safely of proposed bioactives will be discussed.

Optimal Nutrition in the Older Adult: Beneficial Versus Ineffective Supplements

PURPOSE OF REVIEW

Proper nutrition in older adults is essential, as nutritional deficiencies are common in this population. This review aims to summarize the benefits and risks of nutritional supplementation in the older adult population including the efficacy of various supplements, their risks, and common drug interactions with frequently prescribed medications.

RECENT FINDINGS

In recent years, a growing percentage of older adults have been found to take multiple daily nutritional supplements. This population has complex nutritional needs due to the physiology of aging and the presence of comorbidities. However, many primary care providers are unaware of the benefits and drawbacks of nutritional supplementation in the elderly. This review summarizes the current literature to provide more clarity to providers on how to support this population's nutritional needs. Nutritional supplementation is essential for elderly populations who may not be able to obtain adequate nutrition from dietary sources. Supplements vary widely in efficacy and safety. As such, supplementation should be individualized and guided by a qualified healthcare provider to ensure patients receive effective, beneficial nutrition.

Scoping Review and Evidence Map of the Relation between Exposure to Dietary Sweetness and Body Weight-Related Outcomes in Adults

Numerous governmental and health organizations recommend reduced intake of added sugars due to the health risks associated with excess intake, including the risk of obesity. Some organizations further recommend avoiding dietary sweetness, regardless of the source. A scoping review and evidence map were completed to characterize the research that investigated associations between dietary sweetness and body weight. The aim was to identify and map published studies that have investigated total dietary sweetness, sweet food/beverages, sugar, or sweetener intake, and body weight-related outcomes and/or energy intake. Using preregistered search terms (osf.io/my7pb), 36,779 publications (duplicates removed) were identified from PubMed, Cochrane Library, and Scopus and screened for inclusion. Eligible studies were clinical trials, longitudinal cohorts, case-control studies, cross-sectional studies, and systematic reviews conducted among adults (age ≥18 y), which were performed to investigate associations between dietary sweetness, sweet foods/beverages, sugar, or sweetener (energetic or nonenergetic) intake and body weight, BMI, adiposity, and/or energy intake. A total of 833 eligible publications were identified, detailing 804 studies. Only 7 studies (0.9% of included studies; 2 clinical trials, 4 cross-sectional studies, and 1 with another design type) investigated associations between total dietary sweetness and body weight-related outcome and/or energy intake. An additional 608 (75.6%) studies investigated intakes of sweet foods/beverages, sugar, or sweetener, and body weight-related outcomes and/or energy intake, including 225 clinical trials, 81 longitudinal cohorts, 4 case-control studies, and 280 cross-sectional studies. Most studies (90.6%) did not measure the sweetness of the diet or individual foods consumed. Ninety-two (11.4%) publications reported data from studies on dietary patterns that included sweet foods/beverages alongside other dietary components and 97 (12.1%) systematic reviews addressed different but related research questions. Although there is a breadth of evidence from studies that have investigated associations between intakes of sweet foods and beverages, sugars, and sweeteners and body weight, there is a limited depth of evidence on the association between total dietary sweetness and body weight.

Vitamin D intakes and health outcomes in infants and preschool children: Summary of an evidence report

BACKGROUND

A systematic review was commissioned to support an international expert group charged to update the Food and Agriculture Organisation of the United Nations (FAO)/World Health Organisation (WHO)'s vitamin D intake recommendations for children aged 0-4 years.

MATERIALS AND METHODS

Multiple electronic databases were searched to capture studies published from database inception to the 2^nd week of June 2020 according to key questions formulated by the FAO/WHO. Relevant studies were summarised and synthesised by key questions and by health outcomes using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The 146 included studies examined the effects of different vitamin D intake levels on a variety of health outcomes (e.g. infectious disease, growth, neurodevelopment, rickets, and bone mineral density), and on outcomes for setting vitamin D upper limits (e.g. hypercalcemia, hypercalciuria, and nephrocalcinosis). For most outcomes, the strength of evidence was low or very low. Evidence was rated moderate for the effect of daily vitamin D supplementation on raising serum 25(OH)D concentrations, and a random-effects meta-regression analysis of 28 randomised controlled trials (mostly in infants 0-12 months) showed that each 100 IU/d increase in vitamin D supplementation was associated with an average of 1.92 (95% CI 0.28, 3.56) nmol/L increase in achieved 25-hydroxy-vitaminn D (25[OH]D) concentration (n = 53 intervention arms; p = .022) with large residual heterogeneity (I² = 99.39%). Evidence was very low on two of the upper limit outcomes - hypercalcemia and hypercalciuria.

CONCLUSIONS

The evidence report provided the expert group with a foundation and core set of data to begin their work to set vitamin D nutrient reference values. To move the field forward, future studies should use standardised 25(OH)D assay measurements and should examine the relationship between long-term vitamin D status and health outcomes.Key MessagesResults of a large complex systematic review suggest the current totality of evidence from trials and prospective observational studies do not reach sufficient certainty level to support a causal relationship between vitamin D intake and asthma, wheeze, eczema, infectious diseases, or rickets (most trials reported no rickets) in generally healthy infants and young children.In this systematic review, the only body of evidence that reached a moderate level of certainty was regarding the effect of daily vitamin D supplementation (vitamin D₃ or D₂ supplements to infants/children) on increasing serum 25(OH)D concentrations. However, currently there is no consensus on the definitions of vitamin D status, e.g. deficiency, insufficiency, sufficiency and toxicity, based on serum 25(OH)D concentrations.This systematic review provided an international expert group a foundation and core set of data through intake-response modelling to help set vitamin D nutrient reference values for infants and children up to 4 years of age.

Nutrition and stem cell integrity in aging

Adult stem cells (SCs) represent the regenerative capacity of organisms throughout their lifespan. The maintenance of robust SC populations capable of renewing organs and physiological systems is one hallmark of healthy aging. The local environment of SCs, referred to as the niche, includes the nutritional milieu, which is essential to maintain the quantity and quality of SCs available for renewal and regeneration. There is increased recognition that SCs have unique metabolism and conditional nutrient needs compared to fully differentiated cells. However, the contribution of SC nutrition to overall human nutritional requirements is an understudied and underappreciated area of investigation. Nutrient needs vary across the lifespan and are modified by many factors including individual health, disease, physiological states including pregnancy, age, sex, and during recovery from injury. Although current nutrition guidance is generally derived for apparently healthy populations and to prevent nutritional deficiency diseases, there are increased efforts to establish nutrient-based and food-based recommendations based on reducing chronic disease. Understanding the dynamics of SC nutritional needs throughout the life span, including the role of nutrition in extending biological age by blunting biological systems decay, is fundamental to establishing food and nutrient guidance for chronic disease reduction and health maintenance. This review summarizes a 3-day symposium of the Marabou Foundation (www.marabousymposium.org) held to examine the metabolic properties and unique nutritional needs of adult SCs and their role in healthy aging and age-related chronic disease.

Development of an Evidence-Based Risk Assessment Framework

Assessment of potential human health risks associated with environmental and other agents requires careful evaluation of all available and relevant evidence for the agent of interest, including both data-rich and data-poor agents. With the advent of new approach methodologies in toxicological risk assessment, guidance on integrating evidence from mul-tiple evidence streams is needed to ensure that all available data is given due consideration in both qualitative and quantitative risk assessment. The present report summarizes the discussions among academic, government, and private sector participants from North America and Europe in an international workshop convened to explore the development of an evidence-based risk assessment framework, taking into account all available evidence in an appropriate manner in order to arrive at the best possible characterization of potential human health risks and associated uncertainty. Although consensus among workshop participants was not a specific goal, there was general agreement on the key consider-ations involved in evidence-based risk assessment incorporating 21st century science into human health risk assessment. These considerations have been embodied into an overarching prototype framework for evidence integration that will be explored in more depth in a follow-up meeting.

Neuronutraceuticals Combating Neuroinflammaging: Molecular Insights and Translational Challenges—A Systematic Review

Neuropathologies, such as neuroinflammaging, have arisen as a serious concern for preserving the quality of life due to the global increase in neurodegenerative illnesses. Nowadays, neuronutraceuticals have gained remarkable attention. It is necessary to investigate the bioavailability, off-target effects, and mechanism of action of neuronutraceuticals. To comprehend the comprehensive impact on brain health, well-designed randomized controlled trials testing combinations of neuronutraceuticals are also necessary. Although there is a translational gap between basic and clinical research, the present knowledge of the molecular perspectives of neuroinflammaging and neuronutraceuticals may be able to slow down brain aging and to enhance cognitive performance. The present review also highlights the key emergent issues, such as regulatory and scientific concerns of neuronutraceuticals, including bioavailability, formulation, blood–brain permeability, safety, and efficacy.

Identifying and understanding the factors that influence the functioning of integrated healthcare systems in the NHS: a systematic literature review

OBJECTIVES

The National Health Service has been moving towards integrated care for the best part of two decades to address the growing financial and service pressures created by an ageing population. Integrated healthcare systems (IHSs) join up health and social care services and have been established to manage the care of individuals with complex chronic conditions but with varied success. It is therefore imperative to conduct a Systematic Literature Review (SLR) to identify and understand the factors that influence their successful functioning, and ascertain the factor with the greatest influence, in order to ensure positive outcomes when establishing future IHSs.

METHODS

Articles published between 1 January 1997 and 8 March 2020 were analysed from the following six databases: Healthcare Management Information Consortium, Nuffield Trust, Cumulative Index to Nursing and Allied Health Literature, PubMed, National Institute for Health and Care Excellence Evidence and Health Systems Evidence. Those deemed relevant after title and abstract screening were procured for subsequent review of the full-text article.

RESULTS

Thirty-three finalised articles were analysed in this SLR to provide a comprehensive overview of the factors that influence the functioning of IHSs. Factors were stratified into six key categories: organisational culture, workforce management, interorganisational collaboration, leadership ability of staff, economic factors and political factors. Leadership was deemed to be the most influential factor due to its intrinsic and instrumental role in influencing the other key factors.

CONCLUSIONS

The findings of this SLR may serve as a guide to developing tailor-made recommendations and policies that address the identified key factors and thereby improve the functioning of present and future IHSs. Furthermore, due to both its overarching influence and the inadequacy of literature in this field, there is a strong case for further research exploring leadership development specifically for IHSs.

Safety of selenium exposure and limitations of selenoprotein maximization: Molecular and epidemiologic perspectives

Recent evidence from laboratory and epidemiologic studies has shed a different light on selenium health effects and its recommended range of environmental exposure, compared with earlier research. Specifically, epidemiologic studies in Western populations have shown adverse effects of selenium exposure at low levels, sometimes below or slightly above selenium intakes needed to maximize selenoprotein expression and activity. In addition, three recent lines of evidence in molecular and biochemical studies suggest some potential drawbacks associated with selenoprotein maximization: 1) the possibility that selenoprotein upregulation is a compensatory response to oxidative challenge, induced by selenium itself or other oxidants; 2) the capacity of selenoproteins to trigger tumor growth in some circumstances; and 3) the deleterious metabolic effects of selenoproteins and particularly of selenoprotein P. The last observation provides a toxicological basis to explain why in humans selenium intake levels as low as 60 μg/day, still in the range of selenium exposure upregulating selenoprotein expression, might start to increase risk of type 2 diabetes. Overall, these new pieces of evidence from the literature call into question the purported benefit of selenoprotein maximization, and indicate the need to reassess selenium dietary reference values and upper intake level. This reassessment should clarify which range of selenoprotein upregulation follows restoration of adequate selenium availability and which range is driven by a compensatory response to selenium toxicity and oxidative stress.

Feasibility, acceptability, and effectiveness of non-pharmaceutical interventions against infectious diseases among crisis-affected populations: a scoping review

Background

Non-pharmaceutical interventions (NPIs) are a crucial suite of measures to prevent and control infectious disease outbreaks. Despite being particularly important for crisis-affected populations and those living in informal settlements, who typically reside in overcrowded and resource limited settings with inadequate access to healthcare, guidance on NPI implementation rarely takes the specific needs of such populations into account. We therefore conducted a systematic scoping review of the published evidence to describe the landscape of research and identify evidence gaps concerning the acceptability, feasibility, and effectiveness of NPIs among crisis-affected populations and informal settlements.

Methods

We systematically reviewed peer-reviewed articles published between 1970 and 2020 to collate available evidence on the feasibility, acceptability, and effectiveness of NPIs in crisis-affected populations and informal settlements. We performed quality assessments of each study using a standardised questionnaire. We analysed the data to produce descriptive summaries according to a number of categories: date of publication; geographical region of intervention; typology of crisis, shelter, modes of transmission, NPI, research design; study design; and study quality.

Results

Our review included 158 studies published in 85 peer-reviewed articles. Most research used low quality study designs. The acceptability, feasibility, and effectiveness of NPIs was highly context dependent. In general, simple and cost-effective interventions such as community-level environmental cleaning and provision of water, sanitation and hygiene services, and distribution of items for personal protection such as insecticide-treated nets, were both highly feasible and acceptable. Logistical, financial, and human resource constraints affected both the implementation and sustainability of measures. Community engagement emerged as a strong factor contributing to the effectiveness of NPIs. Conversely, measures that involve potential restriction on personal liberty such as case isolation and patient care and burial restrictions were found to be less acceptable, despite apparent effectiveness.

Conclusions

Overall, the evidence base was variable, with substantial knowledge gaps which varied between settings and pathogens. Based on the current landscape, robust evidence-based guidance is not possible, and a research agenda is urgently required that focusses on these specific vulnerable populations. Although implementation of NPIs presents unique practical challenges in these settings, it is critical that such an agenda is put in place, and that the lessons learned from historical and present experiences are documented to build a firm evidence base.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00935-7.

Identification of the interactions between specific genetic polymorphisms and nutrient intake associated with general and abdominal obesity in middle-aged adults

BACKGROUND & AIMS

Comprehensive understanding of gene-diet interactions is necessary to establish proper dietary guidelines to prevent and manage general and abdominal obesity. We investigated the role of genetic variants and their interactions with general and abdominal obesity-associated nutrients using a largescale genome-wide association study of Korean adults.

METHODS

A total of 50,808 participants from a Korean genome and epidemiology study were included. Dietary intake was assessed using a food frequency questionnaire. Obesity was defined as a body mass index ≥25 kg/m². Abdominal obesity (AO) was defined as waist circumference ≥90 cm and 80 cm in males and females, respectively. Dietary nutrient intake was classified based on Korean Dietary Reference Intakes (DRIs). Odds ratios and 95% confidence intervals were calculated after adjusting for age, sex, exercise, smoking, alcohol drinking, total energy consumption, PC1, and PC2.

RESULTS

Among the individuals consuming fat (%) above DRI, carriers of Ca binding protein 39 (CAB39)- rs6722579 minor allele (A) have a higher risk of AO than those not carrying the SNP (odds ration [OR] = 3.73, p-value = 2.05e-07; interaction p-value = 1.80e-07). Among the individuals consuming vitamin C above DRI, carriers of carboxypeptidase Q (CPQ)- rs59465035 minor allele (T) have a lower risk of AO than those without that SNP (OR = 0.89, p-value = 1.44e-08; interaction p-value = 9.50e-06). The genetic association with obesity was stronger among individuals with a genetic variant rs4130113 near GHR gene region in those consume folate above DRI and with a genetic variant rs5760920 near CRYBB2 gene region in those consume vitamin B2 above DRI.

CONCLUSION

Our study results suggested that interactions of specific polymorphisms at loci and certain nutrients may influence obesity and abdominal obesity.

NUQUEST-NUtrition QUality Evaluation Strengthening Tools: development of tools for the evaluation of risk of bias in nutrition studies

BACKGROUND

Dietary exposure assessments are a critical issue in evaluating human nutrition studies; however, nutrition-specific criteria are not consistently included in existing bias assessment tools.

OBJECTIVES

Our objective was to develop a set of risk of bias (RoB) tools that integrated nutrition-specific criteria into validated generic assessment tools to address RoB issues, including those specific to dietary exposure assessment.

METHODS

The Nutrition QUality Evaluation Strengthening Tools (NUQUEST) development and validation process included 8 steps. The first steps identified 1) a development strategy; 2) generic assessment tools with demonstrated validity; and 3) nutrition-specific appraisal issues. This was followed by 4) generation of nutrition-specific items and 5) development of guidance to aid users of NUQUEST. The final steps used established ratings of selected studies and feedback from independent raters to 6) assess reliability and validity; 7) assess formatting and usability; and 8) finalize NUQUEST.

RESULTS

NUQUEST is based on the Scottish Intercollegiate Guidelines Network checklists for randomized controlled trials, cohort studies, and case-control studies. Using a purposive sample of 45 studies representing the 3 study designs, interrater reliability was high (Cohen's κ: 0.73; 95% CI: 0.52, 0.93) across all tools and at least moderate for individual tools (range: 0.57-1.00). The use of a worksheet improved usability and consistency of overall interrater agreement across all study designs (40% without worksheet, 80%-100% with worksheet). When compared to published ratings, NUQUEST ratings for evaluated studies demonstrated high concurrent validity (93% perfect or near-perfect agreement). Where there was disagreement, the nutrition-specific component was a contributing factor in discerning exposure methodological issues.

CONCLUSIONS

NUQUEST integrates nutrition-specific criteria with generic criteria from assessment tools with demonstrated reliability and validity. NUQUEST represents a consistent and transparent approach for evaluating RoB issues related to dietary exposure assessment commonly encountered in human nutrition studies.

Are all dietary fibers equal for patients with inflammatory bowel disease? A systematic review of randomized controlled trials

CONTEXT

Conflicting practice-based dietary recommendations are sometimes given to patients with inflammatory bowel disease (IBD); whereas intake of fiber should increase during remission, it should be avoided during relapse. Moreover, European countries set daily requirements of total fiber and do not specify any types.

OBJECTIVE

This systematic review appraised data from randomized clinical trials (RCTs) of the types of fibers beneficial for patients in the treatment of IBD to guide dietary fiber advice.

DATA SOURCES

The PubMED database was searched following PRISMA guidelines.

DATA EXTRACTION

RCTs evaluating the effects of any type of fiber on clinical and physiological outcomes in patients with IBD were assessed. Quality assessment of the selected full-text articles was conducted using the Cochrane Risk of Bias Tool.

DATA ANALYSIS

Eight studies were included reporting on 5 types of fibers. In 2 RCTs, germinated barley foodstuff (GBF) was shown to lower pro-inflammatory cytokines and clinical disease activity scores. Fructo-oligosaccharides (FOS) were demonstrated to lower IBD Questionnaire scores (lower well-being), in contrast to inulin, which decreased disease activity scores. An RCT could not find lower remission rates in the psyllium treatment group, while another RCT reported that administration led to less symptoms in patients. In RCTs, no concrete evidence was found that wheat bran improves disease course.

CONCLUSIONS

Although the evidence is sparse, GBF and inulin seem propitious and merit further exploration. Evidence on wheat bran and psyllium is still too limited. Adequately powered long-term human RCTs with objective outcomes are needed to improve dietary advice on types of fiber in IBD.

Bellagio II Report: Terrestrial Applications of Space Medicine Research

AbstractINTRODUCTION: For over 50 yr, investigators have studied the physiological adaptations of the human system during short- and long-duration spaceflight exposures. Much of the knowledge gained in developing health countermeasures for astronauts onboard the International Space Station demonstrate terrestrial applications. To date, a systematic process for translating these space applications to terrestrial human health has yet to be defined.METHODS: In the summer of 2017, a team of 38 international scientists launched the Bellagio ll Summit Initiative. The goals of the Summit were: 1) To identify space medicine findings and countermeasures with highest probability for future terrestrial applications; and 2) To develop a roadmap for translation of these countermeasures to future terrestrial application. The team reviewed public domain literature, NASA databases, and evidence books within the framework of the five-stage National Institutes of Health (NIH) translation science model, and the NASA two-stage translation model. Teams then analyzed and discussed interdisciplinary findings to determine the most significant evidence-based countermeasures sufficiently developed for terrestrial application.RESULTS: Teams identified published human spaceflight research and applied translational science models to define mature products for terrestrial clinical practice.CONCLUSIONS: The Bellagio ll Summit identified a snapshot of space medicine research and mature science with the highest probability of translation and developed a Roadmap of terrestrial application from space medicine-derived countermeasures. These evidence-based findings can provide guidance regarding the terrestrial applications of best practices, countermeasures, and clinical protocols currently used in spaceflight.Sides MB, Johnston SL III, Sirek A, Lee PH, Blue RS, Antonsen EL, Basner M, Douglas GL, Epstein A, Flynn-Evans EE, Gallagher MB, Hayes J, Lee SMC, Lockley SW, Monseur B, Nelson NG, Sargsyan A, Smith SM, Stenger MB, Stepanek J, Zwart SR; Bellagio II Team. Bellagio II report: terrestrial applications of space medicine research. Aerosp Med Hum Perform. 2021; 92(8):650669.

Adverse Effects of Medications on Micronutrient Status: From Evidence to Guidelines

Recent dietary reference intake workshops focusing on nutrient requirements in chronic disease populations have called attention to the potential adverse effects of chronic medication use on micronutrient status. Although this topic is mostly ill defined in the literature, several noteworthy drug-nutrient interactions (DNIs) are of clinical and public health significance. The purpose of this narrative review is to showcase classic examples of DNIs and their impact on micronutrient status, including those related to antidiabetic, anticoagulant, antihypertensive, antirheumatic, and gastric acid-suppressing medications. Purported DNIs related to other drug families, while relevant and worthy of discussion, are not included. Unlike previous publications, this review is primarily focused on DNIs that have sufficient evidence supporting their inclusion in US Food and Drug Administration labeling materials and/or professional guidelines. While the evidence is compelling, more high-quality research is needed to establish clear and quantitative relationships between chronic medication use and micronutrient status. Expected final online publication date for the Annual Review of Nutrition, Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Circulating Cytokines and Coronavirus Disease: A Bi-Directional Mendelian Randomization Study

BACKGROUND

Immune system functioning is relevant to vulnerability to coronavirus disease (COVID-19). Cytokines are important to immunity. To further elucidate the role of the immune system in COVID-19, we used Mendelian randomization (MR) to assess comprehensively and bi-directionally the role of cytokines in COVID-19.

METHODS

We assessed primarily whether genetically different levels of 41 cytokines affected risk of any COVID-19 (laboratory confirmed, physician confirmed or self-reported, 36,590 cases, 1,668,938 controls), and conversely if genetic risk of liability to any COVID-19 affected these cytokines (n ≤ 8293) using the most recent genome-wide association studies. We obtained inverse variance weighting (IVW) estimates, conducted sensitivity analyses and used a Benjamini-Hochberg correction to account for multiple comparisons. We also assessed whether any findings were evident for hospitalized COVID-19 (hospitalized laboratory confirmed, 12,888 cases, 1,295,966 controls).

RESULTS

Macrophage inflammatory protein-1β (MIP1b; more commonly known as Chemokine (C-C motif) ligands 4 (CCL4) was inversely associated with COVID-19 [odds ratio (OR) 0.97 per SD, 95% confidence interval (CI) 0.96-0.99] but not after adjustment for multiple comparisons. This finding replicated for hospitalized COVID-19 (OR 0.93, 95% CI 0.89-0.98). Liability to any COVID-19 was nominally associated with several cytokines, such as granulocyte colony-stimulating factor (GCSF) and hepatocyte growth factor (HGF) but not after correction.

CONCLUSION

A crucial element of immune response to infection (CCL4) was related to COVID-19, whether it is a target of intervention to prevent COVID-19 warrants further investigation.

A Proposed Framework for Identifying Nutrients and Food Components of Public Health Relevance in the Dietary Guidelines for Americans

BACKGROUND

Identification of nutrients of public health concern has been a hallmark of the Dietary Guidelines for Americans (DGA); however, a formal systematic process for identifying them has not been published.

OBJECTIVES

We aimed to propose a framework for identifying "nutrients or food components" (NFCs) of public health relevance to inform the DGA.

METHODS

The proposed framework consists of 1) defining terminology; 2) establishing quantitative thresholds to identify NFCs; and 3) examining national data. The proposed framework utilizes available data from 3 key data sources or "prongs": 1) dietary intakes; 2) biological endpoints; and 3) clinical health consequences such as prevalence of health conditions, directly or indirectly through validated surrogate markers.

RESULTS

In identifying potential NFCs of public health concern, the 2020 DGA Committee developed a decision-tree framework with suggestions for combining the 3 prongs. The identified NFCs of public health concern for Americans ≥1 y old included fiber, calcium (≥2 y old), vitamin D, and potassium for low intakes and sodium, added sugars, and saturated fats (≥2 y old) for high intakes that were associated with adverse health consequences. Iron was identified among infants ages 6-12 mo fed human milk. For reproductive-aged and pregnant females, iron (all trimesters) and folate (first trimester) were identified for low intake, based on dietary and biomarker data (iron) or the severity of the consequence (folic acid and neural tube defects). Among pregnant women, low iodine was of potential public health concern based on biomarker data. Other NFCs that were underconsumed, overconsumed, and pose special challenges were identified across the life course.

CONCLUSIONS

The proposed decision-tree framework was intended to streamline and add transparency to the work of this and future Dietary Guidelines Advisory Committees to identify NFCs that need to be encouraged or discouraged in order to help reduce risk of chronic disease and promote health and energy balance in the population.

Discovery and application of dietary compounds to optimize human health, a focus on skeletal muscle regeneration

Worldwide, the number of persons over the age of 65 years and those at risk of malnutrition (over and under) is growing, and the prevalence of diet-related chronic disease is at a record high. Pathologies that are linked to poor nutrition underlie the leading causes of death. Safe and effective strategies to improve human health outcomes are urgently required. Identification of nutrient needs for health outcomes has led to the development of food products, supplements, and dietary pattern recommendations. Application of these nutrient-based therapies have the potential to optimize clinical outcomes, such as tissue regeneration post-skeletal muscle trauma. However, despite progress in identifying nutrient needs there is often a delay in the utilization of products in clinical practice.

Dietary Reference Intakes based on chronic disease endpoints: outcomes from a case study workshop for omega 3's EPA and DHA

Given the focus on developing Dietary Reference Intakes (DRIs) based on chronic disease risk reduction and recent research for omega-3 long chain PUFA since the last DRI review, the Canadian Nutrition Society convened a panel of stakeholders for a 1-day workshop in late 2019. Attendees discussed the new NASEM guidelines for establishing DRI values based on chronic disease risk endpoints and the strength of current evidence for EPA and DHA as it relates to the new guidelines. Novelty: Summarizes evidence and expert opinions regarding the potential for reviewing DRI values for EPA and DHA and cardiovascular disease risk and early development.

Approaches to Defining Healthy Diets: A Background Paper for the International Expert Consultation on Sustainable Healthy Diets

Background:

Healthy diets promote optimal growth and development and prevent malnutrition in all its forms, including undernutrition, obesity, and diet-related noncommunicable diseases (NCDs).

Objective:

This background paper for the International Expert Consultation on Sustainable Healthy Diets characterizes healthy diets and their implications for food system sustainability.

Methods:

Three complementary approaches to defining healthy diets are compared: World Health Organization (WHO) guidelines or recommendations developed between 1996 and 2019; 2017 Global Burden of Disease (GBD) risk factor study estimates of diet-related risk–outcome associations; and analyses associating indices of whole dietary patterns with health outcomes in population studies and clinical trials.

Results:

World Health Organization dietary recommendations are global reference points for preventing undernutrition and reducing NCD risks; they emphasize increasing intakes of fruits, vegetables (excepting starchy root vegetables), legumes, nuts, and whole grains; limiting energy intake from free sugars and total fats; consuming unsaturated rather than saturated or trans fats; and limiting salt intake. Global Burden of Disease findings align well with WHO recommendations but include some additional risk factors such as high consumption of processed meat; this approach quantifies contributions of diet-related risks to the NCD burden. Evidence on whole dietary patterns supports WHO and GBD findings and raises concerns about potential adverse health effects of foods with high levels of industrial processing.

Conclusions:

Implied shifts toward plant foods and away from animal foods (excepting fish and seafood), and for changes in food production systems have direct relevance to the sustainability agenda.

Biomarker-estimated flavan-3-ol intake is associated with lower blood pressure in cross-sectional analysis in EPIC Norfolk

Flavan-3-ols are a group of bioactive compounds that have been shown to improve vascular function in intervention studies. They are therefore of great interest for the development of dietary recommendation for the prevention of cardio-vascular diseases. However, there are currently no reliable data from observational studies, as the high variability in the flavan-3-ol content of food makes it difficult to estimate actual intake without nutritional biomarkers. In this study, we investigated cross-sectional associations between biomarker-estimated flavan-3-ol intake and blood pressure and other CVD risk markers, as well as longitudinal associations with CVD risk in 25,618 participants of the European Prospective Investigation into Cancer (EPIC) Norfolk cohort. High flavan-3-ol intake, achievable as part of an habitual diet, was associated with a significantly lower systolic blood pressure (- 1.9 (- 2.7; - 1.1) mmHg in men and - 2.5 (- 3.3; - 1.8) mmHg in women; lowest vs highest decile of biomarker), comparable to adherence to a Mediterranean Diet or moderate salt reduction. Subgroup analyses showed that hypertensive participants had stronger inverse association between flavan-3-ol biomarker and systolic blood pressure when compared to normotensive participants. Flavanol intake could therefore have a role in the maintenance of cardiovascular health on a population scale.

Knowledge gaps in understanding the metabolic and clinical effects of excess folates/folic acid: a summary, and perspectives, from an NIH workshop

Folate, an essential nutrient found naturally in foods in a reduced form, is present in dietary supplements and fortified foods in an oxidized synthetic form (folic acid). There is widespread agreement that maintaining adequate folate status is critical to prevent diseases due to folate inadequacy (e.g., anemia, birth defects, and cancer). However, there are concerns of potential adverse effects of excess folic acid intake and/or elevated folate status, with the original concern focused on exacerbation of clinical effects of vitamin B-12 deficiency and its role in neurocognitive health. More recently, animal and observational studies have suggested potential adverse effects on cancer risk, birth outcomes, and other diseases. Observations indicating adverse effects from excess folic acid intake, elevated folate status, and unmetabolized folic acid (UMFA) remain inconclusive; the data do not provide the evidence needed to affect public health recommendations. Moreover, strong biological and mechanistic premises connecting elevated folic acid intake, UMFA, and/or high folate status to adverse health outcomes are lacking. However, the body of evidence on potential adverse health outcomes indicates the need for comprehensive research to clarify these issues and bridge knowledge gaps. Three key research questions encompass the additional research needed to establish whether high folic acid or total folate intake contributes to disease risk. 1) Does UMFA affect biological pathways leading to adverse health effects? 2) Does elevated folate status resulting from any form of folate intake affect vitamin B-12 function and its roles in sustaining health? 3) Does elevated folate intake, regardless of form, affect biological pathways leading to adverse health effects other than those linked to vitamin B-12 function? This article summarizes the proceedings of an August 2019 NIH expert workshop focused on addressing these research areas.

Emerging Concepts in Nutrient Needs

Dietary reference intakes (DRIs) are quantitative, nutrient intake-based standards used for assessing the diets and specific nutrient intakes of healthy individuals and populations and for informing national nutrition policy and nutrition programs. Because nutrition needs vary by age, sex, and physiological state, DRIs are often specified for healthy subgroups within a population. Diet is known to be the leading modifiable risk factor for chronic disease, and the prevalence of chronic disease is growing in all populations globally and across all subgroups, but especially in older adults. It is known that nutrient needs can change in some chronic disease and other clinical states. Disease states and/or disease treatment can cause whole-body or tissue-specific nutrient depletion or excess, resulting in the need for altered nutrient intakes. In other cases, disease-related biochemical dysfunction can result in a requirement for a nonessential nutrient, rendering it as conditionally essential, or result in toxicity for a food component at levels usually tolerated by healthy people, as seen in inborn errors of metabolism. Here we summarize examples from a growing body of literature of disease-altering nutrient requirements, supporting the need to give more consideration to special nutrient requirements in disease states.

Combination Therapy for Treatment of Spasticity in Stroke Patients: A Case Study

BACKGROUND AND PURPOSE

Spasticity is a disorder of sensory-motor control that appears as an effect of a lesion in the upper motor neuron and demonstrates sustained or intermittent unintentional muscle activation. Many treatment interventions exist to treat spasticity, and in this study, three of them were combined: vibration, static positioning and transcutaneous nerve stimulation (TENS). Evidence exists regarding the application of each intervention per se, but not in combination. Hence, the aim of the study is to present an innovative treatment approach for spasticity and show the effects it produced on one patient.

METHODS

The study was a case report. The subject was a 31-year-old male patient who had ischemic stroke a year ago. He demonstrated severe plantar flexion of the left foot due to spasticity. There was a baseline assessment and measurement, one on the end of the intervention (10^th week) and a follow-up 8 months after it. Assessment and measurement tools: a dynamic gait analysis on the treadmill by Zebris FDM-T system, electromyography testing (F-wave parameter and stretch reflex activity), the Modified Ashworth Scale (MAS), a standard goniometer, the Motricity index (MI) leg score and a pain dichotomous when stretching and while at rest.

INTERVENTION

The intervention lasted 10 weeks, 5 days per week for 30 minutes. The patient was standing on a 30-degree-inclination wedge. The wedge was positioned on a whole-body vibrator set to vibrate with 91Hz of frequency and 1.0mm amplitude. TENS was offered through surface electrodes which were placed on the tibialis anterior and triceps surae muscles, along the sural nerve (impulse frequency: 100Hz, pulse width: 250μs, intensity: 30mA).

RESULTS

The range of motion and the MI was increased and the swing-phase of the right foot as well as the standing-phase of the left foot were increased an hour after the intervention. The results were slightly diminished a day and a week after the intervention but a statistically significant improvement still remained.

CONCLUSION

Combination therapy intervention could offer an alternative for treating spasticity. Further studies are needed to establish a treatment protocol and maybe combine other spasticity-centered treatment modalities in order to produce new interventions.

Is a Healthy Diet Also Suitable for the Prevention of Fragility Fractures?

Osteoporosis and sarcopenia contribute to the risk of fracture in the population. These conditions share common features, and it is known that a healthy diet may have beneficial effects on both, theoretically resulting in fewer fractures. The present narrative review gives an overview of recent epidemiological research related to the association between healthy diets/dietary patterns, bone health and fragility fractures. The review also gives a brief overview on general dietary recommendations and advice as the cornerstone of public health nutrition. Although muscle health and sarcopenia contribute to the risk of fractures, these endpoints were not the focus of this review. Healthy diets are nutrient dense and contain bioactive components that are needed for the constant remodeling of the skeleton and to slow the rate of bone loss and muscle wasting, thus contributing to the prevention of fragility fractures. Compliance with healthy dietary patterns were predominantly found to be inversely associated with bone outcomes, although this was not entirely consistent across all studies. Different a priori diet scores, such as the Mediterranean diet score and the Dietary Inflammatory Index, as well as a posteriori data driven dietary patterns, such as the prudent or healthy dietary pattern, were inversely associated with fragility fractures in different populations. In conclusion, different healthy dietary patterns may contribute to bone health and less fractures. Following current dietary guidelines is thus advisable for the prevention of fragility fractures.

Critical Analysis of Non-Thermal Plasma-Driven Modulation of Immune Cells from Clinical Perspective

The emerged field of non-thermal plasma (NTP) shows great potential in the alteration of cell redox status, which can be utilized as a promising therapeutic implication. In recent years, the NTP field considerably progresses in the modulation of immune cell function leading to promising in vivo results. In fact, understanding the underlying cellular mechanisms triggered by NTP remains incomplete. In order to boost the field closer to real-life clinical applications, there is a need for a critical overview of the current state-of-the-art. In this review, we conduct a critical analysis of the NTP-triggered modulation of immune cells. Importantly, we analyze pitfalls in the field and identify persisting challenges. We show that the identification of misconceptions opens a door to the development of a research strategy to overcome these limitations. Finally, we propose the idea that solving problems highlighted in this review will accelerate the clinical translation of NTP-based treatments.

Critically Appraised Topics (CATs) in Veterinary Medicine: Applying Evidence in Clinical Practice

Critically appraised topics (CATs) are evidence syntheses that provide veterinary professionals with information to rapidly address clinical questions and support the practice of evidence-based veterinary medicine (EBVM). They also have an important role to play in both undergraduate and post-registration education of veterinary professionals, in research and knowledge gap identification, literature scoping, preparing research grants and informing policy. CATs are not without limitations, the primary one relating to the rapid approach used which may lead to selection bias or restrict information identified or retrieved. Furthermore, the narrow focus of CATs may limit applicability of the evidence findings beyond a specific clinical scenario, and infrequently updated CATs may become redundant. Despite these limitations, CATs are fundamental to EBVM in the veterinary profession. Using the example of a dog with osteoarthritis, the five steps involved in creating and applying a CAT to clinical practice are outlined, with an emphasis on clinical relevance and practicalities. Finally, potential future developments for CATs and their role in EBVM, and the education of veterinary professionals are discussed. This review is focused on critically appraised topics (CATs) as a form of evidence synthesis in veterinary medicine. It aims to be a primary guide for veterinarians, from students to clinicians, and for veterinary nurses and technicians (hereafter collectively called veterinary professionals). Additionally, this review provides further information for those with some experience of CATs who would like to better understand the historic context and process, including further detail on more advanced concepts. This more detailed information will appear in pop-out boxes with a double-lined surround to distinguish it from the information core to producing and interpreting CATs, and from the boxes with a single line surround which contain additional resources relevant to the different parts of the review.

The Nordic Nutrition Recommendations 2022 - handbook for qualified systematic reviews

BACKGROUND

Systematic reviews (SRs) constitute a major part of the Nordic Nutrition Recommendations (NNRs). The step-by-step procedure used to develop SRs has evolved considerably over time and is often tailored to fit the exposure and outcomes in focus.

OBJECTIVE

To describe a detailed procedure for developing qualified SRs commissioned by the NNR2022 project.

DESIGN

Scrutinizing procedures of recent SRs commissioned by leading national food and health authorities or international food and health organizations.

RESULTS

The following eight steps must be included when developing qualified SRs for the NNR2022 project: 1) define research question, 2) protocol development, 3) literature search, 4) screening and selection of studies, 5) data extraction, 6) assessing risk of bias, 7) synthesis and grading of total strength of evidence, and 8) reporting according to certain standards.

DISCUSSION

This guide is based on the guidelines developed for the fifth edition of NNR but includes some important new domains in order to adhere to more recent, authoritative standards.

CONCLUSION

All qualified SRs in the NNR2022 project will follow the protocol described here.

The Nordic Nutrition Recommendations 2022 - structure and rationale of qualified systematic reviews

BACKGROUND

Qualified systematic reviews (SRs) will form the main basis for evaluating causal effects of nutrients or food groups on health outcomes in the sixth edition of Nordic Nutrition Recommendations to be published in 2022 (NNR2022).

OBJECTIVE

To describe rationale and structure of SRs used in NNR2022.

DESIGN

The SR methodologies of the previous edition of NNR were used as a starting point. Methodologies of recent SRs commissioned by leading national food and health authorities or international food and health organizations were examined and scrutinized. Methodologies for developing SRs were agreed by the NNR2022 Committee in a consensus-driven process.

RESULTS

Qualified SRs will be developed by a cross-disciplinary group of experts and reported according to the requirements of the EQUATOR network. A number of additional requirements must also be fulfilled, including 1) a clearly stated set of objectives and research questions with pre-defined eligibility criteria for the studies, 2) an explicit, reproducible methodology, 3) a systematic search that attempts to identify all studies that would meet the eligibility criteria, 4) an assessment of the validity of the findings of the included studies through an assessment of 'risk of bias' of the studies, 5) a systematic presentation and synthesis of the characteristics and findings of the included studies, and 6) a grading of the overall evidence. The complete definition and requirements of a qualified SR are described.

DISCUSSION

Most SRs published in scientific journals do not fulfill all criteria of the qualified SRs in the NNR2022 project. This article discusses the structure and rationale for requirements of qualified SRs in NNR2022. National food and health authorities have only recently begun to use qualified SRs as a basis for nutrition recommendations.

CONCLUSION

Qualified SRs will be used to inform dietary reference values (DRVs) and food-based dietary guidelines (FBDGs) in the NNR2022 project.

The clinical utility of combinatorial pharmacogenomic testing for patients with depression: a meta-analysis

Aim: To perform a meta-analysis of prospective, two-arm studies examining the clinical utility of using the combinatorial pharmacogenomic test, GeneSight Psychotropic, to inform treatment decisions for patients with major depressive disorder (MDD). Patients & methods: The pooled mean effect of symptom improvement and pooled relative risk ratio (RR) of response and remission were calculated using a random effect model. Results: Overall, 1556 patients were included from four studies, with outcomes evaluated at week 8 or week 10. Patient outcomes were significantly improved for patients with MDD whose care was guided by the combinatorial pharmacogenomic test results compared with unguided care (symptom improvement Δ = 10.08%, 95% CI: 1.67-18.50; p = 0.019; response RR = 1.40, 95% CI: 1.17-1.67; p < 0.001; remission RR = 1.49, 95% CI: 1.17-1.89; p = 0.001). Conclusion: GeneSight Psychotropic guided care improves outcomes among patients with MDD.

The Effects of Private Health Insurance on Universal Health Coverage Objectives in China: A Systematic Literature Review

BACKGROUND

We conducted a systematic review on the role of private health insurance to complement the social health insurance system towards achieving universal health coverage in China. This review presents the impacts of private health insurance on expanding coverage, increasing access to healthcare, and financial protection.

METHODS

A systematic review was conducted by searching peer-reviewed articles published between January 2000 and March 2018 in Web of Science, PubMed, and China Knowledge Resource Integrated Database. The search terms included coverage prevalence, access and financial protection related to private health insurance in China. A total of 31 studies were selected.

RESULTS

Coverage prevalence of private health insurance gradually increased but it was unequally distributed across regions and populations. The expansion of social health insurance has enhanced the total aggregate premium of private health insurance but has had a mixed impact on the take-up of private health insurance. Private insurance beneficiaries were found to limit their utilisation of healthcare services and there was no evidence that it ensured financial protection.

CONCLUSION

The role of private health insurance (PHI) in extending universal health coverage in China was limited and therefore should not be overstated.

The Effects of Private Health Insurance on Universal Health Coverage Objectives in China: A Systematic Literature Review

BACKGROUND

We conducted a systematic review on the role of private health insurance to complement the social health insurance system towards achieving universal health coverage in China. This review presents the impacts of private health insurance on expanding coverage, increasing access to healthcare, and financial protection.

METHODS

A systematic review was conducted by searching peer-reviewed articles published between January 2000 and March 2018 in Web of Science, PubMed, and China Knowledge Resource Integrated Database. The search terms included coverage prevalence, access and financial protection related to private health insurance in China. A total of 31 studies were selected.

RESULTS

Coverage prevalence of private health insurance gradually increased but it was unequally distributed across regions and populations. The expansion of social health insurance has enhanced the total aggregate premium of private health insurance but has had a mixed impact on the take-up of private health insurance. Private insurance beneficiaries were found to limit their utilisation of healthcare services and there was no evidence that it ensured financial protection.

CONCLUSION

The role of private health insurance (PHI) in extending universal health coverage in China was limited and therefore should not be overstated.

Ready-to-eat cereal fortification: a modelling study on the impact of changing ready-to-eat cereal fortification levels on population intake of nutrients

OBJECTIVE

Ready-to-eat (RTE) cereal is an important source of nutrients in the American diet. Recent regulatory changes to labelling requirements may impact the fortification of RTE cereal. We used an evidence-based approach to optimize the fortification of RTE cereal considering current dietary patterns and nutrition policy.

DESIGN

A US modelling study of cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2013-2014. The percentage of the population below the Estimated Average Requirement (EAR) and above the Upper Tolerable Intake Level (UL) was modelled under three scenarios: baseline, zero fortification and optimized fortification.

SETTING

USA.

PARTICIPANTS

Toddlers aged 1-3 years, n 559; children aged 4-12 years, n 1540; adolescents aged 13-18 years, n 992; and adults aged ≥19 years, n 576.

RESULTS

Comparing current with optimized fortification, nutrient/100 g RTE cereal decreased for vitamin A, thiamin, riboflavin, niacin, vitamin B6, folic acid, vitamin B12, Ca and Fe (by 2-82 %). The amount of vitamins C and D increased (by 13 and 50 %, respectively). Among RTE cereal eaters, these changes resulted in modest increases in the percentage of the population aged ≥1 year below the EAR (+0·5 to +11·5 percentage points). Decreases were observed in the percentage of the population above the UL.

CONCLUSIONS

Fortification of RTE cereal can be optimized to provide key nutrients and minimize the percentage of the population below the EAR and above the UL. Dietary intake modelling is useful to ensure that RTE cereal continues to help the population meet their nutrient needs.

Combinations of Epidemiological and Experimental Studies in Air Pollution Research: A Narrative Review

Scientific literature is evolving to include more systematic reviews that encompass epidemiological and experimental papers so that the whole picture can be examined. The aim of this narrative review is to bridge that gap by combining epidemiological and experimental studies based on the same setting: Examples of Bitterfeld, Utah Valley, Beijing Olympic Games, and Viadana. This review looks at four examples that incorporate multiple epidemiological and experimental papers about air pollution exposure and health effects. The Bitterfeld (spatial) and Utah Valley (temporal) examples showed that particle composition causes the biggest difference in lung injury. In Beijing, a temporal difference of before/after and during the Olympics showed that traffic and industry air pollution-related health effects like lung cancer and cardiovascular disease could be reduced by improvement of air quality. The Viadana example showed a spatial difference in respiratory injury caused by particle composition and interactions with genotoxicity. Combining experimental and epidemiological methods gives a more in-depth look into the whole picture of exposure and health effects. Our review exemplifies the strength of this strategy and encourages further use of it.

Effects of dietary RRR α-tocopherol vs all-racemic α-tocopherol on health outcomes

Of the 8 vitamin E analogues, RRR α-tocopherol likely has the greatest effect on health outcomes. Two sources of α-tocopherol, naturally sourced RRR α-tocopherol and synthetic all-racemic α-tocopherol, are commonly consumed from foods and dietary supplements in the United States. A 2016 US Food and Drug Administration ruling substantially changed the RRR to all-racemic α-tocopherol ratio of biopotency from 1.36:1 to 2:1 for food-labeling purposes, but the correct ratio is still under debate in the literature. Few studies have directly compared the 2 α-tocopherol sources, and existing studies do not compare the efficacy of either source for preventing or treating disease in humans. To help close this gap, this review evaluates studies that investigated the effects of either RRR α-tocopherol or all-racemic α-tocopherol on health outcomes, and compares the overall findings. α-Tocopherol has been used to prevent and/or treat cancer and diseases of the central nervous system, the immune system, and the cardiovascular system, so these diseases are the focus of the review. No firm conclusions about the relative effects of the α-tocopherol sources on health outcomes can be made. Changes to α-tocopherol-relevant policies have proceeded without adequate scientific support. Additional research is needed to assemble the pieces of the α-tocopherol puzzle and to determine the RRR to all-racemic α-tocopherol ratio of biopotency for health outcomes.

Dietary Quality Assessed by the HEI-2010 and Biomarkers of Cardiometabolic Disease: An Exploratory Analysis

Objectives: This study explores relationships between cardiometabolic measures of antioxidant capacity or inflammation and diet quality assessed by the Healthy Eating Index (HEI)-2010 which measures conformity to Dietary Guidelines for Americans. This cross-sectional study was an ancillary analysis of baseline data for a randomized controlled trial with older adults at risk for cardiometabolic disease (ClinicalTrials.gov #NCT00955903). Methods: Community-dwelling older adults (n = 133, 49% male, 70.4 ± 4.8 years) with a body mass index of 30-40 kg/m² provided a fasted blood sample for measurement of antioxidant capacity, high-sensitivity C-reactive protein, tumor necrosis factor-alpha, and interleukin-6. Dietary data were generated from the mean of three 24-hour recalls. Results: After adjustment for potential confounders, HEI-2010 composite scores were not significantly associated with decreased inflammation or greater antioxidant capacity. In analysis of the 12 components composing the HEI-2010, significant positive association was observed between total dairy and total serum antioxidant capacity (0.043; 95% CI, 0.008-0.069). Significant associations observed in inflammatory markers were between total vegetable and tumor necrosis factor-alpha (-0.078; 95% CI, -0.151 to -0.005), sodium and interleukin-6 (0.091; 95% CI, 0.023-0.158), and scores for combined calories from solid fats, alcoholic beverages, and added sugars and interleukin-6 (0.139; 95% CI, 0.027-0.252). In models adjusting for HEI-2010 composite score when significant associations were observed between component scores and biomarkers, two of six associations were strengthened by adding the composite score as a potential confounder. Conclusions: Largely null findings along with those inconsistent with scientific expectations suggest caution in extrapolating adherence to the HEI-2010 with an individual's inflammatory or antioxidant status. Results merit additional investigation with other biomarkers of chronic disease and emphasis on dietary patterns given potential synergy within food combinations.

Milestones in DRI Development: What Does the Future Hold?

The state of nutritional health in the United States in the early part of the twentieth century was very different from today. Nutrient deficiencies and dental caries were prevalent health concerns for many Americans. In 1940, the US National Defense Advisory Commission asked the National Academy of Sciences for help in studying problems of nutrition in the United States. The outcome was issuance of the first RDAs. The goal of the RDAs was to recommend "…allowances sufficiently liberal to be suitable for maintenance of good nutritional status." In the subsequent decades, a very different nutritional health challenge began to emerge for an increasing proportion of the population, that of overweight and obesity and risk of diet-related chronic disease. In part, as a response to this challenge, the RDA process was revised and the Dietary Reference Intakes (DRIs) were developed. The DRIs are a set of reference values that, when adhered to, predict a low probability of nutrient inadequacy or excessive intake. Recently, new DRI guidelines were proposed to define reference points for nutrient and food component intakes that influence risk of chronic disease. Developing DRIs for chronic disease endpoints presents unique challenges, notably, chronic diseases are multifactorial in nature and not directly nutrient-specific; the body of evidence supporting nutrients and other food substances as modifiers of risk of chronic disease is generally limited; and there is a lack of consistency in findings across study types. In addition, the latency of dietary exposures and chronic disease outcomes makes it difficult to demonstrate causality. Adapting the DRI model to meet the needs of the general population in the current context suggests a need to redefine the boundaries that describe the health of the population and to re-examine how indicators of chronic disease can be integrated effectively into the DRI process.