The Relationship of Circulating Choline and Choline-Related Metabolite Levels with Health Outcomes: A Scoping Review of Genome-Wide Association Studies and Mendelian Randomization Studies

Choline is essential for proper liver, muscle, brain, lipid metabolism, cellular membrane composition, and repair. Understanding genetic determinants of circulating choline metabolites can help identify new determinants of choline metabolism, requirements, and their link to disease endpoints. We conducted a scoping review to identify studies assessing the association of genetic polymorphisms on circulating choline and choline-related metabolite concentrations and subsequent associations with health outcomes. This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement scoping review extension. Literature was searched to September 28, 2022, in 4 databases: Embase, MEDLINE, Web of Science, and the Biological Science Index. Studies of any duration in humans were considered. Any genome-wide association study (GWAS) investigating genetic variant associations with circulating choline and/or choline-related metabolites and any Mendelian randomization (MR) study investigating the association of genetically predicted circulating choline and/or choline-related metabolites with any health outcome were considered. Qualitative evidence is presented in summary tables. From 1248 total reviewed articles, 53 were included (GWAS = 27; MR = 26). Forty-two circulating choline-related metabolites were tested in association with genetic variants in GWAS studies, primarily trimethylamine N-oxide, betaine, sphingomyelins, lysophosphatidylcholines, and phosphatidylcholines. MR studies investigated associations between 52 total unique choline metabolites and 66 unique health outcomes. Of these, 47 significant associations were reported between 16 metabolites (primarily choline, lysophosphatidylcholines, phosphatidylcholines, betaine, and sphingomyelins) and 27 health outcomes including cancer, cardiovascular, metabolic, bone, and brain-related outcomes. Some articles reported significant associations between multiple choline types and the same health outcome. Genetically predicted circulating choline and choline-related metabolite concentrations are associated with a wide variety of health outcomes. Further research is needed to assess how genetic variability influences choline metabolism and whether individuals with lower genetically predicted circulating choline and choline-related metabolite concentrations would benefit from a dietary intervention or supplementation.

Chewing Gum Is Associated with Better Diet Quality but Not Oral Health Measures in U.S. Adults

Objective: Chewing gum (especially sugar-free gum) has been linked to improved oral health, however there is an absence of observational research using nationally-representative data in the United States. We sought to examine the factors associated with chewing gum and its relationship with the oral health status of U.S. adults.Methods: Cross-sectional data from the U.S. National Health and Nutrition Examination Survey (NHANES) 2013-2018 cycles were used in these analyses. Primary outcomes were the odds of having gum disease, treatment for gum disease, ever being told of bone loss around teeth, root caries, caries, and restoration. Unadjusted and multivariate logistic regression models were used to investigate the relationship of chewing gum use with demographic/lifestyle factors and the oral health status of participants.Results: 2.40% (n = 365) of adults were users of chewing gum and the average among users was 5.20 ± 0.40 g/d. Users of chewing gum were more likely to be female, younger in age, and non-Hispanic Black or Hispanic. Self-reported chewing gum use did not affect the oral health status of U.S. adults (OR: 1.10, 95% CI: 0.42-2.88 for gum disease; OR: 1.34, 95% CI: 0.64-2.81 for treatment for gum disease; OR: 0.56, 95% CI: 0.27-1.17 for bone loss around teeth; OR: 1.01, 95% CI: 0.32-3.12 for root caries; OR: 0.96, 95% CI: 0.54-1.69 for caries), except for restoration (OR: 3.54, 95% CI: 1.78-7.06), but was associated with improved diet quality (OR: 1.86, 95% CI: 1.11-3.12 for a healthy eating index (HEI) of 51-59; OR: 1.96, 95% CI: 1.08-3.56 for HEI of 60-93); and decreased intakes of snacks (OR: 1.64, 1.01-2.69), and added sugars.Conclusion: Future observational studies that more accurately capture chewing gum usage are needed, as these analyses have several limitations.

Defining "low-carb" in the scientific literature: A scoping review of clinical studies

There remains a lack of scientific consensus on what level of carbohydrate intake constitutes low-carbohydrate diets. We conducted a scoping review to understand how low-carbohydrate diets were defined in the peer-reviewed literature. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement scoping review extension. Three electronic databases were searched for clinical studies in English. We identified 508 articles (317 randomized controlled, 99 cross-over, 33 before-and-after, 12 non-randomized, and 47 other clinical trials). Most examined effects of low-carbohydrate diets in healthy adults (62.4%), 40 to 59 years old (55.5%), with obesity or overweight (66.1%). The majority reported effects on weight or body composition (29.9%), diabetes (18.7%), or cardiovascular risk factors (12.9%) as primary outcomes. Most articles (56.9%) reported percent of energy from carbohydrates, and of those, 60.3% defined low-carbohydrate diets as being ≤30% of energy from carbohydrates. Some articles (22.9%) reported grams of carbohydrates per day, and of those, most defined low-carbohydrate diets as being under ∼100 grams of carbohydrates per day. Systematic reviews and dose-response meta-regressions utilizing patient-level data on carbohydrate intake, status markers (e.g., RQ/ketones), and health outcomes would be useful in informing consensus around a standardized definition.

Relationship between short-term self-reported dietary magnesium intake and whole blood ionized magnesium (iMg2+) or serum magnesium (s-Mg) concentrations

OBJECTIVE

Since we and others have shown that supplemental magnesium raises whole blood ionized magnesium (iMg²⁺) we investigated the relationships between self-reported dietary magnesium intake and concentrations of whole blood iMg²⁺ and serum magnesium (s-Mg).

METHODS

We obtained whole blood iMg²⁺ concentrations, as well as s-Mg concentrations, from a pilot, three-arm, randomized, controlled, crossover bioavailability study of magnesium supplements (n = 23; 105 measures). Dietary magnesium intake was assessed using three-day food records and the Nutrition Data System for Research (NDSR, University of Minnesota, MN, USA). Whole blood iMg²⁺ was measured with an electrode analyser (NOVA Biochemical, Waltham, MA, USA), whereas s-Mg was measured using atomic absorption spectroscopy. A linear mixed-effects model was employed with dietary magnesium as the outcome variable and iMg²⁺, s-Mg, study treatment and study visit as fixed effects. We adjusted age, gender, race and body mass index covariates.

RESULTS

Values for dietary magnesium, iMg²⁺ and s-Mg were 303.8 ± 118.9 mg/day, 1.3 ± 0.1 mg/dL and 2.2 ± 4.1 mg/dL, respectively. No association was found between dietary magnesium intake and iMg²⁺ -125 ± 176.95 (p = .49) or s-Mg -9.33 ± 5.04 (p = .08).

CONCLUSIONS

Whole blood iMg²⁺ and s-Mg concentrations do not reflect short-term self-reported dietary intake in adults. Further research is needed to determine whether blood biomarkers of magnesium may reflect dietary magnesium intake.Key messagesDietary intake of magnesium, a shortfall nutrient, may be objectively measured using blood biomarkers of magnesium.Serum magnesium and whole blood iMg²⁺ were not associated with short-term dietary intake of magnesium.

Comparison of the nutrient composition of eggs produced in the Guatemalan highlands during the wet and dry seasons

The potential of chicken eggs as a nutritionally complete protein and source of key micronutrients during the first 1000 days post-conception has been progressively recognized across the globe, particularly in resource-poor settings. Fluctuation of egg nutrient content by season is relatively unknown, which may influence international food composition databases and outcomes in intervention studies using egg supplementation. To better interpret the findings of The Saqmolo' Project, we conducted comprehensive nutrient analyses on eggs produced during the wet and dry seasons in the highlands of central Guatemala. We randomly collected 36 shell eggs from a local farm during both seasons, hard-boiled, and prepared them for transport to the United States, where they were pooled and assessed for their nutrient composition. Methods of the Association of Official Analytical Chemists, the American Oil Chemists Society, and the American Association of Cereal Chemists were utilized to determine total energy, moisture, ash, total protein, total fat, fatty acids, total carbohydrates, 12 vitamins, 11 minerals, and carotenoids, by season, in some instances with modifications. Differences in nutrient composition between de-shelled hard-boiled eggs collected between seasons were assessed using an analysis of variance (ANOVA) and Tukey's family error rate comparison test. Most nutrients in eggs produced in the highlands of central Guatemala differed negligibly (but statistically significantly) based on seasonality. Only vitamins A and E, folate, choline, and calcium fluctuated at clinically significant levels relative to the AI/RDA for infants 7-12 months. Total energy, protein, trans fatty acids, moisture, and vitamin D3 levels did not differ between seasons (p > .05). Further multi-year sampling is needed to examine how seasonal variation affects the nutrient composition of eggs. These data may be used to supplement existing national and regional food composition databases.

Systematic Review and Meta-Analysis to Estimate a Reference Range for Circulating Ionized Magnesium Concentrations in Adult Populations

BACKGROUND

There is a lack of consensus on a reference range for ionized magnesium (iMg2+) in blood as a measure of the status of circulating iMg2+ for the screening of populations.

OBJECTIVES

We estimated the reference range of iMg2+ levels for healthy adult populations and the ranges for populations with cardiovascular disease (CVD), type 2 diabetes, hypertension, and renal disease. We also estimated 95% ranges for circulating magnesium (Mg) in healthy and those with cardiometabolic diseases.

METHODS

We searched Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Embase through 24 July, 2020 to identify articles. We included English, peer-reviewed, randomized controlled trials, prospective and retrospective cohort studies, case-control studies, and cross-sectional studies that measured iMg2+ in blood or circulating Mg at baseline. The protocol was registered on PROSPERO (CRD42020216100). Estimated ranges were calculated by employing a frequentist random-effects model using extracted (or calculated) means and SDs from each included study. We determined the 95% confidence interval of the pooled mean.

RESULTS

A total of 95 articles were included with 53 studies having data for healthy participants and 42 studies having data for participants with cardiometabolic diseases. The estimated reference range for iMg2+ for healthy populations was 0.40-0.68 mmol/L, 0.38-0.64 mmol/L for CVD, 0.34-0.66 mmol/L for type 2 diabetes, 0.39-1.04 mmol/L for hypertension, and 0.40-0.76 mmol/L for renal disease. For circulating Mg, the estimated range was 0.72-1.0 mmol/L for healthy adults, 0.56-1.05 mmol/L for CVD, 0.58-1.14 mmol/L for type 2 diabetes, 0.60-1.08 mmol/L for hypertension, and 0.59-1.26 mmol/L for renal disease.

CONCLUSIONS

Estimated reference ranges for cardiometabolic disease states for both iMg2+ and circulating Mg were broad and overlapped with the estimated range for healthy populations (0.40-0.68 mmol/L). Further studies should evaluate whether iMg2+ can be used as a biomarker of cardiometabolic disease.

Consumption Patterns and the Nutritional Contribution of Total, Processed, Fresh, and Fresh-Lean Pork to the U.S. Diet

Pork has the potential to provide several macro and micronutrients to the diet, as it is a commonly consumed protein in the United States and across many cultures worldwide. There is an absence of clinical and observational studies that isolate the nutritional contribution of various types of pork intake from that of other red and/or processed meats. The objective of this study was to assess consumption patterns and the nutritional contribution of total, processed, fresh, and fresh-lean pork to the diets of participants aged 2+ years enrolled in the National Health and Nutrition Examination Survey (NHANES) 2007-2018 data cycles. The recent National Cancer Institute method was used to disaggregate fresh and processed pork intake from the USDA Food Patterns Equivalents Database. The mean intake of total pork among consumers was estimated to be 79.5 ± 0.82, 54.2 ± 0.69, 54.6 ± 0.93, and 45.9 ± 0.73, g/d for men, women, boys, and girls, respectively. Total pork consumption subtly increased intakes of total energy and several macro and micronutrients, decreased diet quality (HEI-2015) scores (adults only), and consumption of other "healthful" food groups. Only subtle but clinically insignificant effects of pork intake on biomarkers of nutritional status were shown. These trends were largely driven by processed pork consumption and the co-consumption of foods such as condiments. Increasing the availability and education around fresh-lean cuts may help to increase intake of protein and other key nutrients across certain subpopulations, without adversely affecting diet quality and biomarkers of health status.

Lactoferrin for Mental Health: Neuro-Redox Regulation and Neuroprotective Effects across the Blood-Brain Barrier with Special Reference to Neuro-COVID-19

Overall mental health depends in part on the blood-brain barrier, which regulates nutrient transfer in-and-out of the brain and its central nervous system. Lactoferrin, an innate metal-transport protein, synthesized in the substantia nigra, particularly in dopaminergic neurons and activated microglia is vital for brain physiology. Lactoferrin rapidly crosses the blood-brain barrier via receptor-mediated transcytosis and accumulates in the brain capillary endothelial cells. Lactoferrin receptors are additionally present on glioma cells, brain micro-vessels, and neurons. As a regulator of neuro-redox, microglial lactoferrin is critical for protection/repair of neurons and healthy brain function. Iron imbalance and oxidative stress are common among patients with neurodegenerative disorders such as Parkinson's disease, Alzheimer's disease, dementia, depression, and multiple sclerosis. As an endogenous iron-chelator, lactoferrin prevents iron accumulation and dopamine depletion in Parkinson's disease patients. Oral lactoferrin supplementation could modulate the p-Akt/PTEN pathway, reduce Aβ deposition, and ameliorate cognitive decline in Alzheimer's disease. Novel lactoferrin-based nano-therapeutics have emerged as effective drug-delivery systems for clinical management of neurodegenerative disorders. Recent emergence of the Coronavirus disease-2019 (COVID-19) pandemic, initially considered a respiratory illness, demonstrated a broader virulence spectrum with the ability to cross the blood-brain barrier and inflict a plethora of neuropathological manifestations in the brain - the Neuro-COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections are widely reported in Parkinson's disease, Alzheimer's disease, dementia, and multiple sclerosis patients with aggravated clinical outcomes. Lactoferrin, credited with several neuroprotective benefits in the brain could serve as a potential adjuvant in the clinical management of Neuro-COVID-19.

Association of Pork Intake with Cognitive Performance in Older Adults Enrolled in the National Health and Nutrition Examination Survey (NHANES), 2011-2014 Data Cycles

BACKGROUND

Pork provides higher levels of several nutrients important for cognitive maintenance in older adults. A pilot clinical study suggests the addition of moderate amounts of pork to a Mediterranean-style diet improves cognition in older adults. There is an absence of observational research that isolates effects of pork from other red meats.

OBJECTIVE

To examine the relationship of pork intake on cognitive performance in older adults.

METHODS

Cross-sectional data from the U.S. National Health and Nutrition Examination Survey (NHANES) 2011-2014 cycles were used in these analyses. Pork intake was assessed using data from two non-consecutive 24-h dietary recalls. Cognitive function was assessed by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Word Learning, CERAD Delayed Recall, Animal Fluency, and Digital Substitution tests. Statistical analyses were adjusted for sample weighting and survey design variables to account for the complex design. Student t-tests (continuous variables) and Pearson chi-squared tests (categorical variables) were employed to compare participant characteristics between the low and normal cognitive performance groups. Logistic regression was used to determine the relationship of pork intake (low, medium, and high) with prevalence of low cognitive performance, with the non-consumer group as the referent category.

RESULTS

Pork intake was not beneficially or detrimentally associated performance on the any of the cognitive tests in both the crude and multivariate models (p > 0.05).

CONCLUSIONS

Prospective cohort investigations and larger/longer-term clinical trials are needed to fully elucidate effects of pork intake on cognition in older adults.

Label compliance for ingredient verification: regulations, approaches, and trends for testing botanical products marketed for "immune health" in the United States

During the COVID-19 pandemic, the botanical product market saw a consumer interest increase in immune health supplements. While data are currently insufficient to support public health guidance for using foods and dietary supplements to prevent or treat COVID-19 and other immune disorders, consumer surveys indicate that immune support is the second-most cited reason for supplement use in the United States. Meanwhile, consumers showed increased attention to dietary supplement ingredient labels, especially concerning authenticity and ingredient claims. Top-selling botanical ingredients such as elderberry, turmeric, and functional mushrooms have been increasingly marketed toward consumers to promote immune health, but these popular products succumb to adulteration with inaccurate labeling due to the intentional or unintentional addition of lower grade ingredients, non-target plants, and synthetic compounds, partially due to pandemic-related supply chain issues. This review highlights the regulatory requirements and recommendations for analytical approaches, including chromatography, spectroscopy, and DNA approaches for ingredient claim verification. Demonstrating elderberry, turmeric, and functional mushrooms as examples, this review aims to provide industrial professionals and scientists an overview of current United States regulations, testing approaches, and trends for label compliance verification to ensure the safety of botanical products marketed for "immune health."

Association of Total, Added, and Natural Phosphorus Intakes with Biomarkers of Health Status and Mortality in Healthy Adults in the United States

The Western diet is high in dietary phosphorus, partially due to added phosphorus, (i.e., phosphates) predominantly present in processed food products. Elevated serum phosphate levels, otherwise known as hyperphosphatemia, have been associated with changes in health status, of note detrimental effects on cardiovascular and renal health. However, the extent to which highly absorbed added phosphorus contributes to these changes is relatively unknown, due to its poor characterization among food composition databases. Industry-provided data on phosphorus source ingredients and ranges of added phosphorus present in food categories to enable a more accurate estimation of the total, added, and natural phosphorus intakes in the U.S. population. Using regression analyses, we then assessed relationships between estimated total, added, and natural phosphorus intakes on biomarkers of health status and mortality in individuals enrolled in the National Health and Nutrition Examination Survey (NHANES) 1988-1994 and 2001-2016 datasets. Total, added, and natural phosphorus intakes were associated with several biomarkers of health status. Added phosphorus intake was consistently inversely associated with HDL cholesterol in both men and women, whereas naturally occurring phosphorus intake was inversely correlated with the risk of elevated blood pressure. However, in most cases, the predicted impact of increases in phosphorus intake would result in small percentage changes in biomarkers. No meaningful associations between phosphorus and mortality were found, but indications of a correlation between mortality with quintiles of naturally occurring phosphorus were present, depending on covariate sets used. The disparate results for natural and added phosphorus intakes within the current study provide increased support for updating current food composition databases to more accurately account for dietary phosphorus intake as total, naturally occurring, and added phosphorus.

Tea intake and cardiovascular disease: an umbrella review

Brewed tea (Camellia sinensis) is a major dietary source of flavonoids, in particular flavan-3-ols. Tea consumption has been suggested to be inversely associated with a decreased risk of cardiovascular disease (CVD). Several biological mechanisms support the inverse relationship between tea flavonoid intake and CVD risk. Given the recent accumulating evidence from various systematic reviews regarding the role of tea as a beverage in reducing CVD risk and severity, we conducted an umbrella review to describe and critically evaluate the totality of evidence to date. We searched the PubMed, Web of Science, Cochrane Database of Systematic Reviews, and BIOSIS databases for systematic reviews published between January 1, 2010 and February 22, 2020 reporting relationships between tea (C. sinensis) consumption and CVD mortality, CVD diagnosis or incidence, CVD events, stroke events, blood pressure, endothelial function, blood lipids and triglycerides, and inflammatory markers. Herein, we describe results from 23 included systematic reviews. Consistently consuming 2 cups of unsweet tea per day offers the right levels of flavonoids to potentially decrease CVD risk and its progression. This is supported by the consistency between a recent high-quality systematic review and dose-response meta-analyses of population-based studies demonstrating beneficial effects of consumption on CVD mortality, CVD events and stroke events and medium- to high-quality systematic reviews of intervention studies that further elucidate potential benefits on both validated (i.e., SBP, DBP, total cholesterol, and LDL-cholesterol) and emerging risk biomarkers of CVD (TNF-ɑ and IL-6). On the basis of this umbrella review, the consumption of tea as a beverage did not seem to be harmful to health; therefore, the benefits of moderate consumption likely outweigh risk. Future large, clinical intervention studies will provide better mechanistic insight with the ability to confirm the outcome effects shown across observational studies. The review protocol was registered on PROSPERO (https://www.crd.york.ac.uk/PROSPERO/) as CRD42020218159.KEY MESSAGESIt is reasonable to judge that 2 cups of unsweet tea per day has the potential to decrease CVD risk and progression due to its flavonoid content.The primary side effects of tea documented in human studies are hepatotoxicity and gastrointestinal disturbances (i.e., vomiting and diarrhea) after high-dose supplemental intake.Additional clinical research is needed to fully elucidate the effects of tea flavonoids on markers of CVD, as many studies were under-powered to detect changes.[Figure: see text].

Perspective: Estrogen and the Risk of Cognitive Decline: A Missing Choline(rgic) Link?

Factors that influence the risk of neurocognitive decline and Alzheimer's disease (AD) may provide insight into therapies for both disease treatment and prevention. While age is the most striking risk factor for AD, it is notable that the prevalence of AD is higher in women, representing two-thirds of cases. To explore potential underlying biological underpinnings of this observation, the intent of this article is to explore the interplay between cognitive aging and sex hormones, the cholinergic system, and novel hypotheses related to the essential nutrient, choline. Mechanistic evidence points toward estrogen's neuroprotective effects being strongly dependent on its interactions with the cholinergic system, a modulator of attentional functioning, learning, and memory. Estrogen has been shown to attenuate anticholinergic-induced impairments in verbal memory and normalize patterns of frontal and occipital cortex activation, resulting in a more "young adult" phenotype. However, similar to estrogen replacement's effect in cardiovascular diseases, its putative protective effects may be restricted to early postmenopausal women only, supportive of the "critical window hypothesis." Estrogen's impact on the cholinergic system may act both locally in the brain but also through peripheral tissues. Estrogen is critical for inducing endogenous choline synthesis via the phosphatidylethanolamine N-methyltransferase (PEMT) pathway of phosphatidylcholine (PC) synthesis. PEMT is dramatically induced in response to estrogen, producing not only a PC molecule and source of choline for the brain but also a key source of the long-chain omega-3 fatty acid, DHA. Herein, we highlight novel hypotheses related to hormone replacement therapy and nutrient metabolism aimed at directing future preclinical and clinical investigation.

Effects of 100% Orange Juice on Markers of Inflammation and Oxidation in Healthy and At-Risk Adult Populations: A Scoping Review, Systematic Review, and Meta-analysis

One hundred percent orange juice (OJ) has no added sugar, naturally contains flavonoids and ascorbic acid, and can modulate the body's oxidative and inflammatory systems. This scoping review, systematic review, and meta-analysis investigated associations between 100% OJ and markers of inflammation or oxidation in healthy adults and those at risk for chronic diseases. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and scoping review extension. Literature in English was searched to July 2021 in Embase and 4 Ovid platform databases. Clinical and observational studies of any duration were eligible. Cochrane Collaboration tools were used to assess the risk of bias in controlled trials. Strength of evidence was determined using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. The scoping review presents a qualitative synthesis of evidence in summary and results tables. Twenty-one interventional studies (16 controlled trials and 5 before-after studies) conducted in 307 healthy and 327 at-risk participants were included. Six common markers [C-reactive protein (CRP) or high-sensitivity CRP (hs-CRP), IL-6, TNF-α, malondialdehyde (MDA), oxidized LDL (oxLDL), and antioxidant capacity] measured across 16 studies were systematically reviewed, and results were synthesized narratively. Random-effects model meta-analyses were conducted on 10 studies reporting hs-CRP, IL-6, and/or MDA. After consuming 100% OJ, healthy and at-risk participants showed significantly lower IL-6 concentrations (pooled net difference: -1.51 pg/mL; 95% CI: -2.31, -0.70) and lower, but nonsignificant, hs-CRP (pooled net change: -0.58 mg/L; 95% CI: -1.22, 0.05) and MDA (crossover trials pooled net difference: -0.06 μmol/L; 95% CI: -0.19, 0.08). Findings suggest that 100% OJ may reduce inflammation, but results should be interpreted with caution due to moderate risk of bias, very low strength of evidence, and the low number of subjects. This study was registered on PROSPERO (https://www.crd.york.ac.uk/prospero/) as CRD42021235438.

Pork consumption and its relationship to human nutrition and health: a scoping review

Pork is a frequently consumed red meat that provides substantial amounts of energy, macronutrients, and micronutrients to the diet. Its role in human nutrition and health is controversial and a plethora of data exist in the peer-reviewed scientific literature. Therefore, we conducted a scoping review of clinical and population-based studies to assess the effects of pork consumption on human nutrition and health. Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Data were extracted from 86 studies, including 16 randomized controlled trials, 1 uncontrolled trial, 7 cohort studies, 4 nonrandomized controlled trials, 4 case-cohort and nested case-control studies, 33 case-control studies, and 21 cross-sectional studies. Intervention studies were conducted in healthy individuals and were short to moderate in duration. The effect of pork intake on patients’ nutrient status was the most commonly assessed outcome. The majority of observational studies assessed the effect of pork on cancer incidence, but no studies assessed the effects of pork on inflammation or oxidative stress. No interventional studies explored diabetes mellitus risk, and only one study assessed cancer risk associated with pork consumption. Several micronutrients in pork, including zinc, iron, selenium, choline, thiamin, and vitamins B6 and vitamin B12, are thought to influence cognitive function and may prove to be a unique area of research. To date, there is a dearth of high-quality randomized controlled trials assessing the effects of pork intake on disease risk factors and outcomes. This review helps highlight the many research gaps that future studies should be designed to address.

Safety of Using Enteral Nutrition Formulations Containing Dietary Fiber in Hospitalized Critical Care Patients: A Systematic Review and Meta-Analysis

Enteral nutrition (EN) is the preferred route of nutrition support for patients with critical illness undergoing intensive care. Experts in the field caution against using fiber during EN because of perceived adverse patient outcomes; however, a comprehensive assessment of this topic is not evident to date. In this systematic review and meta-analysis, we searched four databases from inception to April 20, 2020, for studies on adverse events or health outcomes associated with using EN formulations containing fiber in hospitalized adults with critical illness. Nineteen articles were included. Random-effects meta-analysis models showed significantly lower diarrhea scores for fiber groups compared with nonfiber groups (pooled mean difference: -2.78; 95% CI, -4.10 to -1.47) but mixed results for risk of diarrhea between groups, depending on measures used for diarrhea (Hart and Dobb scale, pooled risk ratio [RR]: 0.68; 95% CI, 0.45-1.02; other diarrhea scales, pooled RR: 0.42; 95% CI, 0.20-0.89). Models showed 39% lower risk of gastrointestinal (GI) complications overall for fiber compared with nonfiber groups (pooled RR: 0.61; 95% CI, 0.47-0.79) but no group differences for individual GI complications, mortality, and intensive care unit or hospital length of stay. Analyses stratified by soluble- or mixed-fiber interventions reduced heterogeneity in models but showed identical conclusions. EN formulas with fiber may help reduce incidence and severity of diarrhea and GI complications overall in critically ill patients, without increased risk of other adverse events. Bias among specific GI measures indicates more high-quality studies are needed to verify these conclusions.

Nutrition care practice patterns for patients with COVID-19-A preliminary report

Background

Severe acute respiratory syndrome coronavirus 2 is a respiratory virus that poses risks to the nutrition status and survival of infected patients, yet there is paucity of data to inform evidence‐based quality care.

Methods

We collected data on the nutrition care provided to patients with coronavirus disease 2019 (COVID‐19) by registered dietitian nutritionists (RDNs).

Results

Hospitalized COVID‐19 patients (N = 101) in this cohort were older adults and had elevated body mass index. The most frequent nutrition problems were inadequate oral intake (46.7%), inadequate energy intake (18.9%), and malnutrition (18.4%). These problems were managed predominantly with enteral nutrition, food supplements, and multivitamin‐multimineral supplement therapy. Over 90% of documented problems required a follow‐up.

Conclusion

This data set is the first of its kind to report on the types of nutrition diagnoses and interventions for COVID‐19 cases used by RDNs and highlights the need for increased and continued nutrition care.

Results of an Online Survey about Food Insecurity and Eating Disorder Behaviors Administered to a Volunteer Sample of Self-Described LGBTQ+ Young Adults Aged 18 to 35 Years

BACKGROUND

There are few published studies addressing food insecurity and eating disorders in lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) individuals.

OBJECTIVE

The primary objective of this study was to describe the proportion of food insecurity and eating disorder behaviors in a volunteer sample of LGBTQ+ individuals aged 18 to 35 years.

DESIGN

This study was a cross-sectional analysis of questionnaire data collected from 253 participants between March 2018 and March 2019.

PARTICIPANTS AND SETTING

To be included in the study, participants had to be aged 18 to 35 years and identify as being LGBTQ+.

MAIN OUTCOME MEASURES

Food security score, Eating Attitudes Test score, Eating Disorder Examination Self-Report Questionnaire score, anxiety score (Beck), and depressive symptoms score.

STATISTICAL ANALYSES PERFORMED

The χ² test was used to analyze the categorical outcomes. One-way analysis of variance was used to compare continuous variables across gender identity groups. All P values < 0.05 were taken as statistically significant.

RESULTS

The proportion of participants identifying as a woman, trans male, gender nonconforming, and a man were 39%, 24%, 24%, and 13%, respectively. Food insecurity was reported by 54.4% of respondents with trans males reporting the highest proportions (64.8%). High levels of depressive symptoms were reported by 68.2% of men, 89.8% of women, 91.4% of trans males, and 95.5% of gender-nonconforming respondents (P = 0.009). High anxiety was reported by 20.5%. Eating Disorder Examination Self-Report Questionnaire scores were significantly higher (P < 0.001) compared with a community-based sample. The eating disorder behavior most frequently reported by respondents was binge eating. Only 4.3% reported having sought treatment for an eating disorder.

CONCLUSIONS

Members of the LGBTQ+ community are at greater risk for food insecurity, eating disorders, and depression, particularly those who identify as trans males. These findings denote the need to focus future research efforts on effective prevention and treatment strategies that are specific to sexual and gender identity groups within the LGBTQ+ community.

Combating COVID-19 and Building Immune Resilience: A Potential Role for Magnesium Nutrition?

Background: In December 2019, the viral pandemic of respiratory illness caused by COVID-19 began sweeping its way across the globe. Several aspects of this infectious disease mimic metabolic events shown to occur during latent subclinical magnesium deficiency. Hypomagnesemia is a relatively common clinical occurrence that often goes unrecognized since magnesium levels are rarely monitored in the clinical setting. Magnesium is the second most abundant intracellular cation after potassium. It is involved in >600 enzymatic reactions in the body, including those contributing to the exaggerated immune and inflammatory responses exhibited by COVID-19 patients.Methods: A summary of experimental findings and knowledge of the biochemical role magnesium may play in the pathogenesis of COVID-19 is presented in this perspective. The National Academy of Medicine's Standards for Systematic Reviews were independently employed to identify clinical and prospective cohort studies assessing the relationship of magnesium with interleukin-6, a prominent drug target for treating COVID-19.Results: Clinical recommendations are given for prevention and treatment of COVID-19. Constant monitoring of ionized magnesium status with subsequent repletion, when appropriate, may be an effective strategy to influence disease contraction and progression. The peer-reviewed literature supports that several aspects of magnesium nutrition warrant clinical consideration. Mechanisms include its "calcium-channel blocking" effects that lead to downstream suppression of nuclear factor-Kβ, interleukin-6, c-reactive protein, and other related endocrine disrupters; its role in regulating renal potassium loss; and its ability to activate and enhance the functionality of vitamin D, among others.Conclusion: As the world awaits an effective vaccine, nutrition plays an important and safe role in helping mitigate patient morbidity and mortality. Our group is working with the Academy of Nutrition and Dietetics to collect patient-level data from intensive care units across the United States to better understand nutrition care practices that lead to better outcomes.

Dose-Response Relation between Tea Consumption and Risk of Cardiovascular Disease and All-Cause Mortality: A Systematic Review and Meta-Analysis of Population-Based Studies

Tea flavonoids have been suggested to offer potential benefits to cardiovascular health. This review synthesized the evidence on the relation between tea consumption and risks of cardiovascular disease (CVD) and all-cause mortality among generally healthy adults. PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials, Food Science and Technology Abstracts, and Ovid CAB Abstract databases were searched to identify English-language publications through 1 November 2019, including randomized trials, prospective cohort studies, and nested case-control (or case-cohort) studies with data on tea consumption and risk of incident cardiovascular events (cardiac or peripheral vascular events), stroke events (including mortality), CVD-specific mortality, or all-cause mortality. Data from 39 prospective cohort publications were synthesized. Linear meta-regression showed that each cup (236.6 mL)  increase in daily tea consumption (estimated 280 mg  and 338 mg  total flavonoids/d for black and green tea, respectively) was associated with an average 4% lower risk of CVD mortality, a 2% lower risk of CVD events, a 4% lower risk of stroke, and a 1.5% lower risk of all-cause mortality. Subgroup meta-analysis results showed that the magnitude of association was larger in elderly individuals for both CVD mortality (n = 4; pooled adjusted RR: 0.89; 95% CI: 0.83, 0.96; P = 0.001), with large heterogeneity (I2 = 72.4%), and all-cause mortality (n = 3; pooled adjusted RR: 0.92; 95% CI: 0.90, 0.94; P < 0.0001; I2 = 0.3%). Generally, studies with higher risk of bias appeared to show larger magnitudes of associations than studies with lower risk of bias. Strength of evidence was rated as low and moderate (depending on study population age group) for CVD-specific mortality outcome and was rated as low for CVD events, stroke, and all-cause mortality outcomes. Daily tea intake as part of a healthy habitual dietary pattern may be associated with lower risks of CVD and all-cause mortality among adults.

Calcium Supplement Use Is Associated With Less Bone Mineral Density Loss, But Does Not Lessen the Risk of Bone Fracture Across the Menopause Transition: Data From the Study of Women's Health Across the Nation

Diet is a modifiable factor that is related to bone mass and risk for fractures; however, the use of calcium supplements for bone health is controversial, with little scientific agreement. The purpose of this analysis was to estimate the change in lumbar spine and femoral neck BMD and the risk of bone fracture by the use of calcium supplements among the Study of Women's Health Across the Nation (SWAN) participants. SWAN is a multicenter, multiethnic, community‐based longitudinal cohort designed to examine the health of women across the menopause transition (n = 1490; aged 42 to 52 years at baseline in 1996 to 1997 and followed annually until 2006 to 2008). A mixed‐effect model for repeated measures was used to estimate annualized BMD change across time between supplement users and nonusers, unadjusted or fully adjusted (age, race, height, weight, menopausal status [pre‐, early peri‐, late peri‐, and postmenopausal], DXA scanner mode, alcohol intake, vitamin D supplement use, smoking, and physical activity) and a log‐linear model with repeated measures was used to estimate the relative risk of fracture by calcium supplement use. All models were also stratified by baseline menopausal status. In fully adjusted models, calcium supplement use was associated with less annualized loss of femoral neck BMD (−0.0032 versus −0.0040 g/cm²/year; p < .001) and lumbar spine BMD (−0.0046 versus −0.0053 g/cm²/year, p = 0.021) in the complete cohort. However, this protective association of calcium supplement use with BMD loss was significant only among premenopausal women (femoral neck: −0.0032 versus −0.0042 g/cm²/year; p = 0.002; lumbar spine: −0.0038 versus −0.0050 g/cm²/year, p = 0.001); no significant differences in BMD were observed among women who were early perimenopausal by calcium supplement use at baseline. No significant differences in the relative risk of fracture were observed, regardless of baseline menopausal status. The use of calcium supplements was associated with less BMD loss over more than a decade, but was not related to the risk of incident bone fracture across the menopause transition. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Current Sodium Intakes in the United States and the Modelling of Glutamate's Incorporation into Select Savory Products

Most Americans have dietary sodium intakes that far exceed recommendations. Given the association of high sodium with hypertension, strategies to reduce sodium intakes are an important public health target. Glutamates, such as monosodium glutamate, represent a potential strategy to reduce overall intakes while preserving product palatability; therefore, this project aimed to model sodium replacement with glutamates. The National Cancer Institute method was used to estimate current sodium intakes, and intakes resulting from glutamate substitution (25%–45%) in a limited set of food groups for which substitution is possible. Data sets for individuals aged ≥1 year enrolled in the U.S. National Health and Nutrition Examination Survey 2013–2016 (n = 16,183) were used in the analyses. Glutamate substitution in accordance with the U.S. Department of Agriculture’s food codes was modeled by conservatively altering estimates of sodium intake reductions derived from the published, peer-reviewed literature. The addition of glutamates to certain food categories has the potential to reduce the population’s sodium intake by approximately 3% overall and by 7%–8% among consumers of ≥1 product category in which glutamates were substituted for sodium chloride. Although using glutamates to substitute the amount of sodium among certain food groups may show modest effects on intakes across the population, it is likely to have a more substantial effect on individuals who consume specific products.

Anthocyanins-Nature's Bold, Beautiful, and Health-Promoting Colors

Anthocyanins are among the most interesting and vigorously studied plant compounds, representing a large class of over 700 polyphenolic pigments within the flavonoid family that exist ubiquitously in the human diet. They are "nature's colors," responsible for providing the beautiful red-orange to blue-violet hues present in many leaves, flowers, vegetables, and fruits, especially berries. The beginning of the 21st century has witnessed a renaissance in research activities on anthocyanins in several areas, mainly related to their potential health-promoting properties and their increased use as alternatives to synthetic food colors. There is increasingly convincing scientific evidence that supports both a preventative and therapeutic role of anthocyanins towards certain chronic disease states. Many anthocyanin-based extracts and juice concentrates from crop and/or food processing waste have become commercially available as colorants and/or value-added food ingredients. There is a large and evolving peer-reviewed literature on how anthocyanin chemistry and concentration may affect their coloring properties in food. Equally as important is the food matrix, which can have large impacts on anthocyanin color expression, stability and degradation, particularly regarding the applications of anthocyanins as food colorants and their health-promoting properties. This Special Edition of Foods, titled "Anthocyanins in Foods," presents original research that extends our understanding of these exciting and complex compounds.

Multivitamin/Multimineral Supplement Use is Associated with Increased Micronutrient Intakes and Biomarkers and Decreased Prevalence of Inadequacies and Deficiencies in Middle-Aged and Older Adults in the United States

Micronutrient inadequacies are common in older adults and using a multivitamin/multimineral supplement (MVM) may improve their nutritional status. National Health and Nutrition Examination Survey data were analyzed to determine micronutrient intakes based on diet and MVM use in adults aged ≥51 years. Deficiencies were evaluated using nutrient biomarkers. The National Cancer Institute Method was used to estimate usual intakes of 18 micronutrients stratified by age and frequency of MVM use. Compared with food alone, MVM use was associated with higher nutrient intake and lower prevalence of inadequacies of almost all micronutrients examined and improved nutrient biomarker status of folate, iodine, selenium, and vitamins B₆, B₁₂, and D. Regular MVM use (≥16 days/month) decreased the odds of clinical deficiency (defined by biomarker status) of vitamins B₆ and D but increased the proportion exceeding the tolerable upper intake level of folic acid. Vitamin B₆ deficiency in MVM non-users was common and increased with age.

Multivitamins and Nutritional Adequacy in Middle-Aged to Older Americans by Obesity Status

Multivitamins are the most commonly consumed dietary supplement in the United States and worldwide. Micronutrient insufficiency and clinical deficiency are more common in middle-aged to older adults, and multivitamin use has been shown to improve status in this population. This analysis aimed to assess contributions of sporadic and consistent multivitamin use to total usual micronutrient intakes and associated nutritional biomarkers among middle-aged to older US adults age ≥51 years, stratified by obesity status. Self-reported dietary intake and laboratory measures from the National Health and Nutrition Examination Survey were used in these analyses. The National Cancer Institute method was used to assess usual intakes of 18 micronutrients. Compared with food alone, multivitamin use was associated with a lower prevalence of inadequacies and improved nutritional biomarker status for folate, iodine, selenium, and vitamins B₆, B₁₂, and D. Consistent use decreased the prevalence of inadequacy for most micronutrients assessed, except for those micronutrients typically not found (or in miniscule amounts) in standard multivitamin products. In addition to a lower prevalence of inadequacy for many micronutrients associated with consistent use of multivitamins, sporadic use decreased the prevalence of inadequacy for a greater number of micronutrients in obese versus nonobese individuals. Multivitamin use (sporadic and consistent) also increased the proportion of individuals who exceeded the tolerable upper intake level for folic acid to 8%-10%. Nutritional biomarker data indicate that obese individuals may be at greater risk of clinical deficiency in vitamins B₆ and D. Use of gender- and age-specific multivitamins may serve as a practical means to increase micronutrient status and decrease prevalences of clinical deficiency in the middle-aged to older population, particularly in those who are obese.

PHAGE Study: Effects of Supplemental Bacteriophage Intake on Inflammation and Gut Microbiota in Healthy Adults

The gut microbiota is increasingly recognized as an important modulator of human health. As such, there is a growing need to identify effective means of selectively modifying gut microbial communities. Bacteriophages, which were briefly utilized as clinical antimicrobials in the early 20th century, present an opportunity to selectively reduce populations of undesirable microorganisms. However, whether intentional consumption of specific bacteriophages affects overall gut ecology is not yet known. Using a commercial cocktail of Escherichia coli-targeting bacteriophages, we examined their effects on gut microbiota and markers of intestinal and systemic inflammation in a healthy human population. In a double-blinded, placebo-controlled crossover trial, normal to overweight adults consumed bacteriophages for 28 days. Stool and blood samples were collected and used to examine inflammatory markers, lipid metabolism, and gut microbiota. Reductions in fecal E. coli loads were observed with phage consumption. However, there were no significant changes to alpha and beta diversity parameters, suggesting that consumed phages did not globally disrupt the microbiota. However, specific populations were altered in response to treatment, including increases in members of the butyrate-producing genera Eubacterium and a decreased proportion of taxa most closely related to Clostridium perfringens. Short-chain fatty acid production, inflammatory markers, and lipid metabolism were largely unaltered, but there was a small but significant decrease in circulating interleukin-4 (Il-4). Together, these data demonstrate the potential of bacteriophages to selectively reduce target organisms without global disruption of the gut community.

Personalized Nutrition in Disrupting Cancer - Proceedings From the 2017 American College of Nutrition Annual Meeting

Cancer is a major public health problem and is the second leading cause of death in the United States and worldwide; nearly one in six deaths are attributable to cancer. Approximately 20% of all cancers diagnosed in the United States are attributable to unhealthy diet, excessive alcohol consumption, physical inactivity, and body fatness. Individual cancers are distinct disease states that are multifactorial in their causation, making them exceedingly cumbersome to study from a nutrition standpoint. Genetic influences are a major piece of the puzzle and personalized nutrition is likely to be most effective in disrupting cancer during all stages. Increasing evidence shows that after a cancer diagnosis, continuing standard dietary recommendations may not be appropriate. This is because powerful dietary interventions such as short-term fasting and carbohydrate restriction can disrupt tumor metabolism, synergizing with standard therapies such as radiation and drug therapy to improve efficacy and ultimately, cancer survival. The importance of identifying dietary interventions cannot be overstated, and the American College of Nutrition's commitment to advancing knowledge and research is evidenced by dedication of the 2017 ACN Annual Meeting to "Disrupting Cancer: The Role of Personalized Nutrition" and this resulting proceedings manuscript, which summarizes the meeting's findings.

Choline: The Underconsumed and Underappreciated Essential Nutrient

Choline has been recognized as an essential nutrient by the Food and Nutrition Board of the National Academies of Medicine since 1998. Its metabolites have structural, metabolic, and regulatory roles within the body. Humans can endogenously produce small amounts of choline via the hepatic phosphatidylethanolamine N-methyltransferase pathway. However, the nutrient must be consumed exogenously to prevent signs of deficiency. The Adequate Intake (AI) for choline was calculated at a time when dietary intakes across the population were unknown for the nutrient. Unlike the traditional National Academy of Medicine approach of calculating an AI based on observed or experimentally determined approximations or estimates of intake by a group (or groups) of healthy individuals, calculation of the AI for choline was informed in part by a depletion-repletion study in adult men who, upon becoming deficient, developed signs of liver damage. The AI for other gender and life-stage groups was calculated based on standard reference weights, except for infants 0 to 6 months, whose AI reflects the observed mean intake from consuming human breast milk. Recent analyses indicate that large portions of the population (ie, approximately 90% of Americans), including most pregnant and lactating women, are well below the AI for choline. Moreover, the food patterns recommended by the 2015-2020 Dietary Guidelines for Americans are currently insufficient to meet the AI for choline in most age-sex groups. An individual's requirement for choline is dependent on common genetic variants in genes required for choline, folate, and 1-carbon metabolism, potentially increasing more than one-third of the population's susceptibly to organ dysfunction. The American Medical Association and American Academy of Pediatrics have both recently reaffirmed the importance of choline during pregnancy and lactation. New and emerging evidence suggests that maternal choline intake during pregnancy, and possibly lactation, has lasting beneficial neurocognitive effects on the offspring. Because choline is found predominantly in animal-derived foods, vegetarians and vegans may have a greater risk for inadequacy. With the 2020-2025 Dietary Guidelines for Americans recommending expansion of dietary information for pregnant women, and the inclusion of recommendations for infants and toddlers 0 to 2 years, better communication of the role that choline plays, particularly in the area of neurocognitive development, is critical. This narrative review summarizes the peer-reviewed literature and discussions from the 2018 Choline Science Summit, held in Washington, DC, in February 2018.

Calculating Intake of Dietary Risk Components Used in the Global Burden of Disease Studies from the What We Eat in America/National Health and Nutrition Examination Surveys

Disability adjusted life years (DALYs) is a health burden metric that combines years of life lost due to disease disability and premature mortality. The Global Burden of Disease (GBD) has been using DALYs to determine the health burden associated with numerous health risks, including risks associated with dietary intakes, at the global and national level. To translate such information at the food level in the U.S., variables in What We Eat in America (WWEIA) need to be aligned with those in the GBD. In this paper, we develop the necessary new variables needed to account for differences in definitions and units between WWEIA and the GBD. We use the Food Patterns Equivalents Database, Food Patterns Equivalents Ingredient Database, Food and Nutrient Database for Dietary Studies, and Standard Reference databases that provide data for WWEIA to develop food group and nutrient variables that align with definitions and units used in the GBD. Considerable effort was needed to disaggregate mixed dishes to GBD components. We also developed a new “non-starchy” vegetable variable, since the GBD vegetables do not include potatoes and corn, and we report fruits and vegetables in grams instead of household measures. New fiber variables were created to avoid double counting of fiber from legumes, whole grains, fruits, and vegetables. Regression analyses were used to predict trans-fat content for foods in WWEIA with missing or incomplete information. The majority of foods in various U.S. Department of Agriculture (USDA) categories contain multiple GBD food groups (e.g., vegetables, whole grains, and processed meat). For most nutrients considered in the GBD, composition is more evenly distributed across the main food categories; however, seafood omega-3 fats were predominantly from either protein foods or mixed dishes and sugar sweetened beverages were from a single category. Dietary intakes in the U.S. fall short of recommendations for all food groups/nutrients with established theoretical minimum-risk targets in GBD. To our knowledge, this is the first approach that aligns WWEIA intake variables with those used in the health burden-based GBD reports. These methods will facilitate researchers to begin comparing data from the U.S. with that from other countries, as well as assess food sustainability performances by concomitantly evaluating DALYs for environmental and nutritional impacts.

Animal versus plant protein and adult bone health: A systematic review and meta-analysis from the National Osteoporosis Foundation

Background

Protein may have both beneficial and detrimental effects on bone health depending on a variety of factors, including protein source.

Objective

The aim was to conduct a systematic review and meta-analysis evaluating the effects of animal versus plant protein intake on bone mineral density (BMD), bone mineral content (BMC) and select bone biomarkers in healthy adults.

Methods

Searches across five databases were conducted through 10/31/16 for randomized controlled trials (RCTs) and prospective cohort studies in healthy adults that examined the effects of animal versus plant protein intake on 1) total body (TB), total hip (TH), lumbar spine (LS) or femoral neck (FN) BMD or TB BMC for at least one year, or 2) select bone formation and resorption biomarkers for at least six months. Strength of evidence (SOE) was assessed and random effect meta-analyses were performed.

Results

Seven RCTs examining animal vs. isoflavone-rich soy (Soy+) protein intake in 633 healthy peri-menopausal (n = 1) and post-menopausal (n = 6) women were included. Overall risk of bias was medium. Limited SOE suggests no significant difference between Soy+ vs. animal protein on LS, TH, FN and TB BMD, TB BMC, and bone turnover markers BSAP and NTX. Meta-analysis results showed on average, the differences between Soy+ and animal protein groups were close to zero and not significant for BMD outcomes (LS: n = 4, pooled net % change: 0.24%, 95% CI: -0.80%, 1.28%; TB: n = 3, -0.24%, 95% CI: -0.81%, 0.33%; FN: n = 3, 0.13%, 95% CI: -0.94%, 1.21%). All meta-analyses had no statistical heterogeneity.

Conclusions

These results do not support soy protein consumption as more advantageous than animal protein, or vice versa. Future studies are needed examining the effects of different protein sources in different populations on BMD, BMC, and fracture.

Dietary Protein Intake above the Current RDA and Bone Health: A Systematic Review and Meta-Analysis

Dietary intake of protein is fundamental for optimal acquisition and maintenance of bone across all life stages; however, it has been hypothesized that intakes above the current recommended dietary allowance (RDA) might be beneficial for bone health. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines when preparing and reporting this systematic review and meta-analysis. A literature search strategy through April 11, 2017, was developed for the following 3 databases: PubMed, Ovid Medline, and Agricola. Included studies were those randomized controlled trials and prospective cohort studies among healthy adults ages 18 and older that examined the relationships between varying doses of protein intake at or above the current U.S. RDA (0.8 g/kg/d or 10%-15% of total caloric intake) from any source on fracture, bone mineral density (BMD)/bone mineral content (BMC), and/or markers of bone turnover. Twenty-nine articles were included for data extraction (16 randomized controlled trials [RCTs] and 13 prospective cohort studies). Meta-analysis of the prospective cohort studies showed high vs low protein intakes resulted in a statistically significant 16% decrease in hip fractures (standardized mean difference [SMD] = 0.84, 95% confidence interval [CI], 0.73, 0.95; I² = 36.8%). Data from studies included in these analyses collectively lean toward the hypothesis that protein intake above the current RDA is beneficial to BMD at several sites. This systematic review supports that protein intakes above the current RDA may have some beneficial role in preventing hip fractures and BMD loss. There were no differences between animal or plant proteins, although data in this area were scarce. Larger, long-term, and more well-controlled clinical trials measuring fracture outcomes and BMD are needed to adequately assess whether protein intake above the current RDA is beneficial as a preventative measure and/or intervention strategy for osteoporosis. Key teaching points: • • Bone health is a multifactorial musculoskeletal issue, and optimal protein intakes are key in developing and maintaining bone throughout the life span. • • Dietary protein at levels above the current RDA may be beneficial in preventing hip fractures and BMD loss. • • Plant vs animal proteins do not seem to differ in their ability to prevent bone loss; however, data in this area are scarce. • • Larger, long-term RCTs using women not using hormone replacement therapy (HRT) are needed to adequately assess the magnitude of impact that protein intakes above the RDA have on preventing bone loss.

Satisfying America's Fruit Gap: Summary of an Expert Roundtable on the Role of 100% Fruit Juice

The 2015 to 2020 Dietary Guidelines for Americans (DGAs) recognize the role of 100% fruit juice in health and in helping people meet daily fruit recommendations and state that 100% fruit juice is a nutrient-dense beverage that should be a primary choice, along with water and low-fat/fat-free milk. The DGAs note that children are consuming 100% fruit juice within recommendations (that is, 120 to 180 mL/d for children aged 1 to 6 y and 236 to 355 mL/d for children aged 7 to 18 y). Evidence shows that compared to nonconsumers, those who consume 100% fruit juice come closer to meeting daily fruit needs and have better diet quality. In children, 100% fruit juice is associated with increased intakes of nutrients such as vitamin C, folate, and potassium. When consumed within the DGA recommendations, 100% fruit juice is not associated with overweight/obesity or childhood dental caries and does not compromise fiber intake. Preliminary data suggest that polyphenols in some 100% fruit juices may inhibit absorption of naturally occurring sugars. Given its role in promoting health and in helping people meet fruit needs, experts participating in a roundtable discussion agreed that there is no science-based reason to restrict access to 100% fruit juice in public health nutrition policy and programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Reducing or eliminating 100% fruit juice could lead to unintended consequences such as reduced daily fruit intake and increased consumption of less nutritious beverages (for example, sugar-sweetened beverages).

Dietary protein and bone health: a systematic review and meta-analysis from the National Osteoporosis Foundation

Background: Considerable attention has recently focused on dietary protein's role in the mature skeleton, prompted partly by an interest in nonpharmacologic approaches to maintain skeletal health in adult life.Objective: The aim was to conduct a systematic review and meta-analysis evaluating the effects of dietary protein intake alone and with calcium with or without vitamin D (Ca±D) on bone health measures in adults.Design: Searches across 5 databases were conducted through October 2016 including randomized controlled trials (RCTs) and prospective cohort studies examining 1) the effects of "high versus low" protein intake or 2) dietary protein's synergistic effect with Ca±D intake on bone health outcomes. Two investigators independently conducted abstract and full-text screenings, data extractions, and risk of bias (ROB) assessments. Strength of evidence was rated by group consensus. Random-effects meta-analyses for outcomes with ≥4 RCTs were performed.Results: Sixteen RCTs and 20 prospective cohort studies were included in the systematic review. Overall ROB was medium. Moderate evidence suggested that higher protein intake may have a protective effect on lumbar spine (LS) bone mineral density (BMD) compared with lower protein intake (net percentage change: 0.52%; 95% CI: 0.06%, 0.97%, I²: 0%; n = 5) but no effect on total hip (TH), femoral neck (FN), or total body BMD or bone biomarkers. Limited evidence did not support an effect of protein with Ca±D on LS BMD, TH BMD, or forearm fractures; there was insufficient evidence for FN BMD and overall fractures.Conclusions: Current evidence shows no adverse effects of higher protein intakes. Although there were positive trends on BMD at most bone sites, only the LS showed moderate evidence to support benefits of higher protein intake. Studies were heterogeneous, and confounding could not be excluded. High-quality, long-term studies are needed to clarify dietary protein's role in bone health. This trial was registered at www.crd.york.ac.uk as CRD42015017751.

Dried Plums, Prunes and Bone Health: A Comprehensive Review

The 2015–2020 Dietary Guidelines for Americans advocate for increasing fruit intake and replacing energy-dense foods with those that are nutrient-dense. Nutrition across the lifespan is pivotal for the healthy development and maintenance of bone. The National Osteoporosis Foundation estimates that over half of Americans age 50+ have either osteoporosis or low bone mass. Dried plums, also commonly referred to as prunes, have a unique nutrient and dietary bioactive profile and are suggested to exert beneficial effects on bone. To further elucidate and summarize the potential mechanisms and effects of dried plums on bone health, a comprehensive review of the scientific literature was conducted. The PubMed database was searched through 24 January 2017 for all cell, animal, population and clinical studies that examined the effects of dried plums and/or extracts of the former on markers of bone health. Twenty-four studies were included in the review and summarized in table form. The beneficial effects of dried plums on bone health may be in part due to the variety of phenolics present in the fruit. Animal and cell studies suggest that dried plums and/or their extracts enhance bone formation and inhibit bone resorption through their actions on cell signaling pathways that influence osteoblast and osteoclast differentiation. These studies are consistent with clinical studies that show that dried plums may exert beneficial effects on bone mineral density (BMD). Long-term prospective cohort studies using fractures and BMD as primary endpoints are needed to confirm the effects of smaller clinical, animal and mechanistic studies. Clinical and prospective cohort studies in men are also needed, since they represent roughly 29% of fractures, and likewise, diverse race and ethnic groups. No adverse effects were noted among any of the studies included in this comprehensive review. While the data are not completely consistent, this review suggests that postmenopausal women may safely consume dried plums as part of their fruit intake recommendations given their potential to have protective effects on bone loss.

Lack of Evidence Linking Calcium With or Without Vitamin D Supplementation to Cardiovascular Disease in Generally Healthy Adults: A Clinical Guideline From the National Osteoporosis Foundation and the American Society for Preventive Cardiology

DESCRIPTION

Calcium is the dominant mineral present in bone and a shortfall nutrient in the American diet. Supplements have been recommended for persons who do not consume adequate calcium from their diet as a standard strategy for the prevention of osteoporosis and related fractures. Whether calcium with or without vitamin D supplementation is beneficial or detrimental to vascular health is not known.

METHODS

The National Osteoporosis Foundation and American Society for Preventive Cardiology convened an expert panel to evaluate the effects of dietary and supplemental calcium on cardiovascular disease based on the existing peer-reviewed scientific literature. The panel considered the findings of the accompanying updated evidence report provided by an independent evidence review team at Tufts University.

RECOMMENDATION

The National Osteoporosis Foundation and American Society for Preventive Cardiology adopt the position that there is moderate-quality evidence (B level) that calcium with or without vitamin D intake from food or supplements has no relationship (beneficial or harmful) to the risk for cardiovascular and cerebrovascular disease, mortality, or all-cause mortality in generally healthy adults at this time. In light of the evidence available to date, calcium intake from food and supplements that does not exceed the tolerable upper level of intake (defined by the National Academy of Medicine as 2000 to 2500 mg/d) should be considered safe from a cardiovascular standpoint.

Perspective: The Case for an Evidence-Based Reference Interval for Serum Magnesium: The Time Has Come

The 2015 Dietary Guidelines Advisory Committee indicated that magnesium was a shortfall nutrient that was underconsumed relative to the Estimated Average Requirement (EAR) for many Americans. Approximately 50% of Americans consume less than the EAR for magnesium, and some age groups consume substantially less. A growing body of literature from animal, epidemiologic, and clinical studies has demonstrated a varied pathologic role for magnesium deficiency that includes electrolyte, neurologic, musculoskeletal, and inflammatory disorders; osteoporosis; hypertension; cardiovascular diseases; metabolic syndrome; and diabetes. Studies have also demonstrated that magnesium deficiency is associated with several chronic diseases and that a reduced risk of these diseases is observed with higher magnesium intake or supplementation. Subclinical magnesium deficiency can exist despite the presentation of a normal status as defined within the current serum magnesium reference interval of 0.75-0.95 mmol/L. This reference interval was derived from data from NHANES I (1974), which was based on the distribution of serum magnesium in a normal population rather than clinical outcomes. What is needed is an evidenced-based serum magnesium reference interval that reflects optimal health and the current food environment and population. We present herein data from an array of scientific studies to support the perspective that subclinical deficiencies in magnesium exist, that they contribute to several chronic diseases, and that adopting a revised serum magnesium reference interval would improve clinical care and public health.

Avenanthramides Prevent Osteoblast and Osteocyte Apoptosis and Induce Osteoclast Apoptosis in Vitro in an Nrf2-Independent Manner

Oats contain unique bioactive compounds known as avenanthramides (AVAs) with antioxidant properties. AVAs might enhance the endogenous antioxidant cellular response by activation of the transcription factor Nrf2. Accumulation of reactive oxygen species plays a critical role in many chronic and degenerative diseases, including osteoporosis. In this disease, there is an imbalance between bone formation by osteoblasts and bone resorption by osteoclasts, which is accompanied by increased osteoblast/osteocyte apoptosis and decreased osteoclast apoptosis. We investigated the ability of the synthethic AVAs 2c, 2f and 2p, to 1-regulate gene expression in bone cells, 2-affect the viability of osteoblasts, osteocytes and osteoclasts, and the generation of osteoclasts from their precursors, and 3-examine the potential involvement of the transcription factor Nrf2 in these actions. All doses of AVA 2c and 1 and 5 µM dose of 2p up-regulated collagen 1A expression. Lower doses of AVAs up-regulated OPG (osteoprotegerin) in OB-6 osteoblastic cells, whereas 100 μM dose of 2f and all concentrations of 2c down-regulated RANKL gene expression in MLO-Y4 osteocytic cells. AVAs did not affect apoptosis of OB-6 osteoblastic cells or MLO-Y4 osteocytic cells; however, they prevented apoptosis induced by the DNA topoisomerase inhibitor etoposide, the glucocorticoid dexamethasone, and hydrogen peroxide. AVAs prevented apoptosis of both wild type (WT) and Nrf2 Knockout (KO) osteoblasts, demonstrating that AVAs-induced survival does not require Nrf2 expression. Further, KO osteoclast precursors produced more mature osteoclasts than WT; and KO cultures exhibited less apoptotic osteoclasts than WT cultures. Although AVAs did not affect WT osteoclasts, AVA 2p reversed the low apoptosis of KO osteoclasts. These in vitro results demonstrate that AVAs regulate, in part, the function of osteoblasts and osteocytes and prevent osteoblast/osteocyte apoptosis and increase osteoclast apoptosis; further, these regulatory actions are independent of Nrf2.

The National Osteoporosis Foundation's methods and processes for developing position statements

The methods and processes described in this manuscript have been approved and adopted by the NOF Board of Trustees on November 11, 2015. This manuscript has been peer-reviewed by the NOF Research Committee and Osteoporosis International. The National Osteoporosis Foundation frequently publishes position statements for the benefit of educating healthcare professionals and the general public on a particular issue and/or concern related to preventing osteoporosis and/or promoting strong bones throughout the lifespan. This manuscript represents the official methods and processes adopted by the NOF Board of Trustees for the purpose developing future position statements in a transparent and unbiased manner.