Nutrition and Frailty: Opportunities for Prevention and Treatment

Frailty is a syndrome of growing importance given the global ageing population. While frailty is a multifactorial process, poor nutritional status is considered a key contributor to its pathophysiology. As nutrition is a modifiable risk factor for frailty, strategies to prevent and treat frailty should consider dietary change. Observational evidence linking nutrition with frailty appears most robust for dietary quality: for example, dietary patterns such as the Mediterranean diet appear to be protective. In addition, research on specific foods, such as a higher consumption of fruit and vegetables and lower consumption of ultra-processed foods are consistent, with healthier profiles linked to lower frailty risk. Few dietary intervention studies have been conducted to date, although a growing number of trials that combine supplementation with exercise training suggest a multi-domain approach may be more effective. This review is based on an interdisciplinary workshop, held in November 2020, and synthesises current understanding of dietary influences on frailty, focusing on opportunities for prevention and treatment. Longer term prospective studies and well-designed trials are needed to determine the causal effects of nutrition on frailty risk and progression and how dietary change can be used to prevent and/or treat frailty in the future.

Regional and hemispheric susceptibility of the temporal lobe to FTLD-TDP type C pathology

Post-mortem studies show that focal anterior temporal lobe (ATL) neurodegeneration is most often caused by frontotemporal lobar degeneration TDP-43 type C pathology. Clinically, these patients are described with different terms, such as semantic variant primary progressive aphasia (svPPA), semantic dementia (SD), or right temporal variant frontotemporal dementia (FTD) depending on whether the predominant symptoms affect language, semantic knowledge for object or people, or socio-emotional behaviors. ATL atrophy presents with various degrees of lateralization, with right-sided cases considered rarer even though estimation of their prevalence is hampered by the paucity of studies on well-characterized, pathology-proven cohorts. Moreover, it is not clear whether left and right variants show a similar distribution of atrophy within the ATL cross-sectionally and longitudinally. Here we study the largest cohort to-date of pathology-proven TDP-43-C cases diagnosed during life as svPPA, SD or right temporal variant FTD. We analyzed clinical, cognitive, and neuroimaging data from 30 cases, a subset of which was followed longitudinally. Guided by recent structural and functional parcellation studies, we constructed four bilateral ATL regions of interest (ROIs). The computation of an atrophy lateralization index allowed the comparison of atrophy patterns between the two hemispheres. This led to an automatic, imaging-based classification of the cases as left-predominant or right-predominant. We then compared the two groups in terms of regional atrophy patterns within the ATL ROIs (cross-sectionally) and atrophy progression (longitudinally). Results showed that 40% of pathology proven cases of TDP-43-C diagnosed with a temporal variant presented with right-lateralized atrophy. Moreover, the findings of our ATL ROI analysis indicated that, irrespective of atrophy lateralization, atrophy distribution within both ATLs follows a medial-to-lateral gradient. Finally, in both left and right cases, atrophy appeared to progress to the contralateral ATL, and from the anterior temporal pole to posterior temporal and orbitofrontal regions. Taken together, our findings indicate that incipient right predominant ATL atrophy is common in TDP-43-C pathology, and that distribution of damage within the ATLs appears to be the same in left- and right- sided variants. Thus, regardless of differences in clinical phenotype and atrophy lateralization, both temporal variants of FTD should be viewed as a spectrum presentation of the same disease.

Exploring the association between ingestion of foods with higher potential salicylate content and symptom exacerbation in chronic rhinosinusitis. Data from the National Chronic Rhinosinusitis Epidemiology Study

INTRODUCTION

Pharmacological salicylates are known to trigger respiratory exacerbations in patients with Non-Steroidal Exacerbated Respiratory Disease (N-ERD), a specific phenotype of Chronic Rhinosinusitis (CRS) and asthma. The impact of dietary sources of salicylates across subgroups of CRS is not well understood. The hypothesis is that in patients with nasal polyps present, there is likely to be a higher incidence of symptom exacerbation due to dietary salicylates regardless of any known response to pharmacological salicylate.

METHODS

The Chronic Rhinosinusitis Epidemiology Study (CRES) was a questionnaire-based case-control study which sought to characterise the UK CRS population in terms of sociological, economic and medical factors. Using specific questions to examine participant responses relating to symptom exacerbation from food groups thought to be high in salicylate content, this analysis of the CRES database sought to compare an estimate of the prevalence of dietary sensitivity due to food with higher potential salicylate content across patients with CRS with (CRSwNPs) and without nasal polyposis (CRSsNPs) and with allergic fungal rhinosinusitis (AFRS).

RESULTS

The CRSwNPs group were significantly more likely than controls to report symptom exacerbation due to ingestion of food groups with higher potential dietary salicylate content. The same trend was observed amongst CRSsNPs participants to a lesser degree. Reported response to the individual specific food groups wine, nuts, spicy foods, fruit and vegetables demonstrated that a statistically significant proportion of CRSwNPs and AFRS participants reported sensitivity to wine.

CONCLUSIONS

This analysis suggests that there is an association between symptom exacerbation in response to food products with higher potential salicylate content, specifically wine, in CRS patients both with and without nasal polyposis when compared to controls, but especially in the CRSwNPs and AFRS phenotypes. Further studies are needed to detail if this relationship represents a causal relationship to dietary salicylate. The data present the possibility that a wider group of CRS patients may elicit salicylate sensitivity than those with known N-ERD.

The Relationship Between Omega-3, Omega-6 and Total Polyunsaturated Fat and Musculoskeletal Health and Functional Status in Adults: A Systematic Review and Meta-analysis of RCTs

We conducted a systematic review and meta-analysis to assess the effects of increasing dietary omega-3, omega-6 and mixed polyunsaturated fatty acids (PUFA) on musculoskeletal health, functional status, sarcopenia and risk of fractures. We searched Medline, Embase, The Cochrane library, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) databases for Randomised Controlled Trials (RCTs) of adults evaluating the effects of higher versus lower oral omega-3, omega-6 or mixed PUFA for ≥ 6 months on musculoskeletal and functional outcomes. We included 28 RCTs (7288 participants, 31 comparisons), 23 reported effects of omega-3, one of omega-6 and four of mixed total PUFA. Participants and doses were heterogeneous. Six omega-3 trials were judged at low summary risk of bias. We found low-quality evidence that increasing omega-3 increased lumbar spine BMD by 2.6% (0.03 g/cm², 95% CI - 0.02 to 0.07, 463 participants). There was also the suggestion of an increase in femoral neck BMD (of 4.1%), but the evidence was of very low quality. There may be little or no effect of omega-3 on functional outcomes and bone mass; effects on other outcomes were unclear. Only one study reported on effects of omega-6 with very limited data. Increasing total PUFA had little or no effect on BMD or indices of fat-free (skeletal) muscle mass (low-quality evidence); no data were available on fractures, BMD or functional status and data on bone turnover markers were limited. Trials assessing effects of increasing omega-3, omega-6 and total PUFA on functional status, bone and skeletal muscle strength are limited with data lacking or of low quality. Whilst there is an indication that omega-3 may improve BMD, high-quality RCTs are needed to confirm this and effects on other musculoskeletal outcomes.

Dehydration and Malnutrition in Residential Care: Recommendations for Strategies for Improving Practice Derived from a Scoping Review of Existing Policies and Guidelines

Preventing malnutrition and dehydration in older care home residents is a complex task, with both conditions remaining prevalent, despite numerous guidelines spanning several decades. This policy-mapping scoping review used snowballing search methods to locate publicly-available policies, reports and best practice guidelines relating to hydration and nutrition in UK residential care homes, to describe the existing knowledge base and pinpoint gaps in practice, interpretation and further investigation. The findings were synthesised narratively to identify solutions. Strategies for improvements to nutritional and hydration care include the development of age and population-specific nutrient and fluid intake guidelines, statutory regulation, contractual obligations for commissioners, appropriate menu-planning, the implementation and auditing of care, acknowledgment of residents’ eating and drinking experiences, effective screening, monitoring and treatment and staff training. The considerable body of existing knowledge is failing to influence practice, relating to translational issues of implementing knowledge into care at the point of delivery, and this is where future research and actions should focus.

Arab female and male perceptions of factors facilitating and inhibiting their physical activity: Findings from a qualitative study in the Middle East

OBJECTIVES

Physical inactivity is a leading global risk to health by contributing to obesity and other chronic diseases. Many chronic non-communicable diseases, such as cancer, diabetes, and cardiovascular diseases (CVDs), can be prevented and controlled by modifying lifestyle behaviors such as physical activity [PA]. However, prevalence of insufficient physical activity and obesity is high in the Middle East Region. In Qatar, the incidence rates of CVDs, diabetes, colon, and breast cancer have been rising rapidly. The purpose of this study was to explore facilitators and barriers influencing PA of adult Arab men and women living in Qatar and to understand what they think would be helpful to increase PA. The goal of the research is to identify culturally appropriate and effective interventions that improve the health of Arab population.

DESIGN

Using the socioecological model as the theoretical framework, we conducted an exploratory qualitative study with 128 Arab adult men and women living in Qatar. We utilized focus group interviews to collect the data and performed thematic analysis to generate themes.

RESULTS

At the individual level, perceived benefits of PA, presence of diseases, person's will, motivation and goals, and time to exercise influenced the individual's PA. At the sociocultural level, religious teachings of Islam, cultural, attitude, beliefs, and practices, and informal support influenced the participants' PA. At the organizational and political level, physical environment to exercise, accessibility of facilities, organizational support, and health information about PA influenced their PA.

CONCLUSION

Arab men and women are aware of the importance and benefits of PA. They have the motivation to be physically active, but in the absence of supportive environment, their knowledge might not translate into action. Creating supportive environments at multiple levels that are conducive to PA is warranted.

Microalbuminuria, cardiovascular risk factors and cardiovascular morbidity in a British population: The EPIC-Norfolk Population-based Study

BACKGROUND

Microalbuminuria is independently associated with increased cardiovascular risk and renal function deterioration in diabetes and hypertension, but the clinical relevance of raised albuminuria in the general population is less certain. We examined the prevalence of microalbuminuria and its relationship to cardiovascular risk factors and cardiovascular morbidity in the UK general population.

METHODS

Cross-sectional population-based study of 23,964 individuals, aged 40-79 years recruited in 1993-1997 for the EPIC-Norfolk Study. Smoking status, prevalent physician diagnosed diabetes, hypertension, cardiovascular disease and cancer were derived from a health and lifestyle questionnaire. Albumin-to-creatinine ratios were estimated from random spot urine specimens collected at the survey visit, and using these ratios participants were categorized into normoalbuminuria, microalbuminuria (2.5-25 mg/mmol), and macroalbuminuria.

RESULTS

The prevalence of microalbuminuria and macroalbuminuria was 11.8% and 0.9% respectively in the total population and significantly higher in women (14.4%) compared with men (8.9%) (P<0.001). Independent determinants of microalbuminuria were age, sex, systolic blood pressure and current smoking. Microalbuminuria was independently associated with cardiovascular morbidity, after adjusting for known cardiovascular risk factors, with odds ratio (95% confidence interval) for prevalent cardiovascular disease of 1.30 (1.12-1.51) in all men and women.

CONCLUSION

Microalbuminuria was present in approximately 12% of this population. It was independently associated with cardiovascular risk factors and prevalent cardiovascular disease. Microalbuminuria may be a useful indicator of high absolute cardiovascular risk in the community but prospective data are needed to establish its independent predictive value for future events.

Amino Acid Intakes Are Inversely Associated with Arterial Stiffness and Central Blood Pressure in Women

BACKGROUND

Although data suggest that intakes of total protein and specific amino acids (AAs) reduce blood pressure, data on other cardiovascular disease risk factors are limited.

OBJECTIVE

We examined associations between intakes of AAs with known mechanistic links to cardiovascular health and direct measures of arterial stiffness, central blood pressure, and atherosclerosis.

METHODS

In a cross-sectional study of 1898 female twins aged 18-75 y from the TwinsUK registry, intakes of 7 cardioprotective AAs (arginine, cysteine, glutamic acid, glycine, histidine, leucine, and tyrosine) were calculated from food-frequency questionnaires. Direct measures of arterial stiffness and atherosclerosis included central systolic blood pressure (cSBP), mean arterial pressure (MAP), augmentation index (AI), pulse wave velocity (PWV), and intima-media thickness (IMT). ANCOVA was used to assess the associations between endpoints of arterial stiffness and intake (per quintile), adjusting for potential confounders.

RESULTS

In multivariable analyses, higher intakes of total protein and 7 potentially cardioprotective AAs were associated with lower cSBP, MAP, and PWV. Higher intakes of glutamic acid, leucine, and tyrosine were most strongly associated with PWV, with respective differences of -0.4 ± 0.2 m/s (P-trend = 0.02), -0.4 ± 0.2 m/s (P-trend = 0.03), and -0.4 ± 0.2 m/s (P-trend = 0.03), comparing extreme quintiles. There was a significant interaction between AA intakes and protein source, and higher intakes of AAs from vegetable sources were associated with lower central blood pressure and AI. Higher intakes of glutamic acid, leucine, and tyrosine from animal sources were associated with lower PWV.

CONCLUSIONS

These data provide evidence to suggest that intakes of several AAs are associated with cardiovascular benefits beyond blood pressure reduction in healthy women. The magnitude of the observed associations was similar to those previously reported for other lifestyle factors. Increasing intakes of these AAs could be an important and readily achievable way to reduce cardiovascular disease risk.

Optimizing Scripted Dialogues for an e-Health Intervention for Suicidal Veterans with Major Depression

Suicide is a health concern among Veterans with depression. We had previously reported on scripted dialogues adapted for an e-health system that engages at-risk veterans with schizophrenia. Here we report a further adaptation of the dialogues for Veterans with depression. Usability was assessed with nine outpatients with a history of major depression and suicidality. We noted that participants preferred greater specificity in the wording of questions. Topics that elicited an emotional response dealt with questions on suicide, social isolation and family relationships. Based on feedback, dialogues were revised for patients with depression. We also compared responses between those with depression and those with schizophrenia who were previously tested. The two groups shared similar themes. Also, individuals with a history of major depression had less trouble with vocabulary comprehension but were less willing to answer more questions daily.

International breast cancer and nutrition: a model for research, training and policy in diet, epigenetics, and chronic disease prevention

This article summarizes presentations from the International Breast Cancer and Nutrition workshop held during the ASN Scientific Sessions and Annual Meeting at Experimental Biology 2014 in San Diego, CA, on 28 April 2014. An international collaboration was described among teams from low-, middle-, and high-income countries addressing environmental factors, especially diet, and epigenetic interactions that affect the risk of chronic disease. Speakers addressed opportunities and challenges involved in this type of international collaboration, assessing diet and nutritional status across a wide range of cultures, and research tools and discoveries from this group.

Comparison of fluorodeoxyglucose uptake in symptomatic carotid artery and stable femoral artery plaques

BACKGROUND

Fluorine-18-labelled fluoroxdeoxyglucose (FDG) positron emission tomography (PET) has been used to evaluate atherosclerotic plaque metabolic activity, and through its uptake by macrophages is believed to have the potential to identify vulnerable plaques. The aims were to compare FDG uptake in carotid plaques from patients who had sustained a recent thromboembolic cerebrovascular event with that in femoral artery plaques from patients with leg ischaemia, and to correlate FDG uptake with the proportion of M1 and M2 macrophages present.

METHODS

Consecutive patients who had carotid endarterectomy for symptomatic, significant carotid stenosis and patients with severe leg ischaemia and significant stenosis of the common femoral artery underwent FDG-PET and histological plaque analysis. The voxel with the greatest activity in the region of interest was calculated using the Patlak method over 60 min. Plaques were dual-stained for CD68, and M1 and M2 macrophage subsets.

RESULTS

There were 29 carotid and 25 femoral artery plaques for study. The maximum dynamic uptake was similar in carotid compared with femoral plaques: median (range) 9·7 (7·1-12·2) versus 10·0 (7·4-16·6) respectively (P = 0·281). CD68 macrophage counts were significantly increased in carotid compared with femoral plaques (39·5 (33·9-50·1) versus 11·5 (7·7-21·3) respectively; P < 0·001), as was the proportion of M1 proinflammatory macrophages. The degree of carotid stenosis correlated with the maximum dynamic FDG uptake (rs  = 0·48, P = 0·008).

CONCLUSION

FDG uptake was no greater in symptomatic carotid plaques than in the less inflammatory femoral plaques. In patients on statin therapy. FDG uptake occurred in areas of significant arterial stenosis, irrespective of the degree of inflammation.

Dietary antioxidants and the aetiology of pancreatic cancer: a cohort study using data from food diaries and biomarkers

OBJECTIVE

To investigate whether the dietary antioxidants vitamins C and E, selenium and zinc decrease the risk of developing pancreatic cancer, for the first time using 7-day food diaries, the most accurate dietary methodology in prospective work.

DESIGN

23,658 participants, aged 40-74 years, recruited into the EPIC-Norfolk Study completed 7-day food diaries which recorded foods, brands and portion sizes. Nutrient intakes were calculated in those later diagnosed with pancreatic cancer and in 3970 controls, using a computer program with information on 11,000 foods. Vitamin C was measured in serum samples. The HRs of developing pancreatic cancer were estimated across quartiles of intake and thresholds of the lowest quartile (Q1) against a summation of the three highest (Q2-4).

RESULTS

Within 10 years, 49 participants (55% men), developed pancreatic cancer. Those eating a combination of the highest three quartiles of all of vitamins C and E and selenium had a decreased risk (HR=0.33, 95% CI 0.13 to 0.84, p<0.05). There were threshold effects (Q2-4 vs Q1) for selenium (HR=0.49, 95% CI 0.26 to 0.93, p<0.05) and vitamin E (HR=0.57, 95% CI 0.29 to 1.09, p<0.10). The HRs of quartiles for antioxidants, apart from zinc, were <1, but not statistically significant. For vitamin C, there was an inverse association with serum measurements (HR trend=0.67, 95% CI 0.49 to 0.91, p=0.01), but the threshold effect from diaries was not significant (HR=0.68, 95% CI 0.37 to 1.26).

CONCLUSION

The results support measuring antioxidants in studies investigating the aetiology of pancreatic cancer. If the association is causal, 1 in 12 cancers might be prevented by avoiding the lowest intakes.

Successful weight management and health behaviour change using a health trainer model

Aim:

NHS Great Yarmouth and Waveney is an area of high deprivation and it is estimated that 49% of the adult population are overweight or obese. The health trainer model, which involves recruiting trainers from local communities, offers an innovative way of supporting individuals in managing their weight through one-to-one support. The aim of the current study was to evaluate the effectiveness of a health trainer-led intervention in terms of weight loss and behaviour change.

Methods:

Data were collected from all participants who visited a health trainer for the purpose of weight loss between February 2008 and March 2011. All participants were seen on a one-to-one basis, with the setting and length of the intervention varying according to individual requirements (median 21 weeks, IQR 12.4–29.6). Weight change was the primary outcome measure; secondary outcomes were blood pressure, fruit and vegetable intake and physical activity levels, measured using established health trainer data recording systems. Data on secondary outcomes were not available for all participants due to lack of compliance.

Results:

Using intention-to-treat analysis, average weight change was -2.5 kg (95% CI - 2.7 – -2.1, n = 541, p < .001) and weight gain was prevented in 90% of participants ( n = 487). The number of participants classified as hypertensive reduced from 60% ( n = 66) to 41% ( n = 45) over the period of the intervention. In terms of behaviour change, fruit and vegetable intake increased significantly by 2.4 portions per day (95% CI 2.1–2.7, n = 248, p < .001) with 46% ( n = 115) of participants increasing their intake to five portions per day. 68% of participants for whom data were available ( n = 227) reported an increase in moderate physical activity, with time increasing by 59.3 minutes per week (95% CI 46.3–72.4, p < .001).

Conclusions:

The health trainer service in Great Yarmouth and Waveney may be effective in helping participants to manage their weight and change their health-related behaviour. Although the degree of weight loss reported was moderate given the high levels of deprivation and the health needs of the local population, these were promising findings. To improve the current evidence base for the effectiveness of health trainer-led interventions, studies need to see if these findings are replicable in other population groups and in other settings.

Association between diet and physical activity and sedentary behaviours in 9-10-year-old British White children

OBJECTIVES

To examine the association between diet and physical activity and sedentary behaviours in 9-10-year-old children.

STUDY DESIGN

A cross-sectional study using data from the SPEEDY (Sport, Physical activity and Eating behaviour: Environmental Determinants in Young People) study undertaken in Norfolk, UK.

METHODS

Data from 4-day food diaries and 7 days of accelerometery were matched on concurrent days. Time spent in moderate-to-vigorous physical activity (MVPA), time spent in sedentary behaviour and various measures of dietary intake were collected. Covariates included age, sex, weight status, family socio-economic status, and energy intake reporting quality. Multivariable regression models, adjusted for clustering of children by school and stratified by sex, were fitted to examine the associations between dietary measures and physical activity and sedentary outcomes.

RESULTS

In total, 1317 children (584 boys and 733 girls) provided concurrent data. Boys in the highest quartile of energy percentage from protein spent approximately 6 min [95% confidence interval (CI) 0-12] less in MVPA compared with boys in the lowest quartile. Those in the highest quartiles of fruit and vegetable intake and fruit juice intake had respective average activity counts per minute that were 56 above (95% CI 8-105) and 48 below (95% CI 2-95) those in the lowest quartiles, whilst those in the highest quartile of fizzy drink consumption spent approximately 7 min (95% CI 2-13) more in MVPA and approximately 14 min (95% CI 5-24 min) less in sedentary behaviour. Boys in the highest quartile of savoury snack consumption spent approximately 8 min (95% CI 2-13 min) more in MVPA per day, and approximately 12 min (95% CI 2-23) less in sedentary behaviour. No significant associations were apparent among girls.

CONCLUSIONS

Few associations were detected, and the directions of those that were apparent were mainly counterintuitive. The extent to which this reflects a true lack of association or is associated with the measurement methods used for diet and physical activity needs further investigation.

Acute Cerebrovascular Disease in the Young

Background and Purpose—

Strokes have especially devastating implications if they occur early in life; however, only limited information exists on the characteristics of acute cerebrovascular disease in young adults. Although risk factors and manifestation of atherosclerosis are commonly associated with stroke in the elderly, recent data suggests different causes for stroke in the young. We initiated the prospective, multinational European study Stroke in Young Fabry Patients (sifap) to characterize a cohort of young stroke patients.

Methods—

Overall, 5023 patients aged 18 to 55 years with the diagnosis of ischemic stroke (3396), hemorrhagic stroke (271), transient ischemic attack (1071) were enrolled in 15 European countries and 47 centers between April 2007 and January 2010 undergoing a detailed, standardized, clinical, laboratory, and radiological protocol.

Results—

Median age in the overall cohort was 46 years. Definite Fabry disease was diagnosed in 0.5% (95% confidence interval, 0.4%–0.8%; n=27) of all patients; and probable Fabry disease in additional 18 patients. Males dominated the study population (2962/59%) whereas females outnumbered men (65.3%) among the youngest patients (18–24 years). About 80.5% of the patients had a first stroke. Silent infarcts on magnetic resonance imaging were seen in 20% of patients with a first-ever stroke, and in 11.4% of patients with transient ischemic attack and no history of a previous cerebrovascular event. The most common causes of ischemic stroke were large artery atherosclerosis (18.6%) and dissection (9.9%).

Conclusions—

Definite Fabry disease occurs in 0.5% and probable Fabry disease in further 0.4% of young stroke patients. Silent infarcts, white matter intensities, and classical risk factors were highly prevalent, emphasizing the need for new early preventive strategies.

Clinical Trial Registration Information—

URL: http://www.clinicaltrials.gov .Unique identifier: NCT00414583

Cigarette Smoking and Fat Distribution in 21, 828 British Men and Women: A Population-based Study

OBJECTIVE

To examine the relationship between cigarette smoking habits and fat distribution in a population-based cohort of men and women.

RESEARCH METHODS AND PROCEDURES

We analyzed cross-sectional data from 21,828 men and women who were 45 to 79 years of age, residents in Norfolk, United Kingdom, and were recruited between 1993 and 1997. Cigarette smoking habits and other lifestyle factors were assessed using self-reported questionnaires. Anthropometric measures were obtained during a health examination.

RESULTS

Waist-hip ratio was highest among current smokers and least among never smokers after adjusting for age, BMI, alcohol intake, total energy intake, physical activity, and education. Higher waist-hip ratio was directly associated with higher smoking pack-years in current and former smokers and inversely with duration since quitting smoking in former smokers. Adjusting for age, BMI, and other covariates, current smokers had higher waist circumference but lower hip circumference compared with former or never smokers.

DISCUSSION

Cigarette smoking habits seem to influence fat distribution patterns. Although smokers have lower mean BMI compared with nonsmokers, they have a more metabolically adverse fat distribution profile, with higher central adiposity. The explanation for this association may help elucidate the mechanisms underlying the adverse health consequences of cigarette smoking and abdominal obesity.

Habitual flavonoid intakes are positively associated with bone mineral density in women

Dietary flavonoids exert bone-protective effects in animal models, but there is limited information on the effect of different flavonoid subclasses on bone health in humans. The aim of this observational study was to examine the association between habitual intake of flavonoid subclasses with bone mineral density (BMD) in a cohort of female twins. A total of 3160 women from the TwinsUK adult twin registry participated in the study. Habitual intakes of flavonoids and subclasses (flavanones, anthocyanins, flavan-3-ols, polymers, flavonols, and flavones) were calculated from semiquantitative food frequency questionnaires using an updated and extended U.S. Department of Agriculture (USDA) database. Bone density was measured using dual-energy X-ray absorptiometry. In multivariate analyses, total flavonoid intake was positively associated with higher BMD at the spine but not at the hip. For the subclasses, the magnitude of effect was greatest for anthocyanins, with a 0.034 g/cm(2) (3.4%) and 0.029 g/cm(2) (3.1%) higher BMD at the spine and hip, respectively, for women in the highest intake quintile compared to those in the lowest. Participants in the top quintile of flavone intake had a higher BMD at both sites; 0.021 g/cm(2) (spine) and 0.026 g/cm(2) (hip). At the spine, a greater intake of flavonols and polymers was associated with a higher BMD (0.021 and 0.024 g/cm(2) , respectively), whereas a higher flavanone intake was positively associated with hip BMD (0.008 g/cm(2) ). In conclusion, total flavonoid intake was positively associated with BMD, with effects observed for anthocyanins and flavones at both the hip and spine, supporting a role for flavonoids present in plant-based foods on bone health. .

Inflammatory myofibroblastic tumours of the respiratory tract: paediatric case series with varying clinical presentations

OBJECTIVES

To highlight the clinical importance of inflammatory myofibroblastic tumours of the respiratory tract in children, and to present a case series of three children which illustrates this tumour's variable clinical presentation.

CASE HISTORY

The series includes: a nine-year-old girl with a diagnosis of juvenile idiopathic arthritis, who presented with finger clubbing and was found to have an inflammatory myofibroblastic tumour in her right upper lobe; a 15-year-old adolescent with a left main stem bronchial inflammatory myofibroblastic tumour, who presented with breathlessness and chest pain; and a 12-year-old girl with a tracheal inflammatory myofibroblastic tumour who presented with stridor. In each case, the tumour was resected surgically.

CONCLUSION

Inflammatory myofibroblastic tumour are a rare but clinically important and pathologically distinct lesion of the respiratory tract in children. The cases in this series highlight some of the varied clinical presentations of inflammatory myofibroblastic tumours, and illustrate some of this tumour's different anatomical locations within the paediatric respiratory tract.

Local food outlets, weight status, and dietary intake: associations in children aged 9-10 years

BACKGROUND

The rising prevalence of childhood obesity is a key public health issue worldwide. Limited evidence suggests that there may be interactions between environmental factors at a neighborhood level and the development of obesity, with the availability and accessibility of food outlets being potentially important.

PURPOSE

To examine how the weight status and dietary intake of 1669 children aged 9-10 years was associated with neighborhood food outlets in a cross-sectional study.

METHODS

Availability of food outlets was computed from GIS data for each child's unique neighborhood. Outlets were grouped into BMI-healthy, BMI-unhealthy, or BMI-intermediate categories according to food type sold. Weight status measurements were objectively collected, and food intake was recorded using 4-day food diaries. Data were collected in 2007 and analyzed in 2009.

RESULTS

Availability of BMI-healthy outlets in neighborhoods was associated with lower body weight (1.3 kg, p=0.03); BMI (0.5 kg/m(2), p=0.02); BMI z-score (0.20, p=0.02); waist circumference (1.3 cm, p=0.02); and percentage body fat (1.1%, p=0.03) compared to no availability. In contrast, neighborhood availability of BMI-unhealthy outlets was inversely associated with body weight (1.3 kg, p=0.02); BMI (0.4 kg/m(2), p=0.05); BMI z-score (0.15, p=0.05); waist circumference (1.1 cm, p=0.04); and percentage body fat (1.0%, p=0.03). Unhealthy food intake (fizzy drinks 15.3%, p=0.04, and noncarbonated "fruit" drinks 11.8%, p=0.03) was also associated with availability of BMI-unhealthy food outlets.

CONCLUSIONS

Features of the built environment relating to food purchasing opportunities are correlated with weight status in children.

Diet quality is independently associated with weight status in children aged 9-10 years

Although energy imbalance is key to the development of childhood obesity, the association between different dietary components, reflected in diet quality scores, and children's weight status has not been extensively studied. The current study determined if diet quality, characterized according to 3 predefined scores, was associated with weight status in a population-based sample of 9- to 10-y-old British children, independently of factors previously associated with weight status. In a cross-sectional study of 1700 children (56% girls), data from 4-d food diaries were used to calculate 3 diet quality scores modified to be reflective of children's diets: the Diet Quality Index (DQI), Healthy Diet Indicator (HDI), and Mediterranean Diet Score (MDS). Physical activity was measured with 7-d accelerometery, and height, weight, waist, and bio-impedance were objectively measured and used to calculate weight status variables. After multiple adjustments, including physical activity and overall energy density, higher DQI and HDI scores were significantly associated with improved weight status. Comparing extreme quintiles of the scores revealed the DQI and HDI were associated with lower waist circumference (-3.0%, P = 0.005 and -2.5%, P = 0.033, respectively), and lower body fat (-5.1%, P = 0.023 and -4.9%, P = 0.026, respectively). The DQI was also associated with lower weight (-5.9%; P = 0.002) and BMI (-4.2%; P = 0.004). No significant associations were observed with the MDS. These findings suggest that diet quality is independently associated with children's weight status. Future work should consider if diet quality scores could be key components of interventions designed to reduce obesity in children.

Innervation and nerve injections of the lumbar spine of the horse: a cadaveric study

REASONS FOR PERFORMING STUDY

The distal limb innervation of the horse has been studied extensively to allow use of local anaesthetic techniques to detect the origin of pain in lameness. However, the innervation of the lumbar spine has so far been poorly described and a more precise description may assist clinicians to localise back pain in the horse.

OBJECTIVES

To gain better knowledge of the innervation of the lumbar spine and identify salient anatomical features that might be used for diagnostic and therapeutic ultrasound guided injections.

METHODS

The spines of 8 mature horses were dissected. Branches of the dorsal rami were followed and their anatomical relationship, with articular facets, interspinous structures and muscles, noted. The spines of 3 other horses were sectioned transversely and dissected to identify ultrasonographic landmarks of the nerves. Six other spines were used to assess the accuracy of ultrasound guided injections of the nerves with blue dye.

RESULTS

Gross dissections confirmed the dual segmental innervation of the articular facets. Each lumbar articular facet of 2 lumbar vertebrae was innervated by the medial branch of the dorsal ramus exiting from the intervertebral foramen between those vertebrae, but also by the branch originating of the dorsal ramus cranial to it. The medial branch divided into 2 nerves before exiting the intertransverse space and has salient anatomical landmarks which could be identified ultrasonographically. The ultrasound guided injection technique appeared to be of an accuracy that would be clinically useful.

CONCLUSION

The results identified that the salient anatomical features of the medial branch of the dorsal ramus, as described in the present study, can be used as landmarks for reliable ultrasound-guided injection.

POTENTIAL RELEVANCE

This study has a clear clinical relevance for development of diagnostic and therapeutic injection techniques of the lumbar spine in the horse.

Dietary habits in three Central and Eastern European countries: the HAPIEE study

BACKGROUND

The high cardiovascular mortality in Eastern Europe has often been attributed to poor diet, but individual-level data on nutrition in the region are generally not available. This paper describes the methods of dietary assessment and presents preliminary findings on food and nutrient intakes in large general population samples in Russia, Poland and the Czech Republic.

METHODS

The HAPIEE (Health, Alcohol and Psychosocial factors In Eastern Europe) study examined random samples of men and women aged 45-69 years at baseline in Novosibirsk (Russia), Krakow (Poland) and six Czech urban centres in 2002-2005. Diet was assessed using a food frequency questionnaire (at least 136 items); complete dietary information was available for 26,870 persons.

RESULTS

Total energy intakes among men ranged between 8.7 MJ in the Czech sample and 11.7 MJ in the Russian sample, while among women, energy intakes ranged between 8.2 MJ in the Czech sample and 9.8 MJ in the Russian sample. A Healthy Diet Indicator (HDI), ranging from a score of 0 (lowest) to 7 (highest), was developed using the World Health Organisation's (WHO) guidelines for the prevention of chronic diseases. The mean HDI scores were low, ranging from 1.0 (SD = 0.7) among the Polish subjects to 1.7 (SD = 0.8) among the Czech females. Very few subjects met the WHO recommended intakes for complex carbohydrates, pulses or nuts; intakes of saturated fatty acids, sugar and protein were too high. Only 16% of Polish subjects met the WHO recommendation for polyunsaturated fat intake. Consumption of fruits and vegetables was lower than recommended, especially among those Russian subjects who were assessed during the low intake season. Fewer than 65% of subjects consumed adequate amounts of calcium, magnesium and potassium, when compared with the United Kingdom's Reference Nutrient Intake.

CONCLUSION

This first large scale study of individual-based dietary intakes in the general population in Eastern Europe implies that intakes of saturated fat, sugar and complex carbohydrates are a cause for concern. The development of country-specific nutritional tools must be encouraged and nutritional campaigns must undergo continuing development.

Plasma adiponectin concentrations are associated with body composition and plant-based dietary factors in female twins

Circulating adiponectin is emerging as an important link between obesity, type 2 diabetes, and cardiovascular disease (CVD). However, the spectrum of lifestyle factors that modulate the adiponectin concentration remains to be elucidated, particularly among women. We conducted a cross-sectional study of 877 female twin pairs from the TwinsUK adult twin registry. Using a co-twin design, we examined dietary and body composition influences on adiponectin by conducting matched, within-pair analyses to eliminate confounding. Following multivariable adjustment within-twin pairs, significant influences on adiponectin (log-transformed, percent change per SD of the dietary/body composition variable) were observed for nonstarch polysaccharides (3.25%; 95% CI: 0.06, 6.54; P < 0.05) and magnesium intake (3.80%; 95%CI: 0.17, 7.57; P < 0.05), with a trend toward an association for fruit and vegetable (F&V) intakes (2.55%; 95% CI: -0.26, 5.45; P = 0.08). These modest positive associations cannot be explained by confounding through other lifestyle factors shared by the twins. A significant relationship between adiponectin and 3 derived dietary patterns (F&V, dieting, traditional English), carbohydrate, protein, trans fat, and alcohol intake was also observed. Strong inverse associations with adiponectin were observed for BMI (-10.72%; 95% CI: -13.78, -7.55), total (-6.89%: 95% CI: -10.34, -3.30; P < 0.05), and central fat mass (-12.50%; 95% CI: -15.82, -9.05; P < 0.05); these relationships were significant both when twins were analyzed as individuals and when characteristics were contrasted within-twin pairs, suggesting a direct effect. We observed modest associations between dietary factors and adiponectin in female twins, independent of adiposity, and report strong inverse associations with body composition. These data reinforce the importance of weight maintenance and increasing consumption of diets rich in plant-based foods to prevent CVD and type 2 diabetes.

Plasma vitamin C level, fruit and vegetable consumption, and the risk of new-onset type 2 diabetes mellitus: the European prospective investigation of cancer--Norfolk prospective study

BACKGROUND

Epidemiologic studies suggest that greater consumption of fruit and vegetables may decrease the risk of diabetes mellitus, but the evidence is limited and inconclusive. Plasma vitamin C level is a good biomarker of fruit and vegetable intake, but, to our knowledge, no prospective studies have examined its association with diabetes risk. This study aims to examine whether fruit and vegetable intake and plasma vitamin C level are associated with the risk of incident type 2 diabetes.

METHODS

We administered a semiquantitative food frequency questionnaire to men and women from a population-based prospective cohort (European Prospective Investigation of Cancer-Norfolk) study who were aged 40 to 75 years at baseline (1993-1997) when plasma vitamin C level was determined and habitual intake of fruit and vegetables was assessed. During 12 years of follow-up between February 1993 and the end of December 2005, 735 clinically incident cases of diabetes were identified among 21 831 healthy individuals. We report the odds ratios of diabetes associated with sex-specific quintiles of fruit and vegetable intake and of plasma vitamin C levels.

RESULTS

A strong inverse association was found between plasma vitamin C level and diabetes risk. The odds ratio of diabetes in the top quintile of plasma vitamin C was 0.38 (95% confidence interval, 0.28-0.52) in a model adjusted for demographic, lifestyle, and anthropometric variables. In a similarly adjusted model, the odds ratio of diabetes in the top quintile of fruit and vegetable consumption was 0.78 (95% confidence interval, 0.60-1.00).

CONCLUSIONS

Higher plasma vitamin C level and, to a lesser degree, fruit and vegetable intake were associated with a substantially decreased risk of diabetes. Our findings highlight a potentially important public health message on the benefits of a diet rich in fruit and vegetables for the prevention of diabetes.

Blood pressure and interactions between the angiotensin polymorphism AGT M235T and sodium intake: a cross-sectional population study

BACKGROUND

Intervention studies have indicated an interaction between the blood pressure response to a low-sodium or a low-fat and high-fruit and -vegetable diet and the angiotensinogen gene (AGT) polymorphisms G-6A and M235T.

OBJECTIVE

We investigated whether this interaction is also present in a large free-living population.

DESIGN

Urinary sodium, potassium as biomarkers of intake, and blood pressure were measured in 11 384 men and women aged 45-79 y participating in the Norfolk arm of the European Prospective Investigation of Nutrition and Cancer (EPIC). The M235T polymorphism was assessed by pyrosequencing.

RESULTS

Highly significant associations between sodium and blood pressure were shown for all genotypes (P < 0.001), but the regression coefficient for systolic blood pressure associated with each unit of sodium for each of the MT and TT genotypes was approximately double that for the MM homozygotes (P < 0.001 for heterogeneity between genotypes). Differences were evident at high exposures to sodium but not at low exposures. There were no significant associations between blood pressure and dietary or urinary potassium.

CONCLUSIONS

This large cross-sectional study supports public health recommendations to reduce salt consumption in the population as a whole, and it confirms intervention trial data showing the greatest response to intervention in persons with the AA and TT genotype in the AGT G-6A and M235T polymorphisms. Genotype effects in populations at low exposure to sodium are not likely to be seen.

Past oral contraceptive and hormone therapy use and endogenous hormone concentrations in postmenopausal women

OBJECTIVE

Exogenous sex hormone use is associated with many health effects. Current exogenous hormone use influences endogenous sex hormone levels, but little is known about longer term effects on endogenous hormones after cessation of use. The aim of this study was to examine the relationship between past hormone use and current endogenous hormone status.

DESIGN

This was a cross-sectional study of 1,983 postmenopausal women aged 55 to 81 years from the general community. The women were not currently using exogenous hormones. Past use of oral contraceptives (OCs) and hormone therapy (HT) as well as circulating endogenous sex hormones and sex hormone-binding globulin concentrations were evaluated.

RESULTS

Past OC users had significantly lower endogenous estradiol, estrone, androstenedione, testosterone, and sex hormone-binding globulin concentrations compared with never users independent of age, body mass index, smoking, physical activity, and reproductive factors. Past HT users had significantly lower testosterone and 17alpha-hydroxyprogesterone concentrations. Past OC use and HT use were both independently associated with lower testosterone concentrations: -9% (95% CI: -16% to -2%) for ever OC use compared with never OC use and -7% (95% CI: -17% to -2%) for ever HT use compared with never HT use. The magnitude of 5% to 10% differences in endogenous hormone concentrations was similar or greater for past OC use compared with past HT use, although OC use occurred earlier in the past.

CONCLUSIONS

Past OC use and HT use seem to be related to long-term differences in endogenous sex hormones and sex hormone-binding globulin concentrations in postmenopausal women many years after cessation of use. These findings have implications for understanding the longer term effects of exogenous hormone exposures earlier in life with health and disease risk in later life.

Associations between dietary methods and biomarkers, and between fruits and vegetables and risk of ischaemic heart disease, in the EPIC Norfolk Cohort Study

BACKGROUND

Methods for assessing diet are prone to measurement error, which may be substantial in large cohort investigations. Biomarkers can be used as objective measures with which to compare estimates of nutritional exposure using different methods

METHODS

Cross sectional comparisons in 12 474 men and women of regression between biomarkers for vitamin C, sodium, potassium, fibre, carbohydrate, fat and phytoestrogens with intakes derived from food diaries and food frequency questionnaires (FFQ), and odds ratios for risk of ischaemic heart disease (IHD) by dietary and plasma vitamin C.

RESULTS

There were strong (P < 0.001) associations between biomarkers and intakes as assessed by food diary. Coefficients were markedly attenuated for data obtained from the FFQ, especially so for vitamin C, potassium and phytoestrogens (Z P < 0.05). Risk of IHD was associated with plasma vitamin C (P < 0.001) and intake of vitamin C and fruit and vegetables assessed by food diary (P quintile trends <0.001, 0.001) but not by the FFQ (P quintile trends 0.923, 0.186).

CONCLUSIONS

Nutritional data that reflect the findings from biomarkers reduce measurement error and will thus improve statistical power in studies of gene nutrient interactions in cohort studies.

Hormone replacement therapy and symptomatic gallstones - a prospective population study in the EPIC-Norfolk cohort

BACKGROUND/AIMS

Hormone replacement therapy (HRT) may increase the risk of symptomatic gallstones, but this association has not been investigated in a prospective study in a European population. The aim of the study was to investigate the relationship between HRT and the development of symptomatic gallstones in a free-living population.

METHODS

Use of HRT was ascertained by questionnaire in 13,433 women aged 45-74 years living in Norfolk, UK, who participated in the EPIC-Norfolk Study (European Prospective Investigation Into Cancer). The use of HRT was that at the time of recruitment rather than at the point of diagnosis. Participants were followed up for the development of symptomatic gallstones. The analysis used a nested case-control method in a prospective study.

RESULTS

A total of 117 women developed symptomatic gallstones. Women who reported either ever using HRT, currently using HRT or who had been past users all had a greater risk of gallbladder disease than age-matched control women who had never used HRT, after adjusting for known risk factors for gallstones. Women who had ever used HRT had a risk of 1.94 (95% CI = 1.17-3.22) compared with women who had never used HRT. For past users of HRT, the risk of symptomatic gallstones was greater, the longer the duration of use (OR = 4.05, 95% CI = 1.12-14.76 for use >1 year, compared to OR = 2.04, 95% CI = 0.79-5.30 for < or =1 year).

CONCLUSIONS

Use of HRT was positively associated with an increased risk of symptomatic gallstones in this population. This confirms trial data and additionally shows effects of duration of use and increased risk associated with past use.

Diet in the aetiology of ulcerative colitis: a European prospective cohort study

BACKGROUND/AIMS

The causes of ulcerative colitis are unknown, although it is plausible that dietary factors are involved. Case-control studies of diet and ulcerative colitis are subject to recall biases. The aim of this study was to examine the prospective relationship between the intake of nutrients and the development of ulcerative colitis in a cohort study.

METHODS

The study population was 260,686 men and women aged 20-80 years, participating in a large European prospective cohort study (EPIC). Participants were residents in the UK, Sweden, Denmark, Germany or Italy. Information on diet was supplied and the subjects were followed up for the development of ulcerative colitis. Each incident case was matched with four controls and dietary variables were divided into quartiles.

RESULTS

A total of 139 subjects with incident ulcerative colitis were identified. No dietary associations were detected, apart from a marginally significant positive association with an increasing percentage intake of energy from total polyunsaturated fatty acids (trend across quartiles OR = 1.19 (95% CI = 0.99-1.43) p = 0.07).

CONCLUSIONS

No associations between ulcerative colitis and diet were detected, apart from a possible increased risk with a higher total polyunsaturated fatty acid intake. A biological mechanism exists in that polyunsaturated fatty acids are metabolised to pro-inflammatory mediators.

Cross-sectional association between fish consumption and albuminuria: the European Prospective Investigation of Cancer-Norfolk Study

BACKGROUND

Studies have shown a potential beneficial role for fish and fish oil consumption in the management of diabetes and its complications. The aim of this study is to examine the association between fish consumption and albuminuria in individuals with and without diabetes.

STUDY DESIGN

A cross-sectional analysis conducted in the European Prospective Investigation of Cancer-Norfolk population-based cohort study.

SETTING & PARTICIPANTS

22,384 men and women from general practices in the city of Norwich and vicinity, of whom 517 had diabetes by self-report and 21,867 did not report diabetes.

PREDICTORS

Fish consumption was measured in a validated semiquantitative food frequency questionnaire and categorized as less than 1, 1 to 2, and more than 2 portions/wk. Interaction between fish intake and diabetes status was hypothesized a priori.

OUTCOMES & MEASUREMENTS

Microalbuminuria and macroalbuminuria were defined as urinary albumin-creatinine ratio of 2.5 or greater to 24.9 and 25 mg/mmol or greater, respectively. Log-transformed albumin-creatinine ratio was used as a continuous variable.

RESULTS

Prevalences of microalbuminuria were 22.6% in participants with diabetes and 11.4% in participants without diabetes. Prevalences of macroalbuminuria were 8.3% and 0.6%, respectively. Fish consumption was associated with a lower risk of macroalbuminuria in participants with diabetes (odds ratio, 0.22, >2 versus <1 portion/wk; 95% confidence interval, 0.07 to 0.70; P for trend = 0.009) after adjustment for confounding. This association was not observed in participants with diabetes with microalbuminuria or in the nondiabetic population. There was a significant interaction between diabetes status and fish consumption of 1 to 2 portions/wk (P = 0.03) and more than 2 portions/wk (P = 0.007) for risk of macroalbuminuria.

LIMITATIONS

Cross-sectional nature of study. Self-report of fish intake and diabetes status.

CONCLUSIONS

Greater fish intake was associated with a lower risk of macroalbuminuria in a self-defined diabetic population. These findings merit confirmation in prospective studies and intervention trials and suggest that fish intake may be beneficial for albuminuria in people with diabetes.

Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study

BACKGROUND

There is overwhelming evidence that behavioural factors influence health, but their combined impact on the general population is less well documented. We aimed to quantify the potential combined impact of four health behaviours on mortality in men and women living in the general community.

METHODS AND FINDINGS

We examined the prospective relationship between lifestyle and mortality in a prospective population study of 20,244 men and women aged 45-79 y with no known cardiovascular disease or cancer at baseline survey in 1993-1997, living in the general community in the United Kingdom, and followed up to 2006. Participants scored one point for each health behaviour: current non-smoking, not physically inactive, moderate alcohol intake (1-14 units a week) and plasma vitamin C >50 mmol/l indicating fruit and vegetable intake of at least five servings a day, for a total score ranging from zero to four. After an average 11 y follow-up, the age-, sex-, body mass-, and social class-adjusted relative risks (95% confidence intervals) for all-cause mortality(1,987 deaths) for men and women who had three, two, one, and zero compared to four health behaviours were respectively, 1.39 (1.21-1.60), 1.95 (1.70--2.25), 2.52 (2.13-3.00), and 4.04 (2.95-5.54) p < 0.001 trend. The relationships were consistent in subgroups stratified by sex, age, body mass index, and social class, and after excluding deaths within 2 y. The trends were strongest for cardiovascular causes. The mortality risk for those with four compared to zero health behaviours was equivalent to being 14 y younger in chronological age.

CONCLUSIONS

Four health behaviours combined predict a 4-fold difference in total mortality in men and women, with an estimated impact equivalent to 14 y in chronological age.

Body fat distribution and risk of coronary heart disease in men and women in the European Prospective Investigation Into Cancer and Nutrition in Norfolk cohort: a population-based prospective study

BACKGROUND

Body fat distribution has been cross-sectionally associated with atherosclerotic disease risk factors, but the prospective relation with coronary heart disease remains uncertain.

METHODS AND RESULTS

We examined the prospective relation between fat distribution indices and coronary heart disease among 24,508 men and women 45 to 79 years of age using proportional hazards regression. During a mean 9.1 years of follow-up, 1708 men and 892 women developed coronary heart disease. The risk for developing subsequent coronary heart disease increased continuously across the range of waist-hip ratio. Hazard ratios (95% CI) of the top versus bottom fifth of waist-hip ratio were 1.55 (1.28 to 1.73) in men and 1.91 (1.44 to 2.54) in women after adjustment for body mass index and other coronary heart disease risk factors. Hazard ratios increased with waist circumference, but risk estimates for waist circumference without hip circumference adjustment were lower by 10% to 18%. After adjustment for waist circumference, body mass index, and coronary heart disease risk factors, hazard ratios for 1-SD increase in hip circumference were 0.80 (95% CI, 0.74 to 0.87) in men and 0.80 (95% CI, 0.69 to 0.93) in women. Hazard ratios for body mass index were greatly attenuated when we adjusted for waist-hip ratio or waist circumference and other covariates.

CONCLUSIONS

Indices of abdominal obesity were more consistently and strongly predictive of coronary heart disease than body mass index. These simple and inexpensive measurements could be used to assess obesity-related coronary heart disease risk in relatively healthy men and women.

Endogenous testosterone and mortality due to all causes, cardiovascular disease, and cancer in men: European prospective investigation into cancer in Norfolk (EPIC-Norfolk) Prospective Population Study

BACKGROUND

The relation between endogenous testosterone concentrations and health in men is controversial.

METHODS AND RESULTS

We examined the prospective relationship between endogenous testosterone concentrations and mortality due to all causes, cardiovascular disease, and cancer in a nested case-control study based on 11 606 men aged 40 to 79 years surveyed in 1993 to 1997 and followed up to 2003. Among those without prevalent cancer or cardiovascular disease, 825 men who subsequently died were compared with a control group of 1489 men still alive, matched for age and date of baseline visit. Endogenous testosterone concentrations at baseline were inversely related to mortality due to all causes (825 deaths), cardiovascular disease (369 deaths), and cancer (304 deaths). Odds ratios (95% confidence intervals) for mortality for increasing quartiles of endogenous testosterone compared with the lowest quartile were 0.75 (0.55 to 1.00), 0.62 (0.45 to 0.84), and 0.59 (0.42 to 0.85), respectively (P<0.001 for trend after adjustment for age, date of visit, body mass index, systolic blood pressure, blood cholesterol, cigarette smoking, diabetes mellitus, alcohol intake, physical activity, social class, education, dehydroepiandrosterone sulfate, androstanediol glucuronide, and sex hormone binding globulin). An increase of 6 nmol/L serum testosterone ( approximately 1 SD) was associated with a 0.81 (95% confidence interval 0.71 to 0.92, P<0.01) multivariable-adjusted odds ratio for mortality. Inverse relationships were also observed for deaths due to cardiovascular causes and cancer and after the exclusion of deaths that occurred in the first 2 years.

CONCLUSIONS

In men, endogenous testosterone concentrations are inversely related to mortality due to cardiovascular disease and all causes. Low testosterone may be a predictive marker for those at high risk of cardiovascular disease.

Usual physical activity and endogenous sex hormones in postmenopausal women: the European prospective investigation into cancer-norfolk population study

BACKGROUND

Short-term trials indicate that intensive physical activity may influence endogenous sex hormone concentrations. However, the relationship between usual daily physical activity and endogenous hormones in postmenopausal women in the general population is still uncertain.

OBJECTIVE AND METHODS

To determine the relationship between usual physical activity and endogenous sex hormones in postmenopausal women. A cross-sectional population-based study of 2,082 postmenopausal women ages 55 to 81 years, residing in the general community of Norfolk, United Kingdom, and not currently using hormone replacement therapy were chosen to participate. Physical activity in the past 1 year was assessed using a validated questionnaire, and endogenous sex hormone and sex hormone-binding globulin (SHBG) concentrations were determined.

RESULTS

Usual physical activity levels were inversely associated with circulating concentrations of testosterone and estradiol, testosterone/SHBG ratio, and positively associated with SHBG. These associations were only slightly attenuated after adjusting for potential covariates including body mass index, smoking status, alcohol intake, and reproductive variables. Testosterone concentrations and testosterone/SHBG ratios were 19% [95% confidence interval (95% CI), 9-27%, P < 0.001] and 24.0% (95% CI, 13-34% P < 0.001) lower, respectively, whereas estradiol concentrations were 6% (95% CI, 0-12%; P < 0.05) lower in the highest compared with lowest activity levels, respectively. A decreasing trend for the estradiol/SHBG ratio and 17alpha-hydroxyprogesterone concentrations was also observed. Androstenedione levels did not differ significantly according to physical activity.

CONCLUSIONS

Higher usual physical activity levels among postmenopausal women seem to be related to lower endogenous testosterone and estradiol concentrations. This may be one mechanism that could partly explain the reported inverse relationship between physical activity and breast cancer risk in some studies.

Preclinical pharmacology and toxicology of intravenous MV-NIS, an oncolytic measles virus administered with or without cyclophosphamide

MV-NIS is an oncolytic measles virus encoding the human thyroidal sodium iodide symporter (NIS). Here, we report the results of preclinical pharmacology and toxicology studies conducted in support of our clinical protocol "Phase I Trial of Systemic Administration of Edmonston Strain of Measles Virus, Genetically Engineered to Express NIS, with or without Cyclophosphamide, in Patients with Recurrent or Refractory Multiple Myeloma." Dose-response studies in the KAS-6/1 myeloma xenograft model demonstrated a minimum effective dose of 4 x 10(6) TCID50 (tissue culture infectious dose 50)/kg. Toxicity studies in measles-naive squirrel monkeys and measles-susceptible transgenic mice were negative at intravenous doses up to 10(8) and 4 x 10(8) TCID50/kg, respectively. Abundant viral mRNA, maximal on day 8, was detected in cheek swabs of squirrel monkeys, more so after pretreatment with cyclophosphamide. On the basis of these data, the safe starting dose of MV-NIS for our clinical protocol was set at 1-2 x 10(4) TCID50/kg (10(6) TCID50 per patient).