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Adherence to the dietary approaches to stop hypertension diet and non-alcoholic fatty liver disease - Cole Zetter

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Adherence to the dietary approaches to stop hypertension diet and non-alcoholic fatty liver disease - Cole Zetter

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After reflecting on the course, this week's weekly wall is reflecting on the hypertension module. I read an article relating dietary approaches to stop hypertension which included the diet and related it to non-alcoholic fatty liver disease. I found this article to be important because hypertension is such a prevalent medical condition within the United States, I felt as though it needs to be addressed again. This article brought up the dietary impact of beverages, sodium, fats, meats, grains, beans, dairy, fruits and vegetables. One key finding to this study that I found was that with their group of patients within the study, those that scored higher in a DASH (dietary approaches to stop hypertension) score showed a lower risk of non-alcoholic fatty liver disease. I would say that the clinical implications of this study would be that to effectively lower a patient's risk of non-alcoholic fatty liver disease, it is very important to maintain a well balanced diet of the foods listed previously. This is mainly important for healthy levels of the blood pressure. The article noted that dietary approach to stop hypertension was especially helpful for overweight individuals.

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Mild Suppression of Hyperinsulinemia to Treat Obesity and Insulin Resistance

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Mild Suppression of Hyperinsulinemia to Treat Obesity and Insulin Resistance

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Page, M. M., & Johnson, J. D. (2018). Mild suppression of hyperinsulinemia to treat obesity and insulin resistance. Trends in Endocrinology & Metabolism, 29(6), 389-399.

-Clarisa Williams

This week I have decided to look find research addressing Obesity and its relation to insulin levels. In my opinion, there has been more awareness made regarding insulin levels and weight gain. This review article through the Trends in Endocrinology and Metabolism addressed the relationship between insulin production and secretion and how those levels impact obesity.

Hyperinsulinemia precedes obesity and further insulin response can lead to additional weight gain. Insulin lowering interventions with diet can result in better insulin response for obese individuals. Those diets should lower postprandial glycemia to help avoid hyperinsulinemia following weight loss. In doing so, those once obese individuals would be less likely to regain the weight. Identifying specific dietary interventions that will not cause a spike in blood sugar will help reduce the risk of regaining the weight.

Insulin lowering treatments might be a reasonable intervention for obese individuals. Lowering glucose levels during a weight loss interventions can also reduce the likelihood of regaining the weight. Dietitians can make appropriate recommendations for patients.

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Nutrition therapy for the management of cancer-related fatigue and quality of life- Tamunoerenomie Inimgba

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Nutrition therapy for the management of cancer-related fatigue and quality of life- Tamunoerenomie Inimgba

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The purpose of this article is to study and review possible nutritional interventions that can be used to reduce the symptoms of cancer related fatigue. Cancer-related fatigue (CRF) is a debilitating syndrome that persists for many cancer survivors for years after treatment. Some symptoms usually include early and persistent fatigue, functional decline, depression, and cognitive difficulties. A key result of the article was implementations of diet plans prior to, during, and after cancer treatment appears to affect fatigue levels. Increased protein intake may help preserve lean mass and body composition. Dietary patterns that reduce inflammation, such as the Mediterranean diet and other plant-based diets, appear tolerable to cancer survivors and may reduce fatigue. Supplementation with ginseng, ginger, or probiotics may improve cancer survivors’ energy levels. Nutritional interventions, alone or in combination with other interventions should be considered as therapy for fatigue in cancer survivors. The clinical implications of the article would be to determine efficient nutrition care plan to help improve cancer related fatigue or the quality of life in cancer patients and survivors as there is currently room for more research in the area.
Baguley, B., Skinner, T., & Wright, O. (2019). Nutrition therapy for the management of cancer-related fatigue and quality of life: A systematic review and meta-analysis. British Journal of Nutrition, 122(5), 527-541. doi:10.1017/S000711451800363X

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The Interplay Between Nutrition and Stress in Pregnancy: Implications for Fetal Programming of Brain Development

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The Interplay Between Nutrition and Stress in Pregnancy: Implications for Fetal Programming of Brain Development

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Stephen Mayer

One thing that we did not talk a lot about is the critical role of nutrition during a pregnancy. In utero, fetal brains are extremely plastic and subtle changes can have long-term implications. This study found that high fat diets and higher dietary intake of nutrients can mitigate prenatal stress. This is a very important study because the fetus senses and responds to the intrauterine environment and this environment can cause the offspring to have chronic diseases, cognitive impairments, or birth defects. Offering the right nutritional recommendations and the proper resources to obtain those nutrients for pregnant mothers is critical to the health of our future generations. It has been found that deficiencies in vitamin D, B complex, zinc, chromium, iron, and iodine have been associated with stress-related orders (anxiety, neuropsychiatric, and depression). An uptake of fat soluble vitamins is critical due to the mammalian brain being comprised of mostly lipids. Nutrition is critical for long-term survival all the way from conception to death.

Lindsay, K. L., Buss, C., Wadhwa, P. D., & Entringer, S. (2019). The Interplay Between Nutrition and Stress in Pregnancy: Implications for Fetal Programming of Brain Development. Biological psychiatry, 85(2), 135–149. https://doi.org/10.1016/j.biopsych.2018.06.021

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. 2019 Jan 15;85(2):135-149.

doi: 10.1016/j.biopsych.2018.06.021.

Affiliations

¹ Department of Pediatrics, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California.

² Department of Pediatrics, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California; Institute of Medical Psychology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.

³ Department of Pediatrics, University of California, Irvine, Irvine, California; Department of Psychiatry and Human Behavior, University of California, Irvine, Irvine, California; Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California.

⁴ Department of Pediatrics, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California; Institute of Medical Psychology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. Electronic address: sonja.entringer@charite.de.

Free PMC article

Karen L Lindsay et al. Biol Psychiatry.

Free PMC article

. 2019 Jan 15;85(2):135-149.

doi: 10.1016/j.biopsych.2018.06.021.

Affiliations

¹ Department of Pediatrics, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California.

² Department of Pediatrics, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California; Institute of Medical Psychology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.

³ Department of Pediatrics, University of California, Irvine, Irvine, California; Department of Psychiatry and Human Behavior, University of California, Irvine, Irvine, California; Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California.

⁴ Department of Pediatrics, University of California, Irvine, Irvine, California; UC Irvine Development, Health and Disease Research Program, University of California, Irvine, Irvine, California; Institute of Medical Psychology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany. Electronic address: sonja.entringer@charite.de.

Abstract

Growing evidence supports an important role for the intrauterine environment in shaping fetal development and subsequent child health and disease risk. The fetal brain is particularly plastic, whereby even subtle changes in structure and function produced by in utero conditions can have long-term implications. Based on the consideration that conditions related to energy substrate and likelihood of survival to reproductive age are particularly salient drivers of fetal programming, maternal nutrition and stress represent the most commonly, but independently, studied factors in this context. However, the effects of maternal nutrition and stress are context dependent and may be moderated by one another. Studies examining the effects of the bidirectional nutrition-stress interplay in pregnancy on fetal programming of brain development are beginning to emerge in the literature. This review incorporates all currently available animal and human studies of this interplay and provides a synthesis and critical discussion of findings. Nine of the 10 studies included here assessed nutrition-stress interactions and offspring neurodevelopmental or brain development outcomes. Despite significant heterogeneity in study design and methodology, two broad patterns of results emerge to suggest that the effects of prenatal stress on various aspects of brain development may be mitigated by 1) higher fat diets or increased intake and/or status of specific dietary fats and 2) higher dietary intake or supplementation of targeted nutrients. The limitations of these studies are discussed, and recommendations are provided for future research to expand on this important area of fetal programming of brain development.

Keywords: Brain development; Fetal programming; Neurodevelopment; Nutrition; Pregnancy; Stress.

Figures

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maternal nutritional physiological phenomena / physiology*

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prenatal exposure delayed effects / physiopathology

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national center for biotechnology information

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The Interplay Between Nutrition and Stress in Pregnancy: Implications for Fetal Programming of Brain Development - PubMed

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Growing evidence supports an important role for the intrauterine environment in shaping fetal development and subsequent child health and disease risk. The fetal brain is particularly plastic, whereby even subtle changes in structure and function produced by in utero conditions can have long-term im ...

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Diagnosis and management of bone fragility in diabetes: an emerging challenge - Dierra Doaks

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Diagnosis and management of bone fragility in diabetes: an emerging challenge - Dierra Doaks

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For this last weekly wall, I decided to look at osteoporosis again. I found an article on bone fragility in diabetes. Fragility fractures have been recognized as a complication for both type I and type 2 diabetes. In addition, fracture risk increases with disease duration and poor control of blood glucose levels. Multiple studies have illustrated that patients with type 1 diabetes have a lower bone mineral density compared to healthy individuals. This relationship is important to note in medications. Some of the anti-diabetic medications should be preferred in diabetics with bone fragility. Medications with a favorable effect on bone metabolism should be favored for anti-diabetic treatment. On the other hand, there is a need for more research on osteoporotic treatments in diabetic patients. The pathophysiology of bone fragility in patients with type I and type 2 diabetes are not completely clear after multiple studies. This article was interesting to read. I appreciate all of the information in it about osteoporosis after learning about it in a previous module.

Ferrari, Abrahamsen, B., Napoli, N., Akesson, K., Chandran, M., Eastell, R., El-Hajj Fuleihan, G., Josse, R., Kendler, D. ., Kraenzlin, M., Suzuki, A., Pierroz, D. ., Schwartz, A. ., & Leslie, W. . (2018). Diagnosis and management of bone fragility in diabetes: an emerging challenge. Osteoporosis International, 29(12), 2585–2596. https://doi.org/10.1007/s00198-018-4650-2

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Sidney Harm: A study of caloric restriction versus standard diet in overweight men with newly diagnosed prostate cancer: A randomized controlled trial

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Sidney Harm: A study of caloric restriction versus standard diet in overweight men with newly diagnosed prostate cancer: A randomized controlled trial

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For this week I decided to bring in two topics from two different classes; cancer which we discussed in this module and caloric restriction which was discussed within another class. This randomized control study looks at a caloric restriction diet versus a standard diet in newly diagnosed cancer patients. These patients are overweight, male, and have prostate cancer. Being overweight or obese  is a risk factor for males for developing prostate cancer. Patients were either calorically restricted or just resumed their normal diet for 6 weeks. It was found after the 6 week intervention that there was changes in weight and certain serum proteins that are related to prostate cancer. This study has shown that there is some type of correlation between caloric restriction and prostate cancer, there should be other studies that look into the possibility of caloric resitrictions versus a standardized diet having a correlation to the progression of the cancer. While this is an extremely small study including 19 patients, it does show that there is a possible link between diets and specifically prostate cancer.

References:
Wright, Plymate, S., D’Oria-Cameron, A., Bain, C., Haugk, K., Xiao, L., Lin, D. W., Stanford, J. L., & McTiernan, A. (2013). A study of caloric restriction versus standard diet in overweight men with newly diagnosed prostate cancer: A randomized controlled trial. The Prostate, 73(12), 1345–1351. https://doi.org/10.1002/pros.22682

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Joe Devine: Exercise, nutrition and the brain

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Joe Devine: Exercise, nutrition and the brain

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For this last paper I wanted to look at how nutrition affects brain health. This paper looks at the effects of diet and exercise on the brain. It has been widely accepted through research that exercise supports brain health and improves over well being and may improve cognition as well Exercise does this by increasing an essential neurotrophin, brain-derived neurotrophic. This also protects the brain neurodegenerative diseases.

The effect nutrition plays on the brain is through micronutrients that occur in thing like fruits and vegetables known as polyphenols. These help support brain health by potentially protecting against neuronal injury due to neurotoxins that may become present in the brain.

It is widely accepted that nutrition plays a role in brain health because it helps things such a neurotransmitter synthesis, membrane support and fluidity, as well transmission. However, the blood brain barrier that protects the brain from outside sources is a formidable foe and acts a natural deterrent to study, and things act different in vivo compared to in vitro studies as there are more systems in play that can have a more convoluted or complicated pathway system.

Meeusen R. Exercise, nutrition and the brain. Sports Med. 2014 May;44 Suppl 1(Suppl 1):S47-56. doi: 10.1007/s40279-014-0150-5. PMID: 24791916; PMCID: PMC4008828.

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Kate Mashburn - The effect of a prevention program based on health belief model on osteoporosis

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Kate Mashburn - The effect of a prevention program based on health belief model on osteoporosis

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Because osteoporosis is the most common of the metabolic bone diseases, this study aimed to evaluate the effectiveness of the health belief model on women with osteoporosis.  This study was conducted on one hundred and twenty women in Iran. A questionnaire was given to the women before intervention, after intervention, and six months later that analyzed their knowledge of how nutrition and moderate exercise could help prevent osteoporosis. Bone mineral density was also analyzed at these intervals. Overall, significant knowledge was gained by these women resulting in a successful study as well as overall bone mass. This just goes to show that giving people more knowledge on the basics of how to prevent diseases can dramatically affect their health for the better. This study gives a good argument for why general public health programs should be set up to inform people on how basic life changes can be made to impact their overall health, not just a specific disease.

https://pubmed.ncbi.nlm.nih.gov/25821026/

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Affiliations

¹ Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. khani_1512@yahoo.com.

² Department of Health Education and health promotion, Shiraz University of Medical Sciences, Shiraz, Iran.

³ Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.

Free article

Free article

Affiliations

¹ Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. khani_1512@yahoo.com.

² Department of Health Education and health promotion, Shiraz University of Medical Sciences, Shiraz, Iran.

³ Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.

Abstract

Background: Osteoporosis is one of the most common metabolic bone diseases. The purpose of this study was to investigate the effect of a prevention program based on health belief model on osteoporosis among women.

Methods: In this quasi-case study, 120 patients (60 cases and 60 control), registered under the health centers in Fasa City, Fars Province, Iran were selected in 2014. A questionnaire consisting of demographic information, Health Belief Model (HBM) constructs was used to measure nutrition and walking performance for prevention of osteoporosis before, immediately after the intervention and six months later. Bone mineral density (BMD) was recorded at the lumbar spine and femur before and six months after intervention. Data were analyzed using SPSS19 via chi-square test, independent t-test, and Repeated Measures ANOVA at significance level of 0.05.

Results: Immediately and six months after the intervention, the case group showed a significant increase in the knowledge, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, internal cues to action, nutrition and walking performance compared to the control group. Six months after the intervention, the value of lumbar spine BMD T-Score in the case group increased to 0.127, while in the control group it reduced to -0.043. The value of the Hip BMD T-Score in the intervention group increased to 0.125 but it decreased to -0.028 in the control group.

Conclusions: This study showed the effectiveness of knowledge, walking and diet on bone mass by HBM model. Hence, these models can act as a framework for designing and implementing educational interventions for the osteoporosis prevention.

Keywords: Health Belief Model; Nutritional Status; walking.

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national center for biotechnology information

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The effect of a prevention program based on health belief model on osteoporosis - PubMed

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1 Department of Health Education and Health Promotion, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. khani_1512@yahoo.com. 2 Department of Health Education and health promotion, Shiraz University of Medical Sciences, Shiraz, Iran. 3 Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.

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Rhoda Inimgba: Lifestyle Factors and Metabolic Syndrome among Workers: The Role of Interactions between Smokingand Alcohol to Nutrition and Exercise.

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Rhoda Inimgba: Lifestyle Factors and Metabolic Syndrome among Workers: The Role of Interactions between Smokingand Alcohol to Nutrition and Exercise.

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The purpose of this article is to show if there is a relationship between smoking and alcohol and the occurrence of metabolic syndrome and also how nutrition affects metabolic syndrome. Metabolic syndrome include elevated blood pressure, abdominal obesity, impaired fasting blood glucose levels. Also the components of metabolic syndrome which include hypertension and dyslipidemia can lead to cardiovascular diseases which can be severe. A key finding of this study is that  alcohol does increase the risk of abdominal obesity and also in females, it decreases the risk of high fast blood glucose. When it comes to smoking, smoking showed higher risks on getting metabolic syndrome and its components. This relates to nutritional sciences as the effect on smoking on abdominal obesity, high blood pressure and metabolic syndrome could decrease with the type of nutrition a person takes in. The clinical implications of this study is physicians making sure they ask thier patients if they smoke or drink to be able to advise them that they should take in more nutrition to prevent nutrient deficiencies.
The purpose of this article is to show if there is a relationship between smoking and alcohol and the occurrence of metabolic syndrome amd also how nutrition affects metabolic syndrome. Metabolic syndrome include eleveated blood pressure, abdominal obesity, impaired fasting blood glucose levels. Also the components of metabolic syndrome which include hypertension and dyslipidemia can lead to cardiovascular diseases which can be severe. A key finding of this study is that  alcohol does increase the risk of abdominal obesity and also in females, it decreases the risk of high fast blood glucose. When it comes to smoking, smoking showed higher risks on getting metabolic syndrome and its components. This relates to nutritional sciences as the effect on smoking on abdominal obesity, high blood pressure and metabolic syndrome could decrease with the type of nutrition a person takes in. The clinical implications of this study is physicians making sure they ask thier patients if they smoke or drink to be able to advise them that they should take in more nutrition to prevent nutrient deficiencies.

Huang, Li, R.-H., Huang, S.-L., Sia, H.-K., Chen, Y.-L., & Tang, F.-C. (2015). Lifestyle Factors and Metabolic Syndrome among Workers: The Role of Interactions between Smoking and Alcohol to Nutrition and Exercise. International Journal of Environmental Research and Public Health, 12(12), 15967–15978. https://doi.org/10.3390/ijerph121215035.

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Analysis of gut microbiome, nutrition and immune status in autism spectrumdisorder: a case-control study in Ecuador

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Analysis of gut microbiome, nutrition and immune status in autism spectrumdisorder: a case-control study in Ecuador

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Ellen Reusch

For this final weekly wall post, I decided to look into the relationship between autism and nutrition. We touched a little bit on psychiatry in this course, but didn't cover autism spectrum disorders specifically and this is a topic I am really interested in. This research article evaluated 60 children (25 with ASD, 35 controls) in Ecuador. Interestingly, in the children without ASD, the likelihood of the child being under-weight or over-weight was higher than in the ASD group. The study found, through review of the childrens' diet and feeding habits, that children with ASD were more likely to have abnormal dietary habits and also to more likely to experience intermittent gastrointestinal upset. A review of the childrens' gut microbiota revealed that those with ASD had more overall gut diversity and also more amounts of certain bacterial species. We know through this class and other nutritional pharmacology classes that the gut microbiome can play a huge role in a disease process or in a patient's management of a disease, so this was a very interesting piece of information I found when reading this article. While I'm not sure if this article would help in any certain way to parents trying to manage their childrens' ASD, I think it provides some useful information that can guide further research into the environmental causes or influences in the development of autism. This could potentially lead physicians and researchers closer to discovering a definite cause of autism, or even towards a better understanding of the risk factors and early clinical signs that could be used for earlier diagnosis. Additionally, this article demonstrates the importance of healthy eating habits, as the patients with ASD were likely to have worse eating habits than those without. Although this article doesn't link the eating habits as causative of ASD, those children with ASD had higher frequency of gastrointestinal upset or GI conditions, which could potentially be due to their altered eating habits (this would require further investigation but is an interesting future research topic!).

Maria Fernanda Zurita, et. al., (2020) Analysis of gut microbiome, nutrition and immune status in autism spectrum
disorder: a case-control study in Ecuador, Gut Microbes, 11:3, 453-464, DOI: 10.1080/19490976.2019.1662260.

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Mortality associated with suboptimal diet - Julie Rees

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Mortality associated with suboptimal diet - Julie Rees

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Researchers analyzed the CDC's NHANES and mortality data against 10 different foods/nutrients consumption categories to determine mortality risk.  The most significant finding was that nearly half (45%) of deaths by CVD, stroke, or type 2 diabetes were associated with a suboptimal diet.  Deaths in all three of these conditions were linked to increased consumption of processed meats, sugary beverages, and red meat.  Persons who died from CVD tended to have higher sodium consumption and decreased consumption of nuts, omega-3 fats, and fruits and vegetables.
Of the deaths associated with poor diet, those at greatest risk tended to be male,  lack or Hispanic, and of lower education levels.  This may indicate that poor nutrition may be associated with lower economic status as well though this was not evaluated.
This study not only reinforces the need for a health diet but also opens our eyes to how many deaths could potentially be saved through dietary changes.

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Mediterranean Diet and Depression- Lydia Duncan

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Mediterranean Diet and Depression- Lydia Duncan

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At the beginning of this course, I had mentioned previous research into the developing field of nutritional psychiatry. Quite a few people seemed interested, so I wanted to use this as my topic of research for this week. Nutritional psychiatry can be defined as the practice of treating mental health disorders using food and supplements. This specific article in the field looks into the impact of the Mediterranean diet pattern (MDP) on individuals at risk of a depression diagnosis. Diet has previously been proposed as a risk modifier when evaluating depression. MDP, which we have discussed before, has been perceived to have health benefits ranging across many different health risks. The difference between this study and the ones that came before it is that this is the largest cohort study performed. The initial data was collected between August of 1991 and March of 1992, in women age 29-49 (and residing in Sweden). Out of all the data collected, 42,515 participants qualified to complete the study, and their data was tracked from the initial data collection to December 31st, 2012, date of death, immigration out of Sweden, or a diagnosis of depression (whichever occurred first). The participants food consumption before the study was measured using a Food Frequency Questionnaire (FFQ). This article is important because it is the first long term cohort study looking into the relationship of diet and mental health.

The largest finding of this study was that adherence to the MDP led to a reduction in the risk of developing depression later in life. With adjustment to things like lifestyle factors, it was determined to be a 5% decrease in risk of developing depression (with medium & high adherences to the MDP). They also found that the "protective effect" of the diet increased with age. These findings relate to nutritional sciences through the relation of MDP adherence to the risks of receiving a diagnosis of Depression.

A clinical implication of this study is that mental health can be affected by diet, just like physical health. Therefore, a more holistic view should be taken into account when considering mental illnesses. As I learned in my previous Health Psychology course, mental and physical health are intertwined. Since we know diet is closely associated as a risk for many physical diseases, it makes sense that it would also play a role in mental illness.

Article Citation:
Yin, W., Löf, M., Chen, R. et al. Mediterranean diet and depression: a population-based cohort study. Int J Behav Nutr Phys Act 18, 153 (2021). https://doi.org/10.1186/s12966-021-01227-3
Additional References:
Selhub, E. (2020, March 26). Nutritional psychiatry: Your brain on food. Harvard Health. Retrieved April 25, 2022, from https://www.health.harvard.edu/blog/nutritional-psychiatry-your-brain-on-food-201511168626

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International Journal of Behavioral Nutrition and Physical Activity 18, Article number: 153 (2021) Cite this article

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Abstract

Background

Depression imposes immense public health burden, demonstrating an urgent need of the identification of modifiable risk factors. Only a few cohort studies have analyzed the association between Mediterranean dietary pattern (MDP) and depression but with mixed results. We examined the impact of MDP on clinically ascertained depression in a large population-based dataset.

Methods

In 1991/92, detailed information on diet, using a food frequency questionnaire, and potential confounding factors (body weight, height, educational attainment, smoking, previous diabetes and hypertension, and physical activity) was collected, in a random sample of 49,261 Swedish women aged 29-49. Adherence to MDP was calculated. Clinical depression was extracted from the National Patient Register. Study participants were followed up through 2012.

Results

During an average follow-up of 20.4 years, 1677 incident cases of depression were diagnosed. We observed a lower risk of depression for medium (score 4-5) and high (6-9) adherence to MDP, compared with low (0-3) adherence (Medium: hazard ratio (HR) = 0.90, 95% confidence interval (CI) = 0.81-1.00; High: HR = 0.82, 95%CI = 0.71-0.94). Per unit increase of adherence, the risk of depression was reduced by 5% (HR = 0.95, 95%CI = 0.92-0.98). The association became stronger when restricting to severe form of depression (HR = 0.51, 95%CI = 0.33-0.76). The HRs were higher from age 50 onward both over the first and the second 10-year follow-up period, compared with before age 50, indicating stronger association with increasing age. Results remained after extensive sensitivity analyses.

Conclusion

Higher adherence to a Mediterranean diet at middle age was associated with a lower risk of depression later in life among Swedish women.

Background

Worldwide, depression is one of the leading causes of disability and mortality, especially among women [ 1], imposing substantial impairment and immense health burden [ 1, 2]. The identification of modifiable risk factors for depression is therefore urgently needed. In addition to genetics [ 3], personality [ 4], and environmental factors [ 5], lifestyle factors such as diet have also been proposed as risk modifiers for depression [ 6]. Dietary factors have been indeed recommended by the International Society for Nutritional Psychiatry Research as promising modifiable targets for prevention and treatment for common mental disorders [ 7].

Mediterranean diet is one of the classical anti-inflammatory dietary patterns [ 8] and has been perceived to have benefits on multiple aspects of human health, including mental and brain health [ 9, 10]. This dietary pattern refers to a food profile characterized by high consumption of vegetables, fruits, legumes, nuts and complex carbohydrates, and mono-unsaturated lipids (coupled with low saturated fat consumption), moderately high consumption of fish, low consumption of dairy and meat products, and regular but low-to-moderate intake of alcohol [ 11]. The underlying mechanisms of action of dietary pattern on health outcomes are complex [ 12]. Besides inflammation, modulation of oxidative stress, mitochondrial dysfunction, the gut microbiota, tryptophan-kynurenine metabolism, the hypothalamic pituitary adrenal (HPA) axis, neurogenesis and brain-derived neurotrophic factor (BDNF) and epigenetics have also been suggested [ 12].

Existing observational studies have so far provided inconclusive evidence for the association between Mediterranean dietary pattern (MDP) and risk of depression [ 13, 14, 15]. The conflicting results may be partly explained by different study design, limited sample size, short follow-up, lack of control for potential confounders and varying definitions of depression. A meta-analysis of 16 interventional studies shows that dietary interventions (e.g., through individual and group counselling on healthy diets) is associated with improved depressive symptoms, particularly in female populations [ 16]. The majority of the studies included in this meta-analysis, however, used self-reported depressive symptoms. A few interventional studies of clinically diagnosed depression indicate larger beneficial effects of dietary interventions among people with higher baseline level of depression [ 17, 18, 19]. Although previous studies were mostly performed in western countries, no research has yet been carried out in Nordic populations.

The aim of this study was to examine the association of adherence to MDP with the risk of depression in a large population-based cohort in Sweden with detailed information about confounding factors and clinically ascertained depression diagnosis.

Materials and methods

Between August 1991 and March 1992, a random sample of 96,000 women at age 29-49 and residing in the Uppsala healthcare region of Sweden was drawn from the Total Population Register by Statistics Sweden. These women were invited to participate in the Women's Lifestyle and Health (WLH) study, through answering a comprehensive questionnaire including food frequency questionnaire (FFQ) at the cohort entry [ 20]. Among the women invited, 49,261 returned the questionnaire and were enrolled in the study. All eligible participants were followed from cohort entry as defined by return of the questionnaire in 1991/92 until the first diagnosis of depression, date of emigration, death, or December 31, 2012, whichever came first, through cross linkages to the Swedish Patient Register (for ascertainment of depression) and Total Population Register (for ascertainment of emigration and death), using the individually unique personal identity numbers [ 21].

Adherence to MDP

At cohort entry, the study participants were asked to recall their dietary habits during the six months before enrolment, through answering an FFQ, which assessed the frequency and quantity of consumption of approximately 80 food items and beverages [ 22]. The consumption (grams/day) of each item and total energy intake (kilo-Joule (kJ)/day) were calculated using the Swedish National Food Administration database [ 23]. To measure adherence to MDP, we used the scale proposed by Trichopoulou et al. [ 9, 24] which has been used extensively in different studies including the WLH study [ 25].

Altogether, nine food groups were constructed as index dietary components, namely vegetables, fruits and nuts, cereals, legumes, dairy products, fish and seafood, meat, alcohol, and monounsaturated-to-saturated fat (M/S) ratio. For dietary components that are presumed to be beneficial (i.e., vegetables, fruits and nuts, cereals, legumes, fish and seafood, and a high M/S ratio), we scored a woman that consumed below the median level of the entire cohort as "0" and a woman that consumed at or above the cohort median as 1. For dietary components that are presumed to be less beneficial (i.e., dairy and meat products), a consumption level below the cohort median was given a score of 1 whereas a consumption level at or above the cohort median was given a score of 0. A moderate level of alcohol consumption (5-25 g/day) was scored 1, or 0 otherwise. Scores on all nine components were then summed up as a proxy for adherence to MDP, with the value 0 as the minimal and 9 as the maximal adherence [ 24].

Diagnosis of depression

The outcome of the study was the first clinical diagnosis of depression during follow-up. The Swedish Patient Register includes nationwide complete information on inpatient psychiatric care since 1973 and outpatient specialist care since 2001, updated on a daily basis [ 26]. A clinical diagnosis of depression was identified using the Swedish revisions of the International Classification of Diseases codes (ICD-7: 301.1, ICD-8: 296.2, ICD-9: 296B, and ICD-10: F32 and F33). The date of first hospital visit concerning depression was used as date of diagnosis for depression.

In a sensitivity analysis, we used both a broader (either ≥1 dispense of selective serotonin reuptake inhibitors (SSRIs) or clinical diagnosis of depression) and a narrower (both dispense of SSRIs and clinical diagnosis of depression) definition to assess the soundness of the main results. Information on dispense of SSRIs was derived from the Swedish Prescribed Drug Register (nationwide available since July 2005) using the Anatomical Therapeutic Chemical classification code N06AB. We also used ICD-10 codes F32.2, F32.3, F33.2 and F33.3 to identify severe depression, to assess if the role of adherence to MDP would differ for severe depression.

Covariates

We considered a range of demographic factors, lifestyle factors, anthropometric profile, and medical history as potential confounders of the studied association, including age (years, continuous), calendar year of birth (continuous), body weight (kg, continuous), height (cm, continuous), total years of education (years, continuous), smoking status (never, former or current), previous diabetes and hypertension (yes or no), as well as level of physical activity (on a 5-point scale ranging from mainly sitting as level 1 to vigorous physical activity as level 5), all collected from the questionnaires at baseline.

Statistical analysis

We calculated incidence rates of depression standardized by age using all person-time experienced by the entire cohort as the standard. Association of adherence to MDP with the risk of depression was estimated by hazard ratios (HRs) and 95% profile likelihood confidence intervals (CIs) obtained from the Cox models. The underlying time scale was attained age [ 27]. Adherence to MDP was analyzed both as a categorical (0-3 low, 4-5 medium, or 6-9 high) and continuous (0-9) variable. In the minimally adjusted model, we adjusted for year of birth (1942-46, 1947-51, 1952-56, or 1957-62). In the fully adjusted model, we additionally adjusted for body mass index (BMI, < 25, 25-29.9, or ≥ 30 kg/m ² calculated from weight and height) [ 28], years of education (0-10, 11-13, or > 13), physical activity (very low, low, moderate, high, or very high), smoking (never, former, or current), diabetes history (yes or no), hypertension history (yes or no), and total energy intake as a continuous variable (kJ/day). Since effect of diet can expect to increase cumulatively with higher age, we repeated the analyses in women younger than 50 and in women aged 50 and older. The cumulative incidence rate of depression over age by adherence to MDP was plotted using Kaplan-Meier method. Natural cubic splines were fitted to display the trend of depression risk across MDP score (0-9), adjusted for attained age, birth year, BMI, smoking, physical activity, education, diabetes, hypertension, and total energy intake.

Sensitivity and supplementary analyses

We tested the robustness of our results through a series of sensitivity analyses. To rule out the possibility of reverse causation, we excluded the first two or five years of follow-up. To address the concern for residual confounding due to a single assessment of dietary habit, we limited the follow-up time to the end of 2002 to estimate the association over the first 10 years of follow-up. We further repeated the age-specific analysis within the first 10 years and the second 10 years of follow-up respectively. We used alternative definitions for depression (broader or narrower definition, and severe depression). To address the influence of other psychiatric comorbidity, we first adjusted the analysis for history of any other psychiatric disorders (ICD-7: 300-326, ICD-8: 290-315, ICD-9: 290-319 and ICD-10: F10-99, excluding ICD codes for depression) before the end of follow-up, and then performed another analysis restricted to women without any psychiatric history before enrolment. The correlations between the nine dietary components and adherence to MDP score were calculated using Spearman's rank correlation coefficients. To check the influence of different food components, we performed another analysis by excluding the nine components one by one from the MDP score. Finally, given the potential distinct health effects of red and white meat, we re-calculated the adherence score based only on red and processed meat [ 29] instead of all kinds of meat products, and also separately assessed the association of red meat with risk of depression.

The assumption of proportional hazards was assessed by examining the standardized Schoenfeld residuals [ 30]. All statistical tests were performed on the two-sided 5% level of significance, corresponding to a two-sided 95% CI. We did not perform any adjustment of p-values for multiplicity of statistical tests. Data management was performed using SAS software version 9. 4 (SAS institute Inc., Cary, NC, USA). Survival analyses were performed using SAS software version 9.4. The cumulative incidence rate and the age-specific analysis were performed using STATA version 14 (StataCorp LP, College Station, TX, USA). SAS codes for the Cox regression analyses are presented in the online appendix. The present study was approved by Regional Ethical Review Board in Stockholm, Sweden.

Results

Baseline characteristics

Of the 49,261 women that returned questionnaire, we excluded 1049 women who emigrated out of Sweden before enrollment, 567 women who did not answer the FFQ, 100 women with prevalent clinically confirmed depression at enrolment, and 603 women with total energy intake below the 1st (1847 kJ/day) or above the 99th (12,474 kJ/day) percentiles of the cohort. The final study cohort comprised of 46,942 women. After exclusion of women with missing data on any of the covariates, 42,515 women with a mean age of 39.5 years (standard deviation = 5.6) remained in the final analysis (Fig. S 1). No major differences existed between the women excluded due to missing data and the women included in the final analysis (Table S 1).

During the average follow-up of 20.4 years, we identified 1677 women with incident depression, leading to an incidence rate of 1.94 per 1000 person-years. Table 1 shows the baseline characteristics of the study participants according to the three categories of adherence to MDP score. Women with a high adherence tended to be older, had higher educational attainment, more physically active, non-smoking, and with a higher total energy intake, compared with women with a low adherence.

Table 1 Baseline characteristics of the study women a by adherence to the Mediterranean dietary pattern

Adherence to MDP and risk of depression

Compared with low adherence to MDP (score 0-3), there was a statistically significantly decreased risk of depression for both medium (score 4-5) (HR adj = 0.90, 95%CI = 0.81-1.0) and high (score 6-9) (HR adj = 0.82, 95%CI = 0.71-0.94) adherence to MDP in all models (Table 2). Per unit increase of adherence to MDP, there was a 5% lower risk of depression in the fully adjusted models. The observed protective effect appeared to increase with age. The HRs were higher from age 50 onward (HR adj = 0.76, 95%CI = 0.64-0.89, high vs low adherence), compared with before age 50 (HR adj = 1.00, 95%CI = 0.78-1.27, high vs low adherence) (Table 2).

Table 2 The association between adherence to the Mediterranean dietary pattern and the risk of depressive disorder

The fully adjusted spline regression showed a similar result pattern (Fig. 1). Examination of the age-specific cumulative incidence rate of depression indicated stronger associations with increasing age and increasing adherence to MDP (Fig. 2).

"Hazard ratios of depression by adherence to Mediterranean dietary pattern score (0-9) based on different definitions of depression". Relative risk of depression (point estimates with pointwise two-sided 95% confidence intervals), by adherence to Mediterranean dietary pattern score (0-9), referenced on a score of 4. A Clinical diagnosis of depression; B Severe form of depression; C Broader definition of depression (at least one dispense of SSRIs or clinical diagnosis of depression); D Combined splines in the Fig. 1A-C. Estimates were derived from natural cubic splines, adjusted for attained age, birth year, body mass index, smoking, physical activity, total energy intake, years of education, and history of diabetes and hypertension. Adherence to Mediterranean dietary pattern score was calculated on a 9-point scale ranging from 0 as the minimal to 9 as the maximal adherence

"Kaplan-Meier curves of depression by adherence to Mediterranean dietary pattern". Cumulative incidence rate of depression with age of follow-up (years) by adherence to Mediterranean dietary pattern using Kaplan-Meier method. A Minimally adjusted Cox model, adjusted for attained age and birth year; B Fully adjusted Cox model, further adjusted for body mass index, smoking, physical activity, total energy intake, years of education, and history of diabetes and hypertension

Sensitivity and supplementary analyses

Excluding the first two or five years of follow-up provided essentially similar results (Table S 2). Compared with the main model, the association appeared to be weaker when using the broader definition of depression (fully-adjusted HR = 0.94, 95%CI = 0.88-1.00, high vs low adherence), but stronger when using the narrower definition of depression (fully-adjusted HR = 0.83, 95%CI = 0.70-0.97, high vs low adherence) (Table 3). The strongest association was noted for severe depression (fully-adjusted HR = 0.51, 95%CI = 0.33-0.76, high vs low adherence). Further adjustment for psychiatric comorbidity (Table S 3) or restricting analysis to women without any psychiatric disorders before enrolment (Table S 4) did not change the results either. Excluding other kinds of meat (e.g., white meat) from the adherence score led to largely similar results (Table S 5). The correlations between individual dietary components and adherence to MDP are shown in Table S 6. The results remained robust after exclusion of individual food components from the adherence score (Fig. S 2). There was no strong support for lack of proportional hazards (Fig. S 3). The pattern of stronger association with age was consistent over the first 10 years and the second 10 years of follow-up (Table S 7).

Table 3 The association between adherence to the Mediterranean dietary pattern and risk of depression based on different definitions

Discussion

In this, to date, largest prospective cohort study examining the association between adherence to Mediterranean-style diet and risk of clinically ascertained depression, we observed a reduction in the risk of depression in relation to higher adherence to Mediterranean diet, compared with a lower adherence, in a dose-response pattern. Among younger women, whose causes of depression are mainly depression with probable genetic influences [ 31, 32], there was no, or only a small, association of the Mediterranean diet score with depression. The results remained robust after a detailed adjustment for potential confounding factors and after an extensive set of sensitivity analyses. The highest reduction in risk was observed for severe depression.

There has been a rapid growth in research concerning the role of diet in depression in recent years [ 6], centered on its modulation of inflammatory level [ 33]. As a supportive evidence, the US Nurses' Health Study observed a positive association between increasing adherence to inflammatory diet and risk of depression [ 34]. Conversely, Mediterranean diet has been frequently referred as a typical food pattern with a lower level of inflammation [ 8], and was found to be inversely associated with risk of depression in our study. Other hypotheses are also proposed as explanations, including pathways in the oxidative and antioxidant defense systems, brain plasticity, microbiota-gut-brain axis, mitochondrial dysfunction, tryptophan-kynurenine metabolism, neurogenesis and BDNF, and epigenetics [ 12]. The action by diet affecting mental health is likely multifaceted and interacting, not restricted to only one pathway [ 12]. However, the majority of identified mechanisms nowadays are derived from animal studies; data of clinically ascertained depression in human beings are lacking.

Previous cohort studies among women showed mixed results on the association between MDP and risk of depression [ 35, 36, 37, 38]. Unlike most earlier studies, which used symptom scales or measures of self-reported depression, our study used clinically ascertained depression. Moreover, the large sample size of the present study allowed us to perform detailed adjustment for potential confounding factors and several sensitivity analyses to challenge assumptions used in the analysis, including the influence from different definitions of depression. When the broader depression definition was used (≥1 dispense of SSRIs or clinical diagnosis of depression), the protective effect from MDP diminished, whereas results remained essentially unchanged with the narrower definition (both dispense of SSRIs and clinical diagnosis of depression), compared with the main analysis. The effect became even more evident when we included only the most severe depression. Similar pattern was described in the Nurses' Health Study between inflammatory diet and depression, with the stronger effect noted for the narrow definition whereas relatively weaker effect noted for the broad definition of depression [ 34]. Furthermore, the age-specific analysis showed a stronger effect with increasing age, indicating a potentially accumulative benefit of MDP. This might partly explain the null association in some of the previous studies with a shorter follow-up period [ 38]. Finally, our finding of reduced risk of clinical depression with MDP is consistent with recent interventional studies which exhibited reduced depressive symptoms after dietary interventions, especially for those of more severe level of depression [ 16, 17, 18, 19].

In our cohort, women with a higher adherence to Mediterranean diet were more likely to have healthier lifestyle behaviors, characterized by being more physically active, of higher educational level, and with lower prevalence of smoking. Our extensive database allowed us to further adjust for these lifestyle factors which slightly attenuated the beneficial effect from MDP. Similarly, metabolic diseases can result in dietary habits which could modulate the risk of depression in turn [ 7, 14]. As obesity is known to stimulate chronic pro-inflammatory status, it is a plausible pathway linking together diet and risk of depression [ 39]. In our study, the results remained robust after adjusting for BMI.

Strengths of our study include the population-based sample, large cohort size, prospective ascertainment of clinically defined depression and long and virtually complete follow-up. Risk of selection bias was limited by the use of data from a health care system with equal access and recorded information on all cohort participants, independent from sociodemographic background. The same system allowed us to screen for presence of psychiatric disorders before the cohort entry.

Our study also has limitations. When at an early stage of depression, women might be more likely to have an unhealthy dietary pattern, indicating a possibility of reverse causation. To rule out potential impact of subclinical depression, we performed lag-time analyses and found that the association remained essentially unchanged after excluding the first two or five years of follow-up. Additionally, we adjusted for history of other psychiatric disorders prior to depression diagnosis in one analysis and excluded women with any psychiatric history before enrolment in another sensitive analysis. Both analyses showed largely comparable results. In the main analysis, we used calendar year of birth, BMI and years of education as categorical variables. In another model adjusting for these variables as continuous variables, we obtained very similar results as the ones from the original analyses (data not shown). The dietary pattern was measured only at enrolment. The long lag between exposure and outcome is therefore a concern because dietary pattern of the participants might have changed during the follow-up. As a result, there is a chance of misclassification of the exposure. Nevertheless, researchers have noticed that individual dietary habit is usually maintained lifelong and unlikely to change greatly over time [ 40, 41]. To compare the risk pattern over the first 10 years and the second 10 years of follow-up, we repeated the age-specific analysis within the two 10-year follow-up periods and found consistently a lower risk of depression in relation to greater adherence to MDP. The magnitude of the association increased with increasing age, potentially suggesting a cumulative protective effect from MDP on depression across life span. Given the observational nature of the study, residual confounding due to unknown or unmeasured confounders such as stress-related factors may still have some influence on our results.

Diet, which every one of the population is exposed to, has been shown associated with overall health and various specific diseases, e.g. cardiovascular disease, cancer, premature mortality and, in this study, depression [ 42]. Considering the health burden of depression worldwide, these results are of great public health importance. More researchers have emphasized the importance of dietary pattern, instead of isolated nutrients [ 43], to achieve interactional effects and to convey easy-to-understand information to the public [ 44]. This is in line with the intention of this study which is to raise awareness of the importance of healthy dietary pattern on mental health. Although MDP is prevalent in Mediterranean countries, the traditional dietary habits in the Scandinavian population are however not a typical Mediterranean style. Compared with a Greek cohort (EPIC) [ 45], the median intake levels of vegetables and fruits and nuts were much lower in our cohort ( Table S6). Due to the relatively low absolute prevalence of MDP, the adherence to a dietary pattern that approximates MDP might bring about even greater benefits to the health of a population outside the Mediterranean region, like Sweden.

Conclusion

Higher adherence to a Mediterranean diet at middle age was associated with a lower risk of depression later in life among Swedish women.

Availability of data and materials

Data described in the manuscript, code book, and analytic code will be made available upon request pending. SAS codes for the main analyses are presented in the online appendix.

Abbreviations

MDP:

Mediterranean dietary pattern

SSRIs:

selective serotonin reuptake inhibitors

WLH:

women's lifestyle and health

HR:

hazard ratio

CI:

confidence interval

ICD:

International Classification of Diseases

References

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Funding

Open access funding provided by Karolinska Institute. This work was partly supported by the Swedish Research Council (2019-01088), Swedish Research Council for Health, Working Life and Welfare (2017-00531), and Karolinska Institutet (Senior Researcher Award and Strategic Research Area in Epidemiology). We confirm the independence of researchers from funders. The contents of this manuscript are the responsibility of the authors and do not reflect the views of the funding bodies.

Author information

Author notes

Fang Fang and Sven Sandin contributed equally to this work.

Affiliations

1. Institute of Environmental Medicine, Karolinska Institutet, Box 210, 171 77, Stockholm, Sweden

Weiyao Yin & Fang Fang

2. Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China

Weiyao Yin

3. Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden

Marie Löf

4. Department of Biosciences and Nutrition, Karolinska Institutet, Stockholm, Sweden

Marie Löf

5. School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China

Ruoqing Chen

6. Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden

Ruoqing Chen

7. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

Christina M. Hultman & Sven Sandin

8. Department of Psychiatry, Ichan School of Medicine, Mount Sinai, New York, USA

Sven Sandin

9. Seaver Autism Center for Research and Treatment at Mount Sinai, New York, USA

Sven Sandin

Contributions

Conception and design: W.Y., R.C., F.F. and S.S.; Acquisition of data: F.F. and S.S.; Analysis and interpretation of data: W.Y., M.L., C.M.H., F.F. and S.S.; Writing of the first draft: W.Y.; Critical revision of the draft: M.L., R.C., C.M.H., F.F. and S.S.; Supervision and coordination of the project: F.F. and S.S.

The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Weiyao Yin.

Ethics declarations

Ethics approval and consent to participate

The present study was approved by Regional Ethical Review Board in Stockholm, Sweden (2020-02976). All women invited had received a letter requesting their written informed consent and asking them to complete an enclosed comprehensive questionnaire.

Consent for publication

Not applicable.

Competing interests

We declare no competing interests.

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Yin, W., Löf, M., Chen, R. et al. Mediterranean diet and depression: a population-based cohort study. Int J Behav Nutr Phys Act 18, 153 (2021). https://doi.org/10.1186/s12966-021-01227-3
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DOI: https://doi.org/10.1186/s12966-021-01227-3

Keywords

Depression

Mental health

Mediterranean

Diet

women's health

Cohort studies

Epidemiology

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Mediterranean diet and depression: a population-based cohort study - International Journal of Behavioral Nutrition and Physical Activity

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Background Depression imposes immense public health burden, demonstrating an urgent need of the identification of modifiable risk factors. Only a few cohort studies have analyzed the association between Mediterranean dietary pattern (MDP) and depression but with mixed results. We examined the impact of MDP on clinically ascertained depression in a large population-based dataset.

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Nutrition in Chronic Kidney Disease - The Role of Proteins and Specific Diets

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Nutrition in Chronic Kidney Disease - The Role of Proteins and Specific Diets

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Posted by Mitchell Watts

I decided to introduce a new topic that I find nutritionally relevant and also a major concern for our population. According to the CDC, chronic kidney disease affects more than 1 in 7 US adults. For Americans with diabetes or HTN (the two most common causes of kidney disease), the risk for CKD is even greater. Nearly 1 in 3 people with DM and 1 in 5 people with HTN have kidney disease.

The optimal diet for CKD patients remains controversial, depending upon the eGFR, type of kidney disease, and the presence of other comorbidities such as DM, HTN, or heart failure. However, increased intake of red and processed meat is associated with a significant risk of GFR decline while an adherence to a diet characterized by high intake of fruits, vegetables, and low-fat dairy products is associated with a lower risk of CKD.

A low protein diet is a long-standing recommendation for CKD management, and limiting protein intake from animal sources and shifting toward a vegetable protein sources is also associated with favorable effects, in addition to the reduced phosphorus load with better control of metabolic bone disorder.

However, concern exists that protein-restricted diets may increase the risk of protein malnutrition. There is increased catabolism and net muscle protein degradation with worsening of kidney function, metabolic acidosis, and insulin resistance. Therefore, in order to avoid protein energy wasting, it is important that caloric intake should be increased well over normal metabolic needs, regardless of the recommended protein intake.

As we have seen before in this course, healthy dietary patterns, such as the DASH diet and Mediterranean diet, have both a protective effect against disease occurrence as well as disease progression. The most well researched and effective diets promote increased intake of fruits and vegetables, fish, legumes, whole grains, and fiber; and lower intake of red meat, salt, and refined sugars.

Apetrii, M., et al. (2021). Nutrition in Chronic Kidney Disease-The Role of Proteins and Specific Diets. Nutrients, 13(3), 956.

Kidney Disease Statistics for the United States. (2021). NIDDK.

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Nutrition in Chronic Kidney Disease-The Role of Proteins and Specific Diets - PubMed

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Chronic kidney disease (CKD) is a global public health burden, needing comprehensive management for preventing and delaying the progression to advanced CKD. The role of nutritional therapy as a strategy to slow CKD progression and uremia has been recommended for more than a century. Although a consi…

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Katelyn Spain: Good Oral Health and Diet

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Katelyn Spain: Good Oral Health and Diet

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The purpose of this study was to describe the relationship between a healthy diet and oral health status. This study discussed how nutritional habits can influence oral diseases. Dental caries are a common dental health issue. The development of caries is caused by the presence of sugars and starches being broken down by bacteria, resulting in the demineralization of tooth enamel. The level of dental caries in a community are decreased in areas that have traditional lifestyles and consume low amounts of sugars. While in areas with an increased quantity of sugars and fermentable carbohydrates are consumed, dental caries increase. Saliva is a neutralizing agent in the mouth. It has a more basic pH and aids in defending acidification by bacteria in the mouth. Peanuts, hard cheeses, and chewing gum have been found to stimulate salivation to aid in decreasing dental caries. Dental erosion is the irreversible loss of dental tissue that is chemically corroded by acids, this does not involve any bacteria in the mouth. Foods that contain citrus, phosphoric, ascorbic, malic and other acids cause dental erosion. Oral cancers are extremely associated with nutritional habits. Smoking, chewing tobacco, and consuming alcohol all increase the risk of the development of oral cancers. The clinical implications of this study is for healthcare providers, such as dentists, to educate their patients on diet and its associations with oral health status.
Scardina, G. A., & Messina, P. (2012). Good oral health and diet. Journal of biomedicine & biotechnology, 2012, 720692. https://doi.org/10.1155/2012/720692

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Abstract

An unhealthy diet has been implicated as risk factors for several chronic diseases that are known to be associated with oral diseases. Studies investigating the relationship between oral diseases and diet are limited. Therefore, this study was conducted to describe the relationship between healthy eating habits and oral health status. The dentistry has an important role in the diagnosis of oral diseases correlated with diet. Consistent nutrition guidelines are essential to improve health. A poor diet was significantly associated with increased odds of oral disease. Dietary advice for the prevention of oral diseases has to be a part of routine patient education practices. Inconsistencies in dietary advice may be linked to inadequate training of professionals. Literature suggests that the nutrition training of dentists and oral health training of dietitians and nutritionists is limited.

1. Introduction

The concept of oral health correlated to quality of life stems from the definition of health that the WHO gave in 1946. Health is understood to be "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity". The programs for the prevention of oral diseases concern teaching about oral hygiene and healthy eating, fluoride prophylaxis, periodic check-ups, sessions of professional oral hygiene, and secondary prevention programs [ 1]. The term "bionutrition" refers to the important interactions which exist between diet, use of nutrients, genetics, and development. This term emphasizes the role of nutrients in maintaining health and preventing pathologies at an organic, cellular, and subcellular level [ 2].

There exists a biunique relationship between diet and oral health: a balanced diet is correlated to a state of oral health (periodontal tissue, dental elements, quality, and quantity of saliva).

Vice versa an incorrect nutritional intake correlates to a state of oral disease [ 3- 6].

2. Diet and the Development of the Oral Cavity

Diet influences the development of the oral cavity: depending on whether there is an early or late nutritional imbalance, the consequences are certainly different. In fact, an early nutritional imbalance influences malformations most. Moreover, the different components of the stomatognathic apparatus undergo periods of intense growth alternated with periods of relative quiescence: it is clear that a nutritional imbalance in a very active period of growth will produce greater damage [ 3].

A shortage of vitamins and minerals in the phase before conception influences the development of the future embryo, influencing dental organogenesis, the growth of the maxilla, and skull/facial development [ 1, 2].

An insufficient supply of proteins can lead to [ 3, 4] the following:

1. atrophy of the lingual papillae,

2. connective degeneration,

3. alteration in dentinogenesis,

4. alteration in cementogenesis,

5. altered development of the maxilla,

6. malocclusion,

7. linear hypoplasia of the enamel.

An insufficient supply of lipids can lead to [ 5, 6] the following:

1. inflammatory and degenerative pathologies,

2. parotid swelling-hyposalivation,

3. degeneration of glandular parenchyma,

4. altered mucosal trophism.

An insufficient supply of carbohydrates can lead to the following:

1. altered organogenesis,

2. influence of the metabolism on the dental plaque,

3. caries,

4. periodontal disease.

Diet influences the health of the oral cavity, conditioning the onset of caries, the development of the enamel, the onset of dental erosion, the state of periodontal health, and of the oral mucous in general.

3. Caries

Caries is a demineralization of the inorganic part of the tooth with the dissolution of the organic substance due to a multifactorial etiology. The demineralization of the enamel and of the dentine is caused by organic acids that form in the dental plaque because of bacterial activity, through the anaerobic metabolism of sugars found in the diet [ 7].

Demineralization occurs when the organic acids produced increase the solubility of the calcium hydroxyapatite that is present in the hard tissue of teeth ( Figure 1 ).

The development of caries requires the presence of sugars and bacteria but it is influenced by the susceptibility of the teeth, by the type of bacteria, and by the quantity and quality of the salivary secretion.

Saliva is supersaturated with calcium and phosphate with a pH equal to 7, a level that favours remineralization. When acid stimulation is too strongdemineralization prevails until the formation of a carious lesion [ 8].

Very low levels of dental caries are found in isolated communities with a traditional lifestyle and low consumption of sugars [ 7- 9]. As soon as economic conditions improve and the quantity of sugars and other fermentable carbohydrates increases in the diet, a notable increase in dental caries is noticed. This has been seen in the Inuit of Alaska and in populations in Ethiopia, Ghana, Nigeria, Sudan, and the islands of Tristan da Cunha and Sant'Elena [ 7- 9].

A Vipeholm study in Sweden between 1945 and 1953 in an institute for the mentally ill underlined the correlation between caries and the intake of sugary food of variable viscosity. If the sugar was ingested up to a maximum of 4 times a day only during meals, it had little effect on the increase of caries, even if this occurred in great quantities; the increase in the frequency of consumption of sugar between meals was associated to an increase in caries; when they no longer ate foods rich in sugar, the incidence in the formation of caries diminished [ 10].

The types of sugar ingested through diet also influence the onset of illness. In fact, studies on the pH of the dental plaque have shown that lactose produces less acidity in comparison to other sugars.

A 1970 Finnish study on a supervised dietary change revealed that, in an adult population, the almost total substitution of sucrose in the diet with xylitol determines a 85% reduction in caries over a 2-year period; its mechanism of action resides in the inhibition of the growth of Streptococcus mutans, the most important microorganism responsible for the formation of caries [ 11].

Diet can be a good ally in the prevention of caries [ 12].

1. Increase in the consumption of fibres: diminution of the absorption of sugars contained in other food.

2. Diets characterized by a ratio of many amides/little sugar have very low levels of caries.

3. Cheese has cariostatic properties.

4. Calcium, phosphorus and casein contained in cow milk inhibit caries.

5. Wholemeal foods have protective properties: they require more mastication, thus stimulating salivary secretion.

6. Peanuts, hard cheeses, and chewing gum are good gustative/mechanical stimulators of salivary secretion.

7. Black tea extract increases the concentration of fluorine in the plaque and reduces the cariogenicity of a diet rich in sugars.

8. Fluorine.

Fluorine remains a milestone in the prevention and in the control of dental caries. It has a preeruptive mechanism of action (incorporation in the enamel during amelogenesis) and a posteruptive mechanism (topical action). Fluorine reduces caries by 20-40% in children, but it does not entirely eliminate them: even when fluorine is used, the association between the intake of sugars and caries continues to be present all the same [ 13].

Diet also influences the qualitative characteristics of salivary secretion. The secretive proteins (mucines) represent an important barrier against the reduction of humidity, against the physical and chemical penetration of irritants and against bacteria [ 14].

The synthesis of glycoproteins requires vitamin A. In an imbalanced diet, there is a reduction in the content of mucines with the consequent risks for oral health (Caries!!).

4. Development of the Enamel

Teeth in a preeruptive phase are influenced by the nutritional state. A lack of vitamins D and A and protein-energy malnutrition have been associated to hypoplasia of the enamel and atrophy of the salivary glands, conditions that determine a greater susceptibility to caries. Some hypoplasia and pits on the surface of the enamel correlate to a lack of vitamin A ( Figure 2 ); a lack of vitamin D is associated to the more diffused hypoplastic forms ( Figure 3 ). The structural damage can testify to the period in which the lack of nutrition occurred [ 15].

5. Dental Erosion

"Dental erosion is the progressive irreversible loss of dental tissue that is chemically corroded by extrinsic and intrinsic acids through a process that does not involve bacteria...."

Extrinsic Acids Derived from Diet -

They citric, phosphoric, ascorbic, malic, tartaric, and carbonic acids that are found in fruit, in fruit juices, in drinks, and in vinegar.

Intrinsic Acids -

They are derived from serious gastroesophageal reflux [ 16- 18] ( Figure 4 ).

6. Periodontal Disease

Periodontal disease evolves more quickly in undernourished populations: "...the pathology starts in the gum and could interest the periodontal ligament up to the alveolar bone...". The most important risk factor in the development of periodontal disease is represented by inadequate oral hygiene ( Figure 5 ). Data supplied by the National Health and Nutrition Examination Survey 2001/02 underlined that a low level of folic acid is associated to periodontal disease. The serum level of folates is an important index of periodontal disease and can represent an objective that should be pursued in the promotion of periodontal health [ 19].

Malnutrition and bad oral hygiene represent two important factors that predispose for necrotizing gingivitis. Prevention programs against disease must therefore include a correct evaluation of the immune system and the promotion of nutritional programs. The aim of nutritional support in inflammatory diseases is to provide the right energy and nourishment to respond to the increased demand for protein synthesis in the acute phase, inflammatory mediators, antioxidant defence mechanisms, as well as for the promotion of tissue reparation. Some nutrients have a very important role in the resolution of the inflammatory process. These observations confirm the relationship between diet and periodontal disease [ 20]. In a recent interview, the president of the American Society of Periodontology, Michael P. Rethman [ 20], underlined the importance of diet for a healthy smile. In particular, the correlation between the income of calcium and periodontal disease can be due to the role that calcium has in the density of the alveolar bone that supports teeth. Also the intake of vitamin C is fundamental for maintenance and for the activation of reparative mechanisms thanks to its antioxidant properties [ 20].

Noma is an orofacial gangrene originating in the gingival-oral mucosa [ 21]. Although cases of noma are now rarely reported in the developed countries, it is still prevalent among children in third world countries, notably in sub-Sahara Africa, where malnutrition and preventable childhood infections are still common [ 21]. Noma can be prevented through promotion of national awareness of the disease, poverty reduction, improved nutrition, promotion of exclusive breastfeeding in the first 3-6 months of life, optimum prenatal care, and timely immunisations against the common childhood diseases [ 21].

7. Gene Disease

Italian researchers have recently identified the genetic defect responsible for cleft lip and palate ( Figure 6 ). The gene is a variation of the maternal gene "MTHFR" that determines the lowering of folate levels in blood. The female carriers of the discovered mutation have a greater risk of giving birth to children affected by cleft lip and palate. Folate is fundamental in the first phases of embryonic development: in fact the lack of this vitamin is able to cause defects in the embryonic development known generically as "defects of the neural tube". For this reason, in the United States B9 is administered with the support of the health authorities to women who are intend to conceive and in the first months of pregnancy. Administering folate in the months preceding conception and in the first months of pregnancy, the risk of defects to the nervous system is reduced and even cleft lip and palate could be avoided with the preventive administration of the vitamin [ 22].

8. Neonatal Diet and Oral Health

The World Health Organization and the American Pediatric Association have shown that breast feeding influences lingual deglutition, the growth of the maxillae and the correct alignment of the teeth, as well as the modelling of the hard palate. Vice versa, bottle feeding the baby influences the formation of the ogival palate as well as the formation of "crossbite", a reduced opening of the back nasal cavity, and an increased incidence of sleep apnea. In addition, artificial feeding influences the possibility of the onset of arterial hypertension, obesity, cardiovascular illnesses, and inflammatory pathologies regarding oral mucous [ 23, 24].

9. Oral Cancer

The association between diet and oral cancer is extremely serious. It is a pathology that is diagnosed in three hundred thousand new cases in the world every year and presents the greatest incidence in people who smoke, chew tobacco, and consume alcohol (Figures ​(Figures7, 7 , ​,8, 8 , and ​and9 9 ).

The use of tobacco can alter the distribution of nutrients such as antioxidants, which develop a protective action toward the cells: smokers present levels of carotenoids and vitamin E in the blood that are superior to those in the oral mucous and, in addition, have a different distribution in comparison to the norm; the levels of folates in the blood and in the cells of the oral tissues of smokers are inferior to those of nonsmokers; the inside of the cheeks of smokers presents numerous micronuclei (modifications typical of pre- and neoplastic lesions) [ 25, 26]. The study of the incidence of this illness has underlined the possibility that diet can represent an important etiological factor for oral carcinogenesis. Vitamins A, E, C, and Beta Carotene have antioxidant properties.

1. They neutralize metabolic products.

2. They interfere with the activation of procarcinogens.

3. They inhibit chromosomal aberration.

4. They potentially inhibit the growth of malignant lesions (leukoplakia).

The mechanism that connects smoke to this disease has not been discovered but some progress has been made: smoke modifies the distribution of protective substances such as folates and some antioxidants. A rebalancing of nutrients obtained through diet can modify the altered distribution caused by the consumption of tobacco. In an imbalanced diet there is a depletion of antioxidant nutrients. Fruit and vegetables have, vice versa, important antioxidant properties. Many micronutrients (vitamins in particular) are used in chemoprevention programs formulated by the US National Cancer Institute [ 27].

The National Cancer Institute and the American Cancer Society have established some prudential dietary recommendations for the choice of food:

1. maintain a desirable body weight,

2. eat a varied diet,

3. include a new variety of fruits and vegetables in the daily diet,

4. consume a greater quantity of foods rich in fibre,

5. decrease the total intake of fats (30% less than the total calories),

6. limit the consumption of alcohol,

7. limit the consumption of salted food or food preserved with nitrates.

In patients with an advanced tumour disease, protein-caloric malnutrition is a recurrent problem due to factors such as a form of anorexia that is established, maldigestion, malabsorption, and to a difficulty in mastication and deglutition [ 26]. Foods should be provided that aim to correct nutritional deficits and ponderal reduction when consumed in a large enough quantity to cover protein and caloric requirements. Malnutrition also interferes negatively with humoral and cellular immunocompetence and with tissue and reparative functions. In addition, the alteration of the liver function can change the way drugs are metabolized. Therefore, malnutrition can interfere with oncological therapy and increase the severity of the collateral effects [ 25].

Some studies show a small effect of dietary supplementation on cancer incidence, while others show that supplementation with antioxidant vitamins may have an adverse effect on the incidence of cancer and cardiovascular diseases or no effect [ 27].

Increasing attention has been given to the potential protective roles of specific antioxidant nutrients found in fruits and vegetables.

In a recent research El-Rouby showed that lycopene can exert protective effects against 4-nitroquinoline-1-oxide induced tongue carcinogenesis through reduction in cell proliferation and enhanced cellular adhesion, suggesting a new mechanism for the anti-invasive effect of lycopene [ 28].

In a recent report Edefonti et al. showed that diets rich in animal origin and animal fats are positively, and those rich in fruit and vegetables and vegetable fats inversely related to oral and pharyngeal cancer risk [ 29].

10. Oral Candidosis

A significant correlation has been evinced with a lack of iron ( Figure 10 ). This causes alterations in the epithelium with consequent atrophy and alteration in cellular turn-over, an alteration in the iron-dependent enzymatic system depression in cell-mediated immunity, phagocytosis, and in the production of antibodies. The correlation between candidiasis and the lack of folic acid, vitamins A, B1, B2, vitamins C, K, zinc, and a diet rich in carbohydrates is also significant [ 30].

11. Potentially Malignant Oral Lesions

These are those pathologies of the oral mucous (oral lichen planus, leukoplakia) that present a tendency for malignant degeneration if some favourable conditions persist ( Figure 11 ). There are conflicting data in literature regarding levels of retinol and beta carotene and the onset of oral lichen planus [ 31]. Ramaswamy et al. affirmed that folate levels should be investigated in patients with oral lesions and symptoms especially those with risk factors of age, poor nutrition, or systemic diseases. When suspected, daily folic acid supplements should be given [ 32].

With regard to leukoplakia, a significant association has been found with reduced serum levels of vitamins A, C, and B12, and folic acid ( Figure 12 ). Data in literature confirm that diets rich in fruit and vegetables, above all tomatoes and products derived from them, significantly reduce the risk of the onset of leukoplakia [ 33]. In a recent report Lodi et al. said that treatment with beta carotene and vitamin A or retinoids was associated with better rates of clinical remission, compared with placebo or absence of treatment. Treatments may be effective in the resolution of lesion; however, relapses and adverse effects are common [ 34].

12. Micronutrient Deficiencies and Mucosal Disorders

Various types of nutritional deficiencies can produce oral mucosal diseases. Changes such as swelling of the tongue, papillary atrophy, and surface ulceration are possible in case of micronutrient deficiencies (iron, folate, vitamin B12) [ 35]. To establish iron, folate, or vitamin B12 deficiency, a hematologic screening that includes complete blood count, red-cell, serum iron, B12, and folate levels should be performed [ 35, 36]. Although they are rarely required, specific tests for suspected niacin, pyridoxine, and riboflavin deficiency are available [ 35]. Although glossodynia related to nutritional deficiency is statistically uncommon, it is easily curable with replacement therapy [ 35]. Identification of a vitamin deficiency through early oral symptoms can forestall development of serious and irreversible systemic and neurologic damage [ 36]. Deficiencies of vitamin B12 can produce oral signs and symptoms, including glossitis, angular cheilitis, recurrent oral ulcer, oral candidiasis, and diffuse erythematous mucositis. Plummer Vinson syndrome is associated with glossitis and angular cheilitis [ 35, 36].

Articles from Journal of Biomedicine and Biotechnology are provided here courtesy of Hindawi Limited

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An unhealthy diet has been implicated as risk factors for several chronic diseases that are known to be associated with oral diseases. Studies investigating the relationship between oral diseases and diet are limited. Therefore, this study was conducted to describe the relationship between healthy eating habits and oral health status.

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https://www.liebertpub.com/doi/10.1089/met.2018.0105

Posted by Richard Proudfoot

For this final week, the research paper selected is titled: “Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016” This February 2019, article was published in the METABOLIC SYNDROME AND RELATED DISORDERS. 2019 Feb;17(1):46-52. doi: 10.1089/met.2018.0105. Epub 2018 Nov 27.. The authors are Joana Arau´ jo, PhD, Jianwen Cai, PhD, and June Stevens, PhD. Their affiliations are Departments of Nutrition, Biostatistics, and Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

The purpose of this research is to determine the number and proportion of American adults who have optimal levels of each of five traditional cardiometabolic risk factors in the absence of pharmaceutical treatment. The study  conducted a focused analysis of five risk factors, grouping variables (e.g., systolic and diastolic blood pressure [SBP and DBP]), and applying cut points using the most recent guidance: (i) WC <102/88 cm in men/women; (ii) SBP <120 mmHg and DBP <80 mmHg2,5; (iii) glucose <100 mg/dL and HbA1c <5.7%6,7; (iv) triglycerides <150 mg/dL4 ; (v) HDL-C ‡40/ 50 mg/dL in men/women. The study also examined the prevalence of not taking medications for blood pressure, diabetes, and cholesterol.

This study is important because currently there are no estimates of current prevalence of metabolic health among adults in the United States.  This study provides a baseline on which changes can be compared.

The key findings from this study are the proportion of metabolically healthy Americans is 12.2% (95% CI: 10.9–13.6). Less than one-third of normal weight adults were metabolically healthy, and the prevalence decreased to 8.0% and 0.5% in overweight and obese individuals, respectively.¹ These findings relate to nutritional sciences because metabolic health is strongly associated with dietary patterns as well as physical activity and not smoking.
Clinical implication of this study is that the medical and nutrition science communities need to take on the responsibility of improving our individual patients and our community populations metabolic health. Most all of our patient encounters need to include discussion of lifestyle improvements. The medical and nutrition science communities need to support efforts to regulate advertising and regulate marketing, and “sin tax” certain goods harmful to metabolic health and costly to individuals and society; for example, sugar-sweetened beverages.  Posted by Richard Proudfoot

1.          Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009-2016. Metabolic Syndrome and Related Disorders. 2019;17(1):46-52. doi:10.1089/met.2018.0105

https://www.liebertpub.com/doi/10.1089/met.2018.0105

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Ivana Djuricic: Osteoporosis in Inflammatory Bowel Disease

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Ivana Djuricic: Osteoporosis in Inflammatory Bowel Disease

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Max Reinshagen, Osteoporosis in inflammatory bowel disease, Journal of Crohn's and Colitis, Volume 2, Issue 3, September 2008, Pages 202–207, https://doi.org/10.1016/j.crohns.2008.01.005

This is a review article that looks at studies that have investigated osteoporosis in inflammatory bowel disease. This paper is important because as I read through it, it seems like there isn't a lot of data or longitudinal studies that look at the progression of osteoporosis, solely based off of IBD conditions. It highlights a need for more controlled studies in IBD patients in order to establish evidence-based therapeutic approaches.

One key thing in this study is that, although the cause of osteoporosis is steroid-induced in most inflammatory disease patients, there is evidence that the inflammatory disease state itself can cause bone loss through the osteoprotegerin (OPG) system. OPG is a receptor antagonist for sRANKL (soluble receptor activator of NK-kB ligand). RANKL is expressed on osteoblasts and the binding to RANK receptor on osteoclast precursors leads to osteoclast differentiation, activation and bone loss. The RANK and RANK-ligand interaction is inhibited by OPG. While glucocorticoids do inhibit OPG production, thereby increasing osteoclast activation, OPG production is also inhibited during flare-ups by inflammatory cytokines released in response to chronic IBD. So the induction of bone loss is not exclusive to the use of steroids in these patients but could be induced through a similar pro-inflammatory pathway that causes active IBD.

In the nutritional aspect, it would be important to recommend calcium and vitamin D supplementation for patients with IBD--not only because of the malabsorption issues that IBD causes, but also because of the ramped up differentiation toward osteoclasts and bone loss that these patients might experience. The paper does note that there are genetic differences in the OPG system that can cause variation in bone loss on an individual level for people with inflammatory diseases, so screening bone density for IBD patients as part of their clinical plan would help the dietician better understand how to plan the dietary recommendations. More research should be done on the interplay between chronic inflammatory states in individuals and the incidence of osteoporosis.

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Obesity with Comorbid Eating Disorders- Andrea Ballinger

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Obesity with Comorbid Eating Disorders- Andrea Ballinger

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The article I chose for this week discusses the interaction between patients with obesity and eating disorders, in particular bulimia. This was really a perfect article because it discussed the intersectionality of what I believed to be two of the most interesting modules of the semester: obesity and eating disorders. What I found particularly interesting was the discussion regarding treatment for someone with obesity and an eating disorder. Obesity is typically treated with diet changes and increased physical activity. With the addition of an eating disorder, treatment can not simply be diet centered for an obese patient. One study concluded that combination therapy was able to target both concerns. Long term, CBT significantly reduced binge eating while behavioral weight loss therapy produced significantly greater weight loss. Additionally, simply focusing on one or the other treatment type resulted in either disengagement from therapy/neglect of the second concern. This is an important study because it shows how nutrition maintenance is not one size fits all. A team of healthcare professionals must really work together to coordinate a plan for patients comorbid with obesity and an eating disorder because nutrition alone cannot alleviate all symptoms.

da Luz, Felipe Q et al. “Obesity with Comorbid Eating Disorders: Associated Health Risks and Treatment Approaches.” Nutrients vol. 10,7 829. 27 Jun. 2018, doi:10.3390/nu10070829

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Abstract

Obesity and eating disorders are each associated with severe physical and mental health consequences, and individuals with obesity as well as comorbid eating disorders are at higher risk of these than individuals with either condition alone. Moreover, obesity can contribute to eating disorder behaviors and vice-versa. Here, we comment on the health complications and treatment options for individuals with obesity and comorbid eating disorder behaviors. It appears that in order to improve the healthcare provided to these individuals, there is a need for greater exchange of experiences and specialized knowledge between healthcare professionals working in the obesity field with those working in the field of eating disorders, and vice-versa. Additionally, nutritional and/or behavioral interventions simultaneously addressing weight management and reduction of eating disorder behaviors in individuals with obesity and comorbid eating disorders may be required. Future research investigating the effects of integrated medical, psychological and nutritional treatment programs addressing weight management and eating disorder psychopathology in individuals with obesity and comorbid eating disorder behaviors-such as binge eating-is necessary.

Keywords: obesity, eating disorders, binge eating, dieting, treatment

1. Introduction

Obesity is commonly associated with health complications. Individuals with obesity are at high risk of several physical diseases, such as certain cancers, diabetes, hypertension, heart disease, stroke, as well as being at increased risk of mortality [ 1, 2, 3, 4, 5, 6, 7]. Obesity is also often associated with mental health problems and psychosocial difficulties. Indeed, women with obesity tend to report worse mental health than women without obesity [ 8]. Moreover, women tend to experience more mental health complications associated with obesity than men [ 9], albeit mental health problems associated with obesity (e.g., anxiety) occur in both women and men [ 9]. One factor that can be detrimental to the mental health of individuals with obesity is exposure to well-documented discriminatory attitudes and behaviors in different areas, such as employment, education and healthcare [ 10]. Additionally, discrimination against individuals with higher body mass index (BMI) can be particularly problematic because it can induce strong dissatisfaction with one's body weight and/or shape, which is a risk factor for the development of comorbid eating disorder behaviors [ 11].

The eating disorders that have been most frequently studied in individuals with obesity are binge eating disorder and bulimia nervosa. Binge eating disorder is defined in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by recurrent binge eating episodes occurring at least once a week for the past 3 months, and associated with marked distress [ 12]. The DSM-5 criteria for binge eating disorder also require that individuals experience at least three of the following five features: eating much more quickly than normal; eating until feeling excessively full; overeating when not feeling physically hungry; eating alone because of embarrassment related to the amount of food consumed; and feeling disgusted, depressed, or very guilty after the binge eating episodes [ 12]. Bulimia nervosa is characterized by self-evaluation that is excessively influenced by body weight and shape, recurrent binge eating, and recurrent unhealthy compensatory behaviors to prevent weight gain (i.e., self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; excessive exercise) [ 12]. The DSM-5 criteria for bulimia nervosa require that the binge eating episodes and compensatory unhealthy behaviors have occurred at least once per week for the past 3 months [ 12]. In addition to binge eating disorder and bulimia nervosa, individuals with obesity can also experience "other specified feeding or eating disorder" when presentations cause significant distress or impairment but do not completely meet the DSM-5 criteria for a specific eating disorder [ 12]. For example, according to the DSM-5, a person may have binge eating disorder of low frequency and/or limited duration. In this case, the person meets the DSM-5 criteria for binge eating disorder, except that binge eating has occurred less than once a week and/or for less than 3 months [ 12].

There is a significant co-occurrence of eating disorders, particularly binge eating disorder, in individuals with higher BMI. In Latin America, for example, the prevalence of binge eating disorder was 16-52% in individuals with obesity (BMI ≥ 30 kg/m ²) attending weight loss programs [ 13]. In the United States, a study with a nationally-representative sample of 9282 people assessed in 2001-2003 found that 42% of individuals that had had a binge eating disorder at any stage in their life had obesity at the time of the survey [ 14]. A more recent study in the United States, with a sample of 36,306 participants assessed in 2012-2013, found that relative to those with no history of eating disorders, participants who met criteria for binge eating disorder in the last 12 months, or at any time in their lives, had significantly increased odds of having obesity or extreme obesity [ 15]. On the flip side, a study with a clinical sample of 1383 individuals with current eating disorders, including 123 with binge eating disorder and 551 with bulimia nervosa, found that 87% of individuals with binge eating disorder, and 33% of individuals with bulimia nervosa, had also had obesity at some point in their lives [ 16]. These studies show a significant co-occurrence of obesity and eating disorders, and are consistent with the hypothesis that these conditions can potentially contribute to and/or exacerbate each other. Additionally, obesity with comorbid eating disorder behaviors, such as binge eating, may be a growing problem. In a population-representative sample of 9053 people in Australia between the years of 1995 to 2015, there were significant increases in the prevalence of obesity and eating disorder behaviors independently; however, the greatest increases were in the prevalence of individuals with obesity and comorbid binge eating or very strict dieting (7.3 fold and 11.5 fold, respectively) [ 17]. The increases in the prevalence of obesity and comorbid eating disorder behaviors mentioned above may be related to a potential contribution of binge eating to obesity [ 14, 18, 19], as well as to the social expectancy for people with obesity to lose excess weight [ 17]. The potentially growing prevalence of individuals with obesity and comorbid eating disorder behaviors is concerning due to the medical and psychosocial risks that these individuals are exposed to.

2. Health Risks of Obesity with Comorbid Eating Disorders

Individuals with obesity and comorbid eating disorders are at high risk of several medical and psychosocial complications. A study with 152 treatment-seeking individuals with obesity found that those with binge eating disorder had higher BMIs, more severe levels of depression and obsessive-compulsive symptoms, and stronger feelings of inadequacy and inferiority than those without binge eating disorder [ 20]. Similarly, bariatric surgery candidates with comorbid binge eating disorder had significantly more mood and anxiety disorders than bariatric surgery candidates without binge eating disorder (27% versus 5% for mood disorders, and 27% versus 8% for anxiety disorders, respectively) [ 21]. Indeed, 40% of bariatric surgery candidates with comorbid binge eating disorder had a mood or anxiety disorder, with some participants having both a mood and an anxiety disorder [ 21]. Similarly, gastric bypass surgery candidates with binge eating disorder had more disordered eating attitudes and behaviors, as well as worse physical, emotional and social quality of life, than gastric bypass surgery candidates without binge eating disorder [ 22]. Not only is binge eating in individuals with obesity associated with poor mental health and poor quality of life, but binge eating can also hinder weight loss in individuals with morbid obesity. For instance, a systematic review found that individuals submitted to bariatric surgery that had clinically significant binge eating before and after the surgery had worse weight loss outcomes than those without pre-surgical binge eating, or than those who stopped binge eating after the surgery [ 23]. The occurrence of obesity in individuals with eating disorders is also associated with greater mental health complications. For instance, individuals with eating disorders that had had obesity at any stage in their lives had higher eating disorder severity and greater general psychopathology than those with eating disorders that had never had obesity [ 16]. Finally, obesity with comorbid binge eating can be functionally detrimental. For example, individuals with obesity and comorbid binge eating had greater work-related impairment in productivity than those with obesity only, or binge eating only, or than those of normal weight without binge eating [ 24]. Thus, individuals with obesity and comorbid eating disorders are at higher risk of medical and psychosocial complications than individuals with only one or the other condition. However, the most appropriate treatment approaches for individuals experiencing these combined conditions is a controversial topic amongst healthcare professionals.

3. The Potential Benefits and Harms of Dieting to Lose Weight

There are often theoretical and clinical debates amongst healthcare professionals regarding the most appropriate treatment approaches for individuals with obesity and comorbid eating disorders. The most controversial aspect of this debate relates to potential benefits and harms of dieting to lose weight. Healthcare professionals specializing in obesity often recommend dieting to their patients or clients with overweight or obesity, encouraging them to reduce and then maintain a healthy weight. Conversely, healthcare professionals specializing in eating disorders, especially those working mainly with individuals with anorexia nervosa and bulimia nervosa, are often concerned about the use of diets driven by idealization of thinness [ 25].

The negative perception that some healthcare professionals may sustain regarding dieting is understandable when one considers that strict dieting is often a core symptom of eating disorders such as anorexia nervosa and bulimia nervosa [ 11]. For example, the trans-diagnostic cognitive-behavioral model of eating disorders, which is used to guide the "gold standard" treatment for binge eating disorder and bulimia nervosa, namely cognitive behavior therapy-enhanced (CBT-E), shows strict dieting as a central behavioral component in the maintenance of eating disorders [ 11]. Furthermore, concerns regarding dieting are derived from studies that found relationships between dieting and eating disorder symptoms [ 26, 27, 28]. A classic study in this field, namely the Keys' study, found that young healthy men submitted to prolonged periods of semi-starvation experienced symptoms that were similar to those experienced by people with eating disorders, such as preoccupation with food, binge eating, distress and depression [ 26]. Additionally, literature reviews of studies including clinical and non-clinical samples suggest that cognitive restraint can make dieters vulnerable to disinhibition and consequent binge eating [ 27], and that dietary restriction can lead to binge eating, emotional alterations, distractibility and preoccupation with food and eating [ 28]. Notwithstanding that dieting can be associated with these negative consequences, one literature review concluded that some dietary restriction (i.e., the consumption of certain foods in moderation) may be necessary for individuals with obesity or for those at risk of developing weight-related health problems in order to reduce the health consequences of overweight [ 28].

Although there are some important concerns regarding the safety of dieting, the relationship between dieting and binge eating is not clear-cut and needs to be further examined. For instance, a study with 166 patients with bulimia nervosa at admission for residential treatment found that a significant proportion of them (43%) were not currently dieting to lose weight or to avoid weight gain [ 29]. Additionally, this study also found that those who were dieting to lose weight reported lower binge eating frequency in comparison to non-dieters [ 29]. In line with this, a literature review of studies on different levels of dietary restraint, and retrospective and prospective studies examining the effects of dieting on eating behavior, did not find consistent evidence supporting the view that medically supervised dietary restriction exacerbates binge eating disorder [ 30]. It is possible that other factors besides dieting need to be present in order to increase the risk for eating disorder behaviors. For example, a prospective study with a population-based sample of 1827 adolescents and young adults and a 10-year follow-up period, found that symptoms of depression and low self-esteem in dieters were important elements increasing the risk of binge eating [ 31]. Moreover, a narrative review concluded that while dieting may contribute to eating disorders, other factors mediate this relationship, namely a family history of eating disorders, mood disorders, problems with substance/alcohol use, personality characteristics, problematic family interactions, and biological vulnerability [ 32]. Finally, a systematic review showed that clinically supervised severe energy restriction to treat obesity-as in that used with total meal replacement diets such as very low energy diets-mostly did not cause binge eating, and even reduced binge eating in those with pre-treatment binge eating behaviors [ 33]. These findings are in line with a previous literature review which showed that moderate dietary energy restriction in combination with behavioral weight loss therapy does not seem to induce binge eating in overweight adults without pre-treatment binge eating, and can reduce binge eating in those with pre-treatment binge eating behaviors [ 34]. Taken together, these findings suggest that the relationship between dieting and binge eating may be significantly influenced by several other variables, e.g., degree of psychological support and medical need for weight loss. Notably, the young men in the Key's experiment (see above) were not in medical need of weight loss. Whilst they considered themselves extremely well supervised from a medical perspective [ 26], psychological effects were less well understood and they would go to great lengths to avoid the shame of dismissal from the trial and the stigma of being a "cheater" when they had broken the diet [ 29]. The complexity of the relationship between dieting to lose weight and eating disorder behaviors and weight stigma potentially contributes to disagreements amongst healthcare professionals regarding the most appropriate treatment approaches for individuals with obesity and comorbid eating disorders.

4. Treatments for Obesity with Comorbid Eating Disorders

Previous studies have examined the effects of treating individuals with obesity and comorbid eating disorders with weight loss or eating disorder treatments, alone or in combination [ 35, 36, 37, 38]. One study investigated the effects of cognitive behavior therapy (CBT), behavioral weight loss therapy, or a sequential approach of CBT followed by behavioral weight loss therapy on body weight and binge eating [ 38]. This study showed that at 12-month follow-up, 51% of participants submitted to CBT, 36% of those submitted to behavioral weight loss therapy, and 40% of those submitted to CBT followed by behavioral weight loss therapy, had achieved binge eating remission [ 39]. It also showed that at 12 months, CBT induced significantly greater reduction in binge eating than behavioral weight loss therapy, and that behavioral weight loss therapy induced significantly greater weight loss than CBT [ 38]. Moreover, participants who exhibited remission from binge eating had significantly greater reductions in BMI compared to participants who did not [ 38]. Nonetheless, the reduction in BMI induced by behavioral weight loss therapy was relatively small (i.e., −2.1 kg/m ²) [ 38], and the combination of CBT with other obesity treatments could potentially induce greater weight loss. In line with this, another study found significant reductions in body weight (average loss of 12 kg) and binge eating at 6 months from treatment commencement in individuals submitted to a diet allowing 7100 kJ (1700 kcal) per day, combined with CBT, sertraline (a serotonin reuptake inhibitor) and topiramate (an anti-convulsant sometimes used in the treatment of obesity) [ 35].This same study did not show any significant change in body weight or binge eating in the comparison groups of individuals submitted to a 7100 kJ (1700 kcal) per day diet, CBT and sertraline (without topiramate), or in those submitted to nutritional counselling and CBT [ 35]. We could thus conclude from this study that complex treatments including dietary intervention, CBT and a combination of pharmaceuticals can induce substantial reductions in body weight and binge eating. Another study assessed the addition of CBT to 16 sessions of group behavioral weight loss therapy in 116 women with overweight/obesity and comorbid binge eating disorder [ 36]. In this study, the serotonin reuptake inhibitor fluoxetine (or placebo) was also investigated. Thus, participants were randomized to one of the following four groups, with all groups receiving the same behavioral weight loss therapy: (1) CBT + fluoxetine; (2) CBT + placebo; (3) fluoxetine; or (4) placebo [ 36]. This study showed that participants in the groups that included CBT had significantly greater reductions in binge eating frequency, and greater abstinence from binge eating, than participants in groups that did not include CBT [ 36]. Additionally, this study found that participants reporting abstinence from binge eating at the end of treatment ( n = 54) exhibited greater weight loss in comparison to those who did not report abstinence from binge eating ( n = 62) (i.e., a weight loss of 6.2 kg versus weight gain of 0.7 kg, respectively) [ 36]. From these findings it thus seems that CBT is particularly important for binge eating reduction and abstinence, and that binge eating abstinence may be necessary for successful weight loss. While CBT appears to be an essential element of treatment, another study suggests that there is some flexibility in the types of dietary interventions that can be combined with CBT in order to reduce body weight and binge eating. Indeed, in another study involving 50 individuals with obesity and comorbid binge eating disorder, participants were randomized to CBT + a diet of low energy density, or CBT + general nutrition counselling [ 37]. This study found that 13 out of the 43 participants that completed their assigned intervention lost at least 5% of their initial body weight, and reduced binge eating episodes by 55-75%, with no significant differences in outcomes between participants in the two groups [ 37]. Overall, the above-mentioned studies showed that certain combinations of obesity treatments with CBT for eating disorders can induce significant reduction of binge eating and weight loss in individuals with obesity and comorbid eating disorders.

While some scientific studies have examined the effects of combining obesity treatments with eating disorder treatments [ 35, 36, 37], most of the current treatment programs for obesity or eating disorders still target only one or the other condition. For example, CBT-E is suitable for use in binge eating disorder, however, it does not encourage weight loss for those with overweight or obesity and comorbid binge eating disorder [ 11], nor does it result in substantial weight loss [ 38, 39]. In the same way, a recent systematic review and meta-analysis on the effectiveness of treatments for binge eating disorder found that therapist-led CBT induced greater reduction of binge eating frequency in comparison to behavioral weight loss therapy; however, greater body weight reduction was achieved with behavioral weight loss therapy in comparison to CBT [ 39]. According to this systematic review, at the end of treatment, participants submitted to CBT reduced BMI by an average of 0.41 kg/m ² (which is not clinically significant), whereas participants submitted to behavioral weight loss therapy reduced BMI by an average of 2.2 kg/m ² (which is clinically significant) [ 39]. Furthermore, another review of treatments for binge eating disorder concluded that weight loss treatments should be offered only to individuals with obesity that do not engage in binge eating [ 40]. This contrasts with a study which found that behavioral weight loss therapy, although not designed to thoroughly address eating disorder psychopathology, concomitantly reduced binge eating and body weight in individuals with obesity and comorbid binge eating disorder [ 38]. Additionally, a systematic review and meta-analyses found a lack of treatments aiming to simultaneously assist weight management and reduce eating disorder behaviors in individuals with obesity and comorbid bulimia nervosa [ 41]. According to that systematic review and meta-analysis, it is necessary to develop and test integrated treatments for obesity with bulimia nervosa due to the rise in prevalence of individuals with obesity and comorbid bulimia nervosa [ 41]. In line with this, we have been involved with the development of a new integrated treatment, named HAPIFED (a H ealthy AP proach to we I ght management and F ood in E ating D isorders), which aims to simultaneously aid weight management (i.e., via a moderate to slow rate of weight loss) and to reduce eating disorder behaviors in individuals with obesity and comorbid eating disorders [ 42]. The feasibility and acceptability of this intervention was shown in a pilot study that used 20 sessions of group multidisciplinary therapy [ 42], and this treatment is currently under examination in a randomized controlled trial comparing 30 sessions of group therapy of either HAPIFED or CBT-E [ 43]. Moreover, the effectiveness of HAPIFED in "real world" clinics is also currently been investigated [ 44].

Integrated treatments, such as HAPIFED, may be particularly attractive to individuals with obesity and comorbid eating disorders. For instance, a systematic review found that only an estimated 23% of individuals with eating disorders sought treatment for their eating disorder, whereas 30-73% of individuals with eating disorders sought treatments for their overweight or obesity (13). This tendency for individuals with eating disorders to seek weight loss treatments instead of eating disorder treatments could potentially be used to facilitate treatment of a significant proportion of individuals with eating disorders that are overweight or have obesity. In addition to potentially improving treatment adherence, integrated treatments for obesity with comorbid eating disorders may also promote greater physical and mental health benefits than treatments focused on only one or the other condition. For instance, individuals with clinically significant binge eating are more susceptible to difficulties achieving a healthy body weight after undergoing a weight loss treatment (i.e., bariatric surgery) in comparison to those without clinically significant binge eating [ 23]. Therefore, it is important to further investigate integrated treatment options aiming to simultaneously reduce body weight and eating disorder behaviors and to discuss these studies with healthcare professionals working with clients with obesity or eating disorders. This is especially important given that healthcare professionals working in the fields of obesity or eating disorders frequently have different professional backgrounds (i.e., psychological versus medical versus nutritional).

5. Conclusions

Individuals with obesity and comorbid eating disorders are at higher risk for several medical and psychosocial complications than individuals with either condition alone. The co-occurrence of obesity with comorbid eating disorders, particularly binge eating disorder, requires attention of healthcare professionals working with clients with either of these conditions. Healthcare professionals specialized in obesity treatment and not addressing eating disorder behaviors of their clients-when these are present-will likely see unsuccessful weight loss interventions in the long-term due to continued binge eating. On the flip side, healthcare professionals specialized in eating disorders and not addressing weight management with their clients with comorbid overweight or obesity may see a reduced interest from their clients, potentially resulting in disengagement from (or lack of engagement at all in) the eating disorder treatment, seeking instead weight loss treatments that do not address their eating disorder behaviors. While these healthcare professionals may sometimes disagree on the potential benefits and harms of recommending weight loss diets to their clients, healthcare professionals working in either of these fields of obesity or eating disorders can acknowledge the common goal of promoting healthy eating behaviors, healthy relationships of their clients with their bodies, and positive personal health goals of weight loss. We contend, it is vital to develop and test innovative medical, psychological, and nutritional treatment options that simultaneously address obesity as well as comorbid eating disorders. Such integrated treatments can potentially induce greater improvements in health-and in more people-than treatments targeting only one or the other condition.

Author Contributions

F.Q.d.L. conceived, reviewed the literature discussed in the paper and wrote his paper P.H. co-conceived and co-wrote the paper and contributed additional literature, S.T. co-conceived and co-wrote the paper and A.S. co-conceived and c0-wrote this paper.

Funding

This work was supported by the CAPES Foundation, Ministry of Education of Brazil, via a postgraduate scholarship to Felipe Q. da Luz, the National Health and Medical Research Council (NHMRC) of Australia via a Senior Research Fellowship to Amanda Sainsbury.

Conflicts of Interest

Amanda Sainsbury has received payment from Eli Lilly, the Pharmacy Guild of Australia, Novo Nordisk and the Dietitians Association of Australia for seminar presentation at conferences, and from Nestlé Nutrition for consulting services. Amanda Sainsbury is also the author of The Don't Go Hungry Diet (Bantam, Australia and New Zealand, 2007) and Don't Go Hungry For Life (Bantam, Australia and New Zealand, 2011). Stephen Touyz receives royalties from Hogrefe and Huber, Routledge and McGraw-Hill Publishers. He has also been the recipient of honoraria and travel and research grants from Shire Pharmaceuticals. He has chaired their Australian Binge Eating Disorder Advisory Board and has been the author of commissioned reports. All views expressed in these reports have been his own. Phillipa Hay receives sessional fees and lecture fees from the Australian Medical Council, Therapeutic Guidelines publication, and New South Wales Institute of Psychiatry and royalties from Hogrefe and Huber, McGraw Hill Education, and Blackwell Scientific Publications, and she has received research grants from the NHMRC and ARC. She is Deputy Chair of the National Eating Disorders Collaboration Steering Committee in Australia (2012-) and Member of the ICD-11 Working Group for Eating Disorders (2012-) and was Chair Clinical Practice Guidelines Project Working Group (Eating Disorders) of RANZCP (2012-2015). She has prepared a report under contract for Shire Pharmaceuticals (July 2017) and conducts educational activities for Shire Pharmaceuticals. All views in this paper are her own.

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Articles from Nutrients are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

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Obesity with Comorbid Eating Disorders: Associated Health Risks and Treatment Approaches

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Obesity and eating disorders are each associated with severe physical and mental health consequences, and individuals with obesity as well as comorbid eating disorders are at higher risk of these than individuals with either condition alone. Moreover, obesity can contribute to eating disorder behaviors and vice-versa.

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Selenium-enriched probiotics improves murine male fertility compromised by high fat diet.-Ashley Wahlman

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Selenium-enriched probiotics improves murine male fertility compromised by high fat diet.-Ashley Wahlman

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Infertility effects about 1 in 8 couples. This is pretty significant that many men and women will experience infertility and may have to seek fertility treatments. However, I feel that men's infertility is sometimes overlooked so I decided to look at an article that discusses men's fertility. In a study researchers looked at 75 mice and measured the effects of probiotics, inorganic selenium, and selenium-enriched probiotics on male fertility in hyperlipidemic status. One key finding in this study is that sperm count and motility values in the OSePB group were higher than in the PB group. The overall percentages of sperm head and tail abnormalities in the OSePB group were lower than those in the PB group. This relates to nutritional sciences because you can also find foods rich in selenium as well as drinks rich in probiotics once again just emphasizing the accessibility of this treatment. This allows us to offer organic selenium probiotics as a supplement to men to help improve their fertility. This is an easy way to help improve fertility without it being invasive or an expensive option. A lot of the fertility options today cost a lot of money and are not covered by insurance.

References:
Ibrahim, H. A., Zhu, Y., Wu, C., Lu, C., Ezekwe, M. O., Liao, S. F., & Huang, K. (2012). Selenium-enriched probiotics improves murine male fertility compromised by high fat diet. Biological trace element research, 147(1-3), 251–260. https://doi.org/10.1007/s12011-011-9308-2

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Selenium-enriched probiotics improves murine male fertility compromised by high fat diet - PubMed

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A total of 75 male mice were allotted to five groups of 15 each in a completely randomized experimental design to study the effects of probiotics, inorganic selenium, and selenium-enriched probiotics on male fertility in hyperlipidemic status. The mice in group 1 were fed a normal basal diet and ser…

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Red and processed meat intake and cancer risk: Results from the prospective NutriNet-Sante cohort study- Esraa Zamzami

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Red and processed meat intake and cancer risk: Results from the prospective NutriNet-Sante cohort study- Esraa Zamzami

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The study I found is one of many studies that study the relationship between red and processed meat consumption on cancer risk. The strength of this study is the large number of participants they included. The researchers found that red meat consumption significantly increased breast and overall cancer risk. However, they found no relationship between processed meat and cancer risk.

Interestingly, the main factor that played a significant role in this study is the amount of meat consumed. These researchers found no evidence that meat consumption increased cancer risk in a former study. The difference between the two studies is that in the first one, where there was no significant effect, participants consumed less than 500 grams of red meat per week. Whereas the current study, they found a significant relationship because participants consumed more than 500 grams of red meat per week. Same for processed meats, many other studies found a strong relationship between cancer risk and processed meat consumption, unlike this study. They did not find a significant relationship because participants’ intake of processed meat was very low.

This study emphasizes the importance of balance. Unfortunately, many people enjoy eating red and processed meat and would not listen to recommendations on cutting them out of their diets. However, health care providers can encourage them to consume fewer amounts to avoid adverse health outcomes.

Diallo, A., Deschasaux, M., Latino-Martel, P., Hercberg, S., Galan, P., Fassier, P., Allès, B., Guéraud, F., Pierre, F. H., & Touvier, M. (2018). Red and processed meat intake and cancer risk: Results from the prospective NutriNet-Santé cohort study. International journal of cancer, 142(2), 230–237. https://doi.org/10.1002/ijc.31046

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Affiliations

¹ Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), Inserm U1153, Inra U1125, Cnam, Paris 13 University, Nutritional Epidemiology Research Team (EREN), Bobigny, France.

² Département de Santé Publique, Hôpital Avicenne (AP-HP), Bobigny, F-93017, France.

³ Toxalim (Research Centre in Food Toxicology), Université de Toulouse, INRA, ENVT, INP-Purpan, UPS, Toulouse, France.

Free article

Randomized Controlled Trial

Free article

Affiliations

¹ Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), Inserm U1153, Inra U1125, Cnam, Paris 13 University, Nutritional Epidemiology Research Team (EREN), Bobigny, France.

² Département de Santé Publique, Hôpital Avicenne (AP-HP), Bobigny, F-93017, France.

³ Toxalim (Research Centre in Food Toxicology), Université de Toulouse, INRA, ENVT, INP-Purpan, UPS, Toulouse, France.

Abstract

The International Agency for Research on Cancer (WHO-IARC) classified red meat and processed meat as probably carcinogenic and carcinogenic for humans, respectively. These conclusions were mainly based on studies concerning colorectal cancer, but scientific evidence is still limited for other cancer locations. In this study, we investigated the prospective associations between red and processed meat intakes and overall, breast, and prostate cancer risk. This prospective study included 61,476 men and women of the French NutriNet-Santé cohort (2009-2015) aged ≥35 y and who completed at least three 24 hrs dietary records during the first year of follow-up. The risk of developing cancer was compared across sex-specific quintiles of red and processed meat intakes by multivariable Cox models. 1,609 first primary incident cancer cases were diagnosed during follow-up, among which 544 breast cancers and 222 prostate cancers. Red meat intake was associated with increased risk of overall cancers [HR Q5 vs. Q1 =1.31 (1.10-1.55), p trend = 0.01) and breast cancer (HR Q5 vs. Q1 = 1.83 (1.33-2.51), p trend = 0.002]. The latter association was observed in both premenopausal [HR Q5 vs. Q1 =2.04 (1.03-4.06)] and postmenopausal women [HR Q5 vs. Q1 =1.79 (1.26-2.55)]. No association was observed between red meat intake and prostate cancer risk. Processed meat intake was relatively low in this study (cut-offs for the 5th quintile = 46 g/d in men and 29 g/d in women) and was not associated with overall, breast or prostate cancer risk. This large cohort study suggested that red meat may be involved carcinogenesis at several cancer locations (other than colon-rectum), in particular breast cancer. These results are consistent with mechanistic evidence from experimental studies.

Keywords: breast cancer; processed meat; prospective study; prostate cancer; red meat.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Red and processed meat intake and cancer risk: Results from the prospective NutriNet-Santé cohort study - PubMed

# data[].attributes.attachment_link.description
The International Agency for Research on Cancer (WHO-IARC) classified red meat and processed meat as probably carcinogenic and carcinogenic for humans, respectively. These conclusions were mainly based on studies concerning colorectal cancer, but scientific evidence is still limited for other cancer ...

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The Influence of Diet on Fertility and the Implications for Public Health Nutrition in the United States: Jaida Garrett

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The Influence of Diet on Fertility and the Implications for Public Health Nutrition in the United States: Jaida Garrett

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Infertility amongst men and women affect 15% of couples in the united states and 25% of cases are male physiological factors. This article provides evidence on how important nutrition and diet is to couples or even individuals who want to reproduce or use assisted reproductive technology to reproduce. Overall it is most important to consume whole foods, whole grains, monounsaturated or polyunsaturated oils, vegetables, and fish. These foods or foods that fall under these categories benefit men and women for improved fertility (Panth, 2018). It is also found that individuals who experience obesity will be at a higher risk for infertility than an individual with normal BMI ranges. Specific nutritional requirements are going to vary per person however it is generally the same in benefits from the recommendations. A key finding is that if one lacks specific nutritional requirements and is able to conceive and get pregnant, the fetus is now at risk for genetic defects. Defects can include neural tube defects or miscarriage. The article talks about the specific Mediterranean diet and also mentions folate supplementation in months before considering conceiving. Higher levels of folate supplementation lowered the risk of spontaneous abortion (Panth, 2018). Clinical implications include the integration of nutritional counseling into fertility treatment. So, again that educational piece between physician to patient is extremely crucial in lowering health risks such as infertility. They also talk about how to maintain a woman’s psychological health and nutrition when dealing with fertility because they can develop anxiety and depression. If nutrition starts to lack the health and quality of the individual will decrease and that certainly does not help with fertility. I really enjoyed this article and I think it is so important for reproductive health.

Panth, N., Gavarkovs, A., Tamez, M., & Mattei, J. (2018). The Influence of Diet on Fertility and the Implications for Public Health Nutrition in the United States. Frontiers in public health, 6, 211. https://doi.org/10.3389/fpubh.2018.00211

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The Effect of Nutrition Intervention with Oral Nutritional Supplements on Pancreatic and Bile Duct Cancer Patients Undergoing Chemotherapy

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Emalee Haynes

The goal of this study was to find helpful ways to provide nutrition supplements to patients with pancreatic and bile duct cancer. It was mentioned how negatively quality of life can be impacted for patients receiving chemotherapy medications, and nutrition takes a large hit in all of this. The study compared a control group to a group of patients who did receive an oral nutritional supplement for 8 weeks. The results found that patients who received the oral nutritional supplements had, “increased daily intakes of energy, carbohydrates, proteins, and lipids. After 8 weeks, fat mass significantly increased in the ONS group.” This is important to note because this is a potential supplement option for cancer patients to help improve their quality of life through helping to better their nutrition through aiding in weight gain or maintenance of initial weight and improve feelings of fatigue. When a patient is receiving chemotherapy, they can have low energy and weight loss which is why this is clinically significant. Clinical implications of this would be another opportunity for counseling patients and helping to give them a holistic treatment regimen.

Kim, Seong Hyeon et al. “The Effect of Nutrition Intervention with Oral Nutritional Supplements on Pancreatic and Bile Duct Cancer Patients Undergoing Chemotherapy.” Nutrients vol. 11,5 1145. 22 May. 2019, doi:10.3390/nu11051145

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Affiliations

¹ Clinical Nutrition Program, Graduate School of Human Environmental Sciences, Yonsei University, Seoul 03722, Korea. cca0926@hanmail.net.

² Department of Nutrition Care, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea. NUTRPINE@yuhs.ac.

³ Cancer Metastasis Research Center, Division of Medical Oncology, Cancer Center Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. jeunghc1123@yuhs.ac.

⁴ Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. ikjae412@yuhs.ac.

⁵ Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. jspark330@yuhs.ac.

⁶ Department of Food and Nutrition, Brain Korea 21 PLUS Project, College of Human Ecology, Yonsei University, Seoul 03722, Korea. msyu@yonsei.ac.kr.

⁷ Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. dklee@yuhs.ac.

⁸ Department of Food and Nutrition, Brain Korea 21 PLUS Project, College of Human Ecology, Yonsei University, Seoul 03722, Korea. leeseungmin@yonsei.ac.kr.

Free PMC article

Randomized Controlled Trial

Free PMC article

Affiliations

¹ Clinical Nutrition Program, Graduate School of Human Environmental Sciences, Yonsei University, Seoul 03722, Korea. cca0926@hanmail.net.

² Department of Nutrition Care, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea. NUTRPINE@yuhs.ac.

³ Cancer Metastasis Research Center, Division of Medical Oncology, Cancer Center Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. jeunghc1123@yuhs.ac.

⁴ Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. ikjae412@yuhs.ac.

⁵ Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. jspark330@yuhs.ac.

⁶ Department of Food and Nutrition, Brain Korea 21 PLUS Project, College of Human Ecology, Yonsei University, Seoul 03722, Korea. msyu@yonsei.ac.kr.

⁷ Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea. dklee@yuhs.ac.

⁸ Department of Food and Nutrition, Brain Korea 21 PLUS Project, College of Human Ecology, Yonsei University, Seoul 03722, Korea. leeseungmin@yonsei.ac.kr.

Abstract

Chemotherapy may negatively affect nutritional status and quality of life (QOL) in pancreatic cancer patients. Our aim was to investigate the beneficial effects of oral nutrition supplements (ONS) on pancreatic and bile duct cancer patients undergoing chemotherapy. Among patients with progressive pancreatic and bile duct cancer receiving chemotherapy, the ONS group ( n = 15) received two packs of ONS daily for 8 weeks while the non-ONS group ( n = 19) did not. Anthropometric measures, dietary intake, nutritional status, and quality of life were assessed. ONS significantly increased daily intakes of energy, carbohydrates, proteins, and lipids at 8 weeks compared to the baseline. After 8 weeks, fat mass significantly increased in the ONS group. For patients in their first cycle of chemotherapy, body weight, fat-free mass, skeletal muscle mass, body cell mass, and fat mass increased in the ONS group but decreased in the non-ONS group. Fat mass increased in second or higher cycle only in the ONS group. Patient-generated subjective global assessments (PG-SGA) and fatigue scores in the Quality of Life Questionnaire Core 30 (QLQ-C30) improved in the ONS group. ONS might improve nutritional status by increasing fat mass and/or maintaining the body composition of pancreatic and bile duct cancer patients with chemotherapy, especially those in the first cycle, and alleviate fatigue symptoms.

Keywords: Quality of Life Questionnaire Core 30; chemotherapy; oral nutritional supplement (ONS), nutritional status; pancreatic and bile duct cancer; patient-generated subjective global assessments.

Conflict of interest statement

The authors declare no conflict of interest.

References

Ferlay J., Shin H.-R., Bray F., Forman D., Mathers C., Parkin D.M. GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10. Volume 2010. International Agency for Research on Cancer; Lyon, France: 2010. p. 29.

Son B.K. Management of Borderline Resectable Pancreatic Cancer and Local Treatment of Locally Advanced Pancreatic Cancer. Korean J. Pancreas Biliary Tract. 2015;20:14-21. doi: 10.15279/kpba.2015.20.1.14. - DOI

Ryu J.K. Recent Advances in Palliative Chemotherapy for Unresectable Pancreatic Cancer. Korean J. Gastroenterol. 2015;66:150-153. doi: 10.4166/kjg.2015.66.3.150. - DOI - PubMed

Capra S., Ferguson M., Ried K. Cancer: impact of nutrition intervention outcome-nutrition issues for patients. Nutrition. 2001;17:769-772. doi: 10.1016/S0899-9007(01)00632-3. - DOI - PubMed

Walsh D., Donnelly S., Rybicki L. The symptoms of advanced cancer: Relationship to age, gender, and performance status in 1000 patients. Support. Care Cancer. 2000;8:175-179. doi: 10.1007/s005200050281. - DOI - PubMed

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national center for biotechnology information

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The Effect of Nutrition Intervention with Oral Nutritional Supplements on Pancreatic and Bile Duct Cancer Patients Undergoing Chemotherapy - PubMed

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Chemotherapy may negatively affect nutritional status and quality of life (QOL) in pancreatic cancer patients. Our aim was to investigate the beneficial effects of oral nutrition supplements (ONS) on pancreatic and bile duct cancer patients undergoing chemotherapy. Among patients with progressive pa ...

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Healthy Foods Can Make You Happier- Cole Cincinelli

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Healthy Foods Can Make You Happier- Cole Cincinelli

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Throughout this course the interaction between several diseases and nutrition have been discussed. Cardiovascular diseases, immune diseases and cancer are only a few of the top diseases around the world that are taking lives. The cure to this issue is improving eating habits and changing lifestyle behaviors and it can not only reduce risk for many diseases but also produce a happier perception of life. Research suggests that “healthy” food choices such as eating fruits and vegetables have not only physical but also mental health benefits and might be a long-term investment in future well-being. A panel survey of over 12,000 adults from Australia, Mujcic and Oswald showed that fruit and vegetable consumption predicted increases in happiness, life satisfaction, and well-being over two years (Wahl et al). This contradicts the idea that high calorie, sugary, comfort foods make us happy but in reality those foods are actually negatively impacting our mental and physical health. This study is one of very few studies that investigated in-the-moment experiences of eating happiness using self-report. Future research could further the evidence of this study by looking at brain areas associated with happiness during eating healthy/unhealthy foods.

Wahl DR, Villinger K, König LM, Ziesemer K, Schupp HT, Renner B. Healthy food choices are happy food choices: Evidence from a real life sample using smartphone based assessments. Sci Rep. 2017;7(1):17069. Published 2017 Dec 6. doi:10.1038/s41598-017-17262-9

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A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. -Seonwook Kim

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A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. -Seonwook Kim

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For my last weekly wall, I selected the topic for hyperlipidemia because I am interested in this topic and enjoyed the lecture and articles in this module. Hyperlipidemia indicates the elevation of cholesterol and/or triglyceride (TG) and is closely related to obesity and cardiovascular diseases. This condition is easily acquired by eating habitats. This study investigated low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia. The key finding of this study is that a low-carbohydrate diet program, compared with low-fat diet, had better participant retention and greater weight loss. In addition, serum TG levels decreased more, and high-density lipoprotein cholesterol levels increased more with the low-carbohydrate diet. In clinical implications, low-carbohydrate ketogenic diet may be a better option to treat hyperlipidemic obesity patients because healthy hyperlipidemic persons who followed a low-carbohydrate diet lost more body weight and body fat than those who followed a low-fat diet. Also, serum lipid profiles improved at the same level as low-fat diet.

Yancy WS Jr, Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med. 2004 May 18;140(10):769-77. doi: 10.7326/0003-4819-140-10-200405180-00006. PMID: 15148063.

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Affiliation

¹ Center for Health Services Research in Primary Care, Department of Veterans Affairs Medical Center, and Duke University Medical Center, Durham, North Carolina 27705, USA.

Free article

Free article

Affiliation

¹ Center for Health Services Research in Primary Care, Department of Veterans Affairs Medical Center, and Duke University Medical Center, Durham, North Carolina 27705, USA.

Abstract

Background: Low-carbohydrate diets remain popular despite a paucity of scientific evidence on their effectiveness.

Objective: To compare the effects of a low-carbohydrate, ketogenic diet program with those of a low-fat, low-cholesterol, reduced-calorie diet.

Design: Randomized, controlled trial.

Setting: Outpatient research clinic.

Participants: 120 overweight, hyperlipidemic volunteers from the community.

Intervention: Low-carbohydrate diet (initially, <20 g of carbohydrate daily) plus nutritional supplementation, exercise recommendation, and group meetings, or low-fat diet (<30% energy from fat, <300 mg of cholesterol daily, and deficit of 500 to 1000 kcal/d) plus exercise recommendation and group meetings.

Measurements: Body weight, body composition, fasting serum lipid levels, and tolerability.

Results: A greater proportion of the low-carbohydrate diet group than the low-fat diet group completed the study (76% vs. 57%; P = 0.02). At 24 weeks, weight loss was greater in the low-carbohydrate diet group than in the low-fat diet group (mean change, -12.9% vs. -6.7%; P < 0.001). Patients in both groups lost substantially more fat mass (change, -9.4 kg with the low-carbohydrate diet vs. -4.8 kg with the low-fat diet) than fat-free mass (change, -3.3 kg vs. -2.4 kg, respectively). Compared with recipients of the low-fat diet, recipients of the low-carbohydrate diet had greater decreases in serum triglyceride levels (change, -0.84 mmol/L vs. -0.31 mmol/L [-74.2 mg/dL vs. -27.9 mg/dL]; P = 0.004) and greater increases in high-density lipoprotein cholesterol levels (0.14 mmol/L vs. -0.04 mmol/L [5.5 mg/dL vs. -1.6 mg/dL]; P < 0.001). Changes in low-density lipoprotein cholesterol level did not differ statistically (0.04 mmol/L [1.6 mg/dL] with the low-carbohydrate diet and -0.19 mmol/L [-7.4 mg/dL] with the low-fat diet; P = 0.2). Minor adverse effects were more frequent in the low-carbohydrate diet group.

Limitations: We could not definitively distinguish effects of the low-carbohydrate diet and those of the nutritional supplements provided only to that group. In addition, participants were healthy and were followed for only 24 weeks. These factors limit the generalizability of the study results.

Conclusions: Compared with a low-fat diet, a low-carbohydrate diet program had better participant retention and greater weight loss. During active weight loss, serum triglyceride levels decreased more and high-density lipoprotein cholesterol level increased more with the low-carbohydrate diet than with the low-fat diet.

Adherence to Low-Carbohydrate Diets in Patients with Diabetes: A Narrative Review.

Kumar NK, Merrill JD, Carlson S, German J, Yancy WS Jr. Kumar NK, et al. Diabetes Metab Syndr Obes. 2022 Feb 18;15:477-498. doi: 10.2147/DMSO.S292742. eCollection 2022. Diabetes Metab Syndr Obes. 2022. PMID: 35210797 Free PMC article. Review.

Low-carbohydrate versus balanced-carbohydrate diets for reducing weight and cardiovascular risk.

Naude CE, Brand A, Schoonees A, Nguyen KA, Chaplin M, Volmink J. Naude CE, et al. Cochrane Database Syst Rev. 2022 Jan 28;1(1):CD013334. doi: 10.1002/14651858.CD013334.pub2. Cochrane Database Syst Rev. 2022. PMID: 35088407 Free PMC article. Review.

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dietary carbohydrates / administration & dosage*

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national center for biotechnology information

# data[].attributes.attachment_link.title
A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial - PubMed

# data[].attributes.attachment_link.description
Compared with a low-fat diet, a low-carbohydrate diet program had better participant retention and greater weight loss. During active weight loss, serum triglyceride levels decreased more and high-density lipoprotein cholesterol level increased more with the low-carbohydrate diet than with the low-f ...

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Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa -Cassie Craig

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Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa -Cassie Craig

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For our last week, I chose a review on the nutritional treatment and effects of Anorexia Nervosa (AN) on patients. The eating disorder module was my favorite to learn about because my goal is to become a behavioral health physician, so I would encounter eating disorders, such as AN, regularly. This review is important because it explores both the physical and nutritional impacts that this disease yields in patients. This review emphasizes the difficulty of implementing dietary changes in patients with AN, but the overall goal is to help the patient increase their nutrient intake until they return to a healthy weight. They found that patients that with AN are deficient in vitamin and mineral levels, making them high risk for developing refeeding syndrome. This is clearly related to nutritional science because AN yields poor nutritional levels in patients and requires dietary intervention for recovery. In a clinical setting, this review aims to help standardize and improve treatment for AN patients, which will hopefully yield faster, long-lasting recovery.

Cuerda, C., Vasiloglou, M. F., & Arhip, L. (2019). Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa. Journal of clinical medicine, 8(7), 1042. https://doi.org/10.3390/jcm8071042