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Sarah Valentina Rangel

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Visit the VCH site to find reliable nutritional information and professionals who can help you make informed nutritional choices!

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Skip to main content

Registered dietitians work across the lifespan with infants to seniors to promote the best possible growth, development, and health outcomes. They are trusted professionals for nutrition therapy and members of the College of Dietitians of British Columbia. Dietitians provide evidence-based information and education to support informed choices about food and diet. They also support, participate in, and encourage nutrition research.

Food Asset Map - Access maps highlighting places where people can grow, prepare, share, buy, receive or learn about food in their community

Home Health dietitians provide personal and individualized nutrition services to adults 19 years of age or older in their home or community health centre. Learn more about our Home Health dietitian services.

Public Health dietitians work to advocate for healthy eating to promote healthy growth, development, and prevention or management of chronic disease across all population groups. We aim to support the development of healthy relationships with food, with a focus on multiculturalism by:

Encouraging the sharing of food with family and friends

Advocating for community food programs that support food security (e.g., community gardens, community kitchens)

Promoting healthy attitudes about food, eating and body size

Creating supportive environments that promote healthy eating and active living

Promoting healthy eating messages

Working with food banks and other community organizations to address food challenges for at-risk populations using a community development approach

Participating in local, provincial and/or national committees that advocate for nutrition policies for various target groups and assist with the development of nutrition standards, food policies and resources

We also provide a range of services for school staff, students, parents and caregivers of infants, children, and youth including:

Program planning (e.g. breakfast and lunch programs, school gardens, farm to school)

Helping daycares, preschools and schools to develop policies about food and healthy eating. Supporting staff, parents and children/students to follow food and healthy eating policies and guidelines.

Providing advice and support on implementing the Guidelines for Food and Beverage Sales in BC Schools (e.g. food service, fundraisers, vending machines, and other school events)

Providing education sessions to staff and parents (e.g. early childhood educator workshops, professional-development day workshops, parent advisory council meetings on topics such as responsive feeding, weight bias, nutrition policy)

Providing healthy eating resources (e.g. Canada's Food Guide, "Appetite to Play" early years tool kit, nutrition and body image lesson plans and resources)

Helping school staff, parents and caregivers find appropriate nutrition services for infant, children and youth

All services are free of charge. To connect with a public health dietitian, contact your local VCH Community Health Centre.

Click on the program listings below for details.

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Skip to main content Registered dietitians work across the lifespan with infants to seniors to promote the best possible growth, development, and health outcomes. They are trusted professionals for nutrition therapy and members of the College of Dietitians of British Columbia. Dietitians provide evidence-based information and education to support informed choices about food and diet.

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Negative attitudes towards food and weight that have been normalized in our society can heavily contribute to eating disorders. Visit this foundation's site to learn more about these disorders or how get support.

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Knowledge Brings Hope

Eating disorders are complex mental illnesses that can be life-threatening. The stigma around eating disorders, as well as the normalization of certain disordered beliefs and behaviours around food, weight and exercise in our culture, contributes to a lack of understanding and awareness. This can act as a barrier to care for people who desperately need and deserve support. Understanding the nuances of this disease is an important step in ensuring no-one has to suffer in silence.

10 Eating Disorder Truths

Eating disorders have the highest mortality rate of any psychiatric illness.

Eating disorders are not a choice. They are not a lifestyle. They are not rooted in vanity, and they are so much more than a diet gone awry.

Eating disorders do not discriminate. They affect people of all genders, sexual orientations, ages, socioeconomic classes, abilities, races and ethnic backgrounds, with certain marginalized communities experiencing higher incidence and more barriers to care.

Eating disorders tend to thrive in isolation and secrecy. They are often accompanied by feelings of shame and individuals may go to great lengths to conceal their behaviour.

People with negative body image have a greater likelihood of developing an eating disorder. Weight stigma, fatphobia and diet culture may also play a role for many people.

What Is An Eating Disorder?

An eating disorder is a condition characterized by severe behaviors, attitudes, and painful emotions around eating, food and body weight or shape. The eating disorder may be used as a way to cope with difficult situations or feelings, often to help the individual feel more in control. Behaviours can include limiting the amount of food eaten, eating very large quantities of food all at once, compensating through unhealthy means such as purging, fasting or excessive exercise, or a combination of these behaviours. Every case is different.

Eating disorders have both psychological and physical implications. They affect every organ system in the body and bring increased risk for cardiac arrest, stroke, and other hormonal and neurological issues. They severely impact a person's social, emotional and spiritual wellness, hindering their ability to feel fulfilled, present and happy.

Visit the National Eating Disorder Information Centre (NEDIC) for more information, statistics and research on eating disorders.

What Causes an Eating Disorder?

There is no one factor alone that causes an eating disorder. Rather, there are contributing factors - biological, genetic, psychological and sociocultural - which, combined, may increase a person's likelihood for developing an eating disorder. There is ongoing research to understand the role biology and genetics play in the development of this illness. Psychological risk factors include low self-esteem, feelings of inadequacy or lack of control, history of trauma, and stress. Many people who struggle with eating disorders have a co-occurring condition, such as anxiety, depression, self-harm, substance use, PTSD or obsessive-compulsive disorder.

The sociocultural environment in which a person lives can also play a role. Cultural norms place unrealistic and harmful expectations on people to achieve "thinness" or muscularity, or to look a particular way based on narrow gender norms or Western beauty ideals. Over-exercising and certain bingeing behaviours have become normalized in our society. Weight shaming, fatphobia and bullying can also contribute to the development of eating disorders.

Family influences can include family attitudes toward eating and weight, difficulty communicating or resolving conflict, neglect, and history of mental illness, among others. Family and caregivers do not cause eating disorders, but they do play an important role in the care and support of someone who is struggling.

Who Do Eating Disorders Affect?

Anyone can develop an eating disorder. Although they have been associated with young, white, cisgender, heterosexual females, in actual fact eating disorders affect people from all demographics. Misconceptions about who is affected by eating disorders can be harmful and impact the diagnoses, support options and access to treatment for those who don't fit the stereotype. Informed, culturally appropriate care is essential in order to facilitate recovery for people of all lived experiences.

Children, adolescents and athletes are particularly vulnerable. The following groups are also worth noting due to the increased risk and/or distinct barriers to care which they face:

2SLGBTQ+ individuals face unique experiences and stressors that result in a higher probability of developing an eating disorder. These can include but are not limited to discrimination, bullying, trauma, lack of support from friends and family, and pressure to look a certain way in order to align their body with their gender identity. 2SLGBTQ+ folks may face barriers to care due to harmful stereotypes, negative experiences or feeling unsafe in healthcare settings, as well as a lack of affirming treatment options.

Despite the dominant narrative of who typically suffers from an eating disorder, it's important to note that people who identify as men are also affected and may face barriers in seeking support due to harmful stereotypes around gender and mental health, and the misconception of eating disorders as a "female illness". In males, eating disorders may present as dissatisfaction with their bodies due to lack of muscle definition, an obsession with fitness and excessive exercise, rigid behaviours and beliefs around food, heightened anxiety or irritability around mealtimes, low self-esteem and distorted body image.

Eating disorders can develop as a way of coping with trauma or difficult situations in a person's life. Marginalized communities typically face higher levels of discrimination, poverty and food insecurity which can seriously impact mental health. The pressure to conform to Western values around weight and appearance may also play a role in the development of body dissatisfaction and disordered eating.

Diabetes is a risk factor for developing an eating disorder due to the intense focus on monitoring food, labels, weight, and glucose levels. Type 1 diabetes with disordered eating (T1DE) or "diabulimia" is an eating disorder that only affects people with type 1 diabetes. It occurs when a person purposefully restricts insulin in order to lose weight. Other medical risk factors include the management of hypoglycaemia (or low blood sugar level), starvation, and other purging behaviours.

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Learn More About Eating Disorders - Looking Glass Foundation

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Eating disorders are complex mental illnesses that can be life-threatening. The stigma around eating disorders, as well as the normalization of certain disordered beliefs and behaviours around food, weight and exercise in our culture, contributes to a lack of understanding and awareness. This can act as a barrier to care for people who desperately need and deserve support.

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Take a look at this study if you'd like to learn more about the principles of intuitive eating and how beneficial it can be in reducing the risk of developing eating disorders. There is a lot of misinformation online about intuitive eating, but when used properly, it can create a healthier relationship with food and body image!

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Abstract

Dietary restraint and low body appreciation are common among female-identifying undergraduates and are related to the development of disordered eating, which female-identifying undergraduates engage in throughout college. Training students in intuitive eating, an approach that promotes eating by internal cues, may be a way to ameliorate dietary restraint and low body appreciation, ultimately decreasing disordered eating. The purpose of this study was to examine the impact of a five-week intuitive eating intervention on dietary restraint, body appreciation, and intuitive eating in female-identifying undergraduates. A five-week intuitive eating intervention ( NCT0394700) was facilitated by two Registered Dietitians. One treatment group (TG) ( n = 7) and one waitlist control group (WLCG) ( n = 7) participated in the trial. From baseline to post-intervention, there was a significant decrease in dietary restraint, t(12) = -2.88, p = 0.01, and a significant increase in intuitive eating, t(12) = 4.03, p = 0.002, in the TG compared to the WLCG. The intervention had replicable effects on all outcome variables. Measurements at the five-week follow-up suggested the impact was sustained. This study provides preliminary data suggesting an intuitive eating intervention may help improve disordered eating risk factors by decreasing dietary restraint and increasing intuitive eating in female-identifying undergraduates.

Keywords: body image; college students; dietary restraint; disordered eating; feeding and eating disorders; intuitive eating.

Conflict of interest statement

The authors declare no conflict of interest.

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References

White S., Reynolds-Malear J.B., Cordero E. Disordered Eating and the Use of Unhealthy Weight Control Methods in College Students: 1995, 2002, and 2008. Eat. Disord. 2011;19:323-334. doi: 10.1080/10640266.2011.584805. - DOI - PubMed

Barrack M.T., West J., Christopher M., Pham-Vera A.-M. Disordered Eating Among a Diverse Sample of First-Year College Students. J. Am. Coll. Nutr. 2019;38:141-148. doi: 10.1080/07315724.2018.1487345. - DOI - PubMed

Lipson S., Sonneville K. Eating disorder symptoms among undergraduate and graduate students at 12 U.S. colleges and universities. Eat. Behav. 2017;24:81-88. doi: 10.1016/j.eatbeh.2016.12.003. - DOI - PubMed

Neumark-Sztainer D., Wall M., Guo J., Story M., Haines J., Eisenberg M. Obesity, Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How Do Dieters Fare 5 Years Later? J. Am. Diet. Assoc. 2006;106:559-568. doi: 10.1016/j.jada.2006.01.003. - DOI - PubMed

Wade T.D., Wilksch S.M., Lee C. A longitudinal investigation of the impact of disordered eating on young women's quality of life. Health Psychol. 2012;31:352-359. doi: 10.1037/a0025956. - DOI - PubMed

Grant support

This research received no external funding.

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national center for biotechnology information

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Impact of an Intuitive Eating Intervention on Disordered Eating Risk Factors in Female-Identifying Undergraduates: A Randomized Waitlist-Controlled Trial - PubMed

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Dietary restraint and low body appreciation are common among female-identifying undergraduates and are related to the development of disordered eating, which female-identifying undergraduates engage in throughout college. Training students in intuitive eating, an approach that promotes eating by int ...

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Green "powders" and other fruit and vegetable supplements are increasingly popular, but do they work? This study says they do. The participants in this study used these supplements and saw a decrease in markers of oxidation, reduced inflammation, and increase in blood flow!

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Abstract

Obesity and sedentary lifestyle are associated with increased oxidative stress, inflammation and vessel dysfunction. Previous research has shown that an encapsulated fruit/berry/vegetable juice powder (FBV) supplement or controlled exercise training improve the markers of redox biology, low-grade inflammation and circulation. The aim of the present study was to assess the effects of 8 weeks of supplementation with FBV or placebo, and a single bout of controlled walking on the markers of oxidation, inflammation and skin capillary microcirculation in forty-two obese pre-menopausal women (41 (sd 5) years, non-smokers and BMI 34·5 (sd 3·8) kg/m ²) using a randomised, double-blind, placebo-controlled design. All assessments were made before and after 8 weeks of capsule supplementation, and pre- and post-30 min of controlled treadmill walking at 70 % of VO 2max. Venous blood was collected for the determination of carbonyl proteins (CP), oxidised LDL (ox-LDL), total oxidation status (TOS) of lipids, malondialdehyde, TNF-α and IL-6. Capillary blood flow, O ₂ saturation of Hb (SO ₂Hb) and the relative concentration of Hb (rHb) were assessed at a 2 mm skin depth. Following 8 weeks of supplementation, compared with placebo, the FBV group had a significant ( P< 0·05) reduction in CP, ox-LDL, TOS and TNF-α, and a significant increase in blood flow, SO ₂Hb and rHb. Independent of supplementation, moderate exercise significantly increased blood flow and rHb, with a trend towards increased SO ₂ Hb. Compared with placebo, 8 weeks of supplementation with FBV decreased the markers of systemic oxidation and inflammation. Both FBV supplementation and a single walking bout improved the markers of the microcirculation in these obese women.

Keywords: Dietary supplements, Exercise and obesity, Oxidation and inflammation, Skin microcirculation

In recent decades, increasing prevalence of obesity has become a serious public health concern. Suboptimal dietary habits coupled with a sedentary lifestyle are thought to be major contributors to this situation. Overweight and obesity are associated with irregularities in redox homeostasis, imbalanced pro-inflammatory and anti-inflammatory states and microcirculatory dysfunction⁽ 1 ⁻ 3 ⁾. Reactive Oxygen and Nitrogen species and pro-inflammatory cytokines from both visceral and subcutaneous fat compartments are implicated in increased cardiometabolic disease risk⁽ 4 , 5 ⁾. Recent research has shown that obese people have structural and functional alterations in skin microcirculation, which are proportional to the increase in the degree of global and central obesity⁽ 6 ⁾. Hence, diets rich in antioxidants and anti-inflammatory nutrients, as well as physical exercise, are of interest to combat some of the detrimental side effects of overweight and obesity.

It has been reported that increased consumption of fruits and vegetables improves the body's antioxidant and anti-inflammatory capacities⁽ 7 ⁻ 9 ⁾. Nutraceuticals providing phytochemicals and vitamins, such as an encapsulated fruit and vegetable juice powder concentrate, have also demonstrated beneficial effects on the markers of oxidative stress, inflammation and skin microcirculation⁽ 10 ⁻ 12 ⁾.

Similar effects are also observed with exercise. Regular exercise training and single bouts of exercise improve redox biology, exert anti-inflammatory effects and are able to enhance the microcirculation in different populations, including overweight subjects⁽ 13 ⁻ 16 ⁾.

However, the influence of both exercise and nutrient supplementation on oxidation, inflammation and skin microcirculation in a target group of obese women has not been established.

Thus, the primary objective of the present study was (1) to explore the effects of a fruit, berry and vegetable juice powder concentrate (FBV) on oxidation, inflammation and skin microcirculation, compared with placebo. The secondary and tertiary goals were (2) to evaluate whether a single bout of defined walking exercise - with or without the FBV treatment - affects the capillary microcirculation from the skin surface to a 2 mm depth, and (3) to evaluate whether a defined model of walking exercise generates oxidative stress - with or without the FBV treatment - in a cohort of obese but otherwise healthy pre-menopausal women.

Experimental methods

Study population

A total of forty-two overweight and obese pre-menopausal women participated in the present trial. Inclusion criteria were as follows: female; age 35-50 years; regular menses; able to participate in walking exercise; non-smokers; sedentary work and lifestyle; BMI between 28 and 40 kg/m ²; no dietary or nutritional supplement use within the 4 weeks before the first exercise test. Exclusion criteria included the following: smokers; women who failed exercise eligibility testing - as described by the Austrian and German standards in sports medicine⁽ 17 ⁾; chronic or excessive alcohol consumption; pregnancy and/or lactation; recent surgery or illness; diabetes; dyslipidaemia; current participation in a weight management programme; diagnosis of osteoporosis or osteopenia; current use of any medication known to significantly influence inflammation, redox biology or haemostasis. In addition to these inclusion and exclusion criteria, a standard blood chemistry panel, exercise echocardiography and maximum O ₂ uptake (VO 2max) were determined in all women to confirm general health before study enrolment. All subjects also completed a medical history and a physical activity/well-being questionnaire.

Ethical aspects, recruitment and randomisation

The present study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving human subjects were approved by the Ethical Review Committee of the Medical University of Graz, Austria. All subjects provided written informed consent before participating in the present investigation. The trial was registered at www.clinicaltrials.gov (identifier no. NCT01476033).

The study focused on office workers and was announced in local newspapers. A telephone screening conducted by study staff resulted in fifty-nine volunteers for further eligibility testing. Among these volunteers, forty-four women met the inclusion and exclusion criteria and were enrolled.

Subjects were randomised in blocks of six and sequentially numbered ( www.randomization.com). To guarantee a balanced BMI distribution between the groups (FBV or placebo), we conducted stratification via BMI rank statistics. The randomisation code was held by a third party (Union of Sport and Exercise Scientists Austria) and provided for statistical analyses of the complete dataset.

Study design and time schedule

This was a randomised, double-blind, placebo-controlled study. All eligibility testing was finalised 4 weeks before the baseline controlled walking bout. On that morning, a standardised breakfast (2-3 h before exercise) was provided. Then, each subject came to the laboratory to perform her 30 min exercise test at an intensity of 70 % of individual VO 2max. After the test, the investigator dispensed the randomised capsule supply according to the subject's BMI ranking. Following 8 weeks of capsule supplementation as directed, they returned their remaining capsules and the same test procedure was repeated. All subjects were checked by a physician before each exercise test. The walking tests were scheduled between days 10 and 20 of the menstrual cycle.

Dietary parameters

Subjects were instructed to maintain their habitual diet and lifestyle during the 8-week study and to duplicate their diet before each exercise testing/blood collection appointment, as described below. Before the first 30 min walking test, subjects completed a 7 d food record to assess nutrient intake. Subjects subsequently received copies of their 7 d diet records and were instructed to replicate the diet before the second exercise test. The standardised breakfast was served 2-3 h before both exercise tests to limit nutrient variation due to self-selection on the morning scheduled for blood collection. The standardised breakfast consisted of 250 ml low-fat yogurt, 10 g butter, 20 g jam or honey, 50 g rye-wheat bread and 500 ml of plain water, providing 1500 kJ, 13 g protein, 47 g carbohydrate and 13 g fat. Diet records were analysed for total energy, protein, carbohydrate, fat, cholesterol, fibre, water, alcohol and several vitamins, minerals and fatty acids using Opti Diet software 5.0 (GOEmbH).

Study capsules

Women randomised to the FBV group ( n 22) received capsules containing primarily a blended fruit, vegetable and berry juice powder concentrate derived from the following: acerola cherry, apple, bilberry, blackberry, black currant, blueberry, beetroot, broccoli, cabbage, carrot, Concord grape, cranberry, elderberry, kale, orange, peach, papaya, parsley, pineapple, raspberry, red currant, spinach and tomato (Juice Plus+ ® Premium; NSA), as described previously⁽ 10 ⁾. Briefly, the FBV capsules provided 7·5 mg β-carotene, 200 mg vitamin C, 60 mg RRR-α-tocopherol, 600 μg folate and 63 kJ/d. Those subjects randomised to the placebo group ( n 22) received identically appearing opaque white capsules containing microcrystalline cellulose. All subjects were instructed to take three capsules twice daily with meals, in agreement with the label use instructions for the retail product, for a total of six capsules per d.

Eligibility exercise test

As part of eligibility testing, each subject performed an incremental exercise test on a treadmill ergometer (QUASARmed; HP Cosmos Sports & Medical GmbH) to check the heart and circulatory function and for the determination of VO 2max. A standard electrocardiogram was recorded throughout all exercise tests, which were supervised by a physician. Respiratory gas exchange variables were measured throughout the incremental exercise tests using a breath-by-breath mode (Metalyzer 3B; Cortex Biophysik GmbH).

Endurance exercise test

For the 30 min aerobic exercise tests, the walking speed was adjusted to 70 % of individual VO 2max on the treadmill ergometer after the standardised breakfast described previously. All tests were performed on the same treadmill, with the same standardised room temperature (20°C) and humidity (60 %). Blood pressure was measured at the beginning and every 10 min until the bout was completed.

Blood collection and sample preparation

At each laboratory visit, two EDTA blood samples were collected from each participant, in a supine position, from a medial cubital vein: before exercise (pre) and immediately post-exercise (post). This venous blood was collected to determine the concentrations of carbonyl proteins (CP), oxidised LDL (ox-LDL), total oxidation status of lipids (TOS), malondialdehyde (MDA), TNF-α and IL-6. After centrifugation for 10 min, plasma was removed and frozen at − 70°C until analysis.

Biochemical analyses

CP concentration was quantified using ELISA methods developed previously by Buss & Winterbourn⁽ 18 ⁾ and Alamdari et al.⁽ 19 ⁾. These methods are based on the antibody recognition of carbonyl protein-bound 2,4-dinitrophenylhydrazine.

For ox-LDL determination, a commercially available immunosorbent kit (Mercodia AB) based on a direct sandwich technique was utilised.

The TOS assay determines total lipid peroxides (Immundiagnostik AG) by the detection of a coloured product from the reaction of a peroxidase with the peroxides in the sample, followed by the conversion of tetramethylbenzidine.

MDA concentration was determined according to a previously described HPLC method by Pilz et al.⁽ 20 ⁾ after derivatisation with 2,4-dinitrophenylhydrazine.

Both TNF-α and IL-6 concentrations were analysed using commercially available ELISA kits with monoclonal antibodies (TNF-α: Immundiagnostik AG; IL-6: Invitrogen; LifeTech Austria).

Microcirculation parameters

Measurements were conducted in a supine position after a 10 min rest before and after the walking exercise bout, on the back of the hand, between the first and second metacarpal bone. This tissue photo spectrometry technology is also called 'oxygen to see' (Lea Instruments). All measurements were performed by the same technician. A laser Doppler effect, as described elsewhere⁽ 12 , 21 ⁾, was used to determine microcirculatory blood flow. For the determination of O ₂ saturation of Hb (SO ₂Hb) and relative Hb concentration (rHb), white-light tissue spectrometry was utilised: SO ₂Hb is identified by the colour of Hb, as the degree of molecular SO ₂Hb relates to a certain colour. rHb was quantified using light absorption by the conversion of white light into red light, which is proportional to the concentration of Hb⁽ 22 ⁾. Blood flow and rHb are expressed in arbitrary units, whereas SO ₂Hb is expressed as a percentage of O ₂ on Hb. This technology measures the microcirculation of blood from the skin surface to a 2 mm depth.

Blood chemistry panel

Standard blood chemistry was determined for eligibility testing after an overnight fast using EDTA plasma from the peripheral venous blood using a routine clinical chemistry analyser (Abbott Diagnostics).

Statistical analyses and sample size calculation

Per-protocol analyses were performed using IBM SPSS for Windows software, version 19.0 (SPSS Inc.). Data are presented as means and standard deviations. Data for pre-post-comparisons were adjusted for plasma volume changes as described elsewhere (except for CP, as it is already expressed in relation to protein concentration)⁽ 23 ⁾. Statistical significance was set at P< 0·05. The Shapiro-Wilk test was used to determine a normal distribution. Baseline characteristics, performance data, nutrient and clinical chemistry data were compared using the unpaired Student's t test. Data obtained for CP, ox-LDL, TOS, MDA, TNF-α, IL-6, SO ₂ Hb, rHb and blood flow were analysed using a univariate, three-factorial, repeated-measures ANOVA. Factors were as follows: treatment (FBV or placebo); exercise (pre- and post-exercise); session (walking test 1 and walking test 2). Significant interactions and main effects were analysed by Bonferroni correction.

The sample size estimate of seventeen subjects per group was based on previous data on oxidation and inflammation markers (markers of primary outcome) and subjected to a probability of error (α = 5 %) and to a test power (1 − β = 80 %). Concerning the mean values, we assumed to discover a difference of 20 % between the FBV and placebo groups after 8 weeks of treatment (and in comparison from pre- to post-exercise) and a standard deviation of 20 % for the oxidation markers CP and MDA. For the mean values of TNF-α and IL-6, we assumed to discover a difference of 30 % between the FBV and placebo groups after 8 weeks of treatment (and in comparison from pre- to post-exercise) and a standard deviation of 30 %. Allowing for an anticipated attrition of 20 % in each group, twenty-two subjects per group were recruited to discover the assumed differences.

Results

Study population and nutrition

A CONSORT (consolidated standards of reporting trials) diagram outlining participant recruitment is depicted in . Of the forty-four randomised women, forty-two completed the full programme and were included in the statistical analyses. There was one early termination in each study group: in the FBV group, one subject was disqualified at the follow-up visit due to weight loss >3 % of baseline body weight; in the placebo group, one person withdrew due to illness unrelated to the study.

The returned capsule count at the end of the study estimated a compliance >85 % in both groups. The groups did not differ in age, BMI, VO 2max, VO 2max related to body weight, maximum workload ( P max), clinical blood chemistry variables and habitual diet ( P>0·05; ).

30 min controlled exercise bout

The post-exercise analyses revealed that these women performed at 68·2 (sd 3·1) % of individual VO 2max. The average walking performance was approximately 6 km/h (). There were no significant differences between the FBV and placebo groups for these parameters ( P>0·05).

Carbonyl proteins

The mean values of both groups were comparable with healthy people of this age (reference interval 0·37-1·16 nmol/mg). There were no differences between the groups at baseline, pre- and post-exercise. After 8 weeks of supplementation, there was a significant difference between the FBV and placebo groups ( P Tx= 0·022; ), both pre- and post-exercise. The FBV group had significantly lower CP concentrations compared with the placebo group. The model of exercise had no influence on CP concentrations.

Oxidised LDL

There were no differences between the groups at baseline, but a significant difference after 8 weeks of FBV or placebo supplementation ( P Tx= 0·015; ). The FBV group showed lower concentrations compared with the placebo group. The model of exercise had no influence on ox-LDL concentrations. However, all concentrations were within the reference interval, at the beginning and end of the study, pre- and post-exercise (30-80 U/l).

Total oxidation status

There were no differences between the groups at baseline, pre- and post-exercise. After 8 weeks of supplementation, there was a significant difference between the groups ( P Tx= 0·010; ). After the supplementation period, FBV supplementation had reduced the elevated baseline values (reference cut-off < 350 μm-H ₂O ₂) from >900 μm-H ₂O ₂ down to approximately 750 μm-H ₂O ₂, which is still above the reference interval. The model of exercise had no influence on TOS.

Malondialdehyde

There were no differences between the groups at baseline and after 8 weeks of supplementation, pre- and post-exercise, with all concentrations within the reference interval (2·16 (sd 0·29) nmol/ml; data not shown). Also, the model of exercise had no influence on MDA concentrations.

TNF-α

Despite the typically high standard deviation for TNF-α, due to the established cytokine inter-individual variability, the data were normally distributed. There were no differences between the groups at baseline, although pre- and post-exercise concentrations at baseline (mean value >24 pg/ml) exceeded the upper reference limit ( < 20 pg/ml; ). Following 8 weeks of FBV supplementation, pre- and post-exercise, TNF-α concentrations were within the normal physiological range, whereas the values remained elevated in the placebo group. Hence, there was a significant difference between the FBV and placebo groups after 8 weeks of intervention. The model of exercise had no influence on TNF-α.

IL-6

There were no observed differences between the groups at baseline and after 8 weeks of capsule supplementation, both pre- and post-exercise. Also, the model of exercise had no influence. IL-6 concentrations for all subjects remained below the reference cut-off value ( < 11·3 pg/ml; data not shown) throughout the investigation.

Skin microcirculation

All values were within the normal limits provided by the equipment manufacturer for healthy people. There were no significant differences between the groups at baseline with pre- and post-exercise blood flow. After the 8-week supplement period, blood flow was significantly higher in the FBV group compared with placebo ( P Tx= 0·029). There was also a significant increase due to exercise from pre- to post-exercise ( P= 0·004) in both groups, at baseline and after 8 weeks.

There were no differences in SO ₂Hb between the groups at baseline, pre- and post-exercise. Following the 8-week capsule supplement period, SO ₂Hb was significantly higher in the FBV group compared with placebo ( P Tx= 0·032), pre- and post-exercise (). The model of exercise also affected the SO ₂Hb values, with increased values from pre- to post-exercise in both groups at both time points, but this effect did not reach significance ( P Ex= 0·075).

As with SO ₂Hb, there were no differences between the groups at baseline with pre- and post-exercise for rHb. After the 8-week supplement period, rHb was significantly higher in the FBV group compared with placebo ( P Tx= 0·041), pre- and post-exercise (). There was also a significant effect of exercise to increase rHb from pre- to post-exercise ( P Ex = 0·021) in both groups, at baseline and after 8 weeks of treatment.

Discussion

Increased protein and lipid oxidation, as well as low-grade inflammation, are conditions associated with increased cardiovascular and chronic disease risk⁽ 1 , 2 , 5 ⁾. Obese people are at a higher risk of developing chronic medical conditions, thus making an interesting study population. The present investigation was primarily focused on the responses of oxidation, inflammation and capillary microcirculation markers in obese pre-menopausal women, after an 8-week intervention with FBV or placebo capsules, followed by a single bout of aerobic exercise. The resulting data show, after the 8-week study period, (1) compared with placebo, the FBV group had a reduction in the markers of protein oxidation, ox-LDL and total lipid oxidation, and lower concentrations of the chronic inflammation marker TNF-α. The study also revealed that (2) FBV supplementation increased the microcirculation in the skin. (3) A 30 min walking exercise at 70 % of VO 2max increased blood flow and rHb in the skin in both groups (secondary outcome) and (4) the walking exercise did not generate additional oxidative stress in these sedentary obese women (tertiary outcome).

Oxidative stress markers

In the present study, protein oxidation (as assessed by CP) was decreased after the 8-week FBV supplementation period. The decrease, or attenuation, of CP in healthy and trained subjects in response to this FBV supplementation has been reported previously⁽ 10 , 24 ⁻ 26 ⁾, and this effect is also now demonstrated in these obese women. The bioavailability of FBV antioxidant vitamins and phytonutrients has been reported previously⁽ 11 , 27 , 28 ⁾ and may be the explanation for the consistent observation of decreased or attenuated protein oxidation. However, all CP values remained within the reference interval throughout the investigation in all participants.

Similar to CP, ox-LDL was reduced after 8 weeks of FBV supplementation. Ox-LDL is one of the few recognised parameters of the European Food Safety Authority to estimate oxidative damage to lipids⁽ 29 ⁾. It is also a recognised cardiovascular risk factor associated with obesity⁽ 30 ⁻ 34 ⁾. Over the study period, the FBV group had a 12 % reduction in ox-LDL concentrations (from 58 to 51 U/l). A similar reduction has been reported in heavy smokers using the same FBV capsules for a 3-month period⁽ 35 ⁾. This consistent finding may be due to the antioxidant activity of FBV, protecting LDL from oxidation.

TOS, another marker of lipid peroxidation, was elevated at all measured time points, indicating higher concentrations of total lipid peroxides in this cohort of obese women. This surrogate marker is a comprehensive indicator of lipid peroxidation, and thus not as specific for the oxidation of certain molecules, unlike ox-LDL or MDA. The elevated TOS values observed here might reflect a higher oxidation state of MUFA or oxidation derived from other sources, such as advanced glycation end products. These substances originate from a fat-rich diet⁽ 36 ⁾, which was consumed by the women in the present study (). The antioxidant functions of FBV decreased TOS concentrations; however, the values remained elevated at the end of the present 8-week study. It would be interesting to observe the response of this marker after long-term FBV supplementation.

MDA is a commonly used marker to estimate lipid peroxidation⁽ 37 ⁻ 39 ⁾. It is an indicator of damage to PUFA⁽ 39 ⁾. Protein-bound MDA was assessed in the present investigation. Neither the capsule treatment nor exercise was distinctive enough to effect changes in MDA concentrations, which remained within the reference interval throughout the study.

Inflammatory markers

Low-grade chronic systemic inflammation has commonly been reported in obese populations, which is accompanied by increased systemic levels of cytokines including TNF-α and IL-6⁽ 14 , 27 ⁾.

The changes in TNF-α concentrations in the FBV group were remarkable. At baseline, both study groups had elevated concentrations, exceeding the reference cut-off value (20 pg/ml). After 8 weeks of supplementation, TNF-α in the FBV group was within the reference limit. This is an important finding in the context of the frequently postulated involvement of TNF-α in obesity and imbalanced insulin metabolism⁽ 40 ⁻ 42 ⁾. It has been postulated that adipose tissue, which produces TNF-α, is the main source of circulating TNF-α⁽ 43 , 44 ⁾. However, it has also been observed that a low intake of β-carotene, found in fruit and vegetables, is inversely related to TNF-α, due to a diet-dependent decreased antioxidant and anti-inflammatory capacity⁽ 9 ⁾. In the present study, overweight and obese women had increased TNF-α concentrations at baseline, along with suboptimal dietary intakes of β-carotene and fruit and vegetables (). We are aware that the lack of serum β-carotene measurements in the present study is a limitation. On the other hand, although β-carotene was not measured, others have consistently reported increased β-carotene concentrations in studies using the same FBV supplementation⁽ 27 , 28 , 45 ⁾. Therefore, it is reasonable to expect the FBV group in the present study also had increased β-carotene concentrations, which may have contributed to the decrease observed in TNF-α in the FBV group, particularly since body weight and exercise habits remained constant during the study.

All subjects had IL-6 values within the normal limit and no changes were observed during the study. Other studies have also reported that FBV supplementation did not influence IL-6 concentrations⁽ 10 , 11 ⁾, and obviously, the model of exercise was not exhaustive enough to generate IL-6 from muscle inflammation.

Microcirculation markers

The maintenance of microvascular integrity is related to intact endothelial NO metabolism and protective against adiposity-linked CVD⁽ 46 , 47 ⁾. As NO metabolism is also dependent on redox biochemistry, we hypothesised that FBV supplementation might exert the effects on the microcirculation assessed on the easily accessible skin surface.

All skin microcirculation values were within the reference limit at all the time points assessed; however, these values did increase with both FBV supplementation and exercise. The observed increases in blood flow, SO ₂Hb and rHB indicate reduced O ₂ extraction and vasodilation of the blood vessels. In theory, perhaps the constituents of FBV would have stimulated NO metabolism, for better oxygenation in the capillaries near the skin surface. Plotnick et al.⁽ 48 ⁾ demonstrated that this FBV provides dietary nitrate, resulting in an increase in nitrate/nitrite levels after a 4-week study of FBV supplementation in healthy volunteers, accompanied by improved flow-mediated dilatation after a high-fat meal. Once NO is generated via nitrate and nitrite reductase, it reduces O ₂ extraction from Hb and also the O ₂ cost in the tissue⁽ 49 ⁾. In addition to the nutrients from FBV, it is presumable that exercise affected NO generation via increased blood flow, exerting shear stress on endothelial cell membranes. It has been well established that an increase in blood flow stimulates vascular endothelial cells and promotes the production of various vasodilator substances including NO or prostacyclin⁽ 50 ⁻ 52 ⁾.

Effect of exercise on oxidation

A null effect was observed in these women with regard to exercise-generated oxidation. The 30 min exercise bout at close to 70 % of VO 2max did not result in increased protein and lipid oxidation (indicated here via CP, ox-LDL, TOS and MDA). This is in line with the recent findings that demonstrated a lack in the increase of CP concentrations with 70 % VO 2max exercise for 40 min in trained men⁽ 53 ⁾. However, to our knowledge, the present investigation demonstrated for the first time that obese, but otherwise healthy, women can perform walking exercise at 70 % VO 2max over 30 min without generating oxidative stress. This suggests that exercise regimens for basically healthy obese women should also include aerobic exercise of higher intensity than is usually applied to accelerate improvements in energy consumption capacity and aerobic fitness.

Conclusions

The overall result from the present study is that 8 weeks of supplementation with an encapsulated fruit, berry and vegetable concentrate decreased the oxidation of proteins and lipids in plasma and reduced low-grade inflammation in overweight and obese women compared with the placebo group. Further, FBV supplementation and 30 min of aerobic walking exercise complemented each other to promote the microcirculation in the skin. In addition, we demonstrated that this population does not suffer oxidative damage or inflammation after 70 % VO 2max walking intensity over 30 min.

Acknowledgements

The present study was funded by a competitive research grant from NSA LLC (Collierville, Tennessee, USA) to the Institute of Nutrient Research and Sport Nutrition (Graz, Austria). The authors wish to thank Dr Anita M. Boddie for improving the English of the manuscript.

M. L. was the principal investigator and contributed to the development of the overall research plan and study protocol, project management and study oversight, statistical analyses and the preparation of the manuscript; G. O. contributed to the microcirculation measurements, data collection, statistical analyses and manuscript revision; K. S. was involved in the performance diagnostics, data collection and manuscript revision; G. C. participated in the blood sampling, laboratory logistics, data collection and manuscript revision; L. H., G. L. and J. F. G. contributed to the laboratory analyses, data collection and manuscript revision; S. H. was responsible for the laboratory analyses, data collection and the preparation of the manuscript.

M. L. and G. O. are affiliated with the Institute of Nutrient Research and Sport Nutrition. The rest of the authors declare no conflict of interest.

Notes

Abbreviations: CP, carbonyl proteins; FBV, fruit, berry and vegetable juice powder concentrate; MDA, malondialdehyde; ox-LDL, oxidised LDL; rHb, relative Hb concentration; SO ₂Hb, O ₂ saturation of Hb; TOS, total oxidation status of lipids; VO 2max, maximum O ₂ uptake

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21. Stirban A, Nandrean S, Götting C, et al. (2010) Effects of [ n-3 fatty acids on macro- and microvascular function in subjects with type 2 diabetes mellitus. Am J Clin Nutr 91, 808-813 [ PubMed] Google Scholar]

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55. Deutsche Gesellschaft für Ernährung (DGE), Österreichische Gesellschaft für Ernährung (ÖGE), Schweizerische Vereinigung für Ernährung (SVE) (2008) Referenzwerte für die Nährstoffzufuhr, Frankfurt, 3. korrigierter Nachdruck der 1. Auflage, Umschau Braus GmbH (German). (German Nutrition Society, Austrian Nutrition Society, Swiss Association of Nutrition (2008) Reference Values for Nutrient Intake, 3rd revision of the 1st issue. Frankfurt: Umschau Braus Limited).

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Supplementation with a juice powder concentrate and exercise decrease oxidation and inflammation, and improve the microcirculation in obese women: randomised controlled trial data

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