Associations between Dietary Pattern and Depression in Korean Adolescent Girls

STUDY OBJECTIVE

Dietary patterns are important for the physical and psychological development of adolescent girls. The purpose of the present study was to evaluate the relationship between dietary patterns and depression in this population.

DESIGN, SETTING, AND POPULATION

We conducted a case-control study in a tertiary university hospital of 849 girls aged 12 to 18 years.

METHODS

The study was conducted from April 2011 to December 2012. Participants were identified as having depression if they had scores greater than 16 on the Korean version of the Beck Depression Inventory. Data were obtained using validated Korean-language questionnaires.

MAIN OUTCOME MEASURES

The subjects' usual dietary patterns during the past 12 months were assessed using the Food Frequency Questionnaire published by the Korean Health and Nutrition Examination Survey.

RESULTS

Among the 849 enrolled volunteers, 116 were identified as having depressive symptoms. The mean age of the participants was 15.0 ± 1.5 years. The prevalence of girls diagnosed with depression was 13.6%. Multivariate adjusted regression analysis demonstrated that the risk of depression was significantly positively associated with the consumption of instant and processed foods and negatively associated with the intake of green vegetables and 1 to 3 servings/day of fruits, after adjusting for energy intake and menstrual regularity. Additionally, depression was negatively associated with intake of fiber, β-carotene, vitamin B6, vitamin E, vitamin C, potassium, zinc, folate, iron, and copper after adjusting for confounding variables.

CONCLUSION

Consumption of fast foods including ramen noodles, hamburger, pizza, fried food, and other processed foods was associated with increased risk of depression in adolescent girls. Thus, caution is required regarding dietary choices in this population.

Periconceptional multiple-micronutrient supplementation and placental function in rural Gambian women: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Maternal micronutrient deficiencies are commonly associated with clinical indicators of placental dysfunction.

OBJECTIVE

We tested the hypothesis that periconceptional multiple-micronutrient supplementation (MMS) affects placental function.

DESIGN

We conducted a double-blind, randomized, placebo-controlled trial of MMS in 17- to 45-y-old Gambian women who were menstruating regularly and within the previous 3 mo. Eligible subjects were pre-randomly assigned to supplementation with the UNICEF/WHO/United Nations University multiple micronutrient preparation (UNIMMAP) or placebo on recruitment and until they reached their first antenatal check-up or for 1 y if they failed to conceive. Primary outcome measures were midgestational indexes of utero-placental vascular-endothelial function [ratio of plasminogen-activator inhibitor (PAI) 1 to PAI-2 and mean uterine-artery resistance index (UtARI)] and placental active transport capacity at delivery [fetal to maternal measles antibody (MMA) ratio].

RESULTS

We recruited 1156 women who yielded 415 pregnancies, of which 376 met all of the inclusion criteria. With adjustment for gestational age at sampling, there were no differences in PAI-1 to PAI-2 or MMA ratios between trial arms, but there was a 0.02-unit reduction in UtARI between 18 and 32 wk of gestation (95% CI: -0.03, -0.00; P = 0.040) in women taking UNIMMAP.

CONCLUSIONS

Placental vascular function was modifiable by periconceptional micronutrient supplementation. However, the effect was small and supplementation did not further affect other variables of placental function. This trial was registered at www.controlled-trials.com as ISRCTN 13687662.

Multiple-micronutrient supplementation for women during pregnancy

BACKGROUND

Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- to middle-income countries. They are exacerbated in pregnancy due to the increased demands, leading to potentially adverse effects on the mother and developing fetus. Though supplementation with MMNs has been recommended earlier because of the evidence of impact on pregnancy outcomes, a consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane review, evidence from a few large trials has recently been made available, the inclusion of which is critical to inform policy.

OBJECTIVES

To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (11 March 2015) and reference lists of retrieved articles and key reviews. We also contacted experts in the field for additional and ongoing trials.

SELECTION CRITERIA

All prospective randomised controlled trials evaluating MMN supplementation during pregnancy and its effects on the pregnancy outcome were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but quasi-randomised trials were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

Nineteen trials (involving 138,538 women) were identified as eligible for inclusion in this review but only 17 trials (involving 137,791 women) contributed data to the review. Fifteen of these 17 trials were carried out in low and middle-income countries and compared MMN supplements with iron and folic acid versus iron with or without folic acid. Two trials carried out in the UK compared MMN with a placebo. MMN with iron and folic acid versus iron, with or without folic acid (15 trials): MMN resulted in a significant decrease in the number of newborn infants identified as low birthweight (LBW) (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.85 to 0.91; high-quality evidence) or small-for-gestational age (SGA) (average RR 0.90, 95% CI 0.83 to 0.97; moderate-quality evidence), and a reduced rate of stillbirth (RR 0.91, 95% CI 0.85 to 0.98; high-quality evidence). No significant differences were shown for other maternal and pregnancy outcomes: preterm births (RR 0.96, 95% CI 0.89 to 1.03; high-quality evidence), maternal anaemia in the third trimester (RR 0.97, 95% CI 0.86 to 1.10), miscarriage (RR 0.89, 95% CI 0.78 to 1.01), maternal mortality (RR 0.97, 95% CI 0.63 to 1.48), perinatal mortality (RR 0.97, 95% CI 0.84 to 1.12; high-quality evidence), neonatal mortality (RR 0.98, 95% CI 0.90 to 1.07; high -quality evidence), or risk of delivery via a caesarean section (RR 1.03; 95% CI 0.75 to 1.43).A number of prespecified, clinically important outcomes could not be assessed due to insufficient or non-available data. Single trials reported results for: very preterm birth < 34 weeks, macrosomia, side-effects of supplements, nutritional status of children, and congenital anomalies including neural tube defects and neurodevelopmental outcome: Bayley Scales of Infant Development (BSID) scores. None of these trials reported pre-eclampsia, placental abruption, premature rupture of membranes, cost of supplementation, and maternal well-being or satisfaction.When assessed according to GRADE criteria, the quality of evidence for the review's primary outcomes overall was good. Pooled results for primary outcomes were based on multiple trials with large sample sizes and precise estimates. The following outcomes were graded to be as of high quality: preterm birth, LBW, perinatal mortality, stillbirth and neonatal mortality. The outcome of SGA was graded to be of moderate quality, with evidence downgraded by one for funnel plot asymmetry and potential publication bias.We carried out sensitivity analysis excluding trials with high levels of sample attrition (> 20%); results were consistent with the main analysis. We explored heterogeneity through subgroup analysis by maternal height and body mass index (BMI), timing of supplementation and dose of iron. Subgroup differences were observed for maternal BMI and timing of supplementation for the outcome preterm birth, with significant findings among women with low BMI and with earlier initiation of supplementation in the prenatal period. Subgroup differences were also observed for maternal BMI, maternal height and dose of iron for the outcome SGA, indicating a significant impact among women with higher maternal BMI and height, and with MMN supplement containing 30 mg of iron versus control receiving 60 mg of iron. The findings between subgroups for other primary outcomes were inconclusive. MMN versus placebo (two trials): A single trial in the UK found no clear differences between groups for preterm birth, SGA, LBW or maternal anaemia in the third trimester. A second trial reported the number of women with pre-eclampsia; there was no evidence of a difference between groups. Other outcomes were not reported.

AUTHORS' CONCLUSIONS

Our findings support the effect of MMN supplements with iron and folic acid in improving birth outcomes. The findings, consistently observed in several systematic evaluations of evidence, provide a strong basis to guide the replacement of iron and folic acid with MMN supplements containing iron and folic acid for pregnant women in developing countries where MMN deficiencies are common among women of reproductive age. Efforts should be focused on the integration of this intervention in maternal nutrition and antenatal care programs in developing countries.

Emergency Department Visits for Adverse Events Related to Dietary Supplements

BACKGROUND

Dietary supplements, such as herbal or complementary nutritional products and micronutrients (vitamins and minerals), are commonly used in the United States, yet national data on adverse effects are limited.

METHODS

We used nationally representative surveillance data from 63 emergency departments obtained from 2004 through 2013 to describe visits to U.S. emergency departments because of adverse events related to dietary supplements.

RESULTS

On the basis of 3667 cases, we estimated that 23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits per year were attributed to adverse events related to dietary supplements. These visits resulted in an estimated 2154 hospitalizations (95% CI, 1342 to 2967) annually. Such visits frequently involved young adults between the ages of 20 and 34 years (28.0% of visits; 95% CI, 25.1 to 30.8) and unsupervised children (21.2% of visits; 95% CI, 18.4 to 24.0). After the exclusion of unsupervised ingestion of dietary supplements by children, 65.9% (95% CI, 63.2 to 68.5) of emergency department visits for single-supplement-related adverse events involved herbal or complementary nutritional products; 31.8% (95% CI, 29.2 to 34.3) involved micronutrients. Herbal or complementary nutritional products for weight loss (25.5%; 95% CI, 23.1 to 27.9) and increased energy (10.0%; 95% CI, 8.0 to 11.9) were commonly implicated. Weight-loss or energy products caused 71.8% (95% CI, 67.6 to 76.1) of supplement-related adverse events involving palpitations, chest pain, or tachycardia, and 58.0% (95% CI, 52.2 to 63.7) involved persons 20 to 34 years of age. Among adults 65 years of age or older, choking or pill-induced dysphagia or globus caused 37.6% (95% CI, 29.1 to 46.2) of all emergency department visits for supplement-related adverse events; micronutrients were implicated in 83.1% (95% CI, 73.3 to 92.9) of these visits.

CONCLUSIONS

An estimated 23,000 emergency department visits in the United States every year are attributed to adverse events related to dietary supplements. Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults. (Funded by the Department of Health and Human Services.).

Diet and esophageal disease

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on macronutrients, dietary patterns, and risk of adenocarcinoma in Barrett's esophagus; micronutrients, trace elements, and risk of Barrett's esophagus and esophageal adenocarcinoma; the role of mate consumption in the development of squamous cell carcinoma; the relationship between energy excess and development of esophageal adenocarcinoma; and the nutritional management of the esophageal cancer patient.

The risks of self-made diets: the case of an amateur bodybuilder

BACKGROUND

Following DIY (do it yourself) diets as well as consuming supplements exceeding by far the recommended daily intake levels, is common among athletes; these dietary habits often lead to an overconsumption of some macro and/or micronutrients, exposing athletes to potential health risks. The aim of this study is to document the development of possible adverse effects in a 33 year-old amateur bodybuilder who consumed for 16 years a DIY high protein diet associated to nutrient supplementation. Body composition, biochemical measures and anamnestic findings were evaluated. We present this case to put on alert about the possible risks of such behavior repeated over time, focusing on the adverse gastrointestinal effects. We discuss the energy and nutrient composition of his DIY diet as well as the use of supplements.

CONCLUSION

This study provides preliminary data of the potential risks of a long-term DIY dietary supplementation and a high protein diet. In this case, permanent abdominal discomfort was evidenced in an amateur body builder with an intake exceeding tolerable upper limit for vitamin A, selenium and zinc, according to our national and updated recommendations. As many amateur athletes usually adopt self-made diets and supplementation, it would be advisable for them to be supervised in order to prevent health risks due to a long-term DIY diet and over-supplementation.

Micronutrients in HIV: a Bayesian meta-analysis

Background

Approximately 28.5 million people living with HIV are eligible for treatment (CD4<500), but currently have no access to antiretroviral therapy. Reduced serum level of micronutrients is common in HIV disease. Micronutrient supplementation (MNS) may mitigate disease progression and mortality.

Objectives

We synthesized evidence on the effect of micronutrient supplementation on mortality and rate of disease progression in HIV disease.

Methods

We searched MEDLINE, EMBASE, the Cochrane Central, AMED and CINAHL databases through December 2014, without language restriction, for studies of greater than 3 micronutrients versus any or no comparator. We built a hierarchical Bayesian random effects model to synthesize results. Inferences are based on the posterior distribution of the population effects; posterior distributions were approximated by Markov chain Monte Carlo in OpenBugs.

Principal Findings

From 2166 initial references, we selected 49 studies for full review and identified eight reporting on disease progression and/or mortality. Bayesian synthesis of data from 2,249 adults in three studies estimated the relative risk of disease progression in subjects on MNS vs. control as 0.62 (95% credible interval, 0.37, 0.96). Median number needed to treat is 8.4 (4.8, 29.9) and the Bayes Factor 53.4. Based on data reporting on 4,095 adults reporting mortality in 7 randomized controlled studies, the RR was 0.84 (0.38, 1.85), NNT is 25 (4.3, ∞).

Conclusions

MNS significantly and substantially slows disease progression in HIV+ adults not on ARV, and possibly reduces mortality. Micronutrient supplements are effective in reducing progression with a posterior probability of 97.9%. Considering MNS low cost and lack of adverse effects, MNS should be standard of care for HIV+ adults not yet on ARV.

Energy drinks and other dietary supplement use among adolescents attending secondary schools in Trinidad and Tobago

OBJECTIVE

The objective of the present study was to determine the knowledge and practices among Trinidad and Tobago school-attending adolescents towards energy drinks (ED), alcohol combined with energy drinks (AwED), weight-altering supplements (WAS) and vitamin/mineral supplements (VMS) and their experience of adverse effects associated with such use.

DESIGN

A cross-sectional, proportionate, stratified sampling strategy was adopted using a self-administered, de novo questionnaire.

SETTING

Secondary schools throughout Trinidad and Tobago.

SUBJECTS

Students aged 15-19 years.

RESULTS

Five hundred and sixty-one students participated, an 84% response rate; 43·0% were male, 40·5% East Indian and 34·1% mixed race. VMS, ED, WAS and anabolic steroids were used by 52·4%, 44·0%, 8·9% and 1·4% of students, respectively, with 51·6% of ED users using AwED. Predictors of use of AwED were males and students who played sport for their school (OR = 1·9; 95% CI 1·2, 3·2 and OR = 2·6; 95% CI 1·4, 4·7, respectively). Predictors of ED use were males and attendees of government secondary schools (OR = 1·7; 95% CI 1·1, 2·4 and OR = 1·7; 95% CI 1·2, 2·4, respectively). Side-effects, mainly palpitations, headaches and sleep disturbances, were reported in 20·7% of dietary supplement users.

CONCLUSIONS

Many adolescent students in Trinidad and Tobago use dietary supplements, including ED and AwED, and about one-fifth of users experience side-effects. Identification of students at risk for ED, AwED and WAS use and education of students about the dangers of using dietary supplements need to be instituted to prevent potential adverse events.

Do nutrients play a role in delirium?

PURPOSE OF REVIEW

This study will review the biologic roles of thiamine, niacin, folic acid, cobalamin, antioxidants, lipids, glucose, and water and their implications as contributors or causal agents in the development of delirium, particularly if deficiencies or excesses exist.

RECENT FINDINGS

Knowledge on how overall nutritional status and individual nutrients predispose or directly lead to the development of delirium is currently very limited. Most studies in the area of nutrition and cognition still describe mental status changes using the term dementia and do not specifically address nutrition and delirium. However, as the brain pathophysiology that accompanies delirium has been furthered elucidated, it has become clear that nutritional imbalances can lead to these same physiologic changes in neuronal tissue.

SUMMARY

Delirium, characterized by an acute change in mental status along with diminished awareness and attention and disturbances in memory, language, or perception, confers high rates of morbidity and mortality and can be difficult to both diagnose and treat. Although the cause of delirium is often multifactorial, nutritional status and nutrients may play a role in predisposing or directly causing this acute cognitive dysfunction. Many nutritional deficiencies or excesses (i.e., B vitamins, antioxidants, glucose, water, lipids) have been shown to alter the way one thinks and restoring the balance in many of these nutrients can lead to resolution of delirium.

Nutritional and safety outcomes from an open-label micronutrient intervention for pediatric bipolar spectrum disorders

OBJECTIVE

The purpose of this study was to report the safety, tolerability, and serum micronutrient concentrations and their correlations with mood changes from an 8 week pilot feasibility study of a 36 ingredient multinutrient supplement, EMPowerplus (EMP+), for pediatric bipolar spectrum disorders (BPSD).

METHODS

Ten children ages 6-12 received EMP+ escalating from one to four capsules t.i.d., with four children increased to the maximum suggested dose, five capsules t.i.d. Outcome measures were micronutrient concentrations in serum and red blood cells, vital signs, body mass index (BMI), dietary intake (Food Frequency Questionnaire and 24 hour dietary recall interview), and mood and global functioning ratings.

RESULTS

Seven children (70%) completed the study. Three (30%) terminated early for tolerability and compliance issues. Adverse effects were mild and transient, and chiefly consisted of initial insomnia or gastrointestinal (GI) upset. No differences occurred in BMI (p = 0.310) or waist-hip ratio (WHR; p = 0.674) pre- to postsupplementation. Four of the tested serum vitamin concentrations increased from pre- to postsupplementation: vitamin A-retinol, vitamin B6, vitamin E-α-tocopherol; and folate (all p<0.05). The increase in serum 25-OH vitamin D approached significance (p = 0.063). No differences were found in dietary intake pre- to postsupplementation, suggesting that blood nutrient level increases were caused by EMP+.

CONCLUSIONS

In this open prospective study, short-term use of EMP+ in children with BPSD appeared safe and well-tolerated, with a side effect profile preferable to first-line psychotropic drugs for pediatric bipolar spectrum disorders. A double-blind, randomized clinical trial is feasible, appears safe, and is warranted by open-label clinical outcomes and plausible mechanisms of action, combined with documentation of increased serum concentrations of specific micronutrients.

[Administration of folic acid and other micronutrients to pregnant women in Colombia]

OBJECTIVE

To characterize the intake of folic acid (FA) and other micronutrients in medicinal form in a group of pregnant women in Colombia.

METHODS

Descriptive observational study. Information was obtained from interviews of pregnant women and from the clinical records of their prenatal check-ups and/or delivery in four cities in Colombia. The sample consisted of 1 637 women seen in 15 institutions.

RESULTS

A total of 1 315 pregnant women (80.3%) were advised to take FA, and 84% received a prescription, 90.3% of whom adhered to the treatment. FA was provided to 85.6% of them by their health insurance company and 10.7% purchased it themselves. The prescription was appropriate for 0.2% of the women; its use was entirely appropriate for 0.2% of the pregnant women and totally inappropriate for 41.9%. Other micronutrients were recommended to 1 192 women (72.8%), 77.6% of whom received the advice from their physician, with 88.7% adhering to the treatment.

CONCLUSIONS

FA and other micronutrients are inappropriately recommended to pregnant women and taken without assessing their individual needs. The usefulness of programs that promote mass consumption of micronutrients in medicinal form during pregnancy should be reexamined. These programs seem not to recognize the fundamental causes of the population's nutritional problems.

Antioxidant micronutrients and cardiovascular risk in patients with diabetes: a systematic review

Background

Inverse associations between micronutrient intake and cardiovascular outcomes have been previously shown, but did not focus on diabetic patients.

Objective

To systematically review the role of micronutrients in the development/presence of cardiovascular outcomes in patients with diabetes.

Methods

We searched Medline, Embase, and Scopus (January/1949-March/2012) for observational studies that evaluated micronutrients and cardiovascular outcomes in patients with diabetes, and then selected and extracted the data (two independent reviewers).

Results

From the 15 658 studies identified, five were included, comprising three case-control and two cohorts, with a follow-up of 7-15 years. A meta-analysis was not performed due to the different antioxidant micronutrients (types and measurement methods) and outcomes evaluated. The micronutrients assessed were vitamin C intake in diet and/ or supplementation, chromium and selenium in toenail samples, and α-tocopherol and zinc in serum levels. Intake of > 300 mg of vitamin C through supplementation was associated with increased risk of cardiovascular disease, coronary artery disease (CAD), and stroke (RR 1.69-2.37). High levels of α-tocopherol in serum were associated with 30% lower CAD risk in another study (HR 0.71; 95%CI 0.53-0.94). Among minerals (zinc, selenium, and chromium), an inverse association between zinc and CAD was observed; levels lower than 14.1 μmol/L were associated with an increased risk for CAD (RR 1.70; 95%CI 1.21-2.38).

Conclusion

The information available on this issue is scarce. Further prospective studies are needed to elucidate the role of these nutrients in the cardiovascular risk of patients with diabetes.

Dietary glycine and blood pressure: the International Study on Macro/Micronutrients and Blood Pressure

BACKGROUND

Available data have indicated independent direct relations of dietary animal protein and meat to the blood pressure (BP) of individuals.

OBJECTIVE

In this study, we aimed to assess whether BP is associated with the intake of dietary amino acids higher relatively in animal than in vegetable protein (alanine, arginine, aspartic acid, glycine, histidine, lysine, methionine, and threonine).

DESIGN

The study was a cross-sectional epidemiologic study that involved 4680 persons aged 40-59 y from 17 random population samples in the People's Republic of China, Japan, the United Kingdom, and the United States. BP was measured 8 times at 4 visits; dietary data (83 nutrients and 18 amino acids) were from four 24-h dietary recalls and two 24-h urine collections.

RESULTS

Dietary glycine and alanine (the percentage of total protein intake) were considered singly related directly to BP; with these 2 amino acids together in regression models (from model 1, which was controlled for age, sex, and sample, to model 5, which was controlled for 16 possible confounders), glycine, but not alanine, was significantly related to BP. Estimated average BP differences associated with a 2-SD higher glycine intake (0.71 g/24 h) were 2.0-3.0-mm Hg systolic BP (z = 2.97-4.32) stronger in Western than in East Asian participants. In Westerners, meat was the main dietary source of glycine but not in East Asians (Chinese: grains/flour and rice/noodles; Japanese: fish/shellfish and rice/noodles).

CONCLUSION

Dietary glycine may have an independent adverse effect on BP, which possibly contributes to direct relations of animal protein and meat to BP.

Main issues in micronutrient supplementation in phenylketonuria

For almost all patients with PKU, a low phenylalanine diet is the basis of the treatment despite a widely varying natural protein tolerance. A vitamin and mineral supplement is essential and it is commonly added to a phenylalanine-free (phe-free) source of L-amino acids. In PKU, many phe-free L-amino acid supplements have age-specific vitamin and mineral profiles to meet individual requirements. The main micronutrient sources are chemically derived and their delivery dosage is usually advised in three or more doses throughout the day. Within the EU, the composition of VM (vitamin and mineral) phe-free L-amino acid supplements is governed by the Foods for Special Medical Purposes (FSMP) directive (European Commission Directive number 1999/21/EC and amended by Directive 2006/141/EC). However the micronutrient composition of the majority fails to remain within FSMP micronutrient maximum limits per 100 kcal due to their low energy content and so compositional exceptions to the FSMP directive have to be granted for each supplement. All patients with PKU require an annual nutritional follow-up, until it has been proven that they are not at risk of any vitamin and mineral imbalances. When non-dietary treatments are used to either replace or act as an adjunct to diet therapy, the quality of micronutrient intake should still be considered important and monitored systematically. European guidelines are required about which micronutrients should be measured and the conditions (fasting status) for monitoring.

Multiple-micronutrient supplementation for women during pregnancy

BACKGROUND

Multiple-micronutrient deficiencies often coexist in low- to middle-income countries. They are exacerbated in pregnancy due to the increased demands, leading to potentially adverse effects on the mother. Substantive evidence regarding the effectiveness of multiple-micronutrient supplements (MMS) during pregnancy is not available.

OBJECTIVES

To evaluate the benefits to both mother and infant of multiple-micronutrient supplements in pregnancy and to assess the risk of adverse events as a result of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 February 2012) and reference lists of retrieved articles and key reviews. We also contacted experts in the field for additional and ongoing trials.

SELECTION CRITERIA

All prospective randomised controlled trials evaluating multiple-micronutrient supplementation during pregnancy and its effects on the pregnancy outcome, irrespective of language or publication status of the trials. We included cluster-randomised trials but quasi-randomised trials were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted the data. Data were checked for accuracy.

MAIN RESULTS

Twenty-three trials (involving 76,532 women) were identified as eligible for inclusion in this review but only 21 trials (involving 75,785 women) contributed data to the review.When compared with iron and folate supplementation, MMS resulted in a statistically significant decrease in the number of low birthweight babies (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.83 to 0.94) and small-for-gestational age (SGA) babies (RR 0.87; 95% CI 0.81 to 0.95). No statistically significant differences were shown for other maternal and pregnancy outcomes: preterm births RR 0.99 (95% CI 0.96 to 1.02), miscarriage RR 0.90 (95% CI 0.79 to 1.02), maternal mortality RR 0.97 (95% CI 0.63 to 1.48), perinatal mortality RR 0.99 (95% CI 0.84 to 1.16), stillbirths RR 0.96 (95% CI 0.86 to 1.07) and neonatal mortality RR 1.01 (95% CI 0.89 to 1.15).A number of prespecified clinically important outcomes could not be assessed due to insufficient or non-available data. These include placental abruption, congenital anomalies including neural tube defects, premature rupture of membranes, neurodevelopmental delay, very preterm births, cost of supplementation, side-effects of supplements, maternal well being or satisfaction, and nutritional status of children.

AUTHORS' CONCLUSIONS

Though multiple micronutrients have been found to have a significant beneficial impact on SGA and low birthweight babies, we still need more evidence to guide a universal policy change and to suggest replacement of routine iron and folate supplementation with a MMS. Future trials should be adequately powered to evaluate the effects on mortality and other morbidity outcomes. Trials should also assess the effect of variability between different combinations and dosages of micronutrients, keeping within the safe recommended levels. In regions with deficiency of a single micronutrient, evaluation of each micronutrient against a placebo in women already receiving iron with folic acid would be especially useful in justifying the inclusion of that micronutrient in routine antenatal care.

Randomized controlled trial of meat compared with multimicronutrient-fortified cereal in infants and toddlers with high stunting rates in diverse settings

BACKGROUND

Improved complementary feeding is cited as a critical factor for reducing stunting. Consumption of meats has been advocated, but its efficacy in low-resource settings has not been tested.

OBJECTIVE

The objective was to test the hypothesis that daily intake of 30 to 45 g meat from 6 to 18 mo of age would result in greater linear growth velocity and improved micronutrient status in comparison with an equicaloric multimicronutrient-fortified cereal.

DESIGN

This was a cluster randomized efficacy trial conducted in the Democratic Republic of Congo, Zambia, Guatemala, and Pakistan. Individual daily portions of study foods and education messages to enhance complementary feeding were delivered to participants. Blood tests were obtained at trial completion.

RESULTS

A total of 532 (86.1%) and 530 (85.8%) participants from the meat and cereal arms, respectively, completed the study. Linear growth velocity did not differ between treatment groups: 1.00 (95% CI: 0.99, 1.02) and 1.02 (95% CI: 1.00, 1.04) cm/mo for the meat and cereal groups, respectively (P = 0.39). From baseline to 18 mo, stunting [length-for-age z score (LAZ) <-2.0] rates increased from ~33% to nearly 50%. Years of maternal education and maternal height were positively associated with linear growth velocity (P = 0.0006 and 0.003, respectively); LAZ at 6 mo was negatively associated (P < 0.0001). Anemia rates did not differ by group; iron deficiency was significantly lower in the cereal group.

CONCLUSION

The high rate of stunting at baseline and the lack of effect of either the meat or multiple micronutrient-fortified cereal intervention to reverse its progression argue for multifaceted interventions beginning in the pre- and early postnatal periods.

The effect of ubiquinone in diabetic polyneuropathy: a randomized double-blind placebo-controlled study

INTRODUCTION

Diabetic polyneuropathy aetiology is based on oxidative stress generation due to production of reactive oxygen species. Ubiquinone is reduced to ubiquinol and redistributed into lipoproteins, possibly to protect them from oxidation.

AIMS

To evaluate the impact of oral ubiquinone in diabetic polyneuropathy, and the role of lipid peroxidation (LPO) and nerve growth factor (NGF-β).

METHODS

We conducted a double-blind, placebo-controlled clinical trial, patients were randomized to ubiquinone (400 mg) or placebo daily for 12 weeks. Main outcomes were clinical scores, nerve conduction studies, LPO, NGF-β and safety.

RESULTS

Twenty four patients on experimental group and twenty five on control group met the inclusion criteria (mean age 56 years, 22% male and 78% female, mean evolution of type 2 diabetes mellitus 10.7 years). Significant improvement on experimental vs control group was found in neuropathy symptoms score (from 2.5 ± 0.7 to 1 ± 0.8, p<0.001), neuropathy impairment score (5.5 ± 4 to 3.1 ± 2.6, p<0.001), sural sensory nerve amplitude (13.0 ± 6.1 to 15.8 ± 5.1 μV, p=0.049), peroneal motor nerve conduction velocity (39.7 ± 5.0 to 47.8 ± 4.9 m/s, p=0.047), and ulnar motor nerve conduction velocity (48.8 ± 6.8 to 54.5 ± 6.1m/s, p=0.046). There was a significant reduction of LPO in subjects treated with ubiquinone vs placebo (16.7 ± 8.6 and 23.2 ± 15.8 nmol/mL, respectively) with p<0.05, and NGF-β did not change (control 66.5 ± 26.7 vs. experimental 66.8 ± 28.4 pg/mL, p=0.856). No drug-related adverse reactions were reported.

CONCLUSIONS

Twelve weeks treatment with ubiquinone improves clinical outcomes and nerve conduction parameters of diabetic polyneuropathy; furthermore, it reduces oxidative stress without significant adverse events.

Nutritional content and a phase-I safety clinical trial of a herbal-nutritional supplement (IMUNITI) with putative immune-modulating properties

The relationship between HIV and AIDS and poor nutrition has been well established. Poor nutrition hastens the progression of HIV infection to AIDS. The rising pandemic of HIV and AIDS and high toxicity associated with anti-retroviral use are major factors that have compelled research to explore traditional herbal medicines as potential alternatives or supplements to anti-retroviral agents. A Phase I clinical trial was conducted on IMUNITI Wellness Pack, a herbal product with putative immune-modulating properties. The product is a combination of 7 herbal preparations, minerals, vitamins, and a specially formulated soya-maize meal porridge and a bottle of water purifier. The aim was to evaluate the safety and tolerability of IMUNITI, with a purpose of developing it for use in HIV-infected patients. The phase I study was conducted at the MRC clinic in Botha's hill and the study lasted 5 weeks from date of participant dosing. The study was a randomised blinded placebo-controlled phase I clinical trial conducted on 48 healthy males. The participants were randomly divided into 4 groups of 12. The 3 groups received different escalating doses of IMUNITI while the forth group received placebo tablets. Participants consumed IMUNITI daily for a period of 5 weeks. Assessments were done at baseline, week 1 and week 5 to determine the safety parameters in all participants. In this study, IMUNITI did not show any safety concerns. In all study participants, there were no significant changes above the upper limit of the reference ranges of the laboratory tests for full blood count, INR, renal and biochemical safety parameters. IMUNITI was well tolerated. Furthermore, the nutritional content analysis of IMUNITI showed that it is a high kilojoule, high protein content product which contains a mixture of sugars, vitamins, traces of calcium, phosphorus and minerals.

Systematic review of safety and tolerability of a complex micronutrient formula used in mental health

BACKGROUND

Theoretically, consumption of complex, multinutrient formulations of vitamins and minerals should be safe, as most preparations contain primarily the nutrients that have been in the human diet for millennia, and at safe levels as defined by the Dietary Reference Intakes. However, the safety profile of commercial formulae may differ from foods because of the amounts and combinations of nutrients they contain. As these complex formulae are being studied and used clinically with increasing frequency, there is a need for direct evaluation of safety and tolerability.

METHODS

All known safety and tolerability data collected on one complex nutrient formula was compiled and evaluated.

RESULTS

Data were assembled from all the known published and unpublished studies for the complex formula with the largest amount of published research in mental health. Biological safety data from 144 children and adults were available from six sources: there were no occurrences of clinically meaningful negative outcomes/effects or abnormal blood tests that could be attributed to toxicity. Adverse event (AE) information from 157 children and adults was available from six studies employing the current version of this formula, and only minor, transitory reports of headache and nausea emerged. Only one of the studies permitted a direct comparison between micronutrient treatment and medication: none of the 88 pediatric and adult participants had any clinically meaningful abnormal laboratory values, but tolerability data in the group treated with micronutrients revealed significantly fewer AEs and less weight gain.

CONCLUSIONS

This compilation of safety and tolerability data is reassuring with respect to the broad spectrum approach that employs complex nutrient formulae as a primary treatment.

Micronutrients versus standard medication management in autism: a naturalistic case-control study

Autism spectrum disorder (ASD) is often accompanied by self-injurious behavior (SIB), aggression, and tantrums, symptoms that have reportedly improved with micronutrient (vitamins and minerals) treatment. The current study took advantage of naturally occurring differences in parental preferences for treatment approaches. The micronutrient group asked for treatment without pharmaceuticals (n = 44, aged 2-28 years at entry [M = 8.39 +/- 5.58]). Their records were matched with those of 44 similar children whose families requested conventional treatment (medication group). Both groups improved on both the Childhood Autism Rating Scale and the Childhood Psychiatric Rating Scale (all p values <0.0001). Both groups also exhibited significant decreases in total Aberrant Behavior Checklist scores, but the micronutrient group's improvement was significantly greater (p < 0.0001). SIB Intensity was lower in the micronutrient group at the end of the study (p = 0.005), and improvement on the Clinical Global Impressions scale was greater for the micronutrient group (p = 0.0029). It is difficult to determine whether the observed changes were exerted through improvement in mood disorder or through an independent effect on autistic disorder. There were some advantages to treatment with micronutrients-lower activity level, less social withdrawal, less anger, better spontaneity with the examiner, less irritability, lower intensity SIB, markedly fewer adverse events, and less weight gain. Advantages of medication management were insurance coverage, fewer pills, and less frequent dosing.