Effects of high-dose B vitamin complex with vitamin C and minerals on subjective mood and performance in healthy males

Prevalence and associated factors of low vigor in patients living with HIV and hemophilia in Japan: A cross-sectional observational study

People living with human immunodeficiency virus (HIV) are at high risk of mental health problems. However, little is known about this risk in HIV-infected patients with hemophilia (HPH) who contracted the virus through blood products. This cross-sectional, observational study assessed patients' mood states and the factors associated with them among Japanese HPH to evaluate the need for psychosocial support. HPH completed self-administered questionnaires (Profile of Mood States [POMS] and General Health Questionnaire-28), neuropsychological tests, and brain magnetic resonance imaging (MRI) and fluorodeoxyglucose positron emission tomography/computerized tomography scans. HIV-infected patients with no hemophilia (HPnH) completed POMS and neuropsychological tests. Socio-demographic characteristics and HIV- and hemophilia-related data were obtained from participants' medical records and interviews. A Mann-Whitney U test and chi-squared analyses were conducted. Fifty-six HPH and 388 HPnH completed the questionnaires and neuropsychological tests. HPH had a significantly lower prevalence of tension-anxiety (HPH, 7%; HPnH, 18%; p = 0.049) and a significantly higher prevalence of low vigor (HPH, 63%; HPnH, 32%; p < 0.001). Low vigor in HPH was significantly associated with impaired executive function (low vigor, 66%; high vigor, 33%; p = 0.019) and a social dysfunction score ≥ 3 (moderate; low vigor, 26%; high vigor, 5%; p = 0.047). Our results highlight the high prevalence of low vigor among HPH, leading to impairments in executive and social functions. Therefore, healthcare workers need to pay attention to the vigor, executive function, and social function of HPH.

Exploring the Impact of Personalized Nutritional Approaches on Metabolism and Immunity: A Systematic Review of Various Nutrients and Dietary Patterns

The systematic review investigates the impact of different nutrients and dietary patterns on metabolism and immunity to answer the research question: "Can personalized nutritional approaches boost immunity?" The importance of diet in supporting the immune system has come to light in today's environment, where a strong immune system is crucial for protection against infectious illnesses, as highlighted by the COVID-19 pandemic. This systematic review adhered to the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. Four databases were screened for relevant data published in 2022-2023: PubMed, PubMed Central (PMC), MEDLINE, and Cochrane Library. Inclusion and exclusion criteria were utilized, and 13 papers were finalized after screening and employing the quality appraisal tool Cochrane Bias assessment for randomized controlled trials (RCT). Personalized nutrition can strengthen immunity and enhance overall health by adjusting dietary recommendations and following a person's genetic makeup, lifestyle, and health state. An adequate supply of vitamins, minerals, proteins, and fatty acids as well as an optimum caloric intake are essential for immune health, and individual requirements can vary significantly due to genetic factors, lifestyle choices, and underlying health conditions. Personalized nutrition considers these factors, enabling tailored dietary recommendations to address specific nutrient needs and optimize nutrient intake, leading to better health outcomes. The review concludes that personalized nutrition is more effective than a one-size-fits-all approach in boosting immunity, and its potential impact on health and immune function is highly important.

[Immunonutrition and (its impact on) health. Micronutrients and debilitating factors]

Introduction

Introduction: the interaction between immunity and nutrition is complex and multifaceted. Micronutrients, including vitamins and minerals, are essential for immune function. In turn, immune function and lifestyle habits can affect nutritional needs and micronutrient utilization, creating an interdependence between nutrition and immunity that can be modulated by both external and internal factors. Objectives: to examine the relationship between micronutrient intake and immune function, and how debilitating factors such as aging, disease, and stress can impact this relationship. Methods: a review of scientific evidence and recommendations from major international scientific societies was conducted to identify the importance of micronutrients in immune function and how debilitating factors can alter their impact. Results: the effect of different micronutrients on immune function is described. Debilitating factors like aging, stress, and chronic diseases can compromise the immune system and make the body more susceptible to infections. However, adequate intake of micronutrients and healthy habits can help to strengthen immunity and mitigate the effects of these debilitating factors. Conclusion: immunonutrition is a critical component for maintaining a strong and healthy immune system. Sufficient intake of micronutrients and healthy lifestyle habits can help improve immunity, especially in the presence of debilitating factors.

The effect of multivitamins on anxiety and depression in patients undergoing methadone maintenance treatment: A double-blind randomized controlled trial

BACKGROUND

The prevalence of addiction is increasing in the world. Methadone Maintenance Treatment (MMT) can be associated with severe stress and mild to moderate depressive symptoms. Vitamins and minerals are commonly found in multivitamins seem to improve mood. Therefore, the aim of this study was to evaluate the effect of multivitamins on anxiety and depression in patients undergoing MMT in a double-blind randomized controlled trial.

METHODS

The study was designed as a double-blind, randomized controlled trial and involved 70 male MMT patients over the age of 18. Participants were randomized to one of two groups, either those receiving multivitamins or those receiving a placebo for 12 weeks. The multivitamin capsule included vitamin E, B1, B2, B3, B5, B6, B12, C, biotin, folic acid, and zinc. Anxiety and depression were measured using standard questionnaires, before and after the intervention.

RESULTS

The between-group comparison (i.e., intervention vs. placebo) indicated there was no significant difference in anxiety scores; however, there was a significant between-group difference in depression scores, favoring the intervention group.

CONCLUSIONS

Multivitamin supplementation improved depression but did not have a significant impact on anxiety in patients undergoing MMT.

Efficacy and safety of a vitamin-mineral intervention for symptoms of anxiety and depression in adults: A randomised placebo-controlled trial "NoMAD"

BACKGROUND

Anxiety and depression are increasingly burdening society. We investigated whether micronutrients (vitamins and minerals), improve anxiety and depression symptoms in an adult community setting.

METHODS

Participants (n = 150) describing functionally-impairing symptoms of anxiety/depression randomly received micronutrients or placebo for 10 weeks. Primary outcome measures were Patient Health Questionnaire-9 (PHQ-9), Generalised Anxiety Disorder Scale-7 (GAD-7), and Clinical Global Impression-Improvement scale (CGII). They were monitored online with regular phone contact with a clinical psychologist.

RESULTS

Linear mixed-effects modelling showed significant improvements in both groups, with the micronutrient group improving significantly more quickly on both the PHQ-9 (t = -2.17, p = 0.03) and the GAD-7 (t = -2.23, p = 0.03). Subsequent models with covariates showed that participant characteristics moderated time-by-group interactions; micronutrients provided fastest improvement relative to placebo for younger participants, those from lower socioeconomic groups and those who had previously tried psychiatric medication. On the CGII, there were no group differences at end-point ((F1,148) = 1.36, p = 0.25, d = 0.19, 95 % CI [-0.13 to 0.51]), with 49 % of the micronutrient and 44 % of the placebo groups being identified responders. Participants on micronutrients had significantly increased bowel motions compared with placebo. There was no increased suicidal ideation, no serious adverse events and the blind was adequately maintained. Drop out was low at 8.7 %.

LIMITATIONS

The improvement under placebo and lack of formal diagnoses limit generalizability.

CONCLUSIONS

Despite limited clinician contact, all participants improved significantly, though improvements were faster with micronutrients. Participants in some subgroups demonstrated a lower response to placebo, identifying where micronutrients may offer greatest potential as an intervention.

A real-world evidence study evaluating consumer experience of Supradyn Recharge or Supradyn Magnesium and Potassium during demanding periods

Background

Challenging periods and/or mild micronutrient deficiencies may result in a lack of energy and general fatigue, frequently occurring in the general population. Supradyn Recharge and Supradyn Magnesium and Potassium (Mg/K) are multimineral/vitamin supplements formulated to ensure adequate daily intake of micronutrients. We conducted an observational study addressing consumption behaviour, reasons for intake, frequency of intake, and consumer experiences, satisfaction and characteristics under real-life conditions.

Methods

This was a retrospective, observational study carried out with two computer-aided web quantitative interviews.

Results

A total of 606 respondents (almost equally split between men and women; median age 40 years) completed the questionnaires. The majority indicated having a family, a job and a good level of education; they stated to be long-time and daily users, reporting an average daily intake of 6 days a week. More than 90% of consumers claimed they were satisfied, would use the products again and recommend them; over two-thirds felt the value for money was good. Supradyn Recharge has been mainly used to support lifestyle change and mental resilience, seasonal changes, and post-illness recovery. Supradyn Mg/K has been used to sustain or regain energy levels during hot weather or physical activity and as a support against stress. Users claimed a positive impact on quality of life.

Conclusion

Overall, the perception of benefit by consumers was extremely positive as reflected in their consumption behaviour, the majority of whom stated to be long-time users and daily consumers, with an average daily intake of 6 days for both products. These data complement and add up to the results of Supradyn clinical trials.

Acute Cognitive Performance and Mood Effects of Coffeeberry Extract: A Randomized, Double Blind, Placebo-Controlled Crossover Study in Healthy Humans

BACKGROUND

Coffeeberry extract, rich in chlorogenic acids, shows promise in improving mood and cognition, particularly when co-supplemented with phenolic compounds. However, limited work has considered the effects of coffeeberry in isolation, especially at low doses.

OBJECTIVE

The current study investigated the effect of low and moderate doses of coffeeberry extract on cognition and mood.

DESIGN

This randomized, double-blind, placebo-controlled crossover design investigated three active beverages on a sample of 72 healthy adults aged 18-49 years. The investigational beverages contained 100 mg or 300 mg coffeeberry extract (standardized to 40% chlorogenic acid), or 75 mg caffeine (positive control). Cognition, mood, and subjective energy were measured at baseline and then again at 60 and 120 min post-treatment.

RESULTS

Analysis revealed no effect of 300 mg coffeeberry extract, while 100 mg resulted in increased mental fatigue during the performance of cognitively demanding tasks (p = 0.025) and decreased accuracy on a task of sustained attention (p = 0.003), compared to placebo, at 60 min post dose.

CONCLUSIONS

Administration of 100 mg and 300 mg coffeeberry extracts revealed limited, transient negative effects following 100 mg coffeeberry. Given the large number of outcome measures analysed and the absence of findings following the 300 mg dose, these negative findings should be interpreted with caution. Overall, the findings of the current study suggest that coffeeberry extract at a low or moderate dose does not have a beneficial effect on mood, mental and physical energy levels, or cognition; higher doses, as have been administered previously, may be more effective.

Functional Beverages in the 21st Century

Underlying the dawn of humanity was primarily the search for food and access to drinking water. Over the course of civilization, there has been a significant increase in drinking water quality. By the average of the nutritional standards, the daily water demand is 2.5 L (also including liquid products such as tea, coffee, or soup). However, it is worth noticing that the need is strictly individual for each person and depends on two major factors, namely, epidemiological (sex, age state of health, lifestyle, and diet) and environmental (humidity and air temperature). Currently, our diet is more and more often enriched with isotonic drinks, functional drinks, or drinks bearing the hallmarks of health-promoting products. As a result, manufacturing companies compete to present more interesting beverages with complex compositions. This article will discuss both the composition of functional beverages and their impact on health.

Effect of a Combination of Magnesium, B Vitamins, Rhodiola, and Green Tea (L-Theanine) on Chronically Stressed Healthy Individuals-A Randomized, Placebo-Controlled Study

The effect of a combination of magnesium, vitamins B6, B9, B12, rhodiola and green tea/L-theanine (Mg-Teadiola) on stress was evaluated in chronically stressed, otherwise healthy individuals. Effects on stress-related quality-of-life parameters (sleep and perception of pain) were also explored. Adults with stress for ≥1 month, scoring ≥14 points on the Depression Anxiety Stress Scale (DASS)-42 questionnaire, were randomized (1:1) to receive oral Mg-Teadiola (n = 49) or a placebo (n = 51), for 28 days, with a follow-up assessment on Day 56 (NCT04391452). The primary endpoint was the change in the DASS-42 stress score from baseline to Day 28 with Mg-Teadiola versus placebo. The DASS-42 stress scores significantly decreased from baseline to Day 28 with Mg-Teadiola versus placebo (effect size, 0.29; 95% CI [0.01, 0.57]; p = 0.04). Similar reductions were observed on Day 14 (p = 0.006) and Day 56 (p = 0.02). A significant reduction in sensitivity to cold pain (p = 0.01) and a trend for lower sensitivity to warm pain was observed (p = 0.06) on Day 28. Improvements in daytime dysfunction due to sleepiness (Pittsburgh Sleep Quality Index-7 component score) were reported on Day 28, and were significant on Day 56 (p < 0.001). Mg-Teadiola is effective in managing stress in otherwise healthy individuals. Its beneficial effects on sleep and pain perception need further investigation.

Associations of depression and intake of antioxidants and vitamin B complex: Results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

BACKGROUND

Optimum functioning of the central nervous system is dependent on a wide range of nutrients, so mental illness can be impacted by diet via several mechanisms. We aimed to investigate the associations of antioxidants (vitamin A, C and E, and selenium and zinc) and vitamin B complex (B6, folate and B12) intake with depression in 14,737 subjects of the Brazilian Longitudinal Study of Adult Health.

METHODS

Baseline cross-sectional data was analyzed. Micronutrients intake was measured using the Food Frequency Questionnaire, and depression was assessed using the Clinical Interview Schedule Revised. Logistic regression models were built using daily intake quintiles of micronutrients.

RESULTS

A significant inverse relationship was observed between depression and higher intake of selenium, zinc, vitamins B6 and B12 for the total sample. Among women, a similar pattern of associations was observed, in addition to the higher intake of vitamins A and C. Among men, a significant inverse relationship between depression was observed only with the intake of vitamins B12 and B6. Higher total antioxidant intake was significantly associated with lower odds of depression and an inverse dose-response effect between total antioxidant intake and clinical severity of depression was observed among women, in adjusted models.

LIMITATIONS

Recall bias in assessing diet. Misclassification bias regarding current depression.

CONCLUSIONS

Depression is associated with lower intake of antioxidants and B vitamins. Higher intake of selected micronutrients may contribute to reduce depression occurrence and severity.

Cross-Sectional Associations between Dietary Daily Nicotinamide Intake and Patient-Reported Outcomes in Colorectal Cancer Survivors, 2 to 10 Years Post-Diagnosis

Supplementation with nicotinamide adenine dinucleotide (NAD⁺) precursors including dietary nicotinamide has been found to boost tissue NAD⁺ levels and ameliorate oxidative stress-induced damage that contributes to aging and aging-related diseases. The association between dietary NAD⁺ precursors and patient-reported health-related outcomes in cancer survivors has not been investigated. This study aimed to determine associations of dietary nicotinamide intake with different patient-reported outcomes in colorectal cancer survivors, 2 to 10 years post-diagnosis. A total of 145 eligible participants were recruited into this cross-sectional study. Dietary nicotinamide intake level was calculated based on data from 7-day food diaries. Fatigue was assessed with the Checklist Individual Strength (CIS), which is a subscale of the cancer-specific European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC), and anxiety and depression were assessed with Hospital Anxiety and Depression Scale (HADS). Oxidative stress marker serum protein carbonyl contents and serum NAD⁺ levels were measured. A hierarchical linear regression model with confounder adjustment was performed to analyze the association of nicotinamide intake, serum protein carbonyl contents, and NAD⁺ levels with patient-reported outcomes. The median values of daily nicotinamide intake for male and female participants were 19.1 and 14.4 mg, respectively. Daily dietary nicotinamide intake was associated with a lower level of fatigue (β: -14.85 (-28.14, -1.56)) and a lower level of anxiety and depression (β: -4.69 (-8.55, -0.83)). Subgroup analyses by sex showed that a beneficial association between nicotinamide intake and patient-reported outcomes was mainly found in men. To conclude, our findings suggested that higher dietary NAD⁺ precursor nicotinamide intake was cross-sectionally associated with less patient-reported outcomes in CRC survivors.

Potential mental and physical benefits of supplementation with a high-dose, B-complex multivitamin/mineral supplement: What is the evidence?

OBJECTIVE

to perform a systematic literature review to examine the effects of high-dose, B-complex multivitamin/mineral supplementation on physical, mental, and energy outcomes in healthy and 'at-risk' (suboptimal nutritional status/subclinical symptoms at baseline) adult populations.

METHODS

PubMed was searched for relevant randomized controlled trials until January 2020.

RESULTS

overall, 136 publications were identified. In the seven randomised, double-blind, placebo-controlled studies considered eligible for inclusion, supplementation in healthy populations predominantly showed improvements in perceived stress, physical stamina, concentration, and general mental health, and significant reductions in anxiety and improvements in self-reported vigour. However, not all of these outcomes were significant, and statistical correction for multiple outcomes was not commonly employed. Studies investigating brain mapping following supplementation indicated increased functional activity in brain regions related to processing of attention, executive control, and working memory during cognitive tasks.

CONCLUSIONS

while there is certainly a need for further studies on the neurocognitive and physical benefits of micronutrient supplementation, this review provides generally supportive evidence for the benefits of a high-dose, B-complex multivitamin/mineral supplement in healthy and at-risk populations in terms of physical, mental, and energy outcomes.

Dietary intake of B vitamins and their association with depression, anxiety, and stress symptoms: A cross-sectional, population-based survey

BACKGROUND

B vitamins have vital roles in the development, maintenance, and functioning of the brain, while severe deficiencies have been linked to increased psychological disorders. However, no published studies have examined the association between dietary intake of vitamin B and depression, anxiety, and stress symptoms in a general population.

METHODS

This cross-sectional study was done on 7387 Iranian adults aged 20-70 years within the population-based cohort study framework. A validated semi-quantitative Food Frequency Questionnaire (DS-FFQ) was used to ascertained vitamin B intake. Participants completed the Iranian validated version of depression, anxiety, and stress scale questionnaire 21 (DASS 21) to assess their psychological health. Multivariable logistic regression analysis was performed to analyze the association between vitamin B intake and psychological disorders.

RESULTS

After adjustment for a wide range of confounders, higher intake of biotin was associated with a lower odds of depression (OR 0.71, 95% CI 0.55-0.91, P-trend=0.008), anxiety (0.71, 0.56-0.89, P-trend=0.003), and stress (0.58, 0.39-0.87, P-trend=0.01). An inverse relationship was found between B₆ and stress risk (0.50, 0.28-0.90, P-trend= 0.01). Moderate intake of thiamin (0.76, 0.61-0.94, P-trend=0.20), niacin (0.78, 0.62-0.97, P-trend=0.41), and pantothenic acid (0.80, 0.65-0.99, P-trend=0.05) were related to lower odds of anxiety. Additionally, moderate folic acid intake was associated with lower odds of depression (0.78, 0.61-0.99, P-trend=0.71). A subgroup analysis based on sex revealed that biotin's dietary intake reduced the risk of depression, anxiety, and stress, but this association was not significant in the male population.

LIMITATIONS

Cross-sectional nature of the data prevents causal associations.

CONCLUSIONS

This study suggests that a higher intake of dietary B vitamins, especially biotin, was associated with a lower prevalence of depression, anxiety, and stress symptoms. The role of B vitamins requires further investigation in randomized controlled trials.

Nutritional supplementation in the treatment of violent and aggressive behavior: A systematic review

Aggression in correctional and psychiatric settings is relatively common and has a negative effect on physical and mental health both among inmates/clients and staff, as well as organizational-level functioning. The aim of the present study was to critically review the evidence on the effectiveness of nutritional supplements in reducing aggression and violence to contribute to a better understanding of options available for managing aggressive behaviors in adults. The EMBASE, MEDLINE, PsycINFO, Cochrane Library, and PubMed databases were searched for effectiveness studies published in English anytime up until March 2020. Study quality was assessed using the Mixed Methods Appraisal Tool. Altogether, 14 studies met inclusion criteria; 2 investigated micronutrients, 10 examined macronutrients, while further 2 examined a combination of micro and macronutrients. Out of the 14 studies, 5 reported a beneficial effect of nutritional supplementation (omega-3 fatty acids, vitamins/minerals, S-adenosyl-l-methionine, or tryptophan). Five studies did not report a significant beneficial effect of nutritional supplementation (omega-3 fatty acids, folic acid, tryptophan, broad range supplement containing vitamins and fatty acids, and fatty acids in augmentation with valproic acid), while four studies reported mixed effects (on l-tryptophan, broad-range micronutrient formula, folic acid, and omega-3 fatty acids). The results overall indicated that research in this area is in its infancy: very few studies examined the same composition of nutritional supplementation and when they did so the results were contradictory. The methodological shortcoming of existing studies and directions for future research are discussed to facilitate high-quality research in this evolving area of nutritional psychiatry.

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

Broad spectrum micronutrient formulas for the treatment of symptoms of depression, stress, and/or anxiety: a systematic review

Introduction: Vitamin and mineral nutritional supplements are becoming increasingly popular as alternative treatments for anxiety and depression, as issues such as side effects from medication, failure to respond to psychotherapy and workforce limitations pose barriers for successful treatment.Areas covered: This review covered double-blind, randomized controlled trials (DBRCTs) testing formulas including at least four vitamins and/or minerals used for the treatment of symptoms of anxiety, stress, or depression in adults not currently taking medication for psychiatric difficulties.Expert opinion: The majority of the 23 trials reviewed were conducted on people without psychological difficulties, limiting the generalizability of the results in people with diagnosed mood and anxiety difficulties. Sixteen studies demonstrated positive effects for symptoms of anxiety, depression, or stress. Micronutrient supplementation in healthy nonclinical adults has limited benefits for mood and anxiety symptoms, although may convey some subtle general improvements. The evidence for adults with physical or mental ill health is more positive although limited by small samples and variability in nutrients studied. Broad-spectrum nutrient products may be more effective than a selected few. While an effect of micronutrients cannot be dismissed, the variability of the studies makes it extremely challenging to identify specific treatment benefits.

The effect of consuming multivitamin/mineral supplements on elderly quality of life: Based on randomized control trial

BACKGROUND

Clinical trials concerning the effect of supplements or multivitamin on improving the quality of life have proven different results. The present study was conducted to examine the effect of multivitamin supplement on quality of life of the elderly.

MATERIALS AND METHODS

Sixty-four old people over 65 years of age in Kermanshah Elderly Care Center participated in this randomized trial. The samples were first selected using the convenience sampling and then were randomly assigned into intervention and control groups. The intervention group received one multivitamin mineral (MVM) supplement capsule every day for 3 months with no intervention for the control group. Standard quality of life questionnaire was used to collect the data. Data were analyzed using the SPSS software version 22.

RESULTS

The mean age of the participants was 70.77 ± 8.29 years. The results of intra-group evaluation of the aspects of quality of life of the elderly show the lack of significant changes in the mean scores of physical health and environmental health of the elderly in the intervention group (P > 0.05) and the significant reduction of these aspects in the control group (P < 0.05) after intervention. The mean score of mental health scores in the intervention group significantly increased (P = 0.01), but there are no significant changes in the control group (P = 0.273). The mean scores of social relationships as well as the overall score of quality of life in the intervention and control groups showed no significant changes (P > 0.05).

CONCLUSION

The present study showed that the consumption of MVM supplements can have a positive effect on increasing the quality of life of the elderly, but it is recommended to be done in the long term along diet. Moreover, considering the fact that no change was observed in the other aspects of the quality of life, attentions should be paid to the environmental and social factors such as social supports and empowerment of the old people in the future studies.

Complementary and Alternative Medicine in Radiotherapy: A Comprehensive Review

Complementary and alternative medicine (CAM) approaches are widely used by patients throughout a broad range of medical fields and diseases, and often self-administered by patients without the involvement of physicians or other members of the health care team. CAM use is well documented in cancer and chronic illnesses, and emerging data in radiation oncology show CAM usage of 26% to 97% in radiation therapy patients. No information is, however, available on CAM usage in radiology and in the imaging procedure fields. This article reviews the fundamental principles and the experience with the wide spectrum of CAM in radiation oncology-a field that shares many parallels with radiology, such as prevalence of imaging, procedural requirements, and cooperation demanded from patients.CAM is defined as "approaches and practices that are typically not part of conventional medical care," and includes the use of mind- and body-based practices (eg, meditation, massage, acupuncture), natural products (eg, herbs, vitamins, minerals), and other interventions. Supplements are used frequently to alleviate side effects of therapy and promote overall well-being. Specifically, the mindfulness/meditation approaches of CAM are known to reduce anxiety and enhance physical and emotional wellbeing in patients with chronic diseases, such as cancer or neurologic diseases, through physiological, psychological, and perhaps placebo mechanisms. Such patients often require repetitive and invasive imaging examinations or procedures, such as for cancer treatment, cancer surveillance/follow-up, or monitoring of chronic diseases, for example, surveillance MRI in multiple sclerosis. Such parallels suggest that the vastly understudied area of CAMs deserve further investigation in both the radiation oncology and the imaging fields. Further research on CAM is needed to develop refined recommendations and national/and international guidelines on its use.

Reduction of fatigue and anger-hostility by the oral administration of 5-aminolevulinic acid phosphate: a randomized, double-blind, placebo-controlled, parallel study

Although large populations feel fatigue, the standardized medicinal therapy is currently absent. In this study, we determined whether 5-aminolevulinic acid (5-ALA) supplementation alleviates the feeling of fatigue in healthy subjects who feel chronic physical tiredness. Males and females between ages of 20 and 64 who felt physical fatigue on a daily basis, with a visual analogue scale (VAS) for fatigue ≥ 40 mm, a T-score of Fatigue-Inertia in the Profile of Mood States—Second Edition—Adult (POMS2-A) ≥ 50, and a T-score of Vigor-Activity in POMS2-A ≤ 60 were recruited. Seventy eligible participants were randomly assigned to either a 5-ALA or a placebo group. During the 8 weeks of consumption, the subjects completed VAS questionnaires for fatigue and POMS2-A at 4-week intervals. The VAS values for overall feeling of fatigue and feeling of work-related fatigue, and the Anger-Hostility subscale of POMS2-A were decreased by 5-ALA with significant time × group interaction effects (p = 0.040, 0.020, and 0.045, respectively). Besides, the 5-ALA group showed significant differences in Fatigue-Inertia, Depression-Dejection and Total Mood Disturbance scores, when compared between pre- and post-intervention, while the placebo group did not. In conclusion, the oral administration of 5-ALA improves fatigue and negative mood in subjects who constantly feel physical fatigue.

This clinical trial was registered with University hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) as UMIN000031528 on 2/3/2018.

Nutritional and medical food therapies for diabetic retinopathy

Diabetic retinopathy (DR) is a form of microangiopathy. Reducing oxidative stress in the mitochondria and cell membranes decreases ischemic injury and end-organ damage to the retina. New approaches are needed, which reduce the risk and improve the outcomes of DR while complementing current therapeutic approaches. Homocysteine (Hcy) elevation and oxidative stress are potential therapeutic targets in DR. Common genetic polymorphisms such as those of methylenetetrahydrofolate reductase (MTHFR), increase Hcy and DR risk and severity. Patients with DR have high incidences of deficiencies of crucial vitamins, minerals, and related compounds, which also lead to elevation of Hcy and oxidative stress. Addressing the effects of the MTHFR polymorphism and addressing comorbid deficiencies and insufficiencies reduce the impact and severity of the disease. This approach provides safe and simple strategies that support conventional care and improve outcomes. Suboptimal vitamin co-factor availability also impairs the release of neurotrophic and neuroprotective growth factors. Collectively, this accounts for variability in presentation and response of DR to conventional therapy. Fortunately, there are straightforward recommendations for addressing these issues and supporting traditional treatment plans. We have reviewed the literature for nutritional interventions that support conventional therapies to reduce disease risk and severity. Optimal combinations of vitamins B1, B2, B6, L-methylfolate, methylcobalamin (B12), C, D, natural vitamin E complex, lutein, zeaxanthin, alpha-lipoic acid, and n-acetylcysteine are identified for protecting the retina and choroid. Certain medical foods have been successfully used as therapy for retinopathy. Recommendations based on this review and our clinical experience are developed for clinicians to use to support conventional therapy for DR. DR from both type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) have similar retinal findings and responses to nutritional therapies.

Effect of a 12-Week Almond-Enriched Diet on Biomarkers of Cognitive Performance, Mood, and Cardiometabolic Health in Older Overweight Adults

Long term nut consumption is associated with reduced risk of coronary heart disease and better cognitive function. This study examined supplementing habitual diets with almonds or carbohydrate-rich snack foods (providing 15% energy) on biomarkers of cardiovascular and metabolic health, mood and cognitive performance. Participants (overweight/obese, 50-80 years) were randomised to an almond-enriched diet (AED) or isocaloric nut-free diet (NFD) for 12 weeks. Body weight, blood lipids, glucose, insulin, blood pressure (BP), arterial stiffness, cell adhesions molecules, C reactive protein (CRP), mood, and cognitive performance (working memory primary outcome), dietary profiles and energy intake/expenditure were measured at baseline and Week 12 in 128 participants (n = 63 AED, n = 65 NFD). Compared with NFD, AED was associated with altered macro and micronutrient profiles, but no differences in energy intake or expenditure. The AED significantly reduced triglycerides and SBP but there were no other changes in cardiometabolic biomarkers, mood, or cognitive performance. The inclusion of almonds in the diet improves aspects of cardiometabolic health without affecting cognitive performance or mood in overweight/obese adults.

Acute and chronic effects of multivitamin/mineral supplementation on objective and subjective energy measures

Background

Vitamins and minerals play an essential role within many cellular processes including energy production and metabolism. Previously, supplementation with a multivitamin/mineral (MVM) for ≥28 days resulted in improvements to cognition and subjective state. We have also demonstrated shifts in metabolism during cognitively demanding tasks following MVM in females, both acutely and following 8-week supplementation. The current study aimed to assess these effects further in males and females using metabolically challenging exercise and cognitive tasks.

Methods

The current randomised, placebo-controlled, parallel groups study investigated the effects of a MVM complex in 82 healthy young (18-35y) exercisers. Subjective ratings and substrate metabolism were assessed during 30 min each of increasingly effortful incremental exercise and demanding cognitive tasks. Assessments took place on acute study days following a single dose (Day 1) of MVM, containing 3 times recommended daily allowance of water-soluble vitamins plus CoQ10, and following 4-week supplementation (Day 28).

Results

Energy expenditure (EE) was increased during cognitive tasks following MVM across Day 1 and Day 28, with greater effects in males. In males, MVM also increased carbohydrate oxidation and energy expenditure during exercise across Day 1 and Day 28. In females, mental tiredness was lower during exercise; increases in physical tiredness following 30 min of exercise were attenuated; and stress ratings following cognitive tasks were reduced following MVM. In males, MVM only lowered mental tiredness following 10 min of exercise. These effects were apparent irrespective of day, but effects on mental tiredness were greater on Day 28. Ferritin levels were also higher on Day 28 in those receiving MVM.

Conclusion

These findings extend on existing knowledge, demonstrating increased carbohydrate oxidation and increased energy expenditure in males following MVM supplementation for the first time. Importantly, they show modulation of energy expenditure and subjective tiredness following a single dose, providing further evidence for acute effects of MVM. Differential effects in men and women suggest that sex may play an important role in the effects of MVM on energy metabolism and should be considered in future research.

Trial registration

ClinicalTrials.gov, NCT03003442. Registered 22nd November 2016 – retrospectively registered

Increasing Dietary Carbohydrate as Part of a Healthy Whole Food Diet Intervention Dampens Eight Week Changes in Salivary Cortisol and Cortisol Responsiveness

It is largely unknown whether and how whole food diets influence psychological stress and stress system responsiveness. To better understand the effects of whole diets on stress system responsiveness, we examined randomized control trial effects of a whole food diet based on the Dietary Guidelines for Americans (DGA) on cortisol responsiveness. A randomized, double-blind, controlled 8-week intervention was conducted in overweight and obese women to examine differentiated effects between two diet intervention groups: one based on the 2010 DGA and the other one based on a typical American diet (TAD). During a test week that occurred at baseline and again after 8 weeks of the intervention, we assessed salivary cortisol collected at 14 selected times across the day, including upon awakening, at bedtime, and during a test visit, and administered a standardized social stress task (Trier Social Stress Test, TSST). There were no statistical differences between the diet groups in salivary cortisol at baseline or after 8 weeks. However, when considering differences in dietary carbohydrate, but not fat or protein, from the pre-intervention (habitual) to the intervention period, there was a significant (P = 0.0001) interaction between diet group, intervention week, saliva sample, and level of intervention-based change in carbohydrate consumption. This interaction was reflected primarily by an 8-week reduction in salivary cortisol during a period just prior to (log Δ −0.35 ± 0.12 nmol/L) and 30 (log Δ −0.49 ± 0.12 nmol/L), 60 (log Δ −0.50 ± 0.13 nmol/L), 90 (log Δ −0.51 ± 0.13 nmol/L), and 120 (log Δ −0.4476 ± 0.1231 nmol/L) min after the TSST in the DGA group having the highest increase (90th percentile) in carbohydrate consumption. In support of this finding, we also found significant (P < 0.05) and inverse linear associations between dietary carbohydrate and log salivary cortisol, with the strongest negative association (β: −0.004 ± 0.0015, P = 0.009) occurring at 30 min post-TSST, but only in the DGA group and at week 9 of the intervention. Together, increasing dietary carbohydrate as part of a DGA-based diet may reduce circulating cortisol and dampen psychological stress-related cortisol responsiveness.

Increased Posterior Cingulate Functional Connectivity Following 6-Month High-Dose B-Vitamin Multivitamin Supplementation: A Randomized, Double-Blind, Placebo-Controlled Trial

B vitamins are essential for optimal brain and body function, and are particularly important for cortical metabolic processes that have downstream effects on mitigating oxidative stress. Oxidative stress has been linked to poor psychological outcomes including psychological distress, which has wide-reaching implications for the community and the workplace. Given work-related stress has been associated with poor mental health outcomes, high-dose B vitamin supplementation may be effective in improving brain function and psychological outcomes via attenuation of oxidative stress. This randomized, double-blind, placebo-controlled study investigated psychological outcomes following 6-month supplementation of a high-B-vitamin multivitamin in a large sample of healthy adults (n = 108, aged 30-70 years), as well as changes in default mode network functional connectivity in a subset of the original sample (n = 28). Improvements in occupational stress, general health, perceived stress, depressive symptoms, and mood profiles were identified for both active and placebo groups over time (p < 0.05 corrected). Seed-based functional connectivity analysis centered on the posterior cingulate cortex (PCC) showed that connectivity between the PCC and the caudate increased for the active treatment group, but decreased for the placebo group (p < 0.05 corrected). These findings reveal a substantial intervention effect for both active and placebo treatments, which could in part be associated with a placebo effect in subjective measures. There was, however, a significant treatment effect in the objective measure of functional connectivity, suggesting that reduced psychological stress and high-B-vitamin multivitamin supplementation may lead to an increase in DMN and caudate functional connectivity, which might reflect a strengthening of neurocircuitry within areas associated with reward and emotion at rest. Future studies should consider a placebo run-in methodology to reduce the placebo effect on the subjective measures of stress.

A Systematic Review and Meta-Analysis of B Vitamin Supplementation on Depressive Symptoms, Anxiety, and Stress: Effects on Healthy and 'At-Risk' Individuals

A systematic review and meta-analysis was undertaken to examine and quantify the effects of B vitamin supplementation on mood in both healthy and 'at-risk' populations. A systematic search identified all available randomised controlled trials (RCTs) of daily supplementation with ≥3 B group vitamins with an intervention period of at least four weeks. Random effects models for a standardized mean difference were used to test for overall effect. Heterogeneity was tested using the I² statistic. Eighteen articles (16 trials, 2015 participants) were included, of which 12 were eligible for meta-analysis. Eleven of the 18 articles reported a positive effect for B vitamins over a placebo for overall mood or a facet of mood. Of the eight studies in 'at-risk' cohorts, five found a significant benefit to mood. Regarding individual facets of mood, B vitamin supplementation benefited stress (n = 958, SMD = 0.23, 95% CI = 0.02, 0.45, p = 0.03). A benefit to depressive symptoms did not reach significance (n = 568, SMD = 0.15, 95% CI = -0.01, 0.32, p = 0.07), and there was no effect on anxiety (n = 562, SMD = 0.03, 95% CI = -0.13, 0.20, p = 0.71). The review provides evidence for the benefit of B vitamin supplementation in healthy and at-risk populations for stress, but not for depressive symptoms or anxiety. B vitamin supplementation may particularly benefit populations who are at risk due to (1) poor nutrient status or (2) poor mood status.

Improvement in Cognition Following Double-Blind Randomized Micronutrient Interventions in the General Population

The impact of poor nutrition on physiological health is well understood (Costarelli et al., 2013). Less is known about the effects of diet on brain function and cognition in the general population (Ames, 2010; Parletta et al., 2013; White et al., 2017) and we are still in the early stages of understanding the role of specific nutrients to normal and pathological neuronal functioning. In the present study, the putative effect of a multivitamin/mineral or vitamin D supplement on cognitive function over an 8-week period was compared with volunteers taking vitamin C. Healthy adults (N = 60) were recruited, age range 21-59 years ( x ¯ = 39.07 years, SD = 11.46), with participants randomly allocated to conditions in a double-blind protocol. Participants also completed a 14-day food diary to gather information on micronutrient intake. The cognitive test battery included measures from the Wechsler Adult Intelligence Scale-III (WAIS-III; Wechsler et al., 2008), Wechsler Memory Scale-IV (WMS-IV; Wechsler, 2009) and Delis-Kaplan Executive Function System (D-KEFS; Delis et al., 2001), along with the Doors and People (Baddeley et al., 1994) and a serial reaction time task. Analyses showed better performance on some tasks in all groups following the intervention period, notably on measures of verbal and visual memory and visuomotor processing speed. The Multivitamin group showed significant improvements on tasks of visual strategy generation (along with the Vitamin C group), motor planning, explicit and implicit learning, and working memory. This evidence suggests that sub-optimal micronutrient intake may have a negative effect on cognition across the lifespan.

Diet Quality for Sodium and Vegetables Mediate Effects of Whole Food Diets on 8-Week Changes in Stress Load

Very little is known about how whole food diets, such as those based on the Dietary Guidelines for Americans (DGA), influence psychological stress and physiological stress load. To better understand the effects of whole food diets on stress, we examined in a randomized control trial the effects of a DGA-based diet on markers of psychological and physiological stress. A randomized, double-blind, controlled 8-week intervention was conducted in overweight and obese women randomly assigned to one of two diet groups: a diet based on the 2010 DGA or a diet based on a Typical American Diet (TAD). The Perceived Stress Scale and allostatic load were used to assess stress load. Eight-week change in perceived stress did not significantly (p = 0.45) differ between the DGA (+0.53 ± 0.99) and TAD (-0.57 ± 0.99) groups. Likewise, 8-week change in allostatic load did not significantly (p = 0.79) differ between the two diet intervention groups (DGA: +0.001 ± 0.26 vs. TAD: +0.105 ± 0.28). However, we did find strong inverse associations between 8-week change in stress and intervention-based improvements in diet quality (lower sodium and higher vegetable consumption). When statistically accounting for these inverse associations, we found that perceived stress and allostatic load were higher (p < 0.04) in the DGA group. These findings suggest that improvements in dietary vegetable and sodium intake mediated effects of the diet intervention on psychological and physiological stress load. That is, adopting and adhering to a diet of higher quality (DGA) for 8 weeks may have been generally more stressful in the absence of improvements in vegetable or sodium consumption. This study provides further evidence for the mental health benefits of maximizing vegetable and minimizing sodium consumption.

Efficacy and safety of Eurycoma longifolia (Physta®) water extract plus multivitamins on quality of life, mood and stress: a randomized placebo-controlled and parallel study

Background

The use of alternative and complementary medicines to alleviate stress has increased to avoid the negative effects of pharmaceutical drugs.

Objective

This study investigated the safety and efficacy of Eurycoma longifolia in combination with multivitamins (EL+MV) versus placebo on improving quality of life (QoL), mood and stress in moderately stressed healthy participants.

Methods

This randomised, double-blind, placebo-controlled 24-week study enrolled 93 participants aged 25-65 years, with a body mass index of 18-30 kg/m², scoring ≤18 in tension and ≤14 in fatigue subscale of Profiles of Mood Scores (POMS) questionnaire and supplemented with EL+MV or placebo. The primary endpoints were QoL measured by 12-Item Short Form Health Survey (SF-12) questionnaire and mood measured by POMS. The secondary endpoint was stress measured by Multi-Modal Stress Questionnaire (MMSQ). The safety of the intervention product was measured by complete metabolic panel, lipid and renal analysis including several immune parameters.

Results

While there were no significant between-group differences, within-group improvements were observed in the SF-12 QoL, POMS and MMSQ domains. In the SF-12 domain, improvements were seen in role limitation due to emotional health (P = 0.05), mental component domain (P < 0.001), emotional well-being (P < 0.001), social functioning (P = 0.002) as well as vitality (P = 0.001) at week 12. An increasing trend in POMS-vigour domain was also observed in the EL+MV group at week 12. A 15% decrease in physical stress domain (P < 0.05) compared with 0.7% in the placebo group was also observed in MMSQ. When the subjects were subgrouped according to age, 25-45 and 46-65 years of age, for primary outcomes, between-group significance was observed in the 25-45 year group in the social functioning domain of SF-12 (P = 0.021) and POMS-vigour (P = 0.036) in the 46-65 year group. No significant changes were observed in vital signs and complete metabolic panel. Regarding immune parameters, the lymphocytes increased significantly in the active group (P≤0.05). In total, 13 adverse events were reported: six on placebo and seven on EL+MV.

Conclusion

EL+MV may support the QoL, mood, stress and immune parameters in healthy participants.

Trial registration

This study has been registered at clinicaltrials.gov (NCT02865863).

Effect of vitamin D supplementation on depression in elderly patients: A randomized clinical trial

BACKGROUND & AIMS

Treatment of depression in elderly population is a crucial issue. The effect of vitamin D supplementation on treatment of depression in older adults was investigated in this clinical trial.

METHODS

It was an 8-week, randomized clinical trial of vitamin D supplementation and placebo in the treatment of depression in 3 psychiatric clinics. The study sample included 78 older adults aged over 60 years with moderate to severe depression. Subjects were randomly allocated to receive 50,000 U vitamin D3 pearl weekly for 8 weeks or placebo (39 subjects in each group). Main outcome measures comprised Geriatric Depression Scale-15 (GDS-15) questionnaire and 25-hydroxyvitamin D3 [25(OH)D3]. The analysis utilized Mann Whitney U test, Wilcoxon signed ranks test, chi-square and multiple regression analysis.

RESULTS

The mean baseline 25(OH)D3 concentration was 22.57 ± 6.2 ng/ml in vitamin D group and 21.2 ± 5.8 ng/ml in placebo group (p = 0.16). The Vitamin D increased to 43.48 ± 9.5 ng/ml in vitamin D and 25.9 ± 15.3 ng/ml in placebo group. The depression score decreased from 9.25 to 7.48 in vitamin D group (p = 0.0001), while there was a non-significant increase in depression score in placebo group. The multiple regression analysis showed that the vitamin D group and the score of depression before study were the variables that could explain 81.8% of depression score after intervention.

CONCLUSION

The findings indicated that vitamin D supplementation can improve the depression score in persons aged 60 and over.

Overfed but undernourished: recognizing nutritional inadequacies/deficiencies in patients with overweight or obesity

Overweight and obesity are highly prevalent throughout the world and can adversely affect the nutritional status of individuals. Studies have shown that many people with obesity have inadequate intake of iron, calcium, magnesium, zinc, copper, folate and vitamins A and B₁₂, likely as a result of poor diet quality. Nutritional inadequacies or deficiencies may also occur due to altered pharmacokinetics in the individual with obesity and due to interactions in those with overweight or obesity with various pharmaceuticals. However, it has been demonstrated that the adult population in the United States as a whole is deficient in certain micronutrients as a result of the availability and overconsumption of high-calorie, low-nutrient processed foods. Poor nutrition may contribute to the development of certain chronic conditions, such as type 2 diabetes, which is already more prevalent in those with obesity. Clinicians need to be aware of these gaps, particularly in those individuals with obesity who are undergoing bariatric surgery or taking pharmaceutical products long term to facilitate weight loss. Patients with overweight or obesity likely struggle to achieve a balanced diet and may benefit from consultation with a dietitian. Along with providing recommendations for healthy eating and exercise, supplementation with specific micronutrients or multivitamins should be considered for individuals at the highest risk for or with established deficiencies. Further research is needed to understand the factors underlying nutritional inadequacies in individuals with overweight or obesity, as well as the outcomes of treatment strategies employed to address them.

Daily oral supplementation with collagen peptides combined with vitamins and other bioactive compounds improves skin elasticity and has a beneficial effect on joint and general wellbeing

Aging is a multifactorial and natural process that causes physiological changes in organs, tissues and cells over time. In the skin and cartilage, aging leads to a decrease in the synthesis and changes in the arrangement of proteoglycans and collagen, in addition to the loss of glycosaminoglycans, which are responsible for the integrity and health of these tissues. We hypothesized that daily oral supplementation with a liquid nutraceutical containing hydrolyzed fish collagen, vitamins, antioxidants and other active ingredients could improve skin texture and elasticity, and in addition have a protective effect on joint health. A double-blind, randomized, placebo-controlled clinical trial was conducted on 120 subjects who consumed either the test product or placebo on a daily basis for 90 days. Subjects consuming the test product had an overall significant increase in skin elasticity (+40%; P < .0001) when compared to placebo. Histological analysis of skin biopsies revealed positive changes in the skin architecture, with a reduction in solar elastosis and improvement in collagen fiber organization in the test product group. As reported in the self-perception questionnaires, these results were confirmed by the subjects' own perceptions in that participants agreed their skin was more hydrated and more elastic. In addition, the consumption of the test product reduced joint pain by -43% and improved joint mobility by +39%. Oral supplementation with collagen bioactive peptides combined with chondroitin sulphate, glucosamine, L-carnitine, vitamins, and minerals significantly improved the clinical parameters related to skin aging and joint health, and therefore, might be an effective solution to slow down the hallmarks of aging.

Effects of vitamin supplementation on inflammatory markers and psychological wellbeing among distressed women: a randomized controlled trial

BACKGROUND

Multivitamins are a popular supplement taken to promote physical and mental health. During periods of stress, they may have a protective role for health and wellbeing, although the current evidence of their efficacy is mixed.

OBJECTIVE

To determine whether multivitamin supplementation impacts psychological and inflammatory markers of women who are experiencing psychological distress.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

An 8-week randomized controlled trial was conducted to assess changes in both psychological state and pro-inflammatory markers of patients receiving multivitamins or placebo. The sample comprised women who reported elevated psychological distress in the previous 4 weeks.

MAIN OUTCOME MEASURES

Psychological state was assessed using Spielberger's State-Trait Personality Inventory to assess anxiety, curiosity, depression and anger. Pro-inflammatory markers comprised interleukin (IL)-1β, IL-5, IL-6, tumour necrosis factor (TNF)-α and TNF-β.

RESULTS

Improvements across time were observed for all psychological measures and cytokines, except IL-5, but were independent of the active intervention. Only TNF-β demonstrated a significant differential change between groups over the course of the intervention, in favour of multivitamin supplementation (active group mean rank decreased from 11.1 to 7.1; placebo group mean rank decreased from 8.9 to 7.8).

CONCLUSION

The results suggest that administration of multivitamins was not effective in improving psychological state. However, some evidence supported the positive impact of multivitamin supplementation on pro-inflammatory cytokine profiles of women currently experiencing stress.

The effect of vitamin B6 on dexamethasone-induced depression in mice model of despair

Objective: Glucocorticoid receptors (GRs) have an important role in mediating the effects of glucocorticoids (GCs) on brain plasticity and mood. GC drugs and elevated cortisol level can cause psychiatric disorders including depression. The B-vitamins have numerous benefits on general health as well as mood, and cognition. The aim was evaluating the effect of vitamin B6 following dexamethasone (DEX)-induced depression in mice, to see if it can be proposed as a remedy for psychiatric problems following GC therapy. Methods: Male mice were housed by six. The immobility time was measured, in the forced swimming test as an animal model of despair and sucrose preference was measured in order to test anhedonia (<65% was taken as a criterion for anhedonia). DEX was administered either single dose (15, 60, 250 mcg/kg) or 15 mcg/kg for 7 consecutive days, vitamin B6 (100 mg/kg) was administered for 7 days. Results: DEX dose dependently increased immobility time that denoted animal depression; as it was 177.5 seconds ± 3 following 60 mcg/kg and 188.3 seconds ± 5 following 250 mcg/kg administration (vs. control animals 164 seconds ± 6, P < 0.01). Premedication with vitamin B6 prevented DEX-induced depression and demonstrated antidepressant effect. It also reduced the immobility time following 7days DEX injection (192.5 seconds ± 6) to 100 seconds ± 5.5; sucrose preference escalated from 50%±3 to 87%±4. Conclusion: Vitamin B6 prevented DEX-induced depression possibly by altering the GR function. Thus Vitamin B6 could be promising in patients suffering from GC-induced psychiatric adverse effects and probably controlling stress and preventing its affective disorder out comes.

Database Analysis of Depression and Anxiety in a Community Sample-Response to a Micronutrient Intervention

Background: Depression and anxiety are common mental health concerns worldwide. Broad-spectrum multi-vitamin/mineral approaches have been found to alleviate a number of psychiatric symptoms. We investigated the effects of a nutrient intervention program, which includes optimizing vitamin D levels, on depression and anxiety outcomes from community-based program. Methods: We evaluated self-reported health measures of depression and anxiety collected as part of a community-based program focused on optimizing overall health through nutritional supplementation, education and lifestyle advice. Results: Data were collected from 16,020 participants, with measures including European Quality of Life Five Dimensions (EQ-5D) and Targeted Symptoms List (TSL) providing self-reported depression and anxiety. More than 56% of participants were identified as having elevated levels of depression and anxiety at baseline as reported on the EQ-5D. After one year in the program, 49.2% (n = 7878) of participants who reported any level of depression or anxiety at baseline reported improvement at follow-up. Of those who reported severe/extreme depression at baseline (n = 829), 97.2% reported improvement after one year. Regression analyses revealed a significant association of improvement in depression and anxiety with higher vitamin D status (>100 nmol/L) and more strenuous physical activity. Conclusion: Overall, people from the general population who suffer from mood and anxiety problems may benefit from improved nutritional status achieved with nutritional supplements.

The Singer's and the Clinician's Perspective on Vitamin B12 Treatment for Vocal Benefits

INTRODUCTION

There is a belief among vocalists that there are voice benefits from vitamin B₁₂ treatment. Yet there are no previous reports regarding vitamin B₁₂ effects on voice.

OBJECTIVES

To assess the prevalence of vitamin B₁₂ use among singers and their beliefs regarding vitamin B₁₂ therapy.

METHODS

Anonymous online survey administered to singers, singing-teachers, speech-language pathologists, and laryngologists.

RESULTS

A total of 192 participants completed the surveys; 128 singers (68 singing-teachers, 30 speech-language pathologists) and 64 laryngologists. Among singers, 12% have perceived voice benefits from vitamin B₁₂ treatment taken for any reason. Four percent used vitamin B₁₂ for voice benefits; all perceived voice benefits as a result. The leading voice benefits were improved stamina, reduced effort, confidence, and control. Nineteen percent of the singers would recommend vitamin B₁₂ treatment to a friend; 15% of the singing-teachers would recommend it to a student. Among laryngologists, 33% been asked by a singer to prescribe vitamin B₁₂ for voice benefits; 9% have prescribed it in the past. Yet only 3% would you recommend it to a patient. When asked "Do you believe vitamin B₁₂ therapy improves vocal performance?" 31% of the singers responded "Yes," compared with none in the laryngologists. When asked "Do you think the singing community believes vitamin B₁₂ therapy improves vocal performance?" 26% of the singers responded "Yes," compared with 53% of the laryngologists (P = 0.0002).

CONCLUSIONS

There is a discrepancy between the singers' and the laryngologists' beliefs regarding vocal benefits perceived by vitamin B₁₂. Blinded randomized trials are required to verify or refute this belief.

Does stress influence sleep patterns, food intake, weight gain, abdominal obesity and weight loss interventions and vice versa?

Decades of research have reported only weak associations between the intakes of specific foods or drinks and weight gain and obesity. Randomized controlled dietary intervention trials have only shown very modest effects of changes in nutrient intake and diet composition on body weight in obese subjects. This review summarizes the scientific evidence on the role mental stress (either in or not in association with impaired sleep) may play in poor sleep, enhanced appetite, cravings and decreased motivation for physical activity. All these factors contribute to weight gain and obesity, possibly via decreasing the efficacy of weight loss interventions. We also review evidence for the role that lifestyle and stress management may play in achieving weight loss in stress-vulnerable individuals with overweight.

Cognitive and Mood Effects of a Nutrient Enriched Breakfast Bar in Healthy Adults: A Randomised, Double-Blind, Placebo-Controlled, Parallel Groups Study

Objectives: Few previous studies have assessed the effects of concomitant administration of multiple potentially psychoactive nutrients. Methods: 95 healthy adult participants consumed either a nutrient enriched breakfast bar (containing α-Linolenic acid, l-tyrosine, l-theanine, vitamins, minerals and 21.5 mg of caffeine) or an isocaloric, macronutrient matched control bar for 56 days. Cognitive function and mood were assessed pre-dose and at 40- and 160-min post-dose on the 1st and 56th day of the intervention period. Results: The results demonstrated acute effects of treatment across post-dose assessments on both assessment days in terms of alertness, and on tasks assessing attention, working and episodic memory and executive function, including cognitively demanding Serial subtraction and Rapid Visual Information Processing tasks. There were no evident chronic effects independent of the breakfast bars’ acute effects. Discussion: These results demonstrate that a nutrient enriched breakfast bar with low caffeine content can exert striking beneficial effects on acute cognitive function and alertness.

Does Health Perception, Dietary Habits and Lifestyle Effect Optimism? A Quantitative and Qualitative Study

The aim of the study was to investigate the relationship between optimism, general health perception, nutritional habits and lifestyle. A quantitative study was conducted on 500 Greek adults. A standardized questionnaire was used which consisted of the General Health Self-Assessment Questionnaire (GHSAQ), the Life Orientation Test-Revised (GrLOT-R), the dietary habits and lifestyle questionnaire. A qualitative study was conducted through interviews and focus groups. Participants' average score of GrLot-R was 20.47 (±4.017) units. The highest GrLot-R score was statistically correlated to more frequent consumption of fruits, salads, dairy products, olive oil, high-fibre cereals and water and to the lower consumption of canned products. Multivariate analysis showed that optimism is significantly positively predicted by the factors "Vitamin K & A", "Vitamin C", and negatively by "Preservatives." There was also a positive correlation between GrLot-R and GHSAQ. The qualitative study analysis showed that physical exercise, duration/quality of sleeping, family and stress affected participants' optimism. It seems that intrinsic factors as vitamins, preservatives, a healthy lifestyle and extrinsic factors as the family background and the environment that someone is raised, affect the level of optimism.

The Essentials of a Global Index for Cognitive Function

Cognition is comprised of the faculties: perception, creativity, intuition, and ratiocination. Optimal levels of cognition are needed for independent functioning and balanced living. With an aging population that continues to grow, dietary supplements that tilt the balance towards maintenance of cognition are being marketed for vulnerable populations facing these challenges. Randomized clinical trials provide the causal inference necessary to define the efficacy of emerging nutraceuticals. Cognition testing, in particular, requires a battery of tests that encompass all brain regions involved in cognition so as to provide endpoints necessary for product validation. The lack of well controlled studies for comparison analyses, limited sample sizes, ambiguous dosages, and poor cognitive measures result in data that cannot be compared across studies to determine the efficacy of supplements claiming to enhance cognition. Clinical trials for the nutraceutical industry should consider the multifaceted nature of supplements, where clinical endpoints must be comprehensive while remaining feasible. Combining endpoints of cognition with physiological biomarkers of immunity and metabolism to arrive at a global index for cognitive health may be necessary for claim substantiation in order to fully justify and scientifically validate improvements in cognitive health. The issues and needs of a global index will be discussed here.

The impact of essential fatty acid, B vitamins, vitamin C, magnesium and zinc supplementation on stress levels in women: a systematic review

BACKGROUND

Women juggling multiple roles in our complex society are increasingly experiencing psychological stress. Dietary supplementation to manage stress is widespread despite limited supporting evidence. A systematic review of the available literature was undertaken to investigate the efficacy of specific dietary supplements in managing female stress and anxiety.

OBJECTIVES

To identify the impact of essential fatty acids (EFAs), B vitamins, vitamin C, magnesium and/or zinc, consumed as dietary supplements to the daily diet, on female stress and anxiety levels.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Women aged 18 years and over, who had participated in a study where stress and/or anxiety were assessed.

TYPES OF INTERVENTION(S)

Dietary supplementation with EFAs, B vitamins, vitamin C, magnesium and/or zinc.

TYPES OF COMPARATORS

Supplements, either alone or combined, were compared with either no intervention or placebo.

TYPES OF STUDIES

Randomized controlled and pseudo-randomized trials were included.

OUTCOMES

Stress and anxiety were assessed using self-report or physiological outcome measures.

SEARCH STRATEGY

Published and unpublished studies were sought via MEDLINE (via PubMed), Embase, Scopus, CINAHL, PsycINFO, PsycARTICLES, MedNar, National Institute of Mental Health and the International Association for Women's Mental Health.

METHODOLOGICAL QUALITY

Methodological quality was evaluated using standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Data were extracted using the standardized data extraction instruments from the Joanna Briggs Institute.

DATA SYNTHESIS

Due to heterogeneity of the included studies, narrative synthesis was performed.

RESULTS

Fourteen studies were included in this review. Essential fatty acids were effective in reducing perceived stress and salivary cortisol levels during pregnancy and anxiety in premenstrual women, and anxiety during menopause in the absence of depression, but were ineffective when depression was disregarded. Disregarding the hormonal phase, EFAs were ineffective in reducing stress or anxiety in four groups of women. Combined magnesium and vitamin B6 supplementation reduced premenstrual anxiety but had no effect when used in isolation and did not affect stress in women suffering from dysmenorrhea when combined or used in isolation. Older women experienced anxiety reduction using vitamin B6, but not folate or vitamin B12. High-dose sustained-release vitamin C was effective in reducing anxiety and blood pressure in response to stress.

CONCLUSION

The current review suggests that EFAs may be effective in reducing prenatal stress and salivary cortisol and may reduce anxiety during premenstrual syndrome and during menopause in the absence of depression. Magnesium and vitamin B6 may be effective in combination in reducing premenstrual stress, and vitamin B6 alone may reduce anxiety effectively in older women. High-dose sustained-release vitamin C may reduce anxiety and mitigate increased blood pressure in response to stress.

IMPLICATIONS FOR PRACTICE

Essential fatty acids may be effective in reducing prenatal stress and salivary cortisol levels, and premenstrual or menopausal anxiety in the absence of depression. Combining magnesium and vitamin B6 may reduce premenstrual anxiety and vitamin B6 may reduce anxiety in older women. High-dose sustained-release vitamin C may reduce anxiety and mitigate increased blood pressure in response to stress.

IMPLICATIONS FOR RESEARCH

Investigating supplementation in longer term studies is warranted and should include compliance testing, the use of inert substances as controls and reliable outcome measures.

The Effects of Four-Week Multivitamin Supplementation on Mood in Healthy Older Women: A Randomized Controlled Trial

Objective. Nutritional deficiencies have been associated with cognitive decline and mood disturbances. Vitamin intake can influence mood and randomized controlled trials have demonstrated that multivitamin supplements are capable of reducing mild symptoms of mood dysfunction. However, few studies have focussed on healthy older women. Methods. This study investigated the effects of four weeks' multivitamin supplementation on mood in 76 healthy women aged 50-75 years. Mood was assessed before and after intervention in the laboratory using measures of current mood and retrospective experiences of mood over the past week or longer. Mobile phones were used to assess changes in real-time mood ratings, twice weekly in the home. Results. There were no multivitamin-related benefits identified for measures of current mood or reflections of recent mood when measured in the laboratory. In-home assessments, where mood was rated several hours after dose, revealed multivitamin supplementation improved ratings of stress, with a trend to reduce mental fatigue. Conclusions. Over four weeks, subtle changes to stress produced by multivitamin supplementation in healthy older women may not be detected when only pre- and posttreatment mood is captured. In-home mobile phone-based assessments may be more sensitive to the effects of nutritional interventions compared to traditional in-laboratory assessments.

Functional Brain Activity Changes after 4 Weeks Supplementation with a Multi-Vitamin/Mineral Combination: A Randomized, Double-Blind, Placebo-Controlled Trial Exploring Functional Magnetic Resonance Imaging and Steady-State Visual Evoked Potentials during Working Memory

This study explored the neurocognitive effects of 4 weeks daily supplementation with a multi-vitamin and -mineral combination (MVM) in healthy adults (aged 18–40 years). Using a randomized, double-blind, placebo-controlled design, participants underwent assessments of brain activity using functional Magnetic Resonance Imaging (fMRI; n = 32, 16 females) and Steady-State Visual Evoked Potential recordings (SSVEP; n = 39, 20 females) during working memory and continuous performance tasks at baseline and following 4 weeks of active MVM treatment or placebo. There were several treatment-related effects suggestive of changes in functional brain activity associated with MVM administration. SSVEP data showed latency reductions across centro-parietal regions during the encoding period of a spatial working memory task following 4 weeks of active MVM treatment. Complementary results were observed with the fMRI data, in which a subset of those completing fMRI assessment after SSVEP assessment (n = 16) demonstrated increased BOLD response during completion of the Rapid Visual Information Processing task (RVIP) within regions of interest including bilateral parietal lobes. No treatment-related changes in fMRI data were observed in those who had not first undergone SSVEP assessment, suggesting these results may be most evident under conditions of fatigue. Performance on the working memory and continuous performance tasks did not significantly differ between treatment groups at follow-up. In addition, within the fatigued fMRI sample, increased RVIP BOLD response was correlated with the change in number of target detections as part of the RVIP task. This study provides preliminary evidence of changes in functional brain activity during working memory associated with 4 weeks of daily treatment with a multi-vitamin and -mineral combination in healthy adults, using two distinct but complementary measures of functional brain activity.

Subjective mood and energy levels of healthy weight and overweight/obese healthy adults on high-and low-glycemic load experimental diets

Emerging evidence suggests a positive association of diet and obesity with depression. Researchers have examined several diet-mood hypotheses, including investigating the extent to which carbohydrates may impact mood. There is limited research on how glycemic load, a characteristic of carbohydrates, impacts mood in healthy adults. Eighty-two healthy weight and overweight/obese, but otherwise healthy, adults enrolled in a randomized, crossover controlled feeding study testing low-compared to high-glycemic load diets. All participants completed self-report mood and energy level questionnaires during each arm of the intervention. Diets were isocaloric and were matched by macronutrient content as a percent of total energy. Mood was assessed with the Profile of Mood States (POMS) subscales; tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment, total mood disturbance (TMD), and negative affect (NA) in addition to the Center for Epidemiological Studies - Depression (CES-D) scale at baseline and end of both 28-day feeding periods. Linear mixed models tested the intervention effect on mood, controlling for baseline POMS and CES-D scores, diet type, diet sequence, feeding period, sex, and percent body fat classification. The consumption of the high-glycemic load diet resulted in a 38% higher score for depressive symptoms on the CES-D (P = 0.002) compared to the low-glycemic load diet as well as 55% higher score for TMD (P = 0.05), and 26% higher score for fatigue/inertia (P = 0.04). In subgroup analyses, the overweight/obese participants had 40% higher scores on the CES-D scale compared to healthy weight participants (P = 0.05). In conclusion, a high-glycemic load diet was associated with higher depression symptoms, total mood disturbance, and fatigue compared to a low-glycemic load diet especially in overweight/obese, but otherwise healthy, adults. This trial was registered at clinicaltrials.gov: NCT00622661.

Effect of B-complex vitamins on the antifatigue activity and bioavailability of ginsenoside Re after oral administration

Background

Both ginsenoside Re and B-complex vitamins are widely used as nutritional supplements. They are often taken together so as to fully utilize their antifatigue and refreshing effects, respectively. Whether actually a drug–nutrient interaction exists between ginsenoside Re and B-complex vitamins is still unknown. The objective of this study was to simultaneously investigate the effect of B-complex vitamins on the antifatigue activity and bioavailability of ginsenoside Re after their oral administration. The study results will provide valuable theoretical guidance for the combined utilization of ginseng and B-complex vitamins.

Methods

Ginsenoside Re with or without B-complex vitamins was orally administered to mice to evaluate its antifatigue effects and to rats to evaluate its bioavailability. The antifatigue activity was evaluated by the weight-loaded swimming test and biochemical parameters, including hepatic glycogen, plasma urea nitrogen, and blood lactic acid. The concentration of ginsenoside Re in plasma was determined by liquid chromatography–tandem mass spectrometry.

Results

No antifatigue effect of ginsenoside Re was noted when ginsenoside Re in combination with B-complex vitamins was orally administered to mice. B-complex vitamins caused to a reduction in the bioavailability of ginsenoside Re with the area under the concentration–time curve from zero to infinity markedly decreasing from 11,830.85 ± 2,366.47 h·ng/mL to 890.55 ± 372.94 h·ng/mL.

Conclusion

The results suggested that there were pharmacokinetic and pharmacodynamic drug–nutrient interactions between ginsenoside Re and B-complex vitamins. B-complex vitamins can significantly weaken the antifatigue effect and decrease the bioavailability of ginsenoside Re when simultaneously administered orally.

Multivitamins and minerals modulate whole-body energy metabolism and cerebral blood-flow during cognitive task performance: a double-blind, randomised, placebo-controlled trial

BACKGROUND

The brain is by far the most metabolically active organ in the body, with overall energy expenditure and local blood-supply closely related to neural activity. Both energy metabolism and cerebral vaso-dilation are dependent on adequate micronutrient status. This study investigated whether supplementation with ascending doses of multi-vitamin/minerals could modulate the metabolic and cerebral blood-flow consequences of performing cognitive tasks that varied in difficulty.

METHODS

In this randomised, double-blind, placebo-controlled, parallel-groups study 97 healthy females (25-49 y), who were not selected on the basis of any nutritional parameters, received either placebo or one of two doses of multivitamins/minerals. Cerebral blood-flow (CBF) parameters in the frontal cortex, and total energy expenditure (TotalEnergy), carbohydrate and fat oxidation (CarbOxi/FatOxi), were measured during 5 tasks of graded cognitive difficulty and a control task (5 min per task) using Near-infrared spectroscopy (NIRS) and Indirect calorimetry of exhaled pulmonary gas (ICa) respectively. Assessments took place 60 min after the first dose and following eight weeks supplementation.

RESULTS

During task performance supplementation with the first dose of micronutrients led to a dose-dependent increase in TotalEnergy and FatOxi throughout the post-dose assessment period following the higher dose, and increases in the total concentration of haemoglobin, a proxy measure for CBF, during task performance following the lower dose of vitamins/minerals (also containing coenzyme-Q10). Chronic supplementation over 8 weeks led to a dose-dependent increase in TotalEnergy during the task period. There were no interpretable effects on mood or cognitive performance.

CONCLUSIONS

These results show that acute supplementation with micronutrients in healthy adults can modulate metabolic parameters and cerebral blood flow during cognitive task performance, and that the metabolic consequences are sustained during chronic supplementation. These findings suggest that both brain function and metabolism are amenable to micronutrient supplementation, even in adults who are assumed to have nutritional status typical of the population.

TRIAL REGISTRATION

ClinicalTrials.gov - NCT02381964.

The Influence of Nutritional Factors on Verbal Deficits and Psychopathic Personality Traits: Evidence of the Moderating Role of the MAOA Genotype

The current study explores whether: (a) nutritional factors among adolescent males predict their risk of exhibiting verbal deficits and psychopathic traits during adulthood and (b) the link between nutritional factors and these outcomes is conditioned by the MAOA genotype. The study analyzes data from the U.S. National Longitudinal Study of Adolescent Health (Add Health), a nationally representative, genetically informative sample. We find evidence that meal deprivation increases the likelihood of both verbal deficits and psychopathic personality traits, whereas poor quality nutrition increases the risk of verbal deficits. We detect the presence of a number of gene-environment interactions between measures of food quality and MAOA genotype, but no evidence of GxE in the case of meal deprivation. Limitations are noted and avenues for future research are discussed.

Clinically Significant Symptom Reduction in Children with Attention-Deficit/Hyperactivity Disorder Treated with Micronutrients: An Open-Label Reversal Design Study

OBJECTIVE

The purpose of this study was to investigate the clinical effect and safety of a broad spectrum, 36 ingredient micronutrient (vitamins and minerals) in treating children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

This open-label, on-off-on-off (reversal design) study followed 14 participants (8-12 years of age) with ADHD, diagnosed using standardized instruments, for 6 months with no dropouts. Following baseline assessment, including hematology and biochemistry screening, participants began an 8 week treatment phase with micronutrients titrated up to maximum dose (15 capsules/day). Treatment was withdrawn for 4 weeks, reinstated for a further 8 weeks, and then withdrawn for 4 weeks. Primary outcomes included the Conners' Parent Rating Scale, the Clinical Global Impressions Scale (CGI), and the Strengths and Difficulties Questionnaire - Parent version (SDQ). Secondary outcomes were mood and global functioning.

RESULTS

Modified Brinley plots revealed a reduction in ADHD symptoms, improved mood, and improved overall functioning during intervention phases, and deterioration in ADHD symptoms, mood, and overall functioning during the withdrawal phases. Reliable change analyses, Cohen's d and percent superiority effect sizes, 95% confidence intervals and t tests confirmed clinically and statistically significant change between the intervention and withdrawal phases, with large effect sizes observed pre- to post-exposure of micronutrients (d = 1.2-2.2) on ADHD symptoms during intervention phases. Seventy-one percent of participants showed at least a 30% decrease in ADHD symptoms by the end of the second treatment phase, and 79% were identified as "much improved" or "very much improved" at the end of the second phase (5 months) based on the clinician-rated CGI when considering functioning generally. The SDQ showed that these benefits occurred across other areas of functioning including emotional symptoms, conduct problems, and prosocial behaviours. The children's self-reports confirmed the improvements. Excellent adherence to treatment occurred throughout, side effects were mild and transitory, and no safety issues were identified through blood analyses.

CONCLUSIONS

This study demonstrates the clinical benefit, feasibility, and safety of broad-spectrum micronutrients in the treatment of childhood ADHD. Replications utilizing double-blind placebo-controlled studies are warranted. Trial is registered with the Australia and New Zealand Clinical Trial Registry: ACTRN12612000645853.

Fatigue and Vitamin D Status in Iranian Female Nurses

Introduction:

Given that nurses are among professions with frequent problems of fatigue, and given the nature of their profession that provides little exposure to sunlight and the subsequent deficiency of vitamin D, the present study examined the relation between fatigue and circulating vitamin D levels in female nurses working in Shahid Beheshti Hospital, Kashan, Iran in 2013.

Material and Methods:

This cross-sectional study was conducted in 200 female nurses working in Shahid Beheshti Hospital. To measure fatigue, fatigue questionnaire containing 9 questions eliciting the subject’s feeling in scales of 1 to 7, getting a possible score of 9 to 63, and Visual Analogue Scale in which nurses specified their fatigue in a band of zero to 10 were used. The 25-hydroxyvitamin D, which is the most important vitamin D metabolite, also was determined. The data was analyzed by SPSS-16. The Pearson’s correlation of coefficients, t-test, and multiple regression analysis were used in this study.

Results:

The mean fatigue score of nurses was 38.76±12.66 in questionnaire and 5.73±2.12 in Visual Analog Scale. The 89 per cent of nurses suffered from vitamin D deficiency, 9.5 percent of them had normal level and 1.5 per cent had toxicity level of vitamin D. There was a significant relationship between vitamin D level and fatigue scores (P<0.0001), and visual fatigue scores (P<0.0001). According to multivariate regression analysis, vitamin D level accounted for 13 per cent of the fatigue based on data on questionnaire and 18.6 per cent of fatigue according to Visual Analog Scale.

Conclusion:

High prevalence of fatigue among nurses could be attributed to vitamin D deficiency.