Sugar and cardiovascular disease: A statement for healthcare professionals from the Committee on Nutrition of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association

Digesting the complex metabolic effects of diet on the host and microbiome

The past 50 years of interdisciplinary research in humans and model organisms has delivered unprecedented insights into the mechanisms through which diet affects energy balance. However, translating these results to prevent and treat obesity and its associated diseases remains challenging. Given the vast scope of this literature, we focus this Review on recent conceptual advances in molecular nutrition targeting the management of energy balance, including emerging dietary and pharmaceutical interventions and their interactions with the human gut microbiome. Notably, multiple current dietary patterns of interest embrace moderate-to-high fat intake or prioritize the timing of eating over macronutrient intake. Furthermore, the rapid expansion of microbiome research findings has complicated multiple longstanding tenets of nutrition while also providing new opportunities for intervention. Continued progress promises more precise and reliable dietary recommendations that leverage our growing knowledge of the microbiome, the changing landscape of clinical interventions, and our molecular understanding of human biology.

John Yudkin's hypothesis: sugar is a major dietary culprit in the development of cardiovascular disease

To date, the risk of developing atherosclerosis has extended beyond Western countries and now affecting individuals from various ethnic backgrounds and age groups. Traditional risk factors of atherosclerosis, such as hypercholesterolemia, has been better controlled than before due to highly effective and inexpensive therapies at lowering plasma cholesterol levels. However, the role of reducing dietary cholesterol intake, as a public healthy strategy, in preventing the occurrence of cardiovascular mortalities has been recently challenged. Indeed, despite our continuous decline of dietary cholesterol intake within the last 50 years, the incidence of cardiovascular mortalities has continued to rise, thus raising the possibility that other dietary factors, such as fructose-containing sugars, are the major culprit. In the 1970s, John Yudkin first proposed that sugar was the predominant dietary factor that underlies the majority of cardiovascular mortalities, yet his hypothesis was dismissed. However, over the last 25 years substantial scientific evidence has been accumulated to support Yudkin's hypothesis. The objectives of this review are to highlight Yudkin's significant contribution to nutritional science by reviewing his hypothesis and summarizing the recent advances in our understanding of fructose metabolism. The metabolic consequences of fructose metabolism, such as fructose-induced uricemia, insulin resistance, lipoprotein hyperproduction and chronic inflammation, and how they are linked to atherosclerosis as risk factors will be discussed. Finally, the review will explore areas that warrant future research and raise important considerations that we need to evaluate when designing future studies.

Metabolomics Profiling of Stages of Coronary Artery Disease Progression

Coronary artery disease (CAD) and atherosclerosis pose significant global health challenges, with intricate molecular changes influencing disease progression. Hypercholesterolemia (HC), hypertension (HT), and diabetes are key contributors to CAD development. Metabolomics, with its comprehensive analysis of metabolites, offers a unique perspective on cardiovascular diseases. This study leveraged metabolomics profiling to investigate the progression of CAD, focusing on the interplay of hypercholesterolemia, hypertension, and diabetes. We performed a metabolomic analysis on 221 participants from four different groups: (I) healthy individuals, (II) individuals with hypercholesterolemia (HC), (III) individuals with both HC and hypertension (HT) or diabetes, and (IV) patients with self-reported coronary artery disease (CAD). Utilizing data from the Qatar Biobank, we combined clinical information, metabolomic profiling, and statistical analyses to identify key metabolites associated with CAD risk. Our data identified distinct metabolite profiles across the study groups, indicating changes in carbohydrate and lipid metabolism linked to CAD risk. Specifically, levels of mannitol/sorbitol, mannose, glucose, and ribitol increased, while pregnenediol sulfate, oleoylcarnitine, and quinolinate decreased with higher CAD risk. These findings suggest a significant role of sugar, steroid, and fatty acid metabolism in CAD progression and point to the need for further research on the correlation between quinolinate levels and CAD risk, potentially guiding targeted treatments for atherosclerosis. This study provides novel insights into the metabolomic changes associated with CAD progression, emphasizing the potential of metabolites as predictive biomarkers.

MASH: MEDIATION ANALYSIS OF SURVIVAL OUTCOME AND HIGH-DIMENSIONAL OMICS MEDIATORS WITH APPLICATION TO COMPLEX DISEASES

Environmental exposures such as cigarette smoking influence health outcomes through intermediate molecular phenotypes, such as the methylome, transcriptome, and metabolome. Mediation analysis is a useful tool for investigating the role of potentially high-dimensional intermediate phenotypes in the relationship between environmental exposures and health outcomes. However, little work has been done on mediation analysis when the mediators are high-dimensional and the outcome is a survival endpoint, and none of it has provided a robust measure of total mediation effect. To this end, we propose an estimation procedure for Mediation Analysis of Survival outcome and High-dimensional omics mediators (MASH) based on sure independence screening for putative mediator variable selection and a second-moment-based measure of total mediation effect for survival data analogous to the R 2 measure in a linear model. Extensive simulations showed good performance of MASH in estimating the total mediation effect and identifying true mediators. By applying MASH to the metabolomics data of 1919 subjects in the Framingham Heart Study, we identified five metabolites as mediators of the effect of cigarette smoking on coronary heart disease risk (total mediation effect, 51.1%) and two metabolites as mediators between smoking and risk of cancer (total mediation effect, 50.7%). Application of MASH to a diffuse large B-cell lymphoma genomics data set identified copy-number variations for eight genes as mediators between the baseline International Prognostic Index score and overall survival.

[Non-alcoholic fatty liver disease: aspects of management of a comorbid patient. A review]

Against the background of the rapid increase in the prevalence of obesity worldwide, the frequency of the development of metabolic disorders associated with it is increasing. Non-alcoholic fatty liver disease (NAFLD) is recognized as the main hepatic manifestation of metabolic syndrome. Currently, NAFLD affects about 25-30% of the world's population and, in most cases, is associated with obesity and type 2 diabetes, as well as with increased cardiovascular risk. Diagnosis of NAFLD includes laboratory and instrumental research methods, various non-invasive tests, and the "gold standard" for confirming the diagnosis is a liver biopsy. Due to the greater availability and sufficient information content, ultrasound methods of research come to the fore in the examination of patients at risk. Lifestyle modification remains the cornerstone in the management of such patients, however, given the complex pathogenesis of the disease, treatment of NAFLD may include several therapeutic strategies. In the treatment of comorbid patients, some groups of hypoglycemic drugs are used, including ar-GLP-1, i-NGL-2, pioglitazone, lipid-lowering drugs, drugs for the treatment of obesity. The so-called hepatoprotectors, including essential phospholipids (EFL), have demonstrated their effectiveness in reducing liver damage due to antioxidant, antifibrotic, and lipid-regulating effects. According to a number of studies, EFL helps to reduce the severity of steatosis, improving both objective and subjective manifestations of hepatic dysfunction. In this connection, the guidelines of various countries include EFL group drugs in the protocol of treatment of patients with NAFLD both in monotherapy and in combination with other drugs.

Non-alcoholic fatty liver disease: pathophysiological concepts and treatment options

The prevalence of non-alcoholic fatty liver disease (NAFLD) is continually increasing due to the global obesity epidemic. NAFLD comprises a systemic metabolic disease accompanied frequently by insulin resistance and hepatic and systemic inflammation. Whereas simple hepatic steatosis is the most common disease manifestation, a more progressive disease course characterized by liver fibrosis and inflammation (i.e. non-alcoholic steatohepatitis) is present in 10-20% of affected individuals. NAFLD furthermore progresses in a substantial number of patients towards liver cirrhosis and hepatocellular carcinoma. Whereas this disease now affects almost 25% of the world's population and is mainly observed in obesity and type 2 diabetes, NAFLD also affects lean individuals. Pathophysiology involves lipotoxicity, hepatic immune disturbances accompanied by hepatic insulin resistance, a gut dysbiosis, and commonly hepatic and systemic insulin resistance defining this disorder a prototypic systemic metabolic disorder. Not surprisingly many affected patients have other disease manifestations, and indeed cardiovascular disease, chronic kidney disease, and extrahepatic malignancies are all contributing substantially to patient outcome. Weight loss and lifestyle change reflect the cornerstone of treatment, and several medical treatment options are currently under investigation. The most promising treatment strategies include glucagon-like peptide 1 receptor antagonists, sodium-glucose transporter 2 inhibitors, Fibroblast Growth Factor analogues, Farnesoid X receptor agonists, and peroxisome proliferator-activated receptor agonists. Here, we review epidemiology, pathophysiology, and therapeutic options for NAFLD.

Deciphering the role of aberrant DNA methylation in NAFLD and NASH

The global incidence of nonalcoholic fatty liver disease (NAFLD) is mounting incessantly, and it is emerging as the most frequent cause of chronic and end stage liver disorders. It is the starting point for a range of conditions from simple steatosis to more progressive nonalcoholic steatohepatitis (NASH) and associated hepatocellular carcinoma (HCC). Dysregulation of insulin secretion and dyslipidemia due to obesity and other lifestyle variables are the primary contributors to establishment of NAFLD. Onset and progression of NAFLD is orchestrated by an interplay of metabolic environment with genetic and epigenetic factors. An incompletely understood mechanism of NAFLD progression has greatly hampered the progress in identification of novel prognostic and therapeutic strategies. Emerging evidence suggests altered DNA methylation pattern as a key determinant of NAFLD pathogenesis. Environmental and lifestyle factors can manipulate DNA methylation patterns in a reversible manner, which manifests as changes in gene expression. In this review we attempt to highlight the importance of DNA methylation in establishment and progression of NAFLD. Development of novel diagnostic, prognostic and therapeutic strategies centered around DNA methylation signatures and modifiers has also been explored.

Associations between dietary patterns, FTO genotype and obesity in adults from seven European countries

PURPOSE

High-fat and low-fibre discretionary food intake and FTO genotype are each associated independently with higher risk of obesity. However, few studies have investigated links between obesity and dietary patterns based on discretionary food intake, and the interaction effect of FTO genotype are unknown. Thus, this study aimed to derive dietary patterns based on intake of discretionary foods, saturated fatty acids (SFA) and fibre, and examine cross-sectional associations with BMI and waist circumference (WC), and interaction effects of FTO genotype.

METHODS

Baseline data on 1280 adults from seven European countries were included (the Food4Me study). Dietary intake was estimated from a Food Frequency Questionnaire. Reduced rank regression was used to derive three dietary patterns using response variables of discretionary foods, SFA and fibre density. DNA was extracted from buccal swabs. Anthropometrics were self-measured. Linear regression analyses were used to examine associations between dietary patterns and BMI and WC, with an interaction for FTO genotype.

RESULTS

Dietary pattern 1 (positively correlated with discretionary foods and SFA, and inversely correlated with fibre) was associated with higher BMI (β:0.64; 95% CI 0.44, 0.84) and WC (β:1.58; 95% CI 1.08, 2.07). There was limited evidence dietary pattern 2 (positively correlated with discretionary foods and SFA) and dietary pattern 3 (positively correlated with SFA and fibre) were associated with anthropometrics. FTO risk genotype was associated with higher BMI and WC, with no evidence of a dietary interaction.

CONCLUSIONS

Consuming a dietary pattern low in discretionary foods and high-SFA and low-fibre foods is likely to be important for maintaining a healthy weight, regardless of FTO predisposition to obesity.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01530139. Registered 9 February 2012 https://clinicaltrials.gov/ct2/show/NCT01530139.

Effect of synbiotic yogurt fortified with monk fruit extract on hepatic lipid biomarkers and metabolism in rats with type 2 diabetes

Monk fruit extract (MFE) is widely used as a sweetener in foods. In this study, the effects of the consumption of MFE-sweetened synbiotic yogurt on the lipid biomarkers and metabolism in the livers of type 2 diabetic rats were evaluated. The results revealed that the MFE-sweetened symbiotic yogurt affected the phosphatidylcholines, phosphatidylethanolamines, phosphatidylglycerol, lysophosphatidic acids, lysophosphatidylcholines, lysophosphatidylethanolamines, lysophosphatidylglycerols, lysophosphatidylinositols, lysophosphatidylserines, and fatty acid-hydroxy fatty acids biomarkers in the livers of type 2 diabetic rats. In addition, the consumption of the MFE-sweetened synbiotic yogurt significantly altered 12 hepatic metabolites, which are involved in phenylalanine metabolism, sphingolipid metabolism, bile secretion, and glyoxylate and dicarboxylate metabolism in the liver. Furthermore, a multiomics (metabolomic and transcriptomic) association study revealed that there was a significant correlation between the MFE-sweetened synbiotic yogurt and the metabolites and genes involved in fatty acid biosynthesis, bile secretion, and glyoxylate and dicarboxylate metabolism. The findings of this study will provide new insights on exploring the function of sweeteners for improving type 2 diabetes mellitus liver lipid biomarkers.

Why Do High-Risk Patients Develop or Not Develop Coronary Artery Disease? Metabolic Insights from the CAPIRE Study

Traditional cardiovascular (CV) risk factors (RFs) and coronary artery disease (CAD) do not always show a direct correlation. We investigated the metabolic differences in a cohort of patients with a high CV risk profile who developed, or did not develop, among those enrolled in the Coronary Atherosclerosis in Outlier Subjects: Protective and Novel Individual Risk Factors Evaluation (CAPIRE) study. We studied 112 subjects with a high CV risk profile, subdividing them according to the presence (CAD/High-RFs) or absence of CAD (No-CAD/High-RFs), assessed by computed tomography angiography. The metabolic differences between the two groups were identified by gas chromatography-mass spectrometry. Characteristic patterns and specific metabolites emerged for each of the two phenotypic groups: high concentrations of pyruvic acid, pipecolic acid, p-cresol, 3-aminoisobutyric acid, isoleucine, glyceric acid, lactic acid, sucrose, phosphoric acid, trimethylamine-N-oxide, 3-hydroxy-3-methylglutaric acid, erythritol, 3-hydroxybutyric acid, glucose, leucine, and glutamic acid; and low concentrations of cholesterol, hypoxanthine, glycerol-3-P, and cysteine in the CAD/High-RFs group vs the No-CAD/High-RFs group. Our results show the existence of different metabolic profiles between patients who develop CAD and those who do not, despite comparable high CV risk profiles. A specific cluster of metabolites, rather than a single marker, appears to be able to identify novel predisposing or protective mechanisms towards CAD beyond classic CVRFs.

Pharmacological significance of extra-oral taste receptors

It has recently been shown that taste receptors, in addition to being present in the oral cavity, exist in various extra-oral organs and tissues such as the thyroid, lungs, skin, stomach, intestines, and pancreas. Although their physiological function is not yet fully understood, it appears that they can help regulate the body's homeostasis and provide an additional defense function against pathogens. Since the vast majority of drugs are bitter, the greatest pharmacological interest is in the bitter taste receptors. In this review, we describe how bitter taste 2 receptors (TAS2Rs) induce bronchodilation and mucociliary clearance in the airways, muscle relaxation in various tissues, inhibition of thyroid stimulating hormone (TSH) in thyrocytes, and release of glucagon-like peptide-1 (GLP-1) and ghrelin in the digestive system. In fact, substances such as dextromethorphan, chloroquine, methimazole and probably glimepiride, being agonists of TAS2Rs, lead to these effects. TAS2Rs and taste 1 receptors (TAS1R2/3) are G protein-coupled receptors (GPCR). TAS1R2/3 are responsible for sweet taste perception and may induce GLP-1 release and insulin secretion. Umami taste receptors, belonging to the same superfamily of receptors, perform a similar function with regard to insulin. The sour and salty taste receptors work in a similar way, both being channel receptors sensitive to amiloride. Finally, gene-protein coupled receptor 40 (GPR40) and GPR120 for fatty taste perception are also protein-coupled receptors and may induce GLP-1 secretion and insulin release, similar to those of other receptors belonging to the same superfamily.

Non-alcoholic fatty liver disease: A patient guideline

This patient guideline is intended for all patients at risk of or living with non-alcoholic fatty liver disease (NAFLD). NAFLD is the most frequent chronic liver disease worldwide and comes with a high disease burden. Yet, there is a lot of unawareness. Furthermore, many aspects of the disease are still to be unravelled, which has an important impact on the information that is given (or not) to patients. Its management requires a close interaction between patients and their many healthcare providers. It is important for patients to develop a full understanding of NAFLD in order to enable them to take an active role in their disease management. This guide summarises the current knowledge relevant to NAFLD and its management. It has been developed by patients, patient representatives, clinicians and scientists and is based on current scientific recommendations, intended to support patients in making informed decisions.

Effects of High-Fat and High-Fat/High-Sucrose Diet-Induced Obesity on PVAT Modulation of Vascular Function in Male and Female Mice

Increased adiposity in perivascular adipose tissue (PVAT) has been related to vascular dysfunction. High-fat (HF) diet-induced obesity models are often used to analyze the translational impact of obesity, but differences in sex and Western diet type complicate comparisons between studies. The role of PVAT was investigated in small mesenteric arteries (SMAs) of male and female mice fed a HF or a HF plus high-sucrose (HF + HS) diet for 3 or 5 months and compared them to age/sex-matched mice fed a chow diet. Vascular responses of SMAs without (PVAT-) or with PVAT (PVAT+) were evaluated. HF and HF + HS diets increased body weight, adiposity, and fasting glucose and insulin levels without affecting blood pressure and circulating adiponectin levels in both sexes. HF or HF + HS diet impaired PVAT anticontractile effects in SMAs from females but not males. PVAT-mediated endothelial dysfunction in SMAs from female mice after 3 months of a HF + HS diet, whereas in males, this effect was observed only after 5 months of HF + HS diet. However, PVAT did not impact acetylcholine-induced relaxation in SMAs from both sexes fed HF diet. The findings suggest that the addition of sucrose to a HF diet accelerates PVAT dysfunction in both sexes. PVAT dysfunction in response to both diets was observed early in females compared to age-matched males suggesting a susceptibility of the female sex to PVAT-mediated vascular complications in the setting of obesity. The data illustrate the importance of the duration and composition of obesogenic diets for investigating sex-specific treatments and pharmacological targets for obesity-induced vascular complications.

Placental insufficiency induces a sexually dimorphic response in the expression of cardiac growth and metabolic signalling molecules upon exposure to a postnatal western diet in guinea pigs

There is a strong relationship between low birth weight (LBW) and an increased risk of developing cardiovascular disease (CVD). In postnatal life, LBW offspring are becoming more commonly exposed to the additional independent CVD risk factors, such as an obesogenic diet. However, how an already detrimentally programmed LBW myocardium responds to a secondary insult, such as an obesogenic diet (western diet; WD), during postnatal life is ill defined. Herein, we aimed to determine in a pre-clinical guinea pig model of CVD, both the independent and interactive effects of LBW and a postnatal WD on the molecular pathways that regulate cardiac growth and metabolism. Uterine artery ablation was used to induce placental insufficiency (PI) in pregnant guinea pigs to generate LBW offspring. Normal birth weight (NBW) and LBW offspring were weaned onto either a Control diet or WD. At ˜145 days after birth (young adulthood), male and female offspring were humanely killed, the heart weighed and left ventricle tissue collected. The mRNA expression of signalling molecules involved in a pathological hypertrophic and fibrotic response was increased in the myocardium of LBW male, but not female offspring, fed a WD as was the mRNA expression of transcription factors involved in fatty acid oxidation. The mRNA expression of glucose transporters was downregulated by LBW and WD in male, but not female hearts. This study has highlighted a sexually dimorphic cardiac pathological hypertrophic and fibrotic response to the secondary insult of postnatal WD consumption in LBW offspring.

Sugar Fructose Triggers Gut Dysbiosis and Metabolic Inflammation with Cardiac Arrhythmogenesis

Fructose is a main dietary sugar involved in the excess sugar intake-mediated progression of cardiovascular diseases and cardiac arrhythmias. Chronic intake of fructose has been the focus on the possible contributor to the metabolic diseases and cardiac inflammation. Recently, the small intestine was identified to be a major organ in fructose metabolism. The overconsumption of fructose induces dysbiosis of the gut microbiota, which, in turn, increases intestinal permeability and activates host inflammation. Endotoxins and metabolites of the gut microbiota, such as lipopolysaccharide, trimethylamine N-oxide, and short-chain fatty acids, also influence the host inflammation and cardiac biofunctions. Thus, high-fructose diets cause heart-gut axis disorders that promote cardiac arrhythmia. Understanding how gut microbiota dysbiosis-mediated inflammation influences the pathogenesis of cardiac arrhythmia may provide mechanisms for cardiac arrhythmogenesis. This narrative review updates our current understanding of the roles of excessive intake of fructose on the heart-gut axis and proposes potential strategies for inflammation-associated cardiac vascular diseases.

Personalised nutrition advice reduces intake of discretionary foods and beverages: findings from the Food4Me randomised controlled trial

BACKGROUND

The effect of personalised nutrition advice on discretionary foods intake is unknown. To date, two national classifications for discretionary foods have been derived. This study examined changes in intake of discretionary foods and beverages following a personalised nutrition intervention using these two classifications.

METHODS

Participants were recruited into a 6-month RCT across seven European countries (Food4Me) and were randomised to receive generalised dietary advice (control) or one of three levels of personalised nutrition advice (based on diet [L1], phenotype [L2] and genotype [L3]). Dietary intake was derived from an FFQ. An analysis of covariance was used to determine intervention effects at month 6 between personalised nutrition (overall and by levels) and control on i) percentage energy from discretionary items and ii) percentage contribution of total fat, SFA, total sugars and salt to discretionary intake, defined by Food Standards Scotland (FSS) and Australian Dietary Guidelines (ADG) classifications.

RESULTS

Of the 1607 adults at baseline, n = 1270 (57% female) completed the intervention. Percentage sugars from FSS discretionary items was lower in personalised nutrition vs control (19.0 ± 0.37 vs 21.1 ± 0.65; P = 0.005). Percentage energy (31.2 ± 0.59 vs 32.7 ± 0.59; P = 0.031), percentage total fat (31.5 ± 0.37 vs 33.3 ± 0.65; P = 0.021), SFA (36.0 ± 0.43 vs 37.8 ± 0.75; P = 0.034) and sugars (31.7 ± 0.44 vs 34.7 ± 0.78; P < 0.001) from ADG discretionary items were lower in personalised nutrition vs control. There were greater reductions in ADG percentage energy and percentage total fat, SFA and salt for those randomised to L3 vs L2.

CONCLUSIONS

Compared with generalised dietary advice, personalised nutrition advice achieved greater reductions in discretionary foods intake when the classification included all foods high in fat, added sugars and salt. Future personalised nutrition approaches may be used to target intake of discretionary foods.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01530139 . Registered 9 February 2012.

The Mediator complex kinase module is necessary for fructose regulation of liver glycogen levels through induction of glucose-6-phosphatase catalytic subunit (G6pc)

OBJECTIVE

Liver glycogen levels are dynamic and highly regulated by nutrient availability as the levels decrease during fasting and are restored during the feeding cycle. However, feeding in the presence of fructose in water suppresses glycogen accumulation in the liver by upregulating the expression of the glucose-6-phosphatase catalytic subunit (G6pc) gene, although the exact mechanism is unknown. We generated liver-specific knockout MED13 mice that lacked the transcriptional Mediator complex kinase module to examine its effect on the transcriptional activation of inducible target gene expression, such as the ChREBP- and FOXO1-dependent control of the G6pc gene promoter.

METHODS

The relative changes in liver expression of lipogenic and gluconeogenic genes as well as glycogen levels were examined in response to feeding standard low-fat laboratory chow supplemented with water or water containing sucrose or fructose in control (Med13fl/fl) and liver-specific MED13 knockout (MED13-LKO) mice.

RESULTS

Although MED13 deficiency had no significant effect on constitutive gene expression, all the dietary inducible gene transcripts were significantly reduced despite the unchanged insulin sensitivity in the MED13-LKO mice compared to that in the control mice. G6pc gene transcription displayed the most significant difference between the Med13 fl/fl and MED13-LKO mice, particularly when fed fructose. Following fasting that depleted liver glycogen, feeding induced the restoration of glycogen levels except in the presence of fructose. MED13 deficiency rescued the glycogen accumulation defect in the presence of fructose. This resulted from the suppression of G6pc expression and thus G6PC enzymatic activity. Among two transcriptional factors that regulate G6pc gene expression, FOXO1 binding to the G6pc promoter was not affected, whereas ChREBP binding was dramatically reduced in MED13-LKO hepatocytes. In addition, there was a marked suppression of FOXO1 and ChREBP-β transcriptional activities in MED13-LKO hepatocytes.

CONCLUSIONS

Taken together, our data suggest that the kinase module of the Mediator complex is necessary for the transcriptional activation of metabolic genes such as G6pc and has an important role in regulating glycogen levels in the liver through altering transcription factor binding and activity at the G6pc promoter.

High sucrose diet-induced dysbiosis of gut microbiota promotes fatty liver and hyperlipidemia in rats

Excess sucrose intake has been found to be a major factor in the development of metabolic syndrome, especially in promoting nonalcoholic fatty liver disease. The excess fructose is believed to targets the liver to promote de novo lipogenesis, as described in major biochemistry textbooks. On the contrary, in this study, we explored the possible involvement of gut microbiota in excess sucrose-induced lipid metabolic disorders, to validate a novel mechanism by which excess sucrose causes hepatic lipid metabolic disorders via alterations to the gut microbial community structure. Wistar male rats were fed either a control starch diet or a high-sucrose diet for 4 weeks. Half of the rats in each group were treated with an antibiotic cocktail delivered via drinking water for the entire experimental period. After 4 weeks, rats fed with the high-sucrose diet showed symptoms of fatty liver and hyperlipidemia. The architecture of cecal microbiota was altered in rats fed with high-sucrose diet as compared to the control group, with traits including increased ratios of the phyla Bacteroidetes/Firmicutes, reduced α-diversity, and diurnal oscillations changes. Antibiotic administration rescued high-sucrose diet-induced lipid accumulation in the both blood and liver. Levels of two microbial metabolites, formate and butyrate, were reduced in rats fed with the high-sucrose diet. These volatile short-chain fatty acids might be responsible for the sucrose-induced fatty liver and hyperlipidemia. Our results indicate that changes in the gut microbiota induced by a high-sucrose diet would promote the development of nonalcoholic fatty liver disease via its metabolites, such as short-chain fatty acids.

The effect of paleolithic diet on glucose metabolism and lipid profile among patients with metabolic disorders: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Several randomized clinical trials (RCTs) have investigated the effects of the Paleolithic diet (PD) in adult patients suffering from metabolic disorders. However, the results of these RCTs are conflicting. Therefore, we conducted a systematic review and meta-analysis to assess the effects of the PD in patients with metabolic disorders.

METHODS

We searched the PubMed/Medline, Scopus, Cochrane Databases, Google Scholar, Web of Science, and Embase databases up to June, 2020. The data were pooled using a random-effects model. From the eligible publications, 10 articles were selected for inclusion in this systematic review and meta-analysis. The meta-analysis was performed using a random-effects model. The heterogeneity was determined using the I² statistics and the Cochrane Q test.

RESULTS

The pooled results from the random-effects model showed a significant reduction of the homeostatic model assessment of insulin resistance (HOMA-IR) (weighted mean difference, WMD: -0.39, 95% CI: -0.70, -0.08), fasting insulin (WMD: -12.17 μU/mL, 95% CI: -24.26, -0.08), total cholesterol (WMD: -0.32 mmol/l, 95% CI: -0.49, -0.15), triglycerides (WMD: -0.29 mmol/L, 95% CI: -0.42, -0.16), low-density lipoprotein cholesterol (WMD: -0.35 mmol/L, 95% CI: -0.67, -0.03), blood pressure (BP)(WMD - 5.89 mmHg; 95% CI - 9.973 to - 1.86 for the systolic BP and WMD - 4.01 mmHg; 95% CI - 6.21 to - 1.80 for the diastolic BP values) and C-reactive protein (CRP) levels (WMD: -0.84, mg/L, 95% CI: -1.62, -0.06) in the PD group versus control group.

CONCLUSIONS

Our findings provide better insights into the effect of the PD on the modulation of the glucose and lipid metabolism factors in patients with metabolic disorders, providing comprehensive information for the development of future RCTs with a high quality design.

Effect of feeding type 2 diabetes mellitus rats with synbiotic yogurt sweetened with monk fruit extract on serum lipid levels and hepatic AMPK (5' adenosine monophosphate-activated protein kinase) signaling pathway

Monk fruit extract (MFE) is a natural sweetener that has been used as an ingredient of food and pharmaceutical products. The effects of feeding synbiotic yogurt fortified with MFE to rats with type 2 diabetes induced by high-fat diet and streptozotocin on serum lipid levels and hepatic AMPK signaling pathway were evaluated. Results showed that oral administration of the synbiotic yogurt fortified with MFE could improve serum lipid levels, respiratory exchange rate, and heat level in type 2 diabetic rats. Transcriptome analysis showed that synbiotic yogurt fortified with MFE may affect the expression of genes involved in binding, catalytic activity, and transporter activity. The Kyoto Encyclopedia of Genes and Genomes enrichment analysis revealed that these differentially expressed genes were related to AMPK signaling pathway, linoleic acid metabolism, and α-linolenic acid metabolism. Western blotting confirmed that synbiotic yogurt fortified with MFE could activate AMPK signaling and improve the protein level of the hepatic gluconeogenic enzyme G6Pase in diabetic rats. The results indicated that MFE could be a novel sweetener for functional yogurt and related products.

Physiochemical, rheological, microstructural, and antioxidant properties of yogurt using monk fruit extract as a sweetener

A yogurt using monk fruit extract (MFE) as a sweetener was developed. The aim of the study was to investigate the viability of using MFE to develop sweetened yogurts without the calories of added sugar. The physiochemical, rheological, microstructural, and antioxidant properties of yogurt were studied. Rheological results showed that MFE affected the yogurt fermentation process and its rheological properties. Yogurt sweetened with MFE had similar microstructural properties to yogurt sweetened with sucrose. Yogurt with MFE showed higher levels of gly-pro-p-nitroanilide and dipeptidyl peptidase IV inhibitory activities, 1,1-diphenyl-2-picrylhydrazyl radical scavenging capacity, α-glucosidase inhibitory activities, and superoxide anion radical scavenging ability compared with other yogurt samples. Results indicated that MFE could be a novel sweetener and a food antioxidant for functional yogurt and related products.

Concurrent and Delayed Behavioral and Monoamine Alterations by Excessive Sucrose Intake in Juvenile Mice

Our daily diet in the modern society has substantially changed from that in the ancient past. Consequently, new disorders associated with such dietary changes have emerged. For instance, excessive intake of compounds, such as sucrose (SUC), has recently been reported to induce pathological neuronal changes in adults, such as food addiction. It is still largely unclear whether and how excessive intake of such nutrients affects neurodevelopment. We investigated changes in behavior and monoamine signaling caused by excessive, semi-chronic intake of SUC and the non-caloric sweetener saccharin (SAC) in juvenile mice, using a battery of behavioral tests and high-performance liquid chromatography. Both SUC and SAC intake induced behavioral alterations such as altered amphetamine responses, sucrose preference, stress response, and anxiety, but did not affect social behavior and cognitive function such as attention in juvenile and adult mice. Moreover, SUC and SAC also altered dopamine and serotonin transmission in mesocorticolimbic regions. Some of these behavioral and neural alterations were triggered by SAC and SUC but others were distinct between the treatments. Moreover, alterations induced in juvenile mice were also different from those observed in adult mice. These results suggest that excessive SUC and SAC intake during the juvenile period may cause concurrent and delayed behavioral and monoamine signaling alterations in juvenile and adult mice, respectively.

Biochemical, Anthropometric, and Physiological Responses to Carbohydrate-Restricted Diets Versus a Low-Fat Diet in Obese Adults: A Randomized Crossover Trial

Some research supports high-fat carbohydrate (CHO)-restricted diets for weight and fat loss and improvement of cardiovascular disease risk factors. To test this, a randomized crossover study was designed. Subjects (17 obese men and women [BMI: 30-38 kg/m²]) were fed three diets (supplying 1600 and 2200 kilocalories (kcal)/day for women and men, respectively) for 4 weeks, with each trial separated by 4-week washout periods. One CHO-restricted diet (10% CHO, 50% fat, and 40% protein content) was rich in plant foods and mushrooms, while the other CHO-restricted diet included more animal foods (10% CHO, 60% fat, and 30% protein content). The third diet was lower in fat and protein content (LF) and higher in CHOs (61% CHO, 21% fat, and 18% protein content). Body composition was assessed through hydrostatic weighing before and after each diet trial. Fasting blood samples were collected weekly for analysis of hormones and lipids. Data were analyzed through repeated measures analysis of variance with post hoc paired comparison t-tests. Weight and fat loss were similar (P > .05) among trials. Subjects lost lean mass (P < .05) during CHO-restricted trials, but not in the LF trial. Insulin concentrations decreased (P < .05) during the CHO-restricted trial and tended (P = .05) to decrease during the LF trial. Total cholesterol decreased (P < .05) for all trials; however, high-density lipoprotein cholesterol decreased (P < .05) and triacylglycerols were higher (P < .05) following the LF trial. Taken together, energy restriction regardless of diet composition promoted similar weight loss; however, CHO-restricted diets based on either plants/mushrooms or animal foods elicited a more beneficial lipid-altering effect in comparison with the LF diet.

Effects of a synbiotic yogurt using monk fruit extract as sweetener on glucose regulation and gut microbiota in rats with type 2 diabetes mellitus

We developed a synbiotic yogurt using monk fruit extract as a sweetener and investigated the effects of feeding the yogurt to rats with type 2 diabetes induced by streptozotocin and a high-fat diet. The rats fed the synbiotic yogurt showed greater blood glucose regulation and a significant decrease in insulin resistance and glycosylated hemoglobin compared with rats fed yogurt sweetened with sucrose, and they showed a remarkable improvement in short-chain fatty acid levels and gut microbiota status. Liver and kidney damage was also ameliorated in the rats fed the synbiotic yogurt. Immunohistochemistry analysis showed that the synbiotic yogurt inhibited β-cell loss compared with the control yogurt. Consuming the synbiotic yogurt helped to restore the islets of Langerhans. Our results indicated that monk fruit extract may be a good alternative to sucrose for synbiotic yogurt products in people with type 2 diabetes to delay the progression of diabetes and associated complications.

Saccharum officinarum molasses adversely alters reproductive functions in male wistar rats

The widely reported anti-androgenic effects of refined sugar led to the exploration of safer alternatives. Saccharum officinarum molasses (SOM), a byproduct of sugar processing is gaining popularity as a substitute. This study investigated the effects of SOM and compared them to those of refined sugar on male reproductive functions. Blackstrap® Saccharum officinarum molasses were subjected to phytochemical screening and proximate analysis and fractionated to obtain methanol (SOMMF) and aqueous (SOMAqF) fractions. Twelve groups (n = 5) of adult male Wistar rats received distilled water (Control); 0.8, 2.5, 7.9 g/kg SOM; 0.0064 g/kg sugar (Dangote®); 0.0064 g/kg sugar+7.9 g/kg SOM; 1.0, 3.2, 10.0 g/kg SOMMF and 0.6, 2.0, 6.4 g/kg SOMAqF, respectively. Administrations were done daily by oral gavage for eight weeks. Sperm profile and testicular and epididymal histology were assessed using microscopy. Serum testosterone was quantified using ELISA. Testicular malondialdehyde (MDA) was assayed by spectrophotometry. Data were analyzed using ANOVA at p < 0.05 significance. Sperm count and viability reduced with 7.9 g/kg SOM, Sugar, 3.2 and 10.0 g/kg SOMMF, 2.0 and 6.4 g/kg SOMAqF. Abnormal sperms increased with 7.9 g/kg SOM, Sugar, 2.0 and 6.4 g/kg SOMAqF. Testosterone level reduced with 6.4 g/kg SOMAqF. Testicular MDA increased with SOM, 3.2 and 10.0 g/kg SOMMF and 6.4 g/kg SOMAqF. Seminiferous tubules and epididymal ducts of 7.9 g/kg SOM, Sugar and SOMAqF-treated rats showed anomalies. Saccharum officinarum molasses altered testicular and epididymal integrity via lipid peroxidation, thus reducing sperm quality and androgen levels in male Wistar rats.

The role of nutrition in non-alcoholic fatty liver disease: Pathophysiology and management

A healthy diet together with physical activity could induce weight loss and control the progression of non-alcoholic fatty liver disease (NAFLD). However, the composition of diet has not been clearly established. Macronutrients such as saturated fatty acids (SFA), trans-fats, simple sugars and animal proteins have a harmful effect on the liver. On the other hand, monounsaturated fats (MUFAs), polyunsaturated (PUFAs) omega-3-fats, plant-based proteins and dietary fibres are considered to be beneficial to the liver. The impact of specific micronutrients is less well-known. Nutrients are part of the food we eat. Food makes up our meals, which compose our dietary patterns. Non-alcoholic fatty liver disease patients usually follow Western diets which are rich in soda, frozen junk food, juice, red meat, lard, processed meats, whole fat dairy foods, fatty snack foods, take-away foods, cakes and biscuits and poor in cereals, whole grains, fruit, vegetables, extra virgin olive oil (EVOO) and fish. On the other hand, the Mediterranean diet (MD) is beneficial for NAFLD even when it is iso-caloric or there are no changes in body weight. A new approach, called 'nutritional geometry' considers the importance of integrating nutrition, animals and the environment. The goal of this approach is to combine nutrients and foods in a model to understand how food components interact to regulate the properties of diets affecting health and disease. The use of algorithms developed by artificial intelligence (AI) to create a personalized diet for patients can provide customized nutritional counselling to prevent and treat NAFLD.

Oxidative Stress Induced DNA Damage and Reproductive Toxicity in Male Albino Mice Orally Exposed to Sorbitol

In this study, the potential DNA damage and reproductive toxicity of sorbitol was investigated using bone marrow micronucleus (MN), sperm morphology, and sperm count in mice. Five doses of 90, 45, 20, 10 and 1 mg/kg/day, defined by allometry, and approximately corresponding to 1.5g, 750mg, 330mg, 165mg and 16mg of sorbitol daily consumption by a 70kg human, respectively, were used. MN analysis showed a dose-dependent induction of micronucleated polychromatic erythrocytes and other nuclear abnormalities across the treatment groups. Assessment of sperm shape showed a significant (p < 0.05) increase in sperm abnormalities with significant (p < 0.05) decrease in mean sperm count in treated groups. The result of the oxidative stress biomarkers showed induction of significant (p < 0.05) increase in liver catalase, MDA and serum ALT and AST activities with concomitant decrease in SOD activities in exposed mice. A significant increase in weight of exposed mice were recorded when compared with the negative control. The results of this study showed the genotoxicity and reproductive effects of sorbitol.

The Mismatch of Nutrition and Lifestyle Beliefs and Actions Among Physicians: A Wake-Up Call

Background. There is a notable lack of education on nutrition and physical activity guidelines in medical schools and postgraduate training. The purpose of this study is to assess the nutrition and exercise knowledge and personal health behaviors of physicians in the Department of Medicine at a large academic center. Methods. We conducted a survey study in the Department of Medicine at the University of Florida in 2018. The survey instrument included questions on demographics, medical comorbidities, baseline perception of health and fitness, and knowledge of nutrition concepts. The Duke Activity Status Index assessed activity/functional capacity and the validated 14-point Mediterranean Diet Survey evaluated dietary preferences. Data were analyzed using descriptive statistics and the χ² test was used to perform comparisons between groups. Statistical significance was determined at P < .05. Results. Out of 331 eligible physicians, 303 (92%) participated in the study. While all respondents agreed that eating well is important for health, less than a fourth followed facets of a plant-based Mediterranean diet. Only 25% correctly identified the American Heart Association recommended number of fruit and vegetable servings per day and fewer still (20%) were aware of the recommended daily added sugar limit for adults. Forty-six percent knew the American Heart Association physical activity recommendations and 52% reported more than 3 hours of personal weekly exercise. Reported fruit and vegetable consumption correlated with perceived level of importance of nutrition as well as nutrition knowledge. Forty percent of physicians (102/253) who considered nutrition at least somewhat important reported a minimum of 2 vegetable and 3 fruit servings per day, compared with 7% (3/44) of those who considered nutrition less important ("neutral," "not important," or "important, but I don't have the time to focus on it right now"; P < .0001). Conclusions. This study highlights the need for significant improvement in education of physicians about nutrition and physical activity and need for physicians to focus on good personal health behaviors, which may potentially improve with better education.

Effects of a Paleolithic Diet on Cardiovascular Disease Risk Factors: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

There is some evidence supporting the beneficial effects of a Paleolithic Diet (PD) on cardiovascular disease risk factors. This diet advises consuming lean meat, fish, vegetables, fruits, and nuts and avoiding intake of grains, dairy products, processed foods, and added sugar and salt. This study was performed to assess the effects of a PD on cardiovascular disease risk factors including anthropometric indexes, lipid profile, blood pressure, and inflammatory markers using data from randomized controlled trials. A comprehensive search was performed in the PubMed, Scopus, ISI Web of Science, and Google Scholar databases up to August, 2018. A meta-analysis was performed using a random-effects model to estimate the pooled effect size. Meta-analysis of 8 eligible studies revealed that a PD significantly reduced body weight [weighted mean difference (WMD) = -2.17 kg; 95% CI: -3.48, -0.87 kg], waist circumference (WMD = -2.90 cm; 95% CI: -4.51, -1.28 cm), body mass index (in kg/m2) (WMD = -1.15; 95% CI: -1.68, -0.62), body fat percentage (WMD = -1.38%; 95% CI: -2.08%, -0.67%), systolic (WMD = -4.24 mm Hg; 95% CI: -7.11, -1.38 mm Hg) and diastolic (WMD = -2.95 mm Hg; 95% CI: -4.72, -1.18 mm Hg) blood pressure, and circulating concentrations of total cholesterol (WMD = -0.22 mg/dL; 95% CI: -0.42, -0.03 mg/dL), TGs (WMD = -0.23 mg/dL; 95% CI: -0.46, -0.01 mg/dL), LDL cholesterol (WMD = -0.13 mg/dL; 95% CI: -0.25, -0.01 mg/dL), and C-reactive protein (CRP) (WMD = -0.41 mg/L; 95% CI: -0.81, -0.008 mg/L) and also significantly increased HDL cholesterol (WMD = 0.05 mg/dL; 95% CI: 0.005, 0.10 mg/dL). However, sensitivity analysis revealed that the overall effects of a PD on lipid profile, blood pressure, and circulating CRP concentrations were significantly influenced by removing some studies, hence the results must be interpreted with caution. Although the present meta-analysis revealed that a PD has favorable effects on cardiovascular disease risk factors, the evidence is not conclusive and more well-designed trials are still needed.

Understanding Barriers and Enablers to State Action on Salt: Analysis of Stakeholder Perceptions of the VicHealth Salt Reduction Partnership

The Victorian Salt Reduction Partnership (VicSalt Partnership) was launched in 2015, bringing together health and research organisations to develop an action plan for salt reduction interventions at a state level. A comprehensive evaluation was designed to assess the impact of the resulting four-year intervention strategy. As part of the process evaluation, semi-structured interviews were undertaken with stakeholders in March⁻May 2017, to understand perceived barriers and enablers to effective strategy implementation. Data were coded in relation to the key topic areas of the interviews with an inductive method used to analyse themes within topics. Seventeen stakeholders were contacted, 14 completed an interview; five from state government or statutory agencies, four from non-government funded organisations, four from research organisations and one from the food industry. Twelve were members of the VicSalt Partnership and two were informal collaborators. Most stakeholders viewed the VicSalt Partnership as a positive example of working collaboratively, and said this was essential for raising awareness of the importance of salt reduction with consumers, the food industry, and the government. Challenges relating to engaging the food industry and federal government through a state-led initiative were identified. New approaches to overcome this, such as forming clear "asks" to government and committing industry to "pledges" on reformulation were suggested. Stakeholder interviews and qualitative analysis have provided a range of important insights into barriers and enablers, many of which have already been used to strengthen intervention implementation. The evaluation of the VicSalt Partnership is ongoing and the program is expected to provide a wealth of lessons for state-led interventions to reduce salt intake in Australia and globally.

Sympathetic Neuronal Activation Triggers Myeloid Progenitor Proliferation and Differentiation

There is a growing body of research on the neural control of immunity and inflammation. However, it is not known whether the nervous system can regulate the production of inflammatory myeloid cells from hematopoietic progenitor cells in disease conditions. Myeloid cell numbers in diabetic patients were strongly correlated with plasma concentrations of norepinephrine, suggesting the role of sympathetic neuronal activation in myeloid cell production. The spleens of diabetic patients and mice contained higher numbers of tyrosine hydroxylase (TH)-expressing leukocytes that produced catecholamines. Granulocyte macrophage progenitors (GMPs) expressed the β2 adrenergic receptor, a target of catecholamines. Ablation of splenic sympathetic neuronal signaling using surgical, chemical, and genetic approaches diminished GMP proliferation and myeloid cell development. Finally, mice lacking TH-producing leukocytes had reduced GMP proliferation, resulting in diminished myelopoiesis. Taken together, our study demonstrates that catecholamines produced by leukocytes and sympathetic nerve termini promote GMP proliferation and myeloid cell development.

Sugar intake in Sudanese individuals was associated with some features of the metabolic syndrome: Population based study

AIM

The aim of this study was to assess the level of sugar intake among Sudanese individuals.

MATERIALS AND METHODS

A cross-sectional study with 323 participants. Respondents were grouped by the total intake of added sugars into two groups, one group with sugar intake more than 200 calories per day and other group with sugar intake less than 200 calories per day. Demographic data were collected with anthropometric measurements like body mass index (BMI) and waist circumference. Chi square, T-Tests and stepwise logistic regression were used (a p-value <0.05 was considered significant).

RESULTS

High sugar intake was noted among 74.6% participants and among overweight, normal weight, followed by obese (p<0.015) and then individuals with diabetes and hypertension (p <0.000 and 0.038 respectively).High sugar intake was also associated with abdominal obesity (p<0.016), mean age of 33 years old (p<0.00) and being married and single(p<0.003). Stepwise logistic regression showed diabetes and BMI<25 were absolute predictors for sugar consumption with p value of 0.001 and 0.039 respectively. Individuals with diabetes have more than five times probability to consume large amount of sugar (Odd ratio 5.6), while those with BMI<25 have two times risk of consuming more sugar compared to those with BMI>25 group (Odd ratio 2.1).

CONCLUSION

A large percentage of Sudanese population uses a high amount of sugar. High sugar intake was associated with normal weight, overweight, abdominal obesity, diabetes and hypertension. Absolute predictors of high sugar intake were diabetes and normal body weight.

Macronutrient Composition and Food Form Affect Glucose and Insulin Responses in Humans

Glycaemic index (GI) is used as an indicator to guide consumers in making healthier food choices. We compared the GI, insulin index (II), and the area under the curve for blood glucose and insulin as glucose (GR) and insulin responses (IR) of a newly developed liquid nutritional formula with one commercially available liquid product with different types of carbohydrates. We then evaluated the glucose and insulin responses of two test foods with comparable energy density and protein percentage but presented in different food forms (liquid vs. solid). Fourteen healthy women participated in the study. GI, II, GR, and IR were assessed after (independent) consumption of two liquid products and a solid breakfast meal. The two liquid foods showed comparable GI, whilst the liquid form appeared to produce lower median GI (25 vs. 54), and II (52 vs. 98) values compared to the solid breakfast (p < 0.02). The median GR and IR for solid breakfast were respectively 44% and 45% higher compared to the liquid product (p < 0.02). Liquid formulas with different carbohydrate qualities produced comparable glucose responses, while foods with comparable energy density and protein percentage but different food form elicited differential effects on GI, II, GR, and IR. Nutrient quality and food form need to be taken into consideration when developing low GI products to manage glycaemic responses.

Comparison of the effect of omega-3 supplements and fresh fish on lipid profile: a randomized, open-labeled trial

Background

Dietary fish is a rich source of Omega-3 poly-unsaturated fatty acids (PUFAs). These compounds may have protective effect against cardiovascular events possibly by modifying lipid profiles. Consequently, fish oil supplements are produced commercially to complement low fish intake. It is not clear if both interventions have similar effects. The aim of this trial was to compare the anti-hyperlipidemic effect of omega3 fatty acid supplements with fresh fish.

Method

A total of 106 patients with hyperlipidemia were randomized. One group received 2 g/day of omega-3 capsules for a period of 8 weeks and the other group received a mean of 250 g trout fish twice weekly (for dinner and lunch) for the same time period. The effects of these diets on the lipid profile after the intervention were compared between the two groups.

Results

Data from 48 patients in fish oil group and 47 patients from fish group was used for final analysis. In both groups, total cholesterol, non-HDL cholesterol, triglyceride (TG) levels, and Castelli I index (total cholesterol/HDL ratio) were reduced significantly following the treatment; however, dietary-fish intake had a more pronounced effect (−85.08 ± 74.82 vs. −30.75 ± 89.00, P < 0.001; 75.06 ± 35.43 vs. −16.93 ± 40.21, P < 0.001; −66.55 ± 30.79 vs. −12.7 ± 35.48, P = 0.003; and −0.77 ± 1.39 vs. −3.02 ± 1.85, P < 0.001; respectively). HDL level was increased in both groups with a higher effect in dietary fish group (4.47 ± 7.83 vs. 8.51 ± 8.79, P = 0.022). Atherogenic (Log [TG/HDL ratio]) and Castelli II (LDL/HDL ratio) indices did not change in fish oil group while were reduced significantly by fresh fish consumption (−0.04 ± 0.27 vs. −0.26 ± 0.17, P < 0.001; and 0.15 ± 0.7 vs. -1.32 ± 1.15, P < 0.001, respectively). LDL level was increased in the supplementation group, while it was significantly reduced in the dietary-fish group (+18.7 ± 24.97 vs. −22.75 ± 27.28, P < 0.001).

Conclusion

Consumption of fresh fish seems to be superior in positively modifying the lipid profiles which may have important translations in the occurrence of cardiovascular events.

Meeting UK dietary recommendations is associated with higher estimated consumer food costs: an analysis using the National Diet and Nutrition Survey and consumer expenditure data, 2008-2012

OBJECTIVE

To test whether diets achieving recommendations from the UK's Scientific Advisory Committee on Nutrition (SACN) were associated with higher monetary costs in a nationally representative sample of UK adults.

DESIGN

A cross-sectional study linking 4 d diet diaries in the National Diet and Nutrition Survey (NDNS) to contemporaneous food price data from a market research firm. The monetary cost of diets was assessed in relation to whether or not they met eight food- and nutrient-based recommendations from SACN. Regression models adjusted for potential confounding factors. The primary outcome measure was individual dietary cost per day and per 2000 kcal (8368 kJ).

SETTING

UK.

SUBJECTS

Adults (n 2045) sampled between 2008 and 2012 in the NDNS.

RESULTS

On an isoenergetic basis, diets that met the recommendations for fruit and vegetables, oily fish, non-milk extrinsic sugars, fat, saturated fat and salt were estimated to be between 3 and 17 % more expensive. Diets meeting the recommendation for red and processed meats were 4 % less expensive, while meeting the recommendation for fibre was cost-neutral. Meeting multiple targets was also associated with higher costs; on average, diets meeting six or more SACN recommendations were estimated to be 29 % more costly than isoenergetic diets that met no recommendations.

CONCLUSIONS

Food costs may be a population-level barrier limiting the adoption of dietary recommendations in the UK. Future research should focus on identifying systems- and individual-level strategies to enable consumers achieve dietary recommendations without increasing food costs. Such strategies may improve the uptake of healthy eating in the population.

Bayesian analysis of multi-type recurrent events and dependent termination with nonparametric covariate functions

Multi-type recurrent event data occur frequently in longitudinal studies. Dependent termination may occur when the terminal time is correlated to recurrent event times. In this article, we simultaneously model the multi-type recurrent events and a dependent terminal event, both with nonparametric covariate functions modeled by B-splines. We develop a Bayesian multivariate frailty model to account for the correlation among the dependent termination and various types of recurrent events. Extensive simulation results suggest that misspecifying nonparametric covariate functions may introduce bias in parameter estimation. This method development has been motivated by and applied to the lipid-lowering trial component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.

Treatment of NAFLD with diet, physical activity and exercise

Lifestyle intervention can be effective when treating non-alcoholic fatty liver diseases (NAFLD) patients. Weight loss decreases cardiovascular and diabetes risk and can also regress liver disease. Weight reductions of ⩾10% can induce a near universal non-alcoholic steatohepatitis resolution and fibrosis improvement by at least one stage. However, modest weight loss (>5%) can also produce important benefits on the components of the NAFLD activity score (NAS). Additionally, we need to explore the role of total calories and type of weight loss diet, micro- and macronutrients, evidence-based benefits of physical activity and exercise and finally support these modifications through established behavioural change models and techniques for long-term maintenance of lifestyle modifications. Following a Mediterranean diet can reduce liver fat even without weight loss and is the most recommended dietary pattern for NAFLD. The Mediterranean diet is characterised by reduced carbohydrate intake, especially sugars and refined carbohydrates (40% of the calories vs. 50-60% in a typical low fat diet), and increased monounsaturated and omega-3 fatty acid intake (40% of the calories as fat vs. up-to 30% in a typical low fat diet). Both TV sitting (a reliable marker of overall sedentary behaviour) and physical activity are associated with cardio-metabolic health, NAFLD and overall mortality. A 'triple hit behavioural phenotype' of: i) sedentary behaviour, ii) low physical activity, and iii) poor diet have been defined. Clinical evidence strongly supports the role of lifestyle modification as a primary therapy for the management of NAFLD and NASH. This should be accompanied by the implementation of strategies to avoid relapse and weight regain.

Bayesian regression model for recurrent event data with event-varying covariate effects and event effect

In the course of hypertension, cardiovascular disease events (e.g., stroke, heart failure) occur frequently and recurrently. The scientific interest in such study may lie in the estimation of treatment effect while accounting for the correlation among event times. The correlation among recurrent event times come from two sources: subject-specific heterogeneity (e.g., varied lifestyles, genetic variations, and other unmeasurable effects) and event dependence (i.e., event incidences may change the risk of future recurrent events). Moreover, event incidences may change the disease progression so that there may exist event-varying covariate effects (the covariate effects may change after each event) and event effect (the effect of prior events on the future events). In this article, we propose a Bayesian regression model that not only accommodates correlation among recurrent events from both sources, but also explicitly characterizes the event-varying covariate effects and event effect. This model is especially useful in quantifying how the incidences of events change the effects of covariates and risk of future events. We compare the proposed model with several commonly used recurrent event models and apply our model to the motivating lipid-lowering trial (LLT) component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) (ALLHAT-LLT).

Relative sweetness and sweetness quality of Xylobiose

Xylobiose (XB), a xylose dimer, is a low-calorie sweetener with prebiotic activity. Unlike its well-defined biosynthesis and production methods, its sensory characteristics have not been well investigated. This study aims to identify the relative sweetness and sensory profile of XB. XB was prepared as an aqueous solution, and its relative sweetness (RS) compared to 5% sucrose was determined using the 2-alternative forced choice method. The sensory profile was identified by 10 trained panelists using descriptive analysis. The RS of XB was determined to be 0.34. XB was characterized by its yellowness, corn aroma and flavor, and its nurungji (scorched rice) candy flavor. The persistence of sweetness of XB was similar to that of sucrose, but its onset of sweetness was slower. When XB was mixed with sucrose at a ratio of 7:93, the mixture exhibited a similar sensory quality to that of sucrose, thereby making it a useful sucrose complement.

Pivotal Cytoprotective Mediators and Promising Therapeutic Strategies for Endothelial Progenitor Cell-Based Cardiovascular Regeneration

Cardiovascular diseases (CVDs), including atherosclerosis, stroke, and myocardial infarction, is a major cause of death worldwide. In aspects of cell therapy against CVD, it is generally accepted that endothelial progenitor cells (EPCs) are potent neovascular modulators in ischemic tissues. In response to ischemic injury signals, EPCs located in a bone marrow niche migrate to injury sites and form new vessels by secreting various vasculogenic factors including VEGF, SDF-1, and FGF, as well as by directly differentiating into endothelial cells. Nonetheless, in ischemic tissues, most of engrafted EPCs do not survive under harsh ischemic conditions and nutrient depletion. Therefore, an understanding of diverse EPC-related cytoprotective mediators underlying EPC homeostasis in ischemic tissues may help to overcome current obstacles for EPC-mediated cell therapy for CVDs. Additionally, to enhance EPC's functional capacity at ischemic sites, multiple strategies for cell survival should be considered, that is, preconditioning of EPCs with function-targeting drugs including natural compounds and hormones, virus mediated genetic modification, combined therapy with other stem/progenitor cells, and conglomeration with biomaterials. In this review, we discuss multiple cytoprotective mediators of EPC-based cardiovascular repair and propose promising therapeutic strategies for the treatment of CVDs.

Antioxidant and Antihyperglycemic Properties of Three Banana Cultivars (Musa spp.)

Background. This study sought to investigate the antioxidant and antihyperglycemic properties of Musa sapientum (Latundan banana) (MSL), Musa acuminata (Cavendish banana) (MAC), and Musa acuminate (Red Dacca) (MAR). Materials and Methods. The sugar, starch, amylose, and amylopectin contents and glycemic index (GI) of the three banana cultivars were determined. Furthermore, total phenol and vitamin C contents and α-amylase and α-glucosidase inhibitory effects of banana samples were also determined. Results. MAC and MAR had the highest starch, amylose, and amylopectin contents and estimated glycemic index (eGI) with no significant different while MSL had the lowest. Furthermore, MAR (1.07 mg GAE/g) had a higher total phenol content than MAC (0.94 mg GAE/g) and MSL (0.96 mg GAE/g), while there was no significant difference in the vitamin C content. Furthermore, MAR had the highest α-amylase (IC₅₀ = 3.95 mg/mL) inhibitory activity while MAC had the least (IC₅₀ = 4.27 mg/mL). Moreover, MAC and MAR inhibited glucosidase activity better than MSL (IC₅₀ 3.47 mg/mL). Conclusion. The low sugar, GI, amylose, and amylopectin contents of the three banana cultivars as well as their α-amylase and α-glucosidase inhibitory activities could be possible mechanisms and justification for their recommendation in the management of type-2 diabetes.

Association between sucrose intake and acute coronary event risk and effect modification by lifestyle factors: Malmö Diet and Cancer Cohort Study

Previous studies have suggested that a high intake of sugar-sweetened beverages is positively associated with the risk of a coronary event. However, a few studies have examined the association between sucrose (the most common extrinsic sugar in Sweden) and incident coronary events. The objective of the present study was to examine the associations between sucrose intake and coronary event risk and to determine whether these associations are specific to certain subgroups of the population (i.e. according to physical activity, obesity status, educational level, alcohol consumption, smoking habits, intake of fat and intake of fruits and vegetables). We performed a prospective analysis on 26 190 individuals (62 % women) free from diabetes and without a history of CVD from the Swedish population-based Malmö Diet and Cancer cohort. Over an average of 17 years of follow-up (457 131 person-years), 2493 incident cases of coronary events were identified. Sucrose intake was obtained from an interview-based diet history method, including 7-d records of prepared meals and cold beverages and a 168-item diet questionnaire covering other foods. Participants who consumed >15 % of their energy intake (E%) from sucrose showed a 37 (95 % CI 13, 66) % increased risk of a coronary event compared with the lowest sucrose consumers (<5 E%) after adjusting for potential confounders. The association was not modified by the selected lifestyle factors. The results indicated that sucrose consumption higher than 15 E% (5 % of this population) is associated with an increased risk of a coronary event.

Relative sweetness and sweetness quality of phyllodulcin [(3R)-8-Hydroxy-3-(3-hydroxy-4-methoxyphenyl)-3,4-dihydro-1H-isochromen-1-one]

Phyllodulcin, a sweet-tasting compound extracted from Hydrangea macrophylla var. thunbergii, has recently received attention as a natural intense alternative sweetener with beneficial health effects. This study was conducted to determine the sweetness potency of phyllodulcin, relative to that of sucrose and to elucidate its sensory profile. Phyllodulcin solution was prepared by dissolving it in 1% ethanol (v/v) at 50°C. Relative sweetness to that of 3% sucrose in 1% ethanol solution was determined using the two-alternative forced-choice test. The sensory profile was obtained based on the descriptive analysis of 10 trained panelists. The relative sweetness of phyllodulcin was 434.8. Phyllodulcin was characterized by its bitterness, alcohol flavor, cooling sensation, and astringent aftertaste, but the persistence and onset of the sweetness of phyllodulcin were similar to those of sucrose. Further studies are required to improve the sweetness quality of phyllodulcin for facilitating its use in industrial applications by reducing its unfavorable flavor attributes.

Impact of metabolic syndrome on the progression of coronary calcium and of coronary artery disease assessed by repeated cardiac computed tomography scans

BACKGROUND

It is not clear how severe metabolic syndrome (MS) affects the development of coronary atherosclerosis.

METHODS

This was an observational, retrospective cohort study with Koreans who received health check-ups voluntarily. A total of 2426 subjects had baseline and follow-up coronary artery calcium score (CACS) data. Among them, 1079 had coronary computed tomography angiography (CCTA) data. We compared baseline CACS and any progression in subjects with and without MS. A more detailed analysis was conducted for coronary artery disease (CAD), which was defined by coronary artery stenosis (≥50 %), multivessel involvement, and coronary plaques in those patients with CCTA data.

RESULTS

At baseline, subjects with MS (34.0 %, n = 825) had higher CACS and more significant coronary artery stenosis, multivessel involvement, and atheromatous plaques than those without MS (P < 0.05 for all). In the follow-up (median 1197 days), subjects with MS showed significant increases in CACS and progression of CAD compared with counterparts without MS, in parallel with the numbers of MS components. Finally, MS was a significant predictor for the progression of CACS (hazard ratio 1.32; 95 % confidence interval 1.06-1.64) and progression of coronary artery stenosis and/or development of vulnerable plaque (hazard ratio 1.47, 95 % confidence interval 1.01-2.15) after adjusting for other cardiovascular risk factors.

CONCLUSIONS

Subjects with MS showed progression of CAD as assessed by CACS and CCTA over ~3 years. Therefore, more vigilant screening for coronary vascular health is needed among those with MS.

Feeding practices and nutritional status of HIV-exposed and HIV-unexposed infants in the Western Cape

Background

Optimal infant- and young child-feeding practices are crucial for nutritional status, growth, development, health and, ultimately, survival. Human breast milk is optimal nutrition for all infants. Complementary food introduced at the correct age is part of optimal feeding practices. In South Africa, widespread access to antiretrovirals and a programme to prevent mother-to-child transmission of HIV have reduced HIV infection in infants and increased the number of HIV-exposed uninfected (HEU) infants. However, little is known about the feeding practices and nutritional status of HEU and HIV-unexposed (HU) infants.

Objective

To assess the feeding practices and nutritional status of HIV-exposed and HIV-unexposed (HU) infants in the Western Cape.

Design

Prospective substudy on feeding practices nested in a pilot study investigating the innate immune abnormalities in HEU infants compared to HU infants. The main study commenced at week 2 of life with the nutrition component added from 6 months. Information on children's dietary intake was obtained at each visit from the caregiver, mainly the mother. Head circumference, weight and length were recorded at each visit. Data were obtained from 6-, 12- and 18-month visits. World Health Organization feeding practice indicators and nutrition indicators were utilised.

Setting

Tygerberg Academic Hospital, Western Cape. Mothers were recruited from the postnatal wards.

Subjects

Forty-seven mother-infant pairs, 25 HEU and 22 HU infants, participated in this nutritional substudy. Eight (17%) infants, one HU and seven HEU, were lost to follow-up over the next 12 months. The HEU children were mainly Xhosa (76%) and HU were mainly mixed race (77%).

Results

The participants were from poor socio-economic backgrounds. In both groups, adherence to breastfeeding recommendations was low with suboptimal dietary diversity. We noted a high rate of sugar- and salt-containing snacks given from a young age. The HU group had poorer anthropometric and nutritional indicators not explained by nutritional factors alone. However, alcohol and tobacco use was much higher amongst the HU mothers.

Conclusion

Adherence to breastfeeding recommendations was low. Ethnicity and cultural milieu may have influenced feeding choices and growth. Further research is needed to understand possible reasons for the poorer nutritional and anthropometric indicators in the HU group.

Lifestyle changes for the treatment of nonalcoholic fatty liver disease: a review of observational studies and intervention trials

Nonalcoholic fatty liver disease (NAFLD) is emerging as a major public health problem because of its association with increased cardiovascular and liver-related morbidity and mortality. Both genetic factors and lifestyle contribute to the pathogenesis of NAFLD. Lifestyle, including dietary habits and physical activity, is a modifiable risk factor and thus represents the main target for the prevention and treatment of NAFLD. In this review, we summarize the evidence regarding nutritional aspects (i.e. total energy intake, saturated fat and carbohydrates intake, certain foods or drinks and dietary patterns as a whole) in the treatment of NAFLD. In addition, we analyze the evidence concerning the independent effect of physical activity, including aerobic and resistance training, in the treatment of NAFLD. A therapeutic algorithm according to results from intervention trials is also provided for clinicians and other healthcare professionals involved in the management of NAFLD.

Factors Affecting Hypertension among the Malaysian Elderly

Hypertension is a common chronic disease in the elderly. This study aimed to determine the effects of age, ethnicity, gender, education, marital status, nutritional parameters, and blood elements on the risk of high blood pressure in the Malaysian elderly. This research was conducted on a group of 2322 non-institutionalized Malaysian elderly. The hierarchy binary logistic regression analysis was applied to estimate the risk of hypertension in respondents. Approximately, 45.61% of subjects had hypertension. The findings indicated that the female gender (Odds ratio (OR) = 1.54), an increase in body weight (OR = 1.61), and an increase in the blood levels of albumin (OR = 1.51), glucose (OR = 1.92), and triglycerides (OR = 1.27) significantly increased the risk of hypertension in subjects (p < 0.05). Conversely, an increase in both dietary carbohydrates (OR = 0.74), and blood cholesterol level (OR = 0.42) significantly reduced the risk of hypertension in samples (p < 0.05). Furthermore, the results showed that ethnicity was a non-relevant factor to increase the risk of hypertension in subjects. It was concluded that female gender, an increase in body weight, and an increase in the blood levels of glucose, triglycerides, and albumin enhanced the risk of high blood pressure in the Malaysian elderly. In addition, an increase in both dietary carbohydrates and blood cholesterol level decreased hypertension in subjects.