Abstract P521: Association Between Dietary Phytosterols and Risk of Cardiovascular Disease Mortality in US Adults: Findings From the Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994

Introduction: Phytosterols (plant sterols) are naturally occurring components of plant food sources, including vegetable oils, nuts, cereals and legumes. Their chemical structure impedes intestinal cholesterol absorption and regular consumption has been related to lower serum low-density cholesterol (LDL-C), a causal risk factor for cardiovascular disease (CVD). The association between dietary plant sterol intake and CVD has yet to be determined.

Objective: We aimed to examine the association of phytosterol consumption in the diet with cardiovascular mortality in US adults the National Health & Nutrition Examination Survey III (NHANES III), 1988-1994.

Methods: We conducted a prospective cohort analysis on National Health and Nutrition Examination Survey (NHANES, 1988-1994 [III]), linked with the National Death Index mortality data (2015) to associate dietary phytosterol intake from 24h dietary recall data with CVD mortality. We included 13,004 adults aged ≥20 years who were non-pregnant, free of CVD at baseline and completed ≥1 24h dietary recall with plausible caloric intake data. We excluded individuals with death occurring within 1 year of baseline. We created a database quantifying the phytosterol content of foods in the 24h dietary recall data and estimated usual intake by quintiles using the NCI method. We determined the risk function by regression calibration and estimated CVD mortality risk between the 10 th (Q1) and 90 th (Q5) percentiles of usual intake. Data was adjusted for sex, age, smoking status and ethnicity.

Results: Over a mean±SD follow-up period of 21.2±5.1y, 949 CVD deaths occurred in a population with a mean±SD age of 44.2±14.3y, BMI 26.7±4.7 kg/m 2 and mean dietary plant sterol usual intake of 272.3 mg/day. The top sources of dietary phytosterols were from potatoes 23%), wheat and other grains (21%) and beans, legumes and nuts (13%). Mean usual intake plant intake in the 10 th (Q1) and 90 th (Q5) percentiles of the population was 150.1 and 414.0 mg/day. The estimated relative risk for CVD mortality between Q1 (ref) and Q5 was 0.972 (p<0.05).

Conclusions: Preliminary analyses suggest a CVD death risk reduction of 2.8% in the highest versus lowest intakes of dietary plant sterols in the US population. We plan to expand the multivariable model to include the Healthy Eating Index (diet quality) and assess stratification by healthful and unhealthful sources of phytosterols and linear and non-linear dose response analyses to determine the robustness of the association.

OSF Registration: osf.io/da4sg

Funding: Amgen Scholars Program, Canadian Institutes of Health Research (CIHR), Banting and Best Diabetes Centre (BBDC), Toronto 3D Knowledge Synthesis and Clinical Trials foundation

Abstract P214: The Portfolio Dietary Pattern and Risk of Cardiovascular Disease in US Adults

Introduction: The plant-based portfolio dietary pattern includes recognized cholesterol-lowering foods shown to improve several cardiovascular disease (CVD) risk factors in clinical trials. Epidemiological evidence on the association between longer-term adherence to the portfolio dietary pattern and CVD risk remains more limited.

Objective: To examine whether the portfolio dietary pattern is associated with the risk of total CVD, coronary heart disease (CHD, including myocardial infarction and fatal coronary deaths), and stroke.

Methods: Participants included 73,925 women in the Nurses’ Health Study (NHS) (1984-2014), 92,354 women in the NHS2 (1991-2017) and 43,970 men from the Health Professionals Follow-up Study (HPFS) (1986-2016) without CVD and cancer at baseline. Diet was assessed using validated food frequency questionnaires at baseline and every four years using a portfolio diet score (PDS) which positively ranks plant protein (soy & pulses), nuts, viscous fiber sources, phytosterols (mg/day) and plant monounsaturated fat sources, and negatively ranks foods high in saturated fat and dietary cholesterol. Cox proportional hazards regressions were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusted for covariates.

Results: During up to 30 years of follow-up, 16,917 incident CVD cases, including 10,666 CHD cases and 6,473 stroke cases, were documented. After multivariable adjustment of lifestyle and other dietary factors, comparing the highest to the lowest quintile, participants with a higher PDS had a lower risk of total CVD (pooled HR: 0.84; 95% CI: 0.80-0.89, P trend<0.001), CHD (pooled HR: 0.82; 95% CI: 0.76-0.87, P trend<0.001) and stroke (pooled HR: 0.88; 95% CI: 0.81-0.97, P trend=0.001). In addition, a 25-percentile higher PDS was associated with a lower risk of total CVD (pooled HR: 0.91; 95% CI: 0.88-0.93), CHD (pooled HR: 0.89; 95% CI: 0.86-0.92) and stroke (pooled HR: 0.93; 95% CI: 0.89-0.97). Results remained largely consistent across sensitivity and subgroup analyses.

Conclusions: Greater adherence to the portfolio dietary pattern was consistently associated with lower risk of CVD, including CHD and stroke, in three large prospective cohorts of U.S. men and women.

417 Vibrational Spectroscopy: A Rapid Tool for Soft Tissue Sarcoma Assessment

Aim

Soft tissue sarcomas (STS) are a comparatively unusual cluster of tumours; they arise from mesenchymal tissues. Surgery remains the primary and the only potentially curative treatment for most STS subtypes.

Existing intraoperative margin assessment techniques are inadequate and the current gold standard for resection margin assessment of STS is post-operative histopathology, but this takes weeks to finalize. Consequently, an augmented surgical technique established by real-time non-destructive recognition of clear margins is essential to diminish the risk of local relapse, decrease the resection area, and enhance the effectiveness of surgical resection of STS.

Vibrational spectroscopy (VS) is a non-destructive evaluation of the atomic oscillation within a molecule. Every molecule has a unique set of vibrational modes called molecular fingerprint. We aim to use Raman spectroscopy to analyse biomolecular spectra of sarcoma and develop a potential tool for intra operative margin assessment

Method

Human sarcoma was tissue obtained from the biobank at QEHB. The samples were identified as Lipoma and Liposarcoma. The samples underwent spectral measurement with the Raman microscope and the tissue samples were then sent for histopathological analysis.

Results

The spectral evaluation clearly demonstrates the biomolecular difference between the two groups and has a potential to become an intraoperative tool.

Conclusions

A positive resection margin is the ultimate prognosticator of local relapse. There is a need for a rapid and reliable tool that can offer surgeons with instant feedback during primary procedure.

Effect of Oats and Oat-Fiber on Glycemic Control in Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objectives

Current approved health claims in Canada, US and Europe recognize the ability of oat ß-glucan to lower blood cholesterol; however, its ability to improve glycemic control is less certain. We undertook a systematic review and meta-analysis of randomized controlled trials to update the evidence of the effect of oats and oat-fiber on markers of glycemic control in people with and without diabetes. Here we present data for the subgroup with diabetes.

Methods

MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched through September 23rd, 2020. We included randomized controlled trials of ≥ 2-weeks of sources of oat ß-glucan and measures of glycemic control in diabetes. Two independent reviewers extracted relevant data and assessed the risk of bias (Cochrane Risk of Bias 2.0 Tool). The outcomes were fasting plasma glucose (FPG), 2h-plasma glucose (2h-PG) from a 75 g-oral glucose tolerance test, HbA1c and fasting

plasma insulin (FPI). Data were pooled using the generic inverse variance method. Heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). Pooled estimates were expressed as mean differences with 95% confidence intervals (CI). GRADE assessed the certainty of the evidence.

Results

Eligibility criteria were met by 5 trial comparisons (N = 359) in type 2 diabetes. No trials were identified in type 1 diabetes. Consumption of oat ß-glucan sources reduced FPG (MD = −0.37 mmol/L [95% CI: −0.70, −0.05 mmol/L], P = 0.03, I2 = 0.00%, PQ = 0.76) and 2h-PG (MD = −1.24 mmol/L [95% CI: −1.97, −0.51 mmol/L], P = 0.00, I2 = 0.00%, PQ = 0.56). There were non-significant reductions in HbA1c (MD = −0.12%, [95% CI: −0.26, 0.01%], P = 0.07, I2 = 0.00%, PQ = 1.00) and FPI (MD = −4.59 pmol/L, [95% CI: −14.71, 5.52 pmol/L], P = 0.37, I2 = 40.84%, PQ = 0.19). The certainty of evidence was high for 2h-PG and moderate for FPG, HbA1c and FPI (single downgrades for imprecision in each case).

Conclusions

Current evidence provides a good indication that consumption of oat ß-glucan results in small improvements of glycemic control in type 2 diabetes. More high quality randomized trials are required to improve the precision of the pooled estimates. (ClinicalTrials.gov identifier, NCT04631913)

Funding Sources

Quaker Oats Center of Excellence, Diabetes Canada, Banting & Best Diabetes Centre, Toronto 3D foundation

Effect of Important Food Sources of Fructose-Containing Sugars on Biomarkers of Inflammation: A Systematic Review and Meta-Analysis of Controlled Trials

Objectives

Excess calories as fructose may initiate pathways increasing biomarkers of inflammation. Whether this effect is mediated by the food matrix at different energy levels is unknown. We conducted a systematic review and meta-analysis of controlled feeding trials of the effect of food sources of fructose-containing sugars at different energy control levels on biomarkers of inflammation (NCT02716870).

Methods

We searched MEDLINE, Embase, and the Cochrane Library through January 15 2020 for controlled trials ≥7d. Trial designs were prespecified based on energy control: substitution (energy-matched replacement of sugar in the diet); addition (excess energy from sugar added to diets); subtraction (energy from sugar subtracted from diets); ad libitum (energy from sugar freely replaced in the diet). The primary outcome was C-reactive protein (CRP). Secondary outcomes were tumor necrosis factor-alpha (TNF-α) and interleukin 6 (IL-6). Independent reviewers extracted data and assessed the risk of bias. Certainty of evidence was assessed by GRADE.

Results

We included 48 trials (109 trial comparisons, n = 2108) assessing the effect of 10 food sources (SSBs, sweetened dairy, sweetened dairy alternatives (soy), fruit, 100% fruit juice, dried fruit, sweetened cereal grains/bars, sweets, added nutritive sweetener, and mixed sources) across the 4 levels of energy control. Total fructose-containing sugars had no effect on any outcome in any level of energy control. There was evidence of interaction by food source; in substitution trials, sweetened dairy alternative (soy) decreased CRP. In addition trials, fruit decreased while added nutritive sweetener increased TNF-α. The certainty of evidence was low for the effect of sweetened dairy alternative (soy) on CRP in substitution trials, and generally moderate for all other comparisons.

Conclusions

Food source more than energy control appears to mediate the effect of fructose-containing sugars on inflammation. The evidence provides some indication that sweetened dairy alternatives (soy) and fruit decrease and added nutritive sweeteners increase biomarkers of inflammation. More high-quality randomized trials of different fructose containing food sources are needed to improve our estimates.

Funding Sources

Diabetes Canada.

Effect of Important Food Sources of Fructose-Containing Sugars on Non-alcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis of Controlled Trials

Objectives

Fructose as a source of excess calories increases non-alcoholic fatty liver disease (NAFLD) markers. Whether this effect is mediated by the food matrix is unknown. We thus conducted a systematic review and meta-analysis of controlled feeding trials assessing the effect of important food sources of fructose-containing sugars at different energy control levels on NAFLD markers.

Methods

MEDLINE, Embase, and Cochrane Library were searched through January 18, 2021 for controlled trials ≥7-days. Four trial designs were prespecified based on energy control: substitution (energy-matched replacement of sugars by other macronutrients); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced by other macronutrients). The primary outcome was intrahepatocellular lipid (IHCL). Secondary outcomes were alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Independent reviewers extracted data and assessed risk of bias. Certainty of evidence was assessed by GRADE.

Results

We included 44 trials (65 trial comparisons, n = 1941) assessing the effect of 8 food sources (sugar-sweetened beverages [SSBs]; sweetened dairy alternative [soy]; fruit juice; fruit; dried fruit; baked goods, desserts and sweets; added nutritive sweetener; and mixed sources) across 4 energy levels. Total fructose-containing sugars increased IHCL in addition trials (standardized mean difference = 1.69 [95% CI, 1.00–2.37], P &lt; 0.001), but no effect in substitution, subtraction and ad libitum trials. There was evidence of interaction by food source in addition trials with SSBs increasing IHCL and ALT, and mixed sources increasing AST. The overall certainty of evidence was high for SSBs on IHCL and ALT in addition trials and high to very low for all other comparisons.

Conclusions

Energy control and food source appear to mediate the effect of fructose-containing sugars on NAFLD markers. High certainty evidence suggests that SSBs providing excess energy increase NAFLD markers, while the evidence is less certain that mixed sources share the same effect and other food sources do not. More high-quality randomized trials of different food sources are needed to improve our estimates (ClinicalTrials.gov identifier, NCT02716870).

Funding Sources

Primary funding: Diabetes Canada.

Effect of Intermittent Fasting Strategies on Cardiometabolic Risk Factors: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Objectives

Intermittent fasting (IF) is a popular trending diet, yet there is limited evidence-based support considering its clinical impact on cardiometabolic outcomes. In an effort to inform the European Association for the Study of Diabetes (EASD) clinical practice guidelines for nutrition therapy, we conducted a network meta-analysis of randomized controlled trials (RCTs) comparing IF strategies and continuous energy restriction (CER) on cardiometabolic outcomes using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

Methods

MEDLINE, EMBASE, and Cochrane databases were searched through Nov 2020. We included RCTs assessing the effect of IF strategies (alternate-day fasting (ADF), whole-day periodic fasting (WDF), time-restricted feeding (TRF)), CER, and ad libitum diet. Outcomes included body weight, fasting glucose and LDL-cholesterol. Two independent researchers extracted data and assessed risk of bias. A network meta-analysis was performed and data were expressed as mean differences (MD) with 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE.

Results

We identified 19 RCTs (n = 590) including adults of varying health backgrounds. ADF and CER both showed a benefit for body weight reduction compared to ad libitum diet (18 trials, n = 520; MD −3.95 kg [95% CI −6.09, −1.81] and MD −2.85 kg [95% CI −4.99, −0.71], respectively). For fasting glucose (17 trials, n = 590), TRF showed a benefit compared to ad libitum diet (MD −0.39 mmol/L [95% CI −0.59, −0.20]), to CER (MD −0.25 mmol/L [95% CI, −0.45 to −0.06]) and to WDF (MD −0.20 mmol/L [95% CI, −0.45, −0.05]). Furthermore, ADF showed a benefit in reducing LDL-cholesterol (17 trials, n = 590) compared to ad libitum diet (MD −0.21 mmol/L [95% CI −0.40, −0.1]), and to CER (MD −0.15 mmol/L [95% CI −0.31, −0.01]). The certainty of the evidence ranged from high to moderate due to variable downgrades for imprecision.

Conclusions

Current evidence provides a good indication that IF strategies have similar benefits to CER for weight loss but may have additional benefits for fasting glucose and LDL-cholesterol. Long-term high quality RCTs are needed to clarify the effect of different IF strategies on cardiometabolic outcomes.

Funding Sources

Diabetes and Nutrition Study Group of the EASD, Canadian Institutes of Health Research (CIHR), Diabetes Canada.

Relation of Food Sources of Fructose Containing Sugars With Incident Obesity Outcomes: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

Objectives

Sugars have been implicated in the epidemic of obesity. It is unclear whether food sources of fructose-containing sugars other than sugar-sweetened beverages (SSBs) are associated with increased risk of obesity. To assess the evidence of the relation of food sources of fructose-containing sugars with incident overweight or obesity, we undertook a systematic review and meta-analysis of prospective cohort studies.

Methods

We searched MEDLINE, EMBASE and Cochrane Library through Aug 2019. We included prospective cohort studies of ≥1 year. Two reviewers extracted data and assessed the risk of bias. The primary outcome was incident overweight/obesity. Data were pooled using generic-inverse variance method (random effects) and expressed as relative risks (RR) for incident outcomes and ß-coefficients for WC with 95% confidence intervals (CI). GRADE assessed the certainty of evidence

Results

We included 12 and 8 prospective cohorts involving 181,295 adults and 31,717 children, respectively. Four food sources of fructose-containing sugars were identified: SSBs, 100% fruit juice, fruit and yogurt. There was no data available in children for yogurt or WC. SSBs were associated with increased incident overweight/obesity in children (RR, 1.22 [95% CI, 1.03 to 1.44] but not in adults and increased incident abdominal obesity in both children (3.78 [1.08 to 13.25]) and adults (1.51 [1.11 to 2.06]), but there was no association with change in WC in adults. Fruit juice was associated with increased incident overweight/obesity in children (1.28 [1.07 to 1.53]) but not in adults, and there was no association with incident abdominal obesity in either children or adults or WC in adults. Fruit was associated with decreased incident overweight/obesity (0.87 [0.82 to 0.92]) and decreased WC (ß, −0.23 cm [−0.33 to −0.13]) in adults. Yogurt was associated with decreased incident abdominal obesity (0.65 [0.47 to 0.90]) in adults with no data available on WC. The certainty of the evidence was graded as “very low” to “moderate”.

Conclusions

Current evidence indicates that the relation between fructose-containing sugars and obesity outcomes differs by food sources. More research of more food sources of sugars is needed to improve our certainty in the evidence. (ClinicalTrials.gov, NCT02558920)

Funding Sources

ASN, Diabetes Canada, Banting and Best Diabetes Centre.

Important Food Sources of Fructose-Containing Sugars and Adiposity: A Systematic Review and Meta-Analysis of Controlled Feeding Trials

Objectives

Sugar-sweetened beverages (SSBs) have been linked to weight gain. It is unclear if other food sources of fructose-containing sugars behave similarly. We conducted a systematic review and meta-analysis of controlled feeding trials to assess the effect of different food sources of fructose-containing sugars on body weight and markers of adiposity.

Methods

MEDLINE, Embase, and the Cochrane Library were searched through January 2020 for controlled feeding trials ≥2 weeks on the effect of fructose-containing sugars. Trial designs were prespecified by energy control: substitution (energy matched replacement of sugars in diets); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced in diets). The primary outcome was body weight. Secondary outcomes were body mass index, body fat and waist circumference. Independent reviewers extracted data and assessed risk of bias. Certainty of evidence was assessed using GRADE. (NCT02558920)

Results

We identified 119 controlled trials (368 trial comparisons, N = 5263) assessing the effect of 10 food sources (SSBs, sweetened dairy alternative (soy), fruit juice, fruit drink, fruit, dried fruit, sweetened cereal grains/bars, sweets, added sweeteners and mixed sources). Total fructose-containing sugars increased body weight (mean difference, 0.29 kg [95% confidence interval, 0.05 to 0.53 kg], P = 0.017) and body fat in addition trials with no effect in other analyses or outcomes. There was evidence of interaction by food source in substitution trials with fruit reducing and mixed sources increasing some outcomes and in addition trials with 100% fruit juice reducing and SSBs and mixed sources increasing some outcomes. The overall certainty of evidence was moderate for the decreasing effect of fruit and fruit juice and the increasing effect of SSBs and mixed sources and high-to-very low for other comparisons.

Conclusions

Energy control and food source may mediate the effect of fructose-containing sugars on adiposity. The evidence provides good indication that fruit and 100% fruit juice decrease and SSBs and mixed sources increase markers of adiposity. More high-quality randomized trials of different foods are needed to improve our estimates.

Funding Sources

American Society for Nutrition, Diabetes Canada, CIHR, Mitacs.

Rationale, Design and Baseline Characteristics for the Strategies to Oppose SUGARS With Non-nutritive Sweeteners or Water (STOP Sugars NOW) Trial

Objectives

Health authorities recommend reducing added or free sugars to ≤5–10% energy. Much attention has focussed of the reduction of SSBs with the recommendation that SSBs be replaced with unsweetened healthy alternatives such as water but not non-nutritive sweetened beverages (NSBs). There are concerns that non-nutritive sweeteners do not have the intended benefits and may induce glucose intolerance through changes in the gut microbiome. Whether NSBs have benefits similar to water in their intended substitution for SSBs is unclear.

Methods

To address this question, we have undertaken the STOP Sugars NOW trial (NCT03543644), a pragmatic “head-to-head” crossover randomized controlled trial of the effect of NSBs (the intended substitution) versus water (the standard of care) as a replacement strategy for SSBs on glucose tolerance and gut microbiome diversity. We recruited overweight or obese participants with a high waist circumference who regularly consume ≥1 SSBs/day. Each participant underwent a ≥2-week run-in period followed by three 4- week treatment phases in random order (usual SSBs, equivalent NSBs, or water) with each phase separated by a ≥4-week washout. The two primary outcomes are change in glucose tolerance and gut microbiome beta- diversity. Adherence to the interventions will be assessed by objective biomarkers of added sugars (13C/12C isotopic ratio in serum fatty acids and urinary fructose and sucrose) and non-nutritive sweeteners (urinary sucralose and acesulfame-potassium).

Results

The trial started on June 1st, 2018 with the first participant undergoing randomization on August 1st, 2019 and the last participant finishing on October 15th, 2020. We screened 1,086 individuals, out of which 80 were randomized. Baseline characteristics showed a mean age of 41.8 ± 13.0 y, BMI of 33.7 ± 6.8 kg/m2, waist circumference of 108.7 ± 13.5 cm, and mean SSBs intake of 2 SSBs/day.

Conclusions

The results of this trial will directly inform public health guidance on the use of NSBs in sugars reduction strategies.

Funding Sources

CIHR.

Important Food Sources of Fructose-Containing Sugars and Fasting Serum Uric Acid Levels: A Systematic Review and Meta-Analysis of Controlled Feeding Trials

Objectives

Fructose as a source of excess calories increases uric acid. Whether this effect is mediated by the food matrix at different levels of energy is unknown. We aim to conduct a systematic review and meta-analysis of controlled feeding trials on the effect of food sources of fructose-containing sugars at different energy levels on uric acid (NCT02716870).

Methods

MEDLINE, Embase and the Cochrane Library were searched through January 27, 2020 for controlled trials ≥7-days assessing the effect of food sources of fructose-containing sugars on uric acid. Trial designs were prespecified based on energy control: substitution (energy matched replacement of sugars by other macronutrients); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced by other macronutrients) trials. Independent reviewers extracted data and assessed risk of bias. Certainty of evidence was assessed using the GRADE approach.

Results

Eligibility was met by 41 trials (72 trial comparisons, N = 2109) assessing the effect of 9 food sources (sugar-sweetened beverages [SSBs], sweetened dairy, fruit drink [lemonade], 100% fruit juice, fruit, dried fruit [raisins], baked goods desserts and sweets, added nutritive [caloric] sweetener and mixed sources) across the 4 energy levels. Total fructose-containing sugars increased uric acid in substitution trials (mean difference, 0.15 mg/dL [95% confidence interval, 0.03 to 0.27 mg/dL], P = 0.012) with no effect in addition, subtraction or ad libitum trials. There was evidence of interaction by food source with SSBs and baked goods, desserts and sweets increasing uric acid in substitution and SSBs increasing and 100% fruit juice decreasing uric acid in addition trials. The overall certainty of evidence was moderate for the increasing effect of SSBs in substitution and addition trials and low to very low for all other comparisons.

Conclusions

Food source more than energy control mediate the effect of fructose-containing sugars on uric acid. SSBs and baked goods, desserts and sweets appear to increase, and 100% fruit juice appear to decrease uric acid. More high-quality trials of different food sources of fructose-containing sugars are needed to improve our estimates.

Funding Sources

Diabetes Canada.

Important Food Sources of Fructose-Containing Sugars and Postprandial Lipids: A Systematic Review and Meta-Analysis of Controlled Feeding Trials

Objectives

Fructose providing excess calories has been shown to increase postprandial triglycerides (TAG). Whether this effect holds for different food sources of fructose-containing sugars is unclear. We conducted a systematic review and meta-analysis of controlled feeding trials on the effect of different food sources of fructose-containing sugars at different levels of energy control on postprandial blood lipids (NCT02716870).

Methods

MEDLINE, EMBASE, and Cochrane Library were searched through June 1st, 2020 for controlled feeding trials ≥7-days assessing the effect of food sources of fructose-containing sugars on postprandial lipids. Trial designs were prespecified based on energy control: substitution (energy matched replacement of sugars by other macronutrients); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced by other macronutrients) trials. Independent reviewers extracted data and assessed risk of bias. Outcomes were postprandial TAG and apoB48. Certainty of evidence was assessed using GRADE.

Results

We included 29 trials (60 trial comparisons, N = 943) assessing 5 food sources (SSBs, fruit, sweets and desserts, added caloric sweetener and mixed sources) across 4 levels of energy control. Total fructose-containing sugars increased postprandial TAG in substitution (MD: 0.17 mmol/L [95% CI: 0.05, 0.30], P = 0.007), addition (0.38 mmol/L [0.13, 0.62], P = 0.003), and ad libitum (0.17 mmol/L [0.02, 0.31], P = 0.024) trials and increased apoB48 in addition trials (0.12 g/L [0.07, 0.18], P &lt; 0.001).There was evidence of interaction by food source with SSBs increasing postprandial TAG and apoB48 in addition trials and mixed sources increasing postprandial TAG in ad libitum trials. The certainty of the evidence was “moderate” for SSBs increasing TAG in addition trials and mixed sources increasing TAG in ad libitum trials and “low” for all other comparisons.

Conclusions

Food source more than energy control appears to mediate fructose-containing sugars on postprandial lipids. Good evidence suggests that SSBs and mixed sources increase postprandial lipids while evidence is less certain for the lack of effect of other food sources. More high-quality trials of different food sources are needed.

Funding Sources

Primary: Diabetes Canada.

Greater Adherence to the Portfolio Diet Is Associated with Lower Incidence of Type 2 Diabetes in the Women's Health Initiative

Objectives

To assess the association of the plant-based cholesterol-lowering diet, the Portfolio Diet, with incident type 2 diabetes in women.

Methods

We followed 147,732 postmenopausal women initially free of diabetes in the Women's Health Initiative (WHI) Clinical Trials and Observational Study from 1993 through 2017. Adherence to the Portfolio Diet was assessed using an a priori diet index based on six food categories (high in plant protein [soy & pulses], nuts, viscous fiber, plant sterols and monounsaturated fat, and low in saturated fat) that were previously found to lower cardiovascular risk factors in the Portfolio Diet trials. We used Cox proportional-hazard models to estimate hazard ratios (HRs) and 95% confidence intervals (CI) of the association of adherence to a Portfolio Diet score with incident type 2 diabetes, adjusting for potential confounders (demographics, lifestyle behaviors, and medical history). The Portfolio Diet score was cumulatively assessed at baseline and year three using a validated food frequency questionnaire. Type 2 diabetes diagnosis was ascertained by self-reported medication use.

Results

There were 14,096 cases of incident type 2 diabetes over a mean follow-up of 14.3 years. In the fully adjusted models, adherence to the Portfolio Diet score was associated with a lower risk of incident type 2 diabetes (HR, 0.88, CIs, 0.83, 0.93; P for trend &lt; 0.001), comparing the highest to lowest quartiles of adherence. Results remained similar across subgroup analyses (age, body mass index, family history of diabetes, and ethnicity) and several sensitivity analyses.

Conclusions

Among postmenopausal women, higher adherence to the Portfolio Diet was associated with lower incident type 2 diabetes. These findings are the first to show that the Portfolio Diet may be associated with a lower risk of type 2 diabetes and warrants further investigation.

Funding Sources

The WHI was funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, and the U.S. Department of Health and Human Services. AJG was supported by the Banting & Best Diabetes Centre Tamarack Graduate Award in Diabetes Research, the Peterborough K.M. Hunter Charitable Foundation Graduate Award, and an Ontario Graduate Scholarship. JLS was funded by a Diabetes Canada Clinician Scientist Award.

Important Food Sources of Fructose-Containing Sugars and Blood Pressure: A Systematic Review and Meta-Analysis of Controlled Trials

Objectives

Overconsumption of fructose-containing sugars may increase blood pressure. Whether this effect is mediated by the food matrix is unclear. We conducted a systematic review and meta-analysis of controlled feeding trials of the effect of food sources of fructose-containing sugars at different levels of energy control on blood pressure (NCT02716870).

Methods

We searched MEDLINE, Embase and the Cochrane Library through January, 2020 for controlled trials ≥7d. Trial designs were prespecified based on energy control: substitution (energy matched replacement of sugars in the diet); addition (excess energy from sugars added to diets); subtraction (energy from sugars subtracted from diets); and ad libitum (energy from sugars freely replaced in the diet) trials. Outcomes were systolic blood pressure (SBP) and diastolic blood pressure (DBP). Independent reviewers extracted data and assessed risk of bias. Certainty of evidence was assessed by GRADE.

Results

We included 76 trials (121 trial comparisons, N = 4 302) assessing 9 food sources (sugar-sweetened beverages [SSBs], sweetened dairy alternatives, 100% fruit juice, fruit, dried fruit, sweets, added nutritive sweetener, sweetened cereal grains/bars, and mixed sources) across the 4 levels of energy control. Total fructose-containing sugars decreased SBP (mean difference, −2.76 mmHg [95% CI, −4.36, −1.16], P = 0.001) and DBP (−1.26 mmHg [−2.29, −0.23], P = 0.016) in addition trials and the removal of these sugars decreased SBP (−1.79 mmHg [−3.36, −0.21], P = 0.026) in subtraction trials. There was evidence of interaction by food source with fruit decreasing and sweets and mixed sources increasing SBP and DBP in addition trials and the removal of SSBs decreased SBP in subtraction trials. The certainty of evidence was generally moderate to low for all food source-outcome relationships, except for the decreasing-effect of fruit on DBP in addition trials (high).

Conclusions

Food source and energy control appear to mediate the effect of fructose-containing sugars on blood pressure. The evidence provides a good indication that fruit decreases while excess calories from SSBs, sweets and mixed sources increase blood pressure. More high-quality trials of different food sources are needed to improve our estimates.

Funding Sources

Diabetes Canada.

Important food sources of fructose-containing sugars and incident gout: a systematic review and meta-analysis of prospective cohort studies

OBJECTIVE

Sugar-sweetened beverages (SSBs) are associated with hyperuricaemia and gout. Whether other important food sources of fructose-containing sugars share this association is unclear.

DESIGN

To assess the relation of important food sources of fructose-containing sugars with incident gout and hyperuricaemia, we conducted a systematic review and meta-analysis of prospective cohort studies.

METHODS

We searched MEDLINE, Embase and the Cochrane Library (through 13 September 2017). We included prospective cohort studies that investigated the relationship between food sources of sugar and incident gout or hyperuricaemia. Two independent reviewers extracted relevant data and assessed the risk of bias. We pooled natural-log transformed risk ratios (RRs) using the generic inverse variance method with random effects model and expressed as RR with 95% confidence intervals (CIs). The overall certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

We identified three studies (1 54 289 participants, 1761 cases of gout), comparing the highest with the lowest level of exposure for SSBs, fruit juices and fruits. No reports were found reporting incident hyperuricaemia. Fruit juice and SSB intake showed an adverse association (fruit juice: RR=1.77, 95% CI 1.20 to 2.61; SSB: RR=2.08, 95% CI 1.40 to 3.08), when comparing the highest to lowest intake of the most adjusted models. There was no significant association between fruit intake and gout (RR 0.85, 95% CI 0.63 to 1.14). The strongest evidence was for the adverse association with SSB intake (moderate certainty), and the weakest evidence was for the adverse association with fruit juice intake (very low certainty) and lack of association with fruit intake (very low certainty).

CONCLUSION

There is an adverse association of SSB and fruit juice intake with incident gout, which does not appear to extend to fruit intake. Further research is needed to improve our estimates.

TRIAL REGISTRATION NUMBER

NCT02702375; Results.

Multi-centre Raman spectral mapping of oesophageal cancer tissues: a study to assess system transferability

The potential for Raman spectroscopy to provide early and improved diagnosis on a wide range of tissue and biopsy samples in situ is well documented. The standard histopathology diagnostic methods of reviewing H&E and/or immunohistochemical (IHC) stained tissue sections provides valuable clinical information, but requires both logistics (review, analysis and interpretation by an expert) and costly processing and reagents. Vibrational spectroscopy offers a complimentary diagnostic tool providing specific and multiplexed information relating to molecular structure and composition, but is not yet used to a significant extent in a clinical setting. One of the challenges for clinical implementation is that each Raman spectrometer system will have different characteristics and therefore spectra are not readily compatible between systems. This is essential for clinical implementation where classification models are used to compare measured biochemical or tissue spectra against a library training dataset. In this study, we demonstrate the development and validation of a classification model to discriminate between adenocarcinoma (AC) and non-cancerous intraepithelial metaplasia (IM) oesophageal tissue samples, measured on three different Raman instruments across three different locations. Spectra were corrected using system transfer spectral correction algorithms including wavenumber shift (offset) correction, instrument response correction and baseline removal. The results from this study indicate that the combined correction methods do minimize the instrument and sample quality variations within and between the instrument sites. However, more tissue samples of varying pathology states and greater tissue area coverage (per sample) are needed to properly assess the ability of Raman spectroscopy and system transferability algorithms over multiple instrument sites.

Expanding conceptualizations of harm reduction: results from a qualitative community-based participatory research study with people who inject drugs

Background

The perspectives of people who use drugs are critical in understanding why people choose to reduce harm in relation to drug use, what practices are considered or preferred in conceptualizations of harm reduction, and which environmental factors interfere with or support the use of harm reduction strategies. This study explores how people who inject drugs (PWID) think about harm reduction and considers the critical imperative of equity in health and social services delivery for this community.

Methods

This community-based participatory research study was conducted in a Canadian urban centre. Using a peer-based recruitment and interviewing strategy, semi-structured qualitative interviews were conducted by and with PWID. The Vidaview Life Story Board, an innovative tool where interviewers and participant co-construct a visual “life-scape” using a board, markers, and customized picture magnets, was used to facilitate the interviews. The topics explored included injection drug use and harm reduction histories, facilitators and barriers to using harm reduction strategies, and suggestions for improving services and supports.

Results

Twenty-three interviews with PWID (14 men and 9 women) were analysed, with a median age of 50. Results highlighted an expanded conceptualization of harm reduction from the perspectives of PWID, including motivations for adopting harm reduction strategies and a description of harm reduction practices that went beyond conventional health-focused concerns. The most common personal practices that PWID used included working toward moderation, employing various cognitive strategies, and engaging in community activities. The importance of social or peer support and improving self-efficacy was also evident. Further, there was a call for less rigid eligibility criteria and procedures in health and social services, and the need to more adequately address the stigmatization of drug users.

Conclusions

These findings demonstrated that PWID incorporate many personal harm reduction practices in their daily lives to improve their well-being, and these practices highlight the importance of agency, self-care, and community building. Health and social services are needed to better support these practices because the many socio-structural barriers this community faces often interfere with harm reduction efforts. Finally, “one size does not fit all” when it comes to harm reduction, and more personalized or de-medicalized conceptualizations are recommended.

Malignant metastatic deposits in an immunocompromised patient—could this be tuberculosis?

We report the case of a 50-year-old female renal transplant patient who developed disseminated deposits initially diagnosed as metastatic malignancy of unknown primary. She declined a tissue diagnosis but subsequently developed recurrent sepsis and symptomatic unilateral pleural effusion. Mycobacterium tuberculosis was cultured from pleural fluid. Following introduction of anti-tuberculous medications, her symptoms improved rapidly and the progression of her disseminated deposits stabilized. Tuberculosis is well-known to be associated with immunocompromised patients. It is a curable disease and should remain an important differential diagnosis for transplant patients who develop suspicious malignant metastatic lesions.

Risk factors associated with resistance to HIV testing among transwomen in Brazil

Transwomen are a high-risk population for HIV/AIDS worldwide. However, many transwomen do not test for HIV. This study aimed to identify factors associated with resistance to HIV testing among transwomen in Fortaleza/CE. A cross-sectional study was conducted between August and December 2008 with a sample of 304 transwomen recruited through respondent-driven sampling. Data analysis utilized Respondent-Driven Sampling Analysis Tool and SPSS 11.0. Univariate, bivariate, and multivariate analyses examined risk factors associated with resistance to HIV testing. Less than 18 years of age (OR = 4.221; CI = 2.419-7.364), sexual debut before 10 years of age (OR = 6.760; CI = 2.996-15.256), using illegal drugs during sex (OR = 2.384; CI = 1.310-4.339), experience of discrimination (OR = 3.962; CI = 1.540-10.195) and a belief that the test results were not confidential (OR = 3.763; CI = 2.118-6.688) are independently associated with resistance to testing. Intersectoral and targeted strategies aimed at encouraging the adoption of safer sexual behaviors and testing for HIV among transwomen are required.

Evaluation of a confocal Raman probe for pathological diagnosis during colonoscopy

AIM

Raman spectroscopy of human tissue can provide a unique biochemical 'fingerprint' that alters with disease progression. Light incident on tissue is scattered and may be altered in wavelength, which can be represented as a Raman spectrum. A confocal fibreoptic Raman probe designed to fit down the accessory channel of a colonoscope has been constructed. This in-vitro study evaluated the accuracy of pathological diagnosis in the colon using probe-based Raman spectroscopy.

METHOD

Biopsy samples were collected at colonoscopy, snap frozen and stored at -80 °C. Raman spectra with 10-s and 1-s acquisition periods were measured with the probe tip in contact with the mucosal surface of thawed specimens. Mathematical modelling using principal component analysis followed by linear discriminant analysis was used to correlate Raman spectra with histopathological diagnoses.

RESULTS

Three-hundred and seventy-five Raman spectra were measured from a total of 356 colon biopsies (81 of normal colon mucosa, 79 of hyperplastic polyps, 92 of adenomatous polyps, 64 of adenocarcinoma and 40 of ulcerative colitis) from 177 patients. Spectral classification accuracies comparing pathology pairs ranged from 72.1 to 95.9% for 10-s acquisitions and from 61.5 to 95.1% for 1-s acquisitions. For a three-group model of normal, adenomatous and adenocarcinoma tissue, accuracies were 74.1% for 10-s acquisitions and 63.5% for 1-s acquisitions.

CONCLUSION

The confocal Raman probe system can distinguish between different colorectal pathologies. The probe has potential to establish Raman spectroscopy as a clinical tool for instant diagnosis at colonoscopy.

The transcultural diabetes nutrition algorithm: a canadian perspective

The Transcultural Diabetes Nutrition Algorithm (tDNA) is a clinical tool designed to facilitate implementation of therapeutic lifestyle recommendations for people with or at risk for type 2 diabetes. Cultural adaptation of evidence-based clinical practice guidelines (CPG) recommendations is essential to address varied patient populations within and among diverse regions worldwide. The Canadian version of tDNA supports and targets behavioural changes to improve nutritional quality and to promote regular daily physical activity consistent with Canadian Diabetes Association CPG, as well as channelling the concomitant management of obesity, hypertension, dyslipidemia, and dysglycaemia in primary care. Assessing glycaemic index (GI) (the ranking of foods by effects on postprandial blood glucose levels) and glycaemic load (GL) (the product of mean GI and the total carbohydrate content of a meal) will be a central part of the Canadian tDNA and complement nutrition therapy by facilitating glycaemic control using specific food selections. This component can also enhance other metabolic interventions, such as reducing the need for antihyperglycaemic medication and improving the effectiveness of weight loss programs. This tDNA strategy will be adapted to the cultural specificities of the Canadian population and incorporated into the tDNA validation methodology.

ILSI Brazil International Workshop on Functional Foods: a narrative review of the scientific evidence in the area of carbohydrates, microbiome, and health

To stimulate discussion around the topic of ‘carbohydrates’ and health, the Brazilian branch of the International Life Sciences Institute held the 11th International Functional Foods Workshop (1–2 December 2011) in which consolidated knowledge and recent scientific advances specific to the relationship between carbohydrates and health were presented. As part of this meeting, several key points related to dietary fiber, glycemic response, fructose, and impacts on satiety, cognition, mood, and gut microbiota were realized: 1) there is a need for global harmonization of a science-based fiber definition; 2) low-glycemic index foods can be used to modulate the postprandial glycemic response and may affect diabetes and cardiovascular outcomes; 3) carbohydrate type may influence satiety and satiation; glycemic load and glycemic index show links to memory, mood, and concentration; 4) validated biomarkers are needed to demonstrate the known prebiotic effect of carbohydrates; 5) negative effects of fructose are not evident when human data are systematically reviewed; 6) new research indicates that diet strongly influences the microbiome; and 7) there is mounting evidence that the intestinal microbiota has the ability to impact the gut–brain axis. Overall, there is much promise for development of functional foods that impact the microbiome and other factors relevant to health, including glycemic response (glycemic index/glycemic load), satiety, mood, cognition, and weight management.

Adding monounsaturated fatty acids to a dietary portfolio of cholesterol-lowering foods in hypercholesterolemia

BACKGROUND

Higher intake of monounsaturated fat may raise high-density lipoprotein (HDL) cholesterol without raising low-density lipoprotein (LDL) cholesterol. We tested whether increasing the monounsaturated fat content of a diet proven effective for lowering LDL cholesterol (dietary portfolio) also modified other risk factors for cardiovascular disease, specifically by increasing HDL cholesterol, lowering serum triglyceride and further reducing the ratio of total to HDL cholesterol.

METHODS

Twenty-four patients with hyperlipidemia consumed a therapeutic diet very low in saturated fat for one month and were then randomly assigned to a dietary portfolio low or high in monounsaturated fatty acid for another month. We supplied participants' food for the two-month period. Calorie intake was based on Harris-Benedict estimates for energy requirements.

RESULTS

For patients who consumed the dietary portfolio high in monounsaturated fat, HDL cholesterol rose, whereas for those consuming the dietary portfolio low in monounsaturated fat, HDL cholesterol did not change. The 12.5% treatment difference was significant (0.12 mmol/L, 95% confidence interval [CI] 0.05 to 0.21, p = 0.003). The ratio of total to HDL cholesterol was reduced by 6.5% with the diet high in monounsaturated fat relative to the diet low in monounsaturated fat (-0.28, 95% CI -0.59 to -0.04, p = 0.025). Patients consuming the diet high in monounsaturated fat also had significantly higher concentrations of apolipoprotein AI, and their C-reactive protein was significantly lower. No treatment differences were seen for triglycerides, other lipids or body weight, and mean weight loss was similar for the diets high in monounsaturated fat (-0.8 kg) and low in monounsaturated fat (-1.2 kg).

INTERPRETATION

Monounsaturated fat increased the effectiveness of a cholesterol-lowering dietary portfolio, despite statin-like reductions in LDL cholesterol. The potential benefits for cardiovascular risk were achieved through increases in HDL cholesterol, further reductions in the ratio of total to HDL cholesterol and reductions in C-reactive protein. (ClinicalTrials.gov trial register no. NCT00430430.).

Signal-to-noise contribution of principal component loads in reconstructed near-infrared Raman tissue spectra

The overall quality of Raman spectra in the near-infrared region, where biological samples are often studied, has benefited from various improvements to optical instrumentation over the past decade. However, obtaining ample spectral quality for analysis is still challenging due to device requirements and short integration times required for (in vivo) clinical applications of Raman spectroscopy. Multivariate analytical methods, such as principal component analysis (PCA) and linear discriminant analysis (LDA), are routinely applied to Raman spectral datasets to develop classification models. Data compression is necessary prior to discriminant analysis to prevent or decrease the degree of over-fitting. The logical threshold for the selection of principal components (PCs) to be used in discriminant analysis is likely to be at a point before the PCs begin to introduce equivalent signal and noise and, hence, include no additional value. Assessment of the signal-to-noise ratio (SNR) at a certain peak or over a specific spectral region will depend on the sample measured. Therefore, the mean SNR over the whole spectral region (SNR(msr)) is determined in the original spectrum as well as for spectra reconstructed from an increasing number of principal components. This paper introduces a method of assessing the influence of signal and noise from individual PC loads and indicates a method of selection of PCs for LDA. To evaluate this method, two data sets with different SNRs were used. The sets were obtained with the same Raman system and the same measurement parameters on bladder tissue collected during white light cystoscopy (set A) and fluorescence-guided cystoscopy (set B). This method shows that the mean SNR over the spectral range in the original Raman spectra of these two data sets is related to the signal and noise contribution of principal component loads. The difference in mean SNR over the spectral range can also be appreciated since fewer principal components can reliably be used in the low SNR data set (set B) compared to the high SNR data set (set A). Despite the fact that no definitive threshold could be found, this method may help to determine the cutoff for the number of principal components used in discriminant analysis. Future analysis of a selection of spectral databases using this technique will allow optimum thresholds to be selected for different applications and spectral data quality levels.

A miniature confocal Raman probe for endoscopic use

Raman spectroscopy is a powerful tool for studying biochemical changes in the human body. We describe a miniature, confocal fibre optic probe intended to fit within the instrument channel of a standard medical endoscope. This probe has been optimized for the study of the carcinogenesis process of oesophageal malignancy. The optical design and fabrication of this probe is described including the anisotropic wet etching technique used to make silicon motherboards and jigs. Example spectra of PTFE reference samples are shown. Spectra with acquisition times as low as 2 s from resected oesophageal tissue are presented showing identifiable biochemical changes from various pathologies.