Dietary strategies for chemotherapy-induced nausea and vomiting: A systematic review

BACKGROUND & AIMS

Chemotherapy-induced nausea and vomiting (CINV) is one of the most distressing cancer treatment side effects, affecting 20-70% of patients despite routine antiemetic prescription. Although dietary modifications are routinely recommended in clinical practice, there is lack of data synthesis to determine which dietary strategies for managing CINV are supported by quality evidence. This systematic review was conducted to examine the effect of dietary strategies on incidence and severity of CINV in adults compared with no intervention, usual care, or alternative strategies.

METHODS

Five electronic databases were searched from inception to 15th July 2021 for original research studies of interventional or observational design assessing dietary strategies for CINV. The quality of evidence was appraised, data were synthesized narratively, and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment of the certainty of the evidence was applied.

RESULTS

Twenty-one studies were included, 10 (48%) interventional studies and 11 (52%) observational studies. Most interventional and observational studies had a high or neutral risk of bias (70% and 72%, respectively). Of the interventions studied, strongest evidence with highest certainty was found for the very large positive effect of CINV-specific education and support with a personalized meal plan from a dietician, implemented in person or in writing, for reducing the severity of nausea and overall CINV (effect size: very large; GRADE: high). A statistically significant very large positive effect of ginger tea consumption was also found on overall CINV severity; however, certainty in this effect was very low. Although confidence in the findings from observational studies was very low to low, a statistically significant positive association was also found between a moderate intake of alcohol and incidence of nausea, vomiting, or overall CINV as well as nausea severity; the Mediterranean diet and nausea incidence and severity; and adequate intake of energy, protein, fat, or carbohydrate and nausea or vomiting incidence.

CONCLUSION

Improved CINV was associated with CINV-specific nutrition education and support from health professionals. Non-restrictive dietary patterns that include adequate energy and macronutrient intakes, particularly protein, and include ginger, and Mediterranean diet concepts may benefit CINV; however, the confidence in the body of evidence to inform these conclusions is mostly very low to moderate. Future rigorous trials with adequate sample sizes, clearly defined dietary strategies, and valid outcome measures are warranted prior to dietary strategies being routinely prescribed alongside antiemetic regimens.

Improvement of Obesity and Dyslipidemic Activity of Amomum tsao-ko in C57BL/6 Mice Fed a High-Carbohydrate Diet

Amomum tsao-ko Crevost et Lemaire (Zingiberaceae) is a medicinal herb found in Southeast Asia that is used for the treatment of malaria, abdominal pain, dyspepsia, etc. The aim of this study was to investigate the effect of an ethanol extract of Amomum tsao-ko (EAT) on obesity and hyperlipidemia in C57BL/6 mice fed a high-carbohydrate diet (HCD). First, the mice were divided into five groups (n = 6/group) as follows: normal diet, HCD, and HCD+EAT (100, 200, and 400 mg/kg/day), which were orally administered with EAT daily for 84 days. Using microcomputed tomography (micro-CT) analysis, we found that EAT inhibited not only body-weight gain, but also visceral fat and subcutaneous fat accumulation. Histological analysis confirmed that EAT decreased the size of fat tissues. EAT consistently improved various indices, including plasma levels of total cholesterol (TC), triglyceride (TG), low-density lipoprotein, high-density lipoprotein, atherogenic index, and cardiac risk factors, which are related to dyslipidemia—a major risk factor for heart disease. The contents of TC and TG, as well as the lipid droplets of HCD-induced hepatic accumulation in the liver tissue, were suppressed by EAT. Taken together, these findings suggest the possibility of developing EAT as a therapeutic agent for improving HCD-induced obesity and hyperlipidemia.

Nutritional adequacy of very low- and high-carbohydrate, low saturated fat diets in adults with type 2 diabetes: A secondary analysis of a 2-year randomised controlled trial

BACKGROUND

Growing evidence supports use of very low-carbohydrate (LC) diets for glycaemic control in type 2 diabetes. However, limited data on the micronutrient adequacy of LC diets exist.

OBJECTIVE

This study compared the long-term effects of a very low-carbohydrate, high unsaturated/low saturated fat (LC) diet to a high-carbohydrate, low-fat (HC) diet on micronutrient biomarkers in adults with obesity and type 2 diabetes.

METHODS

115 adults with type 2 diabetes (mean[SD]; BMI:34.6[4.3]kg/m², age:58[7]yrs, HbA1c:7.3[1.1]%, 56[12]mmol/mol) were randomized to one of two planned, nutritionally-replete, energy-matched, hypocaloric diets (500-1000 kcal/day deficit): (1) LC:14% energy carbohydrate, 28%protein, 58%fat[<10% saturated fat]) or (2) HC:53%carbohydrate, 17%protein, 30%fat [<10%saturated fat]) for 2 years. Nutritional biomarkers- folate, β-carotene, vitamin B12, D, E, copper, zinc, selenium, calcium, magnesium, sodium, potassium, iron, ferritin, transferrin and transferrin saturation were measured in fasting blood at baseline, 24, 52 and 104 weeks.

RESULTS

61 participants completed the study with similar dropouts in each group (P = 0.40). For all biomarkers assessed, there were no differential response between groups overtime (P ≥ 0.17 time × diet interaction). Mean vitamin and mineral levels remained within normal (laboratory-specific) reference ranges without any reported cases of clinical deficiencies.

CONCLUSION

In free-living individuals with type 2 diabetes, nutrition biomarkers within normal ranges at baseline did not change significantly after 2 years on a prescribed LC or HC diet. These results demonstrate the feasibility of delivering a nutritionally replete LC diet and the importance of considering nutritional factors in planning LC diets that have strong public health relevance to the dietary management of type 2 diabetes.

TRIAL REGISTRATION

http://www.anzctr.org.au/, ANZCTR No. ACTRN12612000369820.

Postprandial remodeling of high-density lipoprotein following high saturated fat and high carbohydrate meals

BACKGROUND

Humans spend most of the time in the postprandial state, yet most knowledge about high-density lipoproteins (HDL) derives from the fasted state. HDL protein and lipid cargo mediate HDL's antiatherogenic effects, but whether these HDL constituents change in the postprandial state and are affected by dietary macronutrients remains unknown.

OBJECTIVES

This study aimed to assess changes in HDL protein and lipid composition after the consumption of a high-carbohydrate or high saturated fat (HSF) meal.

METHODS

We isolated HDL from plasma collected during a randomized, cross-over study of metabolically healthy subjects. Subjects consumed isocaloric meals consisting predominantly of either carbohydrate or fat. At baseline and at 3 and 6 hours postprandial, we quantified HDL protein and lipid composition by liquid chromatography-mass spectrometry.

RESULTS

A total of 15 subjects were included (60% female, aged 34 ± 15 years, body mass index: 24.1 ± 2.7 kg/m2). Consumption of the HSF meal led to HDL enrichment in total lipid (P = .006), triglyceride (P = .02), and phospholipid (P = .008) content and a corresponding depletion in protein content. After the HSF meal, 16 of the 25 measured phosphatidylcholine species significantly increased in abundance (P values range from .027 to <.001), along with several sphingolipids including ceramides (P < .004), lactosylceramide (P = .023), and sphingomyelin-14 (P = .013). Enrichment in apolipoprotein A-I (P = .001) was the only significant change in HDL protein composition after the HSF meal. The high-carbohydrate meal conferred only minimal changes in HDL composition.

CONCLUSION

Meal macronutrient content acutely affects HDL composition in the postprandial state, with the HSF meal resulting in enrichment of HDL phospholipid content with possible consequences for HDL function.

Nutritional hypophosphatemic rickets secondary to Neocate® use

Elemental formula is commonly used in children with feeding intolerance. We describe two, medically complex and feeding tube dependent, patients exclusively fed with Neocate® who subsequently developed hypophosphatemic rickets. Both patients had gross motor decline and pain with physical touch. They were found to have low serum phosphorus, normal calcium, and vitamin D studies, with elevated alkaline phosphatase suggestive of nutritional hypophosphatemia. Both courses were complicated by hypocalcemia following formula change and phosphorus supplementation, highlighting the need for careful management of phosphate repletion in affected individuals. Diligent serial electrolyte monitoring as well as attention to bone health is needed in conjunction with elemental nutrition. Formula change led to restoration of calcium and phosphorus homeostasis and radiographic improvement in these patients.

Glycemic index, glycemic load and carbohydrate intake in association with risk of renal cell carcinoma

Carbohydrate intake affects postprandial glucose levels and insulin response, which plays a role in carcinogenesis. The relationship between carbohydrate intake, dietary glycemic index (GI) and glycemic load (GL), and risk of renal cell carcinoma (RCC) remains unclear. We conducted a case-control study including 854 patients with newly diagnosed RCC (cases) and 1255 healthy participants (controls) recruited since 2002. GI, GL and carbohydrate intake were obtained via a validated food frequency questionnaire. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression, adjusting for potential confounders. We found that higher GI was significantly associated with RCC risk with an OR of 1.32 (95% CI, 0.99-1.74; Ptrend = 0.026) (the highest versus the lowest quartiles). We also observed an inverse association between fiber intake and RCC risk with OR of 0.70 (95% CI = 0.50-0.99) as well as between starch intake and risk of RCC with OR of 0.65 (95% CI = 0.49-0.87). Individuals with a high-GI diet and hypertension or high body mass index (BMI) had a 2.7 times (OR = 2.67, 95% CI = 1.96-3.64) and two times (OR = 1.95, 95% CI = 1.29-2.92) higher RCC risk, respectively, than those without these factors. Our findings suggest that a high-GI diet is associated with an increased risk of RCC, whereas increased fiber and starch intakes appear to be associated with a decreased risk of RCC. We found that reducing GI levels and increasing fiber intake could be a dietary strategy to decrease RCC risk, especially for individuals with hypertension or high BMI.

Psychologically Informed Implementations of Sugary-Drink Portion Limits

In 2012, the New York City Board of Health prohibited restaurants from selling sugary drinks in containers that would hold more than 16 oz. Although a state court ruled that the Board of Health did not have the authority to implement such a policy, it remains a legally viable option for governments and a voluntary option for restaurants. However, there is very limited empirical data on how such a policy might affect the purchasing and consumption of sugary drinks. We report four well-powered, incentive-compatible experiments in which we evaluated two possible ways that restaurants might comply with such a policy: bundling (i.e., dividing the contents of oversized cups into two regulation-size cups) and providing free refills (i.e., offering a regulation-size cup with unlimited refills). Bundling caused people to buy less soda. Free refills increased consumption, especially when a waiter served the refills. This perverse effect was reduced in self-service contexts that required walking just a few steps to get a refill.

Lucerastat, an iminosugar with potential as substrate reduction therapy for glycolipid storage disorders: safety, tolerability, and pharmacokinetics in healthy subjects

BACKGROUND

Lucerastat, an inhibitor of glucosylceramide synthase, has the potential to restore the balance between synthesis and degradation of glycosphingolipids in glycolipid storage disorders such as Gaucher disease and Fabry disease. The safety, tolerability, and pharmacokinetics of oral lucerastat were evaluated in two separate randomized, double-blind, placebo-controlled, single- and multiple-ascending dose studies (SAD and MAD, respectively) in healthy male subjects.

METHODS

In the SAD study, 31 subjects received placebo or a single oral dose of 100, 300, 500, or 1000 mg lucerastat. Eight additional subjects received two doses of 1000 mg lucerastat or placebo separated by 12 h. In the MAD study, 37 subjects received placebo or 200, 500, or 1000 mg b.i.d. lucerastat for 7 consecutive days. Six subjects in the 500 mg cohort received lucerastat in both absence and presence of food.

RESULTS

In the SAD study, 15 adverse events (AEs) were reported in ten subjects. Eighteen AEs were reported in 15 subjects in the MAD study, in which the 500 mg dose cohort was repeated because of elevated alanine aminotransferase (ALT) values in 4 subjects, not observed in other dose cohorts. No severe or serious AE was observed. No clinically relevant abnormalities regarding vital signs and 12-lead electrocardiograms were observed. Lucerastat Cmax values were comparable between studies, with geometric mean Cmax 10.5 (95% CI: 7.5, 14.7) and 11.1 (95% CI: 8.7, 14.2) μg/mL in the SAD and MAD study, respectively, after 1000 mg lucerastat b.i.d. tmax (0.5 - 4 h) and t1/2 (3.6 - 8.1 h) were also within the same range across dose groups in both studies. Using the Gough power model, dose proportionality was confirmed in the SAD study for Cmax and AUC0-∞, and for AUC0-12 in the MAD study. Fed-to-fasted geometric mean ratio for AUC0-12 was 0.93 (90% CI: 0.80, 1.07) and tmax was the same with or without food, indicating no food effect.

CONCLUSIONS

Incidence of drug-related AEs did not increase with dose. No serious AEs were reported for any subject. Overall, lucerastat was well tolerated. These results warrant further investigation of substrate reduction therapy with lucerastat in patients with glycolipid storage disorders. SAD study was registered on clinicaltrials.gov under the identifier NCT02944487 on the 24th of October 2016 (retrospectively registered). MAD study was registered on clinicaltrials.gov under the identifier NCT02944474 on the 25th of October 2016 (retrospectively registered).

TRIAL REGISTRATION

A Study to Assess the Safety and Tolerability of Lucerastat in Subjects With Fabry Disease. Clinicaltrials.gov: NCT02930655 .

Associations between Sugar Intake from Different Food Sources and Adiposity or Cardio-Metabolic Risk in Childhood and Adolescence: The Korean Child-Adolescent Cohort Study

The increasing prevalence of childhood obesity is a serious public health problem associated with co-morbidities in adulthood, as well as childhood. This study was conducted to identify associations between total sugar intake and sugar intake from different foods (fruit, milk, and sugar-sweetened beverages (SSBs)), and adiposity and continuous metabolic syndrome scores (cMetS) among Korean children and adolescents using cohort data. The study subjects were children (n = 770) who participated in the 4th year (2008) of the Korean Child–Adolescent Cohort Study (KoCAS). Dietary intake data were collected via three-day 24-h food records, and sugar intake was calculated for the total sugar content of foods using our database compiled from various sources. Anthropometric measurements, assessments of body composition, and blood sample analysis were performed at baseline and at follow-up four years later. The cMetS was calculated based on waist circumference, triglycerides, high-density lipoprotein cholesterol, glucose, and mean arterial blood pressure. According to multiple linear regression analysis, there were no significant associations between total sugar intake and adiposity and cMetS. However, higher intake of fruit sugar at baseline was significantly associated with lower body mass index (BMI) z-scores and body fat percentages at baseline (β = −0.10, p = 0.02 and β = −0.78, p < 0.01, respectively). At follow-up, sugar intake from fruit at baseline was still negatively associated with the above outcomes, but only the relationship with BMI z-scores retained statistical significance (β = −0.08, p < 0.05). There was a significant positive relationship between consumption of sugar from SSBs and cMetS at baseline (β = 0.04, p = 0.02), but that relationship was not observed at follow-up (p = 0.83). Differences in consumption sugars from fruit and SSBs might play an important role in the risk of adiposity and metabolic disease in children and adolescents. Our results suggest that strategies for reducing sugar intake need to target particular food groups. Consequently, this information could be of value to obesity- and metabolic disease-prevention strategies.

Liberalising agricultural policy for sugar in Europe risks damaging public health

Emilie Aguirre and colleagues discuss what changes to Europe’s agricultural policy might mean for our health

Other Dietary Confounders: FODMAPS et al

BACKGROUND

While it is well documented and widely appreciated that ingestion of wheat (and less so rye and barley) is associated with gastrointestinal symptoms such as bloating or abdominal pain, the component of wheat to which such an effect is attributed is less well established.

KEY MESSAGES

Wheat is a complex of proteins (80% gluten, 20% metabolic proteins), carbohydrates (starch, non-starch polysaccharides, fructans), lipids and other components. The majority of attention has focused on gluten as the culprit in triggering symptoms, but re-challenge studies have nearly all used wheat flour-related products (such as bread) as the stimulus. When carbohydrate-deplete gluten was used as the challenge agent, gluten-specific feelings of depression and not gut symptoms were observed in those who fulfilled strict criteria of 'non-coeliac gluten sensitivity', thereby underlining the complexity of cereals and of undertaking research in this area. Candidate components other than gluten include poorly absorbed oligosaccharides (mainly fructans), non-gluten wheat proteins such as amylase-trypsin inhibitors or wheat germ agglutinin, and exorphins released during the digestion of gluten. Specific biological and/or clinical effects associated with gluten-free diets or wheat ingestion need to be carefully dissected before attribution to gluten can be claimed.

CONCLUSIONS

Currently, coeliac disease is the only common condition that has been unequivocally linked to gluten. Inaccurate attribution will be associated with suboptimal therapeutic advice and at least partly underlies the current gluten-free epidemic gripping the Western world.

Caramel color in soft drinks and exposure to 4-methylimidazole: a quantitative risk assessment

Caramel color is added to many widely-consumed beverages as a colorant. Consumers of these beverages can be exposed to 4-methylimidazole (4-MEI), a potential carcinogen formed during its manufacture. California's Proposition 65 law requires that beverages containing 4-MEI concentrations corresponding to exposures that pose excess cancer risks > 1 case per 100,000 exposed persons (29 μg 4-MEI/day) carry warning labels. Using ultrahigh-performance liquid chromatography-tandem mass spectrometry, we assessed 4-MEI concentrations in 12 beverages purchased in California and a geographically distant metropolitan area (New York) in which warning labels are not required. In addition, we characterized beverage consumption by age and race/ethnicity (using weighted means calculated from logistic regressions) and assessed 4-MEI exposure and resulting cancer risks and US population cancer burdens attributable to beverage consumption. Data on beverage consumption were obtained from the National Health and Nutrition Examination Survey, dose-response data for 4-MEI were obtained from the California Environmental Protection Agency Office of Environmental Health Hazards Assessment, and data on population characteristics were obtained from the U.S. Census Bureau. Of the 12 beverages, Malta Goya had the highest 4-MEI concentration (915.8 to 963.3μg/L), lifetime average daily dose (LADD - 8.04x10-3 mg/kgBW-day), lifetime excess cancer risk (1.93x10-4) and burden (5,011 cancer cases in the U.S. population over 70 years); Coca-Cola had the lowest value of each (4-MEI: 9.5 to 11.7μg/L; LADD: 1.01x10-4 mg/kgBW-day; risk: 1.92x10-6; and burden: 76 cases). 4-MEI concentrations varied considerably by soda and state/area of purchase, but were generally consistent across lots of the same beverage purchased in the same state/area. Routine consumption of certain beverages can result in 4-MEI exposures > 29 μg/day. State regulatory standards appear to have been effective in reducing exposure to carcinogens in some beverages. Federal regulation of 4-MEI in caramel color may be appropriate.

Artificially and sugar-sweetened carbonated beverage consumption is not associated with risk of lymphoid neoplasms in older men and women

BACKGROUND

Concern about the carcinogenic potential of aspartame was raised after an increase in lymphomas and leukemia was reported in an animal study at doses similar to human exposure. Two prospective cohort studies published after the report found inconsistent results for estimated aspartame intake, artificially sweetened beverage consumption, and risk of lymphoid neoplasms.

OBJECTIVE

The objective of this study was to examine associations of artificially and sugar-sweetened carbonated beverage consumption (for comparison) and aspartame intake with risk of non-Hodgkin lymphoma (NHL) overall and by major histologic subtype in the Cancer Prevention Study-II Nutrition Cohort.

METHODS

Among 100,442 adult men and women who provided information on diet and lifestyle factors in 1999, 1196 NHL cases were verified during a 10-y follow-up period. Cox proportional hazards regression was used to estimate multivariable-adjusted RRs and 95% CIs.

RESULTS

In women and men combined, there were no associations of consumption of ≥1 (355 mL) servings/d of artificially (RR: 0.92; 95% CI: 0.73, 1.17; P-trend: 0.14) or sugar- (RR: 1.10; 95% CI: 0.77, 1.58; P-trend: 0.62) sweetened carbonated beverages with NHL risk, compared to no consumption (P-heterogeneity by gender: 0.11-1.00). Similarly, aspartame intake was not associated with NHL risk (RR: 1.02; 95% CI: 0.84, 1.24; P-trend: 0.69, top vs. bottom quintile). Associations with NHL subtype (multiple myeloma, diffuse large B-cell lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma, and follicular and other B-cell lymphoma) were generally null.

CONCLUSION

These findings do not support associations of daily consumption of artificially or sugar-sweetened carbonated beverages, or aspartame, with NHL risk.

A thickened amino-acid formula in infants with cow's milk allergy failing to respond to protein hydrolysate formulas: a randomized double-blind trial

INTRODUCTION

Amino-acid-based formulas (AAFs) are recommended for children with cow's milk protein allergy (CMPA) failing to respond to extensively hydrolyzed formulas (eHFs).

OBJECTIVE

This study aimed to assess the tolerance/hypoallergenicity and efficacy of a thickened AAF (TAAF) in these infants.

METHODS

This multicenter, double-blind, randomized controlled trial (NCT01940068) compared 3-month feeding with a pectin-based TAAF (Novalac(®), United Pharmaceuticals, Paris, France) and a commercially available "reference" AAF (RAAF; Neocate(®), Nutricia, Germany) in infants aged <18 months with CMPA and persistent allergy symptoms with eHF feeding. Reported here are the results of an interim analysis after 1 month of feeding.

RESULTS

Of the 86 infants randomized, CMPA with eHF intolerance was confirmed in 75 infants; all of them tolerated the allocated AAFs. The major allergic symptom disappeared within 1 month in 61.9 and 51.5 % and regurgitations disappeared in 66.7 and 42.3 % of infants who received TAAF and RAAF, respectively. Infants had significantly more normal stools (soft or formed consistency) with the TAAF (90.5 vs. 66.7 %; p = 0.011). From baseline, daily family life significantly improved with both AAFs: crying time decreased by 97.3 (p < 0.001) and 28.6 min (p = 0.014) and sleeping time increased by 64.6 (p = 0.009) and 29.0 min with TAAF and RAAF, respectively. At day 30, weight and body mass index z-score gains were 0.1 and 0.2 with TAAF and 0.2 and 0.0 with RAAF.

CONCLUSION

Both AAFs were well tolerated by infants with CMPA and eHF intolerance and ensured appropriate growth, with the TAAF providing additional comfort.

Carbohydrate intake in the etiology of Crohn's disease and ulcerative colitis

BACKGROUND

Diet may have a role in the etiology of inflammatory bowel disease. In previous studies, the associations between increased intakes of carbohydrates, sugar, starch, and inflammatory bowel disease are inconsistent. However, few prospective studies have investigated the associations between these macronutrients and incident Crohn's disease (CD) or ulcerative colitis (UC).

METHODS

A total of 401,326 men and women were recruited between 1991 and 1998. At recruitment, dietary intakes of carbohydrate, sugar, and starch were measured using validated food frequency questionnaires. The cohort was monitored identifying participants who developed incident CD or UC. Cases were matched with 4 controls, and odds ratios were calculated for quintiles of total carbohydrate, sugar, and starch intakes adjusted for total energy intake, body mass index, and smoking.

RESULTS

One hundred ten participants developed CD, and 244 participants developed UC during follow-up. The adjusted odds ratio for the highest versus the lowest quintiles of total carbohydrate intake for CD was 0.87, 95% CI = 0.24 to 3.12 and for UC 1.46, 95% CI = 0.62 to 3.46, with no significant trends across quintiles for either (CD, P trend = 0.70; UC, P trend = 0.41). Similarly, no associations were observed with intakes of total sugar (CD, P trend = 0.50; UC, P trend = 0.71) or starch (CD, P trend = 0.69; UC, P trend = 0.17).

CONCLUSIONS

The lack of associations with these nutrients is in agreement with many case-control studies that have not identified associations with CD or UC. As there is biological plausibility for how specific carbohydrates could have an etiological role in inflammatory bowel disease, future epidemiological work should assess individual carbohydrates, although there does not seem to be a macronutrient effect.

A "naturally sweet" definition: an analysis of the sugar association's definition of the natural as a terministic screen

The political nature of sugar as a cultural commodity can be traced back for centuries. While the issues surrounding sugar consumption have changed, power struggles still exist as stakeholders struggle to identify, make sense of, and manage the relationship between sugar and obesity. I explore the rhetorical contributions of the Sugar Association to public understandings of sweeteners. Specifically, I argue that the Sugar Association positioned sugar as the best choice for consumers by positioning their sweetener within a definition of the natural that the organization constructs. I draw on Burke's (1966) notion of terministic screens as a theoretical framework through which sugar was positioned as the best sweetener option and HFCS and artificial sweeteners were isolated as unnatural and, therefore, unwise choices for consumers. Then, I argue that the association's definition of "the natural" was strategically ambiguous, serving to distinguish sugar from other sweeteners. I conclude by evaluating the soundness and sustainability of the association's discursive contributions to public understandings of health and its implications for key stakeholders in the sweetener community.

Therapy of experimental NASH and fibrosis with galectin inhibitors

Non-alcoholic steatohepatitis (NASH) and resultant liver fibrosis is a major health problem without effective therapy. Some data suggest that galectin-3 null mice are resistant to the development of NASH with fibrosis. We examined the ability of two complex carbohydrate drugs that bind galectin-3, GM-CT-01 and GR-MD-02, to treat NASH with fibrosis in a murine model. GR-MD-02 treatment resulted in marked improvement in liver histology with significant reduction in NASH activity and collagen deposition. Treatments seemed also to improve both glomerulopathy and interstitial fibrosis observed in kidneys. The improvement in liver histology was evident when animals were treated early in disease or after establishment of liver fibrosis. In all measures, GM-CT-01 had an intermediate effect between vehicle and GR-MD-02. Galectin-3 protein expression was increased in NASH with highest expression in macrophages surrounding lipid laden hepatocytes, and reduced following treatment with GR-MD-02, while the number of macrophages was unchanged. Treatment with GR-MD-02 also reduced the expression of pathological indicators including iNOS, an important TH1 inflammatory mediator, CD36, a scavenger receptor for lipoproteins on macrophages, and α-smooth muscle actin, a marker for activated stellate cells which are the primary collagen producing cells in liver fibrosis. We conclude that treatment with these galectin-3 targeting drugs improved histopathological findings of NASH and markedly reduced fibrosis in a murine model of NASH. While the mechanisms require further investigation, the treatment effect is associated with a reduction of galectin-3 expressed by activated macrophages which was associated with regression of NASH, including hepatocellular fat accumulation, hepatocyte ballooning, intra-portal and intra-lobular inflammatory infiltrate, and deposition of collagen. Similar effects were found with GM-CT-01, but with approximately four-fold lower potency than GR-MD-02. The results, in combination with previous experiments in toxin-induced fibrosis, suggest that these galectin-targeting drugs may have potential in human NASH with fibrosis.

In VitroCytotoxic Effects of Stabilizing Sugars within Human Intravenous Immunoglobulin Preparations against the Human Macrophage THP-1 Cell-line

Intravenous immunoglobulin (IVIg) is a safe and effective therapy for the treatment of primary and secondary humoral immune deficiencies and autoimmune disorders. Both minor and more serious side effects may occur following IVIg administration in approximately 1-15% of infusions and stabilizing sugars found in IVIg preparations may contribute some of these. In this report, we aimed to determine the cytotoxic effects of IVIg as compared with four stabilizing sugars (glucose, sucrose, maltose and D-sorbitol) found in IVIg preparations on human monocyte-macrophages. The human THP-1 macrophage cell-line was used as a model to determine the effects of stabilizing sugars and IVIg preparations on cell viability and growth. The sugars differentially affected the viability of THP-1 cells. In experiments using doses of the sugars commonly found in IVIg preparations, cell viability and proliferation was unaffected when compared with doses of IVIg typically administered to patients (5 mg/ml). However, in an LDH-release cell lysis assay that measures changes in cell permeability, glucose (50 mg/ml) induced significant release of LDH as compared with complete IVIg (5 mg/ml, p<0.0001). Intranucleosomal DNA fragmentation was not detected at therapeutically relevant doses of IVIg. This suggested that THP-1 cell death was not due to apoptosis. We conclude that osmotic stress mediated by the sugars at high doses promoted THP-1 cell death. We propose that IVIg per se is not cytotoxic to the autonomously growing human THP-1 cell-line but rather, the stabilizing sugars used in the preparations are the cytotoxic factors. This observation was evident when preparations of IVIg were used at high concentrations but not at levels one would associate with clinically relevant doses of IVIg.

Microbial colonization and their relation with potential cofactors in patients with denture stomatitis

AIM

To determine microbial prevalence in the mucous membrane and prosthesis of denture wearers with and without denture stomatitis and to study its relationship with potential clinical cofactors.

MATERIALS AND METHODS

Saliva was collected from 200 patients (100 female and 100 male) wearing dental prosthesis for measurement of pH. Oral samples of the mucous membrane and of dentures were taken with sterile swab for microbiological analysis. Medical and dietary history of the subjects was recorded. Chi-square test and analysis of varience were used for statistical analysis.

RESULTS

Diabetes, hypertension and high carbohydrate ingestion was observed in majority of patients. The pH average in saliva was of 5.1. The presence of C. albicans, S. aureus and S. mutans in the mucous membrane was of 55.4, 56.4 and 63.6% respectively. C. albicans was isolated in 69.7% from the prosthesis, whereas S. aureus and S. mutans were isolated in 45.3%. The isolation of C.albicans was more frequent in patients with denture stomatitis.

CONCLUSION

C. albicans, S. aureus and S. mutans frequently colonize the oral mucous of denture wearers. This is more frequently observed in patients with denture stomatitis.

CLINICAL SIGNIFICANCE

Denture stomatitis is associated to Candida albicans, different bacteria and other cofactors, such as salivary pH, carbohydrate ingestion, systemic illnesses and medication.

[Sugar substitute products impact on oral fluid biochemical properties]

Sugar substitute products impact on oral fluid protein and carbohydrate content, as well as oxidative balance were studied in 60 medical school students in compare with conventional sugar. Sugar intake proved to cause cariesogenic carbohydrate metabolism disorders in oral fluid, intensification of lipoperoxidation and decrease in antioxidation activity. Sugar substitute products help to prevent dental decay.

Effects of endotoxaemia and carbohydrate overload on glucose and insulin dynamics and the development of laminitis in horses

REASONS FOR PERFORMING STUDY

Insulin resistance (IR) is a risk factor for pasture-associated laminitis in equids and alimentary carbohydrate overload may trigger laminitis. Whether glucose metabolism responses to carbohydrate overload are more pronounced in insulin-resistant horses requires further study.

HYPOTHESIS

Horses pretreated with endotoxin to alter insulin sensitivity differ significantly in their glucose and insulin responses to carbohydrate overload.

METHODS

Horses (n=24) were divided into 3 groups. A lipopolysaccharide (LPS; n=8) group that received endotoxin as an 8 h 7.5 ng/kg bwt/h i.v. continuous rate infusion, an oligofructose (OF; n=8) group that received an infusion of saline followed by 5 g/kg bwt OF via nasogastric intubation, and a LPS/OF (n=8) group that received LPS followed 16 h later by OF. Glucose and insulin dynamics were evaluated at -24 h and 48 h using the frequently sampled i.v. glucose tolerance test and minimal model analysis. Physical examinations and haematology were performed and the severity of laminitis assessed.

RESULTS

Horses receiving LPS developed leucopenia and both LPS and OF induced clinical signs consistent with systemic inflammation. Insulin sensitivity significantly decreased (P < 0.001) over time, but responses did not differ significantly among groups. Time (P < 0.001) and treatment x time (P = 0.038) effects were detected for the acute insulin response to glucose, with mean values significantly increasing in LPS and LPS/OF groups, but not the OF group. Five horses in the LPS/OF group developed clinical laminitis compared with 0 and 2 horses in the LPS and OF groups, respectively.

CONCLUSIONS

Endotoxaemia and carbohydrate overload reduce insulin sensitivity in horses. Endotoxin pretreatment does not affect the alterations in glucose metabolism induced by carbohydrate overload.

POTENTIAL RELEVANCE

Insulin sensitivity decreases after carbohydrate overload in horses, which may be relevant to the development of pasture-associated laminitis.

[Food intake and colorectal cancers; an ecological study in Romania]

The aim of the present study performed in a Romanian population was to identify the food which can be either associated with or protect against colorectal carcinoma.

MATERIAL AND METHOD

Correlation and regression analysis were used to examine the association between dietary intake and the rate of incidence for colon, rectum and anus cancers, in study groups from 7 regions of Romania.

RESULTS

A strong and positive association was observed for colonic cancer and the intake of coffee, tea and cocoa (r = 0.77, p = 0.042) whereas statistical significance of borderline value was found for margarine (r = 0.73, p = 0.06) and sweets (r = 0.74, p = 0.066) intake. A potential protective effect can be attributed to wine consumption ( r = -0.75, p = 0.03). The malignancies of the rectum and anus showed both a strong positive correlation with the intake of red meat ( r = 0.76, p = 0.048), sausages ( r = 0.87, p = 0.012), margarine (r = 0.97, p = 0.0004), butter ( r = 0.76, p = 0.049), sweets ( r = 0.93, p = 0.003), beverages (r = 0.97, p = 0.0003), coffee, tea, cocoa ( r = 0.94, p = 0.002). Negative correlations were reported for the recto-anal cancer and the consumption of: fish (r = -0.8, p = 0.032), cheese (r = -0.9, p = 0.006), wine (r = -0.85, p = 0.015).

CONCLUSION

The need for reducing the dietary intake of margarine, red meat, sausages and sweets while the beneficial effects of wine consumption have been also confirmed.

Effect of a carbohydrate mouthwash on running time-trial performance

The aim of the present study was to determine the effect of a carbohydrate mouthwash on running time-trial performance. On two separate occasions, seven recreationally active males (VO2max 57.8 ml x kg(-1) x min(-1), s = 3.7) completed a preloaded (15 min at 65%VO2max) time-trial of 45 min in duration on a motorized treadmill. At 6-min intervals during the preload and time-trial, participants were given either a 6% maltodextrin, 3% lemon juice solution (carbohydrate trial) or a 3% lemon juice placebo mouthwash (placebo trial) in a double-blind, randomized crossover design. Heart rate, oxygen consumption (VO2), respiratory exchange ratio (RER), and ratings of perceived exertion (RPE) were measured during the preload, and blood glucose and lactate were measured before and after the preload and time-trial. There were no significant differences in distance covered between trials (carbohydrate: 9333 m, s = 988; placebo: 9309 m, s = 993). Furthermore, there were no significant between-trial differences in heart rate and running speed during the time-trial, or VO2, RER or RPE during the preload. Blood lactate and glucose increased as a result of the exercise protocol, with no between-trial differences. In conclusion, there was no positive effect of a carbohydrate mouthwash on running performance of approximately 1 h duration.

Serial alterations in digital hemodynamics and endothelin-1 immunoreactivity, platelet-neutrophil aggregation, and concentrations of nitric oxide, insulin, and glucose in blood obtained from horses following carbohydrate overload

OBJECTIVE

To quantify changes in endothelium-derived factors and relate those changes to various aspects of digital hemodynamics during the prodromal stages of carbohydrate overload (CHO)-induced laminitis in horses.

ANIMALS

20 adult horses without abnormalities of the digit.

PROCEDURES

Digital and jugular venous blood samples were collected at 1-hour intervals (for assessment of endothelin-1 [ET-1] immunoreactivity and measurement of glucose, insulin, and nitric oxide [NO] concentrations) or 4-hour intervals (CBC and platelet-neutrophil aggregate assessment) for 8 hours or 16 hours after induction of CHO-associated laminitis in horses treated with an ET-1 antagonist. Effects of treatment, collection site, and time and the random effects of horse on each variable were analyzed by use of a repeated-measures model. Where treatment and collection site had no significant effect, data were combined.

RESULTS

Compared with baseline values, CHO resulted in changes in several variables, including a significant increase from baseline in digital blood ET-like immunoreactivity at 11 hours; digital blood ET-like immunoreactivity was significantly greater than that in jugular venous blood at 8, 9, 11, and 12 hours. Digital and jugular venous blood concentrations of glucose increased from baseline significantly at 3, 4, and 5 hours; insulin concentration increased significantly at 5 hours; and the number of platelet-neutrophil aggregates increased significantly at 12 hours.

CONCLUSIONS AND CLINICAL RELEVANCE

In horses, concurrent increases in venous blood ET-1 immunoreactivity, insulin and glucose concentrations, and platelet-neutrophil aggregates support a role of endothelial dysfunction in the pathogenesis of CHO-induced laminitis.

Effects of an endothelin receptor antagonist and nitroglycerin on digital vascular function in horses during the prodromal stages of carbohydrate overload-induced laminitis

OBJECTIVE

To evaluate changes in digital vascular function in horses with carbohydrate overload (CHO)-induced laminitis and determine the effects of an endothelin (ET) receptor antagonist and nitroglycerin on laminitis-associated vascular dysfunction.

ANIMALS

20 adult horses without abnormalities of the digit.

PROCEDURES

Hemodynamic variables were recorded before (baseline) and hourly after all horses were administered a CHO ration via nasogastric tube. In 4 groups of 5 horses each, saline (0.9% NaCl) solution or ET receptor antagonist (10(5)M in digital blood) was administered into the digital arterial circulation according to 1 of 2 schedules. During anesthesia, blood flow; arterial, venous, and capillary pressures; and total, precapillary, and postcapillary resistances were measured in an isolated perfused digit of each horse. In all groups, nitroglycerin was infused (10(5)M in digital blood), and digital microvascular assessments were repeated.

RESULTS

The CHO caused a significant decrease in right atrial pressure by 14 hours that was not affected by administration of saline solution or ET receptor antagonist. In isolated digits of anesthetized horses, CHO resulted in a significant decrease in digital blood flow associated with a significant increase in total and postcapillary resistances. Treatment with the ET receptor antagonist and nitroglycerin caused a significant decrease in total resistance. Postcapillary resistance was significantly decreased following treatment with the ET receptor antagonist but was not altered by treatment with nitroglycerin.

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment with an ET receptor antagonist and nitroglycerin resulted in significant improvement in vascular resistance in isolated perfused digits of anesthetized horses with CHO-induced laminitis.

Anti-oxidative effects of pomegranate juice (PJ) consumption by diabetic patients on serum and on macrophages

Diabetes is associated with increased oxidative stress and atherosclerosis development. In the present study, we investigated the effects of pomegranate juice (PJ; which contains sugars and potent anti-oxidants) consumption by diabetic patients on blood diabetic parameters, and on oxidative stress in their serum and macrophages. Ten healthy subjects (controls) and 10 non-insulin dependent diabetes mellitus (NIDDM) patients who consumed PJ (50ml per day for 3 months) participated in the study. In the patients versus controls serum levels of lipid peroxides and thiobarbituric acid reactive substances (TBARS) were both increased, by 350% and 51%, respectively, whereas serum SH groups content and paraoxonase 1 (PON1) activity, were both decreased (by 23%). PJ consumption did not affect serum glucose, cholesterol and triglyceride levels, but it resulted in a significant reduction in serum lipid peroxides and TBARS levels by 56% and 28%, whereas serum SH groups and PON1 activity significantly increased by 12% and 24%, respectively. In the patients versus controls monocytes-derived macrophages (HMDM), we observed increased level of cellular peroxides (by 36%), and decreased glutathione content (by 64%). PJ consumption significantly reduced cellular peroxides (by 71%), and increased glutathione levels (by 141%) in the patients' HMDM. The patients' versus control HMDM took up oxidized LDL (Ox-LDL) at enhanced rate (by 37%) and PJ consumption significantly decreased the extent of Ox-LDL cellular uptake (by 39%). We thus conclude that PJ consumption by diabetic patients did not worsen the diabetic parameters, but rather resulted in anti-oxidative effects on serum and macrophages, which could contribute to attenuation of atherosclerosis development in these patients.

Drug-induced disorders of teeth

It is essential that every health care professional who is involved with the prescription or recommendation of drugs be fully aware of any resultant disorders that may arise as a side-effect. A range of drugs can affect the teeth. In this review article, drugs that have the potential to induce changes in teeth have been classified as those leading to tooth discoloration (intrinsic and extrinsic), physical damage to tooth structure (enamel, dentin, and cementum), and alteration in tooth sensitivity.

Lactose causes heart arrhythmia in the water flea Daphnia pulex

The cladoceran Daphnia pulex is well established as a model for ecotoxicology. Here, we show that D. pulex is also useful for investigating the effects of toxins on the heart in situ and the toxic effects in lactose intolerance. The mean heart rate at 10 degrees C was 195.9+/-27.0 beats/min (n=276, range 89.2-249.2, >80% 170-230 beats/min). D. pulex heart responded to caffeine, isoproteronol, adrenaline, propranolol and carbachol in the bathing medium. Lactose (50-200 mM) inhibited the heart rate by 30-100% (K(1/2)=60 mM) and generated severe arrhythmia within 60 min. These effects were fully reversible by 3-4 h. Sucrose (100-200 mM) also inhibited the heart rate, but glucose (100-200 mM) and galactose (100-200 mM) had no effect, suggesting that the inhibition by lactose or sucrose was not simply an osmotic effect. The potent antibiotic ampicillin did not prevent the lactose inhibition, and two diols known to be generated by bacteria under anaerobic conditions were also without effect. The lack of effect of l-ribose (2 mM), a potent inhibitor of beta-galactosidase, supported the hypothesis that lactose and other disaccharides may affect directly ion channels in the heart. The results show that D. pulex is a novel model system for studying effects of agonists and toxins on cell signalling and ion channels in situ.

[Sugar and the birth of dentistry]

It took mankind some ten thousand years to get sugarcane from the Pacific to the Mediterranean. Once it reached Europe and the Europeans knew how to handle it, it took them only a hundred years to turn the production of sugar into the biggest industry of the world. Exactly in those hundred years the birth of modern medicine--and dentistry--is placed. This coincidence is too particular to be left unnoticed.

Evolutionary legacy: form of ingestion, not quantity, is the key factor in producing the effects of sugar on human health

Tens of dietary trials have been conducted to investigate the metabolic effects of sugar (sucrose) and its impact on human health. All of those studies took into account only the quantity of ingested sugar. By contrast, not a single study attempted to assess whether the form in which sugar is consumed plays a role in producing its metabolic effects. The failure of cohorts of researchers to specify how they administered sugar in their dietary trials may well explain why the results of those studies are extremely contradictory. These discrepant findings, understandably, resulted in conflicting opinions about sugar and in divergent guidelines about its recommended consumption. The evolutionary line of reasoning expounded in this article leads to conclude that the form in which sugar is ingested, not its quantity, constitutes the most important factor in producing the metabolic effects of sugar and its impact on human health. As a consequence, for example, the consumption of 100 g of sugar per day can be either detrimental or innocuous, depending on the form in which sugar is ingested. Specifically, the evolutionary hypothesis advanced in this paper implies that sugar can predispose to type 2 diabetes and can cause unhealthy changes in blood lipids if it is consumed in solid forms or in dense solutions containing more than 250 g/L, whereas sugar is harmless if it is consumed in more dilute concentrations. This evolutionary hypothesis, in view of its intuitively far-reaching clinical implications, should be tested by at least one dietary trial.

Sugars: hedonic aspects, neuroregulation, and energy balance

The prevalence of obesity has increased dramatically in recent years in the United States, with similar patterns seen in several other countries. Although there are several potential explanations for this dramatic increase in obesity, dietary influences are a contributing factor. An inverse correlation between dietary sugar intake and body mass index has been reported, suggesting beneficial effects of carbohydrate intake on body mass index. In this review we discuss how sugars interact with regulatory neurochemicals in the brain to affect both energy intake and energy expenditure. These neurochemicals appear to be involved in dietary selection, and sugars and palatable substances affect neurochemical changes in the brain. For example, rats that drink sucrose solutions for 3 wk have major changes in neuronal activity in the limbic area of the brain, a region involved in pleasure and other emotions. We also investigate the relations between sucrose (and other sweet substances), drugs of abuse, and the mesolimbic dopaminergic system. The presence of sucrose in an animal's cage can affect the animals desire to self-administer drugs of abuse. Also, an animal's level of sucrose preference can predict its desire to self-administer cocaine. Such data suggest a relation between sweet taste and drug reward, although the relevance to humans is unclear. Finally, we address the influence of sugar on body weight control. For example, sucrose feeding for 2 wk decreases the efficiency of energy utilization and increases gene expression of uncoupling protein 3 in muscle, suggesting that sucrose may influence uncoupling protein 3 activity and contribute to changes in metabolic efficiency and thus regulation of body weight.