Lifestyle Medicine and Economics: A Proposal for Research Priorities Informed by a Case Series of Disease Reversal

Chronic disease places an enormous economic burden on both individuals and the healthcare system, and existing fee-for-service models of healthcare prioritize symptom management, medications, and procedures over treating the root causes of disease through changing health behaviors. Value-based care is gaining traction, and there is a need for value-based care models that achieve the quadruple aim of (1) improved population health, (2) enhanced patient experience, (3) reduced healthcare costs, and (4) improved work life and decreased burnout of healthcare providers. Lifestyle medicine (LM) has the potential to achieve these four aims, including promoting health and wellness and reducing healthcare costs; however, the economic outcomes of LM approaches need to be better quantified in research. This paper demonstrates proof of concept by detailing four cases that utilized an intensive, therapeutic lifestyle intervention change (ITLC) to dramatically reverse disease and reduce healthcare costs. In addition, priorities for lifestyle medicine economic research related to the components of quadruple aim are proposed, including conducting rigorously designed research studies to adequately measure the effects of ITLC interventions, modeling the potential economic cost savings enabled by health improvements following lifestyle interventions as compared to usual disease progression and management, and examining the effects of lifestyle medicine implementation upon different payment models.

Randomized trial of a novel lifestyle intervention compared with the Diabetes Prevention Program for weight loss in adult dependents of military service members

BACKGROUND

Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low.

OBJECTIVES

We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity.

METHODS

Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models.

RESULTS

Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to <0.001 for ITT).

CONCLUSIONS

HWL and m-DPP showed equivalent and clinically impactful mean weight loss with cardiometabolic benefits. These results identify an alternative approach for behavioral treatment of overweight and obesity.This trial was registered at clinicaltrials.gov as NCT02348853.

Sugar-Sweetened Beverage Consumption May Modify Associations Between Genetic Variants in the CHREBP (Carbohydrate Responsive Element Binding Protein) Locus and HDL-C (High-Density Lipoprotein Cholesterol) and Triglyceride Concentrations

Supplemental Digital Content is available in the text.

Background:

ChREBP (carbohydrate responsive element binding protein) is a transcription factor that responds to sugar consumption. Sugar-sweetened beverage (SSB) consumption and genetic variants in the CHREBP locus have separately been linked to HDL-C (high-density lipoprotein cholesterol) and triglyceride concentrations. We hypothesized that SSB consumption would modify the association between genetic variants in the CHREBP locus and dyslipidemia.

Methods:

Data from 11 cohorts from the Cohorts for Heart and Aging Research in Genomic Epidemiology consortium (N=63 599) and the UK Biobank (N=59 220) were used to quantify associations of SSB consumption, genetic variants, and their interaction on HDL-C and triglyceride concentrations using linear regression models. A total of 1606 single nucleotide polymorphisms within or near CHREBP were considered. SSB consumption was estimated from validated questionnaires, and participants were grouped by their estimated intake.

Results:

In a meta-analysis, rs71556729 was significantly associated with higher HDL-C concentrations only among the highest SSB consumers (β, 2.12 [95% CI, 1.16–3.07] mg/dL per allele; P<0.0001), but not significantly among the lowest SSB consumers (P=0.81; P_Diff <0.0001). Similar results were observed for 2 additional variants (rs35709627 and rs71556736). For triglyceride, rs55673514 was positively associated with triglyceride concentrations only among the highest SSB consumers (β, 0.06 [95% CI, 0.02–0.09] ln-mg/dL per allele, P=0.001) but not the lowest SSB consumers (P=0.84; P_Diff=0.0005).

Conclusions:

Our results identified genetic variants in the CHREBP locus that may protect against SSB-associated reductions in HDL-C and other variants that may exacerbate SSB-associated increases in triglyceride concentrations.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00005133, NCT00005121, NCT00005487, and NCT00000479.

Evidence mapping to assess the available research on fiber, whole grains, and health

Evidence mapping is a useful methodology for characterizing existing research on a broad topic and identifying gaps in the scientific literature. Evidence mapping entails conducting a systematic literature search and extracting information on study details, often in the form of a database. Researchers at Tufts University and the North American branch of the International Life Sciences Institute created the Diet-Related Fibers & Human Health Outcomes Database, which is publicly available and updated annually. The database captures intervention studies examining dietary fiber and 10 predefined physiological health outcomes, including weight/adiposity, blood pressure, gut microbiota, and bone health. The database and subsequent potential for evidence mapping may be particularly useful in light of new food labeling requirements by the US Food and Drug Administration that require fibers to have accepted scientific evidence of a physiological health benefit in order to be labeled as "dietary fiber." Following the success of the fiber database, Tufts University and the General Mills Bell Institute of Health and Nutrition collaborated to develop a whole grain database and evidence map. This work successfully highlighted the need for better consistency in how whole grains are reported with respect to amount and type of whole grains and intervention compliance.

评估膳食纤维、全谷物和健康关系证据图

证据图是一种非常实用的证据总结方法，通过证据图可以全面检 索所关注问题的相关研究，准确展示该领域科学文章存在的问题。利 用证据图，可实现文献的系统检索，提取研究关键信息，形成信息数 据库。塔夫茨大学和国际生命科学学会(ILSI)北美分会创建了膳食 纤维和人类健康证据数据库，并公开，每年都会定期更新。该数据库 汇编了膳食纤维干预研究，包括10 种预先设定的生理健康结局指标， 包括体重/肥胖、血压、肠道微生物群和骨骼健康。根据美国食品和药 品监督管理局(FDA)颁布的新版食品标签要求，只有在有足够证据 支持膳食纤维与某种生理健康益处相关时，才能在标签上标识“膳食 纤维”。因此，该数据库和证据图的应用潜力就显得特别重要。基于膳 食纤维数据库的成功案例，塔夫茨大学和通用磨坊贝尔健康与营养研 究所又合作开发了一个全谷物数据库和证据图。该项工作强调了所报

告的全谷物数据一致性的重要性，包括全谷物的消费量和类型以及干 预的依从性。

Effect of coccidial challenge and vaccination on the performance, veterinary postmortem scores, and blood biochemistry of broiler chickens

A total of 960 male Cobb 500 broilers were used in a growth performance study to explore the effect of coccidial vaccination and/or coccidial challenge on blood biochemistry and veterinary postmortem metrics. Day-old chicks were randomly divided into one of the 4 experimental treatments. Treatments were arranged in a 2 × 2 factorial arrangement, with the factors being without or with vaccination (administered on day 1) or coccidial challenge (oral gavage on day 7). Growth performance was monitored on a weekly basis. Blood sample collection, as well as full veterinary necropsies, were carried out on days 6, 8, 13, 20, 27, and 34. Birds that did not receive the vaccination but were challenged with coccidiosis had higher feed conversion ratio, lower body weights, and higher mortality than the other experimental groups, and this effect was particularly evident from day 13 to day 20. Birds challenged with coccidiosis had lower plasma sodium and total carotenoid concentrations and higher potassium and globulin concentrations than nonchallenged birds. Significant interactions between age and experimental treatment for these blood parameters were observed, particularly on day 13. The necropsy results confirmed the effectiveness of the challenge and vaccination treatments, wherein birds that were challenged had higher coccidiosis scores on day 13 and day 27 than birds that were not challenged. These results demonstrate the potential for plasma sodium, potassium, total protein, total carbon dioxide, globulin, and carotenoid analysis for early diagnosis of coccidiosis in growing broiler chickens. Further work is necessary to establish whether the changes in blood biochemistry observed in the present study are transferable to alternative flocks of chicken and whether early diagnosis and intervention may mitigate performance losses associated with this disease.

Effect of high concentrations of dietary vitamin D3 on pullet and laying hen performance, skeleton health, eggshell quality, and yolk vitamin D3 content when fed to W36 laying hens from day of hatch until 68 wk of age

The objective of this experiment was to investigate the effects of various dietary concentrations of vitamin D₃ (D₃) on pullet and laying hen performance, eggshell quality, bone health, and yolk D₃ content from day of hatch until 68 wk of age. Initially, 440 Hy-line W36-day-old chicks were randomly assigned to 5 dietary treatments: 1,681 (control); 8,348; 18,348; 35,014; 68,348 IU D₃/kg. At 17 wk of age, pullets were assigned to experimental diets with 12 replicate groups of 6 birds. At 17 wk of age, pullets fed diets containing 8,348 and 35,014 IU D₃/kg had an increased bone mineral density in comparison to the control fed birds (P ≤ 0.01). Body weights of pullets fed the diet with 68,348 IU D₃/kg were lower than other treatments (P ≤ 0.01). Hen-housed egg production (HHEP) of hens fed the 35,014 IU D₃/kg diet was increased in comparison to control-fed hens (P ≤ 0.01), whereas HHEP of those fed 68,348 IU D₃/kg diet was reduced in comparison to all other treatments (P ≤ 0.01). Shell breaking strength of eggs from hens fed 8,348, 35,014 and 68,348 IU D₃/kg was increased in comparison to eggs from control-fed birds (P ≤ 0.01). Fat-free tibia ash content of hens fed any of the diets supplemented with D₃ (8,348 to 68,348 IU D₃/kg) was increased in comparison to control-fed hens (P ≤ 0.05). Yolk D₃ content increased linearly with dietary D₃ and the D₃ transfer efficiency for the control, 8,348 IU, 18,348 IU, 35,014 IU, and 68,348 IU D₃ treatments were 8.24, 10.29, 11.27, 12.42, and 12.06%, respectively. These data suggest that supplementation of dietary D₃ up to 35,014 IU D₃/kg feed maintained if not increased laying hen performance and enhanced pullet and laying hen skeletal quality as well as yolk D₃ content and eggshell quality. Feeding pullets at a higher level 68,348 IU of D₃ resulted in reduced growth and ultimately decreased performance of laying hens.

Using Evidence Mapping to Examine Motivations for Following Plant-Based Diets

Motivations to adopt plant-based diets are of great public health interest. We used evidence mapping to identify methods that capture motivations to follow plant-based diets and summarize demographic trends in dietary motivations. We identified 56 publications that described 90 samples of plant-based diet followers and their dietary motivations. We categorized the samples by type of plant-based diet: vegan (19%), vegetarian (33%), semivegetarian (24%), and other, unspecified plant-based diet followers (23%). Of 90 studies examined, 31% administered multiple-choice questions to capture motivations, followed by rate items (23%), Food Choice Questionnaire (17%), free response (9%), and rank choices (10%). Commonly reported motivations were health, sensory/taste/disgust, animal welfare, environmental concern, and weight loss. The methodological variation highlights the importance of using a structured questionnaire to investigate dietary motivations in epidemiological studies. Motivations among plant-based diet followers appear distinct, but evidence on the association between age and motivations appears limited.

Sustained Long-Term Effectiveness of an Energy Management Training Course on Employee Vitality and Purpose in Life

Purpose:

Programs designed to sustainably improve employee well-being are urgently needed but insufficiently researched. This study evaluates the long-term effectiveness of a commercial well-being intervention in a worksite setting.

Design:

A pre/postintervention repeated analysis with follow-up at 6, 12, and 18 months.

Setting:

Office-based worksites (for-profit, nonprofit, and mixed work-type; n = 8).

Participants:

One hundred sixty-three employees with a mean age of 47 (11) years (57% female).

Intervention:

A 2.5-day group-based behavioral program emphasizing vitality and purpose in life (PiL).

Measures:

Rand Medical Outcomes Survey (MOS) 36-Item Short Form (SF-36) with a focus on vitality (primary outcome), Ryff PiL Scale, Center for Epidemiologic Studies Depression Scale, Profile of Mood States, Rand MOS Sleep Scale, physical activity, body weight, blood pressure, and blood measures for glucose and lipids at baseline, 6, 12, and 18 months.

Analysis:

General linear models with repeated measures for mean values at baseline and follow-up.

Results:

At 18-month follow-up, sustained improvements were observed for vitality, general health, and mental health domains of SF-36 and PiL (P < .001 for all measures). Sleep, mood, vigor, physical activity, and blood pressure were also improved at 18 months (P < .05 for all measures).

Conclusions:

An intensive 2.5-day intervention showed sustained improvement in employee quality of life, PiL, and other measures of well-being over 18 months.

Dietary potassium and available phosphorous on broiler growth performance, carcass characteristics, and wooden breast

Broiler dietary potassium (K) and available phosphorous (AvP) have decreased in recent years but both ions are intimately involved in the elimination of hydrogen ions that are produced during rapid growth. It was hypothesized that the decrease of these dietary electrolytes was related to the development of myopathies, and thus increased dietary K and/or AvP would reduce the occurrence of breast myopathies. A total of 320 Ross male broiler chicks were placed into 16 pens and fed 2 diet series containing either decreasing AvP levels of 0.45, 0.40, and 0.35% in the starter, grower, and finisher diets, respectively (Decline), or a fixed AvP of 0.45% in all dietary phases (Fixed). To complete a 2 × 2 design either normal basal dietary K (K-) (0.86, 0.77, 0.68%) or added dietary K (K+) (1.01, 0.93, 0.88%) were also applied to starter, grower, and finisher diets, respectively. Blood physiology was measured at 29 and 42 d. Carcass data, wooden breast and white striping scores were measured at 35 and 43 d. The K+ diets improved feed conversion ratio at 35 d (1.52 vs 1.57 g: g), reduced body weight at 42 d (3524 vs 3584 g), reduced hemoglobin (6.83 vs 7.58 g/dL), and packed cell volume (20.1 vs 22.3%) at 29 d, reduced ionized blood calcium (1.42 vs 1.47 mmol/L) at 42 d, and reduced partial pressure of blood CO2 (49.1 vs 54.7 mm/Hg) at 42 d relative to broilers fed basal K- diets (P < 0.05). Fixed AvP diets improved feed conversion ratio at 28 and 42 d, increased percentage breast meat (28.85 vs 27.58%) and carcass water pickup (2.72 vs 1.42%) at 35 d, and reduced wooden breast (2.88 vs 3.69) at 43 d (P < 0.05).

Theoretical Food and Nutrient Composition of Whole-Food Plant-Based and Vegan Diets Compared to Current Dietary Recommendations

Public interest in popular diets is increasing, in particular whole-food plant-based (WFPB) and vegan diets. Whether these diets, as theoretically implemented, meet current food-based and nutrient-based recommendations has not been evaluated in detail. Self-identified WFPB and vegan diet followers in the Adhering to Dietary Approaches for Personal Taste (ADAPT) Feasibility Survey reported their most frequently used sources of information on nutrition and cooking. Thirty representative days of meal plans were created for each diet. Weighted mean food group and nutrient levels were calculated using the Nutrition Data System for Research (NDSR) and data were compared to DRIs and/or USDA Dietary Guidelines/MyPlate meal plan recommendations. The calculated HEI-2015 scores were 88 out of 100 for both WFPB and vegan meal plans. Because of similar nutrient composition, only WFPB results are presented. In comparison to MyPlate, WFPB meal plans provide more total vegetables (180%), green leafy vegetables (238%), legumes (460%), whole fruit (100%), whole grains (132%), and less refined grains (−74%). Fiber level exceeds the adequate intakes (AI) across all age groups. WFPB meal plans failed to meet the Recommended Dietary Allowances (RDA)s for vitamin B12 and D without supplementation, as well as the RDA for calcium for women aged 51–70. Individuals who adhere to WFBP meal plans would have higher overall dietary quality as defined by the HEI-2015 score as compared to typical US intakes with the exceptions of calcium for older women and vitamins B12 and D without supplementation. Future research should compare actual self-reported dietary intakes to theoretical targets.

Evaluating Whole Grain Intervention Study Designs and Reporting Practices Using Evidence Mapping Methodology

Consumption of whole grains have been associated with reduced risk of chronic diseases in many observational studies; yet, results of intervention studies are mixed. We aimed to use evidence mapping to capture the methodological and reporting variability in whole grain intervention studies that may contribute to this inconsistency. We conducted a reproducible search in OVID Medline for whole grain human intervention studies (published 1946 to February 2018). After screening based on a priori criteria, we identified 202 publications describing a total of 213 unique trials. Over half (55%) were acute trials, lasting ≤1 day, 30% were moderate duration studies (up to 6 weeks) and 15% were of longer duration (more than 6 weeks). The majority of acute trials (75%) examined measures of glycaemia and/or insulinemia, while most of the longer trials included measures of cardiometabolic health (71%), appetite/satiety (57%) and weight/adiposity (56%). Among the moderate and long duration trials, there was a wide range of how whole grains were described but only 10 publications referenced an established definition. Only 55% of trials reported the actual amount of whole grains (in grams or servings), while 36% reported the amount of food/product and 9% did not report a dose at all. Of the interventions that provided a mixture of whole grains, less than half (46%) reported the distribution of the different grain types. Reporting of subject compliance also varied and only 22% used independent biomarkers of whole grain intake. This evidence map highlights the need to standardize both study protocols and reporting practices to support effective synthesis of study results and provide a stronger foundation to better inform nutrition scientists and public health policy.

Effectiveness of an Energy Management Training Course on Employee Well-Being: A Randomized Controlled Trial

Purpose:

Programs focused on employee well-being have gained momentum in recent years, but few have been rigorously evaluated. This study evaluates the effectiveness of an intervention designed to enhance vitality and purpose in life by assessing changes in employee quality of life (QoL) and health-related behaviors.

Design:

A worksite-based randomized controlled trial.

Setting:

Twelve eligible worksites (8 randomized to the intervention group [IG] and 4 to the wait-listed control group [CG]).

Participants:

Employees (n = 240) at the randomized worksites.

Intervention:

A 2.5-day group-based behavioral intervention.

Measures:

Rand Medical Outcomes Survey (MOS) 36-item Short-Form (SF-36) vitality and QoL measures, Ryff Purpose in Life Scale, Center for Epidemiologic Studies questionnaire for depression, MOS sleep, body weight, physical activity, diet quality, and blood measures for glucose and lipids (which were used to calculate a cardiometabolic risk score) obtained at baseline and 6 months.

Analysis:

General linear mixed models were used to compare least squares means or prevalence differences in outcomes between IG and CG participants.

Results:

As compared to CG, IG had a significantly higher mean 6-month change on the SF-36 vitality scale (P = .003) and scored in the highest categories for 5 of the remaining 7 SF-36 domains: general health (P = .014), mental health (P = .027), absence of role limitations due to physical problems (P = .026), and social functioning (P = .007). The IG also had greater improvements in purpose in life (P < .001) and sleep quality (index I, P = .024; index II, P = .021). No statistically significant changes were observed for weight, diet, physical activity, or cardiometabolic risk factors.

Conclusion:

An intensive 2.5-day intervention showed improvement in employee QoL and well-being over 6 months.

Web-Based Recruitment and Survey Methodology to Maximize Response Rates from Followers of Popular Diets: the Adhering to Dietary Approaches for Personal Taste (ADAPT) Feasibility Survey

BACKGROUND

Although there is interest in popular diets such as vegan and vegetarian, Paleo, and other "whole food" diets, existing cohort studies lack data for these subgroups. The use of electronic data capture and Web-based surveys in nutrition research may be valuable for future studies by allowing targeting of specific dietary subgroups.

OBJECTIVE

The aim was to perform a Feasibility Survey (FS) to assess the practicality of Web-based research methods to gather data and to maximize response rates among followers of popular diets.

METHODS

The FS was an open, voluntary, 15-min survey conducted over 8 wk in the summer of 2015. Recruitment targeted self-identified followers of popular diets from a convenience sample, offering no incentives, via social media and e-newsletters shared by recruitment partners. Feasibility was assessed by number of responses, survey completion rate, distribution of diets, geographic location, and willingness to participate in future research.

RESULTS

A total of 14,003 surveys were initiated; 13,787 individuals consented, and 9726 completed the survey (71% of consented). The numbers of unique visitors to the questionnaire site, view rate, and participation rate were not captured. Among respondents with complete demographic data, 83% were female and 93% were white. Diet designations were collapsed into the following groups: whole-food, plant-based (25%); vegan and raw vegan (19%); Paleo (14%); try to eat healthy (11%); vegetarian and pescatarian (9%); whole food (8%); Weston A Price (5%); and low-carbohydrate (low-carb) (4%). Forced-response, multiple-choice questions produced the highest response rates (0-2% selected "prefer not to answer"). The percentage who were willing to complete future online questionnaires was 86%, diet recall was 93%, and food diary was 75%; the percentages willing to provide a finger-stick blood sample, venipuncture blood sample, urine sample, and stool sample were 60%, 44%, 58%, and 42%, respectively.

CONCLUSIONS

This survey suggests that recruiting followers of popular diets is feasible with the use of Web-based methods. The unbalanced sample with respect to sex and race/ethnicity could be corrected with specific recruitment strategies using targeted online marketing techniques.

Association of nutrition club membership with markers of health: a cross sectional study

Background

Nutrition clubs (NC) operate in community settings and provide members with nutrition education and meal replacements for weight management. NC are owned and operated by distributors of Herbalife products. There are over 6200 NC in the US, but there has been no independent assessment of the association of these NC with biomarkers of health.

Methods

We conducted a cross-sectional pilot study to compare the health status of 100 NC members to 100 community-matched controls (CC) in the greater Boston area. Each CC was matched to a NC member for community of residence (zip code), age category, gender, BMI category, race/ethnicity, education level (category), and readiness to make health changes. Measures obtained included cardio-metabolic risk factors, body composition, markers of nutritional status, reported health status, dietary intake, physical activity, sleep and depression.

Results

Participants were predominantly female (64%) and Hispanic (73%). NC members had significantly lower fasting insulin (P < 0.001) and lower HbA1c (P = 0.008), higher levels of 25 hydroxy-vitamin D (P = 0.001), and vitamin E:cholesterol ratio (P < 0.001), and lower prevalence of metabolic syndrome (P = 0.02) compared to CC. In addition, most of the NC members (99%) were satisfied with Herbalife NC membership for themselves and their families. A higher percentage of NC members (86%) compared to CC (32%) reported being in much better or somewhat better health compared to a year ago (P < 0.001); and they reported significantly better physical health (P = 0.03), and fewer sleep problems (P = 0.03).

Conclusion

Herbalife NC membership was positively associated with perceived health and measured cardiometabolic benefits. However, causality cannot be inferred from these findings.

Comparison of plasma alkylresorcinols (AR) and urinary AR metabolites as biomarkers of compliance in a short-term, whole-grain intervention study

PURPOSE

Alkylresorcinols (AR) are phenolic lipids present in the bran of wheat and rye. Plasma AR and their urinary metabolites may be suitable biomarkers of whole-grain (WG) wheat and rye consumption. The objective of this study was to examine plasma AR and urinary AR metabolites in response to WG wheat consumption.

METHODS

In a randomized crossover study, 19 subjects (10 males, 9 females; BMI 22.0 kg/m(2); age 26 years) incorporated either 3 servings (48 g) or 6 servings (96 g) of WG wheat daily into their regular diet for 1 week. Subjects completed a 2-week washout period, abstaining from all WG consumption, before each intervention. Fasting blood and 24-h urine were collected before and after each intervention. Plasma AR homologues (C19:0, C21:0, C23:0) were quantified by GC-MS after diethyl ether and solid phase extraction and derivatization. Urinary AR metabolites [3,5-dihydroxybenzoic acid and 3-(3,5-dihydroxyphenyl)-propanoic acid] were determined using HPLC with electrochemical detection after enzymatic deconjugation and ethyl acetate extraction.

RESULTS

Urinary total AR metabolites were significantly higher after 6 compared with 3 servings of WG wheat (56 vs. 32 μmol/day, P < 0.001). This dose-response relationship was independent of age, sex, energy intake, and baseline urinary AR metabolite concentration. Plasma total AR tended to be higher after 6 compared with 3 servings of WG wheat (103.0 vs. 86.9 nmol/L), but this difference was not significant (P = 0.42).

CONCLUSION

The results suggest that urinary AR metabolites from 24-h urine collections may be useful as biomarkers of compliance in intervention studies of WG wheat.

Mumps vaccine effectiveness and risk factors for disease in households during an outbreak in New York City

BACKGROUND AND OBJECTIVES

Mumps outbreaks have been reported among vaccinated populations, and declining mumps vaccine effectiveness (VE) has been suggested as one possible cause. During a large mumps outbreak in New York City, we assessed: (1) VE of measles-mumps-rubella vaccine (MMR) against mumps and (2) risk factors for acquiring mumps in households.

METHODS

Cases of mumps were investigated using standard methods. Additional information on disease and vaccination status of household contacts was collected. Case households completed follow-up phone interviews 78-198 days after initial investigation to ascertain additional cases. Mumps cases meeting the study case definition were included in the analysis. Risk factors for mumps were assessed, and VE was calculated using secondary household attack rates.

RESULTS

Three hundred and eleven households with 2176 residents were included in the analysis. The median age of residents was 13 years (range <1-85), and 462 (21.2%) residents met the study mumps case definition. Among 7-17 year olds, 89.7% received one or more doses of MMR vaccine, with 76.7% receiving two doses. Young adults aged 10-14 years (OR=2.4, CI=1.3-4.7) and 15-19 years (OR=2.5, CI=1.3-5.0) were at highest risk of mumps. The overall 2-dose VE for secondary contacts aged five and older was 86.3% (CI 63.3-94.9).

CONCLUSIONS

The two-dose effectiveness of MMR vaccine against mumps was 86.3%, consistent with other published mumps VE estimates. Many factors likely contributed to this outbreak. Suboptimal MMR coverage in the affected population combined with VE may not have conferred adequate immunity to prevent transmission and may have contributed to this outbreak. Achieving high MMR coverage remains the best available strategy for prevention of mumps outbreaks.

Yogurt consumption is associated with better diet quality and metabolic profile in American men and women

The evidence-based Dietary Guidelines for Americans recommends increasing the intake of fat-free or low-fat milk and milk products. However, yogurt, a nutrient-dense milk product, has been understudied. This cross-sectional study examined whether yogurt consumption was associated with better diet quality and metabolic profile among adults (n = 6526) participating in the Framingham Heart Study Offspring (1998-2001) and Third Generation (2002-2005) cohorts. A validated food frequency questionnaire was used to assess dietary intake, and the Dietary Guidelines Adherence Index (DGAI) was used to measure overall diet quality. Standardized clinical examinations and laboratory tests were conducted. Generalized estimating equations examined the associations of yogurt consumption with diet quality and levels of metabolic factors. Approximately 64% of women (vs 41% of men) were yogurt consumers (ie, consumed >0 servings/week). Yogurt consumers had a higher DGAI score (ie, better diet quality) than nonconsumers. Adjusted for demographic and lifestyle factors and DGAI, yogurt consumers, compared with nonconsumers, had higher potassium intakes (difference, 0.12 g/d) and were 47%, 55%, 48%, 38%, and 34% less likely to have inadequate intakes (based on Dietary Reference Intake) of vitamins B2 and B12, calcium, magnesium, and zinc, respectively (all P ≤ .001). In addition, yogurt consumption was associated with lower levels of circulating triglycerides, glucose, and lower systolic blood pressure and insulin resistance (all P < .05). Yogurt is a good source of several micronutrients and may help to improve diet quality and maintain metabolic well-being as part of a healthy, energy-balanced dietary pattern.

Abstract 188: Yogurt Consumption, Blood Pressure, and Incident Hypertension: A Longitudinal Study in the Framingham Heart Study

Background Yogurt is a nutrient-dense, low-fat dairy product. We aimed to examine the longitudinal association of yogurt consumption with blood pressure (BP) levels and hypertension prevention among adults participating in the Framingham Heart Study Offspring Cohort (exams 5 to 8 [1998-2001 to 2005-2008]).

Methods In each exam, dietary intake was assessed by a validated food frequency questionnaire; BP was measured following standardized procedures; and anti-hypertensive medication use was obtained by physician-elicited self-report. Our analyses included 2,197 adults (with 7351 observations) who were free of hypertension at exam 5 (baseline) and had valid measurements of yogurt intake and BP. Logistic regression was used to examine incident hypertension (defined as systolic BP (SBP) ≥140mmHg, or diastolic BP (DBP) ≥90mmHg, or used anti-hypertensive medication). A repeated measures model was used to examine annualized BP change in exam intervals adjusting for BP and anti-hypertensive medication use at the beginning of each interval. All analyses were adjusted for demographic and lifestyle factors (including diet quality).

Results At baseline, 44% (960 of 2197) of participants consumed ≥1 serving of yogurt per month (i.e. defined as consumers); and mean [SD] SBP and DBP were 117 [12] mmHg and 72 [8] mmHg, respectively. BP and yogurt intake both increased over the 14-year follow up; and 913 participants developed incident hypertension. After adjustment for demographic and lifestyle factors and cholesterol-lowering medication use, people who consumed >2% of total calories (kcal) from yogurt (i.e. high-intake group) had lower risk of incident hypertension than non-consumers (OR [95%CI] = 0.69 [0.54-0.87]). The high-intake group had 0.19±0.09 mmHg smaller annualized elevation of SBP than non-consumers ( P =0.04). Excluding the anti-hypertensive medication users at follow-up strengthened the longitudinal association between yogurt intake and annualized SBP change. All findings retained when further controlling for body mass index (BMI) and the change of BMI. Yogurt intake was not related to DBP change over time.

Conclusion Higher yogurt intake, as part of a healthy diet pattern, may be beneficial for BP control and hypertension prevention.

Choosing front-of-package food labelling nutritional criteria: how smart were 'Smart Choices'?

OBJECTIVE

The 'Smart Choices' programme was an industry-driven, front-of-package (FOP) nutritional labelling system introduced in the USA in August 2009, ostensibly to help consumers select healthier options during food shopping. Its nutritional criteria were developed by members of the food industry in collaboration with nutrition and public health experts and government officials. The aim of the present study was to test the extent to which products labelled as 'Smart Choices' could be classified as healthy choices on the basis of the Nutrient Profile Model (NPM), a non-industry-developed, validated nutritional standard.

DESIGN

A total of 100 packaged products that qualified for a 'Smart Choices' designation were sampled from eight food and beverage categories. All products were evaluated using the NPM method.

RESULTS

In all, 64 % of the products deemed 'Smart Choices' did not meet the NPM standard for a healthy product. Within each 'Smart Choices' category, 0 % of condiments, 8·70 % of fats and oils, 15·63 % of cereals and 31·58 % of snacks and sweets met NPM thresholds. All sampled soups, beverages, desserts and grains deemed 'Smart Choices' were considered healthy according to the NPM standard.

CONCLUSIONS

The 'Smart Choices' programme is an example of industries' attempts at self-regulation. More than 60 % of foods that received the 'Smart Choices' label did not meet standard nutritional criteria for a 'healthy' food choice, suggesting that industries' involvement in designing labelling systems should be scrutinized. The NPM system may be a good option as the basis for establishing FOP labelling criteria, although more comparisons with other systems are needed.

Mycobacterium tuberculosis testing practices in hospital, commercial and state laboratories in the New England states

SETTING

The mycobacterial laboratory is assuming an increasingly important role in tuberculosis (TB) control in the United States today.

OBJECTIVE

To assess mycobacterial laboratory capacity and practices in the New England states, USA.

DESIGN

We surveyed 143 hospital and commercial laboratories and five of the six state public health laboratories in New England that offer testing services for Mycobacterium tuberculosis. The survey captured information on types of services offered and volume of testing, use of state laboratories for testing, and promptness of reporting results to TB control programs.

RESULTS

State laboratories perform the majority of testing services, particularly for more specialized tests. All state laboratories surveyed perform species identification of acid-fast isolates, culture and first-line drug susceptibility testing. Less than 20% of hospital and commercial laboratories offer these services, and 78.6% of hospitals and commercial laboratories refer specimens to state laboratories for culture.

CONCLUSION

Surveys of M. tuberculosis testing capacities in a region can help decision makers ensure maintenance of essential services. Hospital and commercial laboratories with lower testing volume might increase efficiency by referring more specimens to state laboratories. State health departments might consider organizing regional laboratory service networks to monitor the provision of services, improve efficiency and oversee quality improvement initiatives.

Retinyl palmitate does not have an adjuvant effect on the antibody response of chicks to keyhole limpet hemocyanin regardless of vitamin A status

To determine whether supplementing retinyl palmitate (RP) to vitamin A-deficient or -adequate chicks during vaccination increased the antibody response, an experiment was conducted that used a 2-generational model. White Leghorn chicks were hatched from eggs that contained 1.06 ± 0.13, 1.41 ± 0.14, or 1.90 ± 0.13 μg of retinol/g of egg yolk. Upon hatch, chicks were allotted to a diet that contained 70, 100, or 130% of the vitamin A requirement (1,500 IU/kg). At 14 d of age, chicks were challenged with keyhole limpet hemocyanin (KLH), Freund's incomplete adjuvant (FIA), KLH and FIA, KLH and RP administered in the same injection, or KLH and RP administered at different injection sites. The RP dosage was 7,000 IU/kg of BW, and dosage of the KLH was 1 mg/kg of BW. Chicks were bled and rechallenged at 19 d of age, and a final blood draw was taken at 29 d of age. The IgM and IgG antibody responses to KLH were determined by ELISA, and agglutination was used to determine natural antibody titers. When compared with chicks fed diets that contained 70 and 100% of the vitamin A requirement, the chicks fed 130% of the vitamin A requirement had a lower primary IgM and IgG antibody response (P < 0.02) and the secondary IgG response was significantly lower (P = 0.004). However, administering RP together or separate from KLH did not significantly change the secondary IgM or IgG responses compared with chicks challenged with KLH and FIA (P < 0.01). Moreover, natural antibody titers were not different among dietary treatments (P = 0.91). In conclusion, administration of RP with KLH did not improve antibody response in chicks.

Behavioural sources of repeat Chlamydia trachomatis infections: importance of different sex partners

OBJECTIVE

To examine sources of repeat Chlamydia trachomatis infections using behavioural and molecular methods.

METHODS

Women with C. trachomatis had baseline and 4-month follow-up visits consisting of behavioural surveys and genotyping of C. trachomatis. Frequencies and population-attributable risk percentages (PAR%) were estimated for possible sources of repeat infections including sex partners not known to be treated, new sex partners, and sex partners not known to be monogamous. Women with different genotypes at baseline and follow-up were classified as different partner sources of infection.

RESULTS

The cumulative incidence of repeat infections in the sample (n=183) was 13% (95% CI 8% to 18%). Predictors of repeat infections included younger age and continued sex with a partner not known to be treated. Frequencies of having partners not known to be treated, new partners, or partners not known to be monogamous at follow-up were 21% (95% CI 15% to 27%), 37% (95% CI 30% to 44%) and 33% (95% CI 28% to 41%), respectively. The PAR% for having a partner not known to be treated was 26% (95% CI 3% to 49%) and for having a new sex partner was 21% (95% CI 0% to 50%). Among eight patients with available genotypes at baseline and follow-up, five had different genotypes and were classified as having a different partner source of infection.

CONCLUSIONS

Different sex partner sources of repeat C. trachomatis infections other than untreated sex partners may contribute substantially to the burden of repeat infections.

Comparison of sexual partnership characteristics and associations with inconsistent condom use among a sample of adolescents and adult women diagnosed with Chlamydia trachomatis

BACKGROUND

This analysis compared characteristics of female adolescent and adult sexual partnerships and related these characteristics to inconsistent condom use.

METHODS

Data are from a study of 126 women with prevalent chlamydia infections who reported information about 172 sexual partnerships in the previous 3 months. Characteristics of sexual partnerships included type of partner (main vs. other), duration of sexual relationship (<3 months vs. > or =3 months), partner age difference (<2 years older vs. > or =2 years older), and two scale measures: overlap of social networks (a measure based on how well the participant knew her partner's friends, for example) and intimacy.

RESULTS

Compared with adult partnerships, adolescent partnerships were of shorter duration and had less social overlap but were more likely to be classified by the participants as main partnerships. Among adolescents, longer partnership duration was not associated with higher intimacy, yet higher intimacy was significantly correlated with inconsistent condom use.

CONCLUSIONS

These differences suggest that adolescent females perceive and characterize their sexual relationships differently from adults. This, in turn, may have implications for risk of sexually transmitted infections (STIs). Prevention efforts for adolescents, including interventions and counseling, should consider the nature of their sexual partnerships.

Behavioral intentions in sexual partnerships following a diagnosis of Chlamydia trachomatis

OBJECTIVES

To describe behavioral intentions regarding notification of sex partners and continuation of sexual relationships after a Chlamydia trachomatis diagnosis among women.

METHODS

Data are from a study of women diagnosed with C. trachomatis during 2005-2007 in Connecticut. Participants (n=135) reported their intentions to notify each of their sex partners in the past 3 months (n=187) of the infection and intentions to continue these relationships; generalized estimating equations were used to determine correlates of intentions. Reasons for these intentions were also described.

RESULTS

Participants intended not to notify 25% of sex partners; correlates were partnership duration and relationship quality. Participants intended not to continue 59% of sexual relationships; correlates included partnership duration, beliefs about partner's monogamy, and relationship quality. Intentions to notify partners and continue relationships were statistically associated (p=0.002). Non-mutually exclusive reasons for intending not to notify partners included no perceived need (46%), unwillingness to discuss the issue (43%), fear/discomfort with potential consequences (19%), and inability to locate partner (8%). Reasons for intending not to continue relationships were often related to the diagnosis (48%).

CONCLUSIONS

Sex partnership characteristics are the most salient correlates for intentions not to notify partners and continue relationships. Clinicians can identify those who are less likely to notify their partners and explore reasons for these intentions to promote behaviors to reduce further C. trachomatis transmission.

Sex partner meeting venues and out-of-state sex partners among men who have sex with men with early syphilis in Connecticut

OBJECTIVES

To examine sex partner meeting venues and out-of-state sex partners among men who have sex with men (MSM) with syphilis in Connecticut, a state with moderate syphilis prevalence.

GOAL

To better understand transmission dynamics in the current syphilis epidemic.

STUDY DESIGN

Review of health department records.

RESULTS

A total of 185 MSM were diagnosed with early syphilis in Connecticut from 2000 to 2005 (mean age, 36 years; 56% white, 37% HIV-positive). Fifty-two percent of cases reported meeting sex partners at venues that facilitate multiple and/or anonymous sexual encounters including gay clubs or bars (22%), Internet (18%), and adult bookstores (12%). Meeting sex partners in venues increased over time and was associated with nonmetropolitan residence of the case. Forty-three percent of cases had an out-of-state sex partner during the time in which they likely acquired their infection. Having out-of-state sex partners decreased during the study period. Throughout 2000-2005, having out-of-state sex partners was positively associated with bathhouse use and negatively associated with use of adult bookstores.

CONCLUSIONS

The observed pattern of increased meeting sex partners in venues located within the state and decreased out-of-state sex partners over time is suggestive of increasing transmission within the state of Connecticut.

Human embryonic stem cells as models for trophoblast differentiation

Trophectoderm is specified from pluripotent blastomeres at some time prior to blastocyst formation. Proliferating cytotrophoblast derived from trophectoderm is the forerunner of the entire trophoblast component of the mature human placenta, including extravillous cytotrophoblast and syncytiotrophoblast. Recently human embryonic stem cells (hESC) have been employed to study these events in an in vitro situation. Here we review some of the work in this emerging area of trophoblast biology. We concentrate primarily on a model in which colonies of hESC are exposed to BMP4 in stem cell growth medium lacking FGF2. Under both low (4%) and high (20%) O(2) conditions, differentiation proceeds unidirectionally towards trophoblast from the outside of the colonies inwards, with the progression fastest under high O(2). Immunohistochemical observations performed on whole colonies combined with microarray analysis of mRNA can be employed to track developmental transitions as they occur over time and in two-dimensional space as the cells respond to BMP4.