Diabetes management in a foreign land: A case study on Chinese Australians

The aim of this study was to understand the experience of Chinese migrants living with type 2 diabetes in Australia and explore their culturally specific diabetes management needs, habits and expectations in the Australian context to help shape an Australian Chinese diabetes service. A case study approach was employed across two Australian cities (Melbourne and Sydney), using participant-observations and qualitative interviews. Purposive sampling was used to find diabetes education sessions for observation and facilitators for interviews before snowball technique was used to identify relevant clinicians. Thematic analysis with pattern matching was used for data analysis. A total of 18 participant-observations and 12 interviews were conducted. Chinese migrants appeared to experience multiple barriers in accessing the Australian diabetes care service further complicated by the mismatch between the expectations of Chinese patients and the services available. Chinese patients were observed to be collectivistic-orientated relying on friends for diabetes management. While health professionals appeared to be perceived as a source of reputable health information, they often did not provide ongoing support. When professional support was limited, Chinese patients adopted alternative strategies to address their diabetes, which often involved seeking help and information from peers. Some of this information was non-reputable, potentially resulting in detrimental health outcomes. In conclusion, redesigning diabetes care services in line with the principles of collectivism may more appropriately match the Chinese migrants' expectations and needs, and better support them in their diabetes journey.

Culturally Tailored Diabetes Education for Chinese Patients: A Qualitative Case Study

Purpose: To explore the range of teaching approaches and cultural-tailoring elements used in diabetes educations directed at Chinese patients and to determine the strategies that appeared to best address Chinese patients’ needs. Design: A case study approach in three countries was employed, using multiple ethnographic data collection methods including participant observations and qualitative interviews. Findings: Data were collected from 39 participant observations and 22 interviews across seven cases. Collective didactic education was most common. Individual clarification at the end of an education session was used to allow patients to derive their own management plan. Clinicians mainly provided information and used knowledge reinforcement to facilitate behavioral change. Participatory diabetes education models borrowed from the West did not translate well culturally and did not appear to meet Chinese patients’ needs. Conclusion and Practical Implications: Diabetes education for the Chinese may be enhanced by building on traditional Confucian education strategies.

Association between salt and hypertension in rural and urban populations of low to middle income countries: a systematic review and meta-analysis of population based studies

BACKGROUND AND OBJECTIVES

The prevalence of hypertension, the greatest contributor to mortality globally, is increasing in low-and-middle income countries (LMICs). In urban regions of LMICs, excessive salt intake is associated with increased risk of hypertension. We aimed to determine whether this is the case in rural regions as well.

METHODS AND STUDY DESIGN

We performed a meta-analysis of studies in rural and urban areas of LMICs in which the association of salt and hypertension were assessed using multivariable models.

RESULTS

We identified 18 studies with a total of 134,916 participants. The prevalence of high salt intake ranged from 21.3% to 89.5% in rural and urban populations. When salt was analysed as a continuous variable, a greater impact of salt on hypertension was found in urban (n=4) (pooled effect size (ES) 1.42, 95% CI 1.19, 1.69) than in rural populations (n=4) (pooled ES 1.07, 95% CI 1.04, 1.10, p for difference <0.001). In studies where salt was analysed continuously, a greater impact of salt on hypertension was observed in lean rural populations (BMI <23 kg/m2) than in non-lean rural populations (BMI >=23 kg/m2, p for difference <0.001).

CONCLUSIONS

The prevalence of high salt intake is similar in rural and urban regions. Excessive salt intake has a greater impact on the prevalence of hypertension in urban than rural regions. BMI appears to modify the relationship between salt and hypertension in rural populations.

Diabetes education for Chinese adults with type 2 diabetes: A systematic review and meta-analysis of the effect on glycemic control

AIMS

The purpose of this study is to systematically review evidence in English and Chinese publications to determine the size of glycemic effect of different diabetes education approaches for Chinese patients.

METHODS

CINAHL Plus, Embase, Ovid Medline, Scopus and the China National Knowledge Infrastructure database were searched. Studies were included if they were randomised controlled trials with a detailed description of education approach, with more than 50 Chinese-adult participants, reporting actual glycemic outcome and with at least 3-month follow-up. Data was systematically extracted and cross-checked by the authors. Methodological quality was assessed.

RESULTS

Fifty-three studies, including five English and 48 Chinese publications, were included. The overall weighted mean difference (WMD) in glycated haemoglobin (HbA1c) was -1.19% (-13mmol/mol). Ongoing regular education was most-commonly employed, with a reported WMD of -2.02% (-22mmol/mol). Glycemic control was further enhanced in studies using information reinforcement strategies.

CONCLUSIONS

Diabetes education in any format generates glycemic improvement for Chinese patients, but is particularly effective when an ongoing regular education is employed. Innovative strategies aligned with cultural concepts, such as employing patient examination to reinforce diabetes management knowledge and/or involving family in patient care deserve further trial to determine whether they enhance glycemic control in this group.

Diet low in advanced glycation end products increases insulin sensitivity in healthy overweight individuals: a double-blind, randomized, crossover trial

BACKGROUND

The consumption of advanced glycation end products (AGEs) has increased because of modern food processing and has been linked to the development of type 2 diabetes in rodents.

OBJECTIVE

We determined whether changing dietary AGE intake could modulate insulin sensitivity and secretion in healthy, overweight individuals.

DESIGN

We performed a double-blind, randomized, crossover trial of diets in 20 participants [6 women and 14 men; mean ± SD body mass index (in kg/m(2)): 29.8 ± 3.7]. Isoenergetic- and macronutrient-matched diets that were high or low in AGE content were alternately consumed for 2 wk and separated by a 4-wk washout period. At the beginning and end of each dietary period, a hyperinsulinemic-euglycemic clamp and an intravenous glucose tolerance test were performed. Dietary, plasma and urinary AGEs N(€)-(carboxymethyl)lysine (CML), N(€)-(carboxyethyl)lysin (CEL), and methylglyoxal-derived hydroimadazolidine (MG-H1) were measured with the use of mass spectrometry.

RESULTS

Participants consumed less CML, CEL, and MG-H1 during the low-AGE dietary period than during the high-AGE period (all P < 0.05), which was confirmed by changes in urinary AGE excretion. There was an overall difference in insulin sensitivity of -2.1 mg · kg(-1) · min(-1) between diets (P = 0.001). Insulin sensitivity increased by 1.3 mg · kg(-1) · min(-1) after the low-AGE diet (P = 0.004), whereas it showed a tendency to decrease by 0.8 mg · kg(-1) · min(-1) after the high-AGE diet (P = 0.086). There was no difference in body weight or insulin secretion between diets (P = NS).

CONCLUSIONS

A diet that is low in AGEs may reduce the risk of type 2 diabetes by increasing insulin sensitivity. Hence, a restriction in dietary AGE content may be an effective strategy to decrease diabetes and cardiovascular disease risks in overweight individuals. This trial was registered at clinicaltrials.gov as NCT00422253.

Novel dietary intake assessment in populations with poor literacy

BACKGROUND AND OBJECTIVES

Cultural and/or environmental barriers make the assessment of dietary intake in rural populations challenging. We aimed to assess the accuracy of a meal recall questionnaire, adapted for use with impoverished South Indian populations living in rural areas.

METHODS AND STUDY DESIGN

Dietary data collected by recall versus weighed meals were compared. Data were obtained from 45 adults aged 19-85 years, living in rural Andhra Pradesh, who were recruited by convenience sampling. Weighed meal records (WMRs) were conducted in the household by a researcher aided by a trained field worker. The following day, field workers conducted a recall interview with the same participant. Eight life size photographs of portions of South Indian foods were created to aid each participant's recall and a database of nutrients was developed to calculate nutrient intake. Pearson correlations were used to assess the strength of associations between intake of energy and nutrients calculated from meal recalls versus WMRs. Least products regression was conducted to examine fixed and proportional bias. Bland-Altman plots were constructed to measure systematic or differential bias.

RESULTS

Significant correlations were observed between estimates for energy and nutrients obtained by the two methods (r2=0.19-0.67, p<0.001). No systematic bias was detected by Bland-Altman plots. Recall method underestimated the intake of protein and fat in a manner proportional to the level of intake.

CONCLUSIONS

Our culturally adapted meal recall questionnaire provides an accurate measure for assessment of the intake of energy, macronutrients and some micronutrients in rural Indian populations.

Dietary Advanced Glycation End Products Consumption as a Direct Modulator of Insulin Sensitivity in Overweight Humans: A Study Protocol for a Double-Blind, Randomized, Two Period Cross-Over Trial

BACKGROUND

Advanced glycation end products (AGEs) are formed during the processing, storage, and cooking of foods. As part of a western diet, AGEs are consumed in excess and impair glucose metabolism in patients with type 2 diabetes. In the absence of diabetes, AGE-mediated decreases in insulin sensitivity and signaling have been postulated. However, randomized studies to test this relationship in humans are limited.

OBJECTIVE

The primary aim of this trial is to determine whether dietary consumption of AGEs will decrease insulin sensitivity in healthy overweight adults. A secondary aim is to determine the effects of dietary AGEs on insulin secretion, circulating soluble receptor for AGEs (sRAGE), and inflammation markers.

METHODS

Overweight, but otherwise healthy, non-diabetic adults (N=20) aged 18-50 years old will complete a randomized cross-over design intervention study alternating low and high (4-fold increase) AGE diets (2-week duration). At baseline, participants will undergo a medical review including an intravenous glucose tolerance test (IVGTT), a hyperinsulinemic-euglycemic clamp, and anthropometric measures and questionnaires assessing diet, physical activity, and general wellness. Each test diet will be followed for 14 days, followed by a 4-week washout period before commencement of the second alternate dietary period. Energy, macronutrient, and AGE intake will be calculated for each dietary period. Additionally, the AGE content of foods used in the study will be measured by ultra performance liquid chromatography mass spectrometry. All measurements will be repeated at the beginning and end of each dietary period. Primary and secondary outcomes will be expressed as a change over the dietary period for insulin sensitivity, secretion, anthropometric parameters, sRAGE, and inflammation markers and compared by paired t test and analysis of variance (ANOVA).

RESULTS

The study will be completed in early 2016.

CONCLUSION

The proposed trial will provide much needed clinical evidence on the impact of excess dietary AGE consumption on insulin sensitivity and will indicate whether lowering dietary AGE intake can improve insulin sensitivity and/or secretion, thereby decreasing risk for type 2 diabetes.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00422253; https://clinicaltrials.gov/ct2/show/NCT00422253 (Archived by Webcite at http://www.webcitation.org/6ZXLhT89c).

Strong correlation between the 6-minute walk test and accelerometry functional outcomes in boys with Duchenne muscular dystrophy

Accelerometry provides information on habitual physical capability that may be of value in the assessment of function in Duchenne muscular dystrophy. This preliminary investigation describes the relationship between community ambulation measured by the StepWatch activity monitor and the current standard of functional assessment, the 6-minute walk test, in ambulatory boys with Duchenne muscular dystrophy (n = 16) and healthy controls (n = 13). All participants completed a 6-minute walk test and wore the StepWatch™ monitor for 5 consecutive days. Both the 6-minute walk test and StepWatch accelerometry identified a decreased capacity for ambulation in boys with Duchenne compared to healthy controls. There were strong, significant correlations between 6-minute walk distance and all StepWatch parameters in affected boys only (r = 0.701-0.804). These data proffer intriguing observations that warrant further exploration. Specifically, accelerometry outcomes may compliment the 6-minute walk test in assessment of therapeutic interventions for Duchenne muscular dystrophy.

Colorectal cancer and nonfermented milk, solid cheese, and fermented milk consumption: a systematic review and meta-analysis of prospective studies

Colorectal cancer is the second most prevalent cancer worldwide. A systematic review and meta-analysis of prospective studies was conducted to examine the association between intake of different types of dairy foods during adulthood and the development of colorectal cancer, specifically comparing nonfermented milk, solid cheese, and fermented milk. Seven databases were systematically searched and 15 cohort studies selected for inclusion, involving over 900,000 subjects and over 5200 colorectal cancer cases. Meta-analysis resulted in an overall relative risk of colon cancer of 0.74 (95% confidence interval 0.60-0.91) in men consuming nonfermented milk (highest intake category averaging 525 g/day). No association was found between consumption of nonfermented milk and rectal cancer in men or nonfermented milk and colon or rectal cancer in women. No protective association was found between consumption of solid cheese or fermented milk and colorectal cancer. Reasons for the differences in the impact of nonfermented milk, solid cheese, and fermented milk in the colon are discussed. This meta-analysis supports the inverse association between nonfermented milk consumption and risk of colon cancer in men, and provides an evidence base to assist in the formulation of dietary guidelines involving dairy foods.

Evidence for low high-density lipoprotein cholesterol levels in Australian indigenous peoples: a systematic review

Background

Low plasma high-density lipoprotein cholesterol (HDL-C) levels are a strong, independent, but poorly understood risk factor for cardiovascular disease (CVD). Although this atherogenic lipid abnormality has been widely reported in Australia’s Indigenous peoples, Aboriginal and Torres Strait Islanders, the evidence has not come under systematic review. This review therefore examines published data for Indigenous Australians reporting 1) mean HDL-C levels for both sexes and 2) factors associated with low HDL-C.

Methods

PubMed, Medline and Informit ATSI Health databases were systematically searched between 1950 and 2012 for studies on Indigenous Australians reporting mean HDL-C levels in both sexes. Retrieved studies were evaluated by standard criteria. Low HDL-C was defined as: <1.0 mmol/L. Analyses of primary data associating measures of HDL-C with other CVD risk factors were also performed.

Results

Fifteen of 93 retrieved studies were identified for inclusion. These provided 58 mean HDL-C levels; 29 for each sex, most obtained in rural/regional (20%) or remote settings (60%) and including 51–1641 participants. For Australian Aborigines, mean HDL-C values ranged between 0.81-1.50 mmol/L in females and 0.76-1.60 mmol/L in males. Two of 15 studies reported HDL-C levels for Torres Strait Islander populations, mean HDL-C: 1.00 or 1.11 mmol/L for females and 1.01 or 1.13 mmol/L for males. Low HDL-C was observed only in rural/regional and remote settings - not in national or urban studies (n = 3) in either gender. Diabetes prevalence, mean/median waist-to-hip ratio and circulating C-reactive protein levels were negatively associated with HDL-C levels (all P < 0.05). Thirty-four per cent of studies reported lower mean HDL-C levels in females than in males.

Conclusions

Very low mean HDL-C levels are common in Australian Indigenous populations living in rural and remote communities. Inverse associations between HDL-C and central obesity, diabetes prevalence and inflammatory markers suggest a particularly adverse CVD risk factor profile. An absence of sex dichotomy in HDL-C levels warrants further investigation.

Observations of body mass index in Duchenne muscular dystrophy: a longitudinal study

BACKGROUND/OBJECTIVES

Nutritional issues that are associated with Duchenne muscular dystrophy (DMD) remain poorly understood. The aim of this analysis was to describe and explore longitudinal observations of body mass index (BMI) in a cohort of children with DMD.

SUBJECTS/METHODS

Anthropometric and clinical characteristics were collected retrospectively and longitudinally for boys with DMD seen in two large neuromuscular clinics. BMI Z-scores were determined using the Centers for Disease Control and Prevention reference values for children (2000).

RESULTS

Medical records (n=193) were examined from which 75% were included for analysis. The mean age of the cohort at the time of data collection was 11.9 years, with 72% of patients currently or previously using steroids. The highest prevalence of obesity based on the BMI Z-score was 50% at the age of 10 years. Longitudinally, BMI Z-scores from the age of 2 to 12 years plot approximately one s.d. above the mean, after which there is a marked and progressive decline. BMI gainers were identified for whom BMI Z-score increased by 1.65 units compared with the 0.09 units in non-gainers. BMI gainers were younger when they had their first BMI measurement (5.9 vs 7.2 years), and this measure was significantly lower compared with the non-gainers (BMI Z-score: 0.04 vs 1.17). In this cohort, BMI was associated with age, ambulatory status and lung function.

CONCLUSIONS

This study demonstrates that boys with DMD using steroid therapy experience shifts in BMI. A declining BMI appears to be associated with increasing age. Interpretation of growth patterns is limited here by a lack of normative growth references in DMD.

Association between farming and chronic energy deficiency in rural South India

Objective

To examine factors associated with chronic energy deficiency (CED) and anaemia in disadvantaged Indian adults who are mostly involved in subsistence farming.

Design

A cross-sectional study in which we collected information on socio-demographic factors, physical activity, anthropometry, blood haemoglobin concentration, and daily household food intake. These data were used to calculate body mass index (BMI), basal metabolic rate (BMR), daily energy expenditure, and energy and nutrient intake. Multivariable backward stepwise logistic regression was used to assess socioeconomic and lifestyle factors associated with CED (defined as BMI<18 kg/m²) and anaemia.

Setting

The study was conducted in 12 villages, in the Rishi Valley, Andhra Pradesh, India.

Subjects

Individuals aged 18 years and above, residing in the 12 villages, were eligible to participate.

Results

Data were available for 1178 individuals (45% male, median age 36 years (inter quartile range (IQR 27–50)). The prevalence of CED (38%) and anaemia (25%) was high. Farming was associated with CED in women (2.20, 95% CI: 1.39–3.49) and men (1.71, 95% CI: (1.06–2.74). Low income was also significantly associated with CED, while not completing high school was positively associated with anaemia. Median iron intake was high: 35.7 mg/day (IQR 26–46) in women and 43.4 mg/day (IQR 34–55) in men.

Conclusions

Farming is an important risk factor associated with CED in this rural Indian population and low dietary iron is not the main cause of anaemia. Better farming practice may help to reduce CED in this population.

Immunological and nutritional factors in elderly people in low-level care and their association with mortality

Background

This study examines associations between markers of nutritional status and lymphocyte subsets and seeks to determine if lymphocyte profile is predictive of survival in elderly Australians residing in aged care facilities. Aged yet still ambulatory subjects (n = 88, 73% female) living in low-level care and requiring minimal assistance were studied for 143 weeks. At baseline when participants were aged (mean ± SD) 86.0 ± 5.9 years, dietary intake was determined by 3-day weighed food record, body composition was assessed by dual energy X-ray absorptiometry (DXA) and a venous blood sample was taken.

Results

At baseline assessment, study participants were consuming nutrient-poor diets and most had symptoms of chronic disease. Although overweight, 40% exhibited sarcopenia. Markers of nutritional status did not relate closely to immune cell numbers (absolute or relative), which on average were within the normal range. Men had lower numbers of CD3⁺CD4⁺ cells (CD4⁺ T cells), a higher proportion of CD3⁻ CD16^± CD56^± (natural killer (NK) cells) and a higher ratio of NK: CD4⁺ T cells than women (all P < 0.05). The main age-related changes evident were decreased T cells, particularly low CD4⁺ T cell counts, and increased numbers of CD19⁺ (B-cell) and NK cells. During the 143 week duration of follow-up, about one quarter of the study participants died, with death more likely in men than women (P < 0.01). Poor survival was predicted by the presence of decreased numbers of CD4⁺ T cells (hazard ratio (HR) 0.919, P < 0.01) and expanded numbers of NK cells (HR 1.085, P < 0.05) in the blood, and therefore the presence of a high NK: CD4⁺ T cell ratio (HR 30.521, P < 0.01).

Conclusions

The NK: CD4⁺ T cell ratio may potentially have clinical utility for predicting longevity in elderly populations. Further studies are needed in other elderly populations to confirm this finding.

Glucose homeostasis can be differentially modulated by varying individual components of a western diet

Chronic overconsumption of a Western diet has been identified as a major risk factor for diabetes, yet precisely how each individual component contributes to defects in glucose homeostasis independent of consumption of other macronutrients remains unclear. Eight-week-old male Sprague Dawley rats were randomized to feeding with one of six semi-pure diets: control, processed (high advanced glycation end products/AGE), high protein, high dextrose (glucose polymer), high in saturated fat (plant origin), or high in saturated fat (animal origin). After chronic feeding for 24 weeks, body composition was determined by bioelectrical impedance spectroscopy and glucose homeostasis was assessed. When compared to the control and high AGE diets, excess consumption of the diet high in saturated fat (animal source) increased body weight and adiposity, and decreased insulin sensitivity, as defined by HOMA IR, impaired skeletal muscle insulin signaling and insulin hypersecretion in the context of increased circulating glucagon-like peptide (GLP-1). Compared to the control diet, chronic consumption of the high AGE, protein or dextrose diet increased fasting plasma glucose, decreased fasting plasma insulin and insulin secretion. These diets also reduced circulating GLP-1 concentrations. These data suggest that individual components of a western diet have differential effects in modulating glucose homeostasis and adiposity. These data provide clear evidence of a link between over-consumption of a western diet and the development of diabetes.

Plasma retinol: a novel marker for cardiovascular disease mortality in Australian adults

BACKGROUND AND AIMS

Vitamin A affects inflammation and immune function and is thus a factor of interest in relation to cardiovascular disease (CVD). As vitamin A circulates in the plasma in the form of retinol, this study aims to describe the relationship between plasma retinol and the 5-year incidence of CVD mortality.

METHODS AND RESULTS

Community-dwelling adults (n = 441, 45% with type 2 diabetes) were recruited in Melbourne, assessed at baseline and followed for 5 years. At baseline, CVD risk factors were assessed by clinical evaluation, by personal lifestyle questionnaire and from biochemistry (plasma fasting glucose, lipids, total homocysteine, C-reactive protein, retinol and carotenoids plus the urinary albumin excretion rate over 24 h.). Dietary intake was assessed by a validated food frequency questionnaire. CVD mortality over 5-years was determined by consulting state or national registries. The majority of participants had adequate plasma retinol concentrations (≥30 μg/dL). The final Cox regression model indicated that those in the highest tertile of plasma retinol (mean ± SD) 76 ± 14 μg/dL) had a significantly lower risk of 5-year CVD mortality (hazard ratio 0.27 [95% confidence interval 0.11, 0.68], P = 0.005), an effect that was not readily explained in terms of traditional CVD risk factors or dietary intake.

CONCLUSION

In well-nourished older Australian adults, plasma retinol was inversely associated with CVD mortality via mechanisms apparently unrelated to established CVD risk factors and dietary intake.

Nutritional quality of Australian breakfast cereals. Are they improving?

The nutritional quality of Australian breakfast cereals is not systematically monitored despite the importance of breakfast for general health. We examined whether the nutritional quality of Australian breakfast cereals has improved between 2004 and 2010, and whether any change could be detected after the introduction of Daily Intake Guide (DIG) front-of-pack labelling. Supermarket surveys were conducted in 2004 and 2010 using the same methodology to collect information from the nutrition information panels of Australian breakfast cereals and the nutrient content of cereals was compared by year. Breakfast cereals with and without DIG labelling in 2010 were also compared. Nutritional quality was assessed using UK Traffic Light criteria. No significant difference was detected in nutritional composition of breakfast cereals between 2004 and 2010. There was no notable improvement in nutritional composition of breakfast cereals marketed as the same product in both years. Overall there has been little improvement in the nutritional quality of Australian breakfast cereals in the 6 year period. A large proportion of Australian breakfast cereals were considered high sugar. In conclusion, the introduction of DIG labelling does not appear to have promoted product reformulation, and breakfast cereals carrying DIG labels were not consistently healthier.

Clinical review: Do glucocorticosteroids alter vitamin D status? A systematic review with meta-analyses of observational studies

CONTEXT

Vitamin D supplementation is an important adjunct therapy for the prevention and management of glucocorticoid-induced osteoporosis. There has been little exploration of the relationship between glucocorticosteroid (GCS) use and serum 25-hydroxyvitamin D [25(OH)D].

OBJECTIVE

The aim of this study was to systematically explore how serum 25(OH)D is altered in adult patients receiving GCS.

DATA SOURCES

We reviewed Medline and Cinahl databases between January 1970 and August 2011.

STUDY SELECTION

Experimental studies were included where 25(OH)D was measured in patients more than 18 yr of age receiving GCS therapy. Studies were excluded if patients received at least 400 IU/d (10 μg/d) vitamin D, if GCS treatment was less than 2-wk duration, if more than 50% of the study population received GCS for renal or hepatic disease or after transplant, or if the study population included patients with Cushing's syndrome. A consensus method was used to classify studies. Of identified studies, 3% met the selection criteria.

DATA EXTRACTION

Data were extracted by a single author. Study quality was assessed using criteria developed by the American Dietetic Association.

DATA SYNTHESIS

The weighted mean 25(OH)D (by sample size or sd) was 22.4 [95% confidence interval (CI), 19.4, 25.3] ng/ml and 21.0 (95% CI, 13.5, 28.5) ng/ml, respectively. Random effects meta-analysis was used to compare serum 25(OH)D in patients treated with GCS compared to steroid-naive controls (either healthy or with active disease) and in patients before and after GCS administration. Serum 25(OH)D in GCS users was on average -0.5 (95% CI, -1.0, -0.1) ng/ml lower than in healthy controls (P=0.03; I2=56.4%). Serum 25(OH)D did not differ between GCS users and disease controls [standardized mean difference=0.0 (95% CI, -0.2, 0.3) ng/ml; P=0.793; I2=16.2%].

CONCLUSION

The suboptimal concentrations of serum 25(OH)D found in adults receiving GCS are inadequate for prevention and management of glucocorticoid-induced osteoporosis. Recommendations for vitamin D supplementation should be adjusted accordingly.

Weight loss in elderly women in low-level care and its association with transfer to high-level care and mortality

Background

The purpose of this study was to determine whether unintentional weight loss in older women predicts an imminent transition out of low-level care (either to higher-level care or by mortality).

Methods

Fifty-three Australian women, ambulatory while living in low-level care and requiring minimal assistance, were studied. At baseline, when the women were aged (mean ± standard deviation) 86.2 ± 5.3 years, body composition was assessed by dual energy X-ray absorptiometry, dietary intake was determined by a three-day weighed food record, a venous blood sample was taken, and both muscle strength and physical functioning were measured. The women were then followed up for 143 weeks to record the composite outcome of transfer to high-level care or mortality.

Results

During follow-up, unintended loss of body weight occurred in 60% of the women, with a mean weight loss of −4.6 ± 3.6 kg. Seven women (13.2%) died, and seven needed transfer to high-level care. At baseline, those who subsequently lost weight had a higher body mass index (P < 0.01) because they were shorter (P < 0.05) but not heavier than the other women. Analysis of their dietary pattern revealed a lower dietary energy (P < 0.05) and protein intake (P < 0.01). The women who lost weight also had lower hip abductor strength (P < 0.01), took longer to stand and walk (P < 0.05), and showed a slower walking speed (P < 0.01). Their plasma C-reactive protein was higher (P < 0.05) and their serum albumin was lower (P < 0.01) than women who did not lose weight. Nonintentional weight loss was a significant predictor of death or transfer to high care (hazards ratio 0.095, P = 0.02).

Conclusion

Weight loss in older women predicts adverse outcomes, so should be closely monitored.

Poor physical function in elderly women in low-level aged care is related to muscle strength rather than to measures of sarcopenia

Purpose:

To determine the prevalence of sarcopenia and investigate relationships among body composition, muscle strength, and physical function in elderly women in low-level aged care.

Subjects and methods:

Sixty-three ambulatory women (mean age 86 years) participated in this cross-sectional study where body composition was determined by dual energy X-ray absorptiometry (DXA); ankle, knee, and hip strength by the Nicholas Manual Muscle Tester; and physical function by ‘timed up and go’ (TUG) and walking speed (WS) over 6 meters. Body composition data from a female reference group (n = 62, mean age 29 years) provided cut-off values for defining sarcopenia.

Results:

Elderly women had higher body mass index (P < 0.001), lower lean mass (P < 0.001), and higher fat mass (P < 0.01) than the young reference group. Only a small proportion (3.2%) had absolute sarcopenia (defined by appendicular skeletal muscle mass/height squared) whereas 37% had relative sarcopenia class II (defined by percentage skeletal muscle mass). Scores for TUG and WS indicated relatively poor physical function, yet these measures were not associated with muscle mass or indices of sarcopenia. In multivariate analysis, only hip abductor strength predicted both TUG and WS (both P = 0.01).

Conclusion:

Hip strength is a more important indicator of physical functioning than lean mass. Measurement of hip strength may therefore be a useful screening tool to detect those at risk of functional decline and requirement for additional care. Further longitudinal studies with a range of other strength measures are warranted.

A systematic review and meta-analysis of elevated blood pressure and consumption of dairy foods

Hypertension is a public health priority in developed countries and worldwide, and is strongly associated with increased risk and progression of cardiovascular and renal diseases. A systematic review and meta-analysis were conducted to examine the association between dairy food intake during adulthood and the development of elevated blood pressure (EBP), specifically comparing the association of EBP with consumption of low-fat dairy foods versus high-fat dairy foods, as well as cheese versus fluid dairy foods (milk or yogurt). Seven databases were searched and five cohort studies selected for inclusion, involving nearly 45,000 subjects and 11,500 cases of EBP. Meta-analysis of consumption of dairy foods and EBP in adults gave a relative risk (RR) of 0.87 (95% confidence interval (CI) 0.81-0.94). Separation of high- and low-fat dairy foods, however, indicated a significant association with low-fat dairy foods only (RR of 0.84 (95% CI 0.74-0.95)). Additional analyses showed no association between EBP and cheese, although fluid dairy foods were significantly associated with a reduced development in EBP (RR of 0.92 (95% CI 0.87-0.98)). Little heterogeneity was observed among the data presented. This meta-analysis supports the inverse association between low-fat dairy foods and fluid dairy foods and risk of EBP. Understanding these relationships can aid in the development of public health messages involving dairy foods, and supports current recommendations.

A1C for screening and diagnosis of type 2 diabetes in routine clinical practice

OBJECTIVE

To evaluate A1C for screening and diagnosis of undiagnosed type 2 diabetes defined by oral glucose tolerance testing in clinical and general populations.

RESEARCH DESIGN AND METHODS

A1C cut offs (< or =5.5% to rule out diabetes; > or =7.0% to rule in diabetes) were derived from a clinical group (Melbourne Pathology [MP] group: n = 2,494; undiagnosed diabetes 34.6%) and then evaluated in a population-based sample (AusDiab group: n = 6,015; undiagnosed diabetes 4.6%).

RESULTS

For diabetes in the MP and AusDiab groups, A1C at 5.5% gave sensitivities of 98.7 and 83.5%, while A1C at 7.0% gave specificities of 98.2 and 100%, respectively. Many (61.9-69.3%) with impaired A1C (5.6-6.9%) in both populations had abnormal glucose status.

CONCLUSIONS

A1C < or =5.5% and > or =7.0% predicts absence or presence of type 2 diabetes, respectively, while at A1C 6.5-6.9% diabetes is highly probable in clinical and population settings. A high proportion of people with impaired A1C have abnormal glucose status requiring follow-up.

Diet and exercise in the prevention of diabetes

BACKGROUND

Individuals with impaired fasting glucose or impaired glucose tolerance are at high risk of progression to type 2 diabetes. Lifestyle modification through change to diet and exercise habit has considerable potential to prevent or delay the onset of this disease.

METHODS

A systematic literature search was undertaken of Medline, EMBASE, the Cochrane library and the Cumulative Index to Nursing and Allied Health Literature for journal articles relevant to the question of whether type 2 diabetes can be prevented by lifestyle change.

RESULTS

Four cohort studies in a total of 4864 high risk individuals followed for a period of 2.5-6 years were identified. These showed that lifestyle change may reduce the incidence of type 2 diabetes by 28-59%. Moreover, follow-up studies also indicate that diabetes incidence rates continue to be depressed many years after the discontinuation of a lifestyle intervention. Evidence from a meta-analysis confirms this evidence and suggests that it would be necessary to treat 6.4 (95% confidence interval 5.0-8.4) individuals to prevent or delay one case of diabetes through lifestyle intervention. An examination of weight loss diets (low fat, high protein or Mediterranean) suggests each may be effective but each has limitations requiring care in food selection. Evidence also suggests that the maintenance of weight loss also requires regular exercise with an additional expenditure of approximately 8.4 MJ week(-1) (2000 kcal week(-1)).

CONCLUSIONS

Diabetes can be prevented by lifestyle change. The challenge is to develop public health approaches to support individuals with respect to incorporating the lifestyle changes needed to reduce the risk of diabetes into their everyday life.

Calcium absorption in Australian osteopenic post-menopausal women: an acute comparative study of fortified soymilk to cows' milk

Calcium loss after menopause increases the risk of osteoporosis in aging women. Soymilk is often consumed to reduce menopausal symptoms, although in its native form, it contains significantly less calcium than cow's milk. Moreover, when calcium is added as a fortificant, it may not be absorbed efficiently. This study compares calcium absorption from soymilk fortified with a proprietary phosphate of calcium versus absorption from cow's milk. Preliminary studies compared methods for labelling the calcium fortificant either before or after its addition to soymilk. It was established that fortificant labelled after it was added to soymilk had a tracer distribution pattern very similar to that shown by fortificant labelled before adding to soymilk, provided a heat treatment (90?C for 30 min) was applied. This method was therefore used for further bioavailability studies. Calcium absorption from fortified soy milk compared to cow's milk was examined using a randomised single-blind acute cross-over design study in 12 osteopenic post-menopausal women aged (mean +/- SD) 56.7+/-5.3 years, with a body mass index of 26.5+/-5.6 kg/m2. Participants consumed 20 mL of test milk labelled after addition of fortificant with 185 kBq of 45Ca in 44 mg of calcium carrier, allowing the determination of the hourly fractional calcium absorption rate (alpha) using a single isotope radiocalcium test. The mean hourly fractional calcium absorption from fortified soymilk was found to be comparable to that of cows' milk: alpha = 0.65+/-0.19 and alpha =0.66+/-0.22, p>0.05, respectively.

Malnutrition on the menu: nutritional status of institutionalised elderly Australians in low-level care

BACKGROUND

Most studies reporting malnutrition in the elderly relate to high-level care. However, one third of Australians in aged care reside in low-level care facilities. Data is limited on their nutritional status.

OBJECTIVE

To investigate the nutritional status of elderly in low-level care facilities.

DESIGN

A cross sectional study design.

SETTING

14 low-level aged care facilities in metropolitan Melbourne.

PARTICIPANTS

Convenience sample of 103 ambulatory elderly (86 +/- 6.6 years (mean +/- SD), 76% female, comprising 15% of the hostel population) able to perform daily functions of living.

MEASUREMENTS

Nutritional intake assessed by three-day weighed food records, and nutritional status by haematological and biochemical markers and body composition (dual energy X-ray absorptiometry).

RESULTS

FOOD served did not supply the estimated average requirements (EAR) for 5 of the 14 nutrients analysed. Compared with EAR, 34% of participants were protein malnourished and 62% had energy intake deficits. Micronutrient intake was low for calcium, magnesium, folate, zinc (for men) and dietary fibre. Vitamin D deficiency (serum 25OH Vitamin D < 50 nmol/L) was present in 58% of residents. More men than women had low haemoglobin (P < 0.000), low red blood cells (P < 0.000), and a raised white blood cell count (P = 0.004). Forty three percent of men and 21% women had sarcopenia, 28% of men and 44% women had excess body fat (> 28% and >40%, respectively) and 14% of men and 12 % of women were sarcopenic-obese. Only 12% showed no sign of undernutrition using seven different nutritional indicators. Around 65% had two or more indicators of undernutrition.

CONCLUSION

These findings highlight the need for the supply of more, better quality, nutrient dense food to residents and better detection of undernutrition in aged care facilities. Maintenance of nutritional status has the potential to reduce morbidity and delay the transition to high-level care.

Potential roles of high salt intake and maternal malnutrition in the development of hypertension in disadvantaged populations

1. It has been argued that all major risk factors for cardiovascular disease have been identified. Yet, epidemiological studies undertaken to identify risk factors have largely focused on populations in developed nations or on the urban or relatively affluent rural populations of developing countries. Poor rural populations are seldom studied. 2. Somewhat different risk factors may operate in poor rural populations. Evidence for this is provided by the finding that, in disadvantaged rural India, the prevalence of hypertension is greater than would be expected based on established risk factors in these populations. One risk factor to be considered is a poor intrauterine environment. 3. In animals, maternal macro- and micronutrient malnutrition can lead to reduced nephron endowment. Nephron deficiency, in turn, can render blood pressure salt sensitive. The combination of nephron deficiency and excessive salt intake will predispose to hypertension. 4. Human malnutrition may have similar effects, particularly in regions of the world where malnutrition is endemic and where women are disadvantaged by existing social practices. 5. Moreover, high salt intake is endemic in many parts of Asia, including India. Therefore, we propose that maternal malnutrition (leading to reduced nephron endowment), when combined with excessive salt intake postnatally, will account, at least in part, for the unexpectedly high prevalence of hypertension in disadvantaged rural communities in India and elsewhere.

The use of contextual learning to teach biochemistry to dietetic students

This article describes the use of contextualized and "blended" learning to teach biochemistry to dietetic students during the second year of their professional training in a 4-year undergraduate degree (Bachelor of Nutrition and Dietetics). Contextualized content was used to engage students and motivate them to learn biochemistry, which many perceived as a "hard" subject. Contextualized learning presented via problem solving exercises, case-studies, and by the use of virtual subjects in laboratory class introduced content material through real life situations highly relevant to their later clinical practice. A "blended" curriculum where content was presented in a number of different modalities (on-line, on CD, or face-to-face in small/large groups and in tutorials/lectures/laboratory class) further enhanced contextualized learning by providing a range of learning modalities catering to different student learning styles. The on-line and CD material also allowed student self-assessment of learning progress through interactive quizzes in varied assessment formats, where feedback was often immediate. Student responses to this biochemistry course have been positive with 89% finding it intellectually stimulating.

Is there a role for monounsaturated fat in the dietary management of obesity?

Animal and human studies indicate that high saturated fat (SFA) diets can be obesogenic. Monounsaturated fat (MUFA) has acute (meal related) effects that influence energy metabolism. These include increased postprandial fat oxidation and greater diet induced thermogenesis, factors that attenuate weight gain. Chronic (diet related) studies for 12 weeks or more, demonstrate that people following high MUFA diets do not gain excessive weight even when eating ad libitum. In fact, we have observed greater body weight and fat loss in men following an ad libitum MUFA diet, when compared to a SFA diet. High MUFA diets designed for weight loss should also incorporate a high vegetable intake according to traditional Mediterranean patterns. Such diets will promote the utilisation of fat and also have a low energy density. In our experience these diets are well accepted, and offer the prospect of greater long-term adherence to dietary advice.

The cost of healthy food in rural Victoria

INTRODUCTION

The cost of healthy food has been associated previously with the degree of remoteness and socioeconomic status. This study aimed to investigate the factors that influence the cost of food in rural Victoria, Australia. It also aimed to compare the cost of nutritious foods with less healthy foods, and to identify the population sub-groups most vulnerable to economic food insecurity.

METHODS

A cross-sectional survey of the cost of food was undertaken in 2007 in a convenience sample of 34 supermarkets in rural areas across Victoria using the Victorian Healthy Food Basket (VHFB). The VHFB was designed to meet the nutritional needs of four different family types for a fortnight.

RESULTS

The cost of the VHFB for a 'typical family' (2 adults, 2 children) was (mean [interquartile range]) AU $402.81 ($26.36). No association was evident between food cost and remoteness as indicated by the Accessibility/Remoteness Index for Australia (ARIA) score, socioeconomic status as indicated by the Socio-Economic Indices for Areas (SEIFA), population size or density, or distance of the town from the state capital, Melbourne. It was more expensive to purchase the VHFB at an independent store (median cost $406.66 [$29.39]) than at a supermarket chain (median cost $394.93 [$26.64]), p<0.05. Vegetables and legumes were the most expensive component of the VHFB to purchase and this food group showed significantly greater variation in food price than cereals (p<0.05), non-core foods (p<0.05) and unhealthy foods (p<0.001). The median cost of the VHFB was most expensive for a typical family and 'single parent family' (40% and 37% of welfare income) and least expensive for a single man (29% of income) and elderly pensioner (19% income).

CONCLUSIONS

The VHFB is an effective tool for assessing economic food security for different population groups. The cost of food in rural Victoria varies in a manner that appears unrelated to remoteness, population, socioeconomic status or distance from the metropolitan centre. Purchase of healthy food requires a considerable proportion of welfare income and may thus be unaffordable for some groups. Food cost must be monitored at a national level to provide a knowledge base to inform development of food and nutrition policies for improved population health.

Fermentation of calcium-fortified soymilk with Lactobacillus: effects on calcium solubility, isoflavone conversion, and production of organic acids

The objective of this study was to enhance calcium solubility and bioavailability from calcium-fortified soymilk by fermentation with 7 strains of Lactobacillus, namely, L. acidophilus ATCC 4962, ATCC33200, ATCC 4356, ATCC 4461, L. casei ASCC 290, L. plantarum ASCC 276, and L. fermentum VRI-003. The parameters that were used are viability, pH, calcium solubility, organic acid, and biologically active isoflavone aglycone content. Calcium-fortified soymilk made from soy protein isolate was inoculated with these probiotic strains, incubated for 24 h at 37 degrees C, then stored for 14 d at 4 degrees C. Soluble calcium was measured using atomic absorption spectrophotometry (AA). Organic acids and bioactive isoflavone aglycones, including diadzein, genistein, and glycetein, were measured using HPLC. Viability of the strains in the fermented calcium-fortified soymilk was > 8.5 log(10) CFU/g after 24 h fermentation and this was maintained for 14-d storage at 4 degrees C. After 24 h, there was a significant increase (P < 0.05) in soluble calcium. L. acidophilus ATCC 4962 and L. casei ASCC 290 demonstrated the highest increase with 89.3% and 87.0% soluble calcium after 24 h, respectively. The increase in calcium solubility observed was related to lowered pH associated with production of lactic and acetic acids. Fermentation significantly increased (P < 0.05) the level of conversion of isoflavones into biologically active aglycones, including diadzein, genistein, and glycetein. Our results show that fermenting calcium-fortified soymilk with the selected probiotics can potentially enhance the calcium bioavailability of calcium-fortified soymilk due to increased calcium solubility and bioactive isoflavone aglycone enrichment.

Arabinoxylan fibre improves metabolic control in people with Type II diabetes

OBJECTIVE

To determine whether diet supplementation with arabinoxylan-rich (AX)-fibre from wheat improves glycaemic control in Type II diabetes.

DESIGN

Randomized, crossover intervention trial.

SETTING

Monash Medical Centre.

SUBJECTS

A total of 15 subjects with Type II diabetes.

INTERVENTIONS

Over two 5-week periods, subjects supplemented their usual diet with control bread and muffins (50% whole wheat, 50% white flour) (control diet) or with AX-bread and muffins (50% whole wheat, 36% white flour, 14% AX fibre) (AX diet). Subjects completed a 7-day food diary. At 0 and 5 weeks, venous blood was collected for determination of fasting and 2 h glucose, insulin, fructosamine and blood lipids. Blood pressure, body weight and body fat were also determined. A 24 h faecal sample, from 12 subjects, was weighed and analysed for faecal polysaccharide as a marker for dietary compliance.

RESULTS

Control and AX diets were similar except the AX diet supplied an additional 15.1 (12.0-18.5) (mean (95% confidence intervals)) g/day dietary fibre (P=0.000). Consumption of the AX diet increased faecal output by 61.5 (0.2-122.8) g/day (P=0.05) on a wet weight basis and significantly lowered fasting and 2 h plasma glucose, 2 h insulin and serum fructosamine (P=0.002, 0.000, 0.015, and 0.02, respectively). Blood lipids, body weight, fat mass and blood pressure remained unchanged.

CONCLUSION

A supplement of 15 g/day of AX-rich fibre can significantly improve glycaemic control in people with Type II diabetes.

Substitution of saturated with monounsaturated fat in a 4-week diet affects body weight and composition of overweight and obese men

A randomised crossover study of eight overweight or obese men (aged 24-49 years, BMI 25.5-31.3 kg/m(2)), who followed two diets for 4 weeks each, was performed to determine whether substitution of saturated fat with monounsaturated fat affects body weight and composition. Subjects were provided with all food and beverages as modules (selected ad libitum) of constant macronutrient composition, but differing energy content. The % total energy from saturated fat, monounsaturated fat and polyunsaturated fat was 24, 13 and 3 % respectively on the saturated fatty acid (SFA)-rich diet and 11, 22 and 7 % respectively on the monounsaturated fatty acid (MUFA)-rich diet. MUFA accounted for about 80 % of the unsaturated fats consumed on both diets. Body composition, blood pressure, energy expenditure (resting and postprandial metabolic rates, substrate oxidation rate, physical activity), serum lipids, the fatty acid profile of serum cholesteryl esters and plasma glucose and insulin concentrations were measured before and after each diet period. Significant (P< or =0.05) differences in total cholesterol and the fatty acid composition of serum cholesteryl esters provided evidence of dietary adherence. The men had a lower weight (-2.1 (SE 0.4) kg, P=0.0015) and fat mass (-2.6 (SE 0.6) kg, P=0.0034) at the end of the MUFA-rich diet as compared with values at the end of the SFA-rich diet. No significant differences were detected in energy or fat intake, energy expenditure, substrate oxidation rates or self-reported physical activity. Substituting dietary saturated with unsaturated fat, predominantly MUFA, can induce a small but significant loss of body weight and fat mass without a significant change in total energy or fat intake.

Inflammation and vascular endothelial activation in an Aboriginal population: relationships to coronary disease risk factors and nutritional markers

OBJECTIVE

To describe the levels of inflammation and vascular endothelial activation in an Aboriginal community, and the relationship of these factors to coronary heart disease (CHD) risk factors and markers of nutritional quality.

DESIGN AND PARTICIPANTS

A cross-sectional survey of 95 women and 76 men participating in a chronic-disease prevention program.

SETTING

A remote Aboriginal community in Western Australia in 1996.

MAIN OUTCOME MEASURES

Concentrations of markers of inflammation (C-reactive protein [CRP]) and vascular endothelial activation (soluble E-selectin [sE-selectin]); presence of metabolic syndrome; concentrations of diet-derived antioxidants.

RESULTS

Participants exhibited very high plasma concentrations of CRP (mean, 5.4 mg/L; 95% CI, 4.6-6.3 mg/L) and sE-selectin (mean, 119 ng/mL; 95% CI, 111-128 ng/mL). Both CRP and sE-selectin concentrations were significantly higher in the presence of the metabolic syndrome. There were significant inverse linear relationships between concentrations of CRP and plasma concentrations of the antioxidants lycopene, beta-carotene, cryptoxanthin and retinol. Even stronger inverse associations were evident between concentrations of sE-selectin and lycopene, beta-carotene, cryptoxanthin and lutein.

CONCLUSIONS

Vascular inflammation and endothelial activation may be important mediators of elevated CHD risk in Aboriginal people. Inadequate nutrition and physical inactivity may contribute to this process.

Whole cereal and legume seeds increase faecal short chain fatty acids compared to ground seeds

We set out to compare the effect of diets containing intact seeds as food ingredients on colon function and fermentation-dependent events. Using a randomized cross over design, twelve healthy adults were recruited and required to consume an experimental diet containing intact or ground seeds for 7-days then after returning to their usual diet for 21-days to consume the second experimental diet for 7-days. All foods consumed during the experimental dietary periods were supplied by the researchers. Stools passed on three consecutive days on the usual diet prior to commencement and on days 5, 6 and 7 during each experimental diet, were collected. Outcome measures were whole gut transit time, 24 h stool output, faecal pH, particle size, and short chain fatty acid content. Seeds recovered from stools were examined by scanning electron microscopy. Nine of the twelve subjects completed all aspects of the study. Consumption of intact seeds compared to ground seeds increased 24 h faecal wet weight (mean 258 g +/- 123 g and 170 g +/- 63 g, respectively; P=0.005) and dry weight (78 g +/- 34 g and 46 g +/- 28 g, respectively; P=0.003). Whole gut transit times and moisture content of stools were not different. There was a trend for stools from the whole seed diet to be more acidic than those from the ground seed diet (pH 6.2 +/- 0.3 and pH 6.6 +/- 0.3, respectively; P=0.06) and they contained more short chain fatty acids (35 +/- 5.2 and 30 +/- 10.5 mmol/kg, respectively; P=0.05). Large amounts of apparently whole seeds were recovered from stools, but internally the endosperm was often eroded and coated with bacteria. Intact seeds as food ingredients bring about changes to the colonic environment and to faecal composition that may reduce the risk of colon cancer.

The influence of the type of dietary fat on postprandial fat oxidation rates: monounsaturated (olive oil) vs saturated fat (cream)

OBJECTIVE

To compare postprandial whole-body fat oxidation rates in humans, following high-fat (43% of total energy) mixed breakfast meals, of fixed energy and macronutrient composition, rich in either monounsaturated fat (MUFA) from extra virgin olive oil or saturated fat (SFA) from cream.

DESIGN

Paired comparison of resting metabolic rate (RMR), thermic effect of a meal and substrate oxidation rates following consumption of isocaloric breakfast meals, differing only in the type of fat, administered in random order 1-2 weeks apart.

SUBJECTS

Fourteen male volunteers, body mass index (BMI) in the range 20-32 kg/m(2), aged 24-49 y and resident in Melbourne, Australia, were recruited by advertisement in the local media or by personal contact.

MEASUREMENTS

Body size and composition was determined by anthropometry and dual energy X-ray absorptiometry (DEXA). Indirect calorimetry was used to measure RMR, thermic effect of a meal, post-meal total energy expenditure and substrate oxidation rate. Blood pressure and pulse rates were measured with an automated oscillometric system. Fasting and 2 h postprandial glucose and insulin concentrations and the fasting lipid profile were also determined.

RESULTS

In the 5 h following the MUFA breakfast, there was a significantly greater postprandial fat oxidation rate (3.08+/-4.58 g/5 h, P=0.017), and lower postprandial carbohydrate oxidation rate (P=0.025), than after the SFA breakfast. Thermic effect of a meal was significantly higher (55 kJ/5 h, P=0.034) after the MUFA breakfast, in subjects with a high waist circumference (HWC > or = 99 cm) than those with a low waist circumference (LWC<99 cm). This difference was not detected following the SFA breakfast (P=0.910).

CONCLUSION

If postprandial fat oxidation rates are higher after high MUFA, rather than SFA meals, then a simple change to the type of dietary fat consumed might have beneficial effects in curbing weight gain in men consuming a relatively high-fat diet. This may be particularly evident in men with a large waist circumference.

Is a low fat diet the optimal way to cut energy intake over the long-term in overweight people?

Successful weight loss depends on maintaining a sustained negative energy balance. This can be achieved on diets with a normal (40% energy) fat content as well as on low fat diets. Using a 'modified fat' (MF) diet enriched with monounsaturated fat (MUFA), body weight may be lost either by calorie counting, or by allowing ad libitum food intake with careful food selection. In the latter approach high energy, high MUFA foods (predominantly olive oil, but also may include nuts and avocado) should contribute no more than 20% total energy to the diet, and other foods should be selected to minimise meal energy density. This can be achieved simply by the consumption of a wide variety of vegetables and whole grain cereal foods. It is also important to restrict foods high in saturated fat and to encourage regular exercise. Such a 'modified fat' low energy diet designed for weight loss should also contribute numerous health benefits in relation to improved metabolic control in Type 2 diabetes and reduced cardiovascular disease risk (as the diet is not only rich in MUFA but also in a range of dietary antioxidants and other bio-active phytochemicals).

Effects of estradiol with and without testosterone on body composition and relationships with lipids in postmenopausal women

OBJECTIVE

The cardioprotective effects of postmenopausal estrogen replacement therapy are mediated by several mechanisms, including favorable effects on lipids and lipoproteins. The extent to which the latter reflects modification of body fat distribution by sex steroids is not known. Hence, we investigated the relationships between changes in lipids and measures of body composition in postmenopausal women who were administered estrogen therapy with and without testosterone.

DESIGN

We randomized 33 postmenopausal women to treatment with either estradiol 50 mg (E) alone or estradiol 50 mg plus testosterone 50 mg implants (E&T) administered every 3 months for 2 years in conjunction with cyclic oral progestins for women with an intact uterus.

RESULTS

Both therapies were associated with sustained reductions in total cholesterol and low-density lipoprotein (LDL) cholesterol. In women who received E but not E&T, hip (p < 0.001) and abdominal circumferences (p < 0.05) and fat mass:fat-free mass (FM:FFM) ratio over the abdomen (p < 0.05) declined. E&T but not E resulted in increased FFM (p < 0.001) and a reduced FM:FFM ratio (p < 0.05). For E but not E&T, the decrease in LDL cholesterol was significantly related to changes in total and compartmental body fat and to change in the FM:FFM ratio (p < 0.05).

CONCLUSION

Estrogen replacement has effects on body fat distribution in postmenopausal women that are associated with improved lipid parameters. Addition ofparenteral testosterone does not negate the favorable effects of estrogen on LDL cholesterol levels but may attenuate the reduction in centralized body fat achieved with E implants.

Changes to the quantity and processing of starchy foods in a western diet can increase polysaccharides escaping digestion and improve in vitro fermentation variables

This study investigated how readily achievable changes to the quantity and processing of starchy foods in a typical Western diet: (1) were reflected in levels of resistant starch (RS) and NSP excreted from the small intestine; and (2) more favourable profiles of butyrate, NH3 and phenol production. Two diets, a low-starch diet (LSD) and a high-starch, low-fat diet (HSLFD) were compared. The LSD with 20% total energy (%E) from starch was based on a 'typical' Australian diet, while the HSLFD (40%E as starch) was the same Australian diet modified by an increased content of legumes, starchy foods and coarsely-ground cereals and by a reduced fat content. Four subjects with iliostomies consumed each diet for 2 d, with ileal effluent collection on the second day. On the HSLFD compared with the LSD, RS in ileal effluent increased from from 0.49 to 1.7 g/MJ per d (P < 0.005) while ileal NSP excretion increased from 2.0 to 3.3 g/MJ per d (P < 0.05). Ileal effluents obtained after each diet were incubated for 24 h in vitro with a human faecal innoculum. After fermentation, ileal effluent from the HSLFD produced more butyrate relative to other short-chain fatty acids (17.5 v. 15.8 molar %, P < 0.005) and less phenol (2.3 v. 5.7 mg/l, P < 0.05) and NH3 (20.3 v. 23.1 mmol/l, P < 0.005) than the LSD diet. The HSLFD also generated a lower pH (6.15 v. 6.27, P < 0.05). On a wt/wt basis, RS was 2.3-fold higher in the HSLFD effluent while NSP did not increase, suggesting that the change in RS largely contributed to the fermentation effects. Changes in in vitro variables when the HSLFD ileal effluent was ground before fermentation indicated the importance of physical structure in determining ileal excretion of RS. We conclude that: (1) readily achievable modifications to the amount and processing of starchy foods in an Australian diet would produce potential benefits for in vitro fermentation variables; and (2) the physical structure of grains and cereals is important in determining access by colonic bacteria to a carbohydrate substrate.

Arabinoxylan fiber, a byproduct of wheat flour processing, reduces the postprandial glucose response in normoglycemic subjects

BACKGROUND

Arabinoxylan (AX) is the major component of dietary fiber in the cereal grains that make up a large proportion of our diet. However, the physiologic effect of AX is unknown.

OBJECTIVE

The objective of this study was to determine whether AX improves postprandial glucose and insulin responses in healthy humans.

DESIGN

AX-rich fiber was extracted from the byproduct of wheat-flour processing. Three isoenergic breakfasts, comprising bread, margarine, and jam, had 75 g available carbohydrate, 10 g protein, and 14 g fat and contained 0, 6, and 12 g AX-rich fiber, respectively. Fourteen healthy subjects consumed the 3 breakfast meals in random order on 3 mornings >/=3 d apart after an overnight fast. Blood was taken from the subjects at regular intervals over 2 h and was analyzed for glucose and insulin. The palatability of bread containing AX-rich fiber was compared with that of a control bread.

RESULTS

Compared with the control meal containing 0 g AX-rich fiber, the peak postprandial glucose concentration after meals containing 6 and 12 g AX-rich fiber was significantly lower (6. 3 +/- 1.3 compared with 7.2 +/- 1.0 mmol/L, P < 0.01; 5.9 +/- 0.9 compared with 7.2 +/- 1.0 mmol/L, P < 0.001, respectively). The incremental area under the curve (IAUC) for glucose was 20.2% (95% CI: 5.8%, 34.7%; P < 0.01) and 41.4% (25.9%, 56.8%; P < 0.001) lower, whereas IAUC for insulin was 17.0% (2.0%, 32.1%; P < 0.05) and 32. 7% (18.8%, 46.6%; P < 0.001) lower, respectively. Bread containing AX-rich fiber was as pala as 50% whole-wheat bread when evaluated with sensory analysis by 30 volunteers.

CONCLUSIONS

Postprandial glucose and insulin responses were improved by ingestion of AX-rich fiber. Further research is required to determine whether AX-rich fiber is of benefit to people with type 2 diabetes.

Dietary composition affects regional body fat distribution and levels of dehydroepiandrosterone sulphate (DHEAS) in post-menopausal women with Type 2 diabetes

OBJECTIVE

To compare effects of a high carbohydrate (high-CHO) and a monounsaturated fat diet (high-MUFA) on body fat distribution and sex hormones in post-menopausal women with Type 2 diabetes.

DESIGN

Randomised cross-over with no washout.

SETTING

Geelong Hospital outpatient.

SUBJECTS

Thirty four women were recruited, 30 completed the study, and data are presented for 21 women compliant to the high-CHO diet.

INTERVENTIONS

Women followed a high-CHO diet (20% energy (%E) from fat, 60%E from carbohydrate and a high-MUFA diet (40%E from fat, half as monounsaturated fat, 40%E from carbohydrate) in random order for 12 weeks each.

MAIN OUTCOME MEASURES

Dietary compliance was measured by change in linoleic acid (C18:2,omega-6) in plasma cholesteryl esters. Body composition was measured by dual-energy X-ray absorptiometry. Fasting concentrations of glucose and insulin were measured in plasma. Steroid hormones and sex hormone binding globulin (SHBG) were measured in serum.

RESULTS

On the high-CHO diet C18:2,omega-6 in plasma cholesteryl esters declined by 5.4% (95% confidence intervals (CI), -2.5% to -8.4%, P=0.0015). Fat was lost mainly from the lower body (lower body loss -0.71 kg, 95%CI, -0.43 to -1.00 kg, P=0.001; upper body loss -0.15 kg, 95%CI, -0.76 to +0.46 kg, P=0.6). Yet on the high-MUFA diet, lower body fat loss was minimal (-0.22 kg, 95%CI, +0.11 to -0.55 kg, P = 0.2). By general linear modelling (GLM), differences in lower body fat loss were significantly related to diet (P = 0.04). After adjustment for age, dehydroepiandrosterone sulphate (DHEAS) concentrations after the high-CHO diet were related to levels of lower body fat (r = 0.394, P = 0.04).

CONCLUSIONS

In women with Type 2 diabetes following a high-CHO diet for 12 weeks the disproportionate loss of lower body fat is related to a decline in DHEAS.

Effects of regular walking on cardiovascular risk factors and body composition in normoglycemic women and women with type 2 diabetes

OBJECTIVE

To examine the impact of a 12-week walking program on body composition and risk factors for cardiovascular disease in women with type 2 diabetes and in normoglycemic women with first-degree diabetic relatives.

RESEARCH DESIGN AND METHODS

There were 11 postmenopausal women with type 2 diabetes and 20 normoglycemic women of similar age and BMI who were asked to walk 1 h per day on 5 days each week for 12 weeks. Fitness (estimated VO2max) was assessed with a 1.6-km walking test; body composition was measured by dual-energy X-ray absorptiometry; and sex hormone, metabolic, and lipid concentrations were measured in serum.

RESULTS

After 12 weeks, estimated VO2max improved in both groups (P < 0.005). In the diabetic women, BMI and fat content of the upper body and android waist region decreased (P < 0.05). Concentrations of fasting blood glucose (P < 0.05) HbAlc (P < 0.05), total cholesterol (P < 0.005), and LDL cholesterol (P < 0.05) decreased, while HDL cholesterol and sex hormones were unchanged. In contrast, normoglycemic women failed to lose body fat after 12 weeks of exercise in a walking program. However, their HbAlc, total cholesterol, LDL cholesterol, sex hormone-binding globulin, and total testosterone concentrations decreased (P < 0.05). On pooling the data and including diabetes as a categorical grouping variable, stepwise multiple regression analysis indicated that the change in centralized body fat, but not the change in VO2max, was related to change in fasting blood glucose.

CONCLUSIONS

Twelve weeks of walking increased the fitness of diabetic and normoglycemic women. Improvement of fasting blood glucose was related to the loss of centralized body fat rather than to improved fitness.

Modulation of fecal markers relevant to colon cancer risk: a high-starch Chinese diet did not generate expected beneficial changes relative to a Western-type diet

In a randomized, crossover dietary intervention study, 12 Australians (of white descent) consumed a diet typical of low-income communities in China and an average Australian diet so that effects on fecal markers thought to be relevant to colon cancer risk could be compared. The Chinese diet contained 35.3 g starch/MJ daily [including 2 g resistant starch (RS)/MJ and 1.5 g nonstarch polysaccharides (NSPs)/MJ]; the Australian diet contained 12 g starch/MJ daily (including 0.8 g RS and 2.7 g NSPs/MJ). Subjects followed each diet for 3 wk. Serum cholesterol concentrations were significantly lower after the low-fat, high-starch Chinese diet than after the Australian diet (mean +/- SEM: 4.17 +/- 0.30 compared with 5.04 +/- 0.28 mmol/L, respectively, P < 0.05), a difference indicative of dietary compliance. Fecal pH was lower after the Chinese diet (6.51 +/- 0.04) than after the Australian diet (6.63 +/- 0.05; P < 0.05). For all other fecal markers examined, however, the Chinese diet produced less favorable changes, including lower fecal bulk (86 +/- 11 compared with 141 +/- 20 g wet wt/d, P < 0.01), slower transit through the gut (69 +/- 6 compared with 56 +/- 7 h, P = 0.06), lower fecal concentrations of short-chain fatty acids [72.8 +/- 7.3 compared with 98 +/- 7.6 mmol/L (including butyrate: 12.2 +/- 1.3 compared with 18.4 +/- 2.3 mmol/L), P < 0.05], and higher fecal concentrations of potentially damaging ammonia (540 +/- 50 compared with 450 +/- 40 mg/L, P < 0.01) and phenols (109.2 +/- 13.2 compared with 68.5 +/- 12.9 mg/L, P < 0.01). These results suggest that consumption of a high-starch diet alone is insufficient to reduce the risk of developing colon cancer.

Do postmenopausal women with NIDDM have a reduced capacity to deposit and conserve lower-body fat?

OBJECTIVE

To compare regional body fat distribution and sex hormone status of postmenopausal women with NIDDM with those of age- and BMI-matched normoglycemic women.

RESEARCH DESIGN AND METHODS

The regional body fat distribution and sex hormone status of 42 postmenopausal women with NIDDM were compared with those of 42 normoglycemic women matched for age and BMI, who served as control subjects. Body composition was measured by dual-energy X-ray absorptiometry, and sex hormone-binding globulin (SHBG) and testosterone were measured in serum.

RESULTS

Although the levels of total body fat were similar between the two groups, the women with NIDDM had significantly less lower-body fat (LBF) (P < 0.01) than the control subjects matched for age and BMI. This pattern of fat deposition in women with NIDDM was accompanied by an androgenic hormone profile, with decreased SHBG concentration and an increased free androgen index (P < 0.05 and P < 0.01, respectively).

CONCLUSIONS

A reduced capacity to deposit and/or conserve LBF may be an independent factor associated with (or may be a marker of) the metabolic manifestations of the insulin resistance syndrome in women with NIDDM. The possibility that the smaller relative accumulation of LBF is a consequence of the androgenic hormonal profile should be investigated in future studies.

The influence of a breakfast meal on the assessment of body composition using bioelectrical impedance

OBJECTIVE

To investigate the effect of a breakfast meal on bioelectrical impedance (BI).

DESIGN

Three separate interventions.

SETTING

A university based study.

SUBJECTS

Young, healthy volunteers recruited from staff. Twenty-nine subjects (11 men, 18 women), ten subjects (two men and eight women) and 13 subjects (2 men and 11 women) completed the first, second and third protocol, respectively.

INTERVENTIONS

Total body BI (protocol 1) or both total body BI and segmental BI (namely arm, leg or torso BI); (protocol 3) was measured in the fasting state and for up to 5 h after the consumption of a breakfast meal containing 28% energy from fat. In the second protocol, total body BI was measured in the same way on two occasions after subjects consumed isocaloric meals containing either 28% energy or 4% energy from fat.

RESULTS

Consumption of a 2300 kJ meal was followed by a significant (P = 0.0002) decrease in BI (95% confidence intervals 12.5 and 35.3), a change which occurred 2 h after the meal and continued until 5 h, irrespective of meal fat content. The fall in total body BI was accounted for primarily by a fall in the BI of the limbs, with virtually no contribution from the torso.

CONCLUSION

To ensure consistency in the interpretation of BI for body composition analysis, it is important that measurements are made in the fasting state.

Effect on serum lipids of monounsaturated oil and margarine in the diet of an Antarctic Expedition

A 13-wk dietary intervention was carried out with 23 members of the 1991 wintering party of an Australian National Antarctic Research Expedition. Canola margarine and canola cooking oil were substituted for usual dietary fats (butter, a margarine containing 28% saturated fat, a polyunsaturated margarine, and vegetable oil). Mean energy intake slowly decreased although body weight slowly increased during the 42-wk wintering-over period. During 13 wk of dietary substitution, mean total cholesterol and low-density-lipoprotein-cholesterol concentrations fell by 7.0% and 10.0%, respectively (P < 0.05, repeated-measures ANOVA). These changes were not found in a second wintering-over group that did not experience this dietary intervention. The data indicate that a relatively simple change to the food supply has the potential to produce significant beneficial changes in lipoprotein lipid profile.

Detection of malignant tumors using Tc-99m labeled Fab' fragments from a monoclonal antibody with specificity for D-dimer of cross-linked fibrin

The authors present the case studies of two patients whose malignant tumors were detected with a Tc-99m labeled antifibrin monoclonal antibody (DD-3B6/22), which is specific for cross-linked fibrin. The first case was a malignant fibrous histiocytoma involving the proximal aspect of the left thigh, whereas in the second case, the patient was receiving treatment for a squamous cell carcinoma of the right mainstem bronchus. The results highlight the potential of this anti-D-dimer radiopharmaceutical for noninvasive detection of malignant tumors.