The association between hydration status and total fluid intake in healthy children and adolescents.

BACKGROUND: Children 10-20 years old in the US have suboptimal hydration status. Hydration is best assessed using an objective marker, such as urine specific gravity (USG) from a 24-h urine collection. There are limited studies associating hydration from an objective marker with intake assessed from 24-h recalls in children. The objective of the study was to evaluate which foods or beverages are significantly associated with an objective marker of hydration (USG) in a sample of children and adolescents. METHODS: Intake was assessed from three 24-h dietary recalls and analyzed using the Nutrition Data System for Research (NDSR). Hydration status was objectively measured using USG via 24-h urine collection. Associations were assessed with logistic regressions. RESULTS: A total of 68 children and adolescents were recruited (50% females). Average overall USG score was 1.020 ± 0.011 uG with 39.7% categorized as dehydrated. After adjusting for age and sex, fruit juice (1.009, 95% CI: 1.001, 1.018) and all beverages (1.001, 95% CI: 1.000, 1.002) were significantly associated with higher odds of being euhydrated. CONCLUSIONS: The main predictors of hydration were fruit juice and all beverages intake. Future research should be conducted to explore differences in dietary patterns in a larger, more generalizable sample. IMPACT: Findings showed that the main predictors of hydration were water and fruit juice intake in children and water intake in adolescents in southern Florida. This is the first study to examine which type of beverages and foods are associated with USG, an objective marker of hydration status, in US children and adolescents. Provides further insight into the use of objective markers to assess hydration status, while providing data to assist epidemiological studies that may have limited resources to examine beverages and foods that contribute to hydration.

Insights from the clinical phenotype of subjects with Laron syndrome in Ecuador.

The Ecuadorian cohort of subjects with LS has taught us valuable lessons since the late 80's. We have learned about migration of Sephardic Jews to our country, their isolation in remote hamlets and further inbreeding. These geographical, historical and social determinants induced dissemination of a growth hormone (GH) receptor mutation which widely occurred in those almost inaccessible villages. Consequently, the world's largest Laron syndrome (LS) cohort emerged in Loja and El Oro, two of the southern provinces of Ecuador. We have been fortunate to study these patients since 1987. New clinical features derived from GH insensitivity, their growth patterns as well as treatment with exogenous insulin-like growth factor I (IGF-I) have been reported. Novel biochemical characteristics in the field of GH insensitivity, IGFs, IGF binding proteins (BP) and their clinical correlates have also been described. In the last few years, studies on the morbidity and mortality of Ecuadorian LS adults surprisingly demonstrated that despite obesity, they had lower incidence of diabetes and cancer than their relatives. These events were linked to their metabolic phenotype of elevated but ineffective GH concentrations and low circulating IGF-I and IGFBP-3. It was also noted that absent GH counter-regulation induces a decrease in insulin resistance (IR), which results in low but highly efficient insulin levels which properly handle metabolic substrates. We propose that the combination of low IGF-I signaling, decreased IR, and efficient serum insulin concentrations are reasonable explanations for the diminished incidence of diabetes and cancer in these subjects.

Obesity in Latin America, a scoping review of public health prevention strategies and an overview of their impact on obesity prevention.

OBJECTIVE: To describe the strategies implemented in seventeen Latin American countries for obesity prevention and to provide an overview of their impact. DESIGN: A thorough search of strategies and their impact was done through an Internet search, governmental webpages, reports and research articles in English, Spanish and Portuguese. SETTING: Latin America (not including the Caribbean countries). PARTICIPANTS: Any. RESULTS: The Ministry of Health is the main oversight for obesity prevention, with six countries having a specific structure for this. Regular obesity monitoring occurs in a few countries, and thirteen countries have a national obesity prevention plan. The main regulations being implemented/designed are front-of-package labelling (sixteen countries), school environment (fifteen countries), school nutrition education (nine countries), promotion of physical activity level (nine countries) and sugar-sweetened beverage tax (eight countries). All countries have dietary guidelines. The main community-based programmes being implemented are school meals (seventeen countries), complementary nutrition (eleven countries), nutrition education (fourteen countries), promotion of physical activity (nine countries) and healthy environments (nine countries). Most of these strategies have not been evaluated. The few with positive results have used a coordinated, multi-disciplinary and multi-sector approach, with legislation and executive-level support. CONCLUSIONS: Important obesity prevention strategies are being implemented in the seventeen Latin American countries included in the present review. However, few have been evaluated to assess their impact on preventing obesity. This information can help assess that actions can be generalised to other countries within the region and can help inform how to prevent obesity in different settings.

Feeding modifications and additional primary caregiver support for infants exposed to Zika virus or diagnosed with congenital Zika syndrome: a rapid review of the evidence.

OBJECTIVE: Infants exposed to Zika virus (ZIKV) or diagnosed with congenital Zika syndrome (CZVS) may present dysphagia, regurgitation and other feeding difficulties. They may require special feeding practices to minimise the risk of mortality, morbidity and developmental problems. Improving knowledge, skills and behaviours of caregivers may preserve health, maximise development and promote quality of life among affected infants. We reviewed intervention studies of modified feeding practices and additional primary caregiver support to improve outcomes among infants 0 to 12 months of age exposed to ZIKV or diagnosed with CZVS. METHODS: Rapid review and meta-analysis. We searched PubMed/MEDLINE and contacted experts. The search is current to 18 July 2020. We planned a meta-analysis using fixed-effect models; if unfeasible, we intended to summarise studies narratively. We planned to assess risk of bias of included studies and quality of evidence using Cochrane guidance. RESULTS: We identified 42 records for title and abstract screening; 14 were eligible for full-text assessment. Among these, no intervention studies were found. Eight observational studies reported on the nutritional status, feeding practices and outcomes among infants affected by ZIKV or diagnosed with CZVS. They are presented and discussed to provide a basis for future research. CONCLUSIONS: While no intervention studies were found, evidence from eight observational studies highlights the need for early nutrition interventions and caregiver support among infants affected by ZIKV or diagnosed with CZSV. More research is needed to assess whether modifications of feeding practices and provision of additional primary caregiver support will impact outcomes of interest.

OBJECTIF: Les nourrissons exposés au virus Zika (VZIK) ou diagnostiqués avec le syndrome congénital Zika (SCZ) peuvent présenter une dysphagie, des régurgitations et d'autres difficultés d'alimentation. Ils peuvent nécessiter des pratiques alimentaires spéciales pour minimiser le risque de mortalité, de morbidité et de problèmes de développement. L'amélioration des connaissances, des compétences et des comportements des soignants peut préserver la santé, maximiser le développement et promouvoir la qualité de vie des nourrissons affectés. Nous avons examiné les études d'intervention sur les pratiques d'alimentation modifiées et le soutien additionnel aux principaux soignants pour améliorer les résultats chez les nourrissons de 0 à 12 mois exposés au VZIK ou diagnostiqués avec le SCZ. MÉTHODES: Revue rapide et méta-analyse. Nous avons effectué des recherches dans PubMed/MEDLINE et contacté des experts. La recherche a été mise à jour au 18 juillet 2020. Nous avons prévu une méta-analyse utilisant des modèles à effets fixes; si cela n'était pas réalisable, nous avions l'intention de résumer les études de manière narrative. Nous avons prévu d'évaluer le risque de biais des études incluses et la qualité des données en utilisant les directives Cochrane. RÉSULTATS: Nous avons identifié 42 reports pour la recherche des titres et des résumés; 14 étaient éligibles pour une évaluation en texte intégral. Parmi ceux-ci, aucune étude d'intervention n'a été trouvée. Huit études observationnelles ont rapporté sur l'état nutritionnel, les pratiques d'alimentation et les résultats chez les nourrissons atteints du VZIK ou diagnostiqués avec le SCZ. Elles sont présentées et discutées pour fournir une base pour les futures recherches. CONCLUSIONS: Bien qu'aucune étude d'intervention n'ait été trouvée, les données de huit études observationnelles mettent en évidence la nécessité d'interventions nutritionnelles précoces et de soutien des soignants des nourrissons atteints de VZIK ou diagnostiqués avec le SCZ. Des recherches supplémentaires sont nécessaires pour évaluer si les modifications des pratiques d'alimentation et la fourniture d'un soutien additionnel aux principaux soignants auront un impact sur les résultats d'intérêt.

Vitamin D supplementation for women during pregnancy.

BACKGROUND: Vitamin D supplementation during pregnancy may be needed to protect against adverse pregnancy outcomes. This is an update of a review that was first published in 2012 and then in 2016. OBJECTIVES: To examine whether vitamin D supplementation alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register (12 July 2018), contacted relevant organisations (15 May 2018), reference lists of retrieved trials and registries at clinicaltrials.gov and WHO International Clinical Trials Registry Platform (12 July 2018). Abstracts were included if they had enough information to extract the data. SELECTION CRITERIA: Randomised and quasi-randomised trials evaluating the effect of supplementation with vitamin D alone or in combination with other micronutrients for women during pregnancy in comparison to placebo or no intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently i) assessed the eligibility of trials against the inclusion criteria, ii) extracted data from included trials, and iii) assessed the risk of bias of the included trials. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included 30 trials (7033 women), excluded 60 trials, identified six as ongoing/unpublished trials and two trials are awaiting assessments.Supplementation with vitamin D alone versus placebo/no interventionA total of 22 trials involving 3725 pregnant women were included in this comparison; 19 trials were assessed as having low-to-moderate risk of bias for most domains and three trials were assessed as having high risk of bias for most domains. Supplementation with vitamin D alone during pregnancy probably reduces the risk of pre-eclampsia (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.30 to 0.79; 4 trials, 499 women, moderate-certainty evidence) and gestational diabetes (RR 0.51, 95% CI 0.27 to 0.97; 4 trials, 446 women, moderate-certainty evidence); and probably reduces the risk of having a baby with low birthweight (less than 2500 g) (RR 0.55, 95% CI 0.35 to 0.87; 5 trials, 697 women, moderate-certainty evidence) compared to women who received placebo or no intervention. Vitamin D supplementation may make little or no difference in the risk of having a preterm birth < 37 weeks compared to no intervention or placebo (RR 0.66, 95% CI 0.34 to 1.30; 7 trials, 1640 women, low-certainty evidence). In terms of maternal adverse events, vitamin D supplementation may reduce the risk of severe postpartum haemorrhage (RR 0.68, 95% CI 0.51 to 0.91; 1 trial, 1134 women, low-certainty evidence). There were no cases of hypercalcaemia (1 trial, 1134 women, low-certainty evidence), and we are very uncertain as to whether vitamin D increases or decreases the risk of nephritic syndrome (RR 0.17, 95% CI 0.01 to 4.06; 1 trial, 135 women, very low-certainty evidence). However, given the scarcity of data in general for maternal adverse events, no firm conclusions can be drawn.Supplementation with vitamin D and calcium versus placebo/no interventionNine trials involving 1916 pregnant women were included in this comparison; three trials were assessed as having low risk of bias for allocation and blinding, four trials were assessed as having high risk of bias and two had some components having a low risk, high risk, or unclear risk. Supplementation with vitamin D and calcium during pregnancy probably reduces the risk of pre-eclampsia (RR 0.50, 95% CI 0.32 to 0.78; 4 trials, 1174 women, moderate-certainty evidence). The effect of the intervention is uncertain on gestational diabetes (RR 0.33,% CI 0.01 to 7.84; 1 trial, 54 women, very low-certainty evidence); and low birthweight (less than 2500 g) (RR 0.68, 95% CI 0.10 to 4.55; 2 trials, 110 women, very low-certainty evidence) compared to women who received placebo or no intervention. Supplementation with vitamin D and calcium during pregnancy may increase the risk of preterm birth < 37 weeks in comparison to women who received placebo or no intervention (RR 1.52, 95% CI 1.01 to 2.28; 5 trials, 942 women, low-certainty evidence). No trial in this comparison reported on maternal adverse events.Supplementation with vitamin D + calcium + other vitamins and minerals versus calcium + other vitamins and minerals (but no vitamin D)One trial in 1300 participants was included in this comparison; it was assessed as having low risk of bias. Pre-eclampsia was not assessed. Supplementation with vitamin D + other nutrients may make little or no difference in the risk of preterm birth < 37 weeks (RR 1.04, 95% CI 0.68 to 1.59; 1 trial, 1298 women, low-certainty evidence); or low birthweight (less than 2500 g) (RR 1.12, 95% CI 0.82 to 1.51; 1 trial, 1298 women, low-certainty evidence). It is unclear whether it makes any difference to the risk of gestational diabetes (RR 0.42, 95% CI 0.10 to 1.73) or maternal adverse events (hypercalcaemia no events; hypercalciuria RR 0.25, 95% CI 0.02 to 3.97; 1 trial, 1298 women,) because the certainty of the evidence for both outcomes was found to be very low. AUTHORS' CONCLUSIONS: We included 30 trials (7033 women) across three separate comparisons. Our GRADE assessments ranged from moderate to very low, with downgrading decisions based on limitations in study design, imprecision and indirectness.Supplementing pregnant women with vitamin D alone probably reduces the risk of pre-eclampsia, gestational diabetes, low birthweight and may reduce the risk of severe postpartum haemorrhage. It may make little or no difference in the risk of having a preterm birth < 37 weeks' gestation. Supplementing pregnant women with vitamin D and calcium probably reduces the risk of pre-eclampsia but may increase the risk of preterm births < 37 weeks (these findings warrant further research). Supplementing pregnant women with vitamin D and other nutrients may make little or no difference in the risk of preterm birth < 37 weeks' gestation or low birthweight (less than 2500 g). Additional rigorous high quality and larger randomised trials are required to evaluate the effects of vitamin D supplementation in pregnancy, particularly in relation to the risk of maternal adverse events.

Regimens of vitamin D supplementation for women during pregnancy.

BACKGROUND: Vitamin D deficiency during pregnancy increases the risk of pre-eclampsia, gestational diabetes, preterm birth, and low birthweight. In a previous Cochrane Review we found that supplementing pregnant women with vitamin D alone compared to no vitamin D supplementation may reduce the risk of pre-eclampsia, gestational diabetes, and low birthweight and may increase the risk of preterm births if it is combined with calcium. However the effects of different vitamin D regimens are not yet clear. OBJECTIVES: To assess the effects and safety of different regimens of vitamin D supplementation alone or in combination with calcium or other vitamins, minerals or nutrients during pregnancy, specifically doses of 601 international units per day (IU/d) or more versus 600 IU/d or less; and 4000 IU/d or more versus 3999 IU/d or less. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (12 July 2018), and the reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials evaluating the effect of different vitamin D regimens (dose, frequency, duration, and time of commencement of supplementation during pregnancy), alone or in combination with other nutrients on pregnancy and neonatal health outcomes. We only included trials that compared 601 IU/d or more versus 600 IU/d or less and 4000 IU/d or more versus 3999 IU/d or less. We did not include in the analysis groups that received no vitamin D, as that comparison is assessed in another Cochrane Review. DATA COLLECTION AND ANALYSIS: Two review authors independently: i) assessed the eligibility of studies against the inclusion criteria; ii) extracted data from included studies, and iii) assessed the risk of bias of the included studies. Our primary maternal outcomes were: pre-eclampsia, gestational diabetes, and any adverse effects; our primary infant outcomes were preterm birth and low birthweight. Data were checked for accuracy. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: In this review, we included data from 30 trials involving 7289 women. We excluded 11 trials, identified 16 ongoing/unpublished trials and two trials are awaiting classification. Overall risk of bias for the trials was mixed.Comparison 1. 601 IU/d or more versus 600 IU/d or less of vitamin D alone or with any other nutrient (19 trials; 5214 participants)Supplementation with 601 IU/d or more of vitamin D during pregnancy may make little or no difference to the risk of pre-eclampsia (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.65 to 1.42); 5 trials; 1553 participants,low-certainty evidence), may reduce the risk of gestational diabetes (RR 0.54, 95% CI 0.34 to 0.86; 5 trials; 1846 participants; moderate-certainty evidence), may make little or no difference to the risk of preterm birth (RR 1.25, 95% CI 0.92 to 1.69; 4 trials; 2294 participants; low-certainty evidence); and may make little or no difference to the risk of low birthweight (RR 0.90, 95% CI 0.66 to 1.24; 4 trials; 1550 participants; very low-certainty evidence) compared to women receiving 600 IU/d or less.Comparison 2. 4000 IU or more versus 3999 IU or less of vitamin D alone (15 trials; 4763 participants)Supplementation with 4000 IU/d or more of vitamin D during pregnancy may make little or no difference to the risk of: pre-eclampsia (RR 0.87, 95% CI 0.62 to 1.22; 4 trials, 1903 participants, low-certainty evidence); gestational diabetes (RR 0.89, 95% CI 0.56 to 1.42; 5 trials, 2276 participants; low-certainty evidence); preterm birth (RR 0.85, 95% CI 0.64 to 1.12; 6 trials, 2948 participants, low-certainty evidence); and low birthweight (RR 0.92, 95% CI 0.49 to 1.70; 2 trials; 1099 participants; low-certainty evidence) compared to women receiving 3999 IU/d or less.Adverse events (such as hypercalcaemia, hypocalcaemia, hypercalciuria, and hypovitaminosis D) were reported differently in most trials; however, in general, there was little to no side effects reported or similar cases between groups. AUTHORS' CONCLUSIONS: Supplementing pregnant women with more than the current vitamin D recommendation may reduce the risk of gestational diabetes; however, it may make little or no difference to the risk of pre-eclampsia, preterm birth and low birthweight. Supplementing pregnant women with more than the current upper limit for vitamin D seems not to increase the risk of the outcomes evaluated. In general, the GRADE was considered low certainty for most of the primary outcomes due to serious risk of bias and imprecision of results. With respect to safety, it appears that vitamin D supplementation is a safe intervention during pregnancy, although the parameters used to determine this were either not reported or not consistent between trials. Future trials should be consistent in their reports of adverse events. There are 16 ongoing trials that when published, will increase the body of knowledge.

Acceptability of a text message-based intervention for obesity prevention in infants from Hawai'i and Puerto Rico WIC.

BACKGROUND: Low-income and minority children are at increased risk for obesity. Text messaging offers advantages for delivering education, but few studies have assessed the acceptability of text messaging in interventions aimed at preventing excessive weight gain in infants. This study investigated the acceptability of a text message-based intervention for prevention of excessive weight gain in infants from Hawai'i and Puerto Rico WIC clinics. METHODS: The four-month text message based intervention designed to improve infant feeding practices and reduce excessive weight gain was a randomized controlled trial that included mothers with infants ages 0-2 months at baseline. Participants in the intervention arm received 18 text messages (1/week) promoting breastfeeding and appropriate complementary feeding. Acceptability of the intervention was assessed from participant retention, satisfaction, and evidence of behavior change in a sequential multimethod approach, quantitatively from questions sent via text and qualitatively during the in-person exit interview. The final analysis included 80 mother-infant pairs from the intervention arm. RESULTS: When asked about messages liked and disliked the most, the majority of responses via text indicated that they liked all messages. From the qualitative analyses, most participants reported that all messages were useful and that the messages led them to make changes in the way they fed their infants. Participant retention was good at 78.4%. CONCLUSIONS: The intervention was acceptable to participants based upon participant retention, measures of satisfaction, and reports of behavior change. Results may inform development of mobile health programs for minority childhood obesity prevention. TRIAL REGISTRATION: ClinicalTrials.gov Identifier; NCT02903186; September 16, 2016.

Breastfeeding Discontinuation Not Associated with Maternal Pregravid BMI But Associated with Native Hawaiian or Other Pacific Islander Race in Hawaii and Puerto Rico WIC Participants.

Objectives This study investigated the association between maternal pregravid body mass index (BMI) and breastfeeding discontinuation at 4-6 months postpartum in Hawaii and Puerto Rico participants from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Methods A secondary data analysis was conducted from a text message-based intervention in WIC participants in Hawaii and Puerto Rico. The analysis included 87 women from the control group who initiated breastfeeding and whose breastfeeding status was known at the end of the study when infants were 4-6 months old. Pregravid BMI and breastfeeding discontinuation were assessed using questionnaires. Results The association between pregravid BMI and breastfeeding discontinuation was not significant in the unadjusted model or in the adjusted model. Native Hawaiian or Other Pacific Islander (NHOPI) participants showed significantly increased odds of discontinuing breastfeeding (adjusted odds ratio [AOR] 7.12; 95% CI 1.34, 37.97; p = .02) compared to all the other racial/ethnic participants, as did older women ages 32-39 years versus women who were 25-31 years old (AOR 4.21; 95% CI 1.13, 15.72; p = .03). Women who took vitamins while breastfeeding had decreased odds of discontinuing breastfeeding (AOR 0.15; 95% CI 0.05, 0.46; p = .0009). Conclusions for Practice Pregravid BMI was not significantly associated with breastfeeding discontinuation at 4-6 months postpartum in women from Hawaii and Puerto Rico WIC, but NHOPIs and women who were older had higher odds of discontinuing breastfeeding. The results of this study may inform strategies for breastfeeding promotion and childhood obesity prevention but should be further investigated in larger studies. ClinicalTrials.gov Identifier: NCT02903186.

Effect of a Multi-Site Trial using Short Message Service (SMS) on Infant Feeding Practices and Weight Gain in Low-Income Minorities.

OBJECTIVE: To test the effects of weekly SMS for improving infant feeding practices and infant weight. METHODS: This was a multi-site randomized clinical trial in a convenience sample of 202 caregivers of healthy term infants 0-2 months participating in the WIC program in Puerto Rico and Hawaii. Participants were randomized to receive SMS about infant's general health issues (control) or SMS for improving feeding practices (intervention) for four months. Weight, length and infant feeding practices were assessed at baseline and four months later. RESULTS: A total of 170 participants completed the study (n = 86 control and n = 84 intervention). Baseline characteristics were similar between groups. At the end, exclusive breastfeeding rates were similar between groups (67.4% control and 59.1% intervention). Introduction of other foods and beverages, addition of foods to the bottle, placing infants to sleep with milk bottles, caregiver's method and response to feeding infants and distractions while feeding infants were similar between groups. Also, weight status or rate of weight gain was similar between groups. CONCLUSION: There were no significant improvements in feeding practices or in weight with the intervention. The timeline of the messages in relation to the targeted behavior may have affected the effectiveness of the intervention. Earlier dissemination of messages, higher level of intensity, longer intervention, additional contacts and inclusion of other caregivers may be needed to achieve the desired effects.

Longitudinal social cognitive influences on physical activity and sedentary time in Hispanic breast cancer survivors.

OBJECTIVE: This study evaluated the effect of two home-based exercise interventions (one culturally adapted and one standard) on changes in social cognitive theory (SCT) variables, physical activity (PA), and sedentary time (ST), and determined the association between changes in SCT variables and changes in PA and ST in Hispanic breast cancer survivors. METHOD: Project VIVA! was a 16-week randomized controlled pilot study to test the effectiveness and feasibility of a culturally adapted exercise intervention for Mexican American and Puerto Rican breast cancer survivors in Houston, Texas and San Juan, Puerto Rico, respectively. Women (N = 89) completed questionnaires on SCT variables, PA, and ST and were then randomized to a 16-week culturally adapted exercise program, a non-culturally adapted standard exercise intervention or a wait-list control group. Multiple regression models were used to determine associations between changes in SCT variables and changes in PA and ST. RESULTS: Participants were in their late 50s (58.5 ± 9.2 years) and obese (31.0 ± 6.5 kg/m2 ). Women reported doing roughly 34.5 min/day of PA and spending over 11 h/day in sedentary activities. Across groups, women reported significant increases in exercise self-efficacy and moderate-intensity, vigorous-intensity, and total PA from baseline to follow-up (p < 0.05). Increased social support from family was associated with increases in vigorous-intensity PA. Increases in social modeling were associated with increases in moderate-intensity and total PA and with decreases in ST from baseline to follow-up (p < 0.05). CONCLUSIONS: Hispanic cancer survivors benefit from PA interventions that focus on increasing social support from family and friends and social modeling. Copyright © 2015 John Wiley & Sons, Ltd.

Vitamin D supplementation for women during pregnancy.

BACKGROUND: Vitamin D deficiency or insufficiency is thought to be common among pregnant women. Vitamin D supplementation during pregnancy has been suggested as an intervention to protect against adverse pregnancy outcomes. OBJECTIVES: To examine whether oral supplements with vitamin D alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2015), the International Clinical Trials Registry Platform (31 January 2015), the Networked Digital Library of Theses and Dissertations (28 January 2015) and also contacted relevant organisations (31 January 2015). SELECTION CRITERIA: Randomised and quasi-randomised trials with randomisation at either individual or cluster level, evaluating the effect of supplementation with vitamin D alone or in combination with other micronutrients for women during pregnancy. DATA COLLECTION AND ANALYSIS: Two review authors independently i) assessed the eligibility of studies against the inclusion criteria ii) extracted data from included studies, and iii) assessed the risk of bias of the included studies. Data were checked for accuracy. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: In this updated review we included 15 trials assessing a total of 2833 women, excluded 27 trials, and 23 trials are still ongoing or unpublished. Nine trials compared the effects of vitamin D alone versus no supplementation or a placebo and six trials compared the effects of vitamin D and calcium with no supplementation. Risk of bias in the majority of trials was unclear and many studies were at high risk of bias for blinding and attrition rates. Vitamin D alone versus no supplementation or a placebo Data from seven trials involving 868 women consistently show that women who received vitamin D supplements alone, particularly on a daily basis, had higher 25-hydroxyvitamin D than those receiving no intervention or placebo, but this response was highly heterogeneous. Also, data from two trials involving 219 women suggest that women who received vitamin D supplements may have a lower risk of pre-eclampsia than those receiving no intervention or placebo (8.9% versus 15.5%; risk ratio (RR) 0.52; 95% CI 0.25 to 1.05, low quality). Data from two trials involving 219 women suggest a similar risk of gestational diabetes among those taking vitamin D supplements or no intervention/placebo (RR 0.43; 95% CI 0.05, 3.45, very low quality). There were no clear differences in adverse effects, with only one reported case of nephritic syndrome in the control group in one study (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women, low quality). Given the scarcity of data for this outcome, no firm conclusions can be drawn. No other adverse effects were reported in any of the other studies.With respect to infant outcomes, data from three trials involving 477 women suggest that vitamin D supplementation during pregnancy reduces the risk preterm birth compared to no intervention or placebo (8.9% versus 15.5%; RR 0.36; 95% CI 0.14 to 0.93, moderate quality). Data from three trials involving 493 women also suggest that women who receive vitamin D supplements during pregnancy less frequently had a baby with a birthweight below 2500 g than those receiving no intervention or placebo (RR 0.40; 95% CI 0.24 to 0.67, moderate quality).In terms of other outcomes, there were no clear differences in caesarean section (RR 0.95; 95% CI 0.69 to 1.31; two trials; 312 women); stillbirths (RR 0.35 95% CI 0.06, 1.99; three trials, 540 women); or neonatal deaths (RR 0.27; 95% CI 0.04, 1.67; two trials, 282 women). There was some indication that vitamin D supplementation increases infant length (mean difference (MD) 0.70, 95% CI -0.02 to 1.43; four trials, 638 infants) and head circumference at birth (MD 0.43, 95% CI 0.03 to 0.83; four trials, 638 women). Vitamin D and calcium versus no supplementation or a placeboWomen who received vitamin D with calcium had a lower risk of pre-eclampsia than those not receiving any intervention (RR 0.51; 95% CI 0.32 to 0.80; three trials; 1114 women, moderate quality), but also an increased risk of preterm birth (RR 1.57; 95% CI 1.02 to 2.43, three studies, 798 women, moderate quality). Maternal vitamin D concentration at term, gestational diabetes, adverse effects and low birthweight were not reported in any trial or reported only by one study. AUTHORS' CONCLUSIONS: New studies have provided more evidence on the effects of supplementing pregnant women with vitamin D alone or with calcium on pregnancy outcomes. Supplementing pregnant women with vitamin D in a single or continued dose increases serum 25-hydroxyvitamin D at term and may reduce the risk of pre-eclampsia, low birthweight and preterm birth. However, when vitamin D and calcium are combined, the risk of preterm birth is increased. The clinical significance of the increased serum 25-hydroxyvitamin D concentrations is still unclear. In light of this, these results need to be interpreted with caution. Data on adverse effects were lacking in all studies.The evidence on whether vitamin D supplementation should be given as a part of routine antenatal care to all women to improve maternal and infant outcomes remains unclear. While there is some indication that vitamin D supplementation could reduce the risk of pre-eclampsia and increase length and head circumference at birth, further rigorous randomised trials are required to confirm these effects.

Association between Type, Amount, and Pattern of Carbohydrate Consumption with Dental Caries in 12-Year-Olds in Puerto Rico.

OBJECTIVE: To identify the types, food sources, and pattern of carbohydrates that significantly contribute to dental caries in Puerto Rican children. METHODS: As part of an island-wide cross-sectional oral health study in 1,587 twelve-year-olds, diet intake was assessed in a representative subset (n = 801) with a 24-hour dietary recall. Carbohydrate intake was quantified using a computer-based diet analysis program. Caries was assessed using the National Institute of Dental and Craniofacial Research diagnostic criteria. Odds ratios were used to associate carbohydrate intake quartiles with caries, after controlling for important confounders. RESULTS: A total of 723 subjects had complete data. Most were females (54%) and attended public schools (77%). The caries prevalence was 33%. The highest quartile intake for the following sugars significantly increased the odds of caries compared to the lowest quartile: total carbohydrates (OR = 1.93, 95% CI = 1.08-3.46), total sugars (OR = 1.88, 95% CI = 1.01-351), sucrose (OR = 2.05, 95% CI = 1.13-3.70), fructose (OR = 1.95, 95% CI = 1.05-3.62), and inositol (OR = 2.52, 95% CI = 1.38-4.63). The main food sources of these sugars were juices, including natural juices with no added sugars, and sweetened beverages. The odds of caries also increased significantly in children whose 10% of total energy intake was from total sugars (OR = 3.76, 95% CI = 1.03-13.7). CONCLUSION: After adjusting for important caries risk factors, total carbohydrates, total sugars, ≥10% kilocaloric energy from total sugars, and sucrose, fructose, and inositol intake significantly increased caries risk. Our findings can help raise awareness about the potential caries risk from the main sources of these sugars, natural fruit juices and sweetened beverages, which are consumed in great quantities in many societies.

Low vitamin D status strongly associated with periodontitis in Puerto Rican adults.

BACKGROUND: Periodontitis and vitamin D deficiency are both highly prevalent in Puerto Rico. The aim of this pilot study was to evaluate the association between vitamin D levels and periodontal disease in Puerto Rican adults. METHODS: A sex-, age-, and BMI-matched case-control, cross-sectional study was conducted on 24 cases of moderate/severe periodontitis and 24 periodontally healthy controls aged 35 to 64 years. Each participant completed a socio-demographic questionnaire, underwent a full-mouth periodontal examination and provided blood sample to measure serum 25-hydroxyvitamin D (25 (OH) D) levels to assess vitamin D status. RESULTS: A total of 19 matched case-control pairs (28 females, 10 males) completed the study. Mean serum 25 (OH) D levels were significantly lower in cases (18.5 ± 4.6 ng/ml) than in controls (24.2 ± 7.1 ng/ml; p = 0.006). Lower odds of periodontal disease were observed per unit of 25 (OH) D level (OR 0.885; 95 % CI 0.785, 0.997; p < 0.05). CONCLUSIONS: Lower serum vitamin D levels are significantly associated with periodontitis in Puerto Rican adults.

Validation and reproducibility of a semi-quantitative FFQ as a measure of dietary intake in adults from Puerto Rico.

OBJECTIVE: We aimed to assess the relative validity and reproducibility of a semi-quantitative FFQ in Puerto Rican adults. DESIGN: Participants completed an FFQ, followed by a 6 d food record and a second administration of the FFQ, 30 d later. All nutrients were log transformed and adjusted for energy intake. Statistical analyses included correlations, paired t tests, cross-classification and Bland-Altman plots. SETTING: Medical Sciences Campus, University of Puerto Rico. SUBJECTS: Convenience sample of students, employees and faculty members (n 100, ≥21 years). Data were collected in 2010. RESULTS: A total of ninety-two participants completed the study. Most were young overweight females. All nutrients were significantly correlated between the two FFQ, with an average correlation of 0·61 (range 0·43-0·73) and an average difference of 4·8 % between them. Most energy-adjusted nutrients showed significant correlations between the FFQ and food record, which improved with de-attenuation and averaged 0·38 (range 0·11-0·63). The lowest non-significant correlations (≤0·20) were for trans-fat, n 3 fatty acids, thiamin and vitamin E. Intakes assessed by the FFQ were higher than those from the food record by a mean of 19 % (range 4-44 %). Bland-Altman plots showed that there was a systematic trend towards higher estimates with the FFQ, particularly for energy, carbohydrate and Ca. Most participants were correctly classified into the same or adjacent quintile (average 66 %) by both methods with only 3 % gross misclassification. CONCLUSIONS: This semi-quantitative FFQ is a tool that offers relatively valid and reproducible estimates of energy and certain nutrients in this group of mostly female Puerto Ricans.

High prevalence of overweight and obesity among a representative sample of Puerto Rican children.

BACKGROUND: The prevalence of childhood overweight and obesity has become a public health problem worldwide. The objectives of the study were: 1) to establish the BMI prevalence in 12-year olds residing in Puerto Rico, and 2) to determine BMI differences by sex, public-private school type, and geographic regions. METHODS: Data was obtained from an island-wide probabilistic stratified sample of 1,582 twelve-year-olds (53% girls and 47% boys). The BMI was determined using the National Health and Nutrition Examination Survey procedures. Children were categorized as underweight, healthy weight, overweight or obese using the Center for Disease Control and Prevention's age and gender specific growth charts. A logistic regression model was used to estimate BMI category prevalence. Odds ratios were calculated using a multinomial regression. RESULTS: In this study, 18.8% of the children were overweight and 24.3% were obese. A higher prevalence of obesity was observed in boys as compared to girls, 28.2% vs. 20.2%, respectively. The estimated prevalence of overweight and obesity in children from public schools was lower than for those from private schools. After adjusting for type of school and region, boys had a significantly higher risk of being obese (64%) as compared to girls. In public schools, boys had a lower prevalence of being overweight while girls had a higher prevalence compared to children attending private schools. Girls attending private schools had a higher obesity prevalence (27.8%) compared to girls from public schools (19.8%). The prevalence of underweight (2.7%) is slightly lower than in the United States. CONCLUSIONS: The prevalence of overweight and obesity of 12-year-olds residing in PR was 18.8% and 24.3%, respectively; higher than in the U.S. (by groups). Boys were at higher risk of obesity than girls. There is an urgent need to implement public health policies/programs to reduce the prevalence of overweight and obesity in children in PR.

Diet, Pre-pregnancy BMI, and Gestational Weight Gain in Puerto Rican Women.

OBJECTIVES: To describe the dietary patterns in pregnant woman and determine the association between diet factors, pre-pregnancy Body Mass Index (BMI) and socio-demographic characteristics with gestational weight gain (GWG). METHODS: This is a secondary analysis of a longitudinal cohort study of pregnant women exploring the risk factors for preterm birth, the Puerto Rico Testsite for Exploring Contamination Threats program. Recruitment was conducted during 2011-2014. Data was collected from multiple sources. GWG was calculated using maternal weight recorded in the medical records at the first and last prenatal visits and classified according to the Institute of Medicine guidelines. Sociodemographic characteristics were obtained at baseline using an interviewed-based questionnaire. Participants completed a self-administered food frequency questionnaire at 20-28 weeks to assess dietary patterns. Analysis of associations between variables was conducted using Chi Square tests. RESULTS: A total of 160 women with term pregnancies were included in this analysis. Mean pre-pregnancy BMI was 25.4 ± 5.48 kg/m(2), with 44.4 % classified as overweight/obese. Excessive GWG was observed in 24.4 % of the participants. Socio-demographic characteristics were not associated with GWG. Being overweight/obese at the start of pregnancy was significantly associated with excessive GWG (p < 0.05). In addition, women consuming one or more fruit drinks per day were more likely to have an excessive GWG while those consuming less than one fruit drink per day were more likely to have an adequate GWG (p < 0.05). CONCLUSIONS FOR PRACTICE: Being obese before pregnancy and frequently consuming fruit drinks were important determinants of excessive GWG in this group.

Micronutrient Intake among Children in Puerto Rico: Dietary and Multivitamin-Multimineral Supplement Sources.

BACKGROUND: Micronutrients are critical for healthy growth and development of children. Micronutrient intake from dietary sources is inadequate among some children and may be improved by use of multivitamin and multimineral (MVMM) supplements. OBJECTIVE: To assess micronutrient intake from dietary and MVMM supplement sources among 12-year-old children in Puerto Rico. METHODS: A representative sample of 732 children enrolled in an oral health study in Puerto Rico, who completed dietary and MVMM assessments through one 24-h recall, were included in this analysis. Micronutrient intake sources were described and compared to the Dietary Reference Intakes (DRIs) using the Estimated Average Requirement when available (used Adequate Intake for vitamin K and pantothenic acid). Micronutrient profiles of MVMM users and non-users were compared using t-tests. RESULTS: Mean intakes of vitamins A, D, E, and K, pantothenic acid, calcium, and magnesium from food and beverage sources were below the DRIs. From food and beverage sources, MVMM users had higher intakes of riboflavin and folate compared to non-users (p < 0.05). When MVMM supplements were taken into account, users had higher intakes of all nutrients except vitamin K. With the help of MVMM, users increased intake of vitamins E, A, D, and pantothenic acid to IOM-recommended levels but calcium, magnesium, and vitamin K remained below guidelines. CONCLUSION: Micronutrient intake from diet was below the IOM-recommended levels in the total sample. MVMM use improved intake of selected micronutrients and facilitated meeting recommendations for some nutrients. Public health measures to improve micronutrient intake among children in Puerto Rico are needed.

Association of the Intestinal Microbiota and Obesity.

Obesity is a condition mainly caused by an alteration in energy intake, shifting towards positive energy balance, which can be influenced by genetic and environmental factors. The human gut is heavily populated with microbial organisms. Recent evidence suggests that obesity is influenced by specific bacterial phyla present in the human gut that have increased energy harvesting capabilities. The main objective of this review is to identify the microbial taxa that are related to obesity and weight loss. In this review, we also discuss the differences between the phylum ratio of the gut microbiota population of obese individuals and that of individuals who have healthy weight. It has been shown that obese individuals have a higher ratio of Firmicutes to Bacteroidetes than healthy weight individuals. The few studies to date have shown that weight-loss treatment may change microbial population of the gut, as there is a decrease in the ratio of Firmicutes to Bacteroidetes. Treating imbalances of the gut microbiota may offer new possibilities for treating obesity.

Association between maternal diet factors and hemoglobin levels, glucose tolerance, blood pressure and gestational age in a Hispanic population.

The aim of this study was to describe the dietary patterns of pregnant women in northern Puerto Rico and explore associations between diet factors with pregnancy related measurements. This analysis is based on the Puerto Rico Testsite for Exploring Contamination Threats (PROTECT), a prospective cohort that is studying environmental risk factors for preterm births in PR. Participants completed a food frequency questionnaire (FFQ) around 20-28 weeks of gestation. The following pregnancy related measures were collected from the medical records: hemoglobin, blood glucose, blood pressure and gestational age. Potential associations between diet factors and pregnancy measures were assessed using chi square analysis with SPSS. A total of 180 participants completed the FFQ; low hemoglobin levels was found in 19.2%, high blood glucose levels was found in 21.1% by fasting blood glucose test and 24.6%by 1-hour 50 g oral glucose screening test, high blood pressure was found in 2.9% (systolic) and 6.5% (diastolic), and pre-term birth was found in 10.4% of the participants. High consumption of rice, desserts and sweets was associated with higher levels of fasting blood glucose levels (p < 0.05), while high consumption of vegetables was associated with higher 1-hour glucose challenge test (p < 0.05).No other significant associations were found. In conclusion, consumption of high dense energy food diets in pregnancy, such as rice, sweets and desserts, can lead to high levels of blood glucose and can be a potential predictor of other pregnancy complications during pregnancy in these study participants, such as gestational diabetes.

Dietary calcium requirements do not differ between Mexican-American boys and girls.

Mexican Americans are an understudied ethnic group for determinants of bone health, although the risk of age-related osteoporosis is high in this rapidly growing sector of the U.S. population. Thus, the objective of the present study was to establish the dietary calcium requirements for bone health in Mexican-American adolescents by measuring calcium retention calculated from balance in response to a range of dietary calcium intakes and to determine predictors of skeletal calcium retention. Adolescents aged 12-15 y were studied twice on paired calcium intakes ranging from 600 to 2300 mg/d using randomized-order, crossover 3-wk balance studies. Skeletal calcium retention was calculated as dietary calcium intake minus calcium excreted in feces and urine over the last 2 wk of balance. A linear model was developed to explain the variation in calcium retention. Boys (n = 20) were taller and had higher lean mass, usual dietary calcium intake, bone mineral content, and serum alkaline phosphatase compared with girls, whereas girls (n = 20) had higher Tanner scores and greater fat mass. Calcium retention increased with calcium intake (P < 0.0001) and did not differ by sex (P = 0.66). In boys and girls considered together, calcium intake explained 33% of the variation in calcium retention. Serum alkaline phosphatase explained an additional 11% of the variation in calcium retention. Other variables measured, including the urine N-telopeptide of type I collagen/creatinine ratio, Tanner score, serum parathyroid hormone and 25-hydroxyvitamin D, weight, height, and body mass index, did not contribute to the variance in calcium retention. In adolescence, calcium retention in both Mexican-American boys and girls was higher than determined previously in adolescent nonHispanic white girls. This trial was registered at clinicaltrials.gov as NCT01277185.