The benefits of breakfast cereal consumption: a systematic review of the evidence base.

There have been no comprehensive reviews of the relation of breakfast cereal consumption to nutrition and health. This systematic review of all articles on breakfast cereals to October 2013 in the Scopus and Medline databases identified 232 articles with outcomes related to nutrient intake, weight, diabetes, cardiovascular disease, hypertension, digestive health, dental and mental health, and cognition. Sufficient evidence was available to develop 21 summary evidence statements, ranked from A (can be trusted to guide practice) to D (weak and must be applied with caution). Breakfast cereal consumption is associated with diets higher in vitamins and minerals and lower in fat (grade B) but is not associated with increased intakes of total energy or sodium (grade C) or risk of dental caries (grade B). Most studies on the nutritional impact are cross-sectional, with very few intervention studies, so breakfast cereal consumption may be a marker of an overall healthy lifestyle. Oat-, barley-, or psyllium-based cereals can help lower cholesterol concentrations (grade A), and high-fiber, wheat-based cereals can improve bowel function (grade A). Regular breakfast cereal consumption is associated with a lower body mass index and less risk of being overweight or obese (grade B). Presweetened breakfast cereals do not increase the risk of overweight and obesity in children (grade C). Whole-grain or high-fiber breakfast cereals are associated with a lower risk of diabetes (grade B) and cardiovascular disease (grade C). There is emerging evidence of associations with feelings of greater well-being and a lower risk of hypertension (grade D), but more research is required.

Nutrition status of primary care patients with depression and anxiety.

The objective of this study was to evaluate the nutrition status of people referred to a nutrition and physical activity program for the management of mental health in general practice. Patients currently being treated for depression and/or anxiety were referred by their GPs to a lifestyle intervention program. The nutrition status was assessed during a comprehensive assessment at the commencement of the program. The lifestyle intervention program, including all assessments, was offered at multiple sites including GP clinics in the Illawarra, and in clinic rooms at the University of Wollongong. Thirty-two men and seventy-seven women completed the assessment. Patients were referred with depression (52%), anxiety (19%) or both (28%). Eighty percent of participants were overweight or obese. All participants completed an assessment that included a diet history, anthropometric measurements and the completion of several questionnaires including the Depression, Anxiety and Stress Scale (DASS). Nutrition status was assessed using mean nutrient intakes and Australian modified Healthy Eating Index scores evaluated against the National Nutrition Survey intakes and DASS scores. Participants met the estimated average requirements for all nutrients except folate (17%), magnesium (78%) and calcium (57%). Intakes were similar to those reported in the National Nutrition Survey. Only magnesium intakes were significantly related to depression (r=-0.26). Australian modified Healthy Eating Index scores were significantly negatively correlated with DASS scores (P<0.01). The associations presented here support the existing body of literature. Nutrition recommendations for patients with depression and anxiety should be based on the Australian Guide to Healthy Eating with particular attention to fruit, vegetables and wholegrains.

Evaluation of the evidence between consumption of refined grains and health outcomes.

This review evaluates the available evidence on the relationship between consumption of refined grains and health outcomes. A total of 135 relevant articles were identified from database searches of studies published between 2000 and 2010. The great majority found no associations between the intake of refined-grain foods and cardiovascular disease, diabetes, weight gain, or overall mortality. A few studies found that very high intakes might be associated with some types of cancers, but at moderate levels of consumption the risks were not significant. The totality of evidence shows that consumption of up to 50% of all grain foods as refined-grain foods (without high levels of added fat, sugar, or sodium) is not associated with any increased disease risk. Nonetheless, eating more whole-grain foods remains an important health recommendation, and most consumers will need to reduce their current consumption of refined grains to no more than one-third to one-half of all grains in order to meet the targets for whole-grain foods.

Validity of the BodyGem calorimeter and prediction equations for the assessment of resting energy expenditure in overweight and obese Saudi males.

OBJECTIVE: To assess the accuracy of resting energy expenditure (REE) measurement in a sample of overweight and obese Saudi males, using the BodyGem device (BG) with whole room calorimetry (WRC) as a reference, and to evaluate the accuracy of predictive equations. METHODS: Thirty-eight subjects (mean +/- SD, age 26.8+/- 3.7 years, body mass index 31.0+/- 4.8) were recruited during the period from 5 February 2007 to 28 March 2008. Resting energy expenditure was measured using a WRC and BG device, and also calculated using 7 prediction equations. Mean differences, bias, percent of bias (%bias), accurate estimation, underestimation and overestimation were calculated. RESULTS: Repeated measures with the BG were not significantly different (accurate prediction: 81.6%; %bias 1.1+/- 6.3, p>0.24) with limits of agreement ranging from +242 to -200 kcal. Resting energy expenditure measured by BG was significantly less than WRC values (accurate prediction: 47.4%; %bias: 11.0+/- 14.6, p = 0.0001) with unacceptably wide limits of agreement. Harris-Benedict, Schofield and World Health Organization equations were the most accurate, estimating REE within 10% of measured REE, but none seem appropriate to predict the REE of individuals. CONCLUSION: There was a poor agreement between the REE measured by WRC compared to BG or predictive equations. The BG assessed REE accurately in 47.4% of the subjects on an individual level.

Validation of an Australian electronic food frequency questionnaire to measure polyunsaturated fatty acid intake.

OBJECTIVE: To develop and validate a simple non-invasive method that estimates the intakes of omega-3 and omega-6 polyunsaturated fatty acids (PUFA) in a healthy adult population. METHODS: A new electronic PUFA food frequency questionnaire (FFQ) was validated by comparison with a 3-d weighed food record and blood biomarkers (erythrocytes and plasma) using the method of triads model and tested for reproducibility. Healthy subjects were recruited from the local Illawarra Region, New South Wales, Australia. RESULTS: The PUFA FFQ adequately estimated intakes for eicosapentaenoic acid, docosahexaenoic acid, total long chain omega-3 PUFA, linoleic acid, total omega-6 PUFA, and total PUFA, which were comparable with results from the 3-d food record. Eicosapentaenoic acid, docosahexaenoic acid, and total long chain omega-3 showed high validity coefficients for erythrocytes (and plasma) 0.92 (0.87), 0.69 (0.64), and 0.78 (0.73) (P < 0.05), respectively. Spearman's rank correlation coefficients ranged from 0.48 to 0.76 when the PUFA FFQ was tested for reproducibility (P < 0.05). CONCLUSION: The electronic PUFA questionnaire was found to be reproducible and is a valid tool to assess PUFA intakes in a healthy adult population.

Performance of body mass index in predicting diabetes and hypertension in the Eastern Province of Saudi Arabia.

BACKGROUND AND OBJECTIVES: Body mass index (BMI) is the most widely used measure to define obesity and predict its complications, such as diabetes and hypertension, but its accuracy and usefulness in Saudi subjects is unknown. This study aimed to assess the validity of standard BMI cut-point values in the Saudi population. SUBJECTS AND METHODS: 197 681 adults participated in a cross-sectional study to detect diabetes and hypertension in the Saudi Eastern province in 2004/2005, with blood pressure, fasting blood sugar, height and weight measurements taken. Sensitivities, specificities, areas under the curves, predictive values, likelihood ratios, false positive, false negatives and total misclassification ratios were calculated for various BMI values determined from receiver operating characteristic (ROC) curves. The significance of the association between risk factors and BMI was assessed using regression analysis. RESULTS: For the definition of overweight, ROC curve analysis suggested optimal BMI cut-offs of 28.50 to 29.50 in men and 30.50 to 31.50 in women, but the levels of sensitivity and specificity were too low to be of clinical value and the overall misclassification was unacceptably high across all the selected BMI values (>0.80). The relationship between BMI and the presence of diabetes and/or hypertension was not improved when a BMI of 25 was used. Using regression analyses, the odds ratios for hypertension and/or diabetes increased significantly from BMI values as low as 21-23 with no improvement in the diagnostic performance of BMI at these cutoffs. CONCLUSION: In Saudi population, there is an increased risk of diabetes and hypertension relative to BMI, starting at a BMI as low as 21 but overall there is no cutoff BMI level with high predictive value for the development of these chronic diseases, including the WHO definition of obesity at BMI of 30.

Cereal grains, legumes, and weight management: a comprehensive review of the scientific evidence.

There is strong evidence that a diet high in whole grains is associated with lower body mass index, smaller waist circumference, and reduced risk of being overweight; that a diet high in whole grains and legumes can help reduce weight gain; and that significant weight loss is achievable with energy-controlled diets that are high in cereals and legumes. There is weak evidence that high intakes of refined grains may cause small increases in waist circumference in women. There is no evidence that low-carbohydrate diets that restrict cereal intakes offer long-term advantages for sustained weight loss. There is insufficient evidence to make clear conclusions about the protective effect of legumes on weight.

Dietary validation of a new Australian food-frequency questionnaire that estimates long-chain n-3 polyunsaturated fatty acids.

Currently, there is no FFQ designed to capture the intakes of the long-chain (LC) n-3 PUFA. The objectives of this study were to validate a new LC n-3 PUFA FFQ by comparison with 3 d weighed food records (FR) and to determine its reproducibility assessed 4 to 6 weeks apart. Healthy male and female subjects (n 53) were recruited from Wollongong and the Australian Capital Territory, Australia. The FFQ and FR were analysed for LC n-3 PUFA intakes using a nutrient analysis software package and these intakes were compared using Wilcoxon signed rank tests and Spearman correlation coefficients. Bland-Altman analysis and quintile assignment assessed the agreement between the two methods and the FFQ's ability to rank individuals according to intakes, respectively. Comparison of intakes from FFQ and FR correlated significantly for total LC n-3 PUFA, EPA, docosapentaenoic acid (DPA) and DHA, 0.75, 0.64, 0.62 and 0.72, respectively (P < 0.05); hence, there is reasonable agreement between the FFQ and the FR in assessing LC n-3 PUFA intakes. Quintile assignments correctly assigned 49 % of subjects into the same quintiles and 87 % of subjects were correctly assigned either to the same or adjacent quintiles. The FFQ was reproducible for intakes of LC n-3 PUFA, EPA, DPA and DHA with Spearman correlation coefficients of 0.88, 0.88, 0.90 and 0.87, respectively. In conclusion, the new FFQ is a valid and reproducible method that can be used to estimate the LC n-3 PUFA intake of healthy adults.

Biomarker validation of a long-chain omega-3 polyunsaturated fatty acid food frequency questionnaire.

Long-chain omega-3 PUFA (LC n-3 PUFA) are beneficial for health. To date there is no specific food frequency questionnaire (FFQ) to assess LC n-3 PUFA intakes. The objective of this study is to validate our newly developed FFQ by comparison with LC n-3 PUFA content of both red blood cells (RBC) and plasma, expressed as a percentage of total FA. Fifty-three healthy male and female subjects were recruited from Wollongong, Australia. Average LC n-3 PUFA intakes (mg/d) were estimated using the new FFQ. RBC and plasma FA were assessed using GC. Spearman correlation coefficients were used to assess the linear relationship between FFQ intakes and both RBC and plasma FA. The results show that there were significant Spearman's correlation coefficients between the FFQ intakes and RBC (and plasma) FA for total LC n-3 PUFA, EPA, and DHA (0.50 (0.54), 0.39 (0.54) and 0.40 (0.48), respectively) but not for docosapentaenoic acid. The FFQ was also an effective ranking tool. The FFQ is a valid method based on erythrocyte and plasma FA as biochemical markers. In conclusion, the new FFQ is a valid method that can be used to estimate the LC n-3 PUFA intake of adults.

Health benefits of herbs and spices: the past, the present, the future.

UNLABELLED: Herbs and spices have a traditional history of use, with strong roles in cultural heritage, and in the appreciation of food and its links to health. Demonstrating the benefits of foods by scientific means remains a challenge, particularly when compared with standards applied for assessing pharmaceutical agents. Pharmaceuticals are small-molecular-weight compounds consumed in a purified and concentrated form. Food is eaten in combinations, in relatively large, unmeasured quantities under highly socialised conditions. The real challenge lies not in proving whether foods, such as herbs and spices, have health benefits, but in defining what these benefits are and developing the methods to expose them by scientific means. CULTURAL ASPECTS: The place of herbs and spices in the diet needs to be considered in reviewing health benefits. This includes definitions of the food category and the way in which benefits might be viewed, and therefore researched. Research may focus on identifying bioactive substances in herbs and spices, or on their properties as a whole food, and/or be set in the context of a dietary cuisine. THE ROLE OF HERBS AND SPICES IN HEALTH: The antioxidant properties of herbs and spices are of particular interest in view of the impact of oxidative modification of low-density lipoprotein cholesterol in the development of atherosclerosis. There is level III-3 evidence (National Health and Medical Research Council [NHMRC] levels of evidence) that consuming a half to one clove of garlic (or equivalent) daily may have a cholesterol-lowering effect of up to 9%. There is level III-1 evidence that 7.2 g of aged garlic extract has been associated with anticlotting (in-vivo studies), as well as modest reductions in blood pressure (an approximate 5.5% decrease in systolic blood pressure). A range of bioactive compounds in herbs and spices have been studied for anticarcinogenic properties in animals, but the challenge lies in integrating this knowledge to ascertain whether any effects can be observed in humans, and within defined cuisines. Research on the effects of herbs and spices on mental health should distinguish between cognitive decline associated with ageing and the acute effects of psychological and cognitive function. There is level I and II evidence for the effect of some herbal supplements on psychological and cognitive function. There is very limited scientific evidence for the effects of herbs and spices on type 2 diabetes mellitus, with the best evidence being available for the effect of ginseng on glycaemia, albeit based on four studies. More research is required, particularly examining the effects of chronic consumption patterns. With increasing interest in alternatives to non-steroidal anti-inflammatory agents in the management of chronic inflammation, research is emerging on the use of food extracts. There is level II evidence for the use of ginger in ameliorating arthritic knee pain; however, the improvement is modest and the efficacy of ginger treatment is ranked below that of ibuprofen. More definitive research is required. PUBLIC HEALTH AND DIETARY IMPLICATIONS: Recommendations for intakes of food in the Australian guide to healthy eating do not yet include suggested intakes of herbs and spices. Future consideration should be given to including more explicit recommendations about their place in a healthy diet. In addition to delivering antioxidant and other properties, herbs and spices can be used in recipes to partially or wholly replace less desirable ingredients such as salt, sugar and added saturated fat in, for example, marinades and dressings, stir-fry dishes, casseroles, soups, curries and Mediterranean-style cooking. Vegetable dishes and vegetarian options may be more appetising when prepared with herbs and spices. FUTURE DIRECTIONS: As several metabolic diseases and age-related degenerative disorders are closely associated with oxidative processes in the body, the use of herbs and spices as a source of antioxidants to combat oxidation warrants further attention. Immediate studies should focus on validating the antioxidant capacity of herbs and spices after harvest, as well as testing their effects on markers of oxidation. This will work in parallel with clinical trials that are aiming to establish antioxidants as mediators of disease prevention. From a dietary perspective, the functionality of herbs and spices will be exposed through consideration of their properties as foods. As with most foods, the real benefits of including them in the diet are likely to emerge with a better understanding of the attributes of health that are best supported by food, and in methodological developments addressing the evidence base for their effects. These developments are well underway through evidence-based frameworks for substantiating health claims related to foods. At present, recommendations are warranted to support the consumption of foods rich in bioactive components, such as herbs and spices. With time, we can expect to see a greater body of scientific evidence supporting the benefits of herbs and spices in the overall maintenance of health and protection from disease.

Plant sterols as dietary adjuvants in the reduction of cardiovascular risk: theory and evidence.

Plant sterol-enriched foods are an effective dietary adjuvant in reducing cardiovascular risk by lowering total cholesterol and low density lipoprotein-cholesterol (LDL-C) in serum by up to approximately 15%. The mechanism of action of plant sterols is different from those of 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) and thus their effect is additive. Combining plant sterols with other dietary components known to reduce cholesterol in a portfolio approach has proven to be most effective for reduction of hypercholesterolemia and provide an alternative treatment option for clinicians. Plant sterol-enriched foods provides clinicians with a relatively cheap, safe, and effective way to help patients manage their cardiovascular risk.

Attitudes and intentions toward purchasing novel foods enriched with omega-3 fatty acids.

OBJECTIVE: To identify the nature, strength, and relative importance of influences on intentions to consume foods that are enriched with omega-3 fatty acids using the Theory of Planned Behavior (TPB). DESIGN: A cross-sectional self-administered questionnaire. SETTING: Community-based residents living in the Illawarra region of New South Wales, Australia. SUBJECTS: Two subsamples were surveyed via questionnaire: community members who responded to a local media advertisement (n = 79), and subjects in a dietary intervention trial for type 2 diabetes mellitus (n = 50). VARIABLES MEASURED: Using the TPB variables-intention, attitude, subjective norm, and perceived behavioral control-questionnaire items were constructed to measure intention to consume omega-3-enriched novel foods. ANALYSIS: The results from subsamples did not differ and were combined for analysis. The determinants of intention defined in the TPB were investigated using multiple linear regressions. RESULTS: Regression analysis showed that the model was a significant determinant of intention (R2 = .725; P < .001). Attitude was a significant determinant of intention, whereas subjective norms and control beliefs were not. DISCUSSION: With attitude having the greatest influence on intentions, immediate prospects for modifying behavior are likely to come through a change in attitude, specifically in beliefs about the effectiveness of enriched products in achieving specific health benefits. CONCLUSIONS AND IMPLICATIONS: Promoters of omega-3-enriched foods would be advised to direct their promotions toward changing the attitudes of consumers about the effectiveness of the functional ingredient.

Overweight consumers' salient beliefs on omega-3-enriched functional foods in Australia's Illawarra region.

OBJECTIVE: To determine consumer salient beliefs toward functional foods enriched with omega-3 fatty acids. DESIGN: Focus group interviews with adult consumers using the Theory of Planned Behavior (TPB) as a theoretical framework. SETTING: Community-based residents living in the Illawarra region of New South Wales, Australia. PARTICIPANTS: Forty-two overweight participants (29 female, 13 male) aged 30 to 80 years recruited by advertisement and attending 1 of 6 focus groups, which were recorded and transcribed verbatim. ANALYSIS: Content analysis was carried out, and subcategories were developed to capture the emerging themes according to the TPB model. RESULTS: Most participants were aware of a range of potential benefits of omega-3 fatty acids, but they had reservations about the ability of omega-3-enriched foods to deliver a health benefit. They were concerned about whether these foods were labeled clearly and about the possibility of overdosing. Family and friends were viewed as important in introducing participants to novel foods on the market. Participants regarded dietitians as a credible source and were least trusting of food companies and scientists. Overall, participants reported that cost was a major barrier, and that they would not necessarily trade taste for health benefits. Adding omega-3 fatty acids to foods regarded as less healthful was viewed more as a gimmick rather than a real health benefit. CONCLUSIONS AND IMPLICATIONS: The consumer attitudes and purchase intentions identified in this study will be helpful to educators as they plan messages and strategies to guide dietary choices related to products enriched with omega-3 fatty acids.

Plant sterol/stanol prescription is an effective treatment strategy for managing hypercholesterolemia in outpatient clinical practice.

OBJECTIVE: To determine the effectiveness of prescribing 2 g plant sterols/stanols per day as an addition to standard practice in a dietary outpatient clinic. DESIGN: A randomized parallel design of comparative 12-week interventions. SUBJECTS/SETTING: Patients referred by a general practitioner to a dietary outpatient clinic for the management of hyperlipidemia were eligible. Twenty-five patients (15 women and 10 men) completed the study. INTERVENTION: Counseling regarding diet for hyperlipidemia was based on the National Cholesterol Education Program guidelines. The intervention group was instructed to incorporate approximately 25 g/day of margarine, containing plant sterols/stanols, which delivered approximately 2 g plant sterols/stanols. MAIN OUTCOME MEASURE: Changes in diet, body weight, and serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides were measured. STATISTICAL ANALYSIS PERFORMED: Changes in dietary and biochemical outcomes were assessed using Student's t test. For nonnormally distributed data, Wilcoxon signed rank test was used, and Mann-Whitney U tests were conducted to determine the proportion of subjects reaching defined goals. The number needed to treat index was used to report effectiveness of the intervention. RESULTS: Five of 14 subjects in the intervention group compared with 0 of 11 in the control group achieved a reduction in serum cholesterol of >/=15% ( P <.05). Using the number needed to treat index, for each 2.8 patients counseled with routine prescription of plant sterols/stanols, one additional patient would obtain a reduction in cholesterol by >/=15% compared with conventional management. This was achieved without any detrimental effects on the dietary fatty acid profile. CONCLUSIONS: Routine prescription of margarine containing plant sterol/stanol is an effective strategy in the management of hypercholesterolemic patients in the clinical setting.

Potential biomarkers of exposure and effect among glass craftsmen and braziers exposed to nitrogen oxides.

The purpose of this research was to determine occupational exposure of glass craftsmen and braziers to inhaled nitrogen oxides nitrogen dioxide and nitric oxide and to relate this to urinary nitrate, hydroxyproline and thioethers and to breath pentane. The glass craftsmen were exposed to nitrogen oxides at levels exceeding the occupational exposure standard and higher than braziers or controls. Urinary nitrate excretion was elevated. In these exposed workers hydroxyproline, thioethers and breath pentane were all elevated compared with controls and higher than in braziers who were less exposed. There was, however, only a correlation between individual levels of exposure nitrogen oxides in the breathing zone and breath pentane and there were no individual correlations between markers of effect and excretion of nitrate in the urine at the sample time.