DHA supplementation for early preterm birth prevention: An application of Bayesian finite mixture models to adaptive clinical trial design optimization.

BACKGROUND: Early preterm birth (ePTB) - born before 34 weeks of gestation - poses a significant public health challenge. Two randomized trials indicated an ePTB reduction among pregnant women receiving high-dose docosahexaenoic acid (DHA) supplementation. One of them is Assessment of DHA on Reducing Early Preterm Birth (ADORE). A survey employed in its secondary analysis identified women with low DHA levels, revealing that they derived greater benefits from high-dose DHA supplementation. This survey's inclusion in future trials can provide critical insights for informing clinical practices. OBJECTIVE: To optimize a Phase III trial design, ADORE Precision, aiming at assessing DHA supplement (200 vs. 1000 mg/day) on reducing ePTB among pregnant women with a low baseline DHA. METHODS: We propose a Bayesian Hybrid Response Adaptive Randomization (RAR) Design utilizing a finite mixture model to characterize gestational age at birth. Subsequently, a dichotomized ePTB outcome is used to inform trial design using RAR. Simulation studies were conducted to compare a Fixed Design, an Adaptive Design with early stopping, an ADORE-like Adaptive RAR Design, and two new Hybrid Designs with different hyperpriors. DISCUSSION: Simulation reveals several advantages of the RAR designs, such as higher allocation to the more promising dose and a trial duration reduction. The proposed Hybrid RAR Designs addresses the statistical power drop observed in Adaptive RAR. The new design model shows robustness to hyperprior choices. We recommend Hybrid RAR Design 1 for ADORE Precision, anticipating that it will yield precise determinations, which is crucial for advancing our understanding in this field.

The Role of Fresh Beef Intake and Mediterranean Diet Adherence during Pregnancy in Maternal and Infant Health Outcomes.

Beef is an excellent source of nutrients important for maternal health and fetal development. It is also true that the Mediterranean diet is beneficial for the health of both the mother and offspring; however, the relative value of fresh beef intake within Mediterranean diet patterns during pregnancy is unknown. The objective of this project was two-fold: (1) assess the relationship between beef intake and nutrient intake in a pregnant population; (2) assess the relationship between maternal beef consumption among varying degrees of Mediterranean diet adherence with maternal risk of anemia and infant health outcomes. This is a secondary analysis of an existing cohort of pregnant women (n = 1076) who participated in one of two completed clinical trials examining the effect of a docosahexaenoic acid supplementation on birth and offspring outcomes. Women were enrolled between 12 and 20 weeks of gestation and were followed throughout their pregnancies to collect maternal and infant characteristics, food frequency questionnaires [providing beef intake and Mediterranean diet (MedD) adherence], and supplement intake. Women with the highest fresh beef intake had the highest intake of many micronutrients that are commonly deficient among pregnant women. Fresh beef intake alone was not related to any maternal or infant outcomes. There was a reduced risk of anemia among women with medium to high MedD quality and higher fresh beef intake. Women in the medium MedD group had 31% lower odds of anemia, and women in the high MedD group had 38% lower odds of anemia with every one-ounce increase in fresh beef intake, suggesting that diet quality indices may be misrepresenting the role of fresh beef within a healthy diet. These findings show that beef intake increases micronutrient intake and may be protective against maternal anemia when consumed within a healthy Mediterranean diet pattern.

Is choline deficiency an unrecognized factor in necrotizing enterocolitis of preterm infants?

We undertook this review to determine if it is plausible that choline or phosphatidylcholine (PC) deficiency is a factor in necrotizing enterocolitis (NEC) after two clinical trials found a dramatic and unexpected reduction in NEC in an experimental group provided higher PC compared to a control group. Sources and amounts of choline/PC for preterm infants are compared to the choline status of preterm infants at birth and following conventional nutritional management. The roles of choline/PC in intestinal structure, mucus, mesenteric blood flow, and the cholinergic anti-inflammatory system are summarized. Low choline/PC status is linked to prematurity/immaturity, parenteral and enteral feeding, microbial dysbiosis and hypoxia/ischemia, factors long associated with the risk of developing NEC. We conclude that low choline status exists in preterm infants provided conventional parenteral and enteral nutritional management, and that it is plausible low choline/PC status adversely affects intestinal function to set up the vicious cycle of inflammation, loss of intestinal barrier function and worsening tissue hypoxia that occurs with NEC. In conclusion, this review supports the need for randomized clinical trials to test the hypothesis that additional choline or PC provided parenterally or enterally can reduce the incidence of NEC in preterm infants. IMPACT STATEMENT: Low choline status in preterm infants who are managed by conventional nutrition is plausibly linked to the risk of developing necrotizing enterocolitis.

Early Life Nutrition and the Developing Brain.

KEY TAKEAWAYS: The developmental origins of health and disease (DOHaD) hypothesis suggests prenatal nutrition sets the stage for the developing brain, with effects that last into adulthood. Macronutrient and micronutrient requirements increase in pregnancy and deficiencies can influence fetal neurodevelopment and cognition. Foods such as eggs, meat, and seafood contain many of the nutrients needed for healthy neurodevelopment and intake should be encouraged among women of reproductive age. Family practice clinicians play an important role in providing nutrition recommendations surrounding food and prenatal supplements to consume before, during, and after pregnancy.

Iodine Intake From Diet and Supplements and Urinary Iodine Concentration in a Cohort of Pregnant Women in the United States.

BACKGROUND: The DRI Estimated Average Requirement (EAR) in pregnancy for Iodine (I), an essential nutrient for fetal neurodevelopment, is 160 µg/d. Supplementation with 150 µg/d I/day is recommended during pregnancy, however, neither dietary intake or the combination of diet and supplement intake has been reported in US pregnant women. OBJECTIVE: Determine iodine intake from diet and supplements and iodine status in pregnancy by urinary iodine concentration in a large cohort of pregnant women. DESIGN: Pregnant women (n=750) completed the Diet History Questionnaire 2.0 from the National Institute of Cancer or multiple 24-hour recalls at baseline and identified their prenatal supplement(s). Dietary iodine intake was estimated using the USDA, FDA and ODS-NIH Database for the Iodine Content of Common Foods at enrollment, supplemental iodine intake throughout the study using content databases, and urinary iodine concentration (UIC) by the modified Sandell-Kolthoff reaction in samples collected between 14-20 weeks gestation (n=966). RESULTS: The median intake of iodine from diet was 108.8 µg/d, and 63% (473/750) were below the Estimated Average Requirement (EAR). Furthermore, 65% (529/818) took a supplement containing iodine, however, only 32% (259/818) took ≥150 µg/d. Median intake increased to 188.5 µg/d with the inclusion of I from supplements, however , 41% (380/925) remained below the EAR even after supplementation suggesting inadequate intake in nearly half of the cohort. A similar 48% (467/966) had UIC ≤150 µg/L. CONCLUSIONS: Assessment of iodine status by UIC and intake of iodine from diet and supplements support a high prevalence of iodine insufficiency during pregnancy in this large cohort of US women.

A Scoping Review of Iodine and Fluoride in Pregnancy in Relation to Maternal Thyroid Function and Offspring Neurodevelopment.

Iodine (I), an essential nutrient, is important for thyroid function and therefore growth and development. Fluoride (F), also an essential nutrient, strengthens bones and teeth, and prevents childhood dental caries. Both severe and mild-to-moderate I deficiency and high F exposure during development are associated to decreased intelligence quotient with recent reports associating high levels of F exposure during pregnancy and infancy to low intelligence quotient. Both F and I are halogens, and it has been suggested that F may interfere with the role of I in thyroid function. We provide a scoping review of the literature on I and F exposure dur pregnancy and their individual effects on thyroid function and offspring neurodevelopment. We first discuss I intake and status in pregnancy and the relationship to thyroid function and offspring neurodevelopment. We follow with the F in pregnancy and offspring neurodevelopment. We then review the interaction between I and F on thyroid function. We searched for, and found only one study that assessed both I and F in pregnancy. We conclude more studies are needed.

DHA Supplementation During Pregnancy Enhances Maternal Vagally Mediated Cardiac Autonomic Control in Humans.

BACKGROUND: DHA is an essential omega-3 (ω-3; n-3) fatty acid that has well-established benefits for the fetus. DHA also has the potential to influence the health of the mother, but this area is understudied. OBJECTIVES: The objective of this secondary analysis was to determine if DHA was related to maternal heart rate (HR) and heart rate variability (HRV) metrics in a large cohort of pregnant women. METHODS: In the parent trial (1R01HD086001) eligible participants (≥18 y old, English speaking, carrying a singleton pregnancy, 12-20 wk of gestation) were randomly assigned to consume 200 mg/d or 800 mg/d DHA for the duration of their pregnancy (n = 300). Weight, blood pressure, and magnetocardiograms (MCGs) were collected at 32 wk and 36 wk of gestation (n = 221). Measures of HR and HRV in time-, frequency-, and nonlinear-domains were determined from the isolated maternal MCG. Treatment group and timepoint were examined as predictors in association with HR and HRV metrics using random-intercept mixed-effects ANOVA unadjusted and adjusted models accounting for weight and dietary DHA intake. RESULTS: Women receiving the higher dose of DHA (800 mg/d) during pregnancy had lower HR, lower sympathetic index, higher vagally mediated HRV indices, and greater HRV complexity when compared with the women who received the lower dose (200 mg/d; all P < 0.05). All the dose relations remained significant even after controlling for the effect of time, maternal weight, and dietary DHA intake. CONCLUSIONS: DHA supplementation increases vagal tone in pregnant women. Longitudinal studies examining the potential link between DHA, enhanced vagal tone, and reported reduction in early preterm birth are warranted.

Intake of eggs, choline, lutein, zeaxanthin, and DHA during pregnancy and their relationship to fetal neurodevelopment.

BACKGROUND: Maternal intake of eggs and nutrients contained within eggs during pregnancy have the potential to impact fetal neurodevelopment; however, this area is understudied. The purpose of this study was to determine whether maternal egg and choline intake and nutrient interactions between choline, lutein and zeaxanthin (L/Z), and DHA predict fetal neurodevelopment in a large cohort of pregnant women (n = 202). NCT02709239. METHODS: Food frequency questionnaires were used to assess egg and nutrient intake during pregnancy. Fetal neurodevelopment was measured using fetal biomagnetometry at 32 and 36wks gestation, and fetal autonomic indices (SDNN, RMSSD) and brain maturation indices (fABAS) were calculated. Generalized linear models tested the relationships between choline intake, egg intake, and nutrient interactions with fetal neurodevelopment. RESULTS: Maternal egg intake predicted RMSSD at 32wks and fABAS at 36wks. The interaction between choline and L/Z intake predicted fABAS at 32wks and 36wks and the interaction between choline intake, L/Z intake, and DHA predicted fABAS at 36wks. At 36wks, SDNN was predicted by L/Z intake and interactions between choline and L/Z, L/Z and DHA, and choline, L/Z, and DHA. CONCLUSION: Eggs and the nutrients contained within eggs showed synergistic associations with fetal neurodevelopment, and consumption should be encouraged among pregnant women.

Prenatal interventions and the development of childhood obesity.

BACKGROUND: Excess maternal adiposity during pregnancy has lasting effects on child outcomes including increased risk of overweight/obesity, which drives disease development. Prenatal interventions are a potential avenue to curb childhood obesity rates, but little is known on their long-term influence on offspring adiposity. OBJECTIVE: Review the evidence for lasting effects of prenatal interventions on child adiposity. METHODS: Three databases were searched for follow-up studies of completed prenatal RCTs that involved a diet, exercise, or combined (diet and exercise) intervention, and assessed offspring adiposity-related outcomes beyond birth. RESULTS: A total of 18 follow-up studies describing 4277 offspring were included. Anthropometrics were collected in all studies while body composition was measured in 15 of the studies. Diet or exercise interventions did not have a consistent significant effect on child adiposity. Three combined interventions resulted in lower levels of child adiposity at 3, 6, and 12 months. CONCLUSIONS: No strong association was found between prenatal diet, exercise, or combined interventions and child adiposity. Data are limited due to 63.6% overall retention rate for the follow-up studies and heterogeneity of intervention approach and child adiposity measures. Findings suggest combined interventions initiated early in pregnancy may decrease offspring adiposity in the first year of life.

Maternal Docosahexaenoic Acid Exposure Needed to Achieve Maternal-Newborn EQ.

Achieving maternal docosahexaenoic acid (DHA) status equal to or greater than the infant's DHA status at delivery is known as maternal-newborn DHA equilibrium (EQ) and is thought to be important for optimizing newborn DHA status throughout infancy. The objective of this study was to determine the daily DHA intake during pregnancy most likely to result in EQ. The participants (n = 1145) were from two randomized control trials of DHA supplementation in pregnancy. DHA intake was estimated using an abbreviated food frequency questionnaire. Total DHA exposure during pregnancy was calculated as a weighted average of the estimated DHA intake throughout pregnancy and the randomized DHA dose (200, 800, 1000 mg). Red blood cell DHA was measured from maternal and cord blood plasma at delivery and EQ status was calculated. The DHA intake required to achieve EQ was estimated by regression. In terms of DHA exposure, the point estimate and 95% confidence interval to achieve EQ was 643 (583, 735) mg of DHA/day. The results of our trial suggest an intake of 650 mg of DHA/day is necessary to increase the potential for EQ at delivery. The clinical benefits of achieving EQ deserves continued study.

Assessing Omega-3 Intake in Sport: the Brief Food Frequency Questionnaire and the Omega-3 Index in Collegiate Women Soccer Players.

CONTEXT: Omega-3 fatty acids modulate inflammatory processes and are considered beneficial for sport populations, highlighting a need to assess omega-3 intake in a practical manner. Food frequency questionnaires (FFQs) are inexpensive, noninvasive tools aimed at evaluating nutrient intakes such as omega-3 fatty acids. In healthy adults, a tailored, brief FFQ for estimating omega-3 intake was associated with the erythrocyte omega-3 fatty acid level, a biomarker for omega-3 tissue status and indicative of intake. However, the association between a brief omega-3 FFQ and erythrocyte levels, particularly the Omega-3 Index (eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], and EPA + DHA), has yet to be explored in a sport population. OBJECTIVE: To examine the association between omega-3 intake using a brief FFQ and the Omega-3 Index in collegiate women soccer players. DESIGN: Cross-sectional study. SETTING: University sport team. PATIENTS OR OTHER PARTICIPANTS: Thirty-one National Collegiate Athletic Association Division I collegiate women soccer players. MAIN OUTCOME MEASURE(S): The brief omega-3 FFQ assessed dietary omega-3 intake: DHA and EPA. The OmegaQuant blood test measured erythrocyte omega-3 fatty acid (EPA, DHA) and Omega-3 Index (EPA + DHA) levels. RESULTS: Brief FFQ intakes of EPA, DHA, and EPA + DHA were positively correlated with the erythrocyte EPA (r = 0.48, P = .007), DHA (r = 0.73, P < .001), and Omega-3 Index (r = 0.73, P < .001). CONCLUSIONS: In a sample of collegiate women soccer players, the brief omega-3 FFQ was correlated with erythrocyte omega-3 fatty acid levels and may offer health practitioners a practical tool for assessing omega-3 intake in this collegiate sport population.

Prenatal docosahexaenoic acid supplementation has long-term effects on childhood behavioral and brain responses during performance on an inhibitory task.

Introduction: Offsprings from a prenatal docosahexaenoic acid (DHA) supplementation trial, in which pregnant women were assigned to placebo or 600mg DHA/day, were followed to determine the effect of prenatal DHA supplementation on the behavior and brain function at 5.5 years (n=81 placebo, n=86 supplemented).Methods: Event-related potentials (ERP) were recorded during a visual task requiring a button press (Go) to frequent target stimuli and response inhibition to the rare stimuli (No-Go). Univariate ANOVAs were used to test differences between group and sex for behavioral measures. ERP differences were tested using a three-way mixed-design multivariate analysis of variance (MANOVA).Results: There was a significant sex × group interaction for hit rate and errors of omission; there was no difference between males and females in the placebo group, but DHA males outperformed DHA females. Males overall and the placebo group made more errors requiring response inhibition; DHA females were significantly better than placebo females and DHA males. ERP P2 amplitude was larger in the DHA group. A significant N2 amplitude condition effect was observed in females and DHA group males, but not in placebo group males.Discussion: Prenatal DHA supplementation improved inhibitory performance overall, especially for females in the DHA group, possibly accounting for their conservative behavior during Go trials. Development of brain regions responsible for visual processing may be sensitive to maternal DHA status, evidenced by greater P2 amplitude. Males may benefit more from maternal DHA supplementation, indicated by the N2 condition effect seen only in males in the DHA group.

Prenatal docosahexaenoic acid effect on maternal-infant DHA-equilibrium and fetal neurodevelopment: a randomized clinical trial.

INTRODUCTION: Maternal-infant equilibrium occurs when cord blood docosahexaenoic acid (DHA) is less than or equal to maternal DHA at delivery. Equilibrium may be an indicator of sufficient DHA for optimal fetal and infant neurodevelopment. The purpose of this study was to test the effect of maternal DHA supplementation on equilibrium status and fetal neurodevelopment. METHODS: Women enrolled between 12 and 20 weeks gestation and were randomized to 200 or 800 mg DHA/day until delivery. Maternal red blood cell (RBC) phospholipids were measured at enrollment, 32 weeks, delivery, and in cord blood at delivery. Fetal neurodevelopment was measured at 32 and 36 weeks gestation. Intent-to-treat analyses were conducted to test differences in equilibrium status by group. Fetal outcomes were assessed by equilibrium status and group. RESULTS: Three hundred women enrolled and 262 maternal-infant dyads provided blood samples at delivery. No maternal-infant dyads with maternal RBC-DHA ≤ 6.96% at delivery achieved equilibrium. The incidence of equilibrium was significantly higher in the 800 mg group. There was no effect of maternal group or equilibrium status on fetal neurodevelopment. CONCLUSION: The significance of maternal-infant DHA equilibrium remains unknown. Ongoing research will test the effect of treatment group, equilibrium, and nutrient status on infant behavior and brain function. IMPACT: Pregnant women who received a higher dose of docosahexaenoic acid (DHA) were more likely to achieve maternal-infant DHA equilibrium at delivery. Equilibrium status had no effect on fetal neurodevelopment in this sample. While DHA is crucial for early life neurodevelopment, the significance of achieving maternal-infant equilibrium above the lower threshold is uncertain. There is a lower threshold of maternal DHA status where maternal-infant DHA equilibrium never occurs. The lack of equilibrium associated with low maternal DHA status may indicate insufficient maternal status for optimal placental transfer.

Maternal Vitamin D Status and Infant Infection.

Maternal vitamin D status during pregnancy may modulate fetal immune system development and infant susceptibility to infections. Vitamin D deficiency is common during pregnancy, particularly among African American (AA) women. Our objective was to compare maternal vitamin D status (plasma 25(OH)D concentration) during pregnancy and first-year infections in the offspring of African American (AA) and non-AA women. We used medical records to record frequency and type of infections during the first year of life of 220 term infants (69 AA, 151 non-AA) whose mothers participated in the Kansas University DHA Outcomes Study. AA and non-AA groups were compared for maternal 25(OH)D by Mann-Whitney U-test. Compared to non-AA women, AA women were more likely to be vitamin D deficient (<50 nmol/L; 84 vs. 37%, p < 0.001), and more of their infants had at least one infection in the first 6 months (78.3% and 59.6% of infants, respectively, p = 0.022). We next explored the relationship between maternal plasma 25(OH)D concentration and infant infections using Spearman correlations. Maternal 25(OH)D concentration was inversely correlated with the number of all infections (p = 0.033), eye, ear, nose, and throat (EENT) infections (p = 0.043), and skin infection (p = 0.021) in the first 6 months. A model that included maternal education, income, and 25(OH)D identified maternal education as the only significant predictor of infection risk in the first 6 months (p = 0.045); however, maternal education, income, and 25(OH)D were all significantly lower in AA women compared to non-AA women . The high degree of correlation between these variables does not allow determination of which factor is driving the risk of infection; however, the one that is most easily remediated is vitamin D status. It would be of value to learn if vitamin D supplementation in this at-risk group could ameliorate at least part of the increased infection risk.

Weight fluctuation during adulthood and weight gain since breast cancer diagnosis predict multiple dimensions of body image among rural breast cancer survivors.

OBJECTIVE: Obesity and weight gain after breast cancer treatment are common among survivors, yet the relationship between weight and body image has received little attention. The purpose of the current study was to examine the relationship between current body mass index, weight gain since diagnosis, and largest weight fluctuation in adulthood with six dimensions of body image among overweight/obese breast cancer survivors. METHODS: The current study used data obtained from a weight control trial with 210 rural overweight/obese breast cancer survivors. Using data collected at baseline, multiple regression models were constructed to examine the relative association of the three weight variables with breast cancer-specific dimensions of body image while controlling for demographic characteristics and cancer treatment-related variables. RESULTS: Largest weight fluctuation in adulthood significantly predicted overall body image (p = 0.01) and was associated with the three socially oriented dimensions of body image: social activity restriction, embarrassment about appearance, and sexuality (all ps = 0.01). Weight gain since diagnosis approached statistical significance in predicting overall body image (p = 0.05) and was associated with embarrassment about appearance (p = 0.03). Current body mass index was not significantly associated with overall body image when controlling for the other weight variables (p = 0.07) and was negatively associated with social activity restriction (p = 0.01) and sexuality (p = 0.01). CONCLUSIONS: Obese breast cancer survivors with a history of a large weight fluctuation in adulthood may be prone to poorer breast cancer-specific body image several years after treatment. Copyright © 2015 John Wiley & Sons, Ltd.

Diet Quality of Breast Cancer Survivors after a Six-Month Weight Management Intervention: Improvements and Association with Weight Loss.

PURPOSE: Obesity and diet quality are two distinct lifestyle factors associated with morbidity and mortality among breast cancer survivors. The purposes of this study were to examine diet quality changes during a weight loss intervention among breast cancer survivors and to examine whether diet quality change was an important factor related to weight loss. METHODS: Participants were overweight/obese breast cancer survivors (n = 180) participating in a weight loss intervention. Diet quality scores were calculated using the Healthy Eating Index (HEI)-2010. Paired sample t-tests were run to examine change in diet quality, and a latent difference model was constructed to examine whether change in diet quality was associated with weight change. RESULTS: Participants significantly improved diet quality (P = 0.001) and lost 13.2 ± 5.8% (mean ± SD) of their weight (P = 0.001). Six-month HEI score was significantly associated with weight loss, controlling for baseline BMI (P = 0.003). Improvement in diet quality was also significantly associated with weight loss (P = 0.01). CONCLUSION: Our findings indicate that a weight loss intervention can result in both clinically significant weight loss and improvement in diet quality, and that improved diet quality is predictive of weight loss. Both weight loss and diet quality are implicated in longevity and quality of life for breast cancer survivors.

Protocol for the Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER) Trial: Comparing three obesity treatment models in rural primary care.

Obesity disproportionately affects rural residents in the United States, and primary care has the potential to fill a major gap in the provision of weight management services for rural communities. The objective of this cluster-randomized pragmatic trial is to evaluate the comparative effectiveness of three obesity treatment models in rural primary care: the Intensive Behavior Therapy fee-for-service (FFS) model reimbursed by Medicare, a team-based model that recognizes the patient-centered medical home (PCMH) as a preferred delivery approach, and the centralized disease management (DM) model, in which phone-based counseling is provided outside of the primary care practice. We hypothesize that the PCMH and DM treatments will be more effective than FFS in reducing weight at 24 months. Thirty-six practices from the rural Midwestern U.S. are randomized to deliver one of the three interventions to 40 patients (N=1440) age 20 to 75 with a BMI 30-45 kg/m(2). In the FFS arm, primary care providers and their personnel counsel patients to follow evidence-based weight loss guidelines using the Medicare-designated treatment schedule. In the PCMH arm, patients receive a comprehensive weight management intervention delivered locally by practice personnel using a combination of in-person and phone-based group sessions. In the DM arm, the same intervention is delivered remotely by obesity treatment specialists via group conference calls. The primary outcome is weight loss at 24 months. Additional measures include fasting glucose, lipids, quality of life indicators, and implementation process measures. Findings will illuminate effective obesity treatment intervention(s) in rural primary care.

Measuring Nutrition Literacy in Breast Cancer Patients: Development of a Novel Instrument.

No nutrition literacy instruments have been tested in breast cancer survivors, yet nutrition is a critical lifestyle factor for optimizing weight and improving quality of life in breast cancer survival. Our objectives were to adapt our Nutrition Literacy Assessment Instrument for breast cancer populations and to pilot test its validity and reliability. We modified the instrument based on review by content experts in cancer and nutrition and cognitive interviews with 18 cancer survivors. The modified instrument (Nutrition Literacy Assessment Instrument for Breast Cancer, NLit-BCa) was pilot-tested with 17 high-risk women and 55 breast cancer survivors. We conducted the NLit-BCa on two separate occasions 4 weeks apart and assessed reliability by confirmatory factor analysis. Construct validity was evaluated by comparing results of the NLit-BCa to a Healthy Eating Index score derived from two separate 24-h dietary recalls. Content validity of the NLit-BCa was acceptable (0.93). Entire reliability for three instrument domains was substantial (>0.80), while remaining domains demonstrated fair or moderate reliability. Significant relationships were found between five of the six domains of nutrition literacy and diet quality (P < 0.05). The NLit-BCa is content valid and demonstrates promising reliability and construct validity related to diet quality, through a larger sample size, and removal of non-discriminating items is needed to confirm these findings. Thus, the NLit-BCa demonstrates potential for comprehensively measuring nutrition literacy in breast cancer populations.

Typical prenatal vitamin D supplement intake does not prevent decrease of plasma 25-hydroxyvitamin D at birth.

OBJECTIVE: The objective of this longitudinal study was to determine what typical vitamin D predictors influence the change in vitamin D status from mid-pregnancy to birth. METHODS: Plasma 25-hydroxyvitamin D [25(OH)D] was determined at mid-pregnancy (8-20 weeks gestation) and following birth (n = 193). Usual predictors of vitamin D status [body mass index (BMI), race, season] in addition to prenatal supplemental vitamin D intake and docosahexaenoic acid (DHA) status at delivery were assessed for their interaction on the change on plasma 25(OH)D concentration between the two time points. RESULTS: Forty-nine percent of women had inadequate vitamin D status [categorized as deficient (<30 nmol/L) or insufficient (30-49.9 nmol/L) by IOM guidelines] at mid-pregnancy and 82% were deficient or insufficient at birth. Plasma 25(OH)D concentration dropped 61% from mid-pregnancy to birth. Season of birth (F = 7.86, P = 0.006) and mid-pregnancy plasma 25(OH)D concentration (F = 6.17, P = 0.014) were significant variables in the change of vitamin D status while BMI, race, DHA status, and typical vitamin D intake (334 IU/day) from prenatal supplements did not have an effect. Women who delivered in summer and fall had a 1.5-fold greater plasma 25(OH)D concentration than women who delivered in winter in spring (41.1 ± 23.1 and 40.7 ± 20.5 nmol/L summer and fall, respectively, versus 27.7 ± 17.9 and 29.3 ± 21.4 nmol/L in winter and spring, respectively). CONCLUSIONS: Typical supplemental vitamin D intake during pregnancy did not prevent precipitous drops in maternal plasma 25(OH)D concentration. Clinicians and dietitians should be aware of the risk of inadequate vitamin D status in pregnant women in the United States relative to their initial vitamin D status and the season of birth.