Protein-Energy Supplementation in Early-Life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala

The prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle-income countries, with a high prevalence of undernutrition. To examine whether exposure to a protein-energy nutritional supplement during the first 1000 d of life decreased odds of mental distress in adulthood among men and women in Guatemala compared with receiving a low energy-no protein supplement or supplementation outside the 1000-d window. Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early-life, supplementation data from 1969 to 1977, ages 0­7 y; life course, outcome data from 2017­2018 follow-up, ages 40­57 y) were analyzed for associations between nutrition in the first 1000 d and mental distress in adulthood (WHO Self- Reporting Questionnaire 20 [SRQ-20]), controlling for early-life variables and current life stress; life course variables (e.g. education) were examined as potential mediators of this relation. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized. Both partial and full supplementation with Atole during the first 1000 d were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Did not differ by sex. These inverse relations remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early-life and life course variables, including life stress. Protein-energy supplementation during the first 1000 d of life in Guatemala, where undernutrition is prevalent, may reduce the prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly, through pathways of life course variables such as education, wealth, and marital status. Keywords: early childhood nutrition, protein-energy

Ultraprocessed Products as Food Fortification Alternatives: A Critical Appraisal from Latin America

Ultraprocessed products (UPPs), associated with obesity and non-communicable diseases (NCDs), are becoming predominant on the global market and a target for market-driven fortification initiatives. The aim of this article is to describe the implications of adding micronutrients to UPPs with excessive amounts of critical nutrients associated with NCDs and provide recommendations for legislation and policies. UPPs with added micronutrients such as breakfast cereals, sugarsweetened beverages, powder beverages, fruit juices, sauces, and bouillon cubes, among others, are commonly available and heavily promoted in Latin American countries. Misleading advertising of UPPs with added micronutrients and with excessive content of sugar, fat, and salt might increase the consumption of such products, giving them a "health halo effect" that leads consumers to overestimate their nutritional quality and healthfulness. Although international collections of standards such as the Codex Alimentarius provide some guidelines on this matter, countries need to implement national legislations, through a food systems approach, to regulate the marketing and labeling of UPPs. Lastly, there is still the need to foster research to close knowledge gaps and help countries to guide the process of food fortification strategies from a regulatory standpoint.

Age at childbirth and change in BMI across the life-course: evidence from the INCAP Longitudinal Study

Background: Parity has been associated with both short- and long-term weight gain in women. However, it is not clear if timing of parity across the reproductive age has different associations with BMI. Methods: To prospectively assess the association between age at childbirth and maternal change in BMI, we analyzed data from the ongoing INCAP Longitudinal Study, which started in 1969 in four villages in Guatemala. Cohort women (n=778) provided information on reproductive history and anthropometric measures were measured in 1988-89 (adolescence, 15 to 25y), 2002-04 (early adulthood, 26 to 36y) and 2015-17 (mid adulthood, 37 to 55y). We evaluated the associations of number of live births in the period preceding each study wave (1969-77 to 1988-89, 1988-89 to 2002-04 and 2002-04 to 2015-17) with BMI change in the same period using multivariable linear regression models. Results: Number of live births between 1988 and 89 and 2002-04 was positively associated with increased BMI, while there was not an association between number of live births and BMI in the other intervals. Women who had one, two, or three or more children between 1988 and 89 and 2002-04 had 0.90 (kg/m2, 95% CI: -0.55, 2.35), 2.39 (kg/m2, 95% CI: 1.09, 3.70) and 2.54 (kg/m2, 95% CI: 1.26, 3.82) higher BMI, respectively, than women who did not give birth in the same period. Conclusions: Our findings suggest that women who had three or more children during early adulthood gained more weight compared to women who had no children in the same period. In contrast, women who had children earlier or later in their reproductive lives did not gain additional weight compared to those who did not have children during that period. Childbirth may have different

Birth attendants as perinatal verbal autopsy respondents in low- and middle-income countries: a viable alternative?

OBJECTIVE: To assess the feasibility of using birth attendants instead of bereaved mothers as perinatal verbal autopsy respondents. METHODS: Verbal autopsy interviews for early neonatal deaths and stillbirths were conducted separately among mothers (reference standard) and birth attendants in 38 communities in four developing countries. Concordance between maternal and attendant responses was calculated for all questions, for categories of questions and for individual questions. The sensitivity and specificity of individual questions with the birth attendant as respondent were assessed. FINDINGS: For early neonatal deaths, concordance across all questions was 94%. Concordance was at least 95% for more than half the questions on maternal medical history, birth attendance and neonate characteristics. Concordance on any given question was never less than 80%. Sensitivity and specificity varied across individual questions, more than 80% of which had a sensitivity of at least 80% and a specificity of at least 90%. For stillbirths, concordance across all questions was 93%. Concordance was 95% or greater more than half the time for questions on birth attendance, site of delivery and stillborn characteristics. Sensitivity and specificity varied across individual questions. Over 60% of the questions had a sensitivity of at least 80% and over 80% of them had a specificity of at least 90%. Overall, the causes of death established through verbal autopsy were similar, regardless of respondent. CONCLUSION: Birth attendants can substitute for bereaved mothers as verbal autopsy respondents. The questions in existing harmonized verbal autopsy questionnaires need further refinement, as their sensitivity and specificity differ widely.

Causes of community stillbirths and early neonatal deaths in low-income countries using verbal autopsy: an International, Multicenter Study.

OBJECTIVE: Six million stillbirths (SB) and early neonatal deaths (END) occur annually worldwide, mostly in rural settings distant from health facilities. We used verbal autopsy (VA), to understand causes of non-hospital, community-based SB and END from four low-income countries. STUDY DESIGN: This prospective observational study utilized the train-the-trainer method. VA interviewers conducted standardized interviews; in each country data were reviewed by two local physicians who assigned an underlying causes of deaths (COD). RESULT: There were 252 perinatal deaths (118 END; 134 SB) studied from pooled data. Almost half (45%) the END occurred on postnatal day 1, 19% on the second day and 16% the third day. Major early neonatal COD were infections (49%), birth asphyxia (26%), prematurity (17%) and congenital malformations (3%). Major causes of SB were infection (37%), prolonged labor (11%), antepartum hemorrhage (10%), preterm delivery (7%), cord complications (6%) and accidents (5%). CONCLUSION: Many of these SB and END were from easily preventable causes. Over 80% of END occurred during the first 3 days of postnatal life, and >90% were due to infection, birth asphyxia and prematurity. The causes of SB were more varied, and maternal infections were the most common cause. Increased attention should be targeting at interventions that reduce maternal and neonatal infections and prevent END, particularly during the first 3 days of life.

An alternative strategy for perinatal verbal autopsy coding: single versus multiple coders.

OBJECTIVE: To determine the comparability between cause of death (COD) by a single physician coder and a two-physician panel, using verbal autopsy. METHODS: The study was conducted between May 2007 and June 2008. Within a week of a perinatal death in 38 rural remote communities in Guatemala, the Democratic Republic of Congo, Zambia and Pakistan, VA questionnaires were completed. Two independent physicians, unaware of the others decisions, assigned an underlying COD, in accordance with the causes listed in the chapter headings of the International classification diseases and related health problems, 10th revision (ICD-10). Cohen's kappa statistic was used to assess level of agreement between physician coders. RESULTS: There were 9461 births during the study period; 252 deaths met study enrolment criteria and underwent verbal autopsy. Physicians assigned the same COD for 75% of stillbirths (SB) (K = 0.69; 95% confidence interval: 0.61-0.78) and 82% early neonatal deaths (END) (K = 0.75; 95% confidence interval: 0.65-0.84). The patterns and proportion of SBs and ENDs determined by the physician coders were very similar compared to causes individually assigned by each physician. Similarly, rank order of the top five causes of SB and END was identical for each physician. CONCLUSION: This study raises important questions about the utility of a system of multiple coders that is currently widely accepted and speculates that a single physician coder may be an effective and economical alternative to VA programmes that use traditional two-physician panels to assign COD.

Using verbal autopsy to ascertain perinatal cause of death: are trained non-physicians adequate?

OBJECTIVES: To develop a standardized verbal autopsy (VA) training program and evaluate whether its implementation resulted in comparable knowledge required to classify perinatal cause of death (COD) by physicians and non-physicians. METHODS: Training materials, case studies, and written and mock scenarios for this VA program were developed using conventional VA and ICD-10 guidelines. This program was used to instruct physicians and non-physicians in VA methodology using a train-the-trainer model. Written tests of cognitive and applied knowledge required to classify perinatal COD were administered before and after training to evaluate the effect of the VA training program. RESULTS: Fifty-three physicians and non-physicians (nurse-midwives/nurses and Community Health Workers [CHW]) from Pakistan, Zambia, the Democratic Republic of Congo, and Guatemala were trained. Cognitive and applied knowledge mean scores among all trainees improved significantly (12.8 and 28.8% respectively, P < 0.001). Cognitive and applied knowledge post-training test scores of nurse-midwives/nurses were comparable to those of physicians. CHW (high-school graduates with 15 months or less formal health/nursing training) had the largest improvements in post-training applied knowledge with scores comparable to those of physicians and nurse-midwives/nurses. However, CHW cognitive knowledge post-training scores were significantly lower than those of physicians and nurses. CONCLUSIONS: With appropriate training in VA, cognitive and applied knowledge required to determine perinatal COD is similar for physicians and nurses-midwives/nurses. This suggests that midwives and nurses may play a useful role in determining COD at the community level, which may be a practical way to improve the accuracy of COD data in rural, remote, geographic areas.

Plasma free amino acid concentrations in healthy Guatemalan adults and in patients with classic dengue.

BACKGROUND: Plasma free amino acid patterns in health and disease have been reported. However, amino acid concentrations in adult populations in developing countries and in patients with dengue, as a model for an acute infectious viral disease endemic to the tropics, have not been reported. OBJECTIVE: The purpose of this study was to determine the amino acid profile in both healthy Guatemalan adults from different socioeconomic backgrounds and at 3 time points during the course of classic dengue. DESIGN: The study was carried out in Guatemala and included measurement of plasma free amino acids in 22 healthy control subjects (14 low income, 8 middle class) and 17 febrile patients. Measurements of amino acids were repeated within a 48-h interval in 20 of the healthy Guatemalans. In 9 patients with dengue, amino acids were assayed 3 times: on admission to a local hospital in the coastal plain of Guatemala, on hospital discharge, and 7 d after hospital discharge. RESULTS: Branched-chain amino acid concentrations in healthy adults and dengue patients in Guatemala were lower than normal values reported in the literature for healthy Swedish adults. With the exception of increased phenylalanine concentrations and an increased ratio of phenylalanine to tyrosine, all amino acids as well as the Fischer molar ratio were decreased in the acute phase of dengue. CONCLUSIONS: Healthy Guatemalans have different amino acid patterns than do Swedish subjects independent of socioeconomic status. The systemic viral disease dengue is associated with changes in the plasma free amino acid pattern, reflecting infection-related alterations in amino acid metabolism.

Hydrational status assessed by bioelectrical impedance spectroscopy and dilution methods in patients with classical dengue fever.

The effects of an episode of acute classical dengue fever on extracellular water (ECW), intracellular water (ICW), and total body water (TBW) were measured in nine patients using conventional dilution techniques; and the findings were compared with the outcome variables from whole body impedance spectroscopy (BIS), extracellular fluid resistance (Recf), and intracellular fluid resistance (Ricf). The patients were assessed on admission with febrile presentation (DI), at discharge after the defervescence of the fever cycle at about five days postadmission (DII), and seven days thereafter (DIII). As a reference group, 15 persons without acute or chronic illness were enrolled. Total body water was unaltered during the course of disease and was not different from that in normal healthy subjects. However, body water shifted from the intracellular to the extracellular compartment in patients from the acute phase to convalescence, as reflected in the ratios of ECW/TBW and ECW/ICW. These ratios were significantly higher in convalescent dengue patients (DIII) than in the reference group (p < 0.05). Increasing ECW, from the acute phase of the disease to convalescence, was associated with a significant decrease in Recf (719 +/- 95, 693 +/- 89, 643 +/- 81 omega; p < 0.0001) and in Recf/Ricf (p < 0.01). Recf and Recf/Ricf were higher in the acute phase (DI) of dengue fever compared to controls (p < 0.05). We conclude that dengue fever is characterized by a relative expansion of ECW during the course of disease and convalescence. BIS was sensitive in determining the hydrational profile in dengue fever patients.

Bioelectrical impedance spectroscopy in health and disease. Correspondence between whole body and segmental bioelectrical impedance spectroscopy indices in patients with classical dengue fever.

Bioelectrical impedance spectroscopy (BIS) can provide estimates of body composition for both whole body (WB) and body segments (BS). In normal, healthy subjects, BS measurements may be expected to serve as surrogates for WB indices; however, very little is known about this correspondence in people suffering from acute illnesses. The aim of this study was to evaluate the degree of this correspondence in patients with an acute, systemic illness, such as classical dengue fever. Ten adult patients were examined upon admission to the community hospital on the Pacific Coast of Guatemala and after clinical recovery about two weeks later, and compared with a group of healthy subjects living in the same region. BIS was measured with a Xitron 4000B analyzer (Xitron Technologies Inc., San Diego, CA, USA). BS measurements were carried out using Organ et al.'s approach. The BIS data were modeled with the manufacturer's software: extra- (Recf) and intracellular- (Ricf) resistances, and the Recf/Ricf ratio. BIS BS measurements correlate closely with WB in both the acute and the recovery stages of dengue fever, with the leg showing the highest degree of correspondence and the trunk the lowest. Recf indices, per se, generally showed higher correspondence than Ricf or the Recf/Ricf ratio.

The pharmacokinetic responses of humans to 20 g of alanyl-glutamine dipeptide differ with the dosing protocol but not with gastric acidity or in patients with acute Dengue fever.

Pharmacokinetic responses to oral doses of the dipeptide, L-alanyl-glutamine (Ala-Gln), were evaluated after a single, bolus load or an intermittent dosing in normal healthy subjects (n = 8) to find the optimal mode of oral administration. In a subgroup (n = 4) of the healthy subjects, the influence of a gastric acid suppressor (Omeprazole) was investigated. The influence of an acute episode of classic Dengue fever was examined in eight patients. All modes of administration to healthy subjects significantly increased free plasma Gln and alanine concentrations. Peak increments of plasma Gln concentration were 794+/-107 micromol/L (mean +/- SEM) after bolus intake of 20 g of Ala-Gln and 398+/-61 micromol/L after intermittent intake of the same cumulative dosage of the dipeptide (P<0.01). After intermittent dosing, the maximum peak increase appeared significantly later (P<0.01). Areas under the curve (AUC), expressing the integrated responses over time of plasma free Gln and alanine concentrations, did not differ after bolus and intermittent loads of Ala-Gln. Pretreatment with the acid suppressor, Omeprazole, did not influence Gln (P = 0.79) or alanine (P = 0.90) plasma increment. Dengue patients manifested the same pharmacokinetic responses to a 20 g Ala-Gln bolus as healthy controls. In general, on a micromolar concentration basis, Gln and alanine followed parallel tracks in terms of plasma appearance, clearance and elimination after the oral administration of 20 g of the Ala-Gln dipeptide through the range of conditions and dosing protocols explored here.

Assessment of total body stores of vitamin A in Guatemalan elderly by the deuterated-retinol-dilution method.

BACKGROUND: Deuterated retinol dilution (DRD) gives quantitative estimates of total body stores of vitamin A. OBJECTIVES: In elderly people, we studied 1) the time when an oral dose of deuterated vitamin A equilibrates with body stores, 2) whether serum ratios of deuterated to nondeuterated retinol (D:H) at 3 or 6 d postdosing predicted body stores, and 3) the ability of DRD to detect changes in the size of the body vitamin A pool. DESIGN: A 10-mg oral dose of [2H4]retinyl acetate was administered to 60-81-y-old Guatemalans (n = 47); percentage enrichment of serum retinol with deuterated retinol was determined at 1-3 time points per subject at 3, 6, 7, 14, 20, 21, and 54 d. In subjects from whom blood was obtained at 3 and 21 d (n = 15) and at 6 and 20 d (n = 9), total body stores were calculated by using the formula of Furr et al (Am J Clin Nutr 1989;49:713-6) with 21- or 20-d data and correlated with serum D:H at 3 or 6 d postdosing. Nine subjects received diets containing 982+/-20 microg RE (x+/-SEM) plus 800 microg RE as retinyl acetate supplements for 32 d. DRD, serum retinol, and relative dose response were used to assess vitamin A status before and after the intervention. RESULTS: Deuterated retinol equilibrated with the body pool by 20 d postdosing. Vitamin A supplementation for 32 d increased body stores, although unexplained exaggerated increases were seen in some subjects. An inverse linear relation was found between estimates of body stores and serum D:H at 3 d postdosing (r = -0.75, P = 0.002); at 6 d postdosing, the correlation was weaker. CONCLUSIONS: DRD can detect changes in total body stores of vitamin A, although factors affecting serum D:H need to be elucidated. Serum D:H 3 d postdosing might be used as an early indicator of total body stores of vitamin A, although a predictive equation will need to be developed.

Influence of sex, seasonality, ethnicity, and geographic location on the components of total energy expenditure in young children: implications for energy requirements.

BACKGROUND: There are limited data on the influence of body composition, sex, seasonality, ethnicity, and geographic location on the components of energy expenditure in children. OBJECTIVE: The objective was to examine the determinants of total energy expenditure (TEE), resting energy expenditure (REE), and activity-related energy expenditure (AEE) in children. DESIGN: Cross-sectional data from 232 children (4-10 y of age) from 4 ethnic groups (white American, African American, Guatemalan Mestizo, and Native American Mohawk) were examined. RESULTS: In 104 white children studied in Vermont and Alabama, TEE was significantly higher in spring than in fall, higher in boys than in girls, and higher in children in Vermont (all effects: approximately 0.42 MJ/d, P < 0.05). The significant effect of sex was explained through REE; the influences of season and location were explained through AEE. In all children, there was no effect of sex but a significant effect of ethnicity (P < 0.01) on TEE: a significant effect of sex (P < 0.01) and no effect of ethnicity (P = 0.16) on REE; and no effect of sex and a significant effect of ethnicity on AEE. The significant effects of ethnicity were due to lower values in Guatemalan children. TEE correlated most strongly with weight (r = 0.81) and fat-free mass (r = 0.79-0.81); REE with weight (r = 0.85) and fat-free mass (r = 0.80-0.87); and AEE with maximal oxygen consumption (r = 0.54), fat-free mass (r = 0.50), and fat mass (r = 0.49). CONCLUSIONS: 1) Season and location influenced TEE in children through their effects on AEE, 2) a higher REE in boys was consistent across all groups examined, 3) Guatemalan children had lower TEE due to a lower AEE, 4) body weight may be the best predictor of TEE, and 5) maximal oxygen consumption was the strongest marker of AEE.

Bioelectrical impedance spectroscopy (BIS) in young children with acute and semi-acute hydration disorders: potentials and limitations.

This study aimed to evaluate the feasibility and reliability of bioelectrical impedance spectroscopy in young children suffering of acute hydrational disorders. Whole body and segmental measurements were carried out in a group of 42 of children aged 4 to 147 months, using a BIS analyzer (Xitron 4000B). This phase of the study involved several hundred of BIS measurement, which showed the feasibility of using this technique in young children. Using the sweep mode and the modeling software provided for the manufacturer of the instrument, the resistance of the extracellular (RECW) and intracellular (RICW) compartment was calculated. Correlation coefficient (r) and technical error of measurement (TEM) were obtained from paired BIS measurements. RECW showed to be highly reproducible (r = 0.99), with a relatively low TEM (from 1 to 3.5%), across all segments. The reliability was markedly lower respect to RICW, which shows the potential application of BIS technique even in critically ill young child populations.

Nutritional status indicators and their interactions in rural Guatemalan elderly: a study in San Pedro Ayampuc.

Anthropometry and body-composition measures, hematologic and biochemical measures of nutritional status, and helminthic infection were studied in the population of elderly persons (> or = 60 y of age) in a rural village in Guatemala that was 65% Mayan (indigenous) and 35% ladino (European). The population had low levels of literacy and formal education. The elderly persons were much shorter and lighter than reference populations. Anemia was present in 18% of the population, and riboflavin and vitamin B-12 deficiencies were detected in 70% and 38%, respectively. Both anthropometric and biochemical-hematologic variables were lower, on average, in the Mayan descendants than in the ladinos. When grouped by body mass index (BMI; in kg/m2), greater BMI signified higher values for almost all biochemical-hematologic measures. Sixty-five percent of the sampled population had mild-to-moderate Ascaris lumbricoides and Trichuris trichiura infections. The lifestyle in rural Guatemala is evolving, and the present findings provide insights into the evolution of nutritional status in the growing number of elderly in the countryside.

Aging, physical activity, insulin-like growth factor I, and body composition in Guatemalan women.

Aging is associated with diminished secretion of growth hormone and the major endogenous mediator of growth hormone action, insulin-like growth factor I (IGF-I). Aging is also associated with decreased physical activity. Alterations in body composition characteristic of the aging process (increased fat mass and decreased lean body mass) may be related to the decline in anabolic effects of IGF-I with aging, decreased physical activity, or both. Guatemalan women often maintain a high level of physical activity during aging. The purpose of this study was to determine whether IGF-I concentrations correlated with physical activity level (determined by standardized scoring of a self-report questionnaire) and body composition (determined by bioelectrical impedance analysis) in elderly Guatemalan women. In 112 women aged 20-87 y, we found a progressively lower serum IGF-I with age (r = -0.732). In subjects > 60 y of age, the self-reported activity level was associated with a lower percentage body fat (P < 0.001) but there was no significant relation between physical activity level and either lean body mass or IGF-I. We conclude that there is a significant age-related decline in serum IGF-I concentrations in Guatemalan women, similar to that observed in both men and women in the United States. An increased level of physical activity in the elderly Guatemalan population was associated with reduced body fat but did not modify the expected reduction in circulating IGF-I concentrations that occurs with aging.

Body composition, resting metabolic rate, and energy requirements of short- and normal-stature, low-income Guatemalan children.

We examined body composition using bioelectrical impedance analysis and isotope dilution (18O and 2H), resting metabolic rate (RMR) by indirect calorimetry, and total energy expenditure (TEE) by doubly labeled water in 15 short-stature (height-for-age < or = -1.5 SD) and 15 normal-stature (height-for-age > -1.5 SD) Guatemalan children aged 4-6 y. Although, in absolute terms significant group differences were found in fat-free mass (FFM), fat mass, and total body water (TBW), there were no significant differences in fat mass and TBW after adjustment for FFM. RMR of the short-stature children (3791 +/- 376 kJ/d) was not significantly different from that of normal-stature children (4038 +/- 531 kJ/d), and the regression between RMR and FFM was also not significantly different between groups. TEE was not significantly different in short-stature (4753 +/- 761 kJ/d) compared with normal-stature children (5304 +/- 1020 kJ/d); the regression between TEE and FFM was not significantly different between the two groups. There were no significant group differences in RMR and TEE after adjustment for FFM. FFM was the strongest predictor of TEE, but could only explain 29% of the variance. We conclude that 1) the lower TBW and fat mass in the short-stature group is proportional to their lower FFM, 2) there is no significant difference in either RMR or TEE between short- and normal-stature children, and 3) TEE is highly variable among these children and cannot be explained by differences in body size alone.

A purified extract from prickly pear cactus (Opuntia fuliginosa) controls experimentally induced diabetes in rats.

The hypoglycemic activity of a purified extract from prickly pear cactus (Opuntia fuliginosa) was evaluated on STZ-induced diabetic rats. Blood glucose and glycated hemoglobin levels were reduced to normal values by a combined treatment of insulin and Opuntia extract. When insulin was withdrawn from the combined treatment, the prickly pear extract alone maintained normoglycemic state in the diabetic rats. The blood glucose response to administered glucose also showed that the rats receiving the combination treatment of insulin and Opuntia extract for 7 weeks followed by Opuntia extract alone were capable of rapidly returning blood glucose to the levels of the nondiabetic rats. Although the mechanism of action is unknown, the magnitude of the glucose control by the small amount of Opuntia extract required (1 mg/kg body weight per day) preclude a predominant role for dietary fiber. These very encouraging results for diabetes control by the purified extract of this Opuntia cactus make the need for clinical studies in humans evident.