Maintaining the gluten-free diet: The key to improve glycemic metrics in youths with type 1 diabetes and celiac disease.

AIMS: Gluten-free diets (GFD) were considered as high glycemic index and/or high content of saturated fats; this could affect keeping good metabolic control in individuals with both type 1 diabetes (T1D) and celiac disease (CD). Our objective was to analyze time in range and other continuous glucose monitoring (CGM) metrics with real-time CGM systems, in youths with T1D and CD, compared to those with T1D only. METHODS: An observational case-control study, comparing youths aged 8-18 years with T1D and CD, with people with T1D only was performed. The degree of maintaining GFD was assessed through anti-tissue transglutaminase antibodies and dietary interview, and maintaining Mediterranean diet through the KIDMED questionnaire. RESULTS: 86 youths with T1D and CD, 167 controls with T1D only, were included in the study and the two groups reported similar real-time CGM metrics. Among the first group, 29 % were not completely maintaining GFD and compared to people with T1D only they showed higher hyperglycemia rates (% time above range: 38.72 ± 20.94 vs 34.34 ± 20.94; P = 0.039). CONCLUSIONS: Individuals with T1D and CD who maintain GFD presented similar glucose metrics compared to youths with T1D only. Individuals not strictly maintaining GFD presented higher hyperglycemia rates.

Microbial and metabolic characterization of organic artisanal sauerkraut fermentation and study of gut health-promoting properties of sauerkraut brine.

Sauerkraut is a traditionally fermented cabbage, and recent evidence suggests that it has beneficial properties for human health. In this work, a multi-disciplinary approach was employed to characterize the fermentation process and gut health-promoting properties of locally produced, organic sauerkraut from two distinct producers, SK1 and SK2. 16S rRNA metataxonomics showed that bacterial diversity gradually decreased as fermentation progressed. Differences in sauerkraut microbiota composition were observed between the two producers, especially at the start of fermentation. Lactic acid bacteria (LAB) dominated the microbiota after 35 days, with Lactiplantibacillus being the dominant genus in both sauerkraut products, together with Leuconostoc and Paucilactobacillus in SK1, and with Pediococcus, Levilactibacillus, and Leuconostoc in SK2. LAB reached between 7 and 8 Log CFU/mL brine at the end of fermentation (35 days), while pH lowering happened within the first week of fermentation. A total of 220 LAB strains, corresponding to 133 RAPD-PCR biotypes, were successfully isolated. Lactiplantibacillus plantarum and Lactiplantibacillus pentosus accounted for 67% of all SK1 isolates, and Lactiplantibacillus plantarum/paraplantarum and Leuconostoc mesenteroides represented 72% of all the isolates from SK2. 1H-NMR analysis revealed significant changes in microbial metabolite profiles during the fermentation process, with lactic and acetic acids, as well as amino acids, amines, and uracil, being the dominant metabolites quantified. Sauerkraut brine did not affect trans-epithelial electrical resistance through a Caco-2 cell monolayer as a measure of gut barrier function. However, significant modulation of inflammatory response after LPS stimulation was observed in PBMCs-Caco-2 co-culture. Sauerkraut brine supported a robust inflammatory response to endotoxin, by increasing TNF-α and IL-6 production while also stimulating the anti-inflammatory IL-10, therefore suggesting positive resolution of inflammation after 24 h and supporting the potential of sauerkraut brine to regulate intestinal immune function.

Impact of wheat aleurone on biomarkers of cardiovascular disease, gut microbiota and metabolites in adults with high body mass index: a double-blind, placebo-controlled, randomized clinical trial.

PURPOSE: Aleurone is a cereal bran fraction containing a variety of beneficial nutrients including polyphenols, fibers, minerals and vitamins. Animal and human studies support the beneficial role of aleurone consumption in reducing cardiovascular disease (CVD) risk. Gut microbiota fiber fermentation, polyphenol metabolism and betaine/choline metabolism may in part contribute to the physiological effects of aleurone. As primary objective, this study evaluated whether wheat aleurone supplemented foods could modify plasma homocysteine. Secondary objectives included changes in CVD biomarkers, fecal microbiota composition and plasma/urine metabolite profiles. METHODS: A parallel double-blind, placebo-controlled and randomized trial was carried out in two groups of obese/overweight subjects, matched for age, BMI and gender, consuming foods supplemented with either aleurone (27 g/day) (AL, n = 34) or cellulose (placebo treatment, PL, n = 33) for 4 weeks. RESULTS: No significant changes in plasma homocysteine or other clinical markers were observed with either treatment. Dietary fiber intake increased after AL and PL, animal protein intake increased after PL treatment. We observed a significant increase in fecal Bifidobacterium spp with AL and Lactobacillus spp with both AL and PL, but overall fecal microbiota community structure changed little according to 16S rRNA metataxonomics. Metabolomics implicated microbial metabolism of aleurone polyphenols and revealed distinctive biomarkers of AL treatment, including alkylresorcinol, cinnamic, benzoic and ferulic acids, folic acid, fatty acids, benzoxazinoid and roasted aroma related metabolites. Correlation analysis highlighted bacterial genera potentially linked to urinary compounds derived from aleurone metabolism and clinical parameters. CONCLUSIONS: Aleurone has potential to modulate the gut microbial metabolic output and increase fecal bifidobacterial abundance. However, in this study, aleurone did not impact on plasma homocysteine or other CVD biomarkers. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT02067026) on the 17th February 2014.

Nutrition and Inflammation in Older Individuals: Focus on Vitamin D, n-3 Polyunsaturated Fatty Acids and Whey Proteins.

Chronic activation of the inflammatory response, defined as inflammaging, is the key physio-pathological substrate for anabolic resistance, sarcopenia and frailty in older individuals. Nutrients can theoretically modulate this phenomenon. The underlying molecular mechanisms reducing the synthesis of pro-inflammatory mediators have been elucidated, particularly for vitamin D, n-3 polyunsaturated fatty acids (PUFA) and whey proteins. In this paper, we review the current evidence emerging from observational and intervention studies, performed in older individuals, either community-dwelling or hospitalized with acute disease, and evaluating the effects of intake of vitamin D, n-3 PUFA and whey proteins on inflammatory markers, such as C-Reactive Protein (CRP), interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor α (TNF-α). After the analysis, we conclude that there is sufficient evidence for an anti-inflammatory effect in aging only for n-3 PUFA intake, while the few existing intervention studies do not support a similar activity for vitamin D and whey supplements. There is need in the future of large, high-quality studies testing the effects of combined dietary interventions including the above mentioned nutrients on inflammation and health-related outcomes.

Nutritional status in older persons according to healthcare setting: A systematic review and meta-analysis of prevalence data using MNA®.

BACKGROUND & AIMS: Old persons are more likely to suffer from malnutrition, which may result in higher dependency in activities of daily living. We aimed to provide a quantitative synthesis of prevalence data on malnutrition and its risk as assessed by the Mini Nutritional Assessment across different healthcare settings. The association between nutritional status and setting-related level of dependence was also investigated. METHODS: Non-interventional studies published as full-text articles in English up to 31th December 2014 were searched for in PubMed and by reviewing references of eligible articles. Meta-analysis and meta-regression of potential sources of heterogeneity were conducted. RESULTS: A total of 240 studies/795 citations - providing 258 setting-specific prevalence estimates (113,967 subjects) - fulfilled inclusion criteria for meta-analysis. Prevalence of malnutrition differed significantly across the healthcare settings considered: community, 3.1% (95%CI, 2.3-3.8); outpatients, 6.0% (95%CI, 4.6-7.5); home-care services, 8.7% (95%CI, 5.8-11.7); hospital, 22.0% (95%CI, 18.9-22.5); nursing homes, 17.5% (95%CI, 14.3-20.6); long-term care, 28.7% (95%CI, 21.4-36.0); rehabilitation/sub-acute care, 29.4% (95%CI, 21.7-36.9). For every setting significant heterogeneity in individual study results was observed (I2 ≥80%, P < 0.001) and meta-regression showed that study quality was the most important determinant. Finally, meta-regression of all the studies included showed that both malnutrition and its risk were directly associated with the setting-related level of dependence (P < 0.001). However, despite multiple adjustments, residual heterogeneity remained high. CONCLUSION: We provided updated estimates of malnutrition and its risk in different healthcare settings. Although the level of dependence appears to be an important determinant, heterogeneity in individual study results remained substantially unexplained. The cause-effect relationship between nutritional status and level of dependence deserves further investigation.

The Geriatric Nutritional Risk Index predicts hospital length of stay and in-hospital weight loss in elderly patients.

BACKGROUND & AIMS: Nutritional derangements are common in elderly patients, but how nutritional risk affects outcome in this subset of hospital inpatients deserves further investigation. We evaluated the impact of nutritional risk on length of stay (LOS) and in-hospital weight loss (WL) in elderly patients (>65 yrs). METHODS: Nutritional risk was assessed by the Geriatric Nutritional Risk Index (GNRI) in a prospective multicentre hospital-based cohort study. The outcomes were LOS and in-hospital WL. RESULTS: In the whole sample (N = 667), the prevalence of high (GNRI < 92) and mild (GNRI: 92-98) nutritional risk were 33% and 25%, respectively. Patients with a high nutritional risk were more likely (OR = 1.89; 95%CI: 1.22-2.92) to stay longer in hospital (fourth quartile, LOS ≥ 20 days) compared to those without. Other factors associated with prolonged LOS were cancer diagnosis (OR = 2.52; 95%CI: 1.69-3.75), the presence of comorbidities (OR = 1.24; 95%CI: 1.11-1.40) and surgical setting (OR = 1.65; 95%CI: 1.10-2.47). In-hospital WL ≥ 5% was recorded in 75 ambulant patients from a representative subgroup (N = 583). It was independently associated with prolonged LOS (OR = 1.80; 95%CI: 1.03-3.06) and was more frequent among cancer patients (OR = 1.88; 95%CI: 1.09-3.24), in patients with a high nutritional risk (OR = 2.23; 95%CI: 1.20-4.14) or those admitted to surgical units (OR = 1.77; 95%CI: 1.02-3.05). CONCLUSIONS: Nutritional risk assessed by the GNRI on admission, predicts LOS and in-hospital WL in elderly patients.

A case of hyperemesis in bulimia nervosa.

Bulimia nervosa is an eating disorder defined by recurrent episodes of binge eating followed by compensatory behaviors, primarily self-induced vomiting. Most common complications are due to purge behaviors and are frequently responsible for hospitalization. These include electrolyte disturbances, dehydration, hypovolemia, stomatitis, esophageal diseases, and functional impairment of the colon. However, an obstruction-like syndrome has never been reported. We report the case of a middle-age woman suffering from bulimia nervosa and referring at the emergency department with a 7-day story of hyperemesis responsible for an acute renal failure. During hospitalization, after the most important and common medical causes of hyperemesis were excluded, an upper gastrointestinal endoscopy was performed. The endoscopist reported the presence of an impressive bezoar, which underwent to mechanical fragmentation and biopsy sampling, revealing it was made up exclusively of liquorice wheels. An endoscopy performed few days after showed the complete dissolution of the bezoar, and the patient was discharged without any further gastrointestinal complaint.

A malfunctioning nasogastric feeding tube.

A critical point of nasogastric feeding tube placement, potentially resulting in an unsafe and/or non-effective operation of the device, is the monitoring of its proper placement into the stomach. A properly obtained and interpreted radiograph is currently recommended to confirm placement. We reported the case of a 68-year-old demented woman referred for complicated dysphagia. A nasogastric tube was blindly inserted and its placement was confirmed by the radiologist. Enteral nutrition was initiated but the patient began to vomit immediately. After reviewing the radiograph it was understood that a gastric loop in the tube and its tip pointing upwards did not allow a safe infusion of the feeding formula. It is not enough having the radiologist reporting that a nasogastric feeding tube is placed in the stomach; the inclusion in the report of specific warnings on any potential cause of malfunctioning of the device should be considered. The presence of a gastric loop should be taken into account as a cause of potential malfunctioning.

Un punto crítico de la colocación del tubo de alimentación nasogástrica, potencialmente resultando en un funcionamiento peligroso y / o no eficaz del dispositivo, es la supervisión de su correcta ubicación en el estómago. Una radiografía obtenido e interpretado correctamente la actualidad se recomienda para confirmar la colocación. Se presenta el caso de una mujer demente de 68 2013s remitido para la disfagia complicado. Una sonda nasogástrica se inserta a ciegas y su ubicación fue confirmada por el radiólogo. La nutrición enteral se inició, pero el paciente empezó a vomitar inmediatamente. Después de revisar la radiografía se entendía que un bucle gástrico en el tubo y su punta hacia arriba apuntando no permitió una infusión segura de la fórmula de alimentación. No es suficiente tener el aviso del radiólogo que un tubo nasogástrico de alimentación se coloca en el estómago, la inclusión en el informe de advertencias específicas en cualquier causa potencial de mal funcionamiento del dispositivo debe ser considerado. La presencia de un bucle gástrico debe ser tenido en cuenta como una causa de mal funcionamiento potencial.

Nutritional risk, functional status and mortality in newly institutionalised elderly.

Previous studies have reported a close relationship between nutritional and functional domains, but evidence in long-term care residents is still limited. We evaluated the relationship between nutritional risk and functional status and the association of these two domains with mortality in newly institutionalised elderly. In the present multi-centric prospective cohort study, involving 346 long-term care resident elderly, nutritional risk and functional status were determined upon admission by the Geriatric Nutritional Risk Index (GNRI) and the Barthel Index (BI), respectively. The prevalence of high (GNRI <92) and low (GNRI 92­98) nutritional risk were 36·1 and 30·6 %, respectively. At multivariable linear regression, functional status was independently associated with age (P=0·045), arm muscle area (P=0·048), the number of co-morbidities (P=0·027) and mainly with the GNRI (P<0·001). During a median follow-up of 4·7 years (25th­75th percentile 3·7­6·2), 230 (66·5 %) subjects died. In the risk analysis, based on the variables collected at baseline, both high (hazard ratio (HR) 1·86, 95% CI 1·32, 2·63; P<0·001) and low nutritional risk (HR 1·52, 95% CI 1·08, 2·14; P=0·016) were associated with all-cause mortality. Participants at high nutritional risk (GNRI <92) also showed an increased rate of cardiovascular mortality (HR 1·93, 95% CI 1·28, 2·91; P<0·001). No association with outcome was found for the BI. Upon admission, nutritional risk was an independent predictor of functional status and mortality in institutionalised elderly. Present data support the concept that the nutritional domain is more relevant than functional status to the outcome of newly institutionalised elderly.

Alzheimer's disease and mortality in traditional long-term care facilities.

Although there is evidence that different types of dementia share similar pathophysiologic mechanisms, research studies support the concept that dementia of the Alzheimer type (AD) is a distinct clinical entity, which may differ in terms of disease progression and outcome. We assessed whether a diagnosis of probable AD in elderly patients admitted to traditional long-term care facilities results in different mortality rates. We analyzed data belonging to a prospective, multi-center (n=4) cohort study involving 378 long-term care facility residents. In our population the prevalence of dementia (any-type) and AD were 46.3% and 11.9%, respectively. During a median follow-up of 5.7 years [25-75th percentile, 2.6-6.9], 262 (69.3%) elderly died. Compared to other admission diagnoses, AD was characterized by lower mortality rates: all-cause hazard risk (HR), 0.64 [95% CI, 0.41-0.99] (P=0.048); HR for cardiovascular (CV) causes, 0.40 [95% CI, 0.20-0.78] (P=0.008). Pre-specified subgroup analyses restricted to patients with dementia (n=175) provided similar results. HRs for AD were: all-cause, 0.60 [95% CI, 0.35-1.00] (P=0.049); CV, 0.43 [95% CI, 0.20-0.91] (P=0.028). However, any-type dementia did not show any difference in risk when compared to other admission diagnosis. In conclusion, probable AD was associated with reduced mortality risk in traditional long-term care facilities. The reasons for these findings deserve further investigation; peculiar pathophysiological features could not be excluded.

Diabetes and risk of Parkinson's disease: a systematic review and meta-analysis.

OBJECTIVE: Diabetes has been associated with chronic neurodegeneration. We performed a systematic review and meta-analysis to assess the relationship between pre-existing diabetes and Parkinson's disease (PD). RESEARCH DESIGN AND METHODS: Original articles in English published up to 10 May 2011 were searched for in electronic databases (PubMed, Embase, and Scopus) and by reviewing references of eligible articles. Prospective cohort and case-control studies providing risk and precision estimates relating to pre-existing diabetes and PD were considered eligible. RESULTS: Nine studies/1,947 citations (cohort, N = 4; case-control, N = 5) fulfilled inclusion criteria for meta-analysis. In prospective studies, the onset of diabetes before onset of PD was found to be a risk factor for future PD (relative risk [RR] = 1.37 [95%CI 1.21-1.55]; P < 0.0001). This association was confirmed by secondary analyses based on estimates derived after the exclusion of participants who had vascular disease at baseline and/or who developed vascular disease during follow-up (RR = 1.34 [1.14-1.58]; P < 0.001) and by sensitivity analyses addressing the association with diabetes at baseline or during follow-up. However, the association found for case-control studies was not significant (odds ratio [OR] 0.75 [95%CI 0.50-1.11]; P = 0.835). Sensitivity analysis based on estimates adjusted for BMI confirmed the lack of a relationship between PD and diabetes (OR 0.56 [0.28-1.15]; P = 0.089). CONCLUSIONS: Although data from cohort studies suggest that diabetes is a risk factor for PD, there is no conclusive evidence on this association. Further prospective studies focused on putative pathogenic pathways and taking a broad range of confounders into account is required to clarify this relationship.

Nutritional screening and mortality in newly institutionalised elderly: a comparison between the geriatric nutritional risk index and the mini nutritional assessment.

BACKGROUND & AIMS: Several tools are available for nutritional screening. We evaluated the risk of mortality associated with the Geriatric Nutritional Risk Index (GNRI) and the Mini Nutritional Assessment (MNA) in newly institutionalised elderly. METHODS: A prospective observational study involving 358 elderly newly admitted to a long-term care setting. Hazard ratios (HR) for mortality among GNRI categories and MNA classes were estimated by multivariable Cox's model. RESULTS: At baseline, 32.4% and 37.4% of the patients were classified as being malnourished (MNA <17) and at severe nutritional risk (GNRI <92), respectively, whereas 57.5% and 35.2%, respectively, were classified as being at risk for malnutrition (MNA 17-23.5) and having low nutritional risk (GNRI 92-98). During a median follow-up of 6.5 years [25th-75th percentile, 5.9-8.6], 297 elderly died. Risk for all-cause mortality was significantly associated with nutritional risk by the GNRI tool (GNRI<92 HR = 1.99 [95%CI, 1.38-2.88]; GNRI 92-98 HR = 1.51 [95%CI, 1.04-2.18]) but not with nutritional status by the MNA. A significant association was also found with cardiovascular mortality (GNRI <92 HR = 1.79 [95%CI, 1.23-2.61]). CONCLUSIONS: Nutritional risk by GNRI but not nutritional status by MNA was associated with higher mortality risk. Present data suggest that in the nutritional screening of newly institutionalised elderly the use of the GNRI should be preferred to that of the MNA.

Body mass index and mortality in institutionalized elderly.

OBJECTIVE: Malnutrition and sarcopenia in institutions are very common and significantly affect the prognosis. Aging is characterized by weight and lean body mass losses. Accordingly, in elderly patients, body mass index (BMI) is considered a marker of protein stores rather than of adiposity. Current guidelines suggest a BMI 21 kg/m(2) or lower as major trigger for nutritional support. We evaluated the association between BMI and mortality in institutionalized elderly. METHODS: This was a multicentric prospective cohort study involving 519 long-term care resident elderly individuals. Risk for mortality across BMI tertiles was estimated by the Cox hazards regression model adjusted for potential confounders recorded at inclusion and collected during the follow-up. RESULTS: During a median follow-up of 5.7 years (25th to 75th percentile, 5.2-8.2], 409 (78.8%) elderly patients died. In primary analyses, based on variables collected at inclusion, patients in the first tertile of BMI (≤ 21 kg/m(2)) were at higher risk for all-cause (hazard ratio [HR] 1.38; 95% confidence interval [CI] 1.04-1.84; P = .025) and cardiovascular mortality (HR = 1.49; 95% CI, 1.00-2.08; P = .045). Increased risk was confirmed even after adjusting for nutritional support during the follow-up (all-cause HR = 1.53; 95% CI, 1.13-2.06; P = .006; cardiovascular HR = 1.62; 95% CI, 1.09-2.40; P = .018), which in turn was associated with a reduced risk (all-cause HR = 0.74; 95% CI, 0.55-0.97; P = .035; cardiovascular HR = 0.62; 95% CI, 0.42-0.91; P = .016). CONCLUSION: BMI is significantly associated with all-cause and cardiovascular mortality in institutionalized elderly patients. A value of 21 kg/m(2) or lower can be considered a useful trigger for nutritional support. These results support intending BMI as nutritional reserve in institutionalized elderly patients.