Identifying Future Study Designs and Indicators for Somatic Health Associated with Diets of Cohorts Living in Eco-Regions: Findings from the INSUM Expert Workshop.

Diets, but also overall food environments, comprise a variety of significant factors with direct and indirect impacts on human health. Eco-Regions are geographical areas with a territorial approach to rural development, utilizing organic food and farming practices, and principles and promoting sustainable communities and food systems. However, so far, little attention has been given to quantifying aspects of the health of citizens living in these sustainable transition territories. The project "Indicators for Assessment of Health Effects of Consumption of Sustainable, Organic School Meals in Eco-Regions" (INSUM) aims to identify and discuss research approaches and indicators that could be applied to effectively measure the somatic, mental, and social health dimensions of citizens in Eco-Regions, linked to the intake of organic foods in their diets. In this paper, we focus on the somatic (physical) health dimension. A two-day workshop was held to discuss suitable methodology with an interdisciplinary, international group of experts. The results showed the limitations of commonly used tools for measuring dietary intake (e.g., relying on the memory of participants), and nutritional biomarkers (e.g., variations in correlations with specific intakes) for research understanding dietary intake and the health effects of diets. To investigate the complexity of this issue, the most suitable approach seems to be the combination of traditional markers of physical and mental health alongside emerging indicators such as the microbiome, nutrigenomics, metabolomics, or inflammatory biomarkers. Using new, digital, non-invasive, and wearable technologies to monitor indicators could complement future research. We conclude that future studies should adopt systemic, multidisciplinary approaches by combining not only indicators of somatic and mental health and social wellbeing (MHSW) but also considering the potential benefits of organic diets for health as well as aspects of sustainability connected to food environments.

The Dietary Inflammatory Index and Its Associations with Biomarkers of Nutrients with Antioxidant Potential, a Biomarker of Inflammation and Multiple Long-Term Conditions.

We aimed to validate the Dietary Inflammatory Index (DII®) and assess the cross-sectional associations between the DII® and multiple long-term conditions (MLTCs) and biomarker concentrations and MLTCs using data from the European Prospective Investigation into Cancer (EPIC-Norfolk) study (11,113 men and 13,408 women). The development of MLTCs is associated with low-grade chronic inflammation, and ten self-reported conditions were selected for our MLTC score. Data from a validated FFQ were used to calculate energy-adjusted DII® scores. High-sensitivity C-reactive protein (hs-CRP) and circulating vitamins A, C, E, ß-carotene and magnesium were available. Micronutrient biomarker concentrations were significantly lower as the diet became more pro-inflammatory (p-trend < 0.001), and hs-CRP concentrations were significantly higher in men (p-trend = 0.006). A lower DII® (anti-inflammatory) score was associated with 12-40% higher odds of MLTCs. Lower concentrations of vitamin C and higher concentrations of hs-CRP were associated with higher odds of MLTCs. The majority of the associations in our study between MLTCs, nutritional biomarkers, hs-CRP and the DII® were as expected, indicating that the DII® score has criterion validity. Despite this, a more anti-inflammatory diet was associated with higher odds of MLTCs, which was unexpected. Future studies are required to better understand the associations between MLTCs and the DII®.

Effect of gut microbiome modulation on muscle function and cognition: the PROMOTe randomised controlled trial.

Studies suggest that inducing gut microbiota changes may alter both muscle physiology and cognitive behaviour. Gut microbiota may play a role in both anabolic resistance of older muscle, and cognition. In this placebo controlled double blinded randomised controlled trial of 36 twin pairs (72 individuals), aged ≥60, each twin pair are block randomised to receive either placebo or prebiotic daily for 12 weeks. Resistance exercise and branched chain amino acid (BCAA) supplementation is prescribed to all participants. Outcomes are physical function and cognition. The trial is carried out remotely using video visits, online questionnaires and cognitive testing, and posting of equipment and biological samples. The prebiotic supplement is well tolerated and results in a changed gut microbiome [e.g., increased relative Bifidobacterium abundance]. There is no significant difference between prebiotic and placebo for the primary outcome of chair rise time (ß = 0.579; 95% CI -1.080-2.239 p = 0.494). The prebiotic improves cognition (factor score versus placebo (ß = -0.482; 95% CI,-0.813, -0.141; p = 0.014)). Our results demonstrate that cheap and readily available gut microbiome interventions may improve cognition in our ageing population. We illustrate the feasibility of remotely delivered trials for older people, which could reduce under-representation of older people in clinical trials. ClinicalTrials.gov registration: NCT04309292.

Alcohol Consumption and Measures of Sarcopenic Muscle Risk: Cross-Sectional and Prospective Associations Within the UK Biobank Study.

Alcohol intake is a major modifiable risk factor for many diseases. Alcohol can also damage skeletal muscle health during ageing which in turn increases risk of sarcopenia, frailty and falls but this relationship is understudied. The aim of this study was to model the relationship between a full range of alcohol consumption and components of sarcopenic risk, skeletal muscle mass and function, in middle-aged and younger older-aged men and women. A cross-sectional analyses was undertaken of 196,561 white participants from the UK Biobank with longitudinal analysis also in 12,298 of these participants, with outcome measures for the latter repeated after around four years. For the cross-sectional analysis fractional polynomial curves were fitted in models of measures of skeletal muscle mass, appendicular lean mass/body mass index (ALM/BMI), fat-free mass as a percentage of body weight (FFM%) and grip strength, all predicted from alcohol consumption with models fitted for men and women separately. Alcohol consumption at baseline was based on the mean of up to five dietary recalls, typically over 16 months. Linear regression was used for longitudinal analyses to model the effects of alcohol consumption groups on these measures. All models were adjusted for covariates. In the cross-sectional analysis, modelled values of the muscle mass measures all showed a peak at medium levels of alcohol consumption and a steep decline with increasing alcohol consumption. Modelled differences in muscle mass from zero consumption of alcohol to 160 g/d ranged from 3.6 to 4.9% for ALM/BMI for men and women, respectively, and 3.6 to 6.1% for FFM%. Grip strength consistently increased with alcohol consumption. No association between alcohol consumption and muscle measures were seen in the longitudinal results. Our results suggest that higher levels of alcohol consumption could have detrimental effects on muscle mass in middle- and older-aged men and women.

Higher dietary protein intake is associated with sarcopenia in older British twins.

BACKGROUND: Sarcopenia, characterised by an accelerated loss of skeletal muscle mass and function, is associated with negative outcomes. This study aimed to evaluate factors associated with skeletal muscle strength, mass and sarcopenia, particularly protein intake, and to assess whether shared twin characteristics are important. METHODS: This study utilised cross-sectional data from a study of community-dwelling twins aged ≥60 years. Multivariable logistic regression and between- and within-twin pair regression modelling were used. RESULTS: Participants (n = 3,302) were 89% female (n = 2,923), aged a mean of 72.1 (±7.3) years and composed of 858 (55%) monozygotic, 709 (45%) dizygotic twin pairs and 168 individual lone twins. Using optimal protein intake as the reference group (1.0-1.3 g/kg/day), there was no significant association between protein intake (neither high nor low) and low muscle strength, or between low protein intake and sarcopenia (odds ratio (OR) 0.7; 95% confidence interval (CI) 0.39-1.25; P = 0.229) in unadjusted models. High protein intake (>1.3 g/kg/day) was associated with low muscle mass (OR 1.76; 95% CI 1.39-2.24; P < 0.0001), while low protein intake was protective (OR 0.52; 95% CI 0.40-0.67; P < 0.0001). High protein intake was associated with sarcopenia (OR 2.04; 95% CI 1.21-3.44; P = 0.008), and this was robust to adjustment for demographic, anthropometric and dietary factors. The association between muscle strength and weight, body mass index, healthy eating index, protein intake and alpha diversity was not significantly influenced by shared twin factors, indicating greater amenability to interventions. CONCLUSIONS: High protein intake is associated with sarcopenia in a cohort of healthy older twins.

Coapplication of Magnesium Supplementation and Vibration Modulate Macrophage Polarization to Attenuate Sarcopenic Muscle Atrophy through PI3K/Akt/mTOR Signaling Pathway.

Sarcopenia is an age-related geriatric syndrome characterized by the gradual loss of muscle mass and function. Low-magnitude high-frequency vibration (LMHFV) was shown to be beneficial to structural and functional outcomes of skeletal muscles, while magnesium (Mg) is a cofactor associated with better indices of skeletal muscle mass and strength. We hypothesized that LMHFV, Mg and their combinations could suppress inflammation and sarcopenic atrophy, promote myogenesis via PI3k/Akt/mTOR pathway in senescence-accelerated mouse P8 (SAMP8) mice and C2C12 myoblasts. Results showed that Mg treatment and LMHFV could significantly decrease inflammatory expression (C/EBPα and LYVE1) and modulate a CD206-positive M2 macrophage population at month four. Mg treatment also showed significant inhibitory effects on FOXO3, MuRF1 and MAFbx mRNA expression. Coapplication showed a synergistic effect on suppression of type I fiber atrophy, with significantly higher IGF-1, MyoD, MyoG mRNA (p < 0.05) and pAkt protein expression (p < 0.0001) during sarcopenia. In vitro inhibition of PI3K/Akt and mTOR abolished the enhancement effects on myotube formation and inhibited MRF mRNA and p85, Akt, pAkt and mTOR protein expressions. The present study demonstrated that the PI3K/Akt/mTOR pathway is the predominant regulatory mechanism through which LMHFV and Mg enhanced muscle regeneration and suppressed atrogene upregulation.

Evidence to Underpin Vitamin A Requirements and Upper Limits in Children Aged 0 to 48 Months: A Scoping Review.

Vitamin A deficiency is a major health risk for infants and children in low- and middle-income countries. This scoping review identified, quantified, and mapped research for use in updating nutrient requirements and upper limits for vitamin A in children aged 0 to 48 months, using health-based or modelling-based approaches. Structured searches were run on Medline, EMBASE, and Cochrane Central, from inception to 19 March 2021. Titles and abstracts were assessed independently in duplicate, as were 20% of full texts. Included studies were tabulated by question, methodology and date, with the most relevant data extracted and assessed for risk of bias. We found that the most recent health-based systematic reviews and trials assessed the effects of supplementation, though some addressed the effects of staple food fortification, complementary foods, biofortified maize or cassava, and fortified drinks, on health outcomes. Recent isotopic tracer studies and modelling approaches may help quantify the effects of bio-fortification, fortification, and food-based approaches for increasing vitamin A depots. A systematic review and several trials identified adverse events associated with higher vitamin A intakes, which should be useful for setting upper limits. We have generated and provide a database of relevant research. Full systematic reviews, based on this scoping review, are needed to answer specific questions to set vitamin A requirements and upper limits.

Effects of fluid and drinking on pneumonia mortality in older adults: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Advice to drink plenty of fluid is common in respiratory infections. We assessed whether low fluid intake (dehydration) altered outcomes in adults with pneumonia. METHODS: We systematically reviewed trials increasing fluid intake and well-adjusted, well-powered observational studies assessing associations between markers of low-intake dehydration (fluid intake, serum osmolality, urea or blood urea nitrogen, urinary output, signs of dehydration) and mortality in adult pneumonia patients (with any type of pneumonia, including community acquired, health-care acquired, aspiration, COVID-19 and mixed types). Medline, Embase, CENTRAL, references of reviews and included studies were searched to 30/10/2020. Studies were assessed for inclusion, risk of bias and data extracted independently in duplicate. We employed random-effects meta-analysis, sensitivity analyses, subgrouping and GRADE assessment. Prospero registration: CRD42020182599. RESULTS: We identified one trial, 20 well-adjusted cohort studies and one case-control study. None suggested that more fluid (hydration) was associated with harm. Ten of 13 well-powered observational studies found statistically significant positive associations in adjusted analyses between dehydration and medium-term mortality. The other three studies found no significant effect. Meta-analysis suggested doubled odds of medium-term mortality in dehydrated (compared to hydrated) pneumonia patients (GRADE moderate-quality evidence, OR 2.3, 95% CI 1.8 to 2.8, 8619 deaths in 128,319 participants). Heterogeneity was explained by a dose effect (greater dehydration increased risk of mortality further), and the effect was consistent across types of pneumonia (including community-acquired, hospital-acquired, aspiration, nursing and health-care associated, and mixed pneumonia), age and setting (community or hospital). The single trial found that educating pneumonia patients to drink ≥1.5 L fluid/d alongside lifestyle advice increased fluid intake and reduced subsequent healthcare use. No studies in COVID-19 pneumonia met the inclusion criteria, but 70% of those hospitalised with COVID-19 have pneumonia. Smaller COVID-19 studies suggested that hydration is as important in COVID-19 pneumonia mortality as in other pneumonias. CONCLUSIONS: We found consistent moderate-quality evidence mainly from observational studies that improving hydration reduces the risk of medium-term mortality in all types of pneumonia. It is remarkable that while many studies included dehydration as a potential confounder, and major pneumonia risk scores include measures of hydration, optimal fluid volume and the effect of supporting hydration have not been assessed in randomised controlled trials of people with pneumonia. Such trials, are needed as potential benefits may be large, rapid and implemented at low cost. Supporting hydration and reversing dehydration has the potential to have rapid positive impacts on pneumonia outcomes, and perhaps also COVID-19 pneumonia outcomes, in older adults.

Identifying Future Study Designs for Mental Health and Social Wellbeing Associated with Diets of a Cohort Living in Eco-Regions: Findings from the INSUM Expert Workshop.

Diets influence our mental health and social wellbeing (MHSW) in multiple ways. A rising community concept, Eco-Regions, has gained interest. The research project "Indicators for assessment of health effects of consumption of sustainable, organic school meals in Ecoregions" (INSUM) aims to develop future-oriented research approaches to measure the potential health effects of more sustainable and healthy diets. This first part of the project focuses on MHSW with the goal to identify suitable study designs and indicators. The methodology is based on a 2-day workshop with an interdisciplinary group of experts. This paper describes commonly applied research methods on the nexus between diet and MHSW as presented by the experts and summarises key points from the discussions. The results show that the dominating tool to investigate MSHW is questionnaires. Questionnaires vary largely depending on the research design, such as participants or distribution channels. Cohort studies addressing families and including in-depth interventional and/or experimental studies may be suitable for an Eco-Region investigation. Those MHSW studies can be conducted and combined with measurements of somatic health effects. We conclude that indicators should be seen as complementary rather than independent. Explorative research designs are required to investigate complex Eco-Regions.

Nutrition and Frailty: Opportunities for Prevention and Treatment.

Frailty is a syndrome of growing importance given the global ageing population. While frailty is a multifactorial process, poor nutritional status is considered a key contributor to its pathophysiology. As nutrition is a modifiable risk factor for frailty, strategies to prevent and treat frailty should consider dietary change. Observational evidence linking nutrition with frailty appears most robust for dietary quality: for example, dietary patterns such as the Mediterranean diet appear to be protective. In addition, research on specific foods, such as a higher consumption of fruit and vegetables and lower consumption of ultra-processed foods are consistent, with healthier profiles linked to lower frailty risk. Few dietary intervention studies have been conducted to date, although a growing number of trials that combine supplementation with exercise training suggest a multi-domain approach may be more effective. This review is based on an interdisciplinary workshop, held in November 2020, and synthesises current understanding of dietary influences on frailty, focusing on opportunities for prevention and treatment. Longer term prospective studies and well-designed trials are needed to determine the causal effects of nutrition on frailty risk and progression and how dietary change can be used to prevent and/or treat frailty in the future.

Micronutrient malnutrition across the life course, sarcopenia and frailty.

Micronutrient malnutrition, the deficiency of vitamins or minerals, impacts on physical and mental health, in clinical and general populations, across the life course. In older western populations the high prevalence and impact of micronutrient malnutrition is less well recognised. Low- and middle-income countries are experiencing the 'double burden of disease' where malnutrition coexists alongside the non-communicable diseases of aging, obesity, type 2 diabetes and cardiovascular disease. Held in December 2020, the Winter Conference of the Nutrition Society was designed to cover new areas of research and concern in micronutrient malnutrition across the life course. Common themes arising from the conference were: 1) The continuing high prevalence of micronutrient malnutrition across the life-course, in diverse populations, in high, middle and low-income countries. 2) That multiple deficiencies of micronutrients frequently exist. 3) The primary cause of deficiency is poor quality diets, of low diversity, low in micronutrient dense foods. 4) Clinical conditions, medications for common non-communicable diseases, and environmental conditions, interact with and exacerbate the effects of poor diet quality. 5) Understanding of the mechanistic effects of micronutrients is still emerging. 6) Micronutrients are necessary for maintaining immune function, which has importance for the COVID-19 epidemic. 7) Better biomarkers are needed detect and understand the effects of deficiency. 7) Dietary recommendations need to be updated regularly. Further research is needed in all these areas. Comprehensive public health and government approaches to ensure access and affordability of good quality foods to populations of all ages, particularly during the ongoing COVID-19 epidemic, are crucial.

Fracture Incidence and the Relevance of Dietary and Lifestyle Factors Differ in the United Kingdom and Hong Kong: An International Comparison of Longitudinal Cohort Study Data.

Geographic variation in fracture risk may be due to divergent profiles of dietary, lifestyle, and other risk factors between populations. We investigated differences in fracture rates between two older-population cohorts: the European Prospective Investigation into Cancer and Nutrition (EPIC) Norfolk cohort (n = 7732) in the United Kingdom (UK), and the Mr and Ms Os cohort (n = 3956) in Hong Kong (HK). Data were collected by questionnaires, laboratory assessments, and hospital records. Incidence of hip, spine, and wrist fractures in the two cohorts was calculated and multivariable regression was used to explore variables important to fracture risk. Total hip, spine, and wrist fracture incidence was higher in the UK vs HK for women (13.70 vs 8.76 per 1000 person-years; p < 0.001), but not men (5.95 vs 5.37 per 1000 person-years; p = 0.337), and the proportions of different fractures also varied between cohorts (p < 0.001). Hip fracture was the most common UK fracture (accounting for 56.8% fractures in men and 52.6% in women), while wrist fracture was most common in HK (42.9% in men and 57.9% in women). The major contributor to total fracture risk in multivariable regression models of both cohorts and sexes, was age; with BMI also an important contributor to fracture risk HK men and UK women. The distribution of factors relevant to fracture risk, and the rates of different fractures, varied significantly between UK and HK cohorts. However, the importance of each factor in contributing to fracture risk was similar between the cohorts. The differences in fracture rates suggest targeted approaches may be required when developing interventions and public health recommendations to reduce the burden of osteoporosis in these two countries.

Predicting Malnutrition Risk with Data from Routinely Measured Clinical Biochemical Diagnostic Tests in Free-Living Older Populations.

Malnutrition (undernutrition) in older adults is often not diagnosed before its adverse consequences have occurred, despite the existence of established screening tools. As a potential method of early detection, we examined whether readily available and routinely measured clinical biochemical diagnostic test data could predict poor nutritional status. We combined 2008-2017 data of 1518 free-living individuals ≥50 years from the United Kingdom National Diet and Nutrition Survey (NDNS) and used logistic regression to determine associations between routine biochemical diagnostic test data, micronutrient deficiency biomarkers, and established malnutrition indicators (components of screening tools) in a three-step validation process. A prediction model was created to determine how effectively routine biochemical diagnostic tests and established malnutrition indicators predicted poor nutritional status (defined by ≥1 micronutrient deficiency in blood of vitamins B6, B12 and C; selenium; or zinc). Significant predictors of poor nutritional status were low concentrations of total cholesterol, haemoglobin, HbA1c, ferritin and vitamin D status, and high concentrations of C-reactive protein; except for HbA1c, these were also associated with established malnutrition indicators. Additional validation was provided by the significant association of established malnutrition indicators (low protein, fruit/vegetable and fluid intake) with biochemically defined poor nutritional status. The prediction model (including biochemical tests, established malnutrition indicators and covariates) showed an AUC of 0.79 (95% CI: 0.76-0.81), sensitivity of 66.0% and specificity of 78.1%. Clinical routine biochemical diagnostic test data have the potential to facilitate early detection of malnutrition risk in free-living older populations. However, further validation in different settings and against established malnutrition screening tools is warranted.

REP1 deficiency causes systemic dysfunction of lipid metabolism and oxidative stress in choroideremia.

Choroideremia (CHM) is an X-linked recessive chorioretinal dystrophy caused by mutations in CHM, encoding for Rab escort protein 1 (REP1). Loss of functional REP1 leads to the accumulation of unprenylated Rab proteins and defective intracellular protein trafficking, the putative cause for photoreceptor, retinal pigment epithelium (RPE), and choroidal degeneration. CHM is ubiquitously expressed, but adequate prenylation is considered to be achieved, outside the retina, through the isoform REP2. Recently, the possibility of systemic features in CHM has been debated; therefore, in this study, whole metabolomic analysis of plasma samples from 25 CHM patients versus age- and sex-matched controls was performed. Results showed plasma alterations in oxidative stress-related metabolites, coupled with alterations in tryptophan metabolism, leading to significantly raised serotonin levels. Lipid metabolism was disrupted with decreased branched fatty acids and acylcarnitines, suggestive of dysfunctional lipid oxidation, as well as imbalances of several sphingolipids and glycerophospholipids. Targeted lipidomics of the chmru848 zebrafish provided further evidence for dysfunction, with the use of fenofibrate over simvastatin circumventing the prenylation pathway to improve the lipid profile and increase survival. This study provides strong evidence for systemic manifestations of CHM and proposes potentially novel pathomechanisms and targets for therapeutic consideration.

Positive Associations of Dietary Intake and Plasma Concentrations of Vitamin E with Skeletal Muscle Mass, Heel Bone Ultrasound Attenuation and Fracture Risk in the EPIC-Norfolk Cohort.

The prevalence of sarcopenia, frailty and fractures is increasing. Prevention options are limited, but dietary factors including vitamin E have the potential to confer some protection. This study investigated cross-sectional associations between dietary and plasma concentrations of vitamin E with indices of skeletal muscle mass (SMM) (n = 14,179 and 4283, respectively) and bone density (n = 14,694 and 4457, respectively) and longitudinal fracture risk (n = 25,223 and 7291, respectively) in European Prospective Investigation Into Cancer and Nutrition (EPIC)-Norfolk participants, aged 39-79 years at baseline. Participants completed a health and lifestyle questionnaire, a 7-day diet diary (7dDD) and had anthropometric measurements taken. Fat-free mass (as a SMM proxy) was measured using bioimpedance and bone density was measured using calcaneal broadband ultrasound attenuation (BUA) and incident fractures over 18.5 years of follow-up. Associations between indices of SMM, BUA and fracture risk were investigated by quintiles of dietary vitamin E intake or plasma concentrations. Positive trends in SMM indices and BUA were apparent across dietary quintiles for both sexes, with interquintile differences of 0.88%-1.91% (p < 0.001), and protective trends for total and hip fracture risk. Circulating plasma α- and γ-tocopherol results matched the overall dietary findings. Dietary vitamin E may be important for musculoskeletal health but further investigation is required to fully understand the relationships of plasma tocopherols.

Cross-sectional associations of schoolchildren's fruit and vegetable consumption, and meal choices, with their mental well-being: a cross-sectional study.

BACKGROUND: Poor mental well-being is a major issue for young people and is likely to have long-term negative consequences. The contribution of nutrition is underexplored. We, therefore, investigated the association between dietary choices and mental well-being among schoolchildren. METHODS: Data from 7570 secondary school and 1253 primary school children in the Norfolk Children and Young People Health and Well-being Survey, open to all Norfolk schools during October 2017, were analysed. Multivariable linear regression was used to measure the association between nutritional factors and mental well-being assessed by the Warwick-Edinburgh Mental Well-being Scale for secondary school pupils, or the Stirling Children's Well-being Scale for primary school pupils. We adjusted all analyses for important covariates including demographic, health variables, living/home situation and adverse experience variables. RESULTS: In secondary school analyses, a strong association between nutritional variables and well-being scores was apparent. Higher combined fruit and vegetable consumption was significantly associated with higher well-being: well-being scores were 3.73 (95% CI 2.94 to 4.53) units higher in those consuming five or more fruits and vegetables (p<0.001; n=1905) compared with none (n=739). The type of breakfast or lunch consumed was also associated with significant differences in well-being score. Compared with children consuming a conventional type of breakfast (n=5288), those not eating any breakfast had mean well-being scores 2.73 (95% CI 2.11 to 3.35) units lower (p<0.001; n=1129) and those consuming only an energy drink had well-being scores 3.14 (95% CI 1.20 to 5.09) units lower (p=0.002; n=91). Likewise, children not eating any lunch had well-being scores 2.95 (95% CI 2.22 to 3.68) units lower (p<0.001; 860) than those consuming a packed lunch (n=3744). In primary school analyses, the type of breakfast or lunch was associated with significant differences in well-being scores in a similar way to those seen in secondary school data, although no significant association with fruit and vegetable intake was evident. CONCLUSION: These findings suggest that public health strategies to optimise the mental well-being of children should include promotion of good nutrition.

High variability of food and nutrient intake exists across the Mediterranean Dietary Pattern-A systematic review.

A Mediterranean style dietary pattern (MDP) is considered beneficial for health. The MD Score (MDS) definition has evolved, resulting in considerable variability in the foods and nutrients associated with MDS adherence. We systematically investigated food and nutrient composition of the MD between studies, countries, and methods of classifying the MDS. We searched Embase for MD systematic reviews and selected observational studies reporting intakes of foods, macronutrients, or micronutrients by categories of MDS adherence. The percentage differences in food and nutrient intakes between categories of high and low adherence to the MDS were calculated for each study. A total of 369 full-text primary papers were reviewed from the included systematic reviews and 74 papers selected (66 adults, 8 children). We found considerable differences in MDS definitions and scoring criteria. Between-study variation in food intake between high- and low-adherence MDS adherence categories ranged from a mean of -23% for meat, to 119% for fruit, and 278% for fish. Greater variability was evident in non-Mediterranean than Mediterranean regions. We conclude that few studies report food and nutrient intakes across the range of the MDP in adults and even fewer in children. The considerable variability in the foods and nutrients reported makes comparison of results from studies and translation into dietary guidelines difficult. We recommend that future publications of MD studies include full details of the range of food and nutrient intakes across the distribution of MD adherence in order to facilitate translation into health policy and practice.

Dietary acid-base load and its association with risk of osteoporotic fractures and low estimated skeletal muscle mass.

BACKGROUND/OBJECTIVES: Age-related decline in skeletal muscle mass and strength, loss of bone density, and increased risk of osteoporotic fractures are important public health issues. Systemic acid-base balance is affected by dietary intake and may be relevant to these conditions. We therefore investigated associations of dietary acid-base load with skeletal muscle mass, bone density status, and fracture risk. SUBJECTS/METHODS: We analysed the European Prospective Investigation into Cancer and Nutrition-Norfolk cohort of >25,000 individuals, 39-79 years at baseline. Potential renal acid load (PRAL) was calculated from 7-day food diary data. As a proxy for skeletal muscle mass, we estimated fat-free mass from bioelectrical impedance analysis and scaled this for BMI (FFMBMI). Bone density status was assessed by heel-bone broadband ultrasound attenuation (BUA), and fracture rates were obtained from health-care records. Multivariable regression was used to test musculoskeletal outcomes across sex-specific quintiles of PRAL. RESULTS: PRAL in quintiles was negatively associated with FFMBMI in men (n = 6350, p < 0.001) and women (n = 7989, p < 0.001), with quintile 5 vs 1 differences of -1.5% and -3.2% (both p < 0.001). PRAL was also negatively associated with BUA in women (n = 8312, p = 0.016; quintile 5 vs 1 difference -1.5%, p = 0.024). The combined hazard of hip, wrist and spine fractures (mean ± SD follow-up 17.9 ± 4.9 years) was higher with increasing quintiles of PRAL in men (610 fractures; n = 11,511; p = 0.013) and women (1583 fractures; n = 13,927; p = 0.009), with quintile 5 vs 1 hazard ratios of 1.33 (95% CI: 1.03-1.72, p = 0.029) and 1.21 (95% CI: 1.03-1.42, p = 0.022), but associations were not consistent for all fractures sites and age groups tested. CONCLUSIONS: This study provides strong evidence, albeit observational, for a negative association between PRAL and musculoskeletal health in middle to older age men and women, and thus supports the rationale for a less acidic dietary load.