Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view.

BACKGROUND & AIMS: Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN). METHODS: On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives. RESULTS: This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum. CONCLUSION: The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

Body composition in patients with primary neuromuscular disease assessed by dual energy X-ray absorptiometry (DXA) and three different bioimpedance devices.

BACKGROUND: Patients with primary neuromuscular disease have reduced muscle mass, and use of body mass index to assess nutritional status and body composition can therefore be questioned. Dual emission X-ray absorptiometry (DXA) can estimate muscle mass, but is not always readily available. Bioimpedance is a simple, portable and "easy to use" method for the assessment of body composition. OBJECTIVES: To assess muscle mass by DXA in 143 patients with primary neuromuscular disease and validate three bioimpedance devices; Impedimed SFB7, (BISIMPEDIMED), Xitron4200 (BISXITRON) and Tanita MC180MA (MFBIATANITA). METHODS: Body composition was assessed by DXA in 143, by BISIMPEDIMED in 116, by MFBIATANITA in 104 and by BISXITRON in 35 patients. RESULTS: Muscle mass assessed by DXA, and phase angle (PhA) were below reference values in all female and 96% of male patients. BISIMPEDIMED underestimated muscle mass by 6.5 ± 14.2 kg (p < 0.001), but this could be corrected after exclusion of resistance (Ri) values > 3500 Ohm (p = 0.84). MFBIATANITA overestimated muscle mass by 30.8 ± 9.1 kg (p < 0.001) with systematic bias, whereas BISXITRON was in agreement with DXA, and without systematic bias. Muscle mass was strongly correlated to PhA (rPEARSON = 0.75, p < 0.01). CONCLUSION: Patients with primary neuromuscular disease have proportionally more fat and less muscle mass than the population in general, despite normal BMI. Muscle mass can be assessed by bioimpedance in these patients, but performance and bias depends on device. Phase angle by bioimpedance correlates to muscle mass, and could therefore potentially be used a surrogate measure of muscle mass during follow up.

Longitudinal changes in phase angle by bioimpedance in intensive care patients differ between survivors and non-survivors.

BACKGROUND & AIMS: Intensive care (ICU) patients suffer from metabolic stress, creating a catabolic state which might disturb nutritional status and body composition. Alterations in body fluid compartments by disease or massive volume resuscitation could invalidate bioimpedance hydrometry. Still bioimpedance might give other information. METHODS: 52 ICU patients (35 male, 17 female, mean age 66 years), BMI 29,2 were assessed by bioimpedance spectroscopy. Phase angle (PhA) at 50 kHz was assessed. RESULTS: On first assessment PhA was 3.7 ± 1.0°. In 26 patients reassessed after median 5 days PhA was not significantly changed, although R 50 kHz and Xc 50 kHz both increased (p = 0.047), indicating diminishing overhydration. Body weight and body cell mass decreased by 1.8 ± 5.7 and 2.8 ± 7.5 kg (p = 0.13). Fat free mass and extracellular water decreased 4.5 ± 8.9 kg (p = 0.032) and 1.5 ± 3.5 kg (p = 0.031), while CRP decreased 63 mg/l (p = 0.002). In 17 survivors PhA increased 0.62 ± 1.24° (NS), while in 9 non-survivors PhA decreased 0.24 ± 0.82° (p = 0.06), with 0.86° difference (p = 0.049) between groups. CONCLUSION: Phase angle by bioimpedance is very low in ICU patients and positive changes in PhA seems to reflect more favorable outcome. Bioimpedance by Body Scout appears unsuitable for the assessment of fat free mass or overhydration in ICU patients.

Vitamin D and vitamin B12 deficiencies are common in patients with midgut carcinoid (SI-NET).

BACKGROUND/OBJECTIVES: Patients with small intestinal neuroendocrine tumours (SI-NET) often have diarrhoea from hormonal overproduction, surgery and medical treatment, leading to malabsorption of bile salts, fats, vitamin B12 and fat-souble vitamins. This could lead to malnutrition. SUBJECTS/METHODS: We assessed nutritional status in 50 consecutive out patients with disseminated SI-NET, 25 patients in each cohort. The first cohort was descriptive and the second cohort supplemented with vitamin D, B12 and calcium. Vitamin D deficiency was defined as <50 nmol/l. All patients were assessed by clinical chemistry and dual-energy X-ray absorptiometry (DXA) and interviewed about weight changes, appetite, gastrointestinal disorders, sunhabits and the use of supplements. RESULTS: In the first cohort, 29% of the patients were severely and 17% moderately vitamin D deficient. In patients without prior substitution, 32% had subnormal vitamin B12 levels. Seventy-six percent had low bone density. In the second cohort with vitamin and mineral supplementation, none had severe vitamin D deficiency, but 28% had moderate deficiency. No patient had subnormal vitamin B12 levels. Sixty percent had low bone density. The serum levels of vitamin D and B12 were higher and parathyroid hormone (PTH) lower in the second cohort compared with the first cohort (P⩽0,022). Vitamin D and PTH were negatively correlated, r=-30, P=⩽0.036. CONCLUSIONS: Low serum levels of vitamin D and vitamin B12, and low bone density are common in patients with disseminated SI-NET. Supplementation of vitamin D, B12 and calcium resulted in higher serum levels of vitamins, lower PTH levels and diminished severe vitamin D deficiency and is thus recommended as standard care.

Body composition in overweight and obese women postpartum: bioimpedance methods validated by dual energy X-ray absorptiometry and doubly labeled water.

BACKGROUND/OBJECTIVES: Obesity, pregnancy and lactation all affect body composition. Simple methods to estimate body composition are useful in clinical practice and to evaluate interventions. In overweight and obese lactating women, such methods are not fully validated. The objective of this study was to validate the accuracy and precision of bioimpedance spectroscopy (BIS) by Xitron 4200 and 8-electrode multifrequency impedance (multifrequency bioimpedance analysis, MFBIA) by Tanita MC180MA with the reference methods dual energy X-ray absorptiometry (DXA) and doubly labeled water (DLW) for the assessment of body composition in 70 overweight and obese women postpartum. SUBJECTS/METHODS: The LEVA-study (Lifestyle for Effective Weight loss during lactation) consisted of an intervention and follow-up with three assessments at 3, 6 and 15 months postpartum, which made possible the validation of both accuracy and precision. Mean differences between methods were tested by a paired t-test and Bland-Altman plots for systematic bias. RESULTS: At baseline, BIS and MFBIA underestimated fat mass (FM) by 2.6±2.8 and 8.0±4.2 kg compared with DXA (P<0.001) but without systematic bias. BIS and MFBIA overestimated total body water (TBW) by 2.4±2.2 and 4.4±3.2 kg (P<0.001) compared with DLW, with slight systematic bias by BIS. BIS correctly estimated muscle mass without systematic bias (P>0.05). BIS overestimated changes in TBW (P=0.01) without systematic bias, whereas MFBIA varied greatly and with systematic bias. CONCLUSIONS: BIS underestimates mean FM compared with DXA but can detect mean changes in body composition, although with large limits of agreement. BIS both accurately and precisely estimates muscle mass in overweight and obese women postpartum. MFBIA underestimates FM and overestimates TBW by proprietary equations compared with DXA and DLW.

Estimation of body fluids with bioimpedance spectroscopy: state of the art methods and proposal of novel methods.

Determination of body fluids is a useful common practice in determination of disease mechanisms and treatments. Bioimpedance spectroscopy (BIS) methods are non-invasive, inexpensive and rapid alternatives to reference methods such as tracer dilution. However, they are indirect and their robustness and validity are unclear. In this article, state of the art methods are reviewed, their drawbacks identified and new methods are proposed. All methods were tested on a clinical database of patients receiving growth hormone replacement therapy. Results indicated that most BIS methods are similarly accurate (e.g. < 0.5 ± 3.0% mean percentage difference for total body water) for estimation of body fluids. A new model for calculation is proposed that performs equally well for all fluid compartments (total body water, extra- and intracellular water). It is suggested that the main source of error in extracellular water estimation is due to anisotropy, in total body water estimation to the uncertainty associated with intracellular resistivity and in determination of intracellular water a combination of both.

Slightly superior performance of bioimpedance spectroscopy over single frequency regression equations for assessment of total body water.

Electrical bioimpedance has been used for several decades to assess body fluid distribution and body composition by using single frequency and bioimpedance spectroscopic (BIS) techniques. It remains uncertain whether BIS methods have better performance compare to single frequency regression equations. In this work the performance of two BIS methods and four different 50 kHz single frequency prediction equations was studied in a data set of wrist-to-ankle tetrapolar BIS measurements (5-1000 kHz) together with reference values of total body water obtained by tritium dilution in 92 patients. Data were compared using regression techniques and Bland-Altman plots. The results of this study showed that all methods produced similarly high correlation and concordance coefficients, indicating good accuracy as a method. Limits of agreement analysis indicated that the population level performance of Sun's prediction equations was very similar to the performance of both BIS methods. However, BIS methods in practice have slightly better predictive performance than the single-frequency equations as judged by higher correlation and the limits of agreement from the Bland-Altman analysis. In any case, the authors believe that an accurate evaluation of performance of the methods cannot be done as long as the evaluation is done using Bland-Altman analysis, the commonly accepted technique for this kind of performance comparisons.

Robustness study of the different immittance spectra and frequency ranges in bioimpedance spectroscopy analysis for assessment of total body composition.

The estimation of body fluids is a useful and common practice for assessment of disease status and therapy outcomes. Electrical bioimpedance spectroscopy (EBIS) methods are noninvasive, inexpensive and efficient alternatives for determination of body fluids. One of the main source of errors in EBIS measurements in the estimation of body fluids is capacitive coupling. In this paper an analysis of capacitive coupling in EBIS measurements was performed and the robustness of the different immittance spectra against it tested. On simulations the conductance (G) spectrum presented the smallest overall error, among all immittance spectra, in the estimation of the impedance parameters used to estimate body fluids. Afterwards the frequency range of 10-500 kHz showed to be the most robust band of the G spectrum. The accuracy of body fluid estimations from the resulting parameters that utilized G spectrum and parameters provided by the measuring device were tested on EBIS clinical measurements from growth hormone replacement therapy patients against estimations performed with dilution methods. Regarding extracellular fluid, the correlation between each EBIS method and dilution was 0.93 with limits of agreement of 1.06 ± 2.95 l for the device, 1.10 ± 2.94 l for G [10-500 kHz] and 1.04 ± 2.94 l for G [5-1000 kHz]. Regarding intracellular fluid, the correlation between dilution and the device was 0.91, same as for G [10-500 kHz] and 0.92 for G [5-1000 kHz]. Limits of agreement were 0.12 ± 4.46 l for the device, 0.09 ± 4.45 for G [10-500 kHz] and 0.04 ± 4.58 for G [5-1000 kHz]. Such close results between the EBIS methods validate the proposed approach of using G spectrum for initial Cole characterization and posterior clinical estimation of body fluids status.

Energy expenditure by multisensor armband in overweight and obese lactating women validated by doubly labeled water.

OBJECTIVE: To validate total energy expenditure (TEE) and activity energy expenditure (AEE) from the portable SenseWear armband (SWA) Pro 2 (TEESWA and AEESWA ; InnerView software versions SWA 5.1 and SWA 6.1) against TEE from doubly labeled water (DLW) and AEE from DLW and indirect calorimetry (TEEDLW and AEEDLW ) in overweight/obese lactating women at 10 weeks postpartum. DESIGN AND METHODS: TEE was measured simultaneously with DLW (14 days) and SWA (first 7 days). Lactating women (n = 62), non-smoking, with a BMI > 25 kg/m(2) and wearing time SWA ≥ 90% were included. RESULTS: Mean TEESWA5.1 was overestimated with 85 kcal/day compared to TEEDLW (P = 0.040), while mean TEESWA6.1 was underestimated with 241 kcal/day compared to TEEDLW (P < 0.001). Mean AEESWA5.1 was similar to mean AEEDLW (P = 0.818), while mean AEESWA6.1 was underestimated with 581 kcal/day compared to AEEDLW (P < 0.001). TEESWA6.1 and AEESWA6.1 were systematically underestimated at higher levels of energy expenditure and BMI while only AEESWA5.1 was systematically overestimated at higher levels of energy expenditure. CONCLUSIONS: TEESWA5.1 and AEESWA5.1 were fairly estimated on a group level while TEESWA6.1 and AEESWA6.1 were significantly and systematically underestimated. Both SWA software versions showed large individual variation in agreement with TEEDLW and AEEDLW , limiting the validity on individual level.

High prevalence of vitamin D deficiency and osteoporosis in out-patients with intestinal failure.

BACKGROUND: In intestinal failure, specific nutrient deficiencies especially for fat-soluble vitamins can be expected in addition to energy-protein malnutrition. We report serum levels of fat soluble vitamins, and bone density in out-patients with intestinal failure (IF). METHODS: 106 outpatients with IF were assessed during routine visits. 78 patients underwent DXA-scan for bone density. Vitamin D levels < 50 nmol/l were defined as deficiency, and 75-150 as optimal. Vitamin A and E deficiencies were defined as <1.0 and <14 µmol/l respectively. INR ≥ 1.2 without liver disease or anti-vitamin K therapy was classified as vitamin K deficiency. RESULTS: Mean serum vitamin D level was 45 nmol/l at first visit, and 64 nmol/l at follow up (n = 76, p = 0.0001 by paired t-test). Overall prevalence of vitamin D deficiency was 67%. Only 12% of all patients had optimal D-vitamin status. 88% of assessed patients had low bone density. 12% had subnormal vitamin A levels and 25% had subnormal vitamin E levels. 32% had abnormal INR values. At follow up 34% remained vitamin D deficient whereas 29% had optimal levels. By oral substitution, vitamin A and E status were normalised, and K status improved. CONCLUSION: Vitamin D deficiency and osteoporosis are common in outpatients with intestinal failure, and should be adequately substituted.

Bioelectric impedance spectroscopy underestimates fat-free mass compared to dual energy X-ray absorptiometry in incurable cancer patients.

BACKGROUND/OBJECTIVES: Weight loss is frequently seen in advanced cancer. Bioelectrical impedance spectroscopy (BIS) is a convenient method for estimating body composition. We examined in a prospective, comparative study if BIS could accurately estimate fat-free mass (FFM) in cancer patients compared to dual-energy X-ray absorptiometry (DXA). SUBJECTS/METHODS: The study was based on 132 consecutive incurable cancer patients with solid tumours in a University hospital outpatient clinic. Comparison of FFM from DXA and BIS with standard and revised equations. Bland-Altman plots, t-tests and linear regression analysis were used to evaluate agreement and differences between methods. RESULTS: BIS significantly underestimated mean FFM with 7.6+/-4.7 kg compared to DXA (P<0.001). Bias was significantly correlated to % weight loss (r=0.32), systemic inflammation as measured by C-reactive protein (r=0.29), malnutrition as assessed by low insulin-like growth factor-1 (r=-0.23) and inversely to the per cent body fat estimated by DXA (P=-0.61) and body mass index (BMI; r=-0.30). Revised BIS equations taking BMI into account reduced bias significantly but still with great individual variation. CONCLUSIONS: BIS by standard equations grossly underestimates FFM compared to DXA in cancer patients. This bias is related to weight loss, malnutrition and systemic inflammation. Revised equations improved FFM estimates, but with large individual variation. Thus, BIS with standard equations is not suitable to estimate FFM in patients with cachexia, inflammation and malnutrition.

Biochemical indices to evaluate nutritional support for malignant disease.

Malignant diseases are often complicated by malnutrition, and nutritional support is often indicated. Nutritional support should be evaluated primarily by improved clinical outcome. During nutritional support as artificial nutrition, monitoring is of paramount importance. Several biochemical markers are frequently used to monitor nutritional status. Most widely used are serum levels of albumin, transferrin, and transthyretin which are subnormal in malnutrition. Unfortunately, monitoring nutritional support by biochemical indices in malignant disease is complicated by the pathophysiology of cancer related malnutrition. Systemic inflammation is central in this context as it perturbs most of the traditional biochemical indices, and is inversely correlated to survival. In addition, systemic inflammation explains variations in body composition. Thus, the most important biochemical index to be measured in malignant disease is the assessment of systemic inflammatory response, preferably by high-resolution CRP, and if normal, common biochemical indices such as albumin, transferrin or transthyretin might be used. Preferentially, indices with high turnover should be used. IGF-1 is an index well suited for assessing nutrition support in conventional malnutrition, but its use in malignant disease is still unproved. If APPR is prevalent, methods detecting changes in body composition, performance or physical activity might offer better options to evaluate nutritional support.

Food sources of plant sterols in the EPIC Norfolk population.

OBJECTIVE: To investigate the intake of plant sterols and identify major dietary sources of plant sterols in the British diet. SUBJECTS: A total of 24 798 men and women recruited during 1993-1997, participating in the European Prospective Investigation into Cancer (EPIC-Norfolk). INTERVENTIONS: A database of the plant sterol (campesterol, beta-sitosterol, stigmasterol, campestanol and beta-sitostanol) content in foods, based on gas-liquid chromatography (GLC) analyses, was linked to nutritional intake data from food frequency questionnaires in the EPIC-Norfolk population. RESULTS: The mean (s.d.) intake of total plant sterols was 300 (108) mg/d for men and 293 (100) mg/d for women. Bread and other cereals, vegetables and added fats were the three major food sources of plant sterols representing 18.6 (8.9), 18.4 (8.5) and 17.3 (10.4)% of the total plant sterol intake respectively. Women had a higher plant sterol density than men (36.4 vs 32.8 mg/1000 kJ, P<0.001) and in relation to energy intake higher intakes of plant sterols from vegetables, bread and other cereals, added fats, fruits and mixed dishes (all P<0.001), whilst men had higher intakes of plant sterols from cakes, scones and chocolate, potatoes (all P<0.001) and other foods (P<0.01). CONCLUSIONS: The intake of plant sterols in UK, mainly from bread, cereals, fats and vegetables, is much higher than previously reported but comparable to recent European studies.

Oat bran rapidly increases bile acid excretion and bile acid synthesis: an ileostomy study.

OBJECTIVE: To study whether oat bran with native beta-glucans increases bile acid excretion and bile acid synthesis as measured by serum concentrations of 7alpha-hydroxy-4-cholesten-3-one (7alpha-HC). DESIGN: Short-term interventional crossover study evaluating cholesterol absorption, ileal excretion of cholesterol and bile acids, and serum levels of cholesterol and bile acid metabolites. Differences between diets evaluated with Wilcoxon's signed rank-sum test. SETTING: Outpatients at a metabolic-ward kitchen. SUBJECTS: Nine volunteers with conventional ileostomies. METHODS: Two 3-day-diet periods, with controlled, blinded basal diet including 75 g extruded oat bran breakfast cereal daily, with either 11.6 g native or hydrolysed beta-glucans. RESULTS: Native oat bran increased median excretion of bile acids by 144% (P=0.008). Cholesterol excretion remained unchanged, cholesterol absorption decreased by 19% (P=0.013), whereas the sum of bile acid and cholesterol excretion increased by 40% (P=0.008) compared with hydrolysed oat bran. 7alpha-HC reflecting bile acid synthesis increased by 57% (P=0.008) within 24 h of consumption, whereas serum lathosterol concentration reflecting cholesterol synthesis increased by 12% (P=0.015). CONCLUSIONS: Oat bran with native beta-glucans increases bile acid excretion within 24 h of consumption and this increase can also be detected by rising serum concentrations of 7alpha-HC. Thus, 7alpha-HC could be used for rapid detection of dietary effects on bile acid metabolism. These effects could possibly be explained by entrapment of whole micelles in the gut owing to higher viscosity.

Phytosterol and phytostanol esters are effectively hydrolysed in the gut and do not affect fat digestion in ileostomy subjects.

BACKGROUND: Hydrolysis of phytosterol ester (PSTE) and phytostanol ester (PSTA) during fat digestion is not well characterised under controlled dietary conditions. AIMS: The main aims of this study were therefore to quantify the PSTE and PSTA hydrolysis after gut passage and to assess whether or not PSTE and PSTA induce fat malabsorption by measuring the fatty acid excretion following PSTE/PSTA consumption. METHODS: Ileostomy subjects (n = 7) were investigated in a randomised crossover study with one control and two intervention periods, when either 2.5 g of PSTE or PSTA corresponding to 1.5 g free sterol or stanol equivalents were added to a controlled diet. Ileostomy bags were collected and immediately frozen for analysis of nutrients, fatty acids and sterols. RESULTS: The study showed that 88.4 +/- 5.9% PSTE and 85.7 +/- 6.5% PSTA were hydrolysed following small bowel passage in the ileostomy subjects. The total excretion of fatty acids was similar in all three periods. CONCLUSIONS: A majority of the 2.5 g PSTE and PSTA was hydrolysed during small bowel passage,which did not affect fat absorption as indicated by similar excretions of fatty acids in all periods. Consumption of increasing amounts of esterified phytosterols and phytostanols from enriched food formats should thereby have no adverse effects in this regard.

Rapeseed oil, olive oil, plant sterols, and cholesterol metabolism: an ileostomy study.

OBJECTIVE: To study whether olive oil and rapeseed oil have different effects on cholesterol metabolism. DESIGN: Short-term experimental study, with controlled diets. SETTING: Outpatients at a metabolic-ward kitchen. SUBJECTS: A total of nine volunteers with conventional ileostomies. INTERVENTIONS: Two 3-day diet periods; controlled diet including 75 g of rapeseed oil or olive oil. MAIN OUTCOME MEASURES: Cholesterol absorption, ileal excretion of cholesterol, and bile acids. Serum levels of cholesterol and bile acid metabolites. Differences between diets evaluated with Wilcoxon's signed rank sum test. RESULTS: Rapeseed oil diet contained 326 mg more plant sterols than the olive oil diet. Rapeseed oil tended to decrease cholesterol absorption by 11% (P = 0.050), and increased excretion of cholesterol, bile acids, and their sum as sterols by 9% (P = 0.021), 32% (P = 0.038), and 51% (P = 0.011) compared to olive oil. A serum marker for bile acid synthesis (7alpha-hydroxy-4-cholesten-3-one) increased by 28% (P = 0.038) within 10 h of consumption, and serum cholesterol levels decreased by 7% (P = 0.024), whereas a serum marker for cholesterol synthesis (lathosterol) as well as serum levels of plant sterols remained unchanged. CONCLUSIONS: Rapeseed oil and olive oil have different effects on cholesterol metabolism. Rapeseed oil, tends to decrease cholesterol absorption, increases excretion of cholesterol and bile acids, increases serum marker of bile acid synthesis, and decreases serum levels of cholesterol compared to olive oil. This could in part be explained by different concentrations of natural plant sterols. SPONSORSHIP: Supported by the Göteborg Medical Society, the Swedish Medical Society, the Swedish Board for Agricultural Research (SJFR) grant 50.0444/98 and by University of Göteborg.

High serum phytosterol levels in short bowel patients on parenteral nutrition support.

BACKGROUND & AIMS: Patients with short bowel syndrome (SBS) are often depending on parenteral nutrition support (PNS), sometimes complicated by liver dysfunction. Phytosterols in parenteral lipid emulsions have been suspected to be responsible for cholestasis in paediatric nutrition support. The aim of the present study was to evaluate phytosterol intake and serum phytosterol levels in adult SBS patients. METHODS: We quantified serum levels of phytosterols, cholesterol, and markers for bile acid and cholesterol synthesis, by gas or liquid chromatography in 21 healthy controls, and in 24 adult SBS-patients, 8 with and 16 without PNS. Phytosterols and cholesterol in parenteral lipid emulsions were also quantified. RESULTS: Serum levels in SBS-patients without PNS; with PNS; and in controls, were on average for phytosterols 11; 63; and 23 micromol/l (P<0.05 for differences), cholesterol 4,2; 3,8; and 5,1 mmol/l, lathosterol 808; 824; and 228 micromol/100 mmol cholesterol, and 7alpha-hydroxy-4-cholesten-3-one 207;191; and 18 nmol/l, respectively (P<0.05 between controls and SBS). Phytosterols in lipid emulsions ranged from 591 to 958 micromol/l. CONCLUSIONS: SBS-patients on PNS have higher serum levels of phytosterols than other SBS-patients and controls, possibly because of phytosterols in lipid emulsions. Patients with SBS, regardless of nutrition support, have lower serum levels of cholesterol but higher cholesterol and bile acid synthesis compared to controls.

Intake of dietary plant sterols is inversely related to serum cholesterol concentration in men and women in the EPIC Norfolk population: a cross-sectional study.

OBJECTIVE: We examined the relation between intake of natural dietary plant sterols and serum lipid concentrations in a free-living population. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional population-based study of 22,256 men and women aged 39-79 y resident in Norfolk, UK, participating in the European Prospective Investigation into Cancer (EPIC-Norfolk). MAIN EXPOSURE AND OUTCOME MEASURES: Plant sterol intake from foods and concentrations of blood lipids. RESULTS: Mean concentrations of total cholesterol and low-density lipoprotein cholesterol, adjusted for age, body mass index and total energy intake, decreased with increasing plant sterol intake in men and women. Mean total serum cholesterol concentration for men in the highest fifth of plant sterol intake (mean intake 463 mg daily) was 0.25 mmol/l lower and for low-density lipoprotein cholesterol 0.14 mmol/l lower than those in the lowest fifth of plant sterol consumption (mean intake 178 mg daily); the corresponding figures in women were 0.15 and 0.13 mmol/l. After adjusting for saturated fat and fibre intakes, the results for total cholesterol and low-density lipoprotein cholesterol were similar, although the strength of the association was slightly reduced. CONCLUSIONS: In a free-living population, a high intake of plant sterols is inversely associated with lower concentrations of total and low-density lipoprotein serum cholesterol. The plant sterol content of foods may partly explain diet-related effects on serum cholesterol concentration.

Energy intake in Swedish adolescents: validation of diet history with doubly labelled water.

OBJECTIVE: To compare habitual energy intake (EI) estimated from diet history (DH) with total energy expenditure (TEE) measured with doubly labelled water (DLW) in adolescents. DESIGN: DH included a detailed questionnaire and an interview. TEE was measured during a 14-day period. Adequate (AR), under- (UR) and over-reporters (OR) were defined from the ratio EI/TEE: AR 0.84-1.16, UR <0.84 and OR >1.16. SETTING: Participants were recruited from grade 9 in a compulsory school in Göteborg, Sweden. All data were collected at school and DLW dosages were distributed at Sahlgrenska University Hospital. SUBJECTS: A total of 35 adolescents (18 boys, 17 girls), 15.7 (0.4) y. RESULTS: EI was 11.0 (3.6) MJ and TEE was 11.4 (2.1) MJ (P=0.42). DH was able to rank EI compared to TEE (Spearman's r=0.59, P< or =0.001). For girls, EI was 18% lower (P=0.0067) and for boys, EI was 7% higher (P=0.26) compared to TEE. The 95% limits of agreement for difference between TEE and EI were -5.6 to 6.5 MJ. In total, 20 subjects were defined as AR (57%), nine as UR (26%) and six as OR (17%). Energy from in-between meals was 33% lower (P=0.0043) in UR girls and 57% higher (P=0.026) in OR boys, compared to adequate reporting girls and boys, respectively. In UR girls, energy-adjusted intake (10 MJ) of specific foods did not differ significantly, fat was lower and carbohydrate and vitamin C were higher compared to AR girls (all P<0.05). OR boys had no significant differences in food and nutrient intake in 10 MJ compared to AR boys. CONCLUSION: The diet history was able to capture EI for the group and to rank subjects. There was a wide individual range in reporting-accuracy related to gender. SPONSORSHIP: The Ingabritt and Arne Lundberg Foundation, The Wilhelm and Martina Lundgren Foundation.

Total energy expenditure in underweight patients with severe chronic obstructive pulmonary disease living at home.

AIM: The aim of the study was to assess total daily energy expenditure (TDE), as measured by doubly labelled water (DLW), and describe its components in home-living underweight patients with severe chronic obstructive pulmonary disease (COPD). METHODS: Basal metabolic rate (BMR) was measured prior to the study. Ten patients received DLW, followed by urine analysis by isotope ratio mass spectrometry from 10 standardised occasions during 15 days. Dietary intake was registered by each patient the first 7 days of the study. The patients were also interviewed about their physical activity pattern. RESULTS: Measured BMR was higher than predicted in five of the 10 patients using equations from WHO. Using disease-specific equations, estimated BMR was higher for male, but not for female COPD patients. The best estimation of BMR resulted from prediction including fat-free mass. TDE varied considerably between 5200 and 11,100 kJ. Physical activity level (PAL) ranged from 1.15 to 1.80. Energy intake varied between 4500 and 9100 kJ. In underweight patients with severe COPD, TDE is highly variable, ranging from 110 to 200 kJ/kg body weight. CONCLUSIONS: This is the first study assessing and describing total energy expenditure in underweight patients with severe COPD living at home. Energy requirement in the patient group cannot solely be calculated from prediction equations. BMR should be measured and physical activity level assessed.