[Confounding in nutritional epidemiology; is Mendelian randomization the answer?] / Het probleem met de voedingsepidemiologie.

Observational studies have reported many beneficial effects of vitamin and mineral supplements on cardiovascular and other diseases, but randomized controlled trials have failed to confirm these. This could be due to the failure of statistical adjustment to eliminate residual and unmeasured confounding by known risk factors. A Mendelian randomization study now suggests a similar problem for the observed beneficial effects of moderate alcohol intake. When 500,000 Chinese people were ranked by self-reported alcohol intake, stroke risk showed a U-shaped curve, risk being lowest at 1-2 units per day. However, when subjects were ranked by genetically conditioned intake, risk was lowest in abstainers and went up linearly with intake. Mendelian randomization may be more suitable for elucidating the effects of diet on health than conventional epidemiology.

[City hall holds the key to weight control]. / De sleutel tot vetzucht ligt op het stadhuis.

Doctors can play a major role in reducing obesity in the community, but that requires an unconventional approach. Treatment of individual patients with diet or drugs is largely ineffective. In contrast, comprehensive community interventions such as one pioneered by EPODE in France have successfully reduced the prevalence of corpulence in children. Such a community approach requires simultaneously engagement by town governments, retailers, associations, restaurants, caterers, media, schools and kindergartens to cooperate in improving diets, reducing caloric intake and increasing activity. Physicians are by far the most highly trusted source of information when it comes to health matters. Therefore, a few words from a doctor at the right time and in the right place, e.g. at a city council meeting, could tip the scales. Individual doctors cannot cure patients' obesity by themselves in their offices, but a few hours per year spent on persuading key stakeholders might help to turn the tide on obesity in the community.

[Fish oil in pregnancy: can it prevent asthma in children?] / Visolie tijdens de zwangerschap.

Taking fish oil supplements in the third trimester of pregnancy was associated with significantly less wheezing or asthma in the child at the age of 3-5 years, according to a randomized clinical trial by Bisgaard et al., NEJM 2017. However, the results of this study should be interpreted with caution. The primary end points were modified at a late stage in the study, and two primary end points, eczema in the first 3 years of life and allergic sensitization at 18 months of age, were demoted to secondary end points, and showed no significant effect of treatment. Furthermore, the age range for the published primary end point, persistent wheeze, differed from that in the protocol. Additional concerns include the emphasis on outcomes by omega-3 fatty acid levels in the blood, a post hoc subgroup analysis not included in the protocol. In our opinion, this study does not justify advising routine fish oil supplements in pregnancy.

Trans fatty acids and cardiovascular health: research completed?

This review asks the question if further research on trans fatty acids and cardiovascular health is needed. We therefore review the evidence from human studies on trans fatty acids and cardiovascular health, and provide a quantitative review of effects of trans fatty acid intake on lipoproteins. The results show that the effect of industrially produced trans fatty acids on heart health seen in observational studies is larger than predicted from changes in lipoprotein concentrations. There is debate on the effect of ruminant trans fatty acids and cardiovascular disease. Of special interest is conjugated linoleic acid (CLA), which is produced industrially for sale as supplements. Observational studies do not show higher risks of cardiovascular disease with higher intakes of ruminant trans fatty acids. However, CLA, industrial and ruminant trans fatty acids all raise plasma low-density lipoprotein and the total to high-density lipoprotein ratio. Gram for gram, all trans fatty acids have largely the same effect on blood lipoproteins. In conclusion, the detrimental effects of industrial trans fatty acids on heart health are beyond dispute. The exact size of effect will remain hard to determine. Further research is warranted on the effects of ruminant trans fatty acids and CLA on cardiovascular disease and its risk factors.

Why the European Food Safety Authority was right to reject health claims for probiotics.

Probiotics are microbes that are claimed to promote health and well-being when added to foods. However, the European Food Safety Authority (EFSA) has so far advised negatively about health claims for probiotics. Companies and scientists have protested against these rejections, sometimes in vigorous language. I argue that EFSA could not have acted differently, given EU regulations and the lack of convincing evidence for some of the claimed effects of probiotics on human health and well-being. One EU regulation that makes it hard to demonstrate the benefits of probiotics is the prohibition of medical claims, i.e. claims that a food prevents or cures a disease. If this prohibition did not exist, manufacturers of nutritional treatments might circumvent the costly procedures required for drugs, and market their products to ill people without thorough proof that they are effective and safe. However, the prohibition is also a legal fiction, because promotion of health and prevention of disease is largely the same thing. EFSA has recently indicated that it will allow health claims based on the ability of probiotics to reduce infections. To a certain extent, this abolishes the distinction between health claims and medical claims. It remains to be seen if probiotics producers can convince EFSA that their products prevent or cure infections and other diseases in humans.

Absorption, distribution, and biliary excretion of cafestol, a potent cholesterol-elevating compound in unfiltered coffees, in mice.

Cafestol is a diterpene present in unfiltered coffees. It is the most potent cholesterol-elevating compound present in the human diet. However, the precise mechanisms underlying this effect are still unclear. In contrast, cafestol is also known as a hepatoprotective compound, which is likely to be related to the induction of glutathione biosynthesis and conjugation. In the present study, we investigated whole-body distribution, biliary excretion, and portal bioavailability of cafestol in mice. First, dissection was used to study distribution. Five hours after an oral dose with (3)H-labeled cafestol, most activity was found in small intestine, liver, and bile. These results were confirmed by quantitative whole-body autoradiography in a time course study, which also showed elimination of all radioactivity within 48 h after administration. Next, radiolabeled cafestol was dosed intravenously to bile duct-cannulated mice. Five hours after the dose 20% of the radioactivity was found in bile. Bile contained several metabolites but no parent compound. After intestinal administration of radioactive cafestol to portal vein-cannulated mice, cafestol was shown to be rapidly absorbed into the portal vein as the parent compound, a glucuronide, and an unidentified metabolite. From the presence of a glucuronide in bile that can be deconjugated by a bacterial enzyme and the prolonged absorption of parent compound from the gastrointestinal tract, we hypothesized that cafestol undergoes enterohepatic cycling. Together with our earlier observation that epoxidation of the furan ring occurs in liver, these findings merit further research on the process of accumulation of this coffee ingredient in liver and intestinal tract.

A high intake of conjugated linoleic acid does not affect liver and kidney function tests in healthy human subjects.

Conjugated linoleic acid (CLA) is consumed widely as a supplement. It causes hepatomegaly in animals, but toxicological data in humans are limited. We therefore studied the effect of a high daily intake of CLA on liver and kidney function in healthy subjects. Twenty subjects received 14.6 g cis-9,trans-11 CLA and 4.7 g trans-10,cis-12 CLA isomers a day for 3 weeks. Liver and kidney function was measured at 0, 3, 7, 10, 16, and 21 days. Mean values of all tests remained within normal limits. Lactate dehydrogenase (mean+/-SD) increased from 290.9+/-43.6 to 322.5+/-60.7 U/L (p=0.04) on day 21. One subject exceeded the upper limit of normal of 450 U/L on day 21, to 472 U/L and another showed an isolated elevation to 555 U/L on day 7. Gamma-glutamyltranspeptidase increased from 12.1+/-5.9 to 13.5+/-6.2U/L (p=0.002). No one exceeded the upper limit of 50 U/L for men and 40 U/L for women. A daily intake of 19.3 g CLA for 3 weeks does not produce clinically relevant effects on markers of liver and kidney function in healthy volunteers.

Which are the greatest recent discoveries and the greatest future challenges in nutrition?

BACKGROUND: Nutrition science aims to create new knowledge, but scientists rarely sit back to reflect on what nutrition research has achieved in recent decades. METHODS: We report the outcome of a 1-day symposium at which the audience was asked to vote on the greatest discoveries in nutrition since 1976 and on the greatest challenges for the coming 30 years. Most of the 128 participants were Dutch scientists working in nutrition or related biomedical and public health fields. Candidate discoveries and challenges were nominated by five invited speakers and by members of the audience. Ballot forms were then prepared on which participants selected one discovery and one challenge. RESULTS: A total of 15 discoveries and 14 challenges were nominated. The audience elected Folic acid prevents birth defects as the greatest discovery in nutrition science since 1976. Controlling obesity and insulin resistance through activity and diet was elected as the greatest challenge for the coming 30 years. This selection was probably biased by the interests and knowledge of the speakers and the audience. For the present review, we therefore added 12 discoveries from the period 1976 to 2006 that we judged worthy of consideration, but that had not been nominated at the meeting. CONCLUSIONS: The meeting did not represent an objective selection process, but it did demonstrate that the past 30 years have yielded major new discoveries in nutrition and health.

[The role of diet in the development of type 2 diabetes mellitus: calories play the leading role]. / De rol van voeding bij het ontstaan van diabetes mellitus type 2: calorieën in de hoofdrol.

Diets high in saturated fat, trans fat and glycaemic load and low in fibre and polyunsaturated fat are associated with a 25 to 50% increase in the risk of type 2 diabetes. However, obesity increases this risk by 500 to 1000%. Effects ascribed to dietary composition might therefore be due to unmeasured effects of body size. In clinical trials, a weight loss of 3-5 kg plus twice to min of walking per day reduced the incidence of diabetes by 58%. The size of this effect is remarkable. It points to the solution to the diabetes epidemic, which is to reconstruct cities so as to make people eat less and move more. There is an analogy here with the cholera epidemics, which also could be solved only by changing the urban environment.

[Fish fatty acids and cardiovascular diseases--an update]. / Visvetzuren en hart-en vaatziekten--een update.

Epidemiologic observational research shows that higher intake of fish fatty acids is associated with a lower risk of fatal heart disease and sudden death, but this effect is not observed with non-fatal heart disease. Currently available trials with clinical endpoints provide no convincing evidence that supplementation with fish oil prevents cardiovascular disease. The theory that fish fatty acids can prevent cardiac arrhythmias is not supported by the trials performed in patients with life-threatening cardiac arrhythmias. For the specific group of patients who have previously experienced a ventricular tachycardia and who have not been prescribed an anti-arrhythmia medication for this, there are indications that the intake of fish oil might even lead to a slightly increased risk ofsevere cardiac arrhythmias. However, other subgroups of patients, such as patients with a recent myocardial infarction may benefit from taking fish oil to prevent cardiac arrhythmias. The advice of the Health Council of the Netherlands to eat fish twice per week, of which fatty fish once per week, or to take 450 mg of the combination eicosapentaenic acid (EPA) and docosahexaenic acid (DHA) per day remains justifiable until the results from current studies become available. However, patients with a ventricular arrhythmia who do not receive specific anti-arrhythmic medication should be careful about taking fish oil capsules.

[The probiotic yogurt Activia shortens intestinal transit, but has not been shown to promote defecation]. / De probiotische yoghurt Activia: versnelde darmpassage wel aangetoond, maar bevordering van de stoelgang niet.

Activia is a yogurt product containing the probiotic bacterium Bifidobacterium animalis DN-173 010. Five clinical trials have been carried out. Four of these show that dairy products containing this bacterium shorten intestinal transit in volunteers. However, except in a subgroup of 19 out of 267 patients in one study, no significant effect of Activia was reported on the frequency, quantity or consistency of stools. In its marketing in the Netherlands, the company that produces Activia, Danone, claims that Activia promotes defecation. There is insufficient scientific evidence to support this claim.

[Elimination of all trans fatty acids]. / Alle transvetzuren de wereld uit.

At the start of the 20th century, the production of trans fatty acids was originally largely driven by the increasing demand for margarine. The two Dutch margarine firms Van den Bergh and Jurgens played an important role in this early development. In the early 1990s it was shown that trans fatty acids increase the risk of heart disease. Unilever, the successor to Van den Bergh and Jurgens, then took the lead in eliminating trans fatty acids from retail foods worldwide. As a result, intake in The Netherlands fell from 15 g per day in 1980 to 3 g per day in 2003. Dairy products and meat are now the major source of trans fatty acids. The effects on health of these ruminant trans fatty acids are unclear. There are three lessons to be learned from the rise and fall of trans fatty acids. First, a history of safe use does not guarantee safety of food components, because routine surveillance will fail to detect adverse effects on common illnesses with long incubation periods. Second, it shows that it is more effective and easier to change the composition of foods than to change consumer behaviour. And third, governments can have a major impact on consumers' health by mandating the use of healthier food ingredients.

[Alcohol should not be recommended for the prevention of heart disease]. / Alcohol geen goed middel om een hartinfarct te voorkomen.

Encouraging teetotallers to drink may reduce the risk of heart disease, but it is not likely to improve public health. The reason is that even one drink a day increases the risk of breast cancer, and alcohol causes serious non-fatal diseases that exceed the reduction in heart disease. Other lifestyle and drug interventions are safer and more effective.

[Uncertain effects of folic acid on disorders other than neural-tube defects]. / Onzekere effecten van foliumzuur op andere aandoeningen dan neuraalbuisdefecten.

Periconceptional supplemention with folic acid prevents neural-tube defects in infants. However, contrary to expectations, clinical trials found no beneficial effect of folic acid on the recurrence of cardiovascular disease. Trial evidence on folic acid and cognitive decline or dementia is scarce, though observational studies suggest that high folate intake may prevent these disorders. In contrast, animal studies suggest that high doses of folic acid enhance the growth of existing tumours. However, recent clinical trials failed to show significant effects of folic acid on cancer incidence and mortality. There are also speculations that folic-acid fortification may increase the number of newborns with the thermolabile variant of methylene tetrahydrofolate reductase. There appears to be little evidence that folic-acid supplementation may mask vitamin-B12 deficiency. In view of these controversies, it is unlikely that The Netherlands will mandate folic-acid fortification of staple foods in the near future. Therefore, women who are planning a pregnancy should be urged to take folic-acid supplements.

[Negligible amounts of cholesterol-raising diterpenes in coffee made with coffee pads in comparison with unfiltered coffee]. / Verwaarloosbare hoeveelheden cholesterolverhogende diterpenen in koffie gezet met de koffiepadzetmethode bij vergelijking met ongefilterde kookkoffie.

OBJECTIVE: To determine the amounts of the serum-cholesterol raising diterpenes cafestol and kahweol in coffee made with coffee pads and the Senseo coffee machine as opposed to filtered and unfiltered coffee. DESIGN: Observational. METHOD: In five cities in the Netherlands coffee was purchased in three major supermarkets resulting in a total of 30 samples of coffee pads. The levels of cafestol and kahweol were determined by gas chromatography. As controls, the diterpene levels in filtered and unfiltered coffee were also measured. RESULTS: Coffee prepared using coffee pads contained on average 0.76 mg/l cafestol (95% CI: 0.69-0.82) and 0.85 mg/l kahweol (95% CI: 0.77-0.94). Filtered coffee contained 0.76 mg/l cafestol (95% CI: 0.63-0.88) and 0.81 mg/l kahweol (95% CI: 0.63-0.99). Unfiltered coffee contained 72.5 mg/l cafestol (95% CI: 48.5-96.4) and 71.5 mg/l kahweol (95% CI: 45.0-98.1). CONCLUSION: Coffee prepared using coffee pads and the Senseo coffee machine contained minute levels of diterpenes comparable to those of filtered coffee. Its effect on serum-cholesterol levels is therefore likely to be negligible.

[How much vitamin B6 is toxic?]. / Hoeveel vitamine B6 is toxisch?

Vitamin B6 (pyridoxine) causes neuropathy at intakes of 1000 mg per day or more, which is about 800 times the daily intake from foods. There have also been occasional reports of toxicity at intakes of 100-300 mg per day. The US authorities set the no-observed-adverse-effect-level at 200 mg per day and the safe upper limit at 100 mg per day. A report of neurotoxicity in 2 patients who had taken 24 mg and 40 mg of vitamin B6 per day respectively, may be coincidence rather than a true toxic effect of such relatively low doses. However, physicians need to remain alert to high intakes of vitamin B6 as a cause of unexplained neuropathy.

[Cost of foods fortified with plant sterols refunded by a health insurance company]. / Halvarine met plantensterolen van de verzekering.

The Dutch health insurance company VGZ recently decided to refund part of the cost of using spread, yogurt and milk fortified with plant sterols. Plant sterols lower plasma cholesterol concentrations but they do so less effectively than statins. For health insurance companies wishing to improve the health of their clients, it would be more logical to reimburse costs of folic acid supplements for the prevention of neural tube defects, and vitamin-D-enriched products to prevent fractures in elderly people.

Differential gene expression in rat colon by dietary heme and calcium.

Dietary heme and calcium are alleged modulators of colon cancer risk. Little is known about the molecular and cellular changes in the colon epithelium that are induced by consumption of these unabsorbed nutrients. In this nutrigenomics study, we fed rats high- and low-calcium diets with or without heme. In agreement with previous studies, we found that dietary heme increased the cytotoxicity of fecal water in the colon and elevated epithelial proliferation, a risk factor in colon carcinogenesis. Calcium reduced cytotoxicity and inhibits heme-induced effects. Among 365 colon-expressed genes, we could identify 10 diet-modulated genes that show >2-fold altered expression, of which several are related to colon cell turnover and disease. Mucosal pentraxin (Mptx) was the strongest differentially expressed gene, approximately 10-fold down-regulated by dietary heme and 3-fold up-regulated by calcium. cDNA microarray and quantitative PCR analysis show that calcium significantly inhibits the effects of heme, which correlates with the physiological effects. Our results indicate that Mptx expression is related to colonic cell turnover, and that Mptx might be a marker for diet-modulated mucosal integrity. We also show that Mptx expression is restricted to the intestine, and occurs predominantly in the colon.