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The clinical effectiveness of bariatric surgery has encouraged the use of bariatric procedures for the treatment of morbid obesity and its comorbidities, with sleeve gastrectomy and Roux-en-Y gastric bypass being the most common procedures. Notwithstanding its success, bariatric procedures are recognised to predispose the development of nutritional deficiencies. A framework is proposed that provides clarity regarding the immediate role of diet, the gastrointestinal tract and the medical state of the patient in the development of nutritional deficiencies after bariatric surgery, while highlighting different enabling resources that may contribute. Untreated, these nutritional deficiencies can progress in the short term into haematological, muscular and neurological complications and in the long term into skeletal complications. In this review, we explore the development of nutritional deficiencies after bariatric surgery through a newly developed conceptual framework. An in-depth understanding will enable the optimisation of the post-operative follow-up, including detecting clinical signs of complications, screening for laboratory abnormalities and treating nutritional deficiencies.
This study aimed to explore the facilitators and barriers to healthy dietary behaviour in adults with type 2 diabetes mellitus (T2DM) in Kenya.
A qualitative descriptive design using telephone interviews was applied. An interview guide was developed through a modified theoretical framework.
This study was conducted in selected hospitals in Nakuru County, located in west-central Kenya.
A two-step sampling strategy was used to select hospitals and study participants. Adult participants aged 30 to 85 years, with T2DM from six hospitals were selected based on their ability to openly elaborate on the theme of dietary behaviour.
Thirty respondents were interviewed (mean age 62 years; 43·3 % females). The average duration of the interviews was 32:02 min (sd 17·07). The highest-ranking internal facilitators of healthy dietary behaviour were knowledge of healthy food choices, gardening, self-efficacy, food preparation skills and eating at home. External facilitators included inaccurate beliefs and information on food and diet, education by healthcare workers, food availability, proximity to food selling points and family support. Internal barriers included tastes and preferences, health conditions barring intake of certain foods, and random eating of unhealthy foods. External barriers included socio-economic factors, seasonal unavailability of fruits and food safety concerns.
Facilitators and barriers to healthy dietary behaviour among Kenyan adults with T2DM are related to food literacy and include selection, preparation and eating. Interventions to enhance healthy dietary behaviour should target context-specific knowledge, skills and self-efficacy.
To explore determinants of dietary and physical activity behaviours among women of reproductive age.
Data were collected through focus group discussions (FGD). The FGD guide was based on a modified theoretical framework; theory of planned behaviour was incorporated with constructs of health belief model, precaution adoption process model, social cognitive and social support theory. Discussions were audio recorded, transcribed verbatim and analysed thematically.
Women were categorised into young adults; 18–34 years and adults; 35–45 years
Separate FGD with independent participants were conducted for dietary and physical activity behaviours until data saturation was achieved. Six FGD were conducted per behaviour. Determinants of dietary behaviours at intra-individual level included gaps in food skills, knowledge and self-efficacy, food safety concerns, convenience, finances and physiological satisfaction. The social-cultural norms were relationship between vegetable consumption and low social status, consideration of fruits as a snack for children and not food and habitual orientation towards carbohydrate foods. At environment level, social networks and increased availability of energy-dense, nutrient poor, street and processed foods influence dietary behaviour. For physical activity, intra-individual determinants were knowledge gaps and self-efficacy, while socio-cultural norms included gender stereotypes. Home (limited space and sedentary entertainment like social media and TV) and physical environment (cheap motorised transportation) influence physical activity.
The existing cultural beliefs promote dietary and physical activity behaviours which are divergent from healthy recommendations. Therefore, a comprehensive intervention is needed to address socio-cultural misconceptions, financial and time limitations in urban Uganda.
A major challenge in dietary assessment is the manual pre-processing of dietary data. Digital food registration via online platforms that are coupled to large food databases can automate this process. The accuracy of such platforms depends on the quality of the associated food database. In this study we validated the database of MyFitnessPal (MFP) versus the Belgian food composition database Nubel.
Fifty participants collected a 4-day dietary record using MFP at 2 time points, T1 and T2. Nutrient intake values extracted from MFP at T1 were used as training set to define a cut-off for each parameter (energy intake (EI), carbohydrates (CH), fat (F), protein (P), fibre (Fi), sugar (S), cholesterol (Ch) and sodium (So)) by optimising correlation with Nubel calculated values. Application of these criteria to the values extracted at T2 (n = 2826) resulted in rejection rate of 2.8%. The remaining values were correlated (Pearson or Spearman) with the Nubel calculated values. Fixed and proportional biases were traced using Bland-Altman analysis and impact on sample size was estimated from a power simulation.
MFP demonstrated strong correlation with the Nubel database for EI (r = 0.95), CH (r = 0.90), F (r = 0.90), P (r = 0.88), Fi (r = 0.80) and S (r = 0.77), but weak correlations for Ch (ρ = 0.51) and So (ρ = 0.53); all p < 0.001. Bland-Altman analysis showed no fixed bias between both methods, whereas a proportional bias was found for cholesterol. A practical implication is a loss of statistical power by 5–10% for EI and macronutrients compared to the Nubel database and the need to increase sample size accordingly.
We conclude that dietary analysis with MFP is accurate and efficient for total energy intake, macronutrients, fibre and sugar, but not for cholesterol and sodium
Recent studies demonstrated that the gut microbiome of Parkinson's Disease (PD) patients differs from that of age-matched healthy controls. Notably less butyrate-producing bacteria and low mucosal and fecal short chain fatty acid (SCFA) concentrations were found in PD patients. SCFA play a role in the interplay of health and disease: SCFA butyrate improves colon motility, protects the colonic epithelium and reduces inflammation. Administration of butyrate in animal models of PD improved motor impairment and dopamine deficiency and reduced early mortality. We hypothesize that certain orally supplemented dietary fibers can stimulate butyrate production in the colon of Parkinson's patients, and consequently can improve the motor impairment and their quality of life. This hypothesis still requires a step-wise approach. Our objective is to investigate the effect of different types of dietary fiber on the gut microbiota and SCFA production in PD patients and healthy elderly.
Material and methods
PD patients and healthy controls (HC) were selected based on age (55–70 years old) and BMI (18.5 -25 kg/m2). For PD patients the Hoehn and Yahr score (I – III) was added to this selection. The effect of inulin varying in degree of polymerization (DP) (average DP ~10 vs. average DP ~23) on the SCFA production was evaluated by ex vivo fermentation experiments with fecal samples of PD patients and HC. Inulin (1% w/v) was incubated in small-scale batch fermentations for 24 h at 37°C in anaerobic conditions. SCFA production was analyzed by solid phase micro-extraction capillary gas chromatography-mass spectrometry detection (SPME-cGS-MS). The clostridia clusters IV and XIVa were quantified through 16s qPCR.
Results and discussion
Short chain (Sc) and long chain(Lc) inulin fermentation resulted in a mean total SCFA increase of respectively 490.3 ± 128.2μmol/ml and 384.3 ± 85.9μmol/ml in HC (n = 7) and 453.9 ± 99.2μmol/ml and 402.9μmol/ml ± 84.1μmol/ml in PD patients (n = 3). Sc inulin fermentation increased butyrate production with 200.0μg/ml ± 46.2μmol/ml in HC and 119.8 ± 94.4μg/ml in PD patients (p = 0.09). Lc inulin fermentation increased butyrate production with 174.9μmol/ml ± 82.2μmol/ml and 113.3μmol/ml ± 21.2μmol/ml in HC and PD patients, respectively (p = 0.25). Large variation between samples was observed in PD patients.
Although sample size is relatively small and data is still collected, we can conclude that both Sc and Lc inulin increase total SCFA and butyrate production in HC and PD patients. This ex vivo study shows that stimulation of the butyrate production is still possible in PD patients and could be beneficial.
The increasing worldwide prevalence of obesity is a major public health concern, which has led to the development of surgical treatment strategies that achieve long-term sustainable weight loss and improvement of comorbidities and quality of life. However, nonsurgical complications can occur which sometimes necessitate hospital readmission depending on the severity. Current literature about hospital admission for nonsurgical complications after bariatric surgery is especially sparse. We performed a 5-year retrospective analysis of patients admitted for nonsurgical complications after bariatric surgery at the Department of Endocrinology, University Hospitals Leuven (Belgium). Patient and readmission characteristics were described by type of first bariatric surgery performed, time after first surgery, amount of bariatric surgeries in total, reason for hospitalization (nutritional, functional, psychological, metabolic and medical), need for parenteral and enteral feeding during hospitalization and duration of hospitalization. In a period of five years, there were 152 hospitalizations of 107 patients (86% females). The majority of patients (53%) underwent Roux-en-Y gastric bypass (RYGB) and had in total 1 (1–2) bariatric procedures. The median BMI before the first bariatric procedure was 40.7 (37.9–46.7) kg/m2. Patients were admitted 7.6 (3.4–13.1) years after surgery at an average age of 49 ± 12 years. Nutritional (66.4%), functional (37.5%) and co-presenting nutritional-functional (25.0%) problems were the most important reasons for hospitalization. In regard to the nutritional complications, the most important reasons for hospital admission were dumping syndrome (19.7%), macro- and micronutrient deficiencies (16.4%), bad compliance to prescribed nutritional guidelines (14.5%), anorexia (11.2%), extensive weight loss (10.5%) and failure to thrive (9.2%). During hospitalization, parenteral and enteral feeding was started in 19.1% and 9.9% of hospitalizations, respectively. The median duration of all hospitalizations was 8 (4–13) days. To conclude, the majority of hospitalized patients underwent RYGB and was female. Most patients were admitted late after surgery and nutritional problems were the most common complication. Nonsurgical complications after bariatric surgery are a clear illustration of the double-edged sword of surgical obesity management. The exact gastrointestinal anatomical and physiological changes provide the intended effect of weight loss, but may also elicit unintended imbalances of excessive losses of nutrients that compromise the outcome. Our findings demonstrate the need for lifelong multidisciplinary follow-up of lifestyle behavior and education on diet both before and after bariatric surgery.
As a preconception healthy diet is not only beneficial for couples’ general health but also for their reproductive health, effective interventions are necessary and lacking. In the field of nutrition, the concept of food literacy is emerging. Food literacy is the interrelated combination of knowledge, skills and self-efficacy on food planning, selecting foods, food preparation, eating and evaluating information about food with the ultimate goal of developing a lifelong healthy, sustainable and gastronomic relationship with food. The present study describes the systematic development of a food literacy intervention for couples trying to conceive.
Materials and methods
The development of the food literacy intervention was guided by Intervention Mapping, a protocol for developing theory- and evidence-based health promotion interventions in combination with consulting stakeholders. Decisions during intervention development were based on literature, an observational study evaluating the diet of couples trying to conceive using a food frequency questionnaire (FFQ) and semi-structured interviews and user tests with experts in the field and couples trying to conceive.
An innovative intervention to influence preconception diet and food literacy based on stakeholders opinion, effective behavior change strategies and attractive intervention channels was developed. Regarding needs assessment, the observational study showed that the diet of couples trying to conceive (n = 57) was inadequate (i.e. lack of vegetable intake) and highly correlated between partners. Objectives regarding food literacy were determined by participating experts (n = 12) rating ‘making healthy food choices’ as most important objective. A blended format (i.e. a mobile application in combination with telephone interaction with a health care professional) was selected as intervention channel based on semi-structured interviews with people trying to conceive (n = 17) as they highlighted the importance of support by experts and a time efficient intervention. Knowledge and self-efficacy regarding food literacy were selected as determinants to address. The main behavioral change strategies included in the intervention were tailoring, goal setting and motivational interviewing resulting in tailored goals, tips about food literacy and recipes. Experts (n = 15) and couples trying to conceive (n = 8) evaluated the intervention as easy to use.
This intervention will be evaluated on reproductive and dietary outcomes via a randomized controlled trial in Belgian Fertility clinics among 460 couples trying to conceive. If this theory- and evidence based food literacy intervention proves to be effective on reproductive and dietary outcomes in couples trying to conceive, it will offer vision and practical tools for implementing food literacy interventions in preconception care.
Urban sub-Saharan Africa is in a nutrition transition shifting towards consumption of energy-dense nutrient-poor diets and decreasing physical activity. Determinants of nutrition transition in sub-Saharan Africa are presently not well understood. The objective of this review was to synthesise available data on determinants of dietary and physical activity behaviours among women of reproductive age in urban sub-Saharan Africa according to the socio-ecological framework. We searched MEDLINE, Embase, Scopus, Web of Science and bibliographies of included articles for qualitative, observational and randomised controlled studies published in English from January 2000 to September 2018. Studies conducted within general populations of women aged 18–49 years were included. Searches were according to a predefined protocol published on PROSPERO (ID = CRD42018108532). Two reviewers independently screened identified studies. From a total of 9853 unique references, twenty-three studies were retained and were mainly from South and West Africa. No rigorous designed quantitative study was identified. Hence, data synthesis was narrative. Notable determinants of dietary behaviour included: convenience, finances, social network, food skills and knowledge gaps, food deserts and culture. Cultural beliefs include strong relationship between high social status and weight gain, energy-dense confectionery, salt or fat-rich foods. Physical activity is influenced by the fast-changing transport environment and cultural beliefs which instigate unfavourable gender stereotypes. Studies with rigorous qualitative and quantitative designs are required to validate and develop the proposed frameworks further, especially within East Africa. Nevertheless, available insights suggest a need for comprehensive skill-based interventions focusing on socio-cultural misconceptions and financial limitations.
The growing prevalence of obesity explains the rising interest in bariatric surgery. Compared with non-surgical treatment options, bariatric surgery results in greater and sustained improvements in weight loss, obesity associated complications, all-cause mortality and quality of life. These encouraging metabolic and weight effects come with a downside, namely the risk of nutritional deficiencies. Particularly striking is the risk to develop iron deficiency. Postoperatively, the prevalence of iron deficiency varies between 18 and 53 % after Roux-en-Y gastric bypass and between 1 and 54 % after sleeve gastrectomy. Therefore, preventive strategies and effective treatment options for iron deficiency are crucial to successfully manage the iron status of patients after bariatric surgery. With this review, we discuss the risks and the contributing factors of developing iron deficiency after bariatric surgery. Furthermore, we highlight the discrepancy in the diagnosis of iron deficiency, iron deficiency anaemia and anaemia and highlight the evidence supporting the current nutritional recommendations in the field of bariatric research. In conclusion, we advocate for more nutrition-related research in patient populations in order to provide strong evidence-based guidelines after bariatric surgery.
The conduct of high-quality nutrition research requires the selection of appropriate markers as outcomes, for example as indicators of food or nutrient intake, nutritional status, health status or disease risk. Such selection requires detailed knowledge of the markers, and consideration of the factors that may influence their measurement, other than the effects of nutritional change. A framework to guide selection of markers within nutrition research studies would be a valuable tool for researchers. A multidisciplinary Expert Group set out to test criteria designed to aid the evaluation of candidate markers for their usefulness in nutrition research and subsequently to develop a scoring system for markers. The proposed criteria were tested using thirteen markers selected from a broad range of nutrition research fields. The result of this testing was a modified list of criteria and a template for evaluating a potential marker against the criteria. Subsequently, a semi-quantitative system for scoring a marker and an associated template were developed. This system will enable the evaluation and comparison of different candidate markers within the same field of nutrition research in order to identify their relative usefulness. The ranking criteria of proven, strong, medium or low are likely to vary according to research setting, research field and the type of tool used to assess the marker and therefore the considerations for scoring need to be determined in a setting-, field- and tool-specific manner. A database of such markers, their interpretation and range of possible values would be valuable to nutrition researchers.
The objective of the present study was to assess the intake of naturally occurring plant sterols and β-carotene via the overall diet of Belgian pre-school children and adults. Two different Belgian food consumption databases were used: (1) one with consumption data of pre-school children (2·5–6·5 years old) and (2) one with consumption data of adults ( ≥ 15 years old). These consumption data were combined with a newly developed database containing the plant sterol and β-carotene content in all relevant food items based on international food composition databases and scientific literature. The results show that Flemish pre-school children have a median plant sterol intake of 172 (interquartile range (IQR) = 47) and 184 (IQR = 52) mg/d for girls and boys, respectively. Their median β-carotene intake was 1857 (IQR = 1250) μg/d, without significant difference between girls and boys. Belgian women and men have a median plant sterol intake of 218 (IQR = 113) and 280 (IQR = 158) mg/d, respectively, and a median β-carotene intake of 2086 (IQR = 1254) μg/d (not significantly different between the sexes). The main food source of naturally occurring plant sterols was bread and other cereal products. For β-carotene, the main food source was vegetables.
The present study describes the consumption of foods enriched with plant sterols (PS) and supplements containing PS, and evaluates PS intakes via the current consumption and for specific consumption scenarios. A market inventory was performed to collate different PS-enriched food items and supplements available in Belgium. An FFQ was developed to investigate the consumption of PS-enriched foods and supplements. A total of 139 pre-school children (2·5–7 years old) and 569 adults (308 women and 261 men) living in Flanders (the northern, Dutch-speaking part of Belgium) participated in the study. Of these, 21 % (Flemish pre-school children) and 28·5 % (Flemish adults) consume PS-enriched food products, leading to a mean PS intake in the consumer group of 0·70 (sd 0·61) g/d for pre-school children and 1·51 (sd 1·42) g/d for adults. Of the adult PS consumers, 23·2 % did not suffer from elevated blood cholesterol levels; 50 % of them had a PS intake less than or equal to 1 g/d and 16·4 % had a PS intake above 3 g/d and 7·8 % even had an intake above 4 g/d. Scenario studies assessed the intake when all Belgian adults would consume PS-enriched margarines without (scenario 1) or with (scenario 2) a daily consumption of a PS-enriched yoghurt drink. This resulted in an intake above 3 g/d in 17 % (women) and 29 % (men) for scenario 1 and 40 % (women) and 53 % (men) for scenario 2. The results indicate that PS-enriched food products are also consumed by the non-target group. Efficient communication tools are needed to inform consumers better about the target group of PS-enriched products, the advised dose per day and alternative dietary strategies to lower the blood cholesterol level.
To investigate associations between nutritional and non-nutritional variables and Fe status parameters, i.e. serum ferritin and soluble transferrin receptors (sTfR).
Cross-sectional design. Fe status parameters were determined on a fasting venous blood sample. Nutritional variables were assessed using a 2 d food record and non-nutritional variables by a general questionnaire. A general linear model was used to investigate associations between the variables and Fe status parameters.
Region of Ghent, Dutch-speaking part of Belgium.
Random sample of 788 women (aged 18–39 years).
Median (interquartile range) ferritin and sTfR were 26·3 (15·9, 48·9) ng/ml and 1·11 (0·95, 1·30) mg/l, respectively. BMI and alcohol intake were positively associated and tea intake was negatively associated with serum ferritin. Women who used a non-hormonal intra-uterine device, who gave blood within the past year or who had been pregnant within the past year had lower serum ferritin values than their counterparts. Significant determinants of sTfR were smoking habit and pregnancy, with higher values for non-smokers and women who had been pregnant within the past year.
The present study indicates that contraceptive use, time since last blood donation, time since last pregnancy, BMI, alcohol and tea intake are determinants of Fe stores, whereas smoking habit and time since last pregnancy are determinants of tissue Fe needs. When developing strategies to improve Fe status, special attention should be given to women who use a non-hormonal intra-uterine device, gave blood within the past year and had been pregnant within the past year.
This study presents an overview of national nutrition action plans in the member states of the European Union (EU), before its enlargement in 2004. In addition, their compliance with key recommendations of the World Health Organization, as documented in the First Action Plan for Food and Nutrition Policy and the Global Strategy on Diet, Physical Activity and Health, has tentatively been evaluated on the basis of the policy documents published.
Literature review of publicly available policy national plans on nutrition and physical activity.
Member states of the EU before enlargement in May 2004.
The development of national nutrition action plans is gaining momentum. Six of the 15 EU member states – namely, Sweden, Finland, Denmark, France, The Netherlands and the UK – have an operational nutrition policy and four of them have published an elaborated description of their nutrition policy in English. By the end of 2004, another four countries are expected to have their plan finalised. The available nutrition action plans generally seem to comply with international recommendations, although large variations are observed between the member states in terms of terminology, nutritional recommendations, institutional framework, nutritional scope, social groups targeted and monitoring and evaluation structures.
Although the importance of nutritional surveillance, a comprehensive approach to nutritional problems and stakeholder involvement is recognised by the action plans, the justification for it is vaguely described. This paper advocates for proper evaluation and documentation of interventions in public health nutrition and nutrition policies.
Relative validity and reproducibility of a semi-quantitative food-frequency questionnaire (FFQ) for measuring preschool children's usual Ca intake were assessed using parents or guardians as a proxy. Estimated diet records (EDR; 3d) were used as the reference method and reproducibility was measured by repeated FFQ administrations 5 weeks apart. From 2095 preschool children (2·5–6·5 years) randomly selected in Flanders (Flemish region of Belgium), 1052 returned a FFQ and EDR. Stringent exclusion procedures reduced the sample for validity analyses to 509 children. From a separate sample of 244 preschool children, 124 returned two FFQ, of whom sixty were included in the reproducibility analysis. Mean Ca intakes were 838 (sd 305) and 777 (sd 296) mg/d for EDR and FFQ respectively, indicating a mean difference of 60·9 (sd 294·4) mg/d (p<0·001). Pearson's correlation was 0·52. Cross-classification analysis of the FFQ and EDR classified 83%of the subjects in the same or adjacent category and 2·4% in extreme quartiles. Actual values for surrogate FFQ quartiles showed a progressive increase in Ca intake (p<0·001). The FFQ correctly identified 77% of the children consuming less Ca than the age-specific RDA (800mg/d). Correlation between repeated administrations was 0·79. No significant difference between mean Ca intakes was established by two administrations (23·8 (sd 161·2) mg/d). Cross-classification of repeated administrations classified 93·4% of the subjects in the same or adjacent category and no subjects in extreme categories. This FFQ tended to underestimate preschool children's Ca intake when administered by a proxy. However, it demonstrated good repeatability and fairly good ability to classify subjects into extremes of Ca intake.
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