A study protocol for a randomised crossover study evaluating the effect of diets differing in carbohydrate quality on ileal content and appetite regulation in healthy humans.

Introduction: A major component of the digesta reaching the colon from the distal ileum is carbohydrate. This carbohydrate is subject to microbial fermentation and can radically change bacterial populations in the colon and the metabolites they produce, particularly short-chain fatty acids (SCFA). However, very little is currently known about the forms and levels of carbohydrate in the ileum and the composition of the ileal microbiota in humans. Most of our current understanding of carbohydrate that is not absorbed by the small intestine comes from ileostomy models, which may not reflect the physiology of an intact gastrointestinal tract. Methods: We will investigate how ileal content changes depending on diet using a randomised crossover study in healthy humans. Participants will be inpatients at the research facility for three separate 4-day visits. During each visit, participants will consume one of three diets, which differ in carbohydrate quality: 1) low-fibre refined diet; 2) high-fibre diet with intact cellular structures; 3) high-fibre diet where the cellular structures have been disrupted (e.g. milling, blending). On day 1, a nasoenteric tube will be placed into the distal ileum and its position confirmed under fluoroscopy. Ileal samples will be collected via the nasoenteric tube and metabolically profiled, which will determine the amount and type of carbohydrate present, and the composition of the ileal microbiota will be measured. Blood samples will be collected to assess circulating hormones and metabolites. Stool samples will be collected to assess faecal microbiota composition. Subjective appetite measures will be collected using visual analogue scales. Breath hydrogen will be measured in real-time as a marker of intestinal fermentation. Finally, an in vitro continuous fermentation model will be inoculated with ileal fluid in order to understand the shift in microbial composition and SCFA produced in the colon following the different diets. Registration: ISRCTN11327221.

Dietary supplementation with inulin-propionate ester or inulin improves insulin sensitivity in adults with overweight and obesity with distinct effects on the gut microbiota, plasma metabolome and systemic inflammatory responses: a randomised cross-over trial.

OBJECTIVE: To investigate the underlying mechanisms behind changes in glucose homeostasis with delivery of propionate to the human colon by comprehensive and coordinated analysis of gut bacterial composition, plasma metabolome and immune responses. DESIGN: Twelve non-diabetic adults with overweight and obesity received 20 g/day of inulin-propionate ester (IPE), designed to selectively deliver propionate to the colon, a high-fermentable fibre control (inulin) and a low-fermentable fibre control (cellulose) in a randomised, double-blind, placebo-controlled, cross-over design. Outcome measurements of metabolic responses, inflammatory markers and gut bacterial composition were analysed at the end of each 42-day supplementation period. RESULTS: Both IPE and inulin supplementation improved insulin resistance compared with cellulose supplementation, measured by homeostatic model assessment 2 (mean±SEM 1.23±0.17 IPE vs 1.59±0.17 cellulose, p=0.001; 1.17±0.15 inulin vs 1.59±0.17 cellulose, p=0.009), with no differences between IPE and inulin (p=0.272). Fasting insulin was only associated positively with plasma tyrosine and negatively with plasma glycine following inulin supplementation. IPE supplementation decreased proinflammatory interleukin-8 levels compared with cellulose, while inulin had no impact on the systemic inflammatory markers studied. Inulin promoted changes in gut bacterial populations at the class level (increased Actinobacteria and decreased Clostridia) and order level (decreased Clostridiales) compared with cellulose, with small differences at the species level observed between IPE and cellulose. CONCLUSION: These data demonstrate a distinctive physiological impact of raising colonic propionate delivery in humans, as improvements in insulin sensitivity promoted by IPE and inulin were accompanied with different effects on the plasma metabolome, gut bacterial populations and markers of systemic inflammation.

Effects of Inulin Propionate Ester Incorporated into Palatable Food Products on Appetite and Resting Energy Expenditure: A Randomised Crossover Study.

Supplementation with inulin-propionate ester (IPE), which delivers propionate to the colon, suppresses ad libitum energy intake and stimulates the release of satiety hormones acutely in humans, and prevents weight gain. In order to determine whether IPE remains effective when incorporated into food products (FP), IPE needs to be added to a widely accepted food system. A bread roll and fruit smoothie were produced. Twenty-one healthy overweight and obese humans participated. Participants attended an acclimatisation visit and a control visit where they consumed un-supplemented food products (FP). Participants then consumed supplemented-FP, containing 10 g/d inulin or IPE for six days followed by a post-supplementation visit in a randomised crossover design. On study visits, supplemented-FP were consumed for the seventh time and ad libitum energy intake was assessed 420 min later. Blood samples were collected to assess hormones and metabolites. Resting energy expenditure (REE) was measured using indirect calorimetry. Taste and appearance ratings were similar between FP. Ad libitum energy intake was significantly different between treatments, due to a decreased intake following IPE-FP. These observations were not related to changes in blood hormones and metabolites. There was an increase in REE following IPE-FP. However, this effect was lost after correcting for changes in fat free mass. Our results suggest that IPE suppresses appetite and may alter REE following its incorporation into palatable food products.

The effects of dietary supplementation with inulin and inulin-propionate ester on hepatic steatosis in adults with non-alcoholic fatty liver disease.

The short chain fatty acid (SCFA) propionate, produced through fermentation of dietary fibre by the gut microbiota, has been shown to alter hepatic metabolic processes that reduce lipid storage. We aimed to investigate the impact of raising colonic propionate production on hepatic steatosis in adults with non-alcoholic fatty liver disease (NAFLD). Eighteen adults were randomized to receive 20 g/d of an inulin-propionate ester (IPE), designed to deliver propionate to the colon, or an inulin control for 42 days in a parallel design. The change in intrahepatocellular lipid (IHCL) following the supplementation period was not different between the groups (P = 0.082), however, IHCL significantly increased within the inulin-control group (20.9% ± 2.9% to 26.8% ± 3.9%; P = 0.012; n = 9), which was not observed within the IPE group (22.6% ± 6.9% to 23.5% ± 6.8%; P = 0.635; n = 9). The predominant SCFA from colonic fermentation of inulin is acetate, which, in a background of NAFLD and a hepatic metabolic profile that promotes fat accretion, may provide surplus lipogenic substrate to the liver. The increased colonic delivery of propionate from IPE appears to attenuate this acetate-mediated increase in IHCL.

Innovative PhD-DNP Faculty Collaboration to Advance Baccalaureate Student Population Health Competencies.

Entry-level nurses require health promotion, chronic disease self-management, care coordination, data utilization, and evidence translation competencies to address complex population health needs. An innovative PhD-DNP faculty collaboration implemented a descriptive survey design to evaluate simulation-based strategies using an unfolding chronically ill adult case to address population health. Results showed the PhD-DNP faculty team was effective in developing clinically meaningful learning experiences to assist baccalaureate students to develop population health competencies. This project provides strong evidence supporting the value and positive impact of engaging faculty from research and practice for future educational research.

Simulation Innovation to Redesign the Baccalaureate Curriculum to Address Population Health.

Prelicensure nursing curricula need to be redesigned to integrate and achieve key population health competencies. Nursing students in generic and second-degree programs had improved learning outcomes and significant increases in population health competencies across the curriculum using simulation-based learning activities developed through an academic-practice partnership. Simulation is an effective, interactive strategy that enhances student knowledge, skills, and competencies in addressing population health.

The effect of L-rhamnose on intestinal transit time, short chain fatty acids and appetite regulation: a pilot human study using combined 13CO2/H2 breath tests.

BACKGROUND: The appetite-regulating effects of non-digestible carbohydrates (NDC) have in part previously been attributed to their effects on intestinal transit rates as well as microbial production of short chain fatty acids (SCFA). Increased colonic production of the SCFA propionate has been shown to reduce energy intake and stimulate gut hormone secretion acutely in humans. OBJECTIVE: We investigated the effect of the propiogenic NDC, L-rhamnose, on gastrointestinal transit times using a combined 13CO2/H2 breath test. We hypothesised that L-rhamnose would increase plasma propionate leading to a reduction in appetite, independent of changes in gastrointestinal transit times. DESIGN: We used a dual 13C-octanoic acid/lactose 13C-ureide breath test combined with breath H2 to measure intestinal transit times following the consumption of 25 g d-1 L-rhamnose, compared with inulin and cellulose, in 10 healthy humans in a randomised cross-over design pilot study. Gastric emptying (GE) and oro-caecal transit times (OCTTs) were derived from the breath 13C data and compared with breath H2. Plasma SCFA and peptide YY (PYY) were also measured alongside subjective measures of appetite. RESULTS: L-rhamnose significantly slowed GE rates (by 19.5 min) but there was no difference in OCTT between treatments. However, breath H2 indicated fermentation of L-rhamnose before it reached the caecum. OCTT was highly correlated with breath H2 for inulin but not for L-rhamnose or cellulose. L-rhamnose consumption significantly increased plasma propionate and PYY but did not significantly reduce subjective appetite measures. CONCLUSIONS: The NDCs tested had a minimal effect on intestinal transit time. Our data suggest that L-rhamnose is partially fermented in the small intestine and that breath H2 reflects the site of gastrointestinal fermentation and is only a reliable marker of OCTT for certain NDCs (e.g. inulin). Future studies should focus on investigating the appetite-suppressing potential of L-rhamnose and verifying the findings in a larger cohort.

Hopelessness and cognitive impairment are risk markers for mortality in systolic heart failure patients.

OBJECTIVE: Depression exacerbates the burden of heart failure and independently predicts mortality. The aim of this study was to investigate which specific symptoms of depression predict all-cause mortality in systolic heart failure patients. METHODS: Consecutive outpatients with heart failure and impaired left ventricular ejection fraction (LVEF), attending an Australian metropolitan heart function clinic between 2001 and 2011, were enrolled. The Cardiac Depression Scale (CDS) was completed as a component of usual care. Baseline clinical characteristics were drawn from hospital databases. The primary end-point was all-cause mortality, obtained from the Australian National Death Index. RESULTS: A total of 324 patients (68.5% male) were included (mean age at enrolment = 66.8 ±â€¯14.36 years), with a median follow-up time of 6.7 years (95% CI 5.97-7.39) and a mortality rate of 50% by the census date. Mean LVEF = 31.0 ±â€¯11.31%, with 25% having NYHA functional class of III or IV. Factor analysis of the CDS extracted six symptom dimensions: Hopelessness, Cognitive Impairment, Anhedonia/Mood, Irritability, Worry, and Sleep Disturbance. Cox regression analyses identified Hopelessness (HR 1.024, 95% CI 1.004-1.045, p = .018) and Cognitive Impairment (HR 1.048, 95% CI 1.005-1.093, p = .028) as independent risk markers of all-cause mortality, following adjustment of known prognostic clinical factors. CONCLUSION: Hopelessness and cognitive impairment are stronger risk markers for all-cause mortality than other symptoms of depression in systolic heart failure. These data will allow more specific risk assessment and potentially new targets for more effective treatment and management of depression in this population.

Acute oral sodium propionate supplementation raises resting energy expenditure and lipid oxidation in fasted humans.

Short-chain fatty acids (SCFAs), produced from fermentation of dietary fibre by the gut microbiota, have been suggested to modulate energy metabolism. Previous work using rodent models has demonstrated that oral supplementation of the SCFA propionate raises resting energy expenditure (REE) by promoting lipid oxidation. The objective of the present study was to investigate the effects of oral sodium propionate on REE and substrate metabolism in humans. Eighteen healthy volunteers (9 women and 9 men; age 25 ± 1 years; body mass index 24.1 ± 1.2 kg/m2 ) completed 2 study visits following an overnight fast. Tablets containing a total of 6845 mg sodium propionate or 4164 mg sodium chloride were provided over the 180-minute study period in random order. REE and substrate oxidation were assessed by indirect calorimetry. Oral sodium propionate administration increased REE (0.045 ± 0.020 kcal/min; P = .036); this was accompanied by elevated rates of whole-body lipid oxidation (0.012 ± 0.006 g/min; P = .048) and was independent of changes in glucose and insulin concentrations. Future studies are warranted to determine whether the acute effects of oral sodium propionate on REE translate into positive improvements in long-term energy balance in humans.

Increased colonic propionate reduces anticipatory reward responses in the human striatum to high-energy foods.

BACKGROUND: Short-chain fatty acids (SCFAs), metabolites produced through the microbial fermentation of nondigestible dietary components, have key roles in energy homeostasis. Animal research suggests that colon-derived SCFAs modulate feeding behavior via central mechanisms. In humans, increased colonic production of the SCFA propionate acutely reduces energy intake. However, evidence of an effect of colonic propionate on the human brain or reward-based eating behavior is currently unavailable. OBJECTIVES: We investigated the effect of increased colonic propionate production on brain anticipatory reward responses during food picture evaluation. We hypothesized that elevated colonic propionate would reduce both reward responses and ad libitum energy intake via stimulation of anorexigenic gut hormone secretion. DESIGN: In a randomized crossover design, 20 healthy nonobese men completed a functional magnetic resonance imaging (fMRI) food picture evaluation task after consumption of control inulin or inulin-propionate ester, a unique dietary compound that selectively augments colonic propionate production. The blood oxygen level-dependent (BOLD) signal was measured in a priori brain regions involved in reward processing, including the caudate, nucleus accumbens, amygdala, anterior insula, and orbitofrontal cortex (n = 18 had analyzable fMRI data). RESULTS: Increasing colonic propionate production reduced BOLD signal during food picture evaluation in the caudate and nucleus accumbens. In the caudate, the reduction in BOLD signal was driven specifically by a lowering of the response to high-energy food. These central effects were partnered with a decrease in subjective appeal of high-energy food pictures and reduced energy intake during an ad libitum meal. These observations were not related to changes in blood peptide YY (PYY), glucagon-like peptide 1 (GLP-1), glucose, or insulin concentrations. CONCLUSION: Our results suggest that colonic propionate production may play an important role in attenuating reward-based eating behavior via striatal pathways, independent of changes in plasma PYY and GLP-1. This trial was registered at clinicaltrials.gov as NCT00750438.

Predicting intention to uptake H1N1 influenza vaccine in a university sample.

OBJECTIVE: Global pandemic H1N1 was atypical of influenza in that it was associated with high symptom severity among young adults. Higher education institutions were therefore understandably concerned about the potential for high infection rates among students. This study examined intention to uptake H1N1 vaccine between November and December 2009, when the virus was classified by the World Health Organization (WHO) as being in the pandemic phase. DESIGN: A cross-sectional survey design was employed. METHOD: Two hundred university students completed a questionnaire battery comprised of health, belief/attitudes, and behavioural intention measures. RESULTS: Findings suggested that non-intention to vaccinate is associated with a strong disbelief in its efficacy, in negative attitudes towards vaccinations, and in lack of perceived threat, which is underscored by a disinterest in others' opinions, including authoritative bodies. Findings also suggested that there is resistance to the idea of vaccinations being mandatory. CONCLUSIONS: Vaccination intent is in some way linked to a range of attitudes and beliefs. The implication for health practitioners is that behaviour intent may be open to influence where psycho-education can create pro-vaccine attitudes and beliefs.

Esomeprazole for the management of upper gastrointestinal symptoms in patients who require NSAIDs: a review of the NASA and SPACE double-blind, placebo-controlled studies.

BACKGROUND AND OBJECTIVE: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used for the treatment of pain in rheumatic disorders and chronic pain syndromes. Their use is, however, limited by gastrointestinal (GI) toxicity, including upper GI symptoms, ulcers and related complications. Using data from the NASA/SPACE studies, we have reviewed the efficacy and tolerability of esomeprazole (20 or 40 mg once daily) in the management (i.e. short-term resolution plus long-term prevention of relapse) of upper GI symptoms in users of continuous daily NSAIDs. METHODS: The NASA/SPACE programme comprised four double-blind, placebo-controlled studies in NSAID users. Two studies evaluated the efficacy of esomeprazole for upper GI symptom relief over 4 weeks. Those patients with symptom relief were then enrolled into a further two studies that assessed efficacy over 6 months. RESULTS: In the 4-week studies, more patients in the esomeprazole groups achieved relief from upper GI symptoms at week 4 compared with placebo (p<0.05). The proportion of patients with symptom relapse at 6 months was lower with esomeprazole 20 mg and 40 mg than with placebo (p

School nurses and childhood obesity: an investigation of knowledge and practice among school nurses as they relate to childhood obesity.

BACKGROUND: Childhood obesity has escalated to an alarming proportion in the last twenty years. It is currently the most preventable nutritional disease of the 21(st) century. Anecdotal literature suggests that school nurses play a pivotal role in the fight against the escalating incidence of childhood obesity. However, research has not clearly shown that school nurses engage in health promotion behaviors that combat childhood obesity. METHODS: A convenience sample of 103 New Jersey school nurses who attended county school nurses association meetings were surveyed. A 55-item tool was used to measure school nurses' knowledge and practice regarding childhood obesity. RESULTS: While ninety-nine percent of the nurses are aware that childhood obesity is becoming more prevalent, more than 35% of the school nurses reported a lack of competence in recommending weight-loss programs for children. More than 65% rated using age-specific BMI to calculate childhood obesity "sometimes," "rarely," or "never." CONCLUSIONS: Data from this study indicates that New Jersey school nurses are knowledgeable regarding childhood obesity, yet many do not report levels of competence in recommending weight-loss treatment to promote healthy lifestyle choices for their students. Further research is needed to understand the barriers to health promotion practices among school nurses.

Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice.

OBJECTIVE: To measure the prevalence of somatisation (multiple somatic symptoms and hypochondriasis) among Australian general practice attendees, its recognition by general practitioners, and its relationship with symptoms of depression and anxiety. DESIGN, SETTING AND PARTICIPANTS: Self-reported questionnaires completed by 10 507 consecutive patients aged > or =18 years attending 340 GPs enrolled in a 6-hour national mental health program of continuing professional development who accepted invitations to participate; audit form completed by GPs for each patient during the period March 2004 to December 2006. MAIN OUTCOME MEASURES: Somatic symptom severity (measured with the 15-item Patient Health Questionnaire [PHQ-15]); hypochondriasis (measured with the Whiteley Index [Whiteley-7]; depression and anxiety (measured by the Kessler Psychological Distress scale [K10]); prevalence of "somatisers" (defined by medium to severe somatic symptom severity and hypochondriasis); GP recognition of somatisation (determined by their responses on audit forms to questions on whether patient's complaints were most likely to have a physical or psychological explanation). RESULTS: 18.5% of patients were classified as somatisers and 9.5% as probable cases of depression or anxiety. While 29.6% of somatisers had high anxiety or depression scores, 57.9% of people with anxiety or depression were also somatisers. Sex and age asserted significant but weak effects on psychometric scores. GPs identified somatic complaints as "mostly explained by a psychological disturbance" in 25.1% of somatisers. CONCLUSIONS: Somatisation is common in general practice, and more prevalent than depression or anxiety. While a minority of somatisers have significant anxiety and depression, most patients with depression and anxiety have a significant degree of somatisation. Recognition of depression and anxiety can be hindered by a somatic presentation and attribution. On the other hand, managing somatisation does not just involve recognising depression and anxiety, but also dealing with the health anxieties that underpin hypochondriasis.