No Effect of Added Sugars in Soft Drink Compared With Sugars in Fruit on Cardiometabolic Risk Factors: Results From a 4-Week, Randomized Controlled Trial.

High intakes of added sugar from soft drinks are associated with negative health outcomes such as the increased risk of gout and type 2 diabetes, weight gain and cardiovascular disease. Fruits are naturally high in sugars but their effect on cardiometabolic risk remains unknown. We examined the effect on cardiometabolic risk factors of consuming natural sugars from fruit or added sugars from sugar-sweetened soft drinks in overweight adults. Forty-eight healthy, overweight (BMI ≥ 28 kg/m2) men (n = 21) and women (n = 20) were randomized to either a fruit (n = 19) or sugar-sweetened soft drink (n = 22) intervention for 4 weeks. The fruit group received 6 items of fresh and dried fruit per day and the sugar-sweetened soft drink group received 955 ml of sugar-sweetened soft drink per day. The interventions were matched for both energy (fruit: 1,800 kJ/d; soft drink: 1,767 kJ/d) and fructose content (fruit: 51.8 g/d; soft drink: 51.7 g/d). The soft drink intervention provided 101 g total sugars, which was all added sugar and the fruit intervention provided 97 g total sugars, which were all natural sugars. Dietary intakes were otherwise ad libitum. Despite being asked to consume additional sugar (up to 1,800 additional kJ/d), there were no changes in weight, blood pressure or other cardiometabolic risk factors, except by uric acid, in any of the intervention groups. In conclusion, our findings do not provide any evidence that short-term regular intake of added sugars is linked to higher cardiometabolic risks, with exception of uric acid in overweight men. Public health interventions to prevent obesity and related diseases should focus on the quality of the whole diet rather than only focusing on reducing sugary drinks or sugar intakes.

Role for colorectal teams to support non-colorectal teams to improve clinical outcomes and adherence to ERAS guidelines for segmental colectomy: a cohort study.

BACKGROUND: To identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards. METHODS: Consecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days). RESULTS: Analysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS. CONCLUSIONS: Non-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team's expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.

Consumption of fortified infant foods reduces dietary diversity but has a positive effect on subsequent growth in infants from Sumedang district, Indonesia.

Stunting and underweight among under-five children in Indonesia are common, raising public health concerns. Whether inappropriate complementary feeding (CF) practices compromise optimal growth during late infancy in Indonesia is uncertain. Therefore we characterized and evaluated CF practices in Indonesian infants and investigated their relationship with subsequent growth. We enrolled breastfed infants at 6 months of age (n = 230); and followed them at 9 (n = 202) and 12 months of age (n = 190). We collected socio-demographic and anthropometric data and two-day in-home weighed food records. Relations between WHO CF indicators, sentinel foods, and energy and micronutrient intakes at 9 months and growth at 12 months were explored using multiple linear regression. Stunting and underweight increased from 15.8% and 4.4% at 6 months to 22.6% and 10.5% at 12 months, respectively. Median intakes of calcium, iron, zinc, and riboflavin were below WHO recommendations. Infants consuming fortified infant foods (FIFs) at 9 months had diets with a lower dietary diversity (DD) score (2.3 vs.3.0), energy density, median energy (250 vs. 310 kcal/d) and protein (6.5 vs. 9.1 g/d) intake than non-consumers (p<0.01), despite higher intakes of calcium, iron, and vitamins A and C (p<0.001). Positive relations existed for 9-month consumption of iron-rich/iron fortified infant foods with length-for-age Z-score (LAZ) at 12 months (ß = 0.22; 95% CI: 0.01, 0.44; P = 0.04), and for fortified infant foods alone with both LAZ (ß = 0.29; 95% CI: 0.09, 0.48; P = 0.04) and weight-for-age Z-score (ß = 0.14; 95% CI: 0.02, 0.26; P = 0.02) at 12 months. The positive association of FIFs with subsequent growth may be attributed to their content of both powdered cow's milk and multi-micronutrient fortificants. Nonetheless, mothers should not be encouraged to over-rely on FIFs as they reduce DD.

Micronutrient Adequacy and Dietary Diversity Exert Positive and Distinct Effects on Linear Growth in Urban Zambian Infants.

BACKGROUND: In the monitoring of infant and young child feeding, dietary diversity is used as an indicator of micronutrient adequacy; however, their relation may have weakened with the increasing use of fortified complementary foods. OBJECTIVE: The objectives were to assess the relation between dietary diversity and micronutrient adequacy in an urban infant population with a high consumption of fortified foods and to investigate whether dietary diversity and micronutrient adequacy were independently associated with subsequent growth. METHODS: We used longitudinal data on 811 infants in the Chilenje Infant Growth, Nutrition, and Infection Study conducted in Lusaka, Zambia. The relation between mean micronutrient adequacies and dietary diversity scores derived from 24-h diet recalls at 6 mo of age was investigated with the use of Spearman rank correlation. Multiple linear regression was used to assess the association between micronutrient adequacy, dietary diversity, and subsequent growth to 18 mo of age. RESULTS: Overall mean micronutrient density adequacy (MMDA) and MMDA of "problem micronutrients," defined as those micronutrients (calcium, iron, zinc) with mean density adequacies less than half of estimated needs, were correlated with dietary diversity scores (ρ = 0.36 and 0.30, respectively, both P < 0.0001). Consumption of "sentinel foods" (iron rich, fortified, animal source, dairy) showed better correlation with MMDA than with dietary diversity (ρ = 0.58-0.69, all P < 0.0001). In fully adjusted analyses, MMDA calcium, iron, zinc, and dietary diversity, but not overall MMDA, were associated with linear growth to 18 mo (both P ≤ 0.028). CONCLUSIONS: Micronutrient adequacy in infants consuming fortified foods may be more accurately assessed using locally specific sentinel food indicators rather than dietary diversity scores. Nonetheless, dietary diversity has a positive effect on subsequent linear growth apart from that of micronutrient adequacy, warranting its continued monitoring and further investigation into the mechanisms underlying this finding. This trial was registered at www.controlled-trials.com as ISRCTN37460449.

Vitamin D status and weight loss: a systematic review and meta-analysis of randomized and nonrandomized controlled weight-loss trials.

BACKGROUND: Obesity is associated with lower concentrations of serum 25-hydroxyvitamin D; however, uncertainty exists as to the direction of causation. To date, meta-analyses of randomized controlled vitamin D-supplementation trials have shown no effect of raising circulating vitamin D on body weight, although several weight-loss-intervention trials have reported an increase in circulating vitamin D after weight reduction. OBJECTIVE: We undertook a systematic review and meta-analysis of randomized and nonrandomized controlled trials to determine whether weight loss compared with weight maintenance leads to an increase in serum 25-hydroxyvitamin D. DESIGN: A systematic search for controlled weight-loss-intervention studies published up to 31 March 2016 was performed. Studies that included participants of any age with changes in adiposity and serum 25-hydroxyvitamin D as primary or secondary outcomes were considered eligible. RESULTS: We identified 4 randomized controlled trials (n = 2554) and 11 nonrandomized controlled trials (n = 917) for inclusion in the meta-analysis. Random assignment to weight loss compared with weight maintenance resulted in a greater increase in serum 25-hydroxyvitamin D with a mean difference of 3.11 nmol/L (95% CI: 1.38, 4.84 nmol/L) between groups, whereas a mean difference of 4.85 nmol/L (95% CI: 2.59, 7.12 nmol/L) was observed in nonrandomized trials. No evidence for a dose-response effect of weight loss on the change in serum 25-hydroxyvitamin D was shown overall. CONCLUSIONS: Our results indicate that vitamin D status may be marginally improved with weight loss in comparison with weight maintenance under similar conditions of supplemental vitamin D intake. Although additional studies in unsupplemented individuals are needed to confirm these findings, our results support the view that the association between obesity and lower serum 25-hydroxyvitamin D may be due to reversed causation with increased adiposity leading to suboptimal concentrations of circulating vitamin D. This trial was registered at www.crd.york.ac.uk/PROSPERO/ as CRD42015023836.

Dietary diversity at 6 months of age is associated with subsequent growth and mediates the effect of maternal education on infant growth in urban Zambia.

BACKGROUND: Although numerous cross-sectional studies have shown an association between WHO infant and young child feeding (IYCF) indicators and child anthropometric measures, limited longitudinal evidence exists linking these indicators with subsequent growth. OBJECTIVES: The purpose of this study was to investigate whether meeting WHO IYCF indicators at 6 and 12 mo of age was associated with growth to 18 mo of age and if dietary diversity mediated the relation between household wealth, maternal education, and child growth. METHODS: We used longitudinal data on 811 infants in the CIGNIS (Chilenje Infant Growth, Nutrition, Infection Study), a randomized controlled trial comparing the effect of micronutrient-fortified porridges on infant growth in Lusaka, Zambia. Twenty-four-h diet recalls were conducted at 6 and 12 mo of age, and length and weight measurements at ages 6 and 18 mo were used to produce height-for-age Z-scores (HAZs) and weight-for-height Z-scores (WHZs). Information on household assets was used to generate a household wealth index, and level of maternal education was collected. RESULTS: In fully adjusted analyses, iron-rich food intake at 6 mo and greater household wealth and maternal education were positively associated with HAZ at 18 mo (all P ≤ 0.016). Iron-rich food intake at 6 and 12 mo, achieving a "minimum acceptable diet" at 12 mo, and higher maternal education were associated with greater WHZ at 18 mo (all P ≤ 0.044). Dietary diversity at 6 mo of age was positively associated with both HAZ and WHZ at 18 mo (both P ≤ 0.001) and mediated 13.4% and 25.9% of the total effect of maternal education on HAZ and WHZ, respectively, at 18 mo. CONCLUSIONS: Our findings indicate that IYCF programs should be targeted toward the early period of complementary food introduction and that policies aimed at increasing formal maternal education may benefit child growth through improved feeding practices. This trial was registered at www.controlled-trials.com as ISRCTN37460449.

Public health policy to redress iodine insufficiency in pregnant women may widen sociodemographic disparities.

OBJECTIVE: To evaluate the impact of a mandatory bread fortification programme on estimated iodine intakes of childbearing women and to describe the extent to which uptake of a maternal iodine supplement recommendation is associated with sociodemographic characteristics. DESIGN: A postpartum survey was conducted using a self-administered questionnaire. Details on pre- and post-conceptional supplement use, bread intake, iodized salt use and maternal sociodemographic and obstetric characteristics were obtained. SETTING: Eleven maternity wards and hospitals located across New Zealand. SUBJECTS: Seven hundred and twenty-three postpartum New Zealand women. RESULTS: Mean iodine intake from fortified bread was 37 µg/d prior to conception. Younger women, women with higher parity, single women and those with unplanned pregnancies were less likely to meet the pregnancy Estimated Average Requirement (EAR) for iodine (all P ≤ 0·022). Although not statistically significant for all months of pregnancy, women with less education and income were less likely to meet the EAR (P ≤ 0·11 and P ≤ 0·2 for all months, respectively) and indigenous Maori women and Pacific women were less likely than New Zealand Europeans to meet the EAR (P ≤ 0·17 and P ≤ 0·051 for all months, respectively). During pregnancy, iodine-containing supplement uptake at the recommended level (150 µg/d) was non-uniform across sociodemographic subgroups, with the most disadvantaged women benefiting the least from this public health policy. CONCLUSIONS: The disparities in supplement uptake noted here highlight the need for prioritizing further efforts towards universal salt iodization, such as the mandatory fortification of additional processed foods with iodized salt.

Socio-demographic characteristics associated with unplanned pregnancy in New Zealand: implications for access to preconception healthcare.

New Zealand's Chief Science Advisor has recommended weight loss interventions be made available to women planning a pregnancy. In a postpartum survey of 723 New Zealand women, 44% of all pregnancies were unplanned, and in multivariate analysis, younger women, women with less income, women with higher parity, and single women were more likely to have an unplanned pregnancy (all P ≤ 0.002). In addition, three-quarters of pregnancies to indigenous Maori and Pacific women were unplanned. In conclusion, New Zealand women known to have the highest rates of overweight and obesity were also most likely to have unplanned pregnancies, thereby preventing their access to any forthcoming preconception weight loss programs.

Maternal factors associated with heavy periconceptional alcohol intake and drinking following pregnancy recognition: a post-partum survey of New Zealand women.

INTRODUCTION AND AIMS: Alcohol consumption during pregnancy places the foetus at risk of Foetal Alcohol Spectrum Disorders. Little is known about the current prevalence and patterns of alcohol consumption before and following pregnancy recognition in New Zealand. DESIGN AND METHODS: A retrospective survey of 723 post-partum women resident in maternity wards located across New Zealand was conducted using a self-administered questionnaire. Maternal sociodemographic and obstetric characteristics and alcohol intake before and after pregnancy recognition were assessed. RESULTS: Of the 968 women invited to participate, 78% agreed. Eighty-two percent of women reported consuming alcohol prior to pregnancy and 20% reported typically consuming >4 New Zealand standard drinks per occasion. Overall, 34% of women reported drinking at some time during pregnancy. Twelve percent of pregnancies were at high risk of heavy alcohol exposure in early gestation. In fully adjusted analysis, pregnancies most at risk were those of indigenous Maori women, Pacific women, smokers and drug users. Almost one-quarter (24%) of drinkers continued to drink following pregnancy recognition, and in fully adjusted analysis, continuing to drink was positively associated with frequency of alcohol consumption before pregnancy (P < 0.001 for linear trend). DISCUSSION AND CONCLUSIONS: To reduce the burden of alcohol-related harm to the foetus, these findings suggest that New Zealand alcohol policy should be focused not only on promoting total abstinence when planning a pregnancy and when pregnant, but also on reducing 'binge drinking' culture and the frequent consumption of lower levels of alcohol.

Folate knowledge and consumer behaviour among pregnant New Zealand women prior to the potential introduction of mandatory fortification.

To reduce the risk of neural tube defects, the New Zealand Ministry of Health recommends women take supplemental folic acid from at least one month preconception until the end of the twelfth week of pregnancy, as well as consume folate-rich foods. A postpartum survey was conducted to describe folate knowledge and consumer behaviour among pregnant New Zealand women prior to the potential implementation of mandatory folic acid fortification of bread in May 2012. Increasing knowledge of folic acid recommendations was associated with higher supplement uptake among women who planned their pregnancies (p=0.001 for linear trend). Folic acid information failed to adequately reach some socio-demographic subgroups before conception, even when pregnancy was planned, including: indigenous Maori, Pacific and Asian women, younger women, women with large families, and women with lower educational attainment and income. Only half of all women surveyed knew some bread contained added folic acid, and among these women, less than 2% consistently chose voluntarily fortified bread during the periconceptional period by inspecting labels. Sixty-one percent of women indicated they were either in favour of mandatory fortification, or held no opinion on the matter, while 4% were opposed to the addition of folic acid to bread. Approximately one-third (35%) of women agreed with voluntary fortification. Future health promotion initiatives should be tailored toward women who are younger, less educated, with lower income, multiparous or of minority ethnicity status. Nonetheless, mandatory folic acid fortification may be required to attain the desired degree of equity.

Periconceptional bread intakes indicate New Zealand's proposed mandatory folic acid fortification program may be outdated: results from a postpartum survey.

BACKGROUND: In September 2009, a folic acid fortification mandate (135 µg/100 g bread) was to be implemented in New Zealand. However, due to political and manufacturer objection, fortification was deferred until May 2012. Based on estimates of bread consumption derived from a 1997 nationally representative survey, this program was intended to deliver a mean additional intake of 140 µg folic acid/d to women of childbearing age. Little is known about current bread consumption patterns in this target group. The aim of this study was to assess bread consumption among women prior to and during pregnancy with the intent to estimate periconceptional folic acid intakes that would be derived from bread if mandatory fortification were implemented as currently proposed. METHODS: A retrospective survey of 723 postpartum women in hospitals and birthing centres across New Zealand was conducted using a self-administered questionnaire on bread intake prior to and during pregnancy and maternal socio-demographic and obstetric characteristics. RESULTS: Median bread intake before conception (2 slices/d) was below that of previous data upon which the current fortification proposal was modeled (3-4 slices/d). If mandatory fortification is implemented as proposed, only 31% (95% CI = 24%-37%) of childbearing-age women would attain an additional folic acid intake of ≥ 140 µg/d, with a mean of 119 µg/d (95% CI = 107 µg/d-130 µg/d). Based on these data, a fortification level of 160 µg/100 g bread is required to achieve the targeted mean of 140 µg folic acid/d. Nonetheless, under the current proposal additional folic acid intakes would be greatest among the least advantaged segments of the target population: Pacific and indigenous Maori ethnic groups; those with increased parity, lower income and education; younger and single mothers; and women with unplanned pregnancies. Subgroups predicted to derive less than adequate folic acid intakes from the proposed policy were women of Asian descent and those with a postgraduate education. CONCLUSIONS: This study provides insight on the ability of a fortification policy to benefit the groups at highest risk of poor folate intakes in a population. However, bread consumption among the target group of childbearing women appears to have declined since the data used in previous dietary modeling were collected. Thus, it seems prudent to re-model dietary folic acid intakes based on more recent national survey data prior to the implementation of a mandatory folic acid fortification policy.

Delaying mandatory folic acid fortification policy perpetuates health inequalities: results from a retrospective study of postpartum New Zealand women.

BACKGROUND: Internationally, poor periconceptional folic acid uptake has been associated with lower socioeconomic status, minority ethnicity status and unintentional pregnancy. The aim of this study was to describe the extent to which a proposed bread fortification mandate would modify these associations. METHODS: A retrospective survey of postpartum women in hospitals and birthing centres across New Zealand was conducted using a self-administered questionnaire. Details on supplement use and bread intake in the periconceptional period, and maternal socio-demographic and obstetric characteristics were obtained. Criteria for the adequate intake of folic acid through proposed mandatory fortification were the habitual consumption of three or more slices of bread/day (118-150 µg folic acid/day) in the month prior to conception, and during the first trimester of pregnancy. RESULTS: Of the 968 women approached, 758 (78%) agreed to participate. Thirty-three percent of women reported having used folic acid supplements as recommended during the periconceptional period. The proportion of women who would have achieved adequate folic acid intake increased to 59% with mandatory fortification. Socio-demographic predictors of poor folic acid intake from supplements, including younger maternal age, increasing parity, minority ethnicity status, lower education and less income, were rendered either non-significant or appreciably attenuated when mandatory fortification was modelled. Notably, the fully adjusted odds ratio for pregnancy planning was reduced from 17.24 [95% confidence interval (CI): 8.13-36.55] to 2.61 (95% CI: 1.73-3.93; both P< 0.001). CONCLUSIONS: Few women comply with periconceptional folic acid recommendations and thus the maximal prevention of neural tube defects is still far from being attained. Data from this retrospective study demonstrate that mandatory fortification benefits segments of the population less likely to use supplements. This finding has compelling policy implications in countries yet to mandate the folic acid fortification of a staple food.