Predispose, precipitate, perpetuate, and protect: how diet and the gut influence mental health in emerging adulthood.

Medicine often employs the 4Ps of predisposing, precipitating, perpetuating, and protective factors to identify salient influences on illness states, and to help guide patient care. Mental illness is a significant cause of morbidity and mortality worldwide. Mental health is a complex combination of biological, psychological, environmental, and social factors. There is growing interest in the gut-brain-microbiome (GBM) axis and its impact on mental health. We use the medical model of the 4Ps to explore factors involving the connection between nutrition and the GBM axis and their associated risks with mental health problems in emerging adults (EAs), a life stage when mental illness onset is the most common. We review the impact of current dietary trends on the GBM and on mental health, and the role that gut microbiome-based interventions can have in modulating the GBM axis of EAs. We discuss the implications of gut health on the GBM and areas for clinical intervention.

Breakfast Consumption and Diet Quality of Teens in Southwestern Ontario.

Background: Breakfast skipping has previously been associated with worse diet quality among adolescents; the latter increases the risk of chronic disease. However, many studies do not consider diet quality as a function of calories, which is problematic as skippers tend to consume less energy than consumers. Additionally, due to the lack of one accepted definition of both breakfast skipping and diet quality, it is unclear how differences found may change when using varying definitions. Objectives: We aimed to compare the Healthy Eating Index-2015 (HEI-2015) scores and nutrient intakes of teen breakfast skippers and consumers in Southwestern Ontario, Canada. Methods: Cross-sectional, baseline data were used from SmartAPPetite, an ongoing nutrition intervention study. Singular 24-h dietary recalls and sociodemographic data from 512 adolescents aged 13-19 y were used to compare HEI-2015 scores and nutrient intakes via multivariable linear regression. Results: Previous day breakfast skippers had significantly lower HEI-2015 scores (-4.4; 95% CI: -8.4, -0.4) and significantly lower intakes of calories, saturated fat, and vitamin C, as well as significantly higher intake of sodium and total fat. Conclusions: Previous day breakfast consumers had significantly higher diet quality scores and better nutrient intakes than breakfast skippers, although, on average, both had poor diet quality. Consequently, it is unlikely that simply advising teens to consume breakfast will result in meaningful change in diet quality, and more effort should be placed on promoting nutritious breakfasts.

Highly Parallel Tissue Grafting for Combinatorial In Vivo Screening.

Material- and cell-based technologies such as engineered tissues hold great promise as human therapies. Yet, the development of many of these technologies becomes stalled at the stage of pre-clinical animal studies due to the tedious and low-throughput nature of in vivo implantation experiments. We introduce a 'plug and play' in vivo screening array platform called Highly Parallel Tissue Grafting (HPTG). HPTG enables parallelized in vivo screening of 43 three-dimensional microtissues within a single 3D printed device. Using HPTG, we screen microtissue formations with varying cellular and material components and identify formulations that support vascular self-assembly, integration and tissue function. Our studies highlight the importance of combinatorial studies that vary cellular and material formulation variables concomitantly, by revealing that inclusion of stromal cells can "rescue" vascular self-assembly in manner that is material-dependent. HPTG provides a route for accelerating pre-clinical progress for diverse medical applications including tissue therapy, cancer biomedicine, and regenerative medicine.

Engineering the multiscale complexity of vascular networks.

The survival of vertebrate organisms depends on highly regulated delivery of oxygen and nutrients through vascular networks that pervade nearly all tissues in the body. Dysregulation of these vascular networks is implicated in many common human diseases such as hypertension, coronary artery disease, diabetes and cancer. Therefore, engineers have sought to create vascular networks within engineered tissues for applications such as regenerative therapies, human disease modelling and pharmacological testing. Yet engineering vascular networks has historically remained difficult, owing to both incomplete understanding of vascular structure and technical limitations for vascular fabrication. This Review highlights the materials advances that have enabled transformative progress in vascular engineering by ushering in new tools for both visualizing and building vasculature. New methods such as bioprinting, organoids and microfluidic systems are discussed, which have enabled the fabrication of 3D vascular topologies at a cellular scale with lumen perfusion. These approaches to vascular engineering are categorized into technology-driven and nature-driven approaches. Finally, the remaining knowledge gaps, emerging frontiers and opportunities for this field are highlighted, including the steps required to replicate the multiscale complexity of vascular networks found in nature.

Drugs, Guts, Brains, but Not Rock and Roll: The Need to Consider the Role of Gut Microbiota in Contemporary Mental Health and Wellness of Emerging Adults.

Emerging adulthood (ages 18-25) is a critical period for neurobiological development and the maturation of the hypothalamic-pituitary-adrenal axis. Recent findings also suggest that a natural perturbation of the gut microbiota (GM), combined with other factors, may create a unique vulnerability during this period of life. The GM of emerging adults is thought to be simpler, less diverse, and more unstable than either younger or older people. We postulate that this plasticity in the GM suggests a role in the rising mental health issues seen in westernized societies today via the gut-brain-microbiota axis. Studies have paid particular attention to the diversity of the microbiota, the specific function and abundance of bacteria, and the production of metabolites. In this narrative review, we focus specifically on diet, physical activity/exercise, substance use, and sleep in the context of the emerging adult. We propose that this is a crucial period for establishing a stable and more resilient microbiome for optimal health into adulthood. Recommendations will be made about future research into possible behavioral adjustments that may be beneficial to endorse during this critical period to reduce the probability of a "dysbiotic" GM and the emergence and severity of mental health concerns.

Polysalicylic Acid Polymer Microparticle Decoys Therapeutically Treat Acute Respiratory Distress Syndrome.

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) remain problematic due to high mortality rates and lack of effective treatments. Neutrophilic injury contributes to mortality in ALI/ARDS. Here, technology for rapid ARDS intervention is developed and evaluated, where intravenous salicylic acid-based polymer microparticles, i.e., Poly-Aspirin (Poly-A), interfere with neutrophils in blood, reducing lung neutrophil infiltration and injury in vivo in mouse models of ALI/ARDS. Importantly, Poly-A particles reduce multiple inflammatory cytokines in the airway and bacterial load in the bloodstream in a live bacteria lung infection model of ARDS, drastically improving survival. It is observed that phagocytosis of the Poly-A microparticles, with salicylic acid in the polymer backbone, alters the neutrophil surface expression of adhesion molecules, potentially contributing to their added therapeutic benefits. Given the proven safety profile of the microparticle degradation products-salicylic acid and adipic acid-it is anticipated that the Poly-A particles represent a therapeutic strategy in ARDS with a rare opportunity for rapid clinical translation.

Examining the Correlates of Adolescent Food and Nutrition Knowledge.

Food literacy is a set of skills and knowledge that are integral to diet. It is common among teenagers to not have basic food literacy skills needed to consume a healthy diet. This study examined: (1) the current state of food and nutrition knowledge among adolescents 13-19 years of age in the census metropolitan area of London, ON, Canada; and (2) correlates of food knowledge and nutrition knowledge among adolescents. Data for this study were drawn from baseline youth and parent survey data collected from a larger population health intervention study. Statistical analysis of the survey data indicates that higher parental education and higher median neighbourhood family income, the use of mobile health applications, liking to cook, as well as confidence in reading and understanding food labels were all consistently associated with increased food and nutrition knowledge. Findings may help guide future research towards optimal methods for delivering food literacy interventions to effectively educate teenagers. Results of this study may help guide policy makers, researchers, and public health professionals in developing appropriate food and nutrition programs and curriculums to combat the decline in food literacy skills.

Exercise capacity and its relationship with body composition and nutrition status in patients with interstitial lung disease.

BACKGROUND: Patients with interstitial lung disease (ILD) are known to have diminished exercise ability. This study aimed to explore the relationship between nutrition status and body composition parameters with exercise capacity in ILD patients. A second aim focused on assessing the appropriateness of surrogate markers of nutrition status in ILD patients. METHODS: Disease severity was determined by the percentage of predicted forced vital capacity. Exercise capacity was determined using 6-minute walk distance. Nutrition status was assessed using the subjective global assessment (SGA), standardized phase angle (SPhA), and impedance ratio z-score (z-IR). Bioelectrical impedance analysis estimated body composition parameters. RESULTS: 45 of 79 participants (57%) were malnourished according to the SGA. FFM index z-score (z-FFMI) (r = 0.42, P = .02) and SGA (r = 0.49, P < .01) were significant predictors of exercise capacity independent of disease severity. Age (odds ratio [OR] = 1.1; 95% CI, 1.01-1.25; P = .04), low body mass index (OR = 0.73; 95% CI, 0.57-0.92; P = .01), z-FFMI (OR = 0.34; 95% CI, 0.17-0.68; P < .01), and body fat mass index z-score (OR = 0.39; 95% CI, 0.17-0.91; P = .03) were significantly associated with severe malnutrition. There was no significant difference in SPhA across SGA groups; however, a higher z-IR (poorer cell health) significantly increased the odds of severe malnutrition (OR = 2.75; 95% CI, 1.27-6.03; P = .02). CONCLUSION: In ILD patients, malnutrition and loss of FFM negatively impact the ability to perform activities of daily living.

Fat-Free Mass Index Controlled for Age and Sex and Malnutrition Are Predictors of Survival in Interstitial Lung Disease.

BACKGROUND: Literature focusing on nutritional variables and survival in interstitial lung disease (ILD) is limited by its focus on weight and BMI and has not considered body composition. OBJECTIVES: The primary objective of this study was to examine whether body composition measures, specifically fat-free mass index z-score (z-FFMI) and body fat mass index z-score (z-BFMI), were predictors of survival in fibrotic ILD patients. The second objective was to examine if nutrition status was a predictor of survival. METHOD: Seventy-eight outpatients diagnosed with fibrotic ILD were recruited in this cross-sectional study. Body composition data using dual frequency bioelectrical impedance analysis (BodyStat 1500MD; UK) and nutrition status using the subjective global assessment (SGA) were determined. To control for age and sex, z-FFMI and z-BFMI were calculated using population means. Participant charts were reviewed for diagnosis, age, disease severity, and exercise capacity. RESULTS: Age (HR 1.08, 95% CI [1.03-1.13], p < 0.01), BMI (HR 0.90, 95% CI [0.84-0.97], p < 0.01]), z-FFMI (HR 0.70, 95% CI [0.56-0.87], p = 0.02), z-BFMI (HR 0.74, 95% CI [0.57-0.96], p < 0.01), 6-min walk distance (6MWD) (HR 0.99, 95% CI [0.99-1.00], p < 0.01), percent predicted diffusing capacity for carbon monoxide (%DLco) (HR 0.93, 95% CI [0.89-0.97], p < 0.01), and severe malnutrition (SGA-C) (HR 6.98, 95% CI [2.00-24.27], p < 0.01) were significant predictors of survival. When controlled for exercise capacity and disease severity, z-FFMI and severe malnutrition were significant predictors of survival independent of %DLco. CONCLUSION: z-FFMI and severe malnutrition were significant predictors of survival in fibrotic ILD patients independent of disease severity.

Greater Severity and Functional Impact of Post-traumatic Headache in Veterans With Comorbid Neck Pain Following Traumatic Brain Injury.

BACKGROUND: Post-traumatic headache (PTH) is a commonly experienced symptom after mild traumatic brain injury (mTBI). Blast injury- or blunt injury-related mechanisms for mTBI in veterans can also affect musculoskeletal structures in the neck, resulting in comorbid neck pain (NP). However, it is unknown whether the presence of comorbid NP may be associated with a different pattern of headache symptoms, physical functioning, or emotional functioning compared to those without comorbid NP. The purpose of this study is to examine the role of comorbid NP in veterans with mTBI and PTH. DESIGN AND METHODS: This was a cross-sectional investigation of an existing dataset that included 33 veterans who met inclusion criteria for PTH after mTBI. Standardized measures of headache severity and frequency, insomnia, fatigue, mood disorders, and physical and emotional role function were compared between groups with and without comorbid NP. RESULTS: The majority of participants with PTH reported comorbid NP (n = 22/33, 67%). Those with comorbid NP experienced more headache symptoms that were severe or incapacitating, as compared to mild or moderate for those without NP (φ = 0.343, P = .049); however, no differences in headache frequency (φ = 0.231, P = .231) or duration (φ = 0.129, P = .712) were observed. Participants with comorbid NP also reported greater insomnia (d = 1.16, P = .003) and fatigue (d = 0.868, P = .040) as well as lower physical functioning (d = 0.802, P = .036) and greater bodily pain (d = 0.762, P = .012). There were no differences in anxiety, depression, mental health, emotional role limitations, vitality, or social functioning between those with and without comorbid NP (d ≤ 0.656, P ≥ .079). CONCLUSIONS: A majority of veterans with mTBI and PTH in our sample reported comorbid NP that was associated with greater headache symptom severity and physical limitations, but not with mood or emotional limitations. Preliminary findings from this small convenience sample indicate that routine assessment of comorbid NP and associated physical limitations should be considered in veterans with mTBI and PTH.

The Ontario Public Does Not Understand the Difference Between Registered Dietitians and Unregulated "Nutritionists": Results from a Cross-Sectional Mixed Methods Study.

BACKGROUND: Current Ontario healthcare policy permits anyone to use the title "nutritionist" and practice as a clinician regardless of education and training. The title "dietitian," on the other hand, is protected under the Dietetics Act (1991) for use exclusively by individuals who undergo rigorous education and training in evidence-based nutrition. OBJECTIVES: The objectives of this study were to: identify whether the Ontario general public understands the difference between a registered dietitian (RD) and an unregulated "nutritionist;" understand experiences with RDs and "nutritionists;" and determine if the current nutrition landscape arising from gaps in healthcare policy has the potential to harm the public. METHODS: A cross-sectional mixed methods survey study was carried out using inductive content analysis, descriptive statistics and chi-square tests. RESULTS: Respondents (n = 402) did not understand the difference between RDs and "nutritionists." Overall, public experiences have been significantly more positive when nutrition information/advice stemmed from an RD. IMPLICATIONS: This study provides justification for proposed legislative amendments to the Dietetics Act (1991) and the Regulated Health Professions Act (1991). These proposed amendments have been detailed in the full-text manuscript.

Enhanced long-term dietary change and adherence in a nutrigenomics-guided lifestyle intervention compared to a population-based (GLB/DPP) lifestyle intervention for weight management: results from the NOW randomised controlled trial.

BACKGROUND: Adherence to nutritional guidelines for chronic disease prevention and management remains a challenge in clinical practice. Innovative strategies are needed to help optimise dietary behaviour change. OBJECTIVE: The objective of this study was to determine if a nutrigenomics-guided lifestyle intervention programme could be used to motivate greater dietary adherence and change in dietary intake short-term, moderate-term and long-term compared to the gold-standard population-based weight management intervention (Group Lifestyle Balance (GLB)/Diabetes Prevention Programme (DPP)). DESIGN: The Nutrigenomics, Overweight/Obesity, and Weight Management (NOW) randomised controlled trial is a pragmatic, parallel-group, superiority clinical trial (n=140), which was conducted at the East Elgin Family Health Team (EEFHT). GLB weight management groups were prerandomised 1:1 to receive either the standard GLB programme or a modified GLB+nutrigenomics (GLB+NGx) programme. Three 24-hour recalls were collected at baseline, 3, 6 and 12 months using the validated multiple pass method. Research assistants collecting the three 24-hour recalls were blinded to the participants' group assignments. Statistical analyses included split plot analyses of variance (ANOVAs), two-way ANOVAs, binary logistic regression, χ2 and Fisher's exact tests. Using the Theory of Planned Behaviour as guidance, key confounding factors of behaviour change were considered in the analyses. This study was registered with clinicaltrials.gov (NCT03015012). RESULTS: Only the GLB+NGx group significantly reduced their total fat intake from baseline to 12-month follow-up (from 36.0%±4.8% kcal to 30.2%±8.7% kcal, p=0.02). Long-term dietary adherence to total fat and saturated fat guidelines was also significantly (p<0.05) greater in the GLB+NGx group compared to the standard GLB group. CONCLUSIONS: Weight management interventions guided by nutrigenomics can motivate long-term improvements in dietary fat intake above and beyond gold-standard population-based interventions.

Can a Lifestyle Genomics Intervention Motivate Patients to Engage in Greater Physical Activity than a Population-Based Intervention? Results from the NOW Randomized Controlled Trial.

BACKGROUND: Lifestyle genomics (LGx) is a science that explores interactions between genetic variation, lifestyle components such as physical activity (PA), and subsequent health- and performance-related outcomes. The objective of this study was to determine whether an LGx intervention could motivate enhanced engagement in PA to a greater extent than a population-based intervention. METHODS: In this pragmatic randomized controlled trial, participants received either the standard, population-based Group Lifestyle BalanceTM (GLB) program intervention or the GLB program in addition to the provision of LGx information and advice (GLB + LGx). Participants (n = 140) completed a 7-day PA recall at baseline, 3, 6, and 12 months. Data from the PA recalls were used to calculate metabolic equivalents (METs), a measure of energy expenditure. Statistical analyses included split plot analyses of covariance and binary logistic regression (generalized linear models). Differences in leisure time PA weekly METs, weekly minutes of moderate + high-intensity PA, and adherence to PA guidelines were compared between groups (GLB and GLB + LGx) across the 4 time points. RESULTS: Weekly METs were significantly higher in the GLB + LGx group (1,114.7 ± 141.9; 95% CI 831.5-1,397.8) compared to the standard GLB group (621.6 ± 141.9 MET/week; 95% CI 338.4-904.8) at the 6-month follow-up (p = 0.01). All other results were non-significant. CONCLUSIONS: The provision of an LGx intervention resulted in a greater weekly leisure time PA energy expenditure after the 6-month follow-up. Future research should determine how this could be sustained over the long-term. CLINICAL TRIAL REGISTRATION: NCT03015012.

Thermofluidic heat exchangers for actuation of transcription in artificial tissues.

Spatial patterns of gene expression in living organisms orchestrate cell decisions in development, homeostasis, and disease. However, most methods for reconstructing gene patterning in 3D cell culture and artificial tissues are restricted by patterning depth and scale. We introduce a depth- and scale-flexible method to direct volumetric gene expression patterning in 3D artificial tissues, which we call "heat exchangers for actuation of transcription" (HEAT). This approach leverages fluid-based heat transfer from printed networks in the tissues to activate heat-inducible transgenes expressed by embedded cells. We show that gene expression patterning can be tuned both spatially and dynamically by varying channel network architecture, fluid temperature, fluid flow direction, and stimulation timing in a user-defined manner and maintained in vivo. We apply this approach to activate the 3D positional expression of Wnt ligands and Wnt/ß-catenin pathway regulators, which are major regulators of development, homeostasis, regeneration, and cancer throughout the animal kingdom.

Change in Weight, BMI, and Body Composition in a Population-Based Intervention Versus Genetic-Based Intervention: The NOW Trial.

OBJECTIVE: The aim of this study was to compare changes in body fat percentage (BFP), weight, and BMI between a standard intervention and a nutrigenomics intervention. METHODS: The Nutrigenomics, Overweight/Obesity and Weight Management (NOW) trial is a parallel-group, pragmatic, randomized controlled clinical trial incorporated into the Group Lifestyle BalanceTM (GLB) Program. Statistical analyses included two-way ANOVA and split-plot ANOVA. Inclusion criteria consisted of: BMI ≥ 25.0 kg/m2 , ≥18 years of age, English speaking, willing to undergo genetic testing, having internet access, and not seeing another health care provider for weight-loss advice outside of the study. Pregnancy and lactation were exclusion criteria. GLB groups were randomly assigned 1 to 1 (N = 140) so that participants received either the standard 12-month GLB program or a modified 12-month program (GLB plus nutrigenomics), which included the provision of nutrigenomics information and advice for weight management. The primary outcome was percent change in BFP. Secondary outcomes were change in weight and BMI. RESULTS: The GLB plus nutrigenomics group experienced significantly (P < 0.05) greater reductions in percent and absolute BFP at the 3-month follow-up and percent BFP at the 6-month follow-up compared with the standard GLB group. CONCLUSIONS: The nutrigenomics intervention used in the NOW trial can optimize change in body composition up to 6 months.

A Case Report of Peripheral Nerve Stimulation for Acute Neuropathic Pain in Guillain-Barre Syndrome.

Guillain-Barre syndrome (GBS) is a peripheral demyelinating neuromuscular disorder occasionally associated with pharmacologically refractory neuropathic pain. We present a case of acute neuropathic pain in a 22-year-old man with GBS managed with percutaneous peripheral nerve stimulation (PNS). Following implantation of leads in the bilateral sciatic, femoral, and brachial plexus nerve distribution, the patient experienced significant pain reduction in both the upper and lower extremities. Analgesic and anxiolytic medications were reduced by 33% on the first day and by 78% on day 21. PNS is a minimally invasive, nonpharmacologic modality for treating acute neuropathic pain in GBS patients.

Nutritional, Microbial, and Allergenic Changes during the Fermentation of Cashew 'Cheese' Product Using a Quinoa-Based Rejuvelac Starter Culture.

Fermentation has been applied to a multitude of food types for preservation and product enhancing characteristics. Interest in the microbiome and healthy foods makes it important to understand the microbial processes involved in fermentation. This is particularly the case for products such as fermented cashew (Anacardium occidentale). We hereby describe the characterisation of cashew samples throughout an entire fermentation production process, starting at the quinoa starter inoculum (rejuvelac). The viable bacterial count was 108 -109 colony forming units/g. The nutritional composition changed marginally with regards to fats, carbohydrates, vitamins, and minerals. The rejuvelac starter culture was predominated by Pediococcus and Weissella genera. The 'brie' and 'blue' cashew products became dominated by Lactococcus, Pediococcus, and Weissella genera as the fermentation progressed. Cashew allergenicity was found to significantly decrease with fermentation of all the end-product types. For consumers concerned about allergic reactions to cashew nuts, these results suggested that a safer option is for products to be made by fermentation.

Study protocol of a pragmatic randomized controlled trial incorporated into the Group Lifestyle Balance™ program: the nutrigenomics, overweight/obesity and weight management trial (the NOW trial).

BACKGROUND: The nutrigenomics, overweight/obesity and weight management trial (NOW Trial) is a pragmatic randomized controlled trial of community-dwelling adults recruited from the Group Lifestyle Balance™ (GLB™) Program. The GLB™ Program (formerly referred to as the Diabetes Prevention Program) is an evidence-based, intensive weight management program, which was offered to overweight/obese patients (BMI ≥ 25.0 kg/m2) in a rural Ontario community. METHODS: Patients enrolled in the GLB™ Program were invited to participate in this study. GLB™ groups were randomized 1:1 to receive either the standard GLB™ program + population-based lifestyle advice for weight management, or a modified GLB™ program + personalized, genetic-based lifestyle advice for weight management. The purpose of this study is to determine if the provision of genetic-based lifestyle guidelines is superior to the provision of population-based guidelines in a pragmatic clinical setting to promote changes in: body composition, weight, body mass index, dietary and physical activity habits, as well as attitudes, subjective norms, and behavioural control. The 12-month intervention protocol consists of 23 group-based sessions and 4 one-on-one sessions. Data collection time points include baseline in addition to 3, 6, and 12-month follow up. The comprehensive study design is described in the present manuscript, using both the extended CONSORT checklist for reporting pragmatic trials and the SPIRIT checklist as guidance during manuscript development. DISCUSSION: Overall, this study seeks to pragmatically determine if the provision of DNA-based lifestyle advice leads to improved health and lifestyle outcomes compared to the provision of standard, population-based lifestyle advice. The results of this trial can be used to inform clinical and community nutrition practice guidelines. TRIAL REGISTRATION: This study was registered with clinicaltrials.gov : NCT03015012 on January 9, 2017.

"Detoxify or Die": Qualitative Assessments of Ontario Nutritionists' and Dietitians' Blog Posts Related to Detoxification Diets.

While the title Registered Dietitian (RD) is regulated under provincial legislation in Ontario and other Canadian provinces, the title "nutritionist" is not regulated in Ontario, which poses potential risks to consumers who place misguided trust in those proclaiming to be nutrition experts. This is concerning as nutrition is a complex health care discipline and RDs, the recognized providers of credible nutrition information, must be registered with an accredited regulatory college that requires them to have undergone rigorous training, practicum placements, entrance examinations, and continuous professional development. The purpose of this study was to determine if Ontario-based unregulated nutritionists and RDs are providing safe, evidence-based, information regarding detoxification diets. Content from 10 blog posts were qualitatively analyzed using deductive content analysis with predetermined categorization matrices. The results revealed that Ontario nutritionists promoted detox diets and provided unproven, misleading, and potentially harmful information, whereas Ontario RDs did not promote detox diets and provided evidence-based, harm-reducing information. Additionally, conflicts of interest arose only in nutritionists' blog posts. RDs provided credible references for their information while nutritionists did not. Protecting the term "nutritionist" for use exclusively by RDs under provincial legislation would be a positive step towards ensuring Ontarians are receiving the highest quality evidence-based nutrition information.

Is phase angle an appropriate indicator of malnutrition in different disease states? A systematic review.

BACKGROUND & AIMS: Subjective Global Assessment (SGA) classifies malnutrition severity via a simple bedside assessment. Phase angle (PhA) is an indicator of cell integrity and has been suggested to be indicator of nutritional status. OBJECTIVE: To explore the relationship between PhA and SGA. METHODS: Relevant studies published through October 31, 2017 were identified using 7 electronic databases. Articles were included for review if they included comparison data between SGA and PhA within adult disease populations. Evidence quality was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines and methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS: 33 articles within four disease states (liver, hospitalization, oncology and renal) met inclusion criteria for review. Results were limited by restricting the database search to articles published in English only, and by the inherent difficulty of comparing 2 methods which are both influenced by the operator. CONCLUSION: Based on GRADE guidelines, evidence quality received a grade of Low. Based on QUADAS-2, 61% of studies had high risk of bias in the index test (PhA), while all other domains had low risk. It is not possible to conclude that PhA is an accurate independent indicator of malnutrition. PROSPERO no. CRD42016050876.