Multiphasic exercise prehabilitation for patients undergoing surgery for head and neck cancer: a hybrid effectiveness-implementation study protocol.

Head and neck cancer (HNC) treatment often consists of major surgery followed by adjuvant therapy, which can result in treatment-related side effects, decreased physical function, and diminished quality of life. Perioperative nutrition interventions and early mobilization improve recovery after HNC treatment. However, there are few studies on prehabilitation that include exercise within the HNC surgical care pathway. We have designed a multiphasic exercise prehabilitation intervention for HNC patients undergoing surgical resection with free flap reconstruction. We will use a hybrid effectiveness-implementation study design guided by the RE-AIM framework to address the following objectives: (1) to evaluate intervention benefits through physical function and patient-reported outcome assessments; (2) to determine the safety and feasibility of the prehabilitation intervention; (3) to evaluate the implementation of exercise within the HNC surgical care pathway; and (4) to establish a post-operative screening and referral pathway to exercise oncology resources. The results of this study will provide evidence for the benefits and costs of a multiphasic exercise prehabilitation intervention embedded within the HNC surgical care pathway. This paper describes the study protocol design, multiphasic exercise prehabilitation intervention, planned analyses, and dissemination of findings. Trial registration: https://clinicaltrials.gov/NCT04598087.

Comparing the Effects of Consuming Almonds or Biscuits on Body Weight in Habitual Snackers: A 1-Year Randomized Controlled Trial.

BACKGROUND: Almonds are nutrient rich, providing a healthier alternative to many snacks. Studies report health benefits with regular almond consumption without adverse weight gain. However, most interventions have been relatively short or have included additional dietary advice. OBJECTIVES: Taking a pragmatic approach, we compared consumption of almonds compared with biscuits on body weight and other health outcomes in a population of regular snackers of discretionary foods, hypothesizing the almonds will displace some of the less-healthful snacks in their current diets. METHODS: We randomly assigned 136 nonobese habitual discretionary snackers to receive almonds or biscuits daily for 1 y. These isocaloric snacks provided either 10% of participants' total energy (TE) requirements or 1030 kJ (equivalent to 42.5 g almonds), whichever was greater. Anthropometry, blood biomarkers, diet, appetite, sleep, and physical activity were assessed at baseline, 3, 6, and 12 mo, and body composition and RMR at baseline and 12 mo. RESULTS: The difference in changes for body weight from baseline to 12 mo was not statistically significant (geometric means: 67.1 and 69.5 kg for almonds and 66.3 and 66.3 kg for biscuits, P = 0.275). There were no statistically significant differences in changes for body composition or other nondietary outcomes (all P ≥ 0.112). Absolute intakes of protein; total, polyunsaturated, and monosaturated fat; fiber; vitamin E; calcium; copper; magnesium; phosphorous; and zinc, and % TE from total monounsaturated, and polyunsaturated fat statistically significantly increased from baseline (all P ≤ 0.033), whereas % TE from carbohydrate and sugar statistically significantly (both P ≤ 0.014) decreased from baseline, in the almond compared with the biscuit group. CONCLUSIONS: Almonds can be incorporated into the diets of habitual snackers to improve diet quality, without evidence for changes in body weight, compared with a popular discretionary snack food. This trial was registered at the Australian New Zealand Clinical Trials Registry (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375610&isReview=true), registration number ACTRN12618001758291.

Snacking on Almonds Lowers Glycaemia and Energy Intake Compared to a Popular High-Carbohydrate Snack Food: An Acute Randomised Crossover Study.

Consuming nuts may have advantages over other snack foods for health and body-weight regulation. Suggested mechanisms include increased satiety and lower glycaemia. We used an acute randomised crossover trial to assess glycaemic and appetite responses to consuming two isocaloric snacks (providing 10% of participants' total energy requirements or 1030 kJ (equivalent to 42.5 g almonds), whichever provided greater energy): raw almonds and sweet biscuits among 100 participants with available data (25 males and 75 females) following 106 being randomised. Two hours after consuming a standardised breakfast, participants consumed the snack food. Finger-prick blood samples measuring blood glucose and subjective appetite ratings using visual analogue scales were taken at baseline and at 15 or 30 min intervals after consumption. Two hours after snack consumption, an ad libitum lunch was offered to participants and consumption was recorded. Participants also recorded food intake for the remainder of the day. The mean area under the blood glucose response curve was statistically and practically significantly lower for almonds than biscuits (mean (95% CI) difference: 53 mmol/L.min (45, 61), p < 0.001). Only the composite appetite score at 90 min was higher in the almond treatment compared to the biscuit treatment (45.7 mm vs. 42.4 mm, p = 0.035 without adjustment for multiple comparisons). There was no evidence of differences between the snacks for all other appetite ratings or for energy intake at the ad libitum lunch. However, mean energy intakes following snack consumption were significantly lower, both statistically and in practical terms, for the almond treatment compared to the biscuit (mean (95% CI) diff: 638 kJ (44, 1233), p = 0.035). Replacing popular snacks with almonds may have advantages in terms of glycaemia and energy balance.

Is a Handful an Effective Way to Guide Nut Recommendations?

Dietary guidelines recommend consuming 30 g of nuts per day to reduce the risk of chronic disease. A 'handful' is commonly used to guide consumers. Research is lacking on how this translates into actual gram amounts. This study quantified the grams of nuts represented by different portion size measures, including a 'handful' and '30 g serving' among 120 participants. Each participant was randomised to a sequence where they received three of six different nut types (from almonds, cashews, hazelnuts, macadamias, peanuts, and walnuts) and were instructed to take a: 'usual serving', 'handful', 'small handful', 'large handful', and '30 g serving' of each. Combining all nut types, the median 'handful' was 36.3 g, compared to 28.7 g for the estimated '30 g serving' and 24.8 for the 'usual serving'. The 'large handful' was approximately double the 'handful' (61.3 g), whereas the 'small handful' was about half (16.7 g). Eighty-three percent of portions chosen were at least 80% of the recommended 30 g intake when participants were asked to take a 'handful', compared to 63% for the '30 g serving'. It appears a 'handful' can be used as a practical tool to guide recommended nut intakes, and increases the amount selected compared to instructions to take a '30 g serving'.

A comparison of perceptions of nuts between the general public, dietitians, general practitioners, and nurses.

BACKGROUND: Nut consumption at the population level remains low despite the well-documented benefits of their consumption, including their cardioprotective effects. Studies have suggested that advice from health professionals may be a means to increase nut consumption levels. Understanding how nuts are perceived by the public and health professionals, along with understanding the public's perceptions of motivators of and deterrents to consuming nuts, may inform the development of initiatives to improve on these low levels of consumption. The aim of this cross-sectional study was to compare perceptions of nuts among three groups of health professionals (dietitians, general practioners, and practice nurses) and the general public in New Zealand (NZ), along with motivators of and deterrents to consuming nuts amongst the general public and their experiences of receiving advice around nut consumption. METHODS: The NZ electoral roll was used to identify dietitians, general practitioners (GPs), and practice nurses, based on their free-text occupation descriptions, who were then invited to complete a questionnaire with 318, 292, and 149 respondents respectively. 1,600 members of the general public were randomly selected from the roll with 710 respondents. Analyses were performed using chi-squared tests to look at differences in categorical variables and linear regression for differences in other variables between the four survey groups. RESULTS: Although there were significant differences between the four groups regarding the perceptions of nuts, in general there was agreement that nuts are healthy, high in protein and fat, are filling, and some nuts are high in selenium. We noted frequent agreement that the general public participants would consume more if nuts: improved health (67%), were more affordable (60%), or improved the nutrient content (59%) and balance of fats (58%) within their diets. Over half the respondents reported they would eat more nuts if they were advised to do so by a dietitian or doctor, despite less than 4% reporting they had received such advice. The most frequently selected deterrents to increasing nut consumption were: cost (67%), potential weight gain (66%), and leading to eating too much fat (63%). DISCUSSION: It is concerning that so few among the general public report receiving advice to consume more nuts from health professionals, especially given their apparent responsiveness to such advice. Health professionals could exploit the motivators of nut consumption, while also addressing the deterrents, to promote nut intake. These factors should also be addressed in public health messages to encourage regular nut consumption among the public. Educational initiatives could also be used to improve the nutritional knowledge of GPs and practice nurses with regard to nuts, although even dietitians were unsure of their knowledge in some cases.

The effects of 'activating' almonds on consumer acceptance and gastrointestinal tolerance.

PURPOSE: Recommendations to soak nuts prior to consumption to reduce phytate concentrations and improve gastrointestinal tolerance have received much attention in the popular press. This is despite no supporting scientific evidence for the practice. There is also a lack of information about how soaking nuts might affect consumer acceptability. This study primarily assessed the effects of soaking almonds on consumer acceptance and secondly assessed effects on gastrointestinal tolerance. METHODS: In this 8-week randomised crossover trial, 76 participants were allocated in balanced order to receive 30 g/day of four different preparations of almonds for 12 days: whole unsoaked, whole soaked, sliced unsoaked, and sliced soaked. Ratings of overall liking, desire to consume, and likelihood of future consumption, and severity of gastrointestinal symptoms were measured daily on visual analogue scales. The phytate concentrations were measured in all four nut types using high-performance liquid chromatography. RESULTS: Mean acceptance ratings of all nut types were above the neutral point indicating they were acceptable. However, sliced soaked almonds were rated significantly lower overall for all three acceptance scales compared to the other treatments (all P ≤ 0.003). The sliced unsoaked almonds were rated lower than both whole nut treatments (all P ≤ 0.006), while there were no significant differences between the two whole nut treatments (all P ≥ 0.511). Gastrointestinal symptoms were minimal, but flatulence was rated significantly higher for all time points combined for soaked whole nuts compared to unsoaked whole nuts (P = 0.005). Compared to the whole unsoaked nuts (mean [SD] 531 [9] mg/100 g), phytate concentration was higher for the whole soaked almonds (563 [38] mg/100 g, P = 0.016), with no evidence of a difference for the sliced soaked almonds (548 [27] mg/100 g, P = 0.197) and no difference between the soaked forms (P = 0.262). CONCLUSIONS: This research supports previous results suggesting nuts, including different forms, are an acceptable food. They are also well tolerated gastrointestinally, but soaking does not improve gastrointestinal tolerance or acceptance as claimed in the lay literature.

Current nut recommendation practices differ between health professionals in New Zealand.

OBJECTIVE: Despite evidence linking regular nut consumption with reduced chronic disease risk, population-level intakes remain low. Research suggests nut-promoting advice from doctors facilitates regular nut consumption. However, there is no information on current nut recommendation practices of health professionals. The aim of the present study was to examine the advice provided by health professionals regarding nut consumption. DESIGN: In this cross-sectional study, participants were invited to complete a survey including questions about their nut recommendation practices. SETTING: New Zealand (NZ). SUBJECTS: The NZ Electoral Roll was used to identify dietitians, general practitioners and practice nurses. RESULTS: In total 318 dietitians, 292 general practitioners and 149 practice nurses responded. Dietitians were more likely (82·7 %) to recommend patients increase consumption of nuts than general practitioners (55·5 %) and practice nurses (63·1 %; both P<0·001). The most popular nuts recommended were almonds, Brazil nuts and walnuts, with most health professionals recommending raw nuts. The most common recommendation for frequency of consumption by dietitians and practice nurses was to eat nuts every day, while general practitioners most frequently recommended 2-4 times weekly, although not statistically significantly different between professions. Dietitians recommended a significantly greater amount of nuts (median 30 g/d) than both general practitioners and practice nurses (20 g/d; both P<0·001). CONCLUSIONS: Dietitians were most likely to recommend consumption of nuts in accordance with current guidelines, but there are opportunities to improve the adoption of nut consumption recommendations for all professions. This may be a viable strategy for increasing population-level nut intakes to reduce chronic disease.

Barriers to and facilitators and perceptions of nut consumption among the general population in New Zealand.

OBJECTIVE: Despite considerable evidence supporting the health benefits of regular nut consumption, nut intakes remain lower than recommended among many populations. Understanding how the general population perceives nuts could inform strategies to promote regular nut consumption and increase intakes among the general public. DESIGN: Cross-sectional study. Participants were invited to complete a questionnaire which included information on nut consumption and knowledge and perceptions of nuts. SETTING: The study was set in New Zealand (NZ). SUBJECTS: Participants (n 1600), aged 18 years or over, were randomly selected from the NZ electoral roll. RESULTS: A total of 710 participants completed the questionnaire (response rate 44 %). More than half of the respondents believed that nuts are healthy, filling, high in protein and high in fat. The most common reason cited by consumers for eating nuts was taste (86 % for nuts, 85 % for nut butters), while dental issues was the most frequent reason for avoidance. About 40 % of respondents were not aware of the effects of nut consumption on lowering blood cholesterol and CVD risk. CONCLUSIONS: Despite overall basic knowledge of the nutritional value of nuts, a substantial proportion of the general population was unaware of the cardioprotective effects of nuts. The present study identified common motivations for eating and avoiding nuts, as well as perceptions of nuts which could affect intake. These should guide the content and direction of public health messages to increase regular nut consumption. The public's knowledge gaps should also be addressed.

Nut consumption is associated with better nutrient intakes: results from the 2008/09 New Zealand Adult Nutrition Survey.

A limited number of studies have examined associations between nut consumption and nutrient intakes or diet quality. None has investigated these associations in the Southern Hemisphere. The purpose of this study was to examine associations between nut consumption and nutrient intakes among adult New Zealanders. Data from the 24-h recalls of 4721 participants from the cross-sectional 2008/09 New Zealand Adult Nutrition Survey (2008/09 NZANS) were used to determine whole nut intake and total nut intake from all sources as well as nutrient intakes. Regression models, both unadjusted and adjusted for potential confounders, were used to estimate differences in nutrient intakes between those consuming and those not consuming nuts. From adjusted models, compared with non-whole nut consumers, whole nut consumers had higher intakes of energy and percentage of energy from total fat, MUFA and PUFA, whereas percentage of energy from SFA and carbohydrate was lower (all P≤0·025). After the additional adjustment for energy intake, whole nut consumers had higher intakes of dietary fibre, vitamin E, folate, Cu, Mg, K, P and Zn (all P≤0·044), whereas cholesterol and vitamin B12 intakes were significantly lower (both P≤0·013). Total nut consumption was associated with similar nutrient profiles as observed in whole nut consumers, albeit less pronounced. Nut consumption was associated with better nutrient profiles, especially a lower intake of SFA and higher intakes of unsaturated fats and a number of vitamins and minerals that could collectively reduce the risk for chronic disease, in particular for CVD.

Acute necrotizing myopathy in a dog.

A 9 yr old spayed female cocker spaniel presented for an acute onset of weakness. Rhabdomyolysis and myoglobinuria were found 36 hr after presentation. The dog was managed for several electrolyte and mineral abnormalities and rhabdomyolysis-induced acute renal failure. The diagnosis of idiopathic necrotizing myopathy was determined by histopathology and by the exclusion of underlying infectious agents and metabolic defects. The dog recovered completely from the acute crisis and acute renal failure.

Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment--Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial.

OBJECTIVE: To determine the extent to which intensive dietary intervention can influence glycaemic control and risk factors for cardiovascular disease in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment. DESIGN: Randomised controlled trial. SETTING: Dunedin, New Zealand. PARTICIPANTS: 93 participants aged less than 70 years with type 2 diabetes and a glycated haemoglobin (HbA(1c)) of more than 7% despite optimised drug treatments plus at least two of overweight or obesity, hypertension, and dyslipidaemia. INTERVENTION: Intensive individualised dietary advice (according to the nutritional recommendations of the European Association for the Study of Diabetes) for six months; both the intervention and control participants continued with their usual medical surveillance. MAIN OUTCOME MEASURES: HbA(1c) was the primary outcome. Secondary outcomes included measures of adiposity, blood pressure, and lipid profile. RESULTS: After adjustment for age, sex, and baseline measurements, the difference in HbA(1c) between the intervention and control groups at six months (-0.4%, 95% confidence interval -0.7% to -0.1%) was highly statistically significant (P=0.007), as were the decreases in weight (-1.3 kg, -2.4 to -0.1 kg; P=0.032), body mass index (-0.5, -0.9 to -0.1; P=0.026), and waist circumference (-1.6 cm, -2.7 to -0.5 cm; P=0.005). A decrease in saturated fat (-1.9% total energy, -3.3% to -0.6%; P=0.006) and an increase in protein (1.6% total energy, 0.04% to 3.1%; P=0.045) in the intervention group were the most striking differences in nutritional intake between the two groups. CONCLUSIONS: Intensive dietary advice has the potential to appreciably improve glycaemic control and anthropometric measures in patients with type 2 diabetes and unsatisfactory HbA(1c) despite optimised hypoglycaemic drug treatment. TRIAL REGISTRATION: Clinical trials NCT00124553.

Rising methods and leavening agents used in the production of bread do not impact the glycaemic index.

The aim of this study was to compare the glycaemic index of breads produced using different rising methods and leavening agents. Eleven bread varieties were selected based on method of production, and divided between three groups of ten participants (mean +/- SD age 30.0 +/- 10.7 years and BMI 22.9 +/- 2.8). Standard glycaemic index testing protocol was implemented after an overnight fast, using glucose as the reference food, and collecting blood samples over a two-hour period. Glycemic index was calculated using the usual method. Additionally, incremental area under the curve data were log transformed and glycaemic index was calculated using regression analysis. Mean glycaemic index values of the breads in ascending order were as follows: Swiss Rye; 60, Long oat; 68, Sourdough+oats; 71, Long rye; 76, Short oat; 77, Short whole meal; 78, Long whole meal; 80, Sourdough; 82, Short rye; 82, Yeast; 88, and Desem; 92. There were significant differences in mean glycaemic index values between Swiss Rye and Yeast (p = 0.010), Swiss Rye and Desem (p = 0.007) and Sourdough+oats and Desem (p = 0.043). The rising method and leavening agents used in this study did not impact on the glycaemic index of the breads tested. Other factors, such as increased bread density, and the addition of whole grains may be required to produce bread with a low glycaemic index.

Isocaloric substitution of plant sterol-enriched fat spread for carbohydrate-rich foods in a low-fat, fibre-rich diet decreases plasma low-density lipoprotein cholesterol and increases high-density lipoprotein concentrations.

BACKGROUND AND AIM: The aim of the study was to determine the effects on plasma cholesterol of replacing a plant sterol-enriched fat spread with carbohydrate-rich foods relative to a diet high in saturated fat. METHODS AND RESULTS: Twenty-nine men and women, from the general community, with mean age (SD) 48 (14)y, body mass index 29.0 (6.2)kg/m(2), and plasma total cholesterol concentration 6.48 (0.97)mmol/L completed the randomised, crossover dietary intervention. There were three diets: New Zealand diet (NZ diet) high in total (34%kJ) and saturated (15%kJ) fat, a cholesterol-lowering fibre-rich diet reduced in total (30%kJ) and saturated fat (8%kJ) but including a plant sterol spread (PS diet), and the same cholesterol-lowering diet with the plant sterol spread isocalorically replaced with carbohydrate (CHO diet); total fat, 26%kJ; saturated fat 7%kJ. All foods were provided and each diet was followed for four weeks. Mean (SD) plasma low-density lipoprotein cholesterol concentration declined from 4.68 (0.91)mmol/L on the high saturated fat diet to 4.12 (0.83)mmol/L (P<0.001) on the carbohydrate diet and 3.76 (0.84)mmol/L (P<0.001) on the plant sterol diet. The 20% decrease on the plant sterol diet was significantly greater (P<0.001) than the 12% decrease on the carbohydrate diet. Relative to the NZ diet, mean (95% CI) plasma high-density lipoprotein cholesterol concentration changed by -0.11 (-0.16, -0.06)mmol/L on the CHO diet but was not different at the end of the PS diet, -0.03 (-0.09, 0.02). CONCLUSION: Including a plant sterol-enriched fat spread in a cholesterol-lowering diet produces a more favourable plasma lipid profile than the same diet made lower in total and saturated fat by replacing the spread with carbohydrate-rich foods.

A new approach to design and implement a lifestyle intervention programme to prevent type 2 diabetes in New Zealand Maori.

Lifestyle programmes provide the greatest opportunity to stem the developing epidemic of type 2 diabetes. This is especially relevant to indigenous people worldwide, and to Maori in New Zealand. The shift from traditional diets and activities to a westernised energy dense diet and a sedentary lifestyle has precipitated the rapid increase in Maori developing type 2 diabetes in New Zealand. Attendance of Maori to mainstream health clinics or programmes has been poor, and a unique approach developed specifically for Maori is required if Maori are going to attend and benefit from lifestyle programmes. We describe the process involved in developing a successful community programme for Maori and outline the novel aspects of the programme which contribute to its acceptability and success in the local community.

Implementation of a successful lifestyle intervention programme for New Zealand Maori to reduce the risk of type 2 diabetes and cardiovascular disease.

Lifestyle programmes have been shown to reduce the risk of type 2 diabetes in European populations. The participation of Maori in many mainstream health programmes is poor. This study evaluates a lifestyle intervention programme which is acceptable to Maori and which has objective outcome measures to determine the effectiveness of the programme. Thirty six Maori men and women were recruited for a 4 month programme involving modification of diet and exercise. Insulin sensitivity was measured using a euglycaemic insulin clamp, body composition using dual-energy-absorptiometry and fitness using a submaximal exercise test. Secondary outcome measures included anthropometry, blood pressure, fasting glucose and insulin levels, and lipid profiles. There was a 24% improvement in insulin sensitivity (from 5.1 to 6.3 G/mIU/L, P=0.03, N=29). This was associated with a reduction of 3.1 kg in weight (95%CI -4 to -2) and a reduction of 7 mmHg in systolic blood pressure (95%CI -13, -1). This approach successfully reduced risk for type 2 diabetes and cardiovascular disease in New Zealand Maori in the short term.

Intensive lifestyle changes are necessary to improve insulin sensitivity: a randomized controlled trial.

OBJECTIVE: The extent to which lifestyle must be altered to improve insulin sensitivity has not been established. This study compares the effect on insulin sensitivity of current dietary and exercise recommendations with a more intensive intervention in normoglycemic insulin-resistant individuals. RESEARCH DESIGN AND METHODS: Seventy-nine normoglycemic insulin-resistant (determined by the euglycemic insulin clamp) men and women were randomized to either a control group or one of two combined dietary and exercise programs. One group (modest level) was based on current recommendations and the other on a more intensive dietary and exercise program. Insulin sensitivity was measured using a euglycemic insulin clamp, body composition was measured using dual-energy X-ray absorptiometry, and anthropometry and aerobic fitness were assessed before and after a 4-month intervention period. Four-day dietary intakes were recorded, and fasting glucose, insulin, and lipids were measured. RESULTS: Only the intensive group showed a significant improvement in insulin sensitivity (23% increase, P=0.006 vs. 9% in the modest group, P=0.23). This was associated with a significant improvement in aerobic fitness (11% increase in the intensive group, P=0.02 vs. 1% in the modest group, P=0.94) and a greater fiber intake, but no difference in reported total or saturated dietary fat. CONCLUSIONS: Current clinical dietary and exercise recommendations, even when vigorously implemented, did not significantly improve insulin sensitivity; however, a more intensive program did. Improved aerobic fitness appeared to be the major difference between the two intervention groups, although weight loss and diet composition may have also played an important role in determining insulin sensitivity.