The International Breakfast Research Initiative-Evaluation and Comparison of Breakfast Nutrient Intakes in Indonesia, Malaysia and the Philippines with a View to Proposing a Harmonised Nutrient-Based Breakfast Recommendation.

The International Breakfast Research Initiative is a global study of breakfast nutrition, involving 17 countries in four continents, aiming to derive nutrient-based regional recommendations for breakfast. This study aimed to propose a harmonised recommendation for three South-East Asian countries: Indonesia, Malaysia, and the Philippines. For each country, data from nationally representative dietary surveys on the contribution of breakfast to daily nutrient intakes at both the adult population level and at the level of the upper tertile of daily nutrient density using the Nutrient Rich Food (NRF) Index were collated and examined. Energy intakes at breakfast ranged from 26 to 27% of daily energy intake. In all three countries, breakfast was carbohydrate-rich, providing 52 to 72% of breakfast energy intake, while it was higher in total and saturated fat in Malaysia and Indonesia. Intakes of fibre and vitamin C were low in all countries, while Malaysia tended to have higher intakes of most minerals, including sodium. Daily and breakfast nutrient intakes (at the population level and in the upper tertile of the NRF Index) were compared to the Codex Alimentarius nutrient reference values (NRVs) to assess adequacy. A decision tree was established based on these data to guide the development of recommendations for nutrient intakes at breakfast across the three countries.

Toward a science-based classification of processed foods to support meaningful research and effective health policies.

Processed foods have been part of the American diet for decades, with key roles in providing a safe, available, affordable, and nutritious food supply. The USDA Food Guides beginning in 1916 and the US Dietary Guidelines for Americans (DGA) since 1980 have included various types of commonly consumed processed foods (e.g., heated, fermented, dried) as part of their recommendations. However, there are multiple classification systems based on "level" of food processing, and additional evidence is needed to establish the specific properties of foods classified as "highly" or "ultra"-processed (HPF/UPFs). Importantly, many foods are captured under HPF/UPF definitions, ranging from ready-to-eat fortified whole grain breakfast cereals to sugar-sweetened beverages and baked goods. The consequences of implementing dietary guidance to limit all intake of foods currently classified as HPF/UPF may require additional scrutiny to evaluate the impact on consumers' ability to meet daily nutrient recommendations and to access affordable food, and ultimately, on health outcomes. Based on a meeting held by the Institute for the Advancement of Food and Nutrition Sciences in May 2023, this paper provides perspectives on the broad array of foods classified as HPF/UPFs based on processing and formulation, including contributions to nutrient intake and dietary patterns, food acceptability, and cost. Characteristics of foods classified as UPF/HPFs are considered, including the roles and safety approval of food additives and the effect of food processing on the food matrix. Finally, this paper identifies information gaps and research needs to better understand how the processing of food affects nutrition and health outcomes.

Ultra-processed foods in public health nutrition: the unanswered questions.

There is a growing interest in the study of the degree of food processing and both health and nutritional outcomes. To that end, several definitions of the degree of processing have been proposed. However, when each of these is used on a common database of nutritional, clinical and anthropometric variables, the observed effect of high intakes of highly processed food, varies considerably.. Moreover, assigning a given food by nutritional experts, to its appropriate level of processing, has been shown to be variable. Thus, the subjective definitions of the degree of food processing and the coding of foods according to these classifications is prone to error is prone to error. Another issue that need resolution is the relative importance of the degree of food processing and the formulation of a processed food. Although correlational studies linking processed food and obesity abound, there is a need for more investigative studies.

Ultra-processed foods in public health nutrition: the unanswered questions.

There is a growing interest in the study of the degree of food processing and both health and nutritional outcomes. To that end, several definitions of the degree of processing have been proposed. However, when each of these is used on a common database of nutritional, clinical and anthropometric variables, the observed effect of high intakes of highly processed food, varies considerably.. Moreover, assigning a given food  by nutritional experts, to its appropriate level of processing, has been shown to be variable. Thus, the subjective definitions of the degree of food processing and the coding of foods according to these classifications is prone to error  is  prone to error. Another issue that need resolution is the relative importance of the degree of food processing and the formulation of a processed food. Although correlational studies linking processed food and obesity abound, there is a need for more investigative studies.

Vitamin B-6 and riboflavin, their metabolic interaction, and relationship with MTHFR genotype in adults aged 18-102 years.

BACKGROUND: The generation of the active form of vitamin B-6, pyridoxal 5'-phosphate (PLP), in tissues is dependent upon riboflavin as flavin mononucleotide, but whether this interaction is important for maintaining vitamin B-6 status is unclear. OBJECTIVE: To investigate vitamin B-6 and riboflavin status, their metabolic interaction, and relationship with methylenetetrahydrofolate reductase (MTHFR) genotype in adulthood. METHODS: Data from 5612 adults aged 18-102 y were drawn from the Irish National Adult Nutrition Survey (NANS; population-based sample) and the Trinity-Ulster Department of Agriculture (TUDA) and Genovit cohorts (volunteer samples). Plasma PLP and erythrocyte glutathione reductase activation coefficient (EGRac), as a functional indicator of riboflavin, were determined. RESULTS: Older (≥65 y) compared with younger (<65 y) adults had significantly lower PLP concentrations (P < 0.001). A stepwise decrease in plasma PLP was observed across riboflavin categories, from optimal (EGRac ≤1.26), to suboptimal (EGRac: 1.27-1.39), to deficient (EGRac ≥1.40) status, an effect most pronounced in older adults (mean ± SEM: 76.4 ± 0.9 vs 65.0 ± 1.1 vs 55.4 ± 1.2 nmol/L; P < 0.001). In individuals with the variant MTHFR 677TT genotype combined with riboflavin deficiency, compared with non-TT (CC/CT) genotype participants with sufficient riboflavin, we observed PLP concentrations of 52.1 ± 2.9 compared with 76.8 ±0.7 nmol/L (P < 0.001). In participants with available dietary data (i.e., NANS cohort, n = 936), PLP was associated with vitamin B-6 intake (nonstandardized regression coefficient ß: 2.49; 95% CI 1.75, 3.24; P < 0.001), supplement use (ß: 81.72; 95% CI: 66.01, 97.43; P < 0.001), fortified food (ß: 12.49; 95% CI: 2.08, 22.91; P = 0.019), and EGRac (ß: -65.81; 95% CI: -99.08, -32.54; P < 0.001), along with BMI (ß: -1.81; 95% CI: -3.31, -0.30; P = 0.019). CONCLUSIONS: These results are consistent with the known metabolic dependency of PLP on flavin mononucleotide (FMN) and suggest that riboflavin may be the limiting nutrient for maintaining vitamin B-6 status, particularly in individuals with the MTHFR 677TT genotype. Randomized trials are necessary to investigate the PLP response to riboflavin intervention within the dietary range. The TUDA study and the NANS are registered at www.ClinicalTrials.gov as NCT02664584 (27 January 2016) and NCT03374748 (15 December 2017), respectively.Clinical Trial Registry details: Trinity-Ulster-Department of Agriculture (TUDA) study, ClinicalTrials.gov no. NCT02664584 (January 27th 2016); National Adult Nutrition Survey (NANS), ClinicalTrials.gov no. NCT03374748 (December 15th 2017).

Nutrition research challenges for processed food and health.

Existing highly processed food (HPF) classification systems show large differences in the impact of these foods on biochemical risk factors for disease. If public health nutrition is to consider the degree of food processing as an important element of the link between food and health, certain gaps in research must be acknowledged. Quantifying the food additive exposure derived from HPFs is a task made challenging by the lack of data available on the occurrence and concentration of additives in food and the degree to which the natural occurrence of additives in unprocessed foods confounds exposure estimates. The proposed role of HPFs in health outcomes could also be associated with altered nutrient profiles. Differences exist within and between HPF classification systems in this regard and there are conflicting data on the impact of controlling for nutrient intake. Furthermore, research is needed on how the sensory aspects of HPFs contribute to energy intake. Current data suggest that high energy intake rate may be the mechanism linking HPFs and increased energy intake. A high priority now is to clarify the basis of definitions used to categorize foods as highly processed and, in a constructive sense, to distinguish between the contributions of nutrients, additives and sensory properties to health.

Genetic and Environmental Contributions to Variation in the Stable Urinary NMR Metabolome over Time: A Classic Twin Study.

Genes, sex, age, diet, lifestyle, gut microbiome, and multiple other factors affect human metabolomic profiles. Understanding metabolomic variation is critical in human nutrition research as metabolites that are sensitive to change versus those that are more stable might be more informative for a particular study design. This study aims to identify stable metabolomic regions and determine the genetic and environmental contributions to stability. Using a classic twin design, 1H nuclear magnetic resonance (NMR) urinary metabolomic profiles were measured in 128 twins at baseline, 1 month, and 2 months. Multivariate mixed models identified stable urinary metabolites with intraclass correlation coefficients ≥0.51. Longitudinal twin modeling measured the contribution of genetic and environmental influences to variation in the stable urinary NMR metabolome, comprising stable metabolites. The conservation of an individual's stable urinary NMR metabolome over time was assessed by calculating conservation indices. In this study, 20% of the urinary NMR metabolome is stable over 2 months (intraclass correlation (ICC) 0.51-0.65). Common genetic and shared environmental factors contributed to variance in the stable urinary NMR metabolome over time. Using the stable metabolome, 91% of individuals had good metabolomic conservation indices ≥0.70. To conclude, this research identifies 20% of the urinary NMR metabolome as stable, improves our knowledge of the sources of metabolomic variation over time, and demonstrates the conservation of an individual's urinary NMR metabolome.

Genetic and environmental influences on covariation in reproducible diet-metabolite associations.

BACKGROUND: Early applications of metabolomics in nutrition and health research identified associations between dietary patterns and metabolomic profiles. Twin studies show that diet-related phenotypes and diet-associated metabolites are influenced by genes. However, studies have not examined whether diet-metabolite associations are explained by genetic or environmental factors and whether these associations are reproducible over multiple time points. OBJECTIVE: This research aims to examine the genetic and environmental factors influencing covariation in diet-metabolite associations that are reproducible over time in healthy twins. METHODS: The UCD Twin Study is a semi-longitudinal classic twin study that collected repeated dietary, anthropometric, and urinary data over 2 months. Correlation analysis identified associations between diet quality measured using the Healthy Eating Index (HEI) and urinary metabolomic profiles at 3 time points. Diet-associated metabolites were examined using linear regression to identify those significantly influenced by familial factors between twins and those significantly influenced by unique factors. Cholesky decomposition modeling quantified the genetic and environmental path coefficients through associated dietary components onto the metabolites. RESULTS: The HEI was associated with 14 urinary metabolites across 3 metabolomic profiles (r: ±0.15-0.49). For 8 diet-metabolite associations, genetic or shared environmental factors influencing HEI component scores significantly influenced variation in metabolites (ß: 0.40-0.52). A significant relation was observed between dietary intakes of whole grain and acetoacetate (ß: -0.50, P < 0.001) and ß-hydroxybutyrate (ß: -0.46, P < 0.001), as well as intakes of saturated fat and acetoacetate (ß: 0.47, P < 0.001) and ß-hydroxybutyrate (ß: 0.52, P < 0.001). For these diet-metabolite associations a common shared environmental factor explained 66-69% of variance in the metabolites. CONCLUSIONS: This study shows that diet-metabolite associations are reproducible in 3 urinary metabolomic profiles. Components of the HEI covary with metabolites, and covariation is largely due to the shared environment.

Impact of the common MTHFR 677C→T polymorphism on blood pressure in adulthood and role of riboflavin in modifying the genetic risk of hypertension: evidence from the JINGO project.

BACKGROUND: Genome-wide and clinical studies have linked the 677C→T polymorphism in the gene encoding methylenetetrahydrofolate reductase (MTHFR) with hypertension, whilst limited evidence shows that intervention with riboflavin (i.e. the MTHFR co-factor) can lower blood pressure (BP) in hypertensive patients with the variant MTHFR 677TT genotype. We investigated the impact of this common polymorphism on BP throughout adulthood and hypothesised that riboflavin status would modulate the genetic risk of hypertension. METHODS: Observational data on 6076 adults of 18-102 years were drawn from the Joint Irish Nutrigenomics Organisation project, comprising the Trinity-Ulster Department of Agriculture (TUDA; volunteer sample) and the National Adult Nutrition Survey (NANS; population-based sample) cohorts. Participants were recruited from the Republic of Ireland and Northern Ireland (UK) in 2008-2012 using standardised methods. RESULTS: The variant MTHFR 677TT genotype was identified in 12% of adults. From 18 to 70 years, this genotype was associated with an increased risk of hypertension (i.e. systolic BP ≥ 140 and/or a diastolic BP ≥ 90 mmHg): odds ratio (OR) 1.42, 95% confidence interval (CI) 1.07 to 1.90; P = 0.016, after adjustment for antihypertensive drug use and other significant factors, namely, age, male sex, BMI, alcohol and total cholesterol. Low or deficient biomarker status of riboflavin (observed in 30.2% and 30.0% of participants, respectively) exacerbated the genetic risk of hypertension, with a 3-fold increased risk for the TT genotype in combination with deficient riboflavin status (OR 3.00, 95% CI, 1.34-6.68; P = 0.007) relative to the CC genotype combined with normal riboflavin status. Up to 65 years, we observed poorer BP control rates on antihypertensive treatment in participants with the TT genotype (30%) compared to those without this variant, CT (37%) and CC (45%) genotypes (P < 0.027). CONCLUSIONS: The MTHFR 677TT genotype is associated with higher BP independently of homocysteine and predisposes adults to an increased risk of hypertension and poorer BP control with antihypertensive treatment, whilst better riboflavin status is associated with a reduced genetic risk. Riboflavin intervention may thus offer a personalised approach to prevent the onset of hypertension in adults with the TT genotype; however, this requires confirmation in a randomised trial in non-hypertensive adults.

User experiences with second-generation 32-gauge × 4 mm vs. thinner comparator pen needles: prospective randomized trial.

OBJECTIVE: Two similarly designed studies compared user experiences with a second-generation extra-thin-wall, 5-bevel 32 G × 4 mm pen needle (PN) with redesigned hub versus four thinner commercially available PNs. METHODS: Adults (18-75 years old) with type 1 or type 2 diabetes and ≥3 months of experience with pen injectors qualified for single-visit, single-blinded randomized studies. The investigational 32 G PN was compared with three 33-34 G × 3.5-4 mm PNs in Study 1 and one 34 G × 4 mm PN in Study 2. Participants completed 12 abdominal injections of 0.3 mL sterile saline using insulin pens in 6 pairs, each comprising one investigational 32 G PN and one comparator PN in random order. After each injection pair, participants compared injection pain via relative 150 mm visual analog scale (VAS) and perceived dose delivery force via relative 5 point Likert scale. Adjusted models tested injection pain scores (primary endpoint) for noninferiority and, if met, then for superiority. ClinicalTrials.gov identifiers: NCT03878758 and NCT03878745. RESULTS: The investigational 32 G PN met noninferiority as well as superiority criteria for less injection pain vs. each comparator (p < .01), with adjusted mean relative VAS scores 9.1-17.6 in Study 1 (n = 154) and 7.3 in Study 2 (n = 55). The investigational 32 G PN was also superior vs. each comparator PN in requiring less relative perceived force to deliver the dose (p < .01). CONCLUSIONS: The investigational 32 G PN was associated with less participant-reported injection pain and less perceived dose delivery force compared with four thinner PNs, suggesting no additional pain reduction or force reduction benefit conferred by the thinner PNs.

Discovery and Characterization of Clinical Candidate LXE408 as a Kinetoplastid-Selective Proteasome Inhibitor for the Treatment of Leishmaniases.

Visceral leishmaniasis is responsible for up to 30,000 deaths every year. Current treatments have shortcomings that include toxicity and variable efficacy across endemic regions. Previously, we reported the discovery of GNF6702, a selective inhibitor of the kinetoplastid proteasome, which cleared parasites in murine models of leishmaniasis, Chagas disease, and human African trypanosomiasis. Here, we describe the discovery and characterization of LXE408, a structurally related kinetoplastid-selective proteasome inhibitor currently in Phase 1 human clinical trials. Furthermore, we present high-resolution cryo-EM structures of the Leishmania tarentolae proteasome in complex with LXE408, which provides a compelling explanation for the noncompetitive mode of binding of this novel class of inhibitors of the kinetoplastid proteasome.

Exploring Covariation between Traditional Markers of Metabolic Health and the Plasma Metabolomic Profile: A Classic Twin Design.

Novel metabolomic profiling techniques combined with traditional biomarkers provide knowledge of mechanisms underlying metabolic health. Twin studies describe the impact of genes and environment on variation in traits. This study aims to identify relationships between traditional markers of metabolic health and the plasma metabolomic profile using a twin modeling approach and determine whether covariation is caused by shared genetic and environmental factors. Using a classic twin design, this study examined covariation between anthropometric, clinical chemistry, and metabolomic profiles. Cholesky decomposition modeling was used to determine the genetic and environmental path coefficients through successive anthropometric and clinical chemistry traits onto metabolomic derived metabolites. This study shows that WC, TAG, and a metabolomic signature composed of 7 metabolites are inter-related, and that covariation can be attributed to common genetic, shared and unique environmental factors as well as unique environmental factors specific to the metabolite. This quantitative modeling connecting the traditional anthropometry and clinical chemistry traits with the more recent and potentially more sensitive metabolomic profile approach may provide further insight on the pleiotropic genes or modifiable environmental factors influencing variation in metabolic health.

Correction to: Evaluating the User Performance and Experience with a Re-Engineered 4mm × 32G Pen Needle: A Randomized Trial with Similar Length/Gauge Needles.

In the original publication, Figure 7 legend was incorrectly published as "A breakdown of preference for the comparator PN (black), no preference (grey), and preference for the investigational PN (white), in all groups combined, in all VAS questions". The correct legend is given below.

Breakfast: Shaping Guidelines for Food and Nutrient Patterns.

Whilst there is extensive literature on the health benefits of a regular breakfast, there are few guidelines to help policy makers to issue specific targets on optimal nutrient intake at breakfast or the selection of foods to attain these targets. The food and nutritional advice on breakfast offered by most governments is confined to simple advice on food servings. The USA and Mexico typify the few countries that have attempted to issue specific nutrient targets for breakfast. However, these simply reflect general nutrient guidelines for adults, adjusted to suit lower energy needs of toddlers and school children. Little guidance is issued on micronutrient intake, and the advice on food choice does not appear to be linked to patterns of nutrient intake. The application of cluster and principal component analysis, which is used to determine the patterns of daily or breakfast food consumption and also link them to nutrient intake, greatly improved our understanding of optimal breakfast choices. Using 6 national nutrition surveys (Canada, Denmark, France, Spain, the UK, and the USA), the International Breakfast Research Initiative has opted to score each individual with a measure of overall daily nutritional quality (based on the nutrient-rich food index). It is hoped that options for the derivation in breakfast nutrient targets and associated food-based guidelines will arise from an analysis of tertiles of this score. Ultimately, meal-based advice will become the basic building block for digitally based personalized dietary analysis and guidelines.

Ultra-Processed Foods: Definitions and Policy Issues.

Four categories of foods are proposed in the NOVA food classification, which seeks to relate food processing as the primary driver of diet quality. Of these, the category "ultra-processed foods" has been widely studied in relation both to diet quality and to risk factors for noncommunicable disease. The present paper explores the definition of ultra-processed foods since its inception and clearly shows that the definition of such foods has varied considerably. Because of the difficulty of interpretation of the primary definition, the NOVA group and others have set out lists of examples of foods that fall under the category of ultra-processed foods. The present manuscript demonstrates that since the inception of the NOVA classification of foods, these examples of foods to which this category applies have varied considerably. Thus, there is little consistency either in the definition of ultra-processed foods or in examples of foods within this category. The public health nutrition advice of NOVA is that ultra-processed foods should be avoided to achieve improvements in nutrient intakes with an emphasis on fat, sugar, and salt. The present manuscript demonstrates that the published data for the United States, United Kingdom, France, Brazil, and Canada all show that across quintiles of intake of ultra-processed foods, nutritionally meaningful changes are seen for sugars and fiber but not for total fat, saturated fat, and sodium. Moreover, 2 national surveys in the United Kingdom and France fail to show any link between body mass index and consumption of ultra-processed foods. The paper concludes that constructive scholarly debate needs to be facilitated on many issues that would be affected by a policy to avoid ultra-processed foods.

Evaluating the User Performance and Experience with a Re-Engineered 4 mm × 32G Pen Needle: A Randomized Trial with Similar Length/Gauge Needles.

INTRODUCTION: Since insulin pens were first introduced in 1985, many advances have been made in pen needles (PNs). In this study we evaluated patient-reported outcomes of an investigational newly re-engineered 4 mm × 32G PN, the BD Nano™ 2nd Gen (also known by its "PRO" brand extension in many markets outside of the USA). In place of a conventional cylindrical posted hub, the investigational PN's hub is contoured with an expanded surface area. The investigational PN also includes a redesigned inner shield that includes tactile ridges and a remodeled outer cover with improved proportions and attachment grips. METHODS: This was a multi-site, prospective, open-label, two-period crossover trial. Individuals with type 1 and type 2 diabetes using 32G PNs of ≤ 6 mm in length for ≥ 4 months were eligible. Subjects using     31G PNs of a similar length were eligible after a 2-week wash-in period. Subjects were assigned to one of four groups, with each group using a commercially available PN to which the investigational PN was compared. Each of the two study periods were 15 days: one with the investigational PN and the other with a comparator PN. After completing both study periods, subjects compared experiences between the two PN types. A 150-mm comparative visual analog scale (VAS) was used to evaluate overall preference (primary endpoint) and several secondary endpoints, including overall comfort, injection pain, and ease of use. Data from the four PN groups were combined after poolability was verified. Subgroup analyses were also conducted on each PN group. For VAS responses, a two-sided 95% confidence interval (CI) was calculated for average rating. Threshold for non-inferiority or superiority was established at the lower bound CI of > - 10 mm or > 0 mm, respectively. RESULTS: At baseline, average age of subjects was 55.6 years; 51.6% were female; and 85.1% has type 2 diabetes mellitus. Average diabetes duration was 14.2 years, and average duration of injecting was 7.8 years. The investigational PN demonstrated superiority for all outcomes, both primary and secondary, for all groups combined (p < 0.05). CONCLUSIONS: The investigational PN was rated as being overall preferred, more comfortable, less painful, and easier to use when compared to comparator PNs of similar gauge and length, in all groups combined. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov (NCT03267264). FUNDING: BD (Becton, Dickinson, and Company).

Whole grain intakes in Irish adults: findings from the National Adults Nutrition Survey (NANS).

PURPOSE: Observational studies link high whole grain intakes to reduced risk of many chronic diseases. This study quantified whole grain intakes in the Irish adult population and examined the major contributing sources. It also investigated potential dietary strategies to improve whole grain intakes. METHODS: Whole grain intakes were calculated in a nationally representative sample of 1500 Irish adults using data from the most recent national food survey, the National Adult Nutrition Survey (NANS). Food consumption was assessed, at brand level where possible, using a 4-day semi-weighed food diary with whole grain content estimated from labels on a dry matter basis. RESULTS: Mean daily whole grain intakes were 27.8 ± 29.4 g/day, with only 19% of the population meeting the quantity-specific recommendation of 48 g per day. Wheat was the highest contributor to whole grain intake at 66%, followed by oats at 26%. High whole grain intakes were associated with higher dietary intakes of fibre, magnesium, potassium, phosphorus, and a higher alternative Mediterranean Diet Score. Whole grain foods were most frequently eaten at breakfast time. Regression analysis revealed that consumption of an additional 10 g of whole grain containing 'ready-to-eat breakfast cereals', 'rice or pastas', or 'breads' each day would increase intake of whole grains by an extra 5, 3.5, and 2.7 g, respectively. CONCLUSIONS: This study reveals low intakes of whole grains in Irish adults. Recommending cereals, breads, and grains with higher whole grain content as part of public health campaigns could improve whole grain intakes.