Looking to the future: Agendas, directions, and resources for nutrition research.

The development and progression of nutrition as a scientific field is ever evolving and complex. Although the history of nutrition research began by exploring specific food components, it has evolved to encompass a more holistic view that considers the impact of dietary patterns over time, interactions with the environment, nutrition's role in disease processes, and public policy related to nutrition health. To guide the future direction of nutrition science, both federal and other professional organizations have established agendas and goals. The Strategic Plan for National Institutes of Health Nutrition Research outlines four goals and five cross-cutting research areas that are priorities to explore between 2020 and 2030. Similarly, the American Society for Parenteral and Enteral Nutrition and other governmental and professional organizations have identified priority areas in their research agendas. Rigorous research studies are needed to explore these areas of interest while also considering practical implementation strategies for translating research into practice. Nutrition clinicians are uniquely positioned to lend expertise in the areas of research design, implementation, advocacy and evidence-based practice; there are numerous resources to support practitioners in these endeavors.

Snacks contribute considerably to total dietary intakes among adults stratified by glycemia in the United States.

Little is known about the snacking patterns among adults with type 2 diabetes. The contribution of snacks to energy and nutrient intakes is important to further understand dietary patterns and glycemic control. The purpose of this study is to evaluate snack consumption among adults according to diabetes status in the United States. One NHANES 24-hour dietary recall for each participant collected between 2005-2016 was utilized for analysis (n = 23,708). Analysis of covariance was used to compare differences in nutrient and food groups intakes from snacks across levels of glycemic control, while controlling for age, race/ethnicity, income, marital status, and gender. Results of this analysis inform that adults with type 2 diabetes consume less energy, carbohydrates, and total sugars from snacks than adults without diabetes. Those with controlled type 2 diabetes consumed more vegetables and less fruit juice than other groups, yet adults with type 2 diabetes in general consumed more cured and luncheon meats than adults without diabetes or with prediabetes. Protein from all snacks for those without diabetes is higher than all other groups. This study elucidates common snacking patterns among US adults with diabetes and highlights the need for clinicians and policymakers to take snacking into consideration when evaluating and providing dietary recommendations.

Contribution of Snacks to Dietary Intakes Stratified by Race/Ethnicity in the United States.

BACKGROUND: Snacking recommendations do not exist, yet snacks contribute substantially to daily energy intakes. While dietary intakes of adults in the United States vary by race/ethnicity, little is known about their snacking patterns. The aim of this study was to assess the quality of snacks stratified by race/ethnicity in adults who participated in the 2011-2018 National Health and Nutrition Examination Survey (NHANES). METHOD: Dietary data from 18,679 adults older than 19 years were assessed to examine differences in intakes from snacking occasions by self-identified race/ethnicity. Mean intakes were estimated for total snacking occasions, percentage of day, nutrient density per 100 kcals, and the average snack. Healthy Eating Index-2015 (HEI) scores were computed for intakes from total day, snack only, and meals only. Analysis of covariance assessed differences between racial/ethnic groups. US Department of Agriculture food categories determined sources of snack foods. Data were weighted to create a nationally representative sample. RESULTS: Asians consumed the least amount of daily energy in the form of snacks, while Blacks and Whites consumed the most. Mean intakes of saturated fats and added sugars consumed during snacking occasions were significantly lowest in Asians, and highest in Blacks and Whites. While total and percentage of daily intakes of sodium were lowest in Asians during snacking occasions, they had significantly lowest meal-only HEI sodium subscore, indicating higher sodium consumption of sodium during mealtimes. CONCLUSIONS: Diet quality of snacks varies significantly by race/ethnicity. These data support the need for development of snacking recommendations with culturally appropriate dietary interventions.

Congenital cytomegalovirus surveillance in the United States.

BACKGROUND: Congenital cytomegalovirus (cCMV) is not a nationally notifiable condition, and little is known about how U.S. health departments (HDs) currently conduct cCMV surveillance. METHODS: We surveyed U.S. HDs that conduct cCMV surveillance or screening activities identified through a web-based assessment. Meetings were held with each HD to enhance our understanding of survey responses. RESULTS: Ten states are systematically collecting cCMV case data to track cCMV cases during early infancy and to provide resources and services to families. Cases are ascertained using cCMV diagnostic codes, reported diagnosis, or laboratory results. Data elements collected for each case include demographics (all 10 states), clinical signs (8 states), laboratory data (4 states), treatment (4 states), and long-term outcomes (1 state). Annual number of cases reported by HDs ranged from 3 to 47 cases/year in seven states, which was much lower than the expected number of cCMV cases. All 10 HDs have the ability to analyze data collected and four disseminate findings. Major challenges of surveillance reported by HDs were lack of standardized case definitions, personnel constraints, and limited funding. CONCLUSIONS: A comprehensive account of cCMV disease burden is severely limited by low case ascertainment and paucity of data on long-term outcomes. A standardized public health case definition for cCMV would improve consistency in measuring disease prevalence across jurisdictions and over time. Surveillance for cCMV has the potential to increase disease awareness and inform strategies to prevent cCMV-associated disabilities.

Anaplasmosis-Related Fatality in Vermont: A Case Report.

Human granulocytic anaplasmosis is an acute febrile tick-borne illness caused by the bacterium Anaplasma phagocytophilum. An anaplasmosis-related fatality in a Vermont resident with multiple comorbidities is described. Clinicians should be aware of the risk factors for severe outcomes of this emerging disease and promptly treat when suspected.

Acute and chronic Q fever national surveillance - United States, 2008-2017.

Q fever is a zoonotic disease caused by the bacterium Coxiella burnetii and can manifest in an acute or chronic form. Many persons with acute Q fever are asymptomatic, but some develop a febrile illness, pneumonia or hepatitis. Chronic infections are rare and occur in less than 5% of persons exposed. Forms of chronic Q fever include endocarditis, infection of vascular grafts or aneurysms, osteomyelitis and osteoarthritis. Acute and chronic Q fever are nationally notifiable diseases, and presented here are the incidence, demographics and distribution of acute and chronic Q fever in the United States during 2008-2017. We summarized passive surveillance data from the Centers for Disease Control and Prevention's (CDC) National Notifiable Diseases Surveillance System (NNDSS) and supplemental case report forms (CRFs). Health departments reported 1,109 cases of acute Q fever and 272 chronic Q fever cases to NNDSS during this period. The 10-year average annual incidence for acute Q fever was 0.36 cases per million persons, and the average annual incidence for chronic Q fever was 0.09. Males accounted for nearly 75% of both acute and chronic Q fever cases. Average annual incidence was highest among persons aged 60-69 years for both acute and chronic Q fever (0.70 cases per million persons and 0.25, respectively). As reported through CRFs, many Q fever cases did not have a known exposure to C. burnetii; 60% (n = 380) of acute Q fever cases did not report exposure to animals in the 2 months before symptom onset. Almost 90% (n = 558) did not report exposure to unpasteurized milk. Only 40% (n = 247) of persons with reported Q fever were employed in high-risk occupations. Even though Q fever is a rare disease in the United States, incidence doubled from 2008 to 2017.

Interaction effect of systemic inflammation and modifiable rheumatoid cachexia risk factors on resting energy expenditure in patients with rheumatoid arthritis.

Background: In rheumatoid cachexia (RC), high resting energy expenditure (REE) is associated with loss of muscle mass driven by proinflammatory cytokines. The objectives of this study were to investigate parameters associated with RC, and the interaction between systemic inflammation and modifiable risk factors for RC on REE. Methods: Thirty-five rheumatoid arthritis (RA) and nineteen non-RA controls comparable in age, sex, race and BMI underwent measures of REE by indirect calorimetry. Clinical, dietary, body composition and physical function data were collected. Homeostasis model assessment for insulin resistance (HOMA-IR) and serum interleukin-6 (IL-6) were used as parameters of IR and systemic inflammation, respectively. Regression models tested association between REE and dependent variables, including pre-specified interaction tests involving HOMA-IR and IL-6 and dietary intake of protein per weight (PPW) and IL-6. Results: RA subjects were mostly women (94%) and had a median age of 54 years (50.5, 70) and BMI of 30.5 kg/m2 (26.1, 36.9). We observed a significant interaction effect between PPW and serum IL-6 on REE among RA subjects in the multiple regression model among RA. The upper tertile of PPW demonstrated a significant negative correlation between REE and IL-6 (ß=-19.97, 95% CI [-35.41, -4.54], p=0.01). The lower tertile of PPW demonstrated a significant positive correlation between REE and IL-6 (ß=42.24, 95% CI [4.25, 80.23], p=0.03). Conclusions: While IR can lead to muscle catabolism, IR was not significantly associated with REE in RA individuals. Higher dietary protein intake could attenuate the effect of systemic inflammation on REE in RA patients.

Epidemiology and Clinical Features of Rocky Mountain Spotted Fever from Enhanced Surveillance, Sonora, Mexico: 2015-2018.

Rocky Mountain spotted fever (RMSF), caused by Rickettsia rickettsii, is a severe and potentially fatal tick-borne disease. In 2015, Mexico issued a declaration of epidemiologic emergency in response to ongoing outbreaks of RMSF in northern Mexico. Sonora state is one of the most heavily impacted states in Mexico, with historic case fatality rates (CFRs) of 18%. We summarized data from enhanced surveillance to understand demographic, clinical, and treatment factors associated with the high mortality. We conducted a retrospective review of confirmed and probable RMSF cases reported to the General Directorate of Health Promotion and Disease Prevention in Sonora. A case of RMSF is defined as fever (> 38.5°C), plus two symptoms, and epidemiologic criteria. A confirmed case requires laboratory evidence. During 2015-2018, a total of 510 cases of RMSF were reported; 252 (49%) were in persons aged ≤ 18 years. Case fatality rate was 44% (n = 222). Older age and being confirmed by PCR were associated with fatal outcome (P-value < 0.01). The mean time from onset of symptoms to treatment with doxycycline was 7.9 days (SD ± 5.5). Hot spot analysis revealed neither areas of inordinately high nor low incidence, rather clusters of disease in population centers. The CFR for RMSF in Sonora remains high, and a large proportion of cases are seen in persons aged ≤ 18 years. Whereas previously children experienced a disproportionately high CFR, interventions have reversed this trend. Disease clusters in urban nuclei, but location remains a predictor of fatal outcome.

Diagnostic Methods Used to Classify Confirmed and Probable Cases of Spotted Fever Rickettsioses - United States, 2010-2015.

Spotted fever rickettsioses (SFR), including Rocky Mountain spotted fever (RMSF), are nationally notifiable diseases in the United States caused by spotted fever group Rickettsia. The annual incidence of SFR increased from 1.7 cases per 1 million persons in 2000 to 13.2 in 2016 (1,2). Although this demonstrates a substantial increase in SFR cases, the actual magnitude of the increase is questionable because the current case definition allows for nonspecific laboratory criteria to support diagnosis (3). To analyze the quality of laboratory data used to support the diagnosis of SFR cases with illness onset during 2010-2015, CDC examined supplementary case report forms. Among 16,807 reported cases, only 167 (1.0%) met the confirmed case definition, and the remaining 16,640 (99.0%) met the probable case definition. The most common supportive laboratory evidence for probable cases was elevated immunoglobulin G (IgG) antibody titer by indirect immunofluorescence assay (IFA), which was reported for 14,784 (88.8%) probable cases. Antibodies to spotted fever group Rickettsia can persist for months or years following infection, making a single antibody titer unreliable for diagnosing incident disease without a convalescent specimen. Increased use of molecular assays and use of paired and appropriately timed IFA IgG testing practices could improve understanding of SFR epidemiology and increase the accuracy of disease incidence estimates.

National Surveillance of Spotted Fever Group Rickettsioses in the United States, 2008-2012.

Spotted fever group (SFG) rickettsioses are notifiable conditions in the United States caused by the highly pathogenic Rickettsia rickettsii and less pathogenic rickettsial species such as Rickettsia parkeri and Rickettsia sp. 364D. Surveillance data from 2008 to 2012 for SFG rickettsioses are summarized. Incidence increased from 1.7 cases per million person-years (PY) in 2000 to 14.3 cases per million PY in 2012. During 2008-2012, cases of SFG rickettsiosis were more frequently reported among males, persons of white race, and non-Hispanic ethnicity. Overall, case fatality rate (CFR) was low (0.4%), however, risk of death was significantly higher for American Indian/Alaska Natives (relative risk [RR] = 5.4) and Asian/Pacific Islanders (RR = 5.7) compared with persons of white race. Children aged < 10 years continue to experience the highest CFR (1.6%). Higher incidence of SFG rickettsioses and decreased CFR likely result from increased reporting of tick-borne disease including those caused by less pathogenic species. Recently, fewer cases have been confirmed using species-specific laboratory methods (such as cell culture and DNA detection using polymerase chain reaction [PCR] assays), causing a clouded epidemiological picture. Use of PCR and improved documentation of clinical signs, such as eschars, will better differentiate risk factors, incidence, and clinical outcomes of specific rickettsioses in the future.

Increasing Incidence of Ehrlichiosis in the United States: A Summary of National Surveillance of Ehrlichia chaffeensis and Ehrlichia ewingii Infections in the United States, 2008-2012.

Human ehrlichiosis is a potentially fatal disease caused by Ehrlichia chaffeensis and Ehrlichia ewingii. Cases of ehrlichiosis are reported to Centers for Disease Control and Prevention through two national surveillance systems: Nationally Notifiable Diseases Surveillance System (NNDSS) and Case Report Forms. During 2008-2012, 4,613 cases of E. chaffeensis infections were reported through NNDSS. The incidence rate (IR) was 3.2 cases per million person-years (PYs). The hospitalization rate (HR) was 57% and the case fatality rate (CFR) was 1%. Children aged < 5 years had the highest CFR of 4%. During 2008-2012, 55 cases of E. ewingii infection were reported through NNDSS. The national IR was 0.04 cases per million PY. The HR was 77%; no deaths were reported. Immunosuppressive conditions were reported by 26% of cases. The overall rate for ehrlichiosis has increased 4-fold since 2000. Although previous literature suggests E. ewingii primarily affects those who are immunocompromised, this report shows most cases occurred among immunocompetent patients. This is the first report to show children aged < 5 years with ehrlichiosis have an increased CFR, relative to older patients. Ongoing surveillance and reporting of tick-borne diseases are critical to inform public health practice and guide disease treatment and prevention efforts.

Undetermined Human Ehrlichiosis and Anaplasmosis in the United States, 2008-2012: A Catch-All for Passive Surveillance.

Human ehrlichiosis and anaplasmosis are potentially severe illnesses endemic in the United States. Several bacterial agents are known causes of these diseases: Ehrlichia chaffeensis, Ehrlichia ewingii, Ehrlichia muris-like agent, Panola Mountain Ehrlichia species, and Anaplasma phagocytophilum. Because more than one agent may be present in one area, cases of human ehrlichiosis and anaplasmosis may be reported as "human ehrlichiosis/anaplasmosis undetermined" when the available evidence does not suggest an etiology to the species level. Here, we present a brief summary of these undetermined cases with onset of symptoms from 2008 to 2012 reported to two passive surveillance systems in the United States. The reported incidence rate during this time was 0.52 cases per million person-years. Many cases (24%) had positive polymerase chain reaction results. Enhanced surveillance in an area where several of these etiologic agents are endemic may provide a better understanding of the epidemiology of ehrlichiosis and anaplasmosis in the United States.

Human granulocytic anaplasmosis in the United States from 2008 to 2012: a summary of national surveillance data.

Human granulocytic anaplasmosis is an acute, febrile illness transmitted by the ticks Ixodes scapularis and Ixodes pacificus in the United States. We present a summary of passive surveillance data for cases of anaplasmosis with onset during 2008-2012. The overall reported incidence rate (IR) was 6.3 cases per million person-years. Cases were reported from 38 states and from New York City, with the highest incidence in Minnesota (IR = 97), Wisconsin (IR = 79), and Rhode Island (IR = 51). Thirty-seven percent of cases were classified as confirmed, almost exclusively by polymerase chain reaction. The reported case fatality rate was 0.3% and the reported hospitalization rate was 31%. IRs, hospitalization rates, life-threatening complications, and case fatality rates increased with age group. The IR increased from 2008 to 2012 and the geographic range of reported cases of anaplasmosis appears to have increased since 2000-2007. Our findings are consistent with previous case series and recent reports of the expanding range of the tick vector I. scapularis.