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Preference: Nutrition

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Animal vegetable vitamin

A new study published in the American Journal of Clinical Nutritional suggests that vitamin D intake needs to be modified so that public health recommendations include nutritional sources of vitamin D (D3) from meat and fish rather than plant based vitamin D (D2).

There have been conflicting views as to whether nutrition from vitamin D2 and D3 were different, with nutritional scientists thinking both forms of the vitamin are “biologically equivalent”.

The double blind placebo study showed that a significant increase in D3 was absorbed when compared to D2. It was undertaken in conjunction with Division of Health Sciences, School of Population Health, University of South Australia by was the largest of its kind to be undertaken.

The study was run during the winter months to exclude any effects of sunlight exposure on vitamin D levels.

Vitamin D levels in women who received vitamin D3 from juice or a biscuit increased their vitamin D levels from their baseline measurements by around 75 per cent, whereas those given vitamin D2 had an average increase in vitamin D levels of around 33 per cent over the course of the 12-week intervention.

As expected, participants who were in the placebo group saw their vitamin D levels fall by a quarter.

Vitamin D is a hormone that controls calcium levels in the blood. It is needed to develop and maintain healthy bones, muscles and teeth and is also important for general health. In Australia Vitamin D occurs naturally in fish and eggs, while margarine and some types of milk have added vitamin D. 

The National Cancer Council of Australia notes a balance is required between excessive sun exposure that increases the risk of skin cancer and enough sun exposure to maintain adequate vitamin D levels. Short periods (of a few minutes) of sun exposure may be more efficient at producing vitamin D than long periods. 

MEREDITH HORNE

Yemen cholera outbreak claims one life every hour

The rising number of suspected cases of cholera resulting from a severe outbreak in Yemen has passed 100,000, the World Health Organization (WHO) reports.

Cholera is affecting the most vulnerable. Children under the age of 15 years account for 46 per cent of cases, and those aged over 60 years represent 33 per cent of fatalities.

Cholera, an acute enteric infection, is caused by the ingestion of food or water contaminated with the bacterium Vibrio cholera. It can kill children within just a few hours. Cholera should be an easily treatable disease when there is access to functioning medical services. 

WHO believes that cholera is primarily linked to insufficient access to safe water and proper sanitation and its impact can be even more dramatic in areas where basic environmental infrastructures are disrupted or have been destroyed.

Humanitarian partners have been responding to the cholera outbreak since October 2016.  However, Yemen’s health, water and sanitation systems are collapsing after two years of war. The risk of the epidemic spreading further and affecting thousands more is real as the water hygiene systems are unable to cope.

The UN Office for the Co-ordinatior of Humanitarian Affairs (OCHA) Jamie McGoldrick said the fast spreading epidemic in Yemen was “of an unprecedented scale”.

Mr Goldrick also fears that hundreds of thousands of people are at a greater risk of dying as they face the “triple threat” of conflict, starvation and cholera. He believes the cause is clear.

“Malnutrition and cholera are interconnected; weakened and hungry people are more likely to contract cholera and cholera is more likely to flourish in places where malnutrition exists,” Mr Goldrick said. 

More than half of Yemen’s health facilities are no longer functioning, with almost 300 having been damaged or destroyed in the fighting.

Systems that are central to help treat and prevent outbreaks of the disease have failing in Yemen. Fifty per cent of medical facilities no longer function. Some have been bombed and others have ground to a halt because there is no funding.

The International Committee of the Red Cross (ICRC) Director of Operations Dominik Stillhart said: “Hospitals are understaffed and cannot accommodate the influx of patients – with up to four people seeking treatment per bed. There are people in the garden, and some even in their cars with the IV drip hanging from the window.”

Local health workers, including doctors and nurses have not been paid for eight months; only 30 per cent of required medical supplies are being imported into the country; rubbish collection in the cities is irregular; and more than eight million people lack access to safe drinking water and proper sanitation.

UNICEF is reported to have flown in over 40 tonnes of medicines, rehydration salts, intravenous fluids and other life-saving supplies to treat approximately 50,000 patients in Yemen.

Meredith Horne

Paradigm shift in monitoring and improving brain health

The world’s most prestigious gathering of medical practitioners in functional medicine and integrative care hosted a symposium in Los Angeles recently, featuring today’s greatest revolutionaries in changing how we view and treat brain health.

The Annual International Conference of the Institute for Functional Medicine chose scientifically-disruptive and broadly-acclaimed neuroscientist Dr Michael Merzenich to address its plenary session.

Dr Merzenich unveiled a revolutionary approach to monitoring, maintaining and improving brain health. The system uses apps and digital therapies.

Dr Merzenich is the Chief Scientific Officer of Posit Science, maker of BrainHQ brain exercises and assessments.

He joined Alzheimer’s experts Dr Dale Bredesen (of UCLA and the Buck institute) and Dr Rudolph Tanzi (of Harvard and Massachusetts General Hospital) for a discussion of the application of neuroplasticity to dementia.

The theme of the conference was The Dynamic Brain: Revealing the Potential of Neuroplasticity to reverse Neurodegeneration. 

Dr Merzenich discussed research supporting the idea that we can systematically harness brain plasticity and drive positive changes in brain systems through plasticity-based training.

“Breakthroughs in technology and science will permit people to monitor their brain health on a daily basis and take appropriate action to maintain their brain health using a device they already carry in their pockets,” he said.

“A phone with apps to assess current condition, to suggest holistic interventions, and to deliver the right brain exercises. This technology already exists, and all the pieces are coming together.”

Dr Merzenich believes we are in the midst of a paradigm shift regarding how we view and treat most aspects of brain health.

“We don’t have a magic pill to prevent or cure heart disease, and instead look to behavioural changes to reduce risk and early interventions to address symptoms,” he said.

“There is a rapidly growing consensus among thought leaders that we need a similar approach to cognitive disorders and improvement. This approach will include nutrition, physical exercise and environmental factors – but the single most important elements will be lifelong monitoring of brain health and appropriate plasticity-based brain exercises.”

Dr Merzenich is professor emeritus at University of California San Francisco, where he maintained a research lab for three decades. He ran the seminal experiments that led to the discovery of lifelong plasticity – the ability of the brain to change chemically, structurally and functionally based on sensory and other inputs. He pioneered harnessing the power of plasticity in the co-invention of the cochlear implant, which has restored hearing to 100,000s of people living with deafness. 

Dr Merzenich also pioneered the application of plasticity in the development of plasticity-based computerised brain exercises, which have helped millions of people.

Chris Johnson

World leading Australian scientists developing nuclear medicine to save lives

The Australian Nuclear Science and Technology Organisation (ANSTO), has signed an MOU with the Sri Lankan Presidential Taskforce for Prevention of Chronic Kidney Disease to assist in the fight against Chronic Kidney Disease of Unknown Etiology (CKDu).

Sri Lanka’s High Commissioner to Australia, H.E. Somasundaram Skandakumar, and the CEO of ANSTO, Dr Adi Paterson, signed an MOU that will see Australia provide new insights into the disease. 

“ANSTO’s expertise is in nuclear science, applied science and management of landmark infrastructure, and this new agreement is an opportunity to bring together all three, and to work on identifying the possible causes and treatments,” said Dr Paterson.

CKDu is a major health problem in Sri Lanka affecting more than 15 per cent of the population aged 15-70 years in the North Central Province, mostly poor farmers living in remote areas.  According to the World Health Organization (WHO), the disease is now also prevalent in the North western, Eastern, Southern and Central provinces.

The true number of CKDu cases and the cause of the disease remain unknown. CKDu is a progressive condition marked by the gradual loss of kidney function. There is an increasingly urgent need to identify the cause of CKDu in order to prevent and treat the disease and save vulnerable lives.

Priorities for addressing CKDu include earlier diagnosis and improved working conditions in such intense heat. Initial symptoms of the disease are nondistinct, such as tiredness and appetite loss, meaning people are usually diagnosed late, when damage to the kidney is extensive and irreversible. The only option at this stage is dialysis, which is not always available or accessible.

It is also a serious public health problem in other countries, particularly in Central America, and despite more than 20 years of study in Sri Lanka and globally, it is not well understood.  While CKDu appears to disproportionally affect poor, rural, male farmers in hot climates, the reasons why are not yet clear.

The World Health Organisation has identified several potential contributing factors, including heavy metals in the groundwater, agrochemicals, heat stress, malnutrition and low birth weight, and leptospirosis.

ANSTO and Australia will bring together several types of science and science infrastructure, including the ANSTO operated Synchrotron, as part of the research effort to investigate the epidemiology of CKDu.

ANSTO has capabilities to investigate a number of the possible causes, routes of distribution and treatments, particularly in relation to studying any causal links with heavy metals in water, or agrochemicals.

Meredith Horne

[Perspectives] Elizabeth Mayer-Davis: leader in adolescent diabetes

“Doing a lot of seemingly different things that are actually connected”, is the way that Elizabeth Mayer-Davis describes working life as Chair of Nutrition at the University of North Carolina at Chapel Hill, NC, USA. She is currently prioritising research into glycaemic control and weight management in type 1 diabetes; and soon hopes to be working on a trial to investigate how an automated insulin delivery system (the so-called bionic pancreas) will impact on diet and bodyweight. “When it comes to research, I try and see where the gaps in research lie, and work out where I can make a difference”, she says.

The sugar content of soft drinks in Australia, Europe and the United States

Despite recommendations by the World Health Organization and the National Health and Medical Research Council to limit the drinking of sugar-sweetened beverages (SSBs), Australians are particularly high consumers of such products.1 In the report of the Australian Health Survey, 39% of males and 29% of females over 2 years of age had consumed SSBs on the day prior to the interview in 2011–2012,1 and these drinks were the largest sources of sugar in the Australian diet.2

Soft drinks in Australia are chiefly sweetened with sugar cane-derived sucrose (online Appendix), a disaccharide of 50% glucose and 50% fructose; overseas, they are predominantly sweetened with high fructose corn syrup (United States) or sucrose-rich sugar beet (Europe). The sucrose, fructose and glucose content of soft drinks therefore varies between regions.

Glucose (but not fructose) rapidly elevates plasma glucose and insulin levels; fructose intake increases triglyceride production in the liver. Sucrose elicits a moderately rapid rise in blood glucose and insulin levels, as it must first be metabolised to free glucose and fructose. Variations in soft drink formulation will therefore have a biological impact because of differences in the final concentrations of glucose and fructose.3 As differences in the sugar content of soft drinks have not been systematically examined, we compared the final glucose and fructose content of popular soft drinks available in different regions.

The concentrations of sugars in five samples each of soft drinks marketed under the trade names Fanta, Sprite, Coca-Cola and Pepsi in the three regions Australia, Europe and the US (that is, 60 samples in total) were analysed by an independent, certified laboratory (National Measurement Institute, Australia) with high performance liquid chromatography. European samples of Fanta, Sprite, and Coca-Cola manufactured by the Coca-Cola Hellenic Bottling Company (HBC) Italia were representative of the corresponding soft drinks available in 28 European countries; samples of Pepsi manufactured by PepsiCo Beverages Italia were representative of the beverage available in 18 European countries. Each soft drink sample was derived from a different production batch; none contained intense sweeteners, such as aspartame or stevia. Total fructose and glucose concentrations (calculated final monosaccharide concentrations), allowing for contributions from sucrose, were calculated for each drink. Concentrations in each drink brand were compared in one-way analyses of variance (ANOVA) and, where appropriate, individual means were compared in post hoc least significant difference tests.

The mean total glucose concentration of Australian soft drinks was 0.96 g/100 mL (SD, 0.22) higher than for the corresponding US drinks, a mean 22% (SD, 6%) difference (P < 0.05; Box). Most glucose in Australian formulations was attributable to sucrose (online Appendix). The total glucose concentration of European soft drinks was generally similar to that of Australian formulations (1.04 g/100 mL [SD, 0.34] higher than US formulations, or 23% [SD, 8%] greater; P < 0.05; Box). The total fructose concentration was lower in Australian (mean difference, 0.97 g/100 mL; SD, 0.28) and European formulations (0.89 g/100 mL; SD, 0.35) than in corresponding US formulations (P < 0.05; Box). The concentration of total sugars was, consequently, similar for corresponding drinks from the three regions.

The potential health implications of regional differences in soft drink sugar content have not previously been examined, despite the differing metabolic effects of glucose and fructose.4 While the potential adverse effects of fructose overconsumption, particularly lipid accumulation, have been widely reported,4,5 those of Australian soft drinks containing high glucose concentrations have not been investigated.

Our short report should motivate specific examination of the health effects of Australian soft drink formulations.

Box –
Mean concentrations of total glucose (A) and total fructose (B) in popular soft drinks in Australia, Europe and the United States

Five samples of each soft drink from each region were analysed. * P < 0.05 v US concentration; † P < 0.05 v European concentration. The full data for the concentrations of glucose, fructose, and sucrose, and of total glucose and total fructose in each drink is included in the online Appendix.

It’s time for a tax on sugary drinks

BY PATRICK WALKER

Soft drinks are fast becoming our nation’s vice; our go-to drink choice that’s more bitter than it is sweet. Sugar-sweetened beverages (SSBs) are packed full of calories, yet provide no additional nutritional value or health benefits, and are a major factor driving obesity in Australia and overseas.

Consider your average 600ml bottle of Coca-Cola – for most people, a single serving. That bottle might cost you $3 from your local supermarket, and contains approximately 64g of sugar.

For the average person, this alone exceeds the WHO recommendation that no more than 10 per cent of your dietary energy should come from free sugars. Not that we’re paying much notice to this recommendation, though – most of us exceed it on a daily basis, and SSBs such as that $3 bottle of coke play a large role in this.

Sugar-sweetened drinks are Australians’ largest source of free sugar intake, perhaps adding flavour and energy to our day, but certainly nothing more. Sugar is only one factor of many that predispose to overweight and obesity, but plays a considerable role that merits attention. A 2006 systematic review, for example, found SSBs to be a ‘key contributor’ to the obesity epidemic, calling for prompt public health strategies to discourage consumption.

In total, 63 per cent of Australians are now overweight or obese, a staggering four-fold increase on 1980 levels. Perhaps more concerning is the fact that one in four children exceed the upper limit of normal for BMI, and many of these kids will continue on to become overweight or obese adults. Most people know that overweight and obesity lead to an increased risk of cardiovascular disease and stroke, diabetes, certain cancers, and a multitude of other diseases. But something that’s often overlooked is their economic toll.

In 2005, data from the Australian Diabetes, Obesity and Lifestyle study put the total direct cost at $21 billion, with the figure ballooning out to $56.6 billion when indirect costs are factored in. Other estimates are more moderate, but the evidence is clear: our waistlines are costing us billions.

Compare that to the $500 million in additional revenue that a well-designed SSB tax could raise annually, as well as bringing about a 15 per cent reduction in SSB consumption and a resulting 2 per cent reduction in the prevalence of obesity.

The link between SSBs and weight gain is well established, as is the link between weight gain and poor outcomes – both health and economic. But where does a tax fit in? And why target SSBs?

Let’s start with the first question. Put simply, price affects consumption. The more things cost, the less likely people are to buy them, particularly products with elastic demand such as SSBs. We saw this with tobacco and alcohol, with increased taxation dramatically reducing consumption. Now is the time to move this strategy to SSBs.

A 2013 meta-analysis on the impact of increased price on SSB consumption found that demand does indeed drop, leading to beneficial health outcomes. Further, the effect is more pronounced for people with low income, due to increased price elasticity. Given these people suffer disproportionately from overweight, obesity, and non-communicable diseases, this means they have the most to gain.

As a discrete and well-defined group of products that provide minimal nutritional value, SSBs are an easy practical target for sound fiscal policy. WHO has publicly recommended an SSB tax, and many countries, including Mexico, France, Denmark, Hungary, Norway, and the USA, have implemented a tax to generally good effect.

Data from Mexico is particularly promising, the tax reducing consumption by an average of 7.6 per cent a year since its introduction in 2010. In low SES households, this figure reached 17 per cent by the end of 2014. Back home, Australian modelling suggests that a 20 per cent tax could significantly reduce SSB consumption, and there is evidence to suggest that while SSB purchasing would drop, overall drink sales would be unaffected.

This is important for two reasons: first, it makes commercial cooperation significantly more likely, removing an important obstacle to implementation; but secondly, and perhaps more importantly, it means people of low SES wouldn’t simply have to fork out more money in their weekly shop, instead being able to switch to alternative, less sugary drinks.

Australia led the way on taxing tobacco and alcohol. We now have a chance to join other nations around the world, and take responsibility for the enormous impact SSBs have on our health. This alone won’t solve the obesity epidemic, but it is an important tool in the array of public health strategies we need. The AMA quite rightly advocates a ‘whole-of-society’, multi-measure approach to tackling the growing issue of obesity, and a tax on sugary drinks is an important part of this.

The health of our nation depends on us taking affirmative action in this space. The clock is ticking. We can’t afford to wait until it’s too late.

 

Patrick Walker is the 2017 Policy Officer for AMSA Global Health, and was a contributing author to the AMSA policy on Global Food & Nutrition (2016), which, amongst other recommendations, advocated for the implementation of a tax on SSBs.

 Twitter: @patrickjbwalker
Email: patrick.walker@amsa.org.au

 

[Correspondence] Health professional associations and industry funding—reply from Forsyth

The letter from Anthony Costello and colleagues1 shows the tangled web that has been woven by WHO to prevent food industry involvement in infant feeding policy and practice. This is despite the core statement within the International Code of Marketing of Breast-milk Substitutes, “affirming the need for governments, organisations of the United Nations system, non-governmental organisations, experts in various related disciplines, consumer groups, and industry to cooperate in activities aimed at the improvement of maternal, infant, and young child health and nutrition”.

[Editorial] Prospects for neonatal intensive care

In today’s Lancet we publish a clinical Series on neonatal intensive care in higher resource settings. The Series, led by Lex Doyle from The Royal Women’s Hospital in Melbourne, VIC, Australia, includes new approaches to the old nemesis of bronchopulmonary dysplasia (which still affects up to 50% of infants born before 28 weeks’ gestation), discusses the delicacy of fine-tuning interventions in response to evolving evidence, and explores the frontier of nutritional research by referring to preterm birth as a nutritional emergency.