An innovative approach to the assessment of nutrient intake in adults with type 2 diabetes : the development, trial and evaluation of a mobile phone photo/voice dietary record

Nutrition interventions in the form of both self-management education and individualised diet therapy are considered essential for the long-term management of type 2 diabetes mellitus (T2DM). The measurement of diet is essential to inform, support and evaluate nutrition interventions in the management of T2DM. Barriers inherent within health care settings and systems limit ongoing access to personnel and resources, while traditional prospective methods of assessing diet are burdensome for the individual and often result in changes in typical intake to facilitate recording. This thesis investigated the inclusion of information and communication technologies (ICT) to overcome limitations to current approaches in the nutritional management of T2DM, in particular the development, trial and evaluation of the Nutricam dietary assessment method (NuDAM) consisting of a mobile phone photo/voice application to assess nutrient intake in a free-living environment with older adults with T2DM. Study 1: Effectiveness of an automated telephone system in promoting change in dietary intake among adults with T2DM The effectiveness of an automated telephone system, Telephone-Linked Care (TLC) Diabetes, designed to deliver self-management education was evaluated in terms of promoting dietary change in adults with T2DM and sub-optimal glycaemic control. In this secondary data analysis independent of the larger randomised controlled trial, complete data was available for 95 adults (59 male; mean age(±SD)=56.8±8.1 years; mean(±SD)BMI=34.2±7.0kg/m2). The treatment effect showed a reduction in total fat of 1.4% and saturated fat of 0.9% energy intake, body weight of 0.7 kg and waist circumference of 2.0 cm. In addition, a significant increase in the nutrition self-efficacy score of 1.3 (p<0.05) was observed in the TLC group compared to the control group. The modest trends observed in this study indicate that the TLC Diabetes system does support the adoption of positive nutrition behaviours as a result of diabetes self-management education, however caution must be applied in the interpretation of results due to the inherent limitations of the dietary assessment method used. The decision to use a close-list FFQ with known bias may have influenced the accuracy of reporting dietary intake in this instance. This study provided an example of the methodological challenges experienced with measuring changes in absolute diet using a FFQ, and reaffirmed the need for novel prospective assessment methods capable of capturing natural variance in usual intakes. Study 2: The development and trial of NuDAM recording protocol The feasibility of the Nutricam mobile phone photo/voice dietary record was evaluated in 10 adults with T2DM (6 Male; age=64.7±3.8 years; BMI=33.9±7.0 kg/m2). Intake was recorded over a 3-day period using both Nutricam and a written estimated food record (EFR). Compared to the EFR, the Nutricam device was found to be acceptable among subjects, however, energy intake was under-recorded using Nutricam (-0.6±0.8 MJ/day; p<0.05). Beverages and snacks were the items most frequently not recorded using Nutricam; however forgotten meals contributed to the greatest difference in energy intake between records. In addition, the quality of dietary data recorded using Nutricam was unacceptable for just under one-third of entries. It was concluded that an additional mechanism was necessary to complement dietary information collected via Nutricam. Modifications to the method were made to allow for clarification of Nutricam entries and probing forgotten foods during a brief phone call to the subject the following morning. The revised recording protocol was evaluated in Study 4. Study 3: The development and trial of the NuDAM analysis protocol Part A explored the effect of the type of portion size estimation aid (PSEA) on the error associated with quantifying four portions of 15 single foods items contained in photographs. Seventeen dietetic students (1 male; age=24.7±9.1 years; BMI=21.1±1.9 kg/m2) estimated all food portions on two occasions: without aids and with aids (food models or reference food photographs). Overall, the use of a PSEA significantly reduced mean (±SD) group error between estimates compared to no aid (-2.5±11.5% vs. 19.0±28.8%; p<0.05). The type of PSEA (i.e. food models vs. reference food photograph) did not have a notable effect on the group estimation error (-6.7±14.9% vs. 1.4±5.9%, respectively; p=0.321). This exploratory study provided evidence that the use of aids in general, rather than the type, was more effective in reducing estimation error. Findings guided the development of the Dietary Estimation and Assessment Tool (DEAT) for use in the analysis of the Nutricam dietary record. Part B evaluated the effect of the DEAT on the error associated with the quantification of two 3-day Nutricam dietary records in a sample of 29 dietetic students (2 males; age=23.3±5.1 years; BMI=20.6±1.9 kg/m2). Subjects were randomised into two groups: Group A and Group B. For Record 1, the use of the DEAT (Group A) resulted in a smaller error compared to estimations made without the tool (Group B) (17.7±15.8%/day vs. 34.0±22.6%/day, p=0.331; respectively). In comparison, all subjects used the DEAT to estimate Record 2, with resultant error similar between Group A and B (21.2±19.2%/day vs. 25.8±13.6%/day; p=0.377 respectively). In general, the moderate estimation error associated with quantifying food items did not translate into clinically significant differences in the nutrient profile of the Nutricam dietary records, only amorphous foods were notably over-estimated in energy content without the use of the DEAT (57kJ/day vs. 274kJ/day; p<0.001). A large proportion (89.6%) of the group found the DEAT helpful when quantifying food items contained in the Nutricam dietary records. The use of the DEAT reduced quantification error, minimising any potential effect on the estimation of energy and macronutrient intake. Study 4: Evaluation of the NuDAM The accuracy and inter-rater reliability of the NuDAM to assess energy and macronutrient intake was evaluated in a sample of 10 adults (6 males; age=61.2±6.9 years; BMI=31.0±4.5 kg/m2). Intake recorded using both the NuDAM and a weighed food record (WFR) was coded by three dietitians and compared with an objective measure of total energy expenditure (TEE) obtained using the doubly labelled water technique. At the group level, energy intake (EI) was under-reported to a similar extent using both methods, with the ratio of EI:TEE was 0.76±0.20 for the NuDAM and 0.76±0.17 for the WFR. At the individual level, four subjects reported implausible levels of energy intake using the WFR method, compared to three using the NuDAM. Overall, moderate to high correlation coefficients (r=0.57-0.85) were found across energy and macronutrients except fat (r=0.24) between the two dietary measures. High agreement was observed between dietitians for estimates of energy and macronutrient derived for both the NuDAM (ICC=0.77-0.99; p<0.001) and WFR (ICC=0.82-0.99; p<0.001). All subjects preferred using the NuDAM over the WFR to record intake and were willing to use the novel method again over longer recording periods. This research program explored two novel approaches which utilised distinct technologies to aid in the nutritional management of adults with T2DM. In particular, this thesis makes a significant contribution to the evidence base surrounding the use of PhRs through the development, trial and evaluation of a novel mobile phone photo/voice dietary record. The NuDAM is an extremely promising advancement in the nutritional management of individuals with diabetes and other chronic conditions. Future applications lie in integrating the NuDAM with other technologies to facilitate practice across the remaining stages of the nutrition care process.

Carbohydrate supplementation and alterations in neutrophils, and plasma cortisol and myoglobin concentration after intense exercise

The present study examined the effect of carbohydrate supplementation on changes in neutrophil counts, and the plasma concentrations of cortisol and myoglobin after intense exercise. Eight well-trained male runners ran on a treadmill for 1 h at 85% maximal oxygen uptake on two separate occasions. In a double-blind cross-over design, subjects consumed either 750 ml of a 10% carbohydrate (CHO) drink or a placebo drink on each occasion. The order of the trials was counter-balanced. Blood was drawn immediately before and after exercise, and 1 h after exercise. Immediately after exercise, neutrophil counts (CHO, 49%; placebo, 65%; P<0.05), plasma concentrations of glucose (CHO, 43%; P<0.05), lactate (CHO, 130%; placebo, 130%; P<0.01), cortisol (CHO, 100%; placebo, 161%; P<0.01), myoglobin (CHO, 194%; placebo, 342%; P<0.01) all increased significantly. One hour post-exercise, plasma myoglobin concentration (CHO, 331%; placebo, 482%; P<0.01) and neutrophil count (CHO, 151%; placebo, 230% P<0.01) both increased further above baseline. CHO significantly attenuated plasma myoglobin concentration and the neutrophil count after exercise (P<0.01), but did not affect plasma cortisol concentration. The effects of CHO on plasma myoglobin concentration may be due to alterations in cytokine synthesis, insulin responses or myoglobin clearance rates from the bloodstream during exercise. Plasma cortisol responses to CHO during exercise may depend on the intensity of exercise, or the amount of CHO consumed. Lastly, cortisol appears to play a minor role in the mobilisation of neutrophils after intense exercise.

Monitoring phase behavior of sub- and supercritical CO2 confined in porous fractal silica with 85% porosity

Phase behavior of CO2 confined in porous fractal silica with volume fraction of SiO2 φs = 0.15 was investigated using small-angle neutron scattering (SANS) and ultrasmall-angle neutron scattering (USANS) techniques. The range of fluid densities (0<(FCO2)bulk<0.977 g/cm3) and temperatures (T=22 °C, 35 and 60 °C) corresponded to gaseous, liquid, near critical and supercritical conditions of the bulk fluid. The results revealed formation of a dense adsorbed phase in small pores with sizes D<40 A° at all temperatures. At low pressure (P <55 bar, (FCO2)bulk <0.2 g/cm3) the average fluid density in pores may exceed the density of bulk fluid by a factor up to 6.5 at T=22 °C. This “enrichment factor” gradually decreases with temperature, however significant fluid densification in small pores still exists at temperature T=60°C, i.e., far above the liquid-gas critical temperature of bulk CO2 (TC=31.1 °C). Larger pores are only partially filled with liquid-like adsorbed layer which coexists with unadsorbed fluid in the pore core. With increasing pressure, all pores become uniformly filled with the fluid, showing no measurable enrichment or depletion of the porous matrix with CO2.

A novel saliva-based microRNA biomarker panel to detect head and neck cancers

Background MicroRNAs (miRNAs) are known to play an important role in cancer development by post-transcriptionally affecting the expression of critical genes. The aims of this study were two-fold: (i) to develop a robust method to isolate miRNAs from small volumes of saliva and (ii) to develop a panel of saliva-based diagnostic biomarkers for the detection of head and neck squamous cell carcinoma (HNSCC). Methods Five differentially expressed miRNAs were selected from miScript™ miRNA microarray data generated using saliva from five HNSCC patients and five healthy controls. Their differential expression was subsequently confirmed by RT-qPCR using saliva samples from healthy controls (n = 56) and HNSCC patients (n = 56). These samples were divided into two different cohorts, i.e., a first confirmatory cohort (n = 21) and a second independent validation cohort (n = 35), to narrow down the miRNA diagnostic panel to three miRNAs: miR-9, miR-134 and miR-191. This diagnostic panel was independently validated using HNSCC miRNA expression data from The Cancer Genome Atlas (TCGA), encompassing 334 tumours and 39 adjacent normal tissues. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic capacity of the panel. Results On average 60 ng/μL miRNA was isolated from 200 μL of saliva. Overall a good correlation was observed between the microarray data and the RT-qPCR data. We found that miR-9 (P <0.0001), miR-134 (P <0.0001) and miR-191 (P <0.001) were differentially expressed between saliva from HNSCC patients and healthy controls, and that these miRNAs provided a good discriminative capacity with area under the curve (AUC) values of 0.85 (P <0.0001), 0.74 (P < 0.001) and 0.98 (P < 0.0001), respectively. In addition, we found that the salivary miRNA data showed a good correlation with the TCGA miRNA data, thereby providing an independent validation. Conclusions We show that we have developed a reliable method to isolate miRNAs from small volumes of saliva, and that the saliva-derived miRNAs miR-9, miR-134 and miR-191 may serve as novel biomarkers to reliably detect HNSCC. © 2014 International Society for Cellular Oncology.