Nutrition, growth and body composition in preterm infants

The goal of neonatal nutrition in the preterm infant is to achieve postnatal growth and body composition approximating that of a normal fetus of the same postmenstrual age and to obtain a functional outcome comparable to infants born at term. However, in clinical practice such a pattern is seldom achieved, with growth failure and altered body composition being extensively reported. The BabyGrow preterm nutrition study was a longitudinal, prospective, observational study designed to investigate nutrition and growth in 59 preterm infants following the implementation of evidence-based nutrition guidelines in the neonatal unit at Cork University Maternity Hospital. Nutrient delivery was precisely measured during the entire hospital stay and intakes were compared with current international recommendations. Barriers to nutrient delivery were identified across the phases of nutritional support i.e. exclusive parenteral nutrition and transition (establishment of enteral feeds) phases of nutrition and nutritional strategies to optimise nutrient delivery were proposed according to these phases. Growth was measured from birth up to 2 months corrected age and body composition was assessed in terms of fat mass and lean body mass by air displacement plethysmography (PEA POD) at 34 weeks gestation, term corrected age and 2 months corrected age. Anthropometric and body composition data in the preterm cohort were compared with a term reference group from the Cork BASELINE Birth Cohort Study (n=1070) at similar time intervals. The clinical and nutritional determinants of growth and body composition during the neonatal period were reported for the first time. These data have international relevance, informing authoritative agencies developing evidence-based practice guidelines for neonatal nutritional support. In the future, the nutritional management of preterm infants may need to be individualised to consider gestational age, birth weight as well as preterm morbidity.

The effect of complex workplace dietary interventions on employees dietary behaviours, nutrition knowledge and health status

Background The growing prevalence and associated burden of diet-related non-communicable diseases is a global public health concern. The environments in which people live and work influences their dietary behaviours. Aim The focus of this thesis was on the effectiveness of complex workplace dietary interventions. The comparative effectiveness of a complex workplace environmental dietary modification intervention and an educational intervention were assessed both alone and in combination relative to a control workplace setting. Methods The systematic review was guided by the PRISMA statement. In a cluster controlled trial, four workplaces were purposively allocated to control, nutrition education alone (Education), environmental dietary modification alone (Environment) and nutrition education and environmental dietary modification (Combined intervention). The interventions were guided by the MRC framework. In the control workplace, data were collected at baseline and follow-up. In the intervention related sub-study, the relationships between nutrition knowledge, diet quality and hypertension were examined. Results The systematic review provided limited evidence. In the FCW study, 850 employees aged 18-64 years were recruited at baseline with N(response rate %) in each workplace as follows: Control: 111(72%), Education: 226(71%), Environment: 113(91%), Combined intervention: 400(61%). Complete follow-up data was obtained for 517 employees (61%). There were significant positive changes in dietary intakes of saturated fat(p=0.013), salt(p=0.010) and nutrition knowledge(p=0.034) between baseline and follow-up at 7-9 months in the combined intervention versus the control workplace in the fully adjusted multivariate analysis. Small but significant changes in BMI(-1.2kg/m2 (p=0.047) were also observed in the combined intervention. In the sub-study, nutrition knowledge was positively significantly associated with diet quality and blood pressure but no evidence of a mediation effect of the DASH score was detected between nutrition knowledge and blood pressure. Conclusion This thesis provides critical evidence on the effectiveness of complex workplace dietary interventions in a manufacturing working population.

Molecular genetic analysis of DNA alterations in Irish colorectal cancer

Colorectal cancer is the most common cause of death due to malignancy in nonsmokers in the western world. In 1995 there were 1,757 cases of colon cancer in Ireland. Most colon cancer is sporadic, however ten percent of cases occur where there is a previous family history of the disease. In an attempt to understand the tumorigenic pathway in Irish colon cancer patients, a number of genes associated with colorectal cancer development were analysed in Irish sporadic and HNPCC colon cancer patients. The hereditary forms of colon cancer include Familial adenomatous polyposis coli (FAP) and Hereditary Non-Polyposis Colon Cancer (HNPCC). Genetic analysis of the gene responsible for FAP, (the APC gene) has been previously performed on Irish families, however the genetic analysis of HNPCC families is limited. In an attempt to determine the mutation spectrum in Irish HNPCC pedigrees, the hMSH2 and hMLHl mismatch repair genes were screened in 18 Irish HNPCC families. Using SSCP analysis followed by DNA sequencing, five mutations were identified, four novel and a previously reported mutation. In families where a mutation was detected, younger asyptomatic members were screened for the presence of the predisposing mutation (where possible). Detection of mutations is particularly important for the identification of at risk individuals as the early diagnosis of cancer can vastly improve the prognosis. The sensitive and efficient detection of multiple different mutations and polymorphisms in DNA is of prime importance for genetic diagnosis and the identification of disease genes. A novel mutation detection technique has recently been developed in our laboratory. In order to assess the efficacy and application of the methodology in the analysis of cancer associated genes, a protocol for the analysis of the K-ras gene was developed and optimised. Matched normal and tumour DNA from twenty sporadic colon cancer patients was analysed for K-ras mutations using the Glycosylase Mediated Polymorphism Detection technique. Five mutations of the K-ras gene were detected using this technology. Sequencing analysis verified the presence of the mutations and SSCP analysis of the same samples did not identify any additional mutations. The GMPD technology proved to be highly sensitive, accurate and efficient in the identification of K-ras gene mutations. In order to investigate the role of the replication error phenomenon in Irish colon cancer, 3 polyA tract repeat loci were analysed. The repeat loci included a 10 bp intragenic repeat of the TGF-β-RII gene. TGF-β-RII is involved in the TGF-β epithelial cell growth pathway and mutation of the gene is thought to play a role in cell proliferation and tumorigenesis. Due to the presence of a repeat sequence within the gene, TGFB-RII defects are associated with tumours that display the replication error phenomenon. Analysis of the TGF-β-RII 10 bp repeat failed to identify mutations in any colon cancer patients. Analysis of the Bat26 and Bat 40 polyA repeat sequences in the sporadic and HNPCC families revealed that instability is associated with HNPCC tumours harbouring mismatch repair defects and with 20 % of sporadic colon cancer tumours. No correlation between K-ras gene mutations and the RER+ phenotype was detected in sporadic colon cancer tumours.

Investigation of global regulators influencing styrene metabolism and bioplastic synthesis in Pseudomonas putida CA-3

The genetics and biochemistry involved in the biodegradation of styrene and the production of polyhydroxyalkanoates in Pseudomonas putida CA-3 have been well characterised to date. Knowledge of the role played by global regulators in controlling these pathways currently represents a critical knowledge gap in this area. Here we report on our efforts to identify such regulators using mini-Tn5 transposon mutagenesis of the P. putida CA-3 genome. The library generated was subjected to phenotypic screening to identify mutants exhibiting a reduced sensitivity to the effects of carbon catabolite repression of aromatic pathway activity. Our efforts identified a clpX disrupted mutant which exhibited wild-type levels of growth on styrene but significantly reduced growth on phenylacetic acid. RT-PCR analysis of key PACoA catabolon genes necessary for phenylacetic acid metabolism, and SDS-PAGE protein profile analyses suggest that no direct alteration of PACoA pathway transcriptional or translational activity was involved. The influence of global regulators affecting the accumulation of PHAs in P. putida CA-3 was also studied. Phenotypic screening of the mini-Tn5 library revealed a gacS sensor kinase gene disruption resulting in the loss of PHA accumulation capacity in P. putida CA-3. Subsequent SDS-PAGE protein analyses of the wild type and gacS mutant strains identified post-transcriptional control of phaC1 synthase as a key point of control of PHA synthesis in P. putida CA-3. Disruption of the gacS gene in another PHA accumulating organism, P. putida S12, also demonstrated a reduction of PHA accumulation capacity. PHA accumulation was observed to be disrupted in the CA-3 gacS mutant under phosphorus limited growth conditions. Over-expression studies in both wild type CA-3 and gacS mutant demonstrated that rsmY over-expression in gacS disrupted P. putida CA-3 is insufficient to restore PHA accumulation in the cell however in wild type cells, over-expression of rsmY results in an altered PHA monomer compositions.

An examination of the underlying trait structure of psychopathy: applications for screening and measurement

This thesis seeks to clarify the faceted organisation of psychopathy with a view to developing a comprehensive protocol for the assessment of core psychopathic personality traits. The framework developed will, as best as possible, be free of sample bias. The Self-and Informant-report Deviant Personality Screen (DPS) is introduced and a series of empirical studies are conducted to examine the psychometric properties and construct validity of these measures in general and offender populations. Findings from these studies provide strong support for the utility of the DPS scales for the appraisal of psychopathy across diverse population samples. In addition to this, the utility of cognitive based performance measures for the assessment of emotional deficits in psychopathy is evaluated. Results from this study suggest limited correspondence between these measurement techniques and self-report psychopathy measures. Finally, research conducted on offenders suggests that information obtained from DPS reports may be useful within a broad framework of risk assessment. Further empirical and theoretical implications of the research are discussed.

Characterisation of the microbiota of traditional fermented beverages and screening these and other populations for novel antimicrobial producers and gene clusters

To screen for novel ribosomally synthesised antimicrobials, in-silico genome mining was performed on all publically available fully sequenced bacterial genomes. 49 novel type 1 lantibiotic clusters were identified from a number of species, genera and phyla not usually associated with lantibiotic production, and indicates high prevalence. A crucial step towards the commercialisation of fermented beverages is the characterisation of the microbial content. To achieve this goal, we applied next-generation sequencing techniques to analyse the bacterial and yeast populations of the organic, symbiotically-fermented beverages kefir, water kefir and kombucha. A number of minor components were revealed, many of which had not previously been associated with these beverages. The dominant microorganism in each of the water kefir grains and fermentates was Zymomonas, an ethanol-producing bacterium that had not previously been detected on such a scale. These studies represent the most accurate description of these populations to date, and should aid in future starter design and in determining which species are responsible for specific attributes of the beverages. Finally, high-throughput robotics was applied to screen for the presence of antimicrobial producers associated with these beverages. This revealed a low frequency of bacteriocin production amongst the bacterial isolates, with only lactococcins A, B and LcnN of lactococcin M being identified. However, a proteinaceous antimicrobial produced by the yeast Dekkera bruxellensis, isolated from kombucha, was found to be active against Lactobacillus bulgaricus. This peptide was patially purified.

A study of diet and health in the elderly; the gut microbiota as a source of bioactive agents

The global proportion of older persons is increasing rapidly. Diet and the intestinal microbiota independently and jointly contribute to health in the elderly. The habitual dietary patterns and functional microbiota components of elderly subjects were investigated in order to identify specific effector mechanisms. A study of the dietary intake of Irish community-dwelling elderly subjects showed that the consumption of foods high in fat and/or sugar was excessive, while consumption of dairy foods was inadequate. Elderly females typically had a more nutrient- dense diet than males and a considerable proportion of subjects, particularly males, had inadequate intakes of calcium, magnesium, vitamin D, folate, zinc and vitamin C. The association between dietary patterns, glycaemic index and cognitive function was also investigated. Elderly subjects consuming ‘prudent’ dietary patterns had better cognitive function compared to those consuming ‘Western’ dietary patterns. Furthermore, fully-adjusted regression models revealed that a high glycaemic diet was associated with poor cognitive function, demonstrating a new link between nutrition and cognition. An extensive screening study of the elderly faecal-derived microbiota was also undertaken to examine the prevalence of antimicrobial production by intestinal bacteria. A number of previously characterised bacteriocins were isolated (gassericin T, ABP-118, mutacin II, enterocin L-50 and enterocin P) in this study. Interestingly, a Lactobacillus crispatus strain was found to produce a potentially novel antimicrobial compound. Full genome sequencing of this strain revealed the presence of three loci which exhibited varying degrees of homology with the genes responsible for helveticin J production in Lb. helveticus. An additional study comparing the immunomodulatory capacity of ‘viable’ and ‘non-viable’ Bifidobacterium strains found that Bifidobacterium-fermented milks (BFMs) containing ‘non-viable’ cells could stimulate levels of IL-10 and TNF-α in a manner similar to those stimulated by BFMs containing ‘viable’ cells in vitro.

Early nutrition and eczema in infancy

Eczema prevalence rates among Irish infants are unreported, despite eczema being the most common inflammatory condition of infancy. Maternal and infant nutritional status including vitamin D and other fat-soluble vitamins as well as early infant feeding have been linked with eczema initiation and development. Therefore, early nutrition could be a potential modifiable risk factor. The objective of this thesis was to prospectively describe early infant feeding and complementary feeding practices, to evaluate infant vitamin D supplementation practice, to quantify cord serum 25-hydroxyvitamin D [25(OH)D] and propose reference intervals for vitamin D metabolites, to report eczema prevalence and explore the potential role of infant nutrition and eczema. These research needs were investigated through the Cork BASELINE (Babies After SCOPE: Evaluating the Longitudinal Impact with Neurological and Nutritional Endpoints) Birth Cohort Study (n 2137). This thesis was the first comprehensive report from the birth cohort, therefore it was important to describe the cohort sociodemographic profile. Although socio-demographic characteristics compared well with national data, there was an over-representation of educated mothers which may limit the generalizability of the results. From August 2008 through November 2011, comprehensive postnatal assessments were completed at day 2 and at 2, 6, 12 and 24 months. Breastfeeding rates were low, while complementary feeding practices were broadly compliant with national guidelines. The implementation of a national infant vitamin D supplementation policy had a major impact on supplementation practice. Low levels of serum 25(OH)D were universal among Irish neonates. Eczema is a complex and multifaceted disease, which is increasing globally. This was the first report of eczema prevalence data among Irish infants which compared with international reports. Given the high prevalence and considerable burden eczema has on the lives of sufferers, intensive research efforts to identify a cause and therapeutic strategies to prevent/reduce eczema was re-emphasized in this thesis.

Monitoring behaviours and experiences before, during and after pregnancy in Ireland

Background: On-going surveillance of behaviours during pregnancy is an important but overlooked population health activity that is particularly lacking in Ireland. Few, if any, nationally representative estimates of most maternal behaviours and experiences are available. While on-going surveillance of maternal behaviours has not been a priority thus far in European countries including Ireland, on-going surveillance was identified as a key priority in the United States (US) during the 1980’s when the Pregnancy Risk Assessment Monitoring System (PRAMS), was established. Today, PRAMS is the only surveillance programme of maternal behaviours and experiences world-wide. Although on-going prevalence estimates are required in Ireland, studies which examine the offspring health effects of maternal behaviours are also required, since various questions regarding maternal exposures and their offspring health effects remain unanswered. Gestational alcohol consumption is one such important maternal exposure which is common in pregnancy, though its offspring health effects are unclear, particularly at lower or moderate levels. Thus, guidelines internationally have not reached consensus on safe alcohol recommendations for pregnant women. The aims of this thesis are to implement the PRAMS in Ireland (PRAMS Ireland), to describe the prevalence of health behaviours around the time of pregnancy in Ireland and to examine the effect of health behaviours on pregnancy and child outcomes (specifically the relationship between alcohol use during pregnancy and infant and child growth). Structure: In Chapter 1, a brief background and rationale for the work, as well as the thesis aims and objective is provided. A detailed description of the design and implementation of PRAMS Ireland is described in Chapter 2. Chapter 3 and Chapter 4 describe the methodological results of the implementation of the PRAMS Ireland pilot study and PRAMS Ireland main study. In Chapter 5, a comparison of alcohol prevalence in two Irish studies (PRAMS Ireland and Growing up in Ireland (GUI)) and one multi-centre prospective cohort study, Screening for Pregnancy Endpoints (SCOPE) Study is detailed. Chapter 6 describes findings on adherence to National Clinical Guidelines on health behaviours and nutrition around the time of pregnancy in PRAMS Ireland. Findings on exposure to alcohol use in pregnancy and infant growth outcomes are described in Chapter 7 and Chapter 8. The results of analysis conducted to examine the impact of gestational alcohol use on offspring growth trajectories to age ten are described in Chapter 9. Finally, a discussion of the findings, strengths and limitations of the thesis, direction for future research, policy, practice and public health implications are discussed in Chapter 10.Results: Implementation of PRAMS: PRAMS may be an effective system for the surveillance of health behaviours around the time of pregnancy in the Irish context. PRAMS Ireland had high response rates (67% and 61% response rates in the pilot and main study respectively), high item completion rates and valid prevalence estimates for many health behaviours. Examining prevalence of health behaviours: We found high levels of alcohol consumption before and during pregnancy, poor adherence to healthy diets and high levels of smoking before and during pregnancy among women in Ireland. Socially disadvantaged women had higher rates of deleterious health behaviours before pregnancy, although women with the most deleterious behaviour profiles before pregnancy appeared to experience the greatest gain in protective health behaviours during pregnancy. The impact of alcohol use on infant and offspring growth: We found that low and moderate levels of alcohol use did not impact on birth outcomes or offspring growth whereas heavy alcohol consumption resulted in reduced birth length and birth weight; however, this finding was not consistently observed across all studies. Selection, reporting and confounding biases which are common in observational research could be masking harmful effects. Conclusion: PRAMS is a valid and feasible method of surveillance of health behaviours around the time of pregnancy in Ireland. A surveillance program of maternal behaviours and experiences is immediately warranted due to high levels of deleterious health behaviours around the time of pregnancy in Ireland. Although our results do not indicate any evidence of harm, given the quality of evidence available, abstinence and advice of abstinence from alcohol may be the most prudent choice for patients and healthcare professionals respectively. Further studies of the effects of gestational alcohol use are required; particularly those which can reduce selection bias, reporting bias and confounding.

Nutrition, growth and body composition in infancy

This thesis is presented in two parts. Data for this research is from the Cork BASELINE (Babies after SCOPE, Evaluating Longitudinal Impact using Neurological and Nutritional Endpoints) Birth Cohort Study (n = 2137). In this prospective birth cohort study, pediatric follow-up with in-person appointments were repeated from the time of birth through to 2, 6 and 12 months, and at 2 years. Body composition was measured by air displacement plethysmography at birth and at 2 months using the PEA POD Infant Body Composition Tracking System. This thesis provides the first extensive report on the study’s 2 year assessment. In part one, the aims were to investigate potential early-life risk factors for childhood overweight and obesity, including rapid growth and body composition in infancy and umbilical cord concentrations of leptin and high molecular weight (HMW) adiponectin. This research is the first to describe rapid growth in early infancy in terms of changes in direct measures of body composition. These are also the first data to examine associations between umbilical cord leptin and HMW adiponectin concentrations and changes in fat and lean mass in early infancy. These data provide additional insight into characterising the growth trajectory in infancy and into the role of perinatal factors in determining infant growth and subsequent overweight/obesity risk. In part two of this thesis, the aims were to quantify vitamin D intake and status at 2 years and to investigate whether 25-hydroxyvitamin D [25(OH)D] concentrations in early pregnancy and in umbilical cord blood are associated with infant growth and body composition. There was a low prevalence of vitamin D deficiency among Irish 2 year olds (n = 742) despite a high prevalence of inadequate intakes and high latitude (51°N). Maternal 25(OH)D concentrations at 15 weeks gestation and cord 25(OH)D concentrations at delivery were not associated with infant growth or adiposity.

Infant nutrition and the gut microbiota

Establishment of the intestinal microbiota commences at birth and this colonisation is influenced by a number of factors including mode of delivery, gestational age, mode of feeding, environmental factors and host genetics. As this initial establishment may well influence the health of an individual later in life, it is imperative to understand this process. Therefore, this thesis set out to investigate how early infant nutrition influences the development of a healthy gut microbiota. As part of the INFANTMET project, the intestinal microbiota of 199 breastfed infants was investigated using both culture-dependent and culture-independent approaches. This study revealed that delivery mode and gestational age had a significant impact on early microbial communities. In order to understand host genotype-microbiota interactions, the gut microbiota composition of dichorionic triplets was also investigated. The results suggested that initially host genetics play a significant role in the composition of an individual’s gut microbiota, but by month 12 environmental factors are the major determinant. To investigate the origin of hydrogen sulphide in a case of nondrug- induced sulfhemoglobinemia in a preterm infant, the gut microbiota composition was determined. This analysis revealed the presence of Morganella morganii, a producer of hydrogen sulphide and hemolysins, at a relative abundance 38%, which was not detected in control infants. Following on from this, the negative and short term consequences of intrapartum antibiotic prophylaxis exposure on the early infant intestinal microbiota composition were demonstrated, particularly in breast-fed infants, which are recovered by day 30. Finally, the composition of the breast milk microbiota over the first three months of life was characterised. A core of 12 genera were identified amongst women and the remainder comprised some 195 genera which were individual specific and subject to variations over time. The results presented in this thesis have demonstrated that the development of the infant gut microbiota is complex and highly individual. Clear alterations in the intestinal microbiota establishment process in C-section delivered, preterm and antibiotic exposed infants were shown. Taken together, long-term health benefits for infants, particularly those vulnerable groups, may be conferred through the design of probiotic and prebiotic food ingredients and supplements.

In two minds about screening: an investigation of cervical cancer prevention among Irish women

Cervical cancer is the second most common female cancer worldwide. Cervical screening programmes can reduce the incidence of cervical cancer by up to 80 percent if the invited women participate. Previous Irish research has associated screening attendance with subjective norms, anticipated regret, higher socio-economic status and education. Greater perceived screening barriers and lacking knowledge were associated with avoidance. These findings support a variety of expectancy-value theories of behaviour. They also suggest that expectancy-value theories could benefit from the inclusion of affective predictors of behaviour, like anticipated regret. In 2008 the Republic of Ireland introduced the National Cervical Screening Programme (NCSP). This research seeks to identify the predictors of participation in the NCSP. A systematic review of reviews showed that predictors of screening participation clustered into environmental and psychological influences. There is a gap in the evidence synthesis of associations with personal characteristics and health beliefs. Thematic analysis of focus group interviews confirmed the validity of many screening predictors identified by the systematic review and expectancy-value theories. A survey of these predictors suggested that reduced screening barriers might encourage first-time participation, while regular attendance requires greater endorsement of screening benefits and stronger subjective norm and intention. Positive attitude, rather than knowledge, appeared to be crucial for strong intention, so the final study piloted an experiment comparing the utility of positive attitude in strengthening intention to the utility of information provision. Despite lacking significant differences between conditions, content analysis of participant comments suggested that a full trial would be worthwhile, given purposive sampling and improved sample retention. These findings agree with previous Irish research on the importance of screening intention, although its association with attitude appeared to be stronger in the present research. The findings further indicate that future screening promotion should consider interventions based on patients’ experiences of screening.