The research by Rogers et al. [1] is certainly encouraging and further proof that the use of levies is an effective lever to not only help reduce the number of child admissions for tooth extractions, but push companies to reduce sugar and calories in their products. We now need to see similar levies introduced across other product ranges, including juice, milk-based drinks, biscuits, cakes, sweets, yoghurts and cereals.
A recent product survey by the campaign group Action on Sugar has revealed more than a third of sweet food and drinks products sold in major UK high street coffee shops exceed an adult’s daily limit of sugar (30g of free sugars) in just one serving. According to the research, 782 sweet food and drink products in 9 leading coffee shops are insufficiently labelled for consumers. If nutrition information was fully transparent, more than half would be marked ‘red’, which means high in total sugars, according to the UK’s traffic light nutritional labelling system. [2]
The World Health Organization released a global report on the use of sugar-sweetened beverage (SSB) taxes in early December 2023. Most countries do not tax fruit juices, sugar-sweetened ready-to-drink tea or coffee, and sugar-sweetened milk-based drinks (including plant-based milk substitutes), even though these products contain free sugars, which might be leading to undesirable substitutions towards these drinks. About 46% of countries that apply excise taxes to SSBs include unsweete...
The research by Rogers et al. [1] is certainly encouraging and further proof that the use of levies is an effective lever to not only help reduce the number of child admissions for tooth extractions, but push companies to reduce sugar and calories in their products. We now need to see similar levies introduced across other product ranges, including juice, milk-based drinks, biscuits, cakes, sweets, yoghurts and cereals.
A recent product survey by the campaign group Action on Sugar has revealed more than a third of sweet food and drinks products sold in major UK high street coffee shops exceed an adult’s daily limit of sugar (30g of free sugars) in just one serving. According to the research, 782 sweet food and drink products in 9 leading coffee shops are insufficiently labelled for consumers. If nutrition information was fully transparent, more than half would be marked ‘red’, which means high in total sugars, according to the UK’s traffic light nutritional labelling system. [2]
The World Health Organization released a global report on the use of sugar-sweetened beverage (SSB) taxes in early December 2023. Most countries do not tax fruit juices, sugar-sweetened ready-to-drink tea or coffee, and sugar-sweetened milk-based drinks (including plant-based milk substitutes), even though these products contain free sugars, which might be leading to undesirable substitutions towards these drinks. About 46% of countries that apply excise taxes to SSBs include unsweetened bottle water, rather than incentivising water as a healthy alternative. [3]
In summary, raising health taxes is a SMART policy because it:
• Saves lives
• Mobilises revenue
• Address health inequities
• Reduces burdens on health systems
• Targets noncommunicable disease risk factors for the achievement of Sustainable Development Goals. [4]
Technology and measures to prevent malnutrition in children
We read with interest the article on‘Improving nutritional status of children using artificial intelligence-based mobile application post-surgery: randomised controlled trial’ by Maryam Zahid, Ume Sughra, Sehrish Mumtaz and Mawara Hassan that has appeared in BMJ, nutrition ,prevention and health 2023( doi: 10.1136/bmjnph-2023-000645)1
It is an important paper denoting how technology giving a mobile app counselling on dietetic advice following surgery has improved nutritional status of children.
We agree with the authors that in LMICs, technological advancement is bringing about radical changes in human behaviour.Similar strategy can be followed by other countries.
Child malnutrition is a major public health issue worldwide. An estimated 144 million children under age 5 are stunted, 47 million are wasted and 38.3 million have overweight or obesity. Around 45% of deaths among children under 5 years of age are linked to undernutrition.2
Nutritional status of children pre and post- surgery is equally important. Good nutrition helps in quick wound healing, early recovery and prevention of complications like pneumonia, diarrhoea which can further aggravate malnutrition.
We urge that countries undertake following protocols to prevent and treat malnutrition which was so rightly followed in the present paper.
1, Measuring the growth of infants and children is an essential part of c...
Technology and measures to prevent malnutrition in children
We read with interest the article on‘Improving nutritional status of children using artificial intelligence-based mobile application post-surgery: randomised controlled trial’ by Maryam Zahid, Ume Sughra, Sehrish Mumtaz and Mawara Hassan that has appeared in BMJ, nutrition ,prevention and health 2023( doi: 10.1136/bmjnph-2023-000645)1
It is an important paper denoting how technology giving a mobile app counselling on dietetic advice following surgery has improved nutritional status of children.
We agree with the authors that in LMICs, technological advancement is bringing about radical changes in human behaviour.Similar strategy can be followed by other countries.
Child malnutrition is a major public health issue worldwide. An estimated 144 million children under age 5 are stunted, 47 million are wasted and 38.3 million have overweight or obesity. Around 45% of deaths among children under 5 years of age are linked to undernutrition.2
Nutritional status of children pre and post- surgery is equally important. Good nutrition helps in quick wound healing, early recovery and prevention of complications like pneumonia, diarrhoea which can further aggravate malnutrition.
We urge that countries undertake following protocols to prevent and treat malnutrition which was so rightly followed in the present paper.
1, Measuring the growth of infants and children is an essential part of child health surveillance and gives an idea about the nutritional status of the baby. Inadequate infant growth leads to under-nutrition in children. Measurement of height, weight of children and categorising them into stunting, wasting and underweight using WHO charts is critical. WHO growth charts are ideal, prescriptive and give an idea about how children should grow. As of date more than 140 countries have adopted WHO growth charts.3
However, there is a likely probability that countries want country specific charts on the grounds that WHO charts are not appropriate and may need modification specially by lowering cut offs using complex statistical calculation4 which itself can be harmful. Lowering this standard means, we will make more children slip into malnutrition and subsequent morbidity in them who are passed as normal due to use of modified charts.
Countries must keep this in mind that if standards are lowered more children will remain undiagnosed and get into complications in subsequent childhood.
2. After diagnosis, every child must be reported not only during health, but also when it may land in complications or succumb to any illness. Therefore, mentioning correct nutritional status of the child using WHO growth charts should be mandatory in health and disease including surgical intervention. Every unfortunate death must mention nutritional status in addition to the actual cause of death. Reporting of nutrition status can be done using apps given to community health workers. Data tracking should be available ‘real time’.
3. After diagnosis, advice should be given using mobile app dietetic advice.
4. Whilst doing this, one must bear in mind affordability of micronutrient rich foods with dietary diversity and breast feeding. Climate blind mitigation measures will not give rewards., hence corrective measures should start soon.
Phadke M*, Menon P**, Saunik S***
We declare no conflict of interest.
* Sr Adv Govt,Ex-Prof and Vice Chancellor,
Maharashtra University of Health Sciences Nashik, Maharashtra, India
ORCID : 0000-0002-1138-6899
** Associate Prof. Ped. Dr DY Patil Medical college and research centre.
Dr D Y Patil Vidyapeeth Pimpri, Pune, Maharashtra India
ORCID: 0000-0002-7780-335X
*** Sujata Saunik
Addl. C.S.Home Govt of Maharashtra India ssaunik@gmail.com
ORCID: 0000-0001-6641-0721
References
1,Maryam Zahid, Ume Sughra, Sehrish Mumtaz and Mawara HassanImproving nutritional status of children using artificial intelligence-based mobile application post-surgery BMJ, nutrition ,prevention and health 2023( doi: 10.1136/bmjnph-2023-000645)1
2.www.who.int › health-topics › child-growthChild growth - World Health Organization (WHO) Mar 31, 2020 ·
3..Mercedes de Onis, Adelheid Onyango, Elaine Borghi, Amani Siyam, Monika Blössner Chessa LutterWorldwide implementation of the WHO Child Growth StandardsPublic Health Nutrition: 15(9), 1603–1610 doi:10.1017/S136898001200105X Published online 2022 Apr 4.
4..Santu Ghosh, Rajesh Majumder , Harshpal Singh Sachdev, Anura V. Kurpad, Tinku Thomas Customization of WHO Under-five Growth Standards for an Appropriate Quantification of Public Health Burden of Growth Faltering in India ,Indian Pediatrics October 2023 60(10):804-810 DOI: 10.1007/s13312-023-3009-8
In the article by Kim et al. on COVID-19 illness in relation to sleep and burnout, the investigators find that night time sleep duration, sleep problems and burnout may be risk factors for viral diseases such as COVID-19. This is not surprising as there are many mechanisms interfering with sleep deprivation and the sleep-wake cycle that can also interact with viral invasion. These include 1) the role of cytokines in sleep deprivation; 2) interactions with proteases that help regulate the sleep process and 3) diurnal variations in cytokines and immune protection. Firstly, many possible pathways for interactions of cytokines with sleep have been described (1). For instance, interleukin-1 beta (IL1) is increased during sleep deprivation (1), but also probably during long mask wear (2). As IL-1 is present in nasal fluid and breath condensate (3-5), a plausible mechanism could be that with a lack of sleep, and due to the insufficient ventilation during mask wear, IL-1 and upregulated trypsin (6) become enriched the airways. Trypsin promotes SARS-CoV-2 invasion in vitro in many host cell studies (7,8), but many other substrates in the breath condensate can possibly interfere (3). Astonishingly, one cannot find studies on the effects of prolonged mask wear on relevant substrates that are present in breath condensate. Also TNF is modulated during sleep (1), and hence deserves to be studied as well.
Secondly, in sleep deprivation, proteolytic processes play an important r...
In the article by Kim et al. on COVID-19 illness in relation to sleep and burnout, the investigators find that night time sleep duration, sleep problems and burnout may be risk factors for viral diseases such as COVID-19. This is not surprising as there are many mechanisms interfering with sleep deprivation and the sleep-wake cycle that can also interact with viral invasion. These include 1) the role of cytokines in sleep deprivation; 2) interactions with proteases that help regulate the sleep process and 3) diurnal variations in cytokines and immune protection. Firstly, many possible pathways for interactions of cytokines with sleep have been described (1). For instance, interleukin-1 beta (IL1) is increased during sleep deprivation (1), but also probably during long mask wear (2). As IL-1 is present in nasal fluid and breath condensate (3-5), a plausible mechanism could be that with a lack of sleep, and due to the insufficient ventilation during mask wear, IL-1 and upregulated trypsin (6) become enriched the airways. Trypsin promotes SARS-CoV-2 invasion in vitro in many host cell studies (7,8), but many other substrates in the breath condensate can possibly interfere (3). Astonishingly, one cannot find studies on the effects of prolonged mask wear on relevant substrates that are present in breath condensate. Also TNF is modulated during sleep (1), and hence deserves to be studied as well.
Secondly, in sleep deprivation, proteolytic processes play an important role in the sleep-wake up cycle (9), including a.o furin, an enzyme that is hijacked by SARS-CoV-2 to prime for the binding via endocytosis, which would rather involve attachment to neuropilin (8,10). The latter invasion route, alternative to ACE2, has been associated with potentiation of its infectivity (10). But also cathepsin L and ACE may play a role in sleep processes and thus may interfere (9,10).
Thirdly, individual diurnal fluctuations in cytokines, immunoglobulins (enhanced during sleep at night) (5), proteases and anti-proteases in airway secretions (3) may complicate the picture. For instance, as napping in Spain was found to be associated with an inverse risk of contracting COVID-19, a hypothesis could be that this cultural innate afternoon habit is associated with longer periods of taking off the facemasks: plausibly, this could lead to better free air exchange for regeneration of the mucociliary clearance (10) and for restoring from inflammatory dynamics due to sustained mask wear (2), while the sleep enabling better regeneration of local nasal immune responses. In conclusion, there remain many complex interactions for researchers to investigate, as to fully understand the interaction of this complex virus with sleep and burnout.
Competing interests: No competing interests
(1) Krueger JM. The role of cytokines in sleep regulation. Curr Pharm Des 2008;14(32):3408-16. doi:10.2174/138161208786549281
(2) Guan T, Hu S, Han Y, Wang R, Zhu Q, Hu Y, Fan H, Zhu T. The effects of facemasks on airway inflammation and endothelial dysfunction in healthy young adults: a double-blind, randomized, controlled crossover study. Part Fibre Toxicol 2018; 15(1):30. doi: 10.1186/s12989-018-0266-0.
(3) Montuschi P. Analysis of exhaled breath condensate in respiratory medicine: methodological aspects and potential clinical applications. Ther Adv Respir Dis 2007;1(1):5-23. doi: 10.1177/1753465807082373
(4) Riechelmann H, Deutschle T, Friemel E, Gross HJ, Bachem M. Biological markers in nasal secretions. Eur Respir J 2003;21(4):600-5. doi: 10.1183/09031936.03.00072003.
(5) Mygind N, Thomsen J. Diurnal variation of nasal protein concentration. Acta Otolaryngol 1976;82(3-4):219-21. doi: 10.3109/00016487609120888.
(6) Indalao IL, Sawabuchi T, Takahashi E, Kido H. IL-1β is a key cytokine that induces trypsin upregulation in the influenza virus-cytokine-trypsin cycle. Arch Virol 2017;162(1):201-11. doi: 10.1007/s00705-016-3093-3.
(7) Ou X, Liu Y, Lei X et al. Characterization of spike glycoprotein of SARS-CoV-2 on virus entry and its immune cross-reactivity with SARS-CoV. Nat Commun 2020;11: 1620. doi: 10.1038/s41467-020-15562-9
(8) Xia S, Lan Q, Su S. et al. The role of furin cleavage site in SARS-CoV-2 spike protein-mediated membrane fusion in the presence or absence of trypsin. Sig Transduct Target Ther 2020;5:92. doi: 10.1038/s41392-020-0184-0 https://doi.org/10.1038/s41392-020-0184-0
(9) Visniauskas B, Julian GS, Oliveira RW, Tufik S, Chagas JR. Sleep, neuropeptides and proteases. Sleep Sci 2012;5(3):92-7.
(10) Adivitiya, Kaushik MS, Chakraborty S, Veleri S, Kateriya S. Mucociliary respiratory epithelium integrity in molecular defense and susceptibility to pulmonary viral infections. Biology (Basel) 2021;10(2):95. doi: 10.3390/biology10020095.
This paper is based on an on-line survey of 2,884 healthcare workers from 6 countries. All data were filled in on-line. All data were self-reported. Participants were asked to choose which of 11 diets (including ‘other’ or ‘none of the above’) they had followed over the year before the COVID-19 outbreak. All diets were self-reported.
The main diets examined in the study were i) ‘whole food, plant-based’ diets ii) ‘whole food, plant-based or pescatarian’ combined and iii) ‘low carbohydrate’ or ‘high protein’ diets combined. These three diet groups comprised just 27% of participants. Most people and most diets were not examined in this study (other than to be grouped as “people not following the diet in question”). Paleo and keto diets were not included in the low carb or high protein group. The ‘whole food, plant-based’ diet was remarkably like, but apparently better than, the ‘Mediterranean’ diet.
There was no vegan diet in this study. The vegetarian diet was combined with the ‘whole food, plant-based’ diet, and thus not even a vegetarian diet was studied separately. Both the ‘plant-based’ diets and non-plant-based diets included eggs, dairy, poultry, red and processed meats, fish and seafood. The ‘plant-based’, ‘plant-based or pescatarian’ and the ‘low carb, high protein’ groups all had higher self-reported intake of legumes and nuts than people not following these diets.
The headline claims were i) that participants who reported following ‘plant-base...
This paper is based on an on-line survey of 2,884 healthcare workers from 6 countries. All data were filled in on-line. All data were self-reported. Participants were asked to choose which of 11 diets (including ‘other’ or ‘none of the above’) they had followed over the year before the COVID-19 outbreak. All diets were self-reported.
The main diets examined in the study were i) ‘whole food, plant-based’ diets ii) ‘whole food, plant-based or pescatarian’ combined and iii) ‘low carbohydrate’ or ‘high protein’ diets combined. These three diet groups comprised just 27% of participants. Most people and most diets were not examined in this study (other than to be grouped as “people not following the diet in question”). Paleo and keto diets were not included in the low carb or high protein group. The ‘whole food, plant-based’ diet was remarkably like, but apparently better than, the ‘Mediterranean’ diet.
There was no vegan diet in this study. The vegetarian diet was combined with the ‘whole food, plant-based’ diet, and thus not even a vegetarian diet was studied separately. Both the ‘plant-based’ diets and non-plant-based diets included eggs, dairy, poultry, red and processed meats, fish and seafood. The ‘plant-based’, ‘plant-based or pescatarian’ and the ‘low carb, high protein’ groups all had higher self-reported intake of legumes and nuts than people not following these diets.
The headline claims were i) that participants who reported following ‘plant-based’ diets and ‘plant-based or pescatarian’ diets had 73% and 59% lower odds of moderate-to-severe COVID-19, respectively, compared with participants who did not follow these diets. And ii) compared with participants who reported following ‘plant-based’ diets, those who reported following ‘low carbohydrate, high protein’ diets had almost four times the odds of moderate-to-severe COVID-19.
Regarding headline claim (i), the paper claimed that there were 568 cases of COVID-19 and this was the number used in the associations claimed. But the paper also reported that there were 298 positive COVID-19 tests (so 270 of the self-reported cases were not supported by a positive test). When just the positive test cases were examined (supplemental material), there was no association between self-reported diet and self-reported COVID-19 severity. This means that the main claim was invalid when positive test cases of COVID-19 (not self-reported cases) were used.
Regarding headline claim (ii), the ‘four times as likely’ claim was based on just four cases of self-reported COVID-19 in the ‘plant-based’ group. Such a tiny (self-reported) denominator is an unreliable basis upon which to make such a strong “four-fold” claim.
Virtually all the findings were non-findings (i.e., not statistically significant). The supplemental material showed that there were no associations between self-reported diet and self-reported cases of COVID-19. There were no associations between self-reported diet and the self-reported duration of cases of COVID-19. There were no associations between self-reported diet and the duration of positive test cases of COVID-19. There were no associations between self-reported diet and the severity of positive test cases of COVID-19.
This paper is misleading and potentially dangerous. Assertions such as those made in this paper should not be made during a public health crisis when they fail to withstand scrutiny.
The article Cost and greenhouse gas emissions of current, healthy, flexitarian and vegan diets in Aotearoa (New Zealand) [1] comes to the conclusion that healthy vegan diets are more expensive than the current omnivorous diet practiced in New Zealand. The authors conclude that there must be a trade off in terms of expense versus health and environmental effects.
The authors provide no costing from externalities, such as the higher health and environmental clean-up costs of the current diet [2]. However, even under their own terms, the cost to the consumer for a healthy whole-foods plant-based diet as advocated by the EAT Lancet recommendations [3] is actually cheaper than the current omnivorous New Zealand diet.
We recently conducted a survey of animal-based and plant-based protein foods in Auckland and Christchurch, New Zealand's two biggest cities [4]. We checked prices in supermarkets and Asian food stores and we calculated cost per gram of digestible protein. Our findings were that the cheapest six sources of protein in Auckland were plant-based. The relative paucity of Asian stores in Christchurch meant that plant protein sources were slightly more expensive, but food such as red lentils and oats were still cheaper than animal products.
Of course, if one substitutes meat products for plant-based highly processed burgers as in the model proposed by the authors of this study [1], then the cost of protein goes up, but this is not a real...
The article Cost and greenhouse gas emissions of current, healthy, flexitarian and vegan diets in Aotearoa (New Zealand) [1] comes to the conclusion that healthy vegan diets are more expensive than the current omnivorous diet practiced in New Zealand. The authors conclude that there must be a trade off in terms of expense versus health and environmental effects.
The authors provide no costing from externalities, such as the higher health and environmental clean-up costs of the current diet [2]. However, even under their own terms, the cost to the consumer for a healthy whole-foods plant-based diet as advocated by the EAT Lancet recommendations [3] is actually cheaper than the current omnivorous New Zealand diet.
We recently conducted a survey of animal-based and plant-based protein foods in Auckland and Christchurch, New Zealand's two biggest cities [4]. We checked prices in supermarkets and Asian food stores and we calculated cost per gram of digestible protein. Our findings were that the cheapest six sources of protein in Auckland were plant-based. The relative paucity of Asian stores in Christchurch meant that plant protein sources were slightly more expensive, but food such as red lentils and oats were still cheaper than animal products.
Of course, if one substitutes meat products for plant-based highly processed burgers as in the model proposed by the authors of this study [1], then the cost of protein goes up, but this is not a realistic scenario for health-conscious vegans on a budget.
We also question the large proportion of the total cost of the vegan diet resulting from the inclusion of dairy substitutes. There are several cultures, including the very long lived Japanese, who traditionally use few dairy products. It is not necessary to include these (expensive) dairy substitutes [5]. Especially almond milk, which is pretty much nutritionally useless.
I congratulate the authors for raising awareness of the need for there to be a transformation of eating habits in Aotearoa, for reasons of personal, public and planetary health. If this is to be achieved, we need to put to rest the fallacy that eating a nutritious and tasty whole-foods plant-based diet is more expensive.
References
[1] Kidd B, Mackay S, Vandevijvere S, et al. Cost and greenhouse gas emissions of current, healthy, flexitarian and vegan diets in Aotearoa (New Zealand). BMJ Nutrition, Prevention & Health 2021;4:doi: 10.1136/bmjnph-2021-000262.
[2] Drew J, Cleghorn C , Macmillan A , et al Healthy and climate-friendly eating patterns in the New Zealand context. Environ Health Perspect 2020;128:17007. doi:10.1289/EHP5996 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31967488.
[3] Willett W, Rockström J, Loken B , et al Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 2019;393:447–92.doi:10.1016/S0140-6736(18)31788-4 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30660336
[4] Morris MC, Livesey JH. Plant-based protein cost survey. Food New Zealand Oct/Nov 2020, 42-44.
[5] Greger M. How not to die. Flatiron Books: New York, 2015.
Firstly, through out the writing, authors keep switching between the terminologies undernutrion and malnutrition even though they have two different meanings. This made it seems as though under nutriton means malnutrition which is not the case. Accoridng to World Health Organization (WHO) (1) manutrition can be defined as unbalanced diet meaning excess or limited amount of any of the six classes of food. Malnutrition can occur when a food supply is either scarce or abundant. For example :
Obesity is a form of malnutrition, but it is not undenturtion, but rather overnutriton. Someone who is overweight can be malnourished. Under nutrition on the other hand refers specifically to a deficiency of food, nutrients and/or energy. It the most common form of malnutrition, but not the only type. Undernutrition is caused by inadequate intake, absorption, or use of nutrients, food and energy. It can also mean insufficient intake of energy, and nutrients an individual need to meet or maintain good health. Someone can be malnourished and not undernourished.
Secondly, the authors mentioned there are three types of undernutition. Accoridng to WHO there are four sub-types of undernutrition which are : stunting, wasting, underweight and deficiency of micronutrients (vitamins and minerals). The authors completely failed to mention the fourth sub-type, although they quickly mentioned about importance of iodine in household cooking salt, but that was all that was mentioned about...
Firstly, through out the writing, authors keep switching between the terminologies undernutrion and malnutrition even though they have two different meanings. This made it seems as though under nutriton means malnutrition which is not the case. Accoridng to World Health Organization (WHO) (1) manutrition can be defined as unbalanced diet meaning excess or limited amount of any of the six classes of food. Malnutrition can occur when a food supply is either scarce or abundant. For example :
Obesity is a form of malnutrition, but it is not undenturtion, but rather overnutriton. Someone who is overweight can be malnourished. Under nutrition on the other hand refers specifically to a deficiency of food, nutrients and/or energy. It the most common form of malnutrition, but not the only type. Undernutrition is caused by inadequate intake, absorption, or use of nutrients, food and energy. It can also mean insufficient intake of energy, and nutrients an individual need to meet or maintain good health. Someone can be malnourished and not undernourished.
Secondly, the authors mentioned there are three types of undernutition. Accoridng to WHO there are four sub-types of undernutrition which are : stunting, wasting, underweight and deficiency of micronutrients (vitamins and minerals). The authors completely failed to mention the fourth sub-type, although they quickly mentioned about importance of iodine in household cooking salt, but that was all that was mentioned about vitamins and minerals.
Furthermore, the authors mentioned collaboration and multisectoral intervention as the only intervention to combat undernutrition. There was several other interventions we must not ignore because they play as much importance as multisectoral interventions if not more. For example:
1. Empowering mothers, parents, caregivers and even teachers and educating them about the importance of eating healthy diet is very crucial. Encouraging pregnant women from early trimester about the importance of healthy food for both mother and child play crucial role to determine the future nutritional status of the child. Teaching mothers how to plant and cook healthy, non expensive food is very important. The authors mentioned collaboration with ministry of health, agriculture and others. How about including ministry of education to play both educational role and also help with interventions? At the age of 3 to 4 children start going to preschools or kindergarten, educating teachers on making sure the kids do not only learn school materials, but also making sure they know about eating healthy food and also giving them free breakfast and lunch at school will play a big role. For some of the children, the meal they eat at school is the only meal they eat all day. Schools can incorporate free meal packages sponsored by ministry of education and other non governmental organization can go a long way to help with undernutrition.
2. Just the way we have blood banks where people can donate free blood to people in need. Food bank can also be encouraged in our communities. Encouraging people to donate healthy meals to a place at anytime and anyone especially children can pick up the food without being charged for it. Collaboration with local restaurants is also very important. They can help to provide free or discounted food to children under the age of 5, they can help by cooking food not only high in calories and strach but also food high in proteins, fibers and other essential nutrients they serve the community, especially children.
3. The authors mentioned introducing solid, semi solid and soft food from 6 month, but mentioned breastfeeding from birth until age 5 months. According to WHO, exclusive breastfeeding should be done from birth until age 6 months without anyone supplement, food or water. Accoridng to United Nation International Children's Emergency Fund (UNICEF) (2) there are 10 action intervention for managing undernutrion which was not included in this stud
Having a balanced diet is very essential to the well-being of an individual. Good nutrition intake is something that is emphasized very heavily from the time a woman becomes pregnant. As a child grows fruits and vegetables are stressed upon. <in developed countries most schools have a feeding program put into place to ensure that.
In the article, it is mentioned that higher fruit and vegetable intake was significantly associated with better well-being. In secondary school students are older therefore the age difference along with maturity might be a key factor. Also in secondary school, students approach to the intake of fruits and vegetables is more welcomed to the pallet as opposed to younger children. A child is well nourished tend to function better in a class because growth and development is strengthened with nutrition
Figure6 shows participants who started with the worst blood sugars (HbA1c) saw the greatest improvements in diabetic control. This impressive correlation is an illusion.
If A are pretreatment values and B postreatment- A is being plotted against A minus B. Thus A appears on both X and Y axes .Thus the positive correlation.If A is always larger than B then A minus B is always positive as here
1. Nowhere in the article do I find a mention of a Research Ethics Committee or Institutional Review Board that reviewed and approved the protocol. Does this university (in Germany, of all places) allow its scientists to perform medical experiments on humans as they see fit?
2. It is not up to the authors to decide that 'trial registration was not necessary'. Trials on humans must be pre-registered. The data analysis in this paper makes abundantly clear why medical journals demand pre-registration; Table 3 is a blatant fishing expedition without correction for multiple testing.
3. How can BMJ publish an article that does not follow the Declaration of Helsinki and the ICMJE Guidelines?
Lanham-New et al. reviewed current evidence of vitamin D associations with health conditions that are pertinent to SARS-CoV-2 virus/COVID-19 disease. Their review highlighted the importance of a well-balanced diet, including an adequate amount of vitamin D intake, to boost the immune system and to resist viral infection. Lanham-New et al. also noted positive associations reported in a single study between the blood metabolite 25-hydroxyvitamin D (25OHD) and lung function and noted that “formal systematic reviews/meta-analyses of these associations are urgently required.” We would like to draw attention to several published reports of observational cohort studies evaluating the association of serum 25OHD with lung function (1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 13; 14; 15; 16; 17; 18) and to our meta-analysis that investigated this association across nine large population-based cohort studies (total N=27,128) (19).
Our cross-ancestry meta-analysis included adults (age range: 19-95 yrs) living in northern latitudes (e.g. the Netherlands, Iceland, northern part of U.S.) and adults with darker skin tones (i.e., African ancestry participants), who may be at greater risk of vitamin D deficiency given limited sun exposure or slower production of vitamin D in the skin. Prior to combining association results for meta-analysis, the lung function outcomes, exposure (25OHD), and the covariates were harmonized, and the same statistical models were applied across the nine coh...
Lanham-New et al. reviewed current evidence of vitamin D associations with health conditions that are pertinent to SARS-CoV-2 virus/COVID-19 disease. Their review highlighted the importance of a well-balanced diet, including an adequate amount of vitamin D intake, to boost the immune system and to resist viral infection. Lanham-New et al. also noted positive associations reported in a single study between the blood metabolite 25-hydroxyvitamin D (25OHD) and lung function and noted that “formal systematic reviews/meta-analyses of these associations are urgently required.” We would like to draw attention to several published reports of observational cohort studies evaluating the association of serum 25OHD with lung function (1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 13; 14; 15; 16; 17; 18) and to our meta-analysis that investigated this association across nine large population-based cohort studies (total N=27,128) (19).
Our cross-ancestry meta-analysis included adults (age range: 19-95 yrs) living in northern latitudes (e.g. the Netherlands, Iceland, northern part of U.S.) and adults with darker skin tones (i.e., African ancestry participants), who may be at greater risk of vitamin D deficiency given limited sun exposure or slower production of vitamin D in the skin. Prior to combining association results for meta-analysis, the lung function outcomes, exposure (25OHD), and the covariates were harmonized, and the same statistical models were applied across the nine cohorts. We reported a statistically significant positive association of 25OHD with lung function, specifically FEV1 and FVC. The positive direction of association was consistent across all cohorts regardless of ancestry. In addition, the positive association of 25OHD with lung function was stronger among current and former smokers, compared with never smokers. Although causality cannot be inferred from the observational studies conducted to date, the indication for a protective effect of vitamin D in individuals with a smoking history, as a vulnerable population, is notable given the current evidence suggesting smoking as a risk factor for worse progression of COVID-19 disease (20). Future prospective studies, including randomized clinical trials, are needed to establish any causal links between 25OHD, cigarette smoking, lung function, and COVID-19 disease. We agree with Lanham-New et al. that the current evidence base is insufficient to include vitamin D supplementation as a prevention or treatment strategy for COVID-19 disease.
Jiayi Xu, Ph.D.
Postdoctoral Fellow, Pamela Sklar Division of Psychiatric Genomics, Icahn School of Medicine at Mount Sinai
Dana B. Hancock, Ph.D.
Senior Genetic Epidemiologist & Director, GenOmics, Bioinformatics, and Translational Research Center, Biostatistics and Epidemiology Division, Research Triangle Institute
Patricia A. Cassano, Ph.D.
Professor & Director, Division of Nutritional Sciences, Cornell University
Reference:
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2. Choi CJ, Seo M, Choi WS et al. (2013) Relationship between serum 25-hydroxyvitamin D and lung function among Korean adults in Korea National Health and Nutrition Examination Survey (KNHANES), 2008-2010. J Clin Endocrinol Metab 98, 1703-1710.
3. Hansen JG, Gao W, Dupuis J et al. (2015) Association of 25-Hydroxyvitamin D status and genetic variation in the vitamin D metabolic pathway with FEV1 in the Framingham Heart Study. Respir Res 16, 81.
4. Afzal S, Lange P, Bojesen SE et al. (2014) Plasma 25-hydroxyvitamin D, lung function and risk of chronic obstructive pulmonary disease. Thorax 69, 24-31.
5. Berry DJ, Hesketh K, Power C et al. (2011) Vitamin D status has a linear association with seasonal infections and lung function in British adults. Br J Nutr 106, 1433-1440.
6. Thuesen BH, Skaaby T, Husemoen LL et al. (2015) The association of serum 25-OH vitamin D with atopy, asthma, and lung function in a prospective study of Danish adults. Clin Exp Allergy 45, 265-272.
7. Tolppanen AM, Williams D, Henderson J et al. (2011) Serum 25-hydroxy-vitamin D and ionised calcium in relation to lung function and allergen skin tests. Eur J Clin Nutr 65, 493-500.
8. Shaheen SO, Jameson KA, Robinson SM et al. (2011) Relationship of vitamin D status to adult lung function and COPD. Thorax 66, 692-698.
9. Niruban SJ, Alagiakrishnan K, Beach J et al. (2015) Association between vitamin D and respiratory outcomes in Canadian adolescents and adults. J Asthma 52, 653-661.
10. Tolppanen AM, Sayers A, Granell R et al. (2013) Prospective association of 25-hydroxyvitamin d3 and d2 with childhood lung function, asthma, wheezing, and flexural dermatitis. Epidemiology 24, 310-319.
11. Lange NE, Sparrow D, Vokonas P et al. (2012) Vitamin D deficiency, smoking, and lung function in the Normative Aging Study. Am J Respir Crit Care Med 186, 616-621.
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13. Rafiq R, Thijs W, Prein R et al. (2018) Associations of Serum 25(OH)D Concentrations with Lung Function, Airway Inflammation and Common Cold in the General Population. Nutrients 10.
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18. Lai SH, Liao SL, Tsai MH et al. (2017) Low cord-serum 25-hydroxyvitamin D levels are associated with poor lung function performance and increased respiratory infection in infancy. PloS one 12, e0173268.
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The research by Rogers et al. [1] is certainly encouraging and further proof that the use of levies is an effective lever to not only help reduce the number of child admissions for tooth extractions, but push companies to reduce sugar and calories in their products. We now need to see similar levies introduced across other product ranges, including juice, milk-based drinks, biscuits, cakes, sweets, yoghurts and cereals.
A recent product survey by the campaign group Action on Sugar has revealed more than a third of sweet food and drinks products sold in major UK high street coffee shops exceed an adult’s daily limit of sugar (30g of free sugars) in just one serving. According to the research, 782 sweet food and drink products in 9 leading coffee shops are insufficiently labelled for consumers. If nutrition information was fully transparent, more than half would be marked ‘red’, which means high in total sugars, according to the UK’s traffic light nutritional labelling system. [2]
The World Health Organization released a global report on the use of sugar-sweetened beverage (SSB) taxes in early December 2023. Most countries do not tax fruit juices, sugar-sweetened ready-to-drink tea or coffee, and sugar-sweetened milk-based drinks (including plant-based milk substitutes), even though these products contain free sugars, which might be leading to undesirable substitutions towards these drinks. About 46% of countries that apply excise taxes to SSBs include unsweete...
Show MoreTechnology and measures to prevent malnutrition in children
Show MoreWe read with interest the article on‘Improving nutritional status of children using artificial intelligence-based mobile application post-surgery: randomised controlled trial’ by Maryam Zahid, Ume Sughra, Sehrish Mumtaz and Mawara Hassan that has appeared in BMJ, nutrition ,prevention and health 2023( doi: 10.1136/bmjnph-2023-000645)1
It is an important paper denoting how technology giving a mobile app counselling on dietetic advice following surgery has improved nutritional status of children.
We agree with the authors that in LMICs, technological advancement is bringing about radical changes in human behaviour.Similar strategy can be followed by other countries.
Child malnutrition is a major public health issue worldwide. An estimated 144 million children under age 5 are stunted, 47 million are wasted and 38.3 million have overweight or obesity. Around 45% of deaths among children under 5 years of age are linked to undernutrition.2
Nutritional status of children pre and post- surgery is equally important. Good nutrition helps in quick wound healing, early recovery and prevention of complications like pneumonia, diarrhoea which can further aggravate malnutrition.
We urge that countries undertake following protocols to prevent and treat malnutrition which was so rightly followed in the present paper.
1, Measuring the growth of infants and children is an essential part of c...
In the article by Kim et al. on COVID-19 illness in relation to sleep and burnout, the investigators find that night time sleep duration, sleep problems and burnout may be risk factors for viral diseases such as COVID-19. This is not surprising as there are many mechanisms interfering with sleep deprivation and the sleep-wake cycle that can also interact with viral invasion. These include 1) the role of cytokines in sleep deprivation; 2) interactions with proteases that help regulate the sleep process and 3) diurnal variations in cytokines and immune protection. Firstly, many possible pathways for interactions of cytokines with sleep have been described (1). For instance, interleukin-1 beta (IL1) is increased during sleep deprivation (1), but also probably during long mask wear (2). As IL-1 is present in nasal fluid and breath condensate (3-5), a plausible mechanism could be that with a lack of sleep, and due to the insufficient ventilation during mask wear, IL-1 and upregulated trypsin (6) become enriched the airways. Trypsin promotes SARS-CoV-2 invasion in vitro in many host cell studies (7,8), but many other substrates in the breath condensate can possibly interfere (3). Astonishingly, one cannot find studies on the effects of prolonged mask wear on relevant substrates that are present in breath condensate. Also TNF is modulated during sleep (1), and hence deserves to be studied as well.
Secondly, in sleep deprivation, proteolytic processes play an important r...
Show MoreThis paper is based on an on-line survey of 2,884 healthcare workers from 6 countries. All data were filled in on-line. All data were self-reported. Participants were asked to choose which of 11 diets (including ‘other’ or ‘none of the above’) they had followed over the year before the COVID-19 outbreak. All diets were self-reported.
The main diets examined in the study were i) ‘whole food, plant-based’ diets ii) ‘whole food, plant-based or pescatarian’ combined and iii) ‘low carbohydrate’ or ‘high protein’ diets combined. These three diet groups comprised just 27% of participants. Most people and most diets were not examined in this study (other than to be grouped as “people not following the diet in question”). Paleo and keto diets were not included in the low carb or high protein group. The ‘whole food, plant-based’ diet was remarkably like, but apparently better than, the ‘Mediterranean’ diet.
There was no vegan diet in this study. The vegetarian diet was combined with the ‘whole food, plant-based’ diet, and thus not even a vegetarian diet was studied separately. Both the ‘plant-based’ diets and non-plant-based diets included eggs, dairy, poultry, red and processed meats, fish and seafood. The ‘plant-based’, ‘plant-based or pescatarian’ and the ‘low carb, high protein’ groups all had higher self-reported intake of legumes and nuts than people not following these diets.
The headline claims were i) that participants who reported following ‘plant-base...
Show MoreThe article Cost and greenhouse gas emissions of current, healthy, flexitarian and vegan diets in Aotearoa (New Zealand) [1] comes to the conclusion that healthy vegan diets are more expensive than the current omnivorous diet practiced in New Zealand. The authors conclude that there must be a trade off in terms of expense versus health and environmental effects.
The authors provide no costing from externalities, such as the higher health and environmental clean-up costs of the current diet [2]. However, even under their own terms, the cost to the consumer for a healthy whole-foods plant-based diet as advocated by the EAT Lancet recommendations [3] is actually cheaper than the current omnivorous New Zealand diet.
We recently conducted a survey of animal-based and plant-based protein foods in Auckland and Christchurch, New Zealand's two biggest cities [4]. We checked prices in supermarkets and Asian food stores and we calculated cost per gram of digestible protein. Our findings were that the cheapest six sources of protein in Auckland were plant-based. The relative paucity of Asian stores in Christchurch meant that plant protein sources were slightly more expensive, but food such as red lentils and oats were still cheaper than animal products.
Of course, if one substitutes meat products for plant-based highly processed burgers as in the model proposed by the authors of this study [1], then the cost of protein goes up, but this is not a real...
Show MoreFirstly, through out the writing, authors keep switching between the terminologies undernutrion and malnutrition even though they have two different meanings. This made it seems as though under nutriton means malnutrition which is not the case. Accoridng to World Health Organization (WHO) (1) manutrition can be defined as unbalanced diet meaning excess or limited amount of any of the six classes of food. Malnutrition can occur when a food supply is either scarce or abundant. For example :
Obesity is a form of malnutrition, but it is not undenturtion, but rather overnutriton. Someone who is overweight can be malnourished. Under nutrition on the other hand refers specifically to a deficiency of food, nutrients and/or energy. It the most common form of malnutrition, but not the only type. Undernutrition is caused by inadequate intake, absorption, or use of nutrients, food and energy. It can also mean insufficient intake of energy, and nutrients an individual need to meet or maintain good health. Someone can be malnourished and not undernourished.
Secondly, the authors mentioned there are three types of undernutition. Accoridng to WHO there are four sub-types of undernutrition which are : stunting, wasting, underweight and deficiency of micronutrients (vitamins and minerals). The authors completely failed to mention the fourth sub-type, although they quickly mentioned about importance of iodine in household cooking salt, but that was all that was mentioned about...
Show MoreHaving a balanced diet is very essential to the well-being of an individual. Good nutrition intake is something that is emphasized very heavily from the time a woman becomes pregnant. As a child grows fruits and vegetables are stressed upon. <in developed countries most schools have a feeding program put into place to ensure that.
In the article, it is mentioned that higher fruit and vegetable intake was significantly associated with better well-being. In secondary school students are older therefore the age difference along with maturity might be a key factor. Also in secondary school, students approach to the intake of fruits and vegetables is more welcomed to the pallet as opposed to younger children. A child is well nourished tend to function better in a class because growth and development is strengthened with nutrition
Figure6 shows participants who started with the worst blood sugars (HbA1c) saw the greatest improvements in diabetic control. This impressive correlation is an illusion.
If A are pretreatment values and B postreatment- A is being plotted against A minus B. Thus A appears on both X and Y axes .Thus the positive correlation.If A is always larger than B then A minus B is always positive as here
1. Nowhere in the article do I find a mention of a Research Ethics Committee or Institutional Review Board that reviewed and approved the protocol. Does this university (in Germany, of all places) allow its scientists to perform medical experiments on humans as they see fit?
2. It is not up to the authors to decide that 'trial registration was not necessary'. Trials on humans must be pre-registered. The data analysis in this paper makes abundantly clear why medical journals demand pre-registration; Table 3 is a blatant fishing expedition without correction for multiple testing.
3. How can BMJ publish an article that does not follow the Declaration of Helsinki and the ICMJE Guidelines?
Lanham-New et al. reviewed current evidence of vitamin D associations with health conditions that are pertinent to SARS-CoV-2 virus/COVID-19 disease. Their review highlighted the importance of a well-balanced diet, including an adequate amount of vitamin D intake, to boost the immune system and to resist viral infection. Lanham-New et al. also noted positive associations reported in a single study between the blood metabolite 25-hydroxyvitamin D (25OHD) and lung function and noted that “formal systematic reviews/meta-analyses of these associations are urgently required.” We would like to draw attention to several published reports of observational cohort studies evaluating the association of serum 25OHD with lung function (1; 2; 3; 4; 5; 6; 7; 8; 9; 10; 11; 12; 13; 14; 15; 16; 17; 18) and to our meta-analysis that investigated this association across nine large population-based cohort studies (total N=27,128) (19).
Show MoreOur cross-ancestry meta-analysis included adults (age range: 19-95 yrs) living in northern latitudes (e.g. the Netherlands, Iceland, northern part of U.S.) and adults with darker skin tones (i.e., African ancestry participants), who may be at greater risk of vitamin D deficiency given limited sun exposure or slower production of vitamin D in the skin. Prior to combining association results for meta-analysis, the lung function outcomes, exposure (25OHD), and the covariates were harmonized, and the same statistical models were applied across the nine coh...
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