Long-term Chronic Disease Research Articles

Guidelines for recognition, assessment and treatment of pain: WSAVA Global Pain Council members and co-authors of this document:.

Karol Mathews DVM DVSc DACVECC (Canada) Peter W Kronen Dr Vet Med, DVM DECVAA (Switzerland) Duncan Lascelles BSc BVSc PhD DSAS DECVS DACVS MRCVS (USA) Andrea Nolan MVB DVA PhD DECVAA DECVPT MRCVS (UK) Sheilah Robertson BVMS (Hons) PhD DACVAA DECVAA DECAWBM (WSEL) DACAW MRCVS (USA) Paulo VM Steagall MV MS PhD DACVAA (Brazil/Canada) Bonnie Wright DVM DACVAA (USA) Kazuto Yamashita DVM MS PhD DJCVS (Japan)

Older age at retirement is associated with decreased risk of dementia

To test the hypothesis that age at retirement is associated with dementia risk among self-employed workers in France, we linked health and pension databases of self-employed workers and we extracted data of those who were still alive and retired as of December 31st 2010. Dementia cases were detected in the database either through the declaration of a long-term chronic disease coded as Alzheimer's disease and other dementia (International Classification of Disease codes G30, F00, F01, F03) or through the claim for reimbursement of one of the anti-dementia drugs. Data were analyzed using Cox proportional hazard model adjusting for potential confounders. Among the 429,803 retired self-employed workers alive on December 31st 2010, prevalence of dementia was 2.65 %. Multivariable analyses showed that the hazard ratio of dementia was 0.968 [95 % confidence interval = (0.962-0.973)] per each extra year of age at retirement. After excluding workers who had dementia diagnosed within the 5 years following retirement, the results remained unchanged and highly significant (p < 0.0001). We show strong evidence of a significant decrease in the risk of developing dementia associated with older age at retirement, in line with the "use it or lose it" hypothesis. Further evidence is necessary to evaluate whether this association is causal, but our results indicate the potential importance of maintaining high levels of cognitive and social stimulation throughout work and retiree life.

Resistance profile for pathogens causing urinary tract infection in a pediatric population, and antibiotic treatment response, at a university hospital 2010-2011

Introduction: Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and causes acute and chronic morbidity and long-term hypertension and chronic kidney disease. Objectives: To describe the demographic characteristics, infectious agents, patterns of antibiotic resistance, etiologic agent and profile of susceptibility and response to empirical treatment of UTI in a pediatric population. Methods: This is a descriptive, retrospective study. Results: Included in the study were 144 patients, 1:2.06 male to female ratio. The most common symptom was fever (79.9%) and 31.3% had a history of previous UTI. 72.0% of the patients had positive urine leukocyte count (&gt;5 per field), urine gram was positive in 85.0% of samples and gram negative bacilli accounted for 77.8% for the total pathogens isolated. The most frequent uropathogens isolated were Escherichia coli and Klebsiella pneumoniae. Our E.coli isolates had a susceptibility rate higher than 90% to most of the antibiotics used, but a resistance rate of 42.6% to TMP SMX and 45.5% to ampicillin sulbactam. 6.3% of E. coliwas extended-spectrum beta-lactamases producer strains. The most frequent empirical antibiotic used was amikacin, which was used in 66.0% of the patients. 17 of 90 patients who underwent voiding cistouretrography (VCUG) had vesicoureteral reflux. Conclusion: This study revealed that E. coli was the most frequent pathogen of community acquired UTI. We found that E. coli and other uropathogens had a high resistance rate against TMP SMX and ampicillin sulbactam. In order to ensure a successful empirical treatment, protocols should be based on local epidemiology and susceptibility rates.

Early serum tacrolimus levels predict long-term chronic kidney disease after liver transplantation

OBJECTIVE: To investigate risk factors for the development of chronic kidney disease and death two years postliver transplantation. METHOD: Associations between clinical and laboratory parameters and the development of chronic kidney disease and survival two years post-liver transplant were analyzed in a cohort of 148 adult patients with hepatic cirrhosis consecutively submitted to liver transplantation in a referral Brazilian center. RESULTS: Median age at liver transplantation was 56 (range, 20-73) years, and 105 (70.9%) patients were males. The prevalence of chronic kidney disease at two years post-liver transplantation was: stage 1 or no chronic kidney disease, 27.5%; stage 2, 33.8%; stage 3, 34.6%; stages 4-5, 4.7%. Four variables were independently associated with the stage of chronic kidney disease two years after liver transplantation: (i) age (at liver transplantation), (ii) male gender, (iii) median tacrolimus levels in the first three months post-liver transplantation, and (iv) median of serum creatinine in the first six months post-liver transplantation. Two variables showed independent association with death in two years post-liver transplantation: (i) stay in Intensive Care Unit for three or more days after the liver transplantation surgery and (ii) median of serum creatinine levels in the first six months post-liver transplantation equal or higher than 1.3 mg/dL. CONCLUSIONS: Administration of the lowest effective dose of tacrolimus and adoption of strategies to spare renal function are important measures to reduce the risk of late chronic kidney disease and death post-liver transplantation especially in high risk patients.

Prevalence, Awareness, Control, and Treatment of Hypertension and Diabetes in Korean Cancer Survivors: A Cross-Sectional Analysis of the Fourth and Fifth Korea National Health and Nutrition Examination Surveys

Management of hypertension and diabetes in cancer survivors is an important issue; however, not much is known about the level of management of such chronic disease in Korea. This study therefore assessed the prevalence, awareness, control, and treatment of hypertension and diabetes in Korean cancer survivors compared to non-cancer survivors. A cross-sectional design was employed, wherein data were obtained from standardized questionnaires completed by 943 cancer survivors and 41,233 non-cancer survivors who participated in the Fourth and Fifth Korea National Health and Nutrition Examination Surveys (2007-2011). We calculated adjusted proportions for prevalence and management of hypertension and diabetes in non-cancer survivors and cancer survivors. We also assessed the associated factors with prevalence and management of cancer survivors. Cancer survivors are more likely than the general population to have higher prevalence, awareness, treatment, and control of hypertension. However, diabetic management was not significantly higher in cancer survivors than in non-cancer survivors, despite their having a higher prevalence. Several factors, such as, age, drinking, years since cancer diagnosis, self-perceived health status, and specific cancer types were found to affect to management of hypertension and diabetes. These data suggest that cancer survivors appear to be better than non-cancer survivors at management of hypertension, but not diabetes. There is a need for healthcare providers to recognize the importance of long-term chronic disease management for cancer survivors and for the care model to be shared between primary care physicians and oncologists.

Preterm Birth and Hypertension Risk

The majority of epidemiological studies in developmental programming have explored the influence of low birth weight (irrespective of gestational age) on long-term chronic disease in individuals born during the first half of the 20th century.1,2 Low birth weight neonates may represent infants born at term with intrauterine growth restriction (IUGR) or born preterm with or without IUGR. As such, there is emerging interest in the effects of preterm birth alone (beyond birth weight and IUGR) on specific aspects of human development and long-term health. Approximately 10% of all births worldwide are preterm (before 37 completed weeks of gestation).3 Besides being of low birth weight, preterm neonates are suddenly and prematurely exposed to the extrauterine environment at a time when organogenesis is incomplete. Exposure postnatally to factors such as high oxygen concentrations,4 medications5 (including glucocorticoids),6 and inadequate nutrition7 likely adversely influence postnatal growth and ongoing organ development. In addition to possible genetic and epigenetic factors that may contribute to hypertension risk (including hypertension-related complications of pregnancy), a multitude of aspects related to both intrauterine and extrauterine growth, as well as the postnatal environment, may all play an important role in the programming of hypertension in individuals born preterm. In this review, we will highlight, in particular, the potential effect of oxidative stress associated with preterm birth on neonatal development and future disease risk. The survival of neonates born at low and very low gestational ages is recent in the history of medicine and has increased remarkably over the last few decades. The first generations of survivors of very preterm birth are currently just reaching adulthood and as such are providing emerging evidence of chronic health conditions, such as hypertension. The link between preterm birth and hypertension risk (independent of birth weight) has been …

Evolution of Environmental Exposure Science: Using Breath-Borne Biomarkers for “Discovery” of the Human Exposome

According to recent research, 70-90% of long-term latency and chronic human disease incidence is attributable to environmental (human exposome) factors through the gene-environment interaction. Environmental exposure science is now embarking on a new "discovery" path for decoding the human exposome using biomarkers in breath and other biological media.

Clinical Practice Guidelines for Healthy Eating for the Prevention and Treatment of Metabolic and Endocrine Diseases in Adults: Cosponsored by the American Association of Clinical Endocrinologists/The American College of Endocrinology and the Obesity Society Executive Summary

J. Michael Gonzalez-Campoy, MD, PhD, FACE1; Sachiko T. St. Jeor, PhD, RD2; Kristin Castorino, DO3; Ayesha Ebrahim, MD, FACE4; Dan Hurley, MD, FACE5; Lois Jovanovic, MD, MACE6; Jeffrey I. Mechanick, MD, FACP, FACN, FACE, ECNU7; Steven M. Petak, MD, JD, MACE, FCLM8; Yi-Hao Yu, MD, PhD, FACE9; Kristina A. Harris10; Penny Kris-Etherton, PhD, RD11; Robert Kushner, MD12; Maureen Molini-Blandford, MPH, RD13; Quang T. Nguyen, DO14; Raymond Plodkowski, MD15; David B. Sarwer, PhD16; Karmella T. Thomas, RD17

Reduction in Cardiometabolic Disease Risk Following Gastric Bypass Surgery Among Hispanic Adults

The increasing prevalence of US morbid obesity is associated with serious health consequences and high medical costs, particularly among ethnic minority groups. Little information is available on the long-term weight and chronic disease risk reduction effectiveness of bariatric surgery among Hispanics. A retrospective medical chart analysis of 633 Hispanic adults (76% female, mean age at surgery 41.3 years) from Central and South America and the Caribbean who underwent gastric bypass surgery from 2002 to 2010 was conducted. A presurgery and 1-year postsurgery comparative means analysis of weight, body mass index (BMI), and cardiometabolic disease risk factors [systolic (SBP) and diastolic blood pressure (DBP), fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC), and triglycerides (TGs) was performed. Mean weight (127-109 kg) and BMI (46.4-39.9 kg/m(2)) significantly decreased and all cardiometabolic disease risk factors improved from before to 1 year after surgery. Males were significantly more likely than females to show postsurgery improvement in weight (-21.7 kg versus -16.9 kg, P<0.0001), HbA1c (-1.1% versus -0.7%, P=0.02), HDL (3.2 mg/dL versus -0.6 mg/dL, P=0.04), and TGs (-97.2 mg/dL versus -54.5 mg/dL, P=0.006) versus females. Conversely, women were significantly more likely than men to have postsurgery improvements in LDL (-24.5 mg/dL versus -12.7 mg/dL, P=0.04). Gastric bypass surgery results in significant weight loss and cardiometabolic disease risk reduction among Hispanic adults 1 year after surgery. These improvements vary by gender. Gastric bypass surgery is an effective treatment option for weight loss and chronic disease risk improvements in Hispanic adults who are not Mexican American.

The Patient Journey in Chronic Myeloid Leukemia Patients on Tyrosine Kinase Inhibitor Therapies: Qualitative Insights Using a Global Ethnographic Approach

The advent and approval of tyrosine kinase inhibitors (TKIs) have dramatically improved the life expectancy of patients with chronic myeloid leukemia (CML), which has been transformed into a chronically manageable disease. The objective was to qualitatively assess the effects of diagnosis and treatment on patients with CML to offer recommendations for health-care providers (HCPs) for the better support of patients. By use of an ethnographic approach based on in-home interviews, photo journals, and an optional telephone debriefing interview, this study included 50 patients with CML from Brazil, France, Germany, Russia, and Spain, including patients within 18months of diagnosis and receiving frontline TKI therapy (n=20), patients between >18months and 7years from diagnosis and receiving ongoing frontline therapy (n=20), and patients who switched to second- or third-line TKI therapy (n=10). In-home interviews were designed to address patient perceptions and experiences regarding such issues as adherence, disease knowledge, disease management, and relationships with HCPs. Transcripts from these interviews and other data were analyzed to identify similar patterns and themes experienced by patients with CML. The investigation generated a five-stage, patient-centered model of the experience of the patient throughout diagnosis, treatment, and management of CML: crisis, hope, adaptation, new normal, and uncertainty. Patients proceeded through these stages in the course of their disease management. The stages were affected by the patients' emotional and social experiences, their knowledge about CML, their positive experiences with their HCPs and/or treatment, and their optimism about their long-term prognosis. We identified five common stages experienced by patients with CML and suggest several recommendations for HCPs on the management of patients through their disease journey. By providing support, education, and reassurance, HCPs can help patients as they move through the early stages of crisis and hope. When patients are in the adaptation and new-normal stages, HCPs can help patients achieve and maintain a new normality by setting expectations for the risks/benefits of long-term chronic drug therapy and disease monitoring and by continuing to support patient adherence.

Immunosignaturing Microarrays Distinguish Antibody Profiles of Related Pancreatic Diseases

Immunosignaturing is a technology that allows the humoral immune response to be observed through the binding of antibodies to random sequence peptides. Profiles of the antibody repertoire produced during infection or during long-term chronic disease have proven to be informative for disease classification. An important unanswered question relative to this technology is whether different diseases that target the same organ and result in similar early phenotypes have similar or distinguishable immunosignatures. This question is of clinical relevance when considering patients who present with similar symptoms early during their disease. The pancreas is one such organ; diseases that affects this organ can cause the patient both broad and acute distress, with little to distinguish the disease source. If the cause were made clear without biopsy, and could be accomplished during routine monitoring, earlier intervention could improve health. Pancreatic cancer, chronic or acute pancreatitis, diabetes mellitus, hepatitis B or C infection, and other diseases can deeply affect the function of the pancreas, complicating diagnosis. We tested the immunosignaturing platform for its ability to resolve four different diseases that target the same organ; pancreatic cancer, pre-pancreatic cancer (panIN), type II diabetes and acute pancreatitis. These diseases were separated with >90% specificity from controls and from each other. We also describe a mathematical method that allows identification of 3 distinct components of an immunosignature: disease specific, ‘housekeeping’ and patient specific variation. The first component is useful in diagnosing disease, the second for baseline for the technology and third for monitoring changes in a healthy individual over time.

Changes in Eating and Physical Activity Behaviors Across Seven Semesters of College

The transition from adolescence to adulthood is an important period for establishing behavioral patterns that affect long-term health and chronic disease risk. Nelson and colleagues speculated that developmental changes and changes in living situation may play an important role in the nutrition and physical activity behaviors of college students. Data from the University Life Study, a longitudinal study of college students that includes web-based surveys administered 14 consecutive days each semester, were used to examine fruit, vegetable, and sugared soda consumption, physical activity, and sedentary activity behaviors across seven semesters. Estimates for each semester were calculated to determine the frequency with which students consumed fruits, vegetables, and sugared soda, engaged in moderate to vigorous physical activity, and engaged in sedentary activities. Four models, estimated with HLM 6.04, were used to predict changes in these behaviors across the seven semesters. Living on or off campus was included to determine if this explained additional variance. Results indicated that few college students consumed fruits and vegetables or exercised at optimal levels during the seven semesters surveyed. Daily fruit and vegetable consumption and daily physical activity declined significantly from the first to the seventh semester. For both of these findings, living off campus exacerbated the problem. Average number of hours of sedentary behaviors declined over time, as did number of days on which at least one sugared soda was consumed. Living location did not explain additional variance in these positive trends. Implications for policy, practice, and future research are discussed.

Extreme Tooth Abnormalities and Treatment under General Anesthesia in a Child with chronic GVHD Surviving Relapse of Acute Lymphoblastic Leukemia

Treatment for acute lymphoblastic leukemia (ALL) mainly consists of chemotherapy, irradiation and bone marrow transplantation. In terms of long-term treatment effects, dental abnormalities and chronic graft-versus host disease (GVHD) are problems. We present a patient surviving relapse of ALL at one year of age. He had extreme dental abnormalities and multiple caries. Most of his permanent teeth were abnormal, and multiple caries were observed. Since he had a strong vomiting reaction to dental treatment, general anesthesia was given. During the general anesthesia, much sputum was aspirated because of chronic GVHD. His dental condition was worse than other cases reported previously. Since the survival rate has increased recently, the dental effects of ALL treatment have become significant. Especially, in patients undergoing total body irradiation at under 2 years of age, it is highly likely that dental problems will occur in the future.

A whole-economy model of the health co-benefits of strategies to reduce greenhouse gas emissions in the UK

BackgroundThe UK Government has set specific targets for greenhouse gas emissions to lower the risk of dangerous climate change. Previous research has shown that important health co-benefits could result from strategies targeting the domains of transport, built environment, and agriculture. This study assesses the full general equilibrium economy-wide macroeconomic effects of health co-benefits from three similar UK strategies to meet locally specific 2030 greenhouse gas emission targets. MethodsEconomy-wide effects of health co-benefits were modelled with a dynamic extension of the widely used International Food Policy Research Institute standard computable general equilibrium model for 2011–30. Four forms of economic agents are modelled: firms (who combine resource inputs to maximise profits), consumers (who consume and save to maximise their welfare), government, and foreign agents. The method consists of simulation of three greenhouse gas policy scenarios and a counterfactual do-nothing scenario. Basic health co-benefits (years lived with disability [YLD] and years of life lost [YLL]) were measured for a range of illnesses, on the basis of the comparative risk assessment approach. Combined with incidence numbers and prevalence trends, these basic YLD (morbidity) and YLL (mortality) co-benefits were used to calculate dynamic sequences of demographic and labour market effects on population and productive labour supply, and public budget implications for averted health-care costs and increased social security transfers (including benefit payments for working-age individuals and pension payments for old-age individuals). These economic shocks were subsequently imposed on the computable general equilibrium model and used to measure the combined macroeconomic effect of health co-benefits. The method for measuring averted health-care costs was published in The Lancet in 2012. Three scenarios were modelled: active travel (transport sector; health co-benefits of an assumed transformation of urban transport behaviour to reduce motorised transportation and increase walking [2·5-times] and cycling [8·0-times] in urban England and Wales); healthy diet (food and agriculture sector; health co-benefits of an assumed UK-wide 30% reduction in consumption of dietary saturated fat); and household energy (household energy sector; health co-benefits of an assumed UK-wide improvement in home insulation and ventilation, including reduced household energy use, improved indoor temperature, and associated changes in indoor pollutants). FindingsFor all scenarios, the macroeconomic effects of health co-benefits are positive. Overall, substantial savings on health-care costs represent the main contributing factor. Increased labour supplies also contribute positively, whereas increased social security transfers (due to larger working-age and old-age population segments) detract. The largest potential cumulative gross domestic product gains from health co-benefits are associated with the active travel scenario (around £19 billion), in which increased physical activity averts large-scale and long-term chronic disease burdens and health-system costs. The healthy diet scenario also leads to important potential gains (around £5 billion), whereas the full potential health co-benefits from the household energy scenario will not be realised until beyond 2030. Three economic sensitivity analyses were undertaken to test the sensitivity of results to variations in assumptions concerning: the substitutability of labour for other factors of production; the effectiveness of the interventions; and changes in the discount rate (the present value of the economic effects). Overall, the core results can be considered relatively robust to changes in these three factors. InterpretationStrategies to reduce greenhouse gas emissions and improve health are likely to result in substantial and increasing positive contributions to the economy. This effect might offset some economic costs and thereby allow such strategies to be seen more favourably, especially in times of economic austerity. FundingDepartment of Health Policy Research Programme.

Effect of the protein:carbohydrate ratio in hypoenergetic diets on metabolic syndrome risk factors in exercising overweight and obese women

Overweight and obesity are growing problems both in Canada and around the world. Obesity is associated with a number of chronic diseases including type 2 diabetes and CVD, which puts a tremendous burden on the health care systems in place. The present study sought to investigate whether there were differences in the effectiveness of three low-fat, hypo- and isoenergetic diets differing in protein:carbohydrate ratio, low protein (LP, 1g protein:4g carbohydrate), normal protein (NP, 1g protein:2g carbohydrate) or high protein (HP, 1g protein:1g carbohydrate), on weight loss and markers of the metabolic syndrome (MetS) in overweight women. Subjects were randomly assigned to receive one of three intervention diets, all of which included a 60min exercise programme three times/week for 12 weeks. Of the total subjects, fifty-four overweight and obese local women with MetS risk factors completed the study. All groups had similar improvements in body weight, insulin sensitivity, lipid profile, blood pressure and fitness. Subjects reported that the NP diet was easier to comply with and achieved better improvements in body fat, waist circumference and waist:hip ratio, and preservation of lean mass compared with the other two diets. In conclusion, energy restriction and exercise both facilitate weight loss in overweight and obese subjects and reduce symptoms of the MetS. A diet with a 1:2 protein:carbohydrate ratio promoted better improvements than either the LP or HP diets, and may be superior in reducing long-term chronic disease risk in this population.

Early Changes in Kidney Function Predict Long-Term Chronic Kidney Disease and Mortality in Patients After Liver Transplantation

Early Changes in Kidney Function Predict Long-Term Chronic Kidney Disease and Mortality in Patients After Liver Transplantation

Early Changes in Kidney Function Predict Long-Term Chronic Kidney Disease and Mortality in Patients After Liver Transplantation

Chronic kidney disease (CKD) is a well-known complication after liver transplantation (LT) and is associated with increased mortality. The purpose of this study was to determine risk factors of advanced CKD and mortality after LT. Four hundred forty-five adult patients underwent LT between June 1990 and September 2007 and survived more than 1 month. Multivariate Cox regression analyses were performed for time to CKD stage 4 (glomerular filtration rate [GFR] ≤30 mL/min), time to chronic dialysis, and all-cause mortality. Several patient and disease characteristics were used as independent pre- and posttransplant variables. We specifically analyzed a drop more than or equal to 30% in the estimated GFR (eGFR) during the first year posttransplant. Diabetes mellitus pretransplant and a drop more than or equal to 30% in the eGFR between 3 and 12 months predicted CKD stage 4 (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.9-5.4, P<0.001 and OR 16.1, 95% CI 5.9-44.5, P<0.0001, respectively), the need for chronic dialysis (OR 3.8, 95% CI 1.1-13.2, P=0.03 and OR 14.6, 95% CI 3.0-71.4, P<0.001, respectively), and all-cause mortality (OR 1.9, 95% CI 1.2-2.9, P=0.004 and OR 2.6, 95% CI 1.6-4.4, P<0.001, respectively), more than 1 year after LT. Diabetes mellitus pretransplant and a drop more than or equal to 30% in the eGFR within the first year are strong predictors of advanced CKD, chronic dialysis, and death more than 1 year after LT. These easily determined clinical variables define a population at risk for CKD who should be targeted for renal protection strategies.

Interprofessional education: a review of context, learning and the research agenda

Interprofessional education (IPE) is not a recent phenomenon and has been the subject of several World Health Organization reports. Its focus is on health professionals and students learning with, from and about one another to improve collaboration and the quality of patient care. The drivers for IPE include new models of health care delivery in the context of an ageing population and the increasing prevalence of long-term chronic disease, in addition to the patient safety agenda. The delivery of complex health care requires a team-based and collaborative approach, although teamwork and collaborative practice are not necessarily synonymous. The rationale for IPE is that learning together enhances future working together. Systematic reviews of IPE have shown some evidence that IPE fosters positive interaction among different professions and variable evidence that it improves attitudes towards other professionals. Generalisation across published papers is difficult because IPE initiatives are diverse and good evaluation methodology and data are lacking. In terms of constructive alignment from an education viewpoint, there is a need for educators to define learning outcomes and match these with learning activities to ensure that IPE demonstrates added value over uniprofessional learning. Assessment is difficult as pre-qualification professional education focuses on the individual and professional accreditation organisations mandate only for their own professions. Interprofessional education draws from a number of education, sociology and psychology theories, and these are briefly discussed. The most pressing research questions for the IPE community are defined and the challenges for IPE explored.

Food Synergy: The Key to Balancing the Nutrition Research Effort

Mediterranean-type diet patterns are consistently associated with reduced risk for cardiovascular disease, diabetes, and cancer in the general population. In contrast, several randomized controlled trials (RCTs) focusing on nutrient supplements have shown no or adverse long-term effects on long-term chronic disease. Food in its natural form is a nonrandom mixture of numerous molecules, orchestrated evolutionarily to maintain the life of the organism being eaten. Food synergy assumes that the biologically determined combination of nutrients and other bioactive substances found in food plays a concerted role in influencing health. Coupled with reduced risk in the Mediterranean-type diet pattern, food synergy implies that the concerted action of nutrients and other bioactive substances in fruit, vegetables, whole grain cereals, nuts, and legumes is beneficial for health. The assumption that single molecules work in isolation as they work in food violates the food synergy concept of concerted action and often leads to a partial picture. Public health nutrition strategies that focus on single nutrients have led to a flourishing diet supplement industry and advice to the public to eat low-fat diets. The latter is questionable in two respects: not all fats are equal, and industry efforts to comply spun-off products high in refined carbohydrates. It is time to rethink the research paradigm concerning diet and health. Reductionist research, though valuable, focuses on partial pathways, rather than the whole system integrating a lifetime of food intake with the long-term health of intact humans. Epidemiology provides this information, but is subject to residual confounding. RCTs are useful, but RCTs of food differ fundamentally from RCTs of drugs; for example, in terms of blinding, long-term adherence, and specificity of the reference treatment. All research inferences are most secure when based on convergent evidence from multiple research approaches. A balanced approach is therefore needed in nutrition research.

Pores for Thought

Ischemia-reperfusion injury (IRI) is a major cause of acute kidney injury (AKI) in both native and transplanted organs. Given that AKI is associated with significant patient morbidity and mortality and the development of long-term chronic kidney disease, there is an urgent need to develop new