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Influence of fruit, meal distribution and dental health on cardio-metabolic risk
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences.
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background   

Fruit is often recommended as a snack between meals and a main component of the cardioprotective Mediterranean diet. The sugar content might be of concern since it theoretically could lead to hepatic fat accumulation and affect dental status negatively. Dental status is associated with cardiovascular disease, but subjective dental health’s association has barely been studied. The aim of this thesis was to study dietary recommendations, as in fruit consumption and meal frequency, and their effect on cardio-metabolic risk factors and dental status. Another aim was to study dissatisfaction with teeth as a marker of cardiovascular risk in type 2 diabetes.  

Methods   

Paper I-II studied the effect of extra fruit or nuts as a snack between meals on hepatic fat content and dental status. A study population of 30 young, healthy, normal-weight participants were recruited and randomized to each intervention by 1:1 allotment. The amount of hepatic fat content (HFC) was quantified by MRI-examination. Dental status was investigated by the same licensed dentist. In both cases were examinators blinded to the allotted intervention. Other parameters were markers cardiometabolic risk, inflammatory markers, and vitamin levels. Paper III is a randomized cross-over study with the primary outcome of post-prandial energy expenditure after varying meal frequency and fat- /carbohydrate content in fourteen study participants. In parallel the hormones ghrelin and GLP-1 were measured as secondary outcomes. There were 4 types of test meals served with either a single large drink of 750 kcal or divided into five smaller drinks (150 kcal) with the same total energy content in a series every 30 minutes for 2.5 hours. Macronutrient content was varied by low- or high carbohydrate content (54.9 E%/20.0 E%). Protein content was similar (9.9 E%). The remainder of energy was from fat. Paper IV explored the association between dissatisfaction with teeth and major adverse cardiovascular events (MACEs) defined as hospitalization or death due to myocardial infarction or stroke in a population of 601 available cases with type 2 diabetes in primary care. The Cox regression was adjusted for age, sex, inflammation, BMI, duration of diabetes, HbA1c, total cholesterol, office systolic blood pressure, prior MACE, currently smoking, marital status, being born in Sweden, self-reported stress, and self-reported happiness. Paper V investigated the association of self-reported frequency of consumed bananas, apples/pears, and oranges/citrus fruit with office- and home blood pressure in a study population of 2 283 available participants. Adjustments were made for the covariates sex, age, BMI, smoking, alcohol consumption, salt consumption, educational level, physical activity, HbA1c, total cholesterol and S-creatinine levels in a multivariable linear regression. Subgroup analysis by sex was also performed.  

Results  

In paper I there was no change in HFC in either group. There was a decrease in number of deep gingival pockets in the fruit group with a statistically significant different change compared to the nut group as sign of a potentially improved dental status. In paper III post-prandial energy expenditure was higher after one large drink compared to the series of smaller drinks and the drinks with high-carbohydrate content. GLP-1 levels were higher after the large drink, while similar with varying fat-/carbohydrate content. Ghrelin did not differ at any test occasion at group level. Paper IV revealed an increased risk of MACE when dissatisfied with teeth independent of sex, age, and inflammation. When also adjusting for cardiovascular risk factors and socio-psychological factors the increased risk was attenuated. Paper V showed an independent association between lower systolic- and diastolic home blood pressures for apples/pears and oranges/citrus fruits in total study population. Diastolic home blood pressure was independently associated with all types of fruit consumption in women only.   

Conclusions  

Fruit as snack in addition to habitual diet in quantities greater than the minimum recommended amount did not increased HFC. Periodontal status was improved in the fruit group with a statistically significant change compared to the nut group. The acute effects of a large meal compared to a series of smaller and high-carbohydrate content resulted in a higher post-prandial energy expenditure. Dissatisfaction with teeth could help determine cardiovascular risk associated with a range of biological and social factors. Fruit consumption was independently associated with lower home blood pressure, predominately diastolic blood pressure in women. There is an undeniable opportunity for future collaboration between health care and dental health care to further expand the knowledge and increase the evidence behind dietary recommendations promoting general- and dental health. 

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2023. , p. 102
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1821
National Category
Nutrition and Dietetics
Identifiers
URN: urn:nbn:se:liu:diva-190451DOI: 10.3384/9789179294489ISBN: 9789179294472 (print)ISBN: 9789179294489 (electronic)OAI: oai:DiVA.org:liu-190451DiVA, id: diva2:1717661
Public defence
2023-01-27, Berzeliussalen, Building 463, Campus US, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Note

Updates:

2022-12-09 The thesis was first published online. The onlinepublished version reflects the printed version.

2023-02-09 The thesis was updated with an errata list which isalso downloadable from the DOI landing page.Before this date the PDF was downloaded 85 times.

Available from: 2022-12-09 Created: 2022-12-09 Last updated: 2025-02-11Bibliographically approved
List of papers
1. A Randomized Study of the Effects of Additional Fruit and Nuts Consumption on Hepatic Fat Content, Cardiovascular Risk Factors and Basal Metabolic Rate
Open this publication in new window or tab >>A Randomized Study of the Effects of Additional Fruit and Nuts Consumption on Hepatic Fat Content, Cardiovascular Risk Factors and Basal Metabolic Rate
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2016 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 11, no 1, p. e0147149-Article in journal (Refereed) Published
Abstract [en]

Background

Fruit has since long been advocated as a healthy source of many nutrients, however, the high content of sugars in fruit might be a concern.

Objectives

To study effects of an increased fruit intake compared with similar amount of extra calories from nuts in humans.

Methods

Thirty healthy non-obese participants were randomized to either supplement the diet with fruits or nuts, each at +7 kcal/kg bodyweight/day for two months. Major endpoints were change of hepatic fat content (HFC, by magnetic resonance imaging, MRI), basal metabolic rate (BMR, with indirect calorimetry) and cardiovascular risk markers.

Results

Weight gain was numerically similar in both groups although only statistically significant in the group randomized to nuts (fruit: from 22.15±1.61 kg/m2 to 22.30±1.7 kg/m2, p = 0.24 nuts: from 22.54±2.26 kg/m2 to 22.73±2.28 kg/m2, p = 0.045). On the other hand BMR increased in the nut group only (p = 0.028). Only the nut group reported a net increase of calories (from 2519±721 kcal/day to 2763±595 kcal/day, p = 0.035) according to 3-day food registrations. Despite an almost three-fold reported increased fructose-intake in the fruit group (from 9.1±6.0 gram/day to 25.6±9.6 gram/day, p<0.0001, nuts: from 12.4±5.7 gram/day to 6.5±5.3 gram/day, p = 0.007) there was no change of HFC. The numerical increase in fasting insulin was statistical significant only in the fruit group (from 7.73±3.1 pmol/l to 8.81±2.9 pmol/l, p = 0.018, nuts: from 7.29±2.9 pmol/l to 8.62±3.0 pmol/l, p = 0.14). Levels of vitamin C increased in both groups while α-tocopherol/cholesterol-ratio increased only in the fruit group.

Conclusions

Although BMR increased in the nut-group only this was not linked with differences in weight gain between groups which potentially could be explained by the lack of reported net caloric increase in the fruit group. In healthy non-obese individuals an increased fruit intake seems safe from cardiovascular risk perspective, including measurement of HFC by MRI.

Keywords
Fruits Basal metabolic rate measurement Fats Vitamin C Fructoses Diet Fatty liver Magnetic resonance imaging
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:liu:diva-124605 (URN)10.1371/journal.pone.0147149 (DOI)000368529100062 ()26788923 (PubMedID)
Note

Funding agencies: County Council of Ostergotland; Linkoping University, Department of Medical and Health Sciences

Available from: 2016-02-05 Created: 2016-02-05 Last updated: 2022-12-09
2. A randomised study in young subjects of the effects of eating extra fruit or nuts on periodontal inflammation
Open this publication in new window or tab >>A randomised study in young subjects of the effects of eating extra fruit or nuts on periodontal inflammation
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2018 (English)In: BDJ Open, E-ISSN 2056-807X, Vol. 3, article id 17022Article in journal (Refereed) Published
Abstract [en]

Objectives/Aims:

Fruit is often advocated as a healthy source of nutrients and vitamins. However, the high contents of sugars in many fruits could potentially counteract positive effects on the teeth.

Materials and methods:

We recruited 30 healthy non-obese participants who were randomised to either supplement their diet with extra fruits or nuts, each at +7 kcal/kg body weight/day, for 2 months.

Results:

Fructose intake increased from 9.1±6.0 to 25.6±9.6 g/day, P<0.0001, in the fruit group and was reduced from 12.4±5.7 to 6.5±5.3 g/day, P=0.007, in the nut group. Serum-vitamin C increased in both groups (fruit: P=0.017; nuts: P=0.009). α-Tocopherol/cholesterol ratio increased in the fruit group (P=0.0033) while β-carotene/cholesterol decreased in the nut group (P<0.0001). The amount of subjects with probing pocket depths ⩾4 mm in the fruit group was reduced (P=0.045) according to blinded examinations, and the difference in the changes in probing pockets ⩾4 mm was also statistically significant between the food groups (P=0.010).

Conclusion:

A large increase of fruit intake, compared with nuts, had a favourable effect on periodontal status in some respects, despite the high sugar contents. To search for potential protective micronutrients in fruit that protect the teeth could be an aim for further research.

Place, publisher, year, edition, pages
Nature Publishing Group, 2018
National Category
Nutrition and Dietetics
Identifiers
urn:nbn:se:liu:diva-152523 (URN)10.1038/bdjopen.2017.22 (DOI)000582630200001 ()29607092 (PubMedID)
Available from: 2019-03-28 Created: 2019-03-28 Last updated: 2025-02-11Bibliographically approved
3. A randomized cross-over study of the effects of macronutrient composition and meal frequency on GLP-1, ghrelin and energy expenditure in humans
Open this publication in new window or tab >>A randomized cross-over study of the effects of macronutrient composition and meal frequency on GLP-1, ghrelin and energy expenditure in humans
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2017 (English)In: Peptides, ISSN 0196-9781, E-ISSN 1873-5169, Vol. 93, p. 20-26Article in journal (Refereed) Published
Abstract [en]

Objective: Little is known about human postprandial increase of energy expenditure and satiety-associated hormones in relation to both meal frequency and macronutrient composition. Design: Randomized cross-over study with four conditions for each participant. Methods: Seven men and seven women (mean age 23 +/- 1.5 years) were randomly assigned to the order of intake of a 750 kcal drink with the same protein content while having either 20 energy-percent (E%) or 55 E% from carbohydrates and the remaining energy from fat. Participants were also randomized to consume the drinks as one large beverage or as five 150 kcal portions every 30 min, starting in the fasting state in the morning. Energy expenditure (EE) was determined every 30 min by indirect calorimetry. Hormonal responses and suppression of hunger (by visual-analogue scales) were also studied. A p amp;lt; 0.013 was considered statistically significant following Bonferroni-correction. Results: The area under the curve (AUC) for EE was higher during the 2.5 h after the high-carbohydrate drinks (p = 0.005 by Wilcoxon) and also after ingesting one drink compared with five (p = 0.004). AUC for serum active GLP-1 was higher after single drinks compared with five beverages (p = 0.002). Although GLP-1 levels remained particularly high at the end of the test during the low-carbohydrate meals, the AUC did not differ compared with the high-carbohydrate occasions (low-carbohydrate: 58.9 +/- 18 pg/ml/h, high-carbohydrate: 45.2 +/- 16 pg/ml/h, p = 0.028). Hunger sensations were suppressed more after single beverages compared with five small drinks (p = 0.009). Conclusions: We found higher EE during 2.5 h following one large drink compared with five smaller beverages. Since hunger was also suppressed more efficiently, and serum GLP-1 levels were higher after one compared with five smaller drinks, our findings do not support nibbling to avoid hunger or to keep up EE from morning to noon.

Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2017
Keywords
Ghrelin; GLP-1; Hunger; Indirect calorimetry; Low-carbohydrate; Meal frequency
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:liu:diva-139272 (URN)10.1016/j.peptides.2017.04.011 (DOI)000403732000003 ()28487141 (PubMedID)
Note

Funding Agencies|County Council of ostergotland; Linkoping University, Department of Medical and Health Sciences; Swedish Heart-Lung Foundation; Gamla Tjanarinnor

Available from: 2017-07-07 Created: 2017-07-07 Last updated: 2022-12-09
4. Dissatisfaction with teeth in type 2 diabetes is associated with increased risk of cardiovascular disease
Open this publication in new window or tab >>Dissatisfaction with teeth in type 2 diabetes is associated with increased risk of cardiovascular disease
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2022 (English)In: Diabetes Epidemiology and Management, ISSN 2666-9706, Vol. 8, article id 100090Article in journal (Refereed) Published
Abstract [en]

Background and aim

Poor dental health status has been linked to increased risk of cardiovascular events in type 2 diabetes (T2D). Less is known about self-perceived dental health and cardiovascular risk. Our aim with this study was to investigate this association.

Methods

Recruitment of T2D patients took place between 2005 and 2008 in Swedish primary care. Teeth satisfaction was assessed by questionnaire at baseline. The major adverse cardiovascular events (MACE) in this study were hospitalization due to myocardial infarction, stroke or cardiovascular death. Cox regression models were used.

Results

Out of 761 participants 601 had complete data. Ninety-two MACEs occurred (median follow-up time: 11.6 years). Those satisfied with their teeth (n = 458) had 61 events (1.2 events per 100 person-years), while those dissatisfied with teeth (n = 143) had 31 events (2.2 events per 100 person-years). Dissatisfaction with teeth was associated with an increased risk of MACE independent of age, sex and levels of CRP (HR 1.85, 95% CI 1.20 – 2.86).

Conclusions

In patients with T2D, dissatisfaction with teeth was associated with increased risk of MACE and may be considered as a marker of risk.

Place, publisher, year, edition, pages
Elsevier, 2022
Keywords
Epidemiology, type 2 diabetes, self-reported dental health
National Category
Cardiology and Cardiovascular Disease
Identifiers
urn:nbn:se:liu:diva-190447 (URN)10.1016/j.deman.2022.100090 (DOI)001136741300010 ()
Note

Funding agencies: This work was supported by grant support from FORSS, the Medical Research Council of Southeast Sweden.

Available from: 2022-12-09 Created: 2022-12-09 Last updated: 2025-02-10Bibliographically approved
5. Associations between fruit consumption and home blood pressure in a randomly selected sample of the general Swedish population
Open this publication in new window or tab >>Associations between fruit consumption and home blood pressure in a randomly selected sample of the general Swedish population
2022 (English)In: The Journal of Clinical Hypertension, ISSN 1524-6175, E-ISSN 1751-7176, Vol. 24, no 6, p. 723-730Article in journal (Refereed) Published
Abstract [en]

Frequent fruit consumption has been associated with lower office blood pressure. Less is known about associations between fruit consumption and home blood pressure. Our aim was to study the correlation between consumption of specific fruits and home blood pressure in a large randomly selected study population. The main outcome was systolic home blood pressure. Home blood pressure measurements were performed with calibrated oscillometric meters during seven consecutive days. Means for all available measurements were used. Validated food frequency questionnaires were used for estimating frequency of fruit consumption. The specified fruits were bananas, apples/pears and oranges/citrus fruit. Complete case analysis regarding fruit consumption, office- and home blood pressure measurements and other relevant variables was performed in 2283 study participants out of 2603 available. Multivariable linear regression analysis was performed. There were statistically significant associations between consumption of all fruit types and lower systolic home blood pressure unadjusted (p for trend; bananas, apples/pears and oranges/citrus fruit p &lt; .001). The numerical differences between most and least frequent consumption of fruit were for bananas -2.7 mm Hg, apples/pears -3.9 mm Hg and for oranges/citrus fruit -3.4 mm Hg. When adjusted for covariates, both consumption of apples/pears and oranges/citrus fruit had an independent statistically significant association with lower blood pressure (p = .048 resp. p = .009). Future controlled interventional studies are needed to evaluate the effect of specific fruit on home blood pressure.

Place, publisher, year, edition, pages
Wiley, 2022
Keywords
ambulatory blood pressure; home blood pressure monitor; diet; epidemiology
National Category
General Practice
Identifiers
urn:nbn:se:liu:diva-185007 (URN)10.1111/jch.14491 (DOI)000789556900001 ()35499960 (PubMedID)2-s2.0-85129221844 (Scopus ID)
Note

Funding Agencies|Swedish Heart-Lung Foundation; Knut and Alice Wallenbergs Foundation; Vinnova; Swedish Research Council; UppsalaUniversity; Umea University; Linkoping University; Lund University; University of Gothenburg; Karolinska Institute; Uppsala University Hospital; University Hospital of Umea; Linkoping University Hospital; Skane University Hospital; Sahlgrenska University Hospital; Karolinska University Hospital; FORSS, that is, the Medical Research Council of Southeast Sweden

Available from: 2022-05-17 Created: 2022-05-17 Last updated: 2023-03-31

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