The Department of Clinical Sciences and Nutrition has an experienced team of researchers, with an international reputation. Their main research themes are Public Health Nutrition and Physical Activity, Cardiometabolic Health, and Clinical Practice.

Recent Submissions

  • Ketogenic diets for drug-resistant epilepsy

    Martin-McGill, Kirsty J; Bresnahan, Rebecca; Levy, Robert G; Cooper, Paul N; University of Chester; University of Liverpool; The CroD ShiDa Health Centre, Rochdale; Salford Royal Hospitals NHS Trust
    Background Ketogenic diets (KDs) are high in fat and low in carbohydrates and have been suggested to reduce seizure frequency in people with epilepsy. Such diets may be beneficial for children with drug-resistant epilepsy. This is an update of a review first published in 2003, and last updated in 2018. Objectives To assess the effects of ketogenic diets for people with drug-resistant epilepsy. Search methods For this update, we searched the Cochrane Register of Studies (CRS Web) and MEDLINE (Ovid, 1946 to 26 April 2019) on 29 April 2019. The Cochrane Register of Studies includes the Cochrane Epilepsy Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), and randomised controlled trials (RCTs) from Embase, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We imposed no language restrictions. We checked the reference lists of retrieved studies for additional relevant studies. Selection criteria RCTs or quasi-RCTs of KDs for people of any age with drug-resistant epilepsy. Data collection and analysis Two review authors independently applied predefined criteria to extract data and evaluated study quality. We assessed the outcomes: seizure freedom, seizure reduction (50% or greater reduction in seizure frequency), adverse effects, cognition and behaviour, quality of life, and attrition rate. We incorporated a meta-analysis. We utilised an intention-to-treat (ITT) population for all primary analyses. We presented the results as risk ratios (RRs) with 95% confidence intervals (CIs). Main results We identified 13 studies with 932 participants; 711 children (4 months to 18 years) and 221 adults (16 years and over). We assessed all 13 studies to be at high risk of performance and detection bias, due to lack of blinding. Assessments varied from low to high risk of bias for all other domains. We rated the evidence for all outcomes as low to very low certainty. Ketogenic diets versus usual care for children Seizure freedom (RR 3.16, 95% CI 1.20 to 8.35; P = 0.02; 4 studies, 385 participants; very low-certainty evidence) and seizure reduction(RR 5.80, 95% CI 3.48 to 9.65; P < 0.001; 4 studies, 385 participants; low-certainty evidence) favoured KDs (including: classic KD, medium-chain triglyceride (MCT) KD combined, MCT KD only, simplified modified Atkins diet (MAD) compared to usual care for children. We are not confident that these estimated effects are accurate. The most commonly reported adverse effects were vomiting, constipation and diarrhoea for both the intervention and usual care group, but the true effect could be substantially different (low-certainty evidence). Ketogenic diet versus usual care for adults In adults, no participants experienced seizure freedom. Seizure reduction favoured KDs (MAD only) over usual care but, again, we are not confident that the effect estimated is accurate (RR 5.03, 95% CI 0.26 to 97.68; P = 0.29; 2 studies, 141 participants; very low-certainty evidence). Adults receiving MAD most commonly reported vomiting, constipation and diarrhoea (very low-certainty evidence). One study reported a reduction in body mass index (BMI) plus increased cholesterol in the MAD group. The other reported weight loss. The true effect could be substantially different to that reported. Ketogenic diet versus ketogenic diet for children Up to 55% of children achieved seizure freedom with a classical 4:1 KD aDer three months whilst up to 85% of children achieved seizure reduction (very low-certainty evidence). One trial reported a greater incidence of seizure reduction with gradual-onset KD, as opposed to fasting-onset KD. Up to 25% of children were seizure free with MAD and up to 60% achieved seizure reduction.Up to 25% of children became seizure free with MAD and up to 60% experienced seizure reduction. One study used a simplified MAD (sMAD)and reported that 15% of children gained seizure freedom rates and 56% achieved seizure reduction. We judged all the evidence described as very low certainty, thus we are very unsure whether the results are accurate.The most commonly reported adverse effects were vomiting, constipation and diarrhoea (5 studies, very low-certainty evidence). Two studies reported weight loss. One stated that weight loss and gastrointestinal disturbances were more frequent, with 4:1 versus 3:1 KD,whilst one reported no difference in weight loss with 20 mg/d versus 10 mg/d carbohydrates. In one study, there was a higher incidence of hypercalcuria amongst children receiving classic KD compared to MAD. All effects described are unlikely to be accurate. Ketogenic diet versus ketogenic diet for adults One study randomised 80 adults (aged 18 years and over) to either MAD plus KetoCal during the first month with MAD alone for the second month, or MAD alone for the first month followed by MAD plus KetoCal for the second month. No adults achieved seizure freedom. More adults achieved seizure reduction at one month with MAD alone (42.5%) compared to MAD plus KetoCal (32.5%), however, by three months only 10% of adults in both groups maintained seizure reduction. The evidence for both outcomes was of very low certainty; we are very uncertain whether the effects are accurate.Constipation was more frequently reported in the MAD plus KetoCal group (17.5%) compared to the MAD only group (5%) (1 study, very low-certainty evidence). Diarrhoea and increase/change in seizure pattern/semiology were also commonly reported (17.5% to 20% of participants). The true effects of the diets could be substantially different to that reported. Authors' conclusions The evidence suggests that KDs could demonstrate effectiveness in children with drug-resistant epilepsy, however, the evidence for the use of KDs in adults remains uncertain. We identified a limited number of studies which all had small sample sizes. Due to the associatedr isk of bias and imprecision caused by small study populations, the evidence for the use of KDs was of low to very low certainty.More palatable but related diets, such as the MAD, may have a similar effect on seizure control as the classical KD, but could be associated with fewer adverse effects. This assumption requires more investigation. For people who have drug-resistant epilepsy or who are unsuitable for surgical intervention, KDs remain a valid option. Further research is required, particularly for adults with drug-resistant epilepsy.
  • Gestational diabetes and progression to type two diabetes mellitus: missed opportunities of follow up and prevention?

    Walker, Emma; Flannery, Orla; Mackillop, Lucy; University of Chester; Manchester Metropolitan University; Nuffield Department of Reproductive Health, Oxford University Hospitals NHS Foundation Trust;
    Abstract Background: The incidence of type 2 diabetes (T2DM) is increasing. Having a pregnancy complicated by gestational diabetes mellitus (GDM) is a potent risk factor for the later development of T2DM. Aims: To explore the characteristics of women diagnosed with GDM in a single centre and their follow up for progression to T2DM. Methods: A retrospective cohort study using anonymised data of one hundred and fifty four (154) women with GDM receiving maternity care at the Oxford University Hospitals NHS Foundation Trust (OUHFT) in 2010 and their follow up until 2018. Results: The prevalence of GDM in women delivering in Oxfordshire in 2010 was 3.4%. 70% of pregnant women were overweight or obese (with 51% being obese) at booking. Gestational weight gain (GWG) was excessive in 29% of women, when compared to Institute of Medicine (IOM) guidelines. Almost a quarter of women (23.4%) had no follow up after delivery. Over a median follow up of 3.5 years (range 0-8 years) nearly one in six (16.9%) of the total cohort (22% of those tested) went on to develop T2DM. 74% of women with GDM were multiparous, and 65% of nulliparous women were tested compared to 81% of multiparous women. There was a significant difference between multiparous women (53.8%) compared to nulliparous women (46.2%) developing T2DM (p=0.01). There was no significant difference in BMI (p=0.866) or GWG (p=0.83) in women who progressed to T2DM versus those who did not. Conclusion: The risk of T2DM after GDM is substantial however, follow up rates of this population is poor. Subsequent screening of women with GDM and their management crosses secondary and primary care with scope for improvement in counselling of women of the importance of annual reviews, in data collection and follow up in both obstetrics and general practice. The implementation of a recall system, an education programme for general practitioners and/or a registry of women diagnosed with GDM could be useful to identify those at high risk of developing T2DM as well as providing a platform for the potential development of interventions to prevent progression to T2DM after GDM.
  • Retention of cardiac rehabilitation services during the COVID-19 pandemic A joint position statement from the British Association for Cardiovascular Prevention and Rehabilitation (BACPR) British Cardiovascular Society (BCS) British Heart Foundation (BHF)

    Dawkes, Susan; Hughes, Sally; Ray, Simon; Nichols, Simon; Hinton, Sally; Roberts, Ceri; Butler, Thomas; Delal, Hayes; Docherty, Patrick; University of York/National Audit of Cardiac Rehabilitation
    The British Association for Cardiovascular Prevention and Rehabilitation (BACPR), the British Cardiovascular Society (BCS) and the British Heart Foundation (BHF) have issued a joint position statement ‘Retention of cardiac rehabilitation services during the COVID-19 pandemic’.
  • Factors influencing dietary behaviours in urban food environments in Africa: a systematic mapping review.

    Osei-Kwasi, Hibbah; orcid: 0000-0001-5084-6213; Mohindra, Aarti; Booth, Andrew; Laar, Amos; Wanjohi, Milka; Graham, Fiona; Pradeilles, Rebecca; Cohen, Emmanuel; orcid: 0000-0001-5643-1473; Holdsworth, Michelle; orcid: 0000-0001-6028-885X (2020-05-26)
    To identify factors influencing dietary behaviours in urban food environments in Africa and identify areas for future research. We systematically reviewed published/grey literature (protocol CRD4201706893). Findings were compiled into a map using a socio-ecological model on four environmental levels: individual, social, physical and macro. Urban food environments in Africa. Studies involving adolescents and adults (11-70 years, male/female). Thirty-nine studies were included (six adolescent, fifteen adolescent/adult combined and eighteen adult). Quantitative methods were most common (twenty-eight quantitative, nine qualitative and two mixed methods). Studies were from fifteen African countries. Seventy-seven factors influencing dietary behaviours were identified, with two-thirds at the individual level (45/77). Factors in the social (11/77), physical (12/77) and macro (9/77) environments were investigated less. Individual-level factors that specifically emerged for adolescents included self-esteem, body satisfaction, dieting, spoken language, school attendance, gender, body composition, pubertal development, BMI and fat mass. Studies involving adolescents investigated social environment-level factors more, for example, sharing food with friends. The physical food environment was more commonly explored in adults, for example, convenience/availability of food. Macro-level factors associated with dietary behaviours were food/drink advertising, religion and food prices. Factors associated with dietary behaviour were broadly similar for men and women. The dominance of studies exploring individual-level factors suggests a need for research to explore how social, physical and macro-level environments drive dietary behaviours of adolescents and adults in urban Africa. More studies are needed for adolescents and men, and studies widening the geographical scope to encompass all African countries.
  • Optimum nutritional strategies for cardiovascular disease prevention and rehabilitation (BACPR)

    Butler, Thomas; Kerley, Conor, P; Altieri, Nunzia; Alvarez, Joe; Green, Jane; Hinchliffe, Julie; Stanford, Dell; Paterson, Katherine; Norfolk and Norwich University Hospital
    Nutrition has a central role in both primary and secondary prevention of cardiovascular disease (CVD) yet only relatively recently has food been regarded as a treatment, rather than as an adjunct to established medical and pharmacotherapy. As a field of research, nutrition science is constantly evolving making it difficult for patients and practitioners to ascertain best practice. This is compounded further by the inherent difficulties in performing double-blind randomised controlled trials. This paper covers dietary patterns that are associated with improved cardiovascular outcomes, including the Mediterranean Diet but also low-carbohydrate diets and the potential issues encountered with their implementation. We suggest there must be a refocus away from macronutrients and consideration of whole foods when advising individuals. This approach is fundamental to practice, as clinical guidelines have focussed on macronutrients without necessarily considering their source, and ultimately people consume foods containing multiple nutrients. The inclusion of food-based recommendations aids the practitioner to help the patient make genuine and meaningful changes in their diet. We advocate that the cardioprotective diet constructed around the traditional Mediterranean eating pattern (based around vegetables and fruits, nuts, legumes, and unrefined cereals, with modest amounts of fish and shellfish, and fermented dairy products) is still important. However there are other approaches that can be tried, including low-carbohydrate diets. We encourage practitioners to adopt a flexible dietary approach, being mindful of patient preferences and other comorbidities that may necessitate deviations away from established advice, and advocate for more dietitians in this field to guide the multi-professional team.
  • Ketogenic diets as an adjuvant therapy for glioblastoma (KEATING): a randomized, mixed methods, feasibility study

    Martin-McGill, KJ; Marson, Anthony; Tudur Smith, Catrin; Young, Bridget; Mills, Samantha; Cherry, M. Gemma; Jenkinson, Michael; University of Chester; University of Liverpool; The Walton Centre NHS Foundation Trust;
    Purpose We conducted a feasibility study to investigate the use of ketogenic diets (KDs) as an adjuvant therapy for patients with glioblastoma (GBM), investigating (i) trial feasibility; (ii) potential impacts of the trial on patients’ quality of life and health; (iii) patients’ perspectives of their decision-making when invited to participate in the trial and (iv) recommending improvements to optimize future phase III trials. Methods A single-center, prospective, randomized, pilot study (KEATING), with an embedded qualitative design. Twelve newly diagnosed patients with GBM were randomized 1:1 to modifed ketogenic diet (MKD) or medium chain triglyceride ketogenic diet (MCTKD). Primary outcome was retention at three months. Semi-structured interviews were conducted with a purposive sample of patients and caregivers (n=15). Descriptive statistics were used for quantitative outcomes and qualitative data were analyzed thematically aided by NVivo. Results KEATING achieved recruitment targets, but the recruitment rate was low (28.6%). Retention was poor; only four of 12 patients completed the three-month diet (MCTKD n=3; MKD n=1). Participants’ decisions were intuitive and emotional; caregivers supported diet implementation and infuenced the patients’ decision to participate. Those who declined made a deliberative and considered decision factoring diet burden and quality of life. A three-month diet was undesirable to patients who declined and withdrew. Conclusion Recruitment to a KD trial for patients with GBM is possible. A six-week intervention period is proposed for a phase III trial. The role of caregiver should not be underestimated. Future trials should optimize and adequately support the decision-making of patients.
  • Biochemical assessment of patients following ketogenic diets for epilepsy: current practice in the UK and Ireland

    Schoeler, Natasha; Simpson, Zoe; Whiteley, Victoria; Nguyen, Patty; Meskell, Rachel; Lightfoot, Kathryn; Martin-McGill, Kirsty; Olpin, Simon; Ivison, Fiona
    Objective: Biochemical assessment is recommended for patients prior to initiating and following a ketogenic diet (KD). There is no published literature regarding current practice in the UK and Ireland. We aimed to explore practice in comparison to international guidelines, determine approximate costs of biochemical testing in KD patients across the UK and Ireland, and promote greater consistency in KD services nationally. Methods: A survey was designed to determine the biochemical tests requested for patients at baseline, 3-, 6-, 12-, 18- and 24-months+ on KD. The survey was circulated to 39 centres across the UK and Ireland. Results: 16 centres completed the survey. Full blood count, electrolytes, calcium, liver function tests (LFTs), lipid profile and vitamin D were requested at all centres at baseline, in keeping with international guidelines. Bicarbonate, total protein and urinalysis were less consistently requested. Magnesium and zinc were requested by all centres, despite not being specifically recommended for pre-diet evaluation in guidelines. Urea and electrolyte profiles and some LFTs were consistently requested at follow-up, in accordance with guidelines. Other LFTs and renal tests, full blood count, lipid profile, acylcarnitine profile, selenium, vitamin D and urinalysis were less consistently requested at follow-up. The mean costs of the lowest and highest number of tests requested at baseline in our participating centres was £167.54 and £501.93; the mean costs of the lowest and highest number of tests requested at 3-month follow-up was £19.17 and £450.06. Significance: Biochemical monitoring of KD patients varies widely across the UK and Ireland and does not fully correspond to international best practice guidelines. With an ongoing drive for cost-effectiveness within healthcare, further work is needed to streamline practice whilst ensuring patient safety.
  • Impacts of Reducing UK Beef Consumption Using a Revised Sustainable Diets Framework

    Chalmers, Neil; email: neil.chalmers@abdn.ac.uk; Stetkiewicz, Stacia; email: s.stetkiewicz@lancaster.ac.uk; Sudhakar, Padhmanand; orcid: 0000-0003-1907-4491; email: Padhmanand.Sudhakar@earlham.ac.uk; Osei-Kwasi, Hibbah; orcid: 0000-0001-5084-6213; email: h.oseikwasi@chester.ac.uk; Reynolds, Christian J; orcid: 0000-0002-1073-7394; email: c.reynolds@sheffield.ac.uk (MDPI, 2019-12-02)
    The impact of beef consumption on sustainability is a complex and evolving area, as sustainability covers many areas from human nutrient adequacy to ecosystem stability. Three sustainability assessment frameworks have been created to help policy makers unpack the complexities of sustainable food systems and healthy sustainable dietary change. However, none of these frameworks have yet to be applied to a case study or individual policy issue. This paper uses a hybrid version of the sustainability assessment frameworks to investigate the impact of reducing beef consumption (with a concurrent increase in consumption of plant-based foods, with a focus on legumes) on sustainability at a UK level. The aim of this paper is to understand the applicability of these overarching frameworks at the scale of an individual policy. Such an assessment is important, as this application of previously high-level frameworks to individual policies makes it possible to summarise, at a glance, the various co-benefits and trade-offs associated with a given policy, which may be of particular value in terms of stakeholder decision-making. We find that many of the proposed metrics found within the sustainability assessment frameworks are difficult to implement at an individual issue level; however, overall they show that a reduction in beef consumption and an increase in consumption of general plant-based foods, with a focus around legumes production, would be expected to be strongly beneficial in five of the eight overarching measures which were assessed.
  • A UK consensus on optimising CVD secondary prevention care: perspectives from multidisciplinary team members

    The ICON (Integrating Care Opportunities across the NHS) CVD Secondary Prevention Working Group (2019-10-03)
    Although overall cardiovascular (CV) mortality has declined in recent years, patients with clinically manifest cardiovascular disease (CVD) remain at increased risk of recurrent CV events. To minimise the likelihood of future CV events following an acute myocardial infarction (MI), changes in diet and lifestyle, alongside pharmaceutical interventions, such as dual antiplatelet therapy, a β-blocker, an ACE inhibitor, and a statin, are recommended within current clinical guidelines. The use of cardiac rehabilitation (CR) programmes has been shown to be highly effective in reducing mortality and morbidity following MI, and a cost-benefit analysis suggests that increasing the uptake of CR to 65% among eligible patient would result in potential cost savings of over £30 million annually for the NHS. The involvement of a multidisciplinary team (MDT) of healthcare professionals is central to delivering post-MI care, with initial and/or ongoing input from cardiologists, hospital-based specialist pharmacists, specialist nurses, GPs, dietitians, smoking cessation specialists and practice-based and community pharmacists, among others. This consensus statement was developed based on a meeting of HCPs actively involved in delivering CV secondary prevention care at primary and secondary care centres across the UK. Recognising that HCP team configuration and availability of resources/services vary by location, the authors have focused on three common themes which have broad relevance in CVD secondary prevention, specifically: integration of care, medicines optimisation, and encouraging patient activation. Opportunities for MDT members to improve outcomes in post-MI patients are suggested and examples of best practice models which have been implemented successfully are described.
  • Western diet increases cardiac ceramide content in healthy and hypertrophied hearts.

    Butler, Thomas; University of Chester, University of York, University of Hull (Elsevier, 2017-11-01)
    BACKGROUND AND AIMS: Obesity and cardiac left ventricular hypertrophy (LVH) are recognised independent risk factors in the development of heart failure (HF). However, the combination of these factors may exacerbate the onset of cardiovascular disease by mechanisms as yet unclear. LVH leads to significant cellular remodelling, including alterations in metabolism which may result in an inappropriate accumulation of lipids and eventual lipotoxicity and apoptosis. The aim of the study was to determine the impact of dietary manipulation on cardiac metabolism in the obese and hypertrophied heart. METHODS AND RESULTS: LVH was induced via aortic constriction (AC) in an experimental model of cardiac hypertrophy and animals subjected to 9 weeks of dietary manipulation with either a standard, high fat, or a sucrose containing Western-style diet (SD, HFD and WD, respectively). This latter diet resulted in accelerated weight gain in both LVH/AC and control animals. LVH was greater in AC animals fed a WD, and both control and AC animals from this diet showed a significant reduction in cardiac fatty acid oxidation and increased triacylglycerol content. Ceramide content was significantly increased in the WD groups, with no additional effect of LVH. Comparison with a model of HF induced by exposure to Doxorubicin and WD showed exacerbated remodelling of cardiac ceramide species leading to increased C16 and C18 content. CONCLUSIONS: These findings highlight the inappropriate accumulation and re-distribution of cardiac ceramide species in a diet-induced model of obesity and LVH, potentially increasing susceptibility to cell death. The combination of increased fat and sugar leads to greater pathological remodelling and may explain why this diet pattern is consistently linked with poor cardiovascular outcomes.
  • Clobazam add-on therapy for drug-resistant epilepsy

    Bresnahan, Rebecca; Williamson, John; Martin-McGill, Kirsty J.; Michael, Benedict D.; Marson, Anthony G. (Wiley, 2019-10-22)
  • The effects of intake of bread with treated corn bran inclusion on postprandial glycaemic response

    Cui, Zhiming; Li, Weili; Kennedy, Lynne; Department of Clinical Sciences and Nutrition, University of Chester
    In the current study, corn bran was treated with hydrothermal processing and then incorporated into bread. The consumption of bread with inclusion of treated corn bran (TCB) and control bread (CB) on postprandial glycaemic response was investigated in a randomised crossover intervention trial with eleven healthy participants and one hyperglycaemicparticipant, capillary blood samples were measured at 0, 15, 30, 45, 60, 75, 90, 105 and 120 minutes after consuming the bread. The results showed the baseline-adjusted peak value of postprandial blood glucose with consumption of CB, containing 75 g carbohydrate was 4.27 mmol/L at 60 min after meal, but with consumption of treated corn bran bread (TCBB), containing 75 g carbohydrate was 3.88 mmol/L at 45 min after meal. In addition, the postprandial blood glucose concentration with consumption of CB is consistently higher than that with the consumption of TCBB since the peak time to 120 min. However, there was no significant differences, in turn, the incremental area under the curves (IAUC) with baseline-adjusted for CB consumption is consistently higher than that of TCBB consumption, but not any significant difference either (p>0.05). However, it is interesting to notice that more considerable difference in rise of blood sugar at peak time and thereafter for hyperglycaemicparticipant between the consumptions of TCBB and CB. In conclusion, the consumption of bread with inclusion of TCB is able to reduce the postprandial glycaemic response to a lower level compared with the consumption of CB and the more obvious difference was observed with the hyperglycaemicparticipant and healthy group Key words: Corn bran, hydrothermal treatment, postprandial glycaemic response. Intervention trial.
  • The composition and oxidative stability of vegetarian omega-3 algal oil nanoemulsions suitable for functional food enrichment

    Li, Weili; Lane, Katie E.; Robinson, Sharon; ZHOU, Qiqian; Liverpool John Moores University, School of Sport and Exercise Sciences, Faculty of Science, University of Chester
    Abstract Background: Long chain omega-3 polyunsaturated fatty acid (LCn3PUFA) nanoemulsion enriched foods offer potential to address habitually low oily fish intakes. Nanoemulsions increase LCn3PUFA bioavailability, but may cause lipid oxidation. This study examined oxidative stability of LCn3PUFA algal oil-in-water nanoemulsions created by ultrasound using natural and synthetic emulsifiers during 5-weeks of storage at 4, 20 and 40°C. Fatty acid composition, droplet size ranges and volatile compounds were analysed. Results: No significant differences were found for fatty acid composition at various temperatures and storage times. Lecithin nanoemulsions had significantly larger droplet size ranges at baseline and during storage regardless of temperatures. While combined Tween 40 and lecithin nanoemulsions had low initial droplet size ranges, there were significant increases at 40°C after 5-weeks storage. Gas chromatograms identified hexanal and propanal as predominant volatile compounds, along with 2-ethylfuran; propan-3-ol; valeraldehyde. The Tween 40 only nanoemulsion sample showed formation of lower concentrations of volatiles compared to lecithin samples. Formation of hexanal and propanal remained stable at lower temperatures although higher concentrations were found in nanoemulsions than bulk oil. The lecithin only sample had formation of higher concentrations of volatiles at increased temperatures despite having significantly larger droplet size ranges than the other samples. Conclusions: Propanal and hexanal were the most prevalent of five volatile compounds detected in bulk oil and lecithin and/or Tween 40 nanoemulsions. Oxidation compounds remained more stable at lower temperatures indicating suitability for enrichment of refrigerated foods. Further research to evaluate the oxidation stability of these systems 35 within food matrices is warranted.
  • Tiagabine add-on therapy for drug-resistant focal epilepsy

    Bresnahan, Rebecca; Martin-McGill, Kirsty J.; Hutton, Jane L.; Marson, Anthony G. (Wiley, 2019-10-14)
  • Acculturation and Food Intake Among Ghanaian Migrants in Europe: Findings From the RODAM Study

    Boateng, Daniel; Danquah, Ina; Holdsworth, Michelle; Mejean, Caroline; Terragni, Laura; Powell, Katie; Schulze, Matthias B.; Owusu-Dabo, Ellis; Beune, Erik; Agyemang, Charles; et al.
    Abstract Objective This study examined the role of migration and acculturation in the diet of Ghanaian migrants in Europe by (1) comparing food intake of Ghanaian migrants in Europe with that of Ghanaians living in Ghana and (2) assessing the association between acculturation and food intake. Design Data from the cross-sectional multicenter study Research on Obesity and Diabetes among African Migrants were used. Food intake was assessed using a Ghana-specific food propensity questionnaire (134 items and 14 food groups); foods were grouped based on a model of dietary change proposed by Koctürk-Runefors. Setting Ghana, London, Amsterdam, and Berlin. Participants A total of 4,534 Ghanaian adults living in Ghana and Europe, with complete dietary data. Of these, 1,773 Ghanaian migrants had complete acculturation data. Main Outcome Measure Food intake (the weighted intake frequency per week of food categories). Analysis Linear regression. Results Food intake differed between Ghanaians living in Ghana and Europe. Among Ghanaian migrants in Europe, there were inconsistent and small associations between acculturation and food intake, except for ethnic identity, which was consistently associated with intake only of traditional staples. Conclusions and Implications Findings indicate that migration is associated with dietary changes that cannot be fully explained by ethnic, cultural, and social acculturation. The study provides limited support to the differential changes in diet suggested by the Koctürk-Runefors’ model of dietary change.
  • Numerical simulation of non-Newtonian polymer film flow on a rotating spoked annulus

    Hossain, Mohammad Sayeed; Ashraf, Muhammad Arif; Al-Assaf, Saphwan; McMillan, Alison (Wiley, 2017-03-03)
  • Arabinoxylans from rice bran and wheat immunomodulatory potentials: a review article

    Fadel, Abdulmannan; Plunkett, Andrew; Li, Weili; Ranneh, Yazan; Tessu Gyamfi, Vivian Elewosi; Salmon, Yasser; Nyaranga, Rosemarie Roma; Ashworth, Jason (Emerald, 2018-02-12)
  • Nice to know: impact of NICE guidelines on ketogenic diet services nationwide

    Whiteley, Victoria; Carroll, Jennifer; Taylor, Hannah; Schoeler, Natasha; Martin-McGill, Kirsty J.; Royal Manchester Childrens Hospital; University of Salford; University of Chester; University of Liverpool; University of Plymouth; Sheffield Childrens Hospital; UCL Great Ormond Street Institute of Child Health (Wiley, 2019-08-20)
    Background In 2012, the National Institute for Health and Care Excellence (NICE) Clinical Guidelines for Epilepsies: Diagnosis and Management (CG137) included, for the first time, ketogenic diets (KDs) as a treatment option for drug‐resistant paediatric epilepsy. The recommendation was made to refer children and young people with epilepsy whose seizures have not responded to appropriate anti‐epileptic drugs to a tertiary paediatric epilepsy specialist for consideration of the use of KDs. We aimed to assess the impact of this change in guidance on the numbers of ketogenic centres and patients following KDs for epilepsy in the UK and Ireland. Methods An online survey was circulated to ketogenic dietitians from the UK and Ireland. The results were compared with similar surveys published in 2000 and 2010. Results The number of centres offering KDs for treatment of epilepsy has risen from 22 in 2000, to 28 in 2010, and to 39 in 2017 (77% overall increase). Seven of these centres accept adult referrals, in comparison to only two centres in 2010. Patient numbers have increased from 101 in 2000 to 754 in 2017. In total, 267 patients are waiting to commence KD at 31 centres. Conclusions Over the last 7 years, the number of patients treated with a KD for epilepsy in the UK and Ireland has increased by 647%, with a 77% increase in the number of centres offering KDs. Despite this rapid growth, there is ongoing demand for patients to be considered for dietary therapy, highlighting the need for continued expansion of KD services nationally.
  • Sulthiame add-on therapy for epilepsy

    Bresnahan, Rebecca; Milburn-McNulty, Philip; Powell, Graham; Sills, Graeme; Marson, Anthony G.; Martin-McGill, Kirsty J.; University of Chester; University of Liverpool; The Walton Centre NHS Foundation Trust; University of Glasgow; Liverpool Health Partners (Wiley, 2019-08-27)
    Background This is an updated version of the Cochrane Review previously published in the Cochrane Database of Systematic Reviews 2015, Issue 10. Epilepsy is a common neurological condition, characterised by recurrent seizures. Most people respond to conventional antiepileptic drugs, however, around 30% will continue to experience seizures, despite treatment with multiple antiepileptic drugs. Sulthiame, also known as sultiame, is a widely used antiepileptic drug in Europe and Israel. We present a summary of the evidence for the use of sulthiame as add-on therapy in epilepsy. Objectives To assess the efficacy and tolerability of sulthiame as add-on therapy for people with epilepsy of any aetiology compared with placebo or another antiepileptic drug. Search methods For the latest update, we searched the Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group’s Specialized Register and CENTRAL (17 January 2019), MEDLINE Ovid (1946 to January 16, 2019), ClinicalTrials.gov and the WHO ICTRP Search Portal (17 January 2019). We imposed no language restrictions. We contacted the manufacturers of sulthiame, and researchers in the field to seek any ongoing or unpublished studies. Selection criteria Randomised controlled trials of add-on sulthiame, with any level of blinding (single, double or unblinded) in people of any age, with epilepsy of any aetiology. Data collection and analysis Two review authors independently selected trials for inclusion, and extracted relevant data. We assessed these outcomes: (1) 50% or greater reduction in seizure frequency between baseline and end of follow-up; (2) complete cessation of seizures during follow-up; (3) mean seizure frequency; (4) time-to-treatment withdrawal; (5) adverse effects; and (6) quality of life. We used intention-to-treat for primary analyses. We presented results as risk ratios (RR) with 95% confidence intervals (CIs). However, due to the paucity of trials, we mainly conducted a narrative analysis. Sulthiame add-on therapy for epilepsy (Review) 1 Copyright © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. For Preview Only Main results We included one placebo-controlled trial that recruited 37 infants with newly diagnosed West syndrome. This trial was funded by DESITIN Pharma, Germany. During the study, sulthiame was given as an add-on therapy to pyridoxine. No data were reported for the outcomes: 50% or greater reduction in seizure frequency between baseline and end of follow-up; mean seizure frequency; or quality of life. For complete cessation of seizures during a nine-day follow-up period for add-on sulthiame versus placebo, the RR was 11.14 (95% CI 0.67 to 184.47; very low-certainty evidence), however, this difference was not shown to be statistically significant (P = 0.09). The number of infants experiencing one or more adverse events was not significantly different between the two treatment groups (RR 0.85, 95% CI 0.44 to 1.64; very low-certainty evidence; P = 0.63). Somnolence was more prevalent amongst infants randomised to add-on sulthiame compared to placebo, but again, the difference was not statistically significant (RR 3.40, 95% CI 0.42 to 27.59; very low-certainty evidence; P = 0.25). We were unable to conduct meaningful analysis of time-to-treatment withdrawal and adverse effects due to incomplete data. Authors’ conclusions Sulthiame may lead to a cessation of seizures when used as an add-on therapy to pyridoxine in infants with West syndrome, however, we are very uncertain about the reliability of this finding. The included study was small and had a significant risk of bias, largely due to the lack of details regarding blinding and the incomplete reporting of outcomes. Both issues negatively impacted the certainty of the evidence. No conclusions can be drawn about the occurrence of adverse effects, change in quality of life, or mean reduction in seizure frequency. No evidence exists for the use of sulthiame as an add-on therapy in people with epilepsy outside West syndrome. Large, multi-centre randomised controlled trials are needed to inform clinical practice, if sulthiame is to be used as an add-on therapy for epilepsy
  • Felbamate add‐on therapy for drug‐resistant focal epilepsy

    Shi, Li LI; Bresnahan, Rebecca; Martin-McGill, Kirsty J.; Dong, JianCheng; Ni, HengJian; Geng, JinSong; Medical School of Nantong University, China; University of Liverpool; University of Chester (John Wiley & Sons, Ltd, 2019-08-01)
    Background This is an updated version of the Cochrane Review previously published in 2017. Epilepsy is a chronic and disabling neurological disorder, affecting approximately 1% of the population. Up to 30% of people with epilepsy have seizures that are resistant to currently available antiepileptic drugs and require treatment with multiple antiepileptic drugs in combination. Felbamate is a second-generation antiepileptic drug that can be used as add-on therapy to standard antiepileptic drugs. Objectives To evaluate the efficacy and tolerability of felbamate versus placebo when used as an add-on treatment for people with drug-resistant focal-onset epilepsy. Search methods For the latest update we searched the Cochrane Register of Studies (CRS Web), MEDLINE, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP), on 18 December 2018. There were no language or time restrictions. We reviewed the reference lists of retrieved studies to search for additional reports of relevant studies. We also contacted the manufacturers of felbamate and experts in the field for information about any unpublished or ongoing studies. Selection criteria We searched for randomised placebo-controlled add-on studies of people of any age with drug-resistant focal seizures. The studies could be double-blind, single-blind or unblinded and could be of parallel-group or crossover design. Data collection and analysis Two review authors independently selected studies for inclusion and extracted information. In the case of disagreements, the third review author arbitrated. Review authors assessed the following outcomes: 50% or greater reduction in seizure frequency; absolute or percentage reduction in seizure frequency; treatment withdrawal; adverse effects; quality of life. Main results We included four randomised controlled trials, representing a total of 236 participants, in the review. Two trials had parallel-group design, the third had a two-period cross-over design, and the fourth had a three-period cross-over design. We judged all four studies to be at an unclear risk of bias overall. Bias arose from the incomplete reporting of methodological details, the incomplete and selective reporting of outcome data, and from participants having unstable drug regimens during experimental treatment in one trial. Due to significant methodological heterogeneity, clinical heterogeneity and differences in outcome measures, it was not possible to perform a meta-analysis of the extracted data. Only one study reported the outcome, 50% or greater reduction in seizure frequency, whilst three studies reported percentage reduction in seizure frequency compared to placebo. One study claimed an average seizure reduction of 35.8% with add-on felbamate while another study claimed a more modest reduction of 4.2%. Both studies reported that seizure frequency increased with add-on placebo and that there was a significant difference in seizure reduction between felbamate and placebo (P = 0.0005 and P = 0.018, respectively). The third study reported a 14% reduction in seizure frequency with add-on felbamate but stated that the difference between treatments was not significant. There were conflicting results regarding treatment withdrawal. One study reported a higher treatment withdrawal for placebo-randomised participants, whereas the other three studies reported higher treatment withdrawal rates for felbamate-randomised participants. Notably, the treatment withdrawal rates for felbamate treatment groups across all four studies remained reasonably low (less than 10%), suggesting that felbamate may be well tolerated. Felbamate-randomised participants most commonly withdrew from treatment due to adverse effects. The adverse effects consistently reported by all four studies were: headache, dizziness and nausea. All three adverse effects were reported by 23% to 40% of felbamate-treated participants versus 3% to 15% of placebo-treated participants. We assessed the evidence for all outcomes using GRADE and found it as being very-low certainty, meaning that we have little confidence in the findings reported. We mainly downgraded evidence for imprecision due to the narrative synthesis conducted and the low number of events. We stress that the true effect of felbamate could likely be significantly different from that reported in this current review update. Authors' conclusions In view of the methodological deficiencies, the limited number of included studies and the differences in outcome measures, we have found no reliable evidence to support the use of felbamate as an add-on therapy in people with drug-resistant focal-onset epilepsy. A large-scale, randomised controlled trial conducted over a longer period of time is required to inform clinical practice.

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