The association between index of nutritional quality and ulcerative colitis: A case control study

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1 Originl Article The ssocition between index of nutritionl qulity nd ulcertive colitis: A cse control study Frhd Vhid 1,2, Smneh Rshvnd 1, Mhy Sdeghi 2, Azit Hekmtdoost 1 1 Deprtment of Clinicl Nutrition nd Dietetics, Fculty of Nutrition Sciences nd Food Technology, Ntionl Nutrition nd Food Technology Reserch Institute, Shhid Beheshti University of Medicl Sciences, 2 Cncer Reserch Center, Shhid Beheshti University of Medicl Sciences, Tehrn, Irn Bckground: Ulcertive colitis (UC) is chronic inflmmtory bowel disese. Recent studies hve shown tht dietry fctors ply n importnt role in the development of UC. Index of Nutritionl Qulity (INQ) is suitble method tht nlyzes quntittively nd qulittively single foods, mels, nd diets. The im of this study ws to determine the ssocition between INQ nd UC. Mterils nd Methods: Overll, 62 newly dignosed cses with UC nd 124 helthy ge nd sex mtched controls were studied in referrl hospitl in Tbriz, Irn. INQ scores were clculted bsed on informtion on the usul diet tht ws mesured by vlid nd relible Food Frequency Questionnire consisting of 168 food items. Logistic regression nlysis djusting for ge, gender, body mss index, eduction, smoking, Helicobcter pylori, fmily history of UC, ppendectomy, lcohol, nd totl energy intke ws used to estimte multivrible odds rtios (ORs). Results: After controlling for severl covrites, we found inverse ssocitions between UC risk nd INQs of Vitmin C (OR = 0.34 [ ]) nd folte (OR = 0.11 [ ]). In crude model of nlysis, cses hd higher intke of totl energy, protein, crbohydrte, totl ft, sturted ftty cid, monounsturted ftty cid, polyunsturted ftty cid, nicin, Vitmin B6, Vitmin B12, mgnesium, zinc, copper, selenium, nd iron compred to controls, wheres controls hd higher intkes of Vitmin C, Vitmin D, folte, nd biotin compred to cses. Conclusion: Our results indicte tht enough consumption of Vitmin C nd folte ws ssocited with lower risk of UC. Key words: Folte, Index of Nutritionl Qulity, inflmmtory bowel disese, nutritionl ssessment, ulcertive colitis, Vitmin C How to cite this rticle: Vhid F, Rshvnd S, Sdeghi M, Hekmtdoost A. The ssocition between index of nutritionl qulity nd ulcertive colitis: A cse control study. J Res Med Sci 2018;23:67. INTRODUCTION Ulcertive colitis (UC) is chronic inflmmtory bowel disese with multifctoril etiologies of genetics immunity nd environmentl fctors. Potentilly, environmentl fctors influence on disese incidence nd include brestfeeding, use of ntibiotic in infncy, stress in life, diet, nd lifestyle. [1] Epidemiologicl studies showed tht environmentl fctors, especilly dietry fctors, ply n importnt role in the incidence nd development of UC. [2 6] It hs been shown tht diet nd dietry fctors influence the intestinl microbiome, epithelil function, nd mucosl immune system. [7] There re severl methods for nlyzing dietry dt, Access this rticle online Quick Response Code: Website: DOI: /jrms.JRMS_555_17 one of them is ssessing the nutritionl qulity of the diet which hs n importnt role for helth situtions, nd it summrizes diet in broder mnner thn ny single nutrient or food. [8] Assessing of dietry qulity should be simple nd prcticl, [9] so the Index of Nutritionl Qulity (INQ) is suitble method which plys n importnt role in the ssessment of clinicl nutritionl problem. This method nlyzes quntittively nd qulittively single foods, mels, nd diets. The INQ is rtio of the nutrient to clorie content of foods, which it cn be shown s br grphs nd tbulr dt. [10,11] We conducted this study to determine the reltionship between INQ scores nd nutrients intke nd risk of UC in cse control study. This is n open ccess journl, nd rticles re distributed under the terms of the Cretive Commons Attribution NonCommercil ShreAlike 4.0 License, which llows others to remix, twek, nd build upon the work non commercilly, s long s pproprite credit is given nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com Address for correspondence: Dr. Azit Hekmtdoost, Deprtment of Clinicl Nutrition nd Dietetics, Fculty of Nutrition Sciences nd Food Technology, Ntionl Nutrition nd Food Technology Reserch Institute, Shhid Beheshti University of Medicl Sciences, Tehrn, Irn. E mil: _hekmt2000@yhoo.com Received: ; Revised: ; Accepted: Journl of Reserch in Medicl Sciences Published by Wolters Kluwer Medknow 2018

2 MATERIALS AND METHODS Prticipnts Detils of the study hve been reported previously. [12] Overll, 62 new cses of UC nd 124 helthy controls were included in the study. The study protocol ws pproved by our locl Ethics Committee. The study protocol hs published elsewhere. [12] Dietry intkes of the prticipnts over the pst yer were ssessed using vlid nd relible Food Frequency Questionnire (FFQ). [13] The study protocol ws pproved t the Ethics Committee of Ntionl Nutrition nd Food Technology Institute, Shhid Beheshti University, Tehrn, Irn, with Ethics number of NNFTRI 523. Assessment of Index of Nutritionl Qulity The INQ is rtio of the nutrient to clorie content of foods. [14] The number of nutrients nd the nutrient stndrds used for nlysis re flexible prmeters, which my be vried for ech clinicl sitution. Illustrtive exmples include INQ nlysis of simple foods, n institutionl house diet, the dibetic exchnge list, nd the dignostic evlution of the dietry intke of hospitlized ptient. [15] We clculted the INQ of ech nutrient, using the following formule: INQ = consumed mount of nutrient per 1000 kcl/recommended dietry dequte or dequte intke of tht nutrient per 1000 kcl. FFQ derived dietry dt were used to clculte INQ scores for ll the prticipnts. Nutrients intke ws clculted using USDA food composition tble. Mjor food items tht were used in the clcultion of INQ were s follows: protein, Vitmins A, D, K, E, iron, thimin, riboflvin, nicin, folte, biotin, pntothenic cid, Vitmins B6 nd B12, mgnesium, copper, selenium, nd mngnese. Sttisticl nlysis Chi squre or Fisher s exct test ws used for the comprison of ctegoricl vribles between groups. Before choosing the sttisticl test, the normlity of their distribution for ech vrible ws tested using the Kolmogorov Smirnov test. Then, the independent smples t test or Mnn Whitney U tests were used for the comprison of the continuous vribles with norml nd nonnorml distribution between groups, respectively. Age djusted nd multivrible djusted logistic regression models were used to estimte odds rtios (ORs) nd 95% confidence intervls (CIs) of hving UC in reltion to ech nutrient s INQ. Adjustments were done for ge, gender, body mss index, eduction, smoking, Helicobcter pylori infection, fmily history of UC, ppendectomy, lcohol consumption, nd totl energy intke in the djusted models. RESULTS The distribution of demogrphic chrcteristics cross cses (n = 62) nd controls (n = 124) is shown in Tble 1. Quntittive nd qulittive vribles re shown s men ± stndrd devition nd number (%), respectively. Cses hd more history of ppendectomy nd H. pylori infection compred to controls. Tble 2 shows the distribution of dietry intkes of mcro micronutrients cross cses nd controls. As presented in this tble, cses hd higher intke of totl energy ( ± vs ± ), protein ( ± vs ± 23.82), crbohydrte ( ± vs ± 88.05), totl ft ( ± vs ± 25.46), sturted ftty cid (SFA, ± vs ± 9.78), monounsturted ftty cid (MUFA, ± vs ± 8.27), polyunsturted ftty cid (PUFA, ± 9.06 vs ± 7.08), nicin (29.81 ± 9.29 vs ± 7.99), Vitmin B6 (2.09 ± 0.55 vs ± 0.56), Vitmin B12 (6.61 ± 6.46 vs ± 2.83), mgnesium ( ± vs ± ), zinc (14.55 ± 5.29 vs ± 3.45), copper (2.12 ± 0.70 vs ± 0.56), selenium ( ± vs ± 36.08), nd iron (20.08 ± 4.96 vs ± 5.03) compred to controls. There ws no significnt difference between groups in terms of Vitmins A, D, E, K, nd C, thimin, riboflvin, folte, biotin, pntothenic cid, nd mngnese nd clcium intke. Comprison of the INQ of the subjects is shown in Tble 3. According to this tble, the INQ of Vitmin C (1.30 ± 0.58 vs ± 0.43), Vitmin D (1.08 ± 0.80 vs ± 0.68), folte (1.14 ± 0.18 vs ± 0.17), nd Biotin (0.81 ± 0.25 vs ± 0.22) re higher in controls compred to cses. Tble 4 shows ORs nd 95% CI for the ssocition between INQ nd UC. After controlling for severl covrites, inverse ssocitions were observed between UC risk nd INQs of Vitmin C (OR = 0.34 [ ]) nd folte (OR = 0.11 [ ]). Tble 1: Distribution of demogrphic chrcteristics cross cses nd controls Chrcteristics Men±SD or n (%) Cses (n=62) Controls (n=124) P,b Age (yers) 37.43± ± Sex Mles 27 (44) 54 (44) 1 Femles 35 (56) 70 (56) BMI (kg/m 2 ) 24.81± ± Eduction Primry 7 (11) 6 (5) 0.17 Secondry nd 28 (45) 69 (55) high school University 27 (43) 49 (40) Smoking 6 (10) 10 (8) 0.71 Helicobcter pylori 7 (11) 1 (0.8) < Fmily history 2 (3) 0 (0) 0.11 Appendectomy 4 (6) 0 (0) < Independent smples t-test ws used for continuous vribles; b Chi-squre test ws used for ctegoricl vribles. BMI=Body mss index; SD=Stndrd devition Journl of Reserch in Medicl Sciences

3 Tble 2: Distribution of dietry intkes of mcro-micronutrients cross cses nd controls Men±SD Cses (n=62) Controls (n=124) P Totl energy intke ± ± < (kcl/dy) Protein (g/dy) ± ±23.82 < Crbohydrte (g/dy) ± ±88.05 < Totl ft (g/dy) ± ±25.46 < SFA (g/dy) 32.92± ±9.78 < MUFA (g/dy) 39.17± ±8.27 < PUFA (g/dy) 26.02± ±7.08 < Vitmin A (RAE/dy) ± ± Vitmin D (ug/dy) 1.90± ± Vitmin E (mg/dy) 18.73± ± Vitmin K (ug/dy) ± ± Vitmin C (mg/dy) ± ± Thimin (mg/dy) 2.34± ± Riboflvin (mg/dy) 2.41± ± Nicin (mg/dy) 29.81± ±7.99 < Vitmin B6 (mg/dy) 2.09± ±0.56 < Folte (ug/dy) ± ± Vitmin B12 (ug/dy) 6.61± ±2.83 < Biotin (ug/dy) 31.16± ± Pntothenic cid 5.72± ± (mg/dy) Mg (mg/dy) ± ± < Mn (mg/dy) 6.80± ± Zinc (mg/dy) 14.55± ±3.45 < Cu (ug/dy) 2.12± ±0.56 < Selenium (ug/dy) ± ±36.08 < Iron (mg/dy) 20.08± ±5.03 < Clcium (mg/dy) ± ± Independent smples t-test ws used. SAFA=Sturted ftty cids; MUFA=Monounsturted ftty cids; PUFA=Polyunsturted ftty cids; SD=Stndrd devition DISCUSSION This study is the first one to exmine the ssocition between INQ nd UC risk. Our results showed inverse ssocitions between UC risk nd INQs of Vitmin C nd folte. In ddition, this cse control study showed tht UC ptients hd higher intke of totl energy, protein, crbohydrte, totl ft, SFA, MUFA, nd PUFA compred to controls. These results were in greement with studies, in which ssocitions were observed between high totl protein intke with significntly incresed risk of UC. [16] However, some studies hve found no ssocition between energy, protein nd crbohydrte intke, nd UC risk. [17] In ddition, similr previous studies hve shown tht there is positive ssocition between UC risk nd intkes of totl ft, SFA, PUFA, nd MUFA. [12] In contrst, in the Nurses Helth Study, intkes of totl ft, SFA, nd PUFA were not ssocited with risk of UC. [18] Furthermore, met nlysis study suggested lck of ssocition between ft intke nd UC risk. [19] Tble 3: Comprison of the Index of Nutritionl Qulity of the subjects Men±SD Cses (n=62) Controls (n=124) P Protein 1.49± ± Vitmin A 0.65± ± Vitmin C 1.05± ±0.58 < Fe 1.73± ± Vitmin D 0.86± ±0.80 < Vitmin E 0.87± ± Thimin 1.36± ± Riboflvin 1.38± ± Nicin 1.36± ± Vitmin B6 1.12± ± Folte 1.06± ±0.18 < Vitmin B ± ± Biotin 0.73± ±0.25 < Pntothenic cid 0.79± ± Vitmin K 1.19± ± Mgnesium 0.82± ± Zinc 1.04± ± Mngnese 2.43± ± Selenium 1.66± ± Copper 1.63± ± Independent smples t-test ws used. SD=Stndrd devition We found tht UC ptients intke of Vitmin B6 nd B12, mgnesium, zinc, selenium, nd iron were significntly higher compred to controls. In contrst, other studies reported tht there is inverse ssocition between UC risk nd intkes of Vitmins B12 nd B6, [20] zinc, [21] selenium, [22] iron, [23] nd mgnesium, [24] which this conflict could be due to host of different resons such s difference in methodology nd residul confounding. Different tools were used to nlyze diet qulity to evlute the dily nutrition nd the food intke sttus of ptients. INQ is one of these methods for ssessing dietry dt; the nutritionl qulity of the diet, which plys n importnt role in ssessing the clinicl nutritionl problem. In the present study, when we use the INQ insted of bsolute intkes, there were fewer differences between groups in dietry intkes. In ddition, this method summrized diet in broder mnner thn ny single nutrient or food. Micronutrients such s Vitmin C nd folte ply n importnt role in the prevention of UC. [25] These vitmins lter the bowel flor nd hve n immune modultory effect through severl mechnisms. [26] Rective oxygen species (ROS) nd other indices such s nitrogen species generted by inflmmtory cells in dmged tissues. [27] An imblnce in the production of ROS nd ntioxidnt components my ply n importnt role in the pthogenesis of UC. [28] The presence of Vitmin C s n ntioxidnt component prevents oxidtive injury in the inflmed mucos nd increses ntioxidnt defense tht my be decresed susceptible to oxidtive tissue dmge in UC pthogenesis. [29] Epigenetic regultion, through DNA 3 Journl of Reserch in Medicl Sciences 2018

4 P ORs for Tble 4: Odds rtios nd confidence intervls for the ssocition between Index of Nutritionl Qulity nd ulcertive colitis ORs for P continuous INQ continuous INQ b INQ protein 1.20 ( ) ( ) 0.82 INQ Vitmin A 0.91 ( ) ( ) 0.35 INQ Vitmin C 0.36 ( ) < ( ) < INQ iron 0.68 ( ) ( ) 0.54 INQ Vitmin D 0.63 ( ) ( ) 0.11 INQ Vitmin E 0.65 ( ) ( ) 0.81 INQ thimin 0.42 ( ) ( ) 0.57 INQ riboflvin 0.45 ( ) ( ) 0.16 INQ nicin 0.91 ( ) ( ) 0.58 INQ 0.55 ( ) ( ) 0.72 Vitmin B6 INQ folte 0.08 ( ) < ( ) < INQ 1.18 ( ) ( ) 0.69 Vitmin B12 INQ biotin 0.22 ( ) ( ) 0.18 INQ 0.38 ( ) ( ) 0.42 pntothenic cid INQ Vitmin K 0.90 ( ) ( ) 0.70 INQ Mg 0.42 ( ) ( ) 0.75 INQ Cu 1.31 ( ) ( ) 0.82 INQ selenium 0.97 ( ) ( ) 0.91 INQ Mn 0.91 ( ) ( ) 0.51 Age djusted, b Adjusting for ge, gender, BMI, eduction, smoking, Helicobcter pylori, fmily history of UC, ppendectomy, nd totl energy intke. INQ=Index of Nutritionl Qulity; UC=Ulcertive colitis; OR=Odds rtio; BMI=Body mss index methyltion, hs n importnt role in the protection from diseses such s UC. [30] However, there is little informtion bout the role of nutrition in the epigenetic regultion of UC; [7] folte hs n essentil role in the synthesis, methyltion, nd repir of DNA tht prevents from the lterntion of gene expression nd incresed DNA dmge nd UC development. [31] This study hs severl strengths; the present study is the first one to report the ssocition between INQ nd UC risk. In ddition, ssessment of dietry qulity by the INQ is simple nd ccurte in comprison to other methods becuse it djusts the effects of energy intke. Another strength of this study is the use of vlid nd relible FFQ [24] for ssessing food nd nutrient intkes. Finlly, the selection of controls ws crefully nd they hd not sitution relted to diet or other mjor risk fctors ssocited with UC. This study hd some limittions. Since we used n FFQ, mesurement errors were inevitble. Other limittions include reltively low smple size nd recll bis due to its cse control design. In ddition, use of INQ is one of the limittions. We clculted INQ bsed on Dietry Reference Intke (DRI) nd since there is not DRI for ll nutrients or food items, so INQ cnnot be clculted for ll of them. Therefore, it is possible tht the potentil effects of these nutrients or food items on UC hve been ignored in the present study. CONCLUSION Our findings suggest tht enough intke of Vitmin C nd folte ws ssocited with lower risk of UC. Therefore, public helth dvice should emphsize the importnce of incresing intke of these nutrients from nutrient rich diet for prevention of UC. These findings need to be confirmed in other popultions with high methodologicl qulity. Acknowledgments We thnk ll prticipnts in this study without whom this study ws not possible. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. REFERENCES 1. Annthkrishnn AN. Epidemiology nd risk fctors for IBD. Nt Rev Gstroenterol Heptol 2015;12: Hekmtdoost A, Feizbdi MM, Djzyery A, Mirshfiey A, Eshrghin MR, Yegneh SM, et l. The effect of dietry oils on cecl microflor in experimentl colitis in mice. Indin J Gstroenterol 2008;27: Hekmtdoost A, Mirshfiey A, Feizbdi MM, Djzyeri A. Polyunsturted ftty cids, microflor nd colitis. Ann Nutr Metb 2009;55: Hekmtdoost A, Wu X, Mormpudi V, Innis SM, Jcobson K. Dietry oils modify the host immune response nd colonic tissue dmge following Citrobcter rodentium infection in mice. Am J Physiol Gstrointest Liver Physiol 2013;304:G Smsmikor M, Dryni NE, Asl PR, Hekmtdoost A. Resvertrol supplementtion nd oxidtive/anti oxidtive sttus in ptients with ulcertive colitis: A Rndomized, double blind, plcebo controlled pilot study. Arch Med Res 2016;47: Smsmi Kor M, Dryni NE, Asl PR, Hekmtdoost A. Anti inflmmtory effects of resvertrol in ptients with ulcertive colitis: A Rndomized, double blind, plcebo controlled pilot study. Arch Med Res 2015;46: Vhid F, Znd H, Nosrt Mirshekrlou E, Njfi R, Hekmtdoost A. The role dietry of bioctive compounds on the regultion of histone cetylses nd decetylses: A review. Gene 2015;562: Slttery ML. Defining dietry consumption: Is the sum greter thn its prts? Am J Clin Nutr 2008;88: Coulston AM. The serch continues for tool to evlute dietry qulity. Am J Clin Nutr 2001;74: Vhid F, Htmi M, Sdeghi M, Ameri F, Fghfoori Z, Dvoodi SH, et l. The ssocition between the Index of nutritionl qulity (INQ) nd brest cncer nd the evlution of nutrient intke of brest cncer ptients: A cse control study. Nutrition 2018;45: Vhid F, Rhmni G, Neini AF, Flhnejd H, Dvoodi SH. The ssocition between index of nutritionl qulity (inq) nd gstric cncer nd evlution of nutrient intkes of gstric cncer ptients: Journl of Reserch in Medicl Sciences

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