PEN eNews 10(1) January 2020
eNews is a monthly e-newsletter shared with the global PEN Community and created to help dietitians position themselves as leaders in evidence-based nutrition practice. In addition, users of the PEN System will find articles on the new evidence, resources and features available and how to maximize one's use of PEN.
Is Learning Part of your new year's resolution? become a pEN® reviewer!
Peer review is an important part of PEN content development. PEN Reviewers are involved in providing feedback on new and updated PEN content including knowledge pathways, practice questions, backgrounds and Trending Topics.
Different perspectives are essential in the review process, including those of practitioners and academics from different areas in the country and the world. You can review one practice question or background or an entire knowledge pathway. It is a great way to volunteer and many regulatory bodies recognize PEN reviewing as continuing education credits.
So, what do you need to be a PEN Reviewer? Take a look at this short presentation. You need to have interest and some time, which can range from a few hours to many hours, depending on how much time you wish to contribute. We provide guidance and training on how to become a PEN Reviewer.
We are currently looking for reviewers for these topics:
- Low Carbohydrate (not Ketogenic) and Diabetes
- Intestinal Permeability
- Organic Foods
- Parkinson's Disease
- Prostate Cancer
- Hepatic Disorders
- Irritable Bowel Disease
There are currently more than 300 PEN Reviewers. We would love for you to join this group and share your expertise and energy. For more information, contact http://www.pennutrition.com/BecomeAuthor.aspx.
PEN® Backgrounds – Ready for You When Needed
Many knowledge pathways in the PEN System have a background. Backgrounds provide general information about a topic/condition/issue for new practitioners as well as for experienced health professionals. There are two types of backgrounds, clinical and nonclinical. Not sure about an area of practice or need a refresher? The background is a good place to start.
There are more than 160 backgrounds in the PEN System. Here are the latest ones that are new or have been updated:
Breakfast and Weight – What Does the Evidence Tell Us?
The QuestionDoes regularly consuming breakfast, versus regularly skipping breakfast, aid in weight loss, weight control or prevent weight gain over time?
Systematic reviews of observational studies found that adults who skip breakfast were more likely to have a higher BMI or to be classified as overweight or obese on the BMI scale than adults who eat breakfast. Consuming breakfast was also associated with less weight gain over time. However, observational studies on this topic are highly subject to numerous confounding factors, not all of which can be or have been controlled. A systematic review also found that claims regarding breakfast consumption and weight loss are widespread and not grounded in evidence and that a significant proportion of the studies in this field inaccurately cited their own data and other’s data as having demonstrated causal relationships, when in fact none were established. Review authors speculated that this may have contributed to the widespread presumption that breakfast consumption aids weight loss or weight control.
Systematic review of RCTs found that assigning individuals to either breakfast or no breakfast conditions for two to 16 weeks did not result in any difference in weight changes between the two but did find that those who did not have breakfast consumed approximately 250 kcalories less per day. Those who consumed breakfast had higher total daily caloric intakes. The short duration and small samples sizes of the RCTs published to date limits the ability to draw conclusions. As a result, it is not clear if or how breakfast consumption effects weight control over time.
There is not enough quality evidence to recommend for or against regularly consuming breakfast for the purposes of weight control or weight loss.
To see the entire practice question, including evidence statements and references, click here
The PEN® Gerontology Knowledge Pathway – Young Again!
The Gerontology Knowledge Pathway is aging well! There are new and updated practice questions on:
- Diet prescriptions and older adults with chronic disease in long-term care settings
- Individuals in long-term care settings and energy-restricted diets
- The effects of shared mealtimes in residential care settings on nutritional outcomes in older adults.
Current content includes evidence on:
- Nutrition screening tools for identifying malnutrition or the risk of malnutrition in older adults independently living in the community
- Nutrition screening/assessment tools for identifying malnutrition or the risk of malnutrition in frail older adults who are institutionalized or living in nursing homes, care homes or long-term care homes
- Folic acid-fortified foods or supplements and the risk of vitamin B12 deficiency.
Content that will be added/updated soon in the Gerontology Knowledge Pathway includes:
- Vitamin and mineral needs
- Folate, B12 and cardiovascular disease.
to see the Gerontology Knowledge Pathway, including consumer and professional tools and resources.
Dawna Royall's Surprising Findings - Why do Omega-3 Fatty Acid Recommendations Differ?
Recently, I was asked to comment on a Harvard newsletter article
about a new meta-analysis of the “most up-to-date evidence regarding the effects of omega-3 supplementation on risk of multiple CVD [cardiovascular disease] outcomes”. The study was an update of a 2018 meta-analysis of 10 trials (1), which included three additional RCTs published since the review (2). The meta-analysis included individual patient data from over 127,000 participants at high CVD risk obtained from large trials (>500 participants followed for at least one year). Results found that omega-3 supplements contributed to a modest reduction in coronary heart disease (CHD) events (n=12 RCTs: RR, 0.95; 95%CI, 0.91 to 0.99). Modest reductions in other CVD outcomes, except stroke, were also reported (Table 1).
How does this new information compare to PEN content?
For the primary or secondary prevention of CVD, we suggest not taking omega-3 fatty acid supplements (EPA and DHA) (conditional recommendation
, moderate quality evidence ⊕⊕⊕⊝
The PEN question is based on a 2018 Cochrane review of 79 RCTs of more than 112,000 participants including primary and secondary prevention trials (3). Results suggested a beneficial effect of omega-3 fatty acid supplements on CHD events (n=28 RCTs: RR, 0.93; 95%CI, 0.88 to 0.97). However, no beneficial effect on CHD events was observed in sensitivity analysis when only trials at low risk of bias were analyzed (n=12 RCTs; RR, 0.97; 95%CI, 0.90 to 1.05) and no effects on other CVD outcomes were reported (Table 1). Although there was little to no effect of omega-3 fatty acids on clinical endpoints, there were no serious adverse events reported.
Which review should we rely on?
Fewer trials included in the new meta-analysis
While the Hu et al. review (2) represents newer work by including results of three additional RCTs (in fact most of the analyses included only two RCTs as REDUCE-IT was excluded because it used a much larger prescription dose of EPA), overall much fewer trials were included compared to the Cochrane review (3). This is because collecting individual patient data includes fewer trials in order to collect the outcome data to match precisely between trials.
Weaknesses of the new meta-analysis
A weakness of the new meta-analysis (2) involved the use of a fixed-effect model rather than a random-effects model to analyze the data. Under the fixed effect model, it is assumed that the true effect size for all studies is identical (i.e. all studies come from the same population, are conducted in the same way and are therefore measuring the same effect) (4). Fixed-effect models have a higher probability of achieving statistical significance than random-effect models as used in the Cochrane review (3). The Cochrane review (3) also used the rigorous GRADE process to evaluate the quality of included trials, consistency among studies, generalizability and precision of results, publication bias and disclosed conflict of interest related to industry support.
Table 1. Comparison of omega-3 fatty acid interventions from Cochrane (3) and updated Hu et al. (2) reviews
|PEN Content based on |
Cochrane review(3) N= 28 RCTs
|Hu et al. (2) N = 12 RCTs|
|Clinical outcomes||# of people|
|RR (95% CI)||# of people|
|RR (95% CI)|
|CVD death||4763||0.95 (0.87 to 1.03)||2238||0.93 (0.88 to 0.99)|
|CVD events||15614||0.99 (0.94 to 1.04)||7230||0.97 (0.94 to 0.99)|
|CHD deaths||1791||0.93 (0.79 to 1.09)||1405||0.92 (0.86 to 0.98)|
|CHD events||5865||0.93 (0.88 to 0.97)||3668||0.95 (0.91 to 0.99)|
|Stroke||1871||1.06 (0.96 to 1.16)||1260||1.05 (0.98 to 1.14)|
The Bottom Line
While the Cochrane review (3) is more robust and rigorous than the Hu et al. review (2), it does not include results of a couple recently published large RCTs. Both reviews suggest the potential of omega-3 fatty acid supplements to reduce heart attack risk by about 5 to 7%. Would most individuals want to purchase omega-3 supplements to achieve these small potential benefits? This may be a consideration for some individuals based on their values and preferences. A recommendation focusing on increasing fish consumption as part of an overall healthy dietary pattern is likely to benefit most individuals.
- Aung T, Halsey J, Kromhout D, et al. Associations of omega-3 fatty acid supplement use with cardiovascular disease risks: meta-analysis of 10 trials involving 77 917 individuals. JAMA Cardiol. 2018;3(3):225-34. doi:10.1001/jamacardio.2017.5205. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/29387889
- Hu Y, Hu FB, Manson JE. Marine omega-3 supplementation and cardiovascular disease: an updated meta-analysis of 13 randomized controlled trials involving 127 477 participants. J Am Heart Assoc. 2019;8(19):e013543. doi:10.1161/JAHA.119.013543. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/31567003
- Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, et al. Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2018 Nov 30;11:CD003177. doi: 10.1002/14651858.CD003177.pub4. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/30521670
- Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Introduction to Meta-Analysis. UK: John Wiley & Sons, Ltd.; 2009
How do I....Use My PEN® Favourites
Written by Lisa Koo, PEN® Quality Assistant (Reposted from October 2013)
There is a new feature available on the PEN® Homepage called My PEN® Favourites*. It allows you to save your favourite practice questions, practice guidance summaries, toolkits, evidence summaries, backgrounds and tools & resources so they are all conveniently located in one place.
How do I add items to My PEN® Favourites?
Simply go the practice question, tool or resource that you would like to make a favourite and click on the white star icon
located next to the title and once it has been saved the star turns to gold
. This will save the resource into the “My PEN®
Favourites” section on the PEN®
How do I remove items from My PEN® Favourites?
If you would like to remove items from “My PEN® Favourites”, simply click on the “Manage my PEN® Favourites” link on the right hand side of the My PEN® Favourites screen. You will be taken to a screen that will allow you to remove specific items. You can also remove items from “My PEN® Favourites” by going back to the item and deselecting the star.
We hope that you enjoy this new feature. We have added it so that all of your favourite PEN® resources can now be available at the click of your mouse.
* Please note that this feature only applies to PEN® individual as it needs to be associated with an individual’s log in information.
January 2020 Volume
A Publication of the PEN® System Global Partners,
a collaborative partnership between International Dietetic Associations.
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