XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao
 2/Fio
 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao
 2/Fi
 o
 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.

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Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

A large number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC Web Site (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/rules-writing.aspx).

In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger societies are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tables 1 and 2 .

View this table:

Table 1 
Classes of recommendations



View this table:

Table 2 
Levels of evidence



The experts of the writing panels have provided disclosure statements of all relationships they may have that might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. Any changes in conflict of interest that arise during the writing period must be notified to the ESC. The Task Force report received its entire financial support from …

/pdf/guidelines-for-the-management-of-atrial-fibrillation-the-1cikaj4630.pdf

Guidelines for the management of atrial fibrillation The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC)

The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC)  

Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC  

Endorsed by the European Stroke Organisation (ESO)

/pdf/2016-esc-guidelines-for-the-management-of-atrial-ba0601yb9m.pdf

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

The reverberations of the Ukraine–Russia conflict have been keenly felt in 2022 as the impacts of Russia's invasion of Ukraine quickly cascaded across the globe, significantly exacerbating existing pressures on global systems. The vulnerabilities of the global food system have been particularly laid bare with significant disruptions to food and fertiliser supply chains instigating profound shocks on global food supply – disproportionately affecting poorer and vulnerable populations of the Global South. The immediate concerns and potential solutions to the global impacts of the Ukraine–Russia conflict were recently discussed by a panel of industry, academic and civil society experts convened by the European branch of the International Life Sciences Institute, all of whom are authors of this manuscript. The key concerns: the reduced affordability of food – focussing on those most vulnerable to its effects; the socio-political implications of reduced food security; food safety; and nutrition security are all discussed in this Point de Vue. The authors voice the need for improved resilience to future shocks and stress on the food system. Les répercussions du conflit Ukraine-Russie ont été vivement ressenties en 2022 alors que les impacts de l'invasion russe de l'Ukraine se propageaient rapidement à travers le monde, exacerbant considérablement les pressions existantes sur les systèmes mondiaux. Les vulnérabilités du système alimentaire mondial en particulier ont été mises à nu avec des perturbations importantes des chaînes d'approvisionnement en aliments et en engrais, provoquant de profonds chocs sur l'approvisionnement alimentaire mondial - affectant de manière disproportionnée les populations les plus pauvres et les plus vulnérables des pays du sud. Les préoccupations immédiates et les solutions potentielles aux impacts mondiaux du conflit Ukraine-Russie ont été récemment examinées par un groupe d'experts de l'industrie, du milieu universitaire et de la société civile convoqué par la branche européenne de l'Institut international des sciences de la vie, qui sont tous les auteurs de ce manuscrit. Les principales préoccupations : la réduction de l'accessibilité des aliments – en se concentrant sur les personnes les plus vulnérables à ses effets; les implications sociopolitiques d'une sécurité alimentaire réduite; la sécurité sanitaire des aliments; et la sécurité nutritionnelle sont tous abordés dans ce Point de vue. Les auteurs expriment la nécessité d'une meilleure résilience aux futurs chocs et pressions sur le système alimentaire. Die Folgen des Ukraine-Russland-Konflikts waren im Jahr 2022 erheblich. Schnell waren die Auswirkungen des russischen Angriffskriegs auf der ganzen Welt spürbar und verschärften den Druck auf die globalen Systeme. Die Anfälligkeit des Lebensmittelsystems wurde dabei besonders deutlich, denn es kam zu gravierenden Unterbrechungen in den Warenketten für Lebensmittel und Düngemittel. Ärmere und gefährdete Menschen im Süden waren davon unverhältnismäßig stark betroffen. Die unmittelbaren Befürchtungen und potenzielle Lösungen für die Probleme in Anbetracht des russischen Angriffskriegs wurden kürzlich von einem Gremium aus Experten und Expertinnen der Industrie, der Wissenschaft und der Zivilgesellschaft erörtert, das vom europäischen Zweig des International Life Sciences Institute einberufen wurde. Sie alle sind Autoren bzw. Autorinnen des vorliegenden Beitrags, in dem die folgenden Hauptprobleme erörtert werden: die geringere Bezahlbarkeit von Lebensmitteln – mit Schwerpunkt auf denjenigen, die von den Auswirkungen am stärksten betroffen sind, die soziopolitischen Auswirkungen einer verminderten Nahrungsmittelsicherheit; die Lebensmittelsicherheit und die Ernährungssicherheit. Die Autoren und Autorinnen weisen auf die Notwendigkeit hin, die Resilienz gegenüber künftigen Schocks und Belastungen des Lebensmittelsystems zu verbessern. Since Russia's outrageous invasion of Ukraine in February 2022 food supply chain disruptions have arisen, as both countries are significant net exporters of agricultural commodities. Their combined exports represent a total of 55 per cent of the global market of sunflower oil, 35 per cent of wheat, and 19 per cent of maize, while they are also significant suppliers of fertiliser (FAO, 2022a). The cascading effects of reduced supplies can curtail the production of many other downstream commodities. Most countries are already facing many stressors along the supply chain in the wake of the financial and labour market crises instigated by the Covid-19 pandemic. The Ukraine–Russia conflict exacerbates the current problems, and the global consequences are disproportionately affecting poorer and vulnerable populations. For example, many North and East African nations are heavily (Egypt: 82 per cent) or wholly (Benin, Somalia) dependent on wheat imports from Ukraine and/or Russia (UNCTAD, 2022). The United Nations World Food Programme (WFP) estimates that 47 million more people could become acutely food insecure in 2022 due to the Ukraine conflict (Husain et al., 2022); hunger and malnutrition are resurging across the world. The progress made towards the Sustainable Development Goals of the United Nations and the European Union's Green Deal is at risk. Due to global reliance on Russian crude oil and natural gas, energy prices are soaring, cascading downstream effects on transportation and on energy-intensive industries including food manufacturing. Ingredient shortages due to disrupted supplies have led to significant rises in food prices – the effects of which will be most acutely felt by the poorest and most vulnerable households – and amplified the risk of food fraud which creates food safety concerns including the presence of undeclared allergens. In addition, higher energy prices coupled with imposed export bans in Belarus have caused fertiliser shortages, thus increasing agricultural input costs and generating volatility in crop yields, which will likely have profound impacts on food supply into 2023 and beyond. “ Les pays à revenu faible et intermédiaire connaîtront les impacts les plus importants sur la sécurité nutritionnelle en raison de leurs ressources économiques limitées.” Due to the urgency of these issues, the European branch of the International Life Sciences Institute convened a meeting of industry, academic and civil society experts to discuss the immediate concerns and potential solutions to the global impact of the Ukraine–Russia conflict on food supply chains. All experts involved contributed to the production of this summary report of the expert discussion. Following the onset of the conflict a strong positive correlation between the world price indices for food, edible oils, and cereals has been evident; this suggests that the Russian invasion of Ukraine instigated a marked increase in global inflation (Ozili, 2022). The Ukraine–Russia conflict and the enduring impacts of the Covid-19 cost of living crisis have led European inflation rates to rise to a 30-year high. Food is becoming less affordable, particularly for lower-income households, who will be disproportionately affected as food constitutes a greater proportion of their household spending (Lall, Henderson and Venables, 2017). As food prices rise, households shift their diets towards staple grains that become more dominant, while consumption of more micronutrient dense animal source foods, fruits and vegetables decline. This is likely to result in child stunting, that can often lead to lifelong costs to the child and the economy, due to poorer cognitive development and educational outcomes, reduced productivity and increased morbidity. In low-income countries, food price increases can have political implications and cause civil unrest, as seen during the 2007/08 financial crises in Cameroon, Burkina Faso, Sri Lanka and Côte d'Ivoire amongst others. Egypt and Yemen may be particularly vulnerable to such impacts due to their heavy reliance on imports of Ukrainian and Russian grain. Prior to the conflict, 6 million tonnes of agricultural commodities per month were exported from Ukrainian Black Sea ports. The UN and Turkey recently negotiated a deal with Russia to reopen the Black Sea trade routes to export wheat and foodstuffs from Ukrainian borders allowing the WFP to resume the purchase, transport and distribution of wheat. As of 5 December 2022, five maritime shipments containing wheat have left Ukrainian ports to aid humanitarian operations in countries such as Ethiopia, Yemen, Somalia and Afghanistan (European Council, 2022; WFP, 2022). The Ukraine–Russia conflict has instigated significant cascading impacts on global food supply chains © SvetaKost/Shutterstock.com Beyond the increased cost of food felt at the individual level, national budgets are challenged by greater need to deliver social protection programmes, particularly safety nets, and face heightened pressure to enable their citizens to access adequate food. As the Ukraine–Russia conflict will exacerbate existing stress already placed on food systems by the Covid-19 pandemic, this will have long-term impacts on food and nutrition security. As many governments subsidise food products, there is concern that further increases in food prices will constrain their ability to do so. The WFP's budget has a current shortfall of US$ 10 billion due to the rising cost of fuel, food and shipping, making UN intervention difficult. From an agricultural production standpoint, with an increase in cereal and edible oil prices, production in less economically developed countries can be expected to increase; however, this will partly be offset by higher input prices. Poorer countries in Africa that rely on imports of Ukrainian/Russian agri-foods may try to incentivise higher production to feed their respective populations, but this would require huge investments that may not be available. Even with more WFP resources directed to parts of the Middle East, Africa and Asia, supply would react with a time lag. “Länder mit niedrigem und mittlerem Einkommen werden aufgrund ihrer begrenzten wirtschaftlichen Ressourcen die größten Auswirkungen auf die Ernährungssicherheit erfahren.” Immediate actions that could mitigate the impacts of the conflict on food affordability include higher government subsidies for vulnerable people to access food, and action to prevent unnecessary product shortages. Disparities between the wealth of countries and their resilience in the face of the Covid-19 pandemic means that many countries’ financial resources are overstretched. In Europe, government and industry have the resources to support the additional costs despite price increases, but most low-income countries do not have any emergency reserves to do this. One solution to maintain global affordability of food could be the creation of a pooled global fund to share wealth between countries. For example, the Food and Agriculture Organization (FAO) has called for a global Food Import Financing Facility to help poorer countries deal with surging prices (FAO, 2022c). Whilst stockpiling of goods can be employed as a legitimate tool to smooth supply chain pressures, systems need to be established to prevent businesses and traders from speculative stockpiling which can exacerbate or instigate product shortages. Additionally, the panic-buying that was seemingly inspired by the media during the Covid-19 pandemic, should also be mitigated. This will require clear and timely communication from governments and retailers to provide information and reassure consumers. Food retailers should implement limits on quantities of specific products that consumers are permitted to purchase as seen across Europe for vegetable oils. This will help to mitigate unnecessary product shortages and any further price increases that such shortages can generate. Markets will be driven to substitute food products that are in short supply. Most refined vegetable oils do not contain allergens, so common substitutions for vegetable oils, such as sunflower oil are unlikely to pose a high risk of allergenicity. Challenges can be expected where there are rapid and frequent changes to labelling or requirements for labelling flexibility due to the introduction of substitutes. There is concern about toxic residues being present in substitutes due to differences in environmental stewardship and food safety and human health policies around the world, placing an increased need for testing on both companies and governments. The global food supply chain impacts of the Ukraine–Russia conflict will be most acutely felt by the poorest and most vulnerable households © M7Studio/Shutterstock.com As there are possible public health concerns, it is imperative that any substitutions made are safe for human consumption. Therefore, risk assessors and risk managers need to be consulted when selecting substitutes. The risk from chemical contaminants is extremely low, so small risks of contamination may have to be tolerated in order to feed the population and maintain an adequate food supply. Risk-benefit assessments would be invaluable in supporting such management decisions. “Low and middle-income countries will experience the greatest impacts on nutritional security due to their limited economic resources.” Food fraud can pose a high risk to food safety, depending on the type of adulterant. Therefore, meticulous food testing and traceability need to be maintained, and increased where necessary, to enable the detection of food fraud. Further development in traceability and testing facilities is essential to eliminate the risk of contamination because of food fraud. For food manufacturers it is important that they revisit their vulnerability assessments to minimise the heightened food fraud risk caused by price volatility and ingredient shortages. Temporary derogations to food labelling regulations, or to their enforcement, can facilitate food supply but there must be clear risk assessments and parameters around the substitutions. Uniformity of labelling regulation, and consistent derogation across countries would be useful for streamlining international trade. In addition, to reduce risks of incorrect labelling, packaging will need to be adapted quickly to correctly label any substitutions. There are a multitude of ways in which this can be achieved, for example by using stickers over labels, labelling multiple potential ingredients and signposting in stores. Potential reputational damage as a result of selling contaminated substitutes will serve as a powerful incentive to retailers to ensure appropriate checks are implemented. Education and communication with consumers about substitutes and the associated (absence of) risks is essential for consumer acceptance. The media can play a vital role in minimising stress and anxiety of consumers caused by substitutions. Previous economic crises have highlighted that when food prices rise, people maintain their consumption of calories by replacing healthy diets with highly processed foods or cheap staples that have lower micronutrient value. Now, with shortages of certain ingredients, there may be difficulty in identifying other food products that can provide similar intakes of micronutrients. These disruptions to supply chains will result in fewer people having access to adequate nutrition, with the FAO estimating that 8 to 13 million more people would become undernourished in 2022 (FAO, 2022c). In wealthier countries, food price increases will lead some people to turn to more obesogenic diets which are often more affordable, exacerbating diet-related health inequalities. However, low- and middle-income countries will experience the greatest impacts on nutritional security due to their limited economic resources, with malnutrition expected to result in a short-term increase in death rates in these countries. Severe acute malnutrition already kills 1–2 million children each year. Currently an additional 47 million people are at risk of starvation with children the most vulnerable to severe acute malnutrition, which will result in an inevitable spike in child mortality. Hidden hunger and micronutrient malnutrition get less attention than hunger because it is largely invisible; children, women and girls of reproductive age will bear the brunt as they are disproportionately more vulnerable to micronutrient malnutrition than the general population due to their greater need for specific nutrients (Osendarp et al., 2022). Prior to the conflict, 6 million tonnes of agricultural commodities per month were exported from Ukrainian Black Sea ports, such as Odessa © Elena Larina/Shutterstock.com As seen during previous financial crises, many countries have imposed export bans on some food commodities to address growing domestic food insecurity. For example, India has issued an export ban on wheat. This is expected to have a profound impact on neighbouring and vulnerable countries. When financially and/or politically powerful countries impose export bans acting in their own interests, prices are driven higher, exacerbating food insecurity (FAO, 2022b). In terms of ingredients, one of the biggest challenges currently is sourcing sunflower oil, and this is already impacting buyers and food manufacturers who are considering substitutes. Substitute oils will have different technical properties, fatty acid profiles and for some, environmental impacts. The Ukraine–Russia conflict has highlighted the vulnerability of the global food system, demonstrating the importance of restructuring the food system to improve resilience to future shocks and stresses. In terms of long-term resilience, one proposed solution is to call upon governing bodies to reduce restrictions on global exports: 21 countries (as of October 2022) have already implemented export bans, thus impacting global access to important commodities and food products (Laborde, 2022). Additionally, governments are called upon to scale up coverage of social protection programmes. Strategies and implementation frameworks need to be drawn up to facilitate responses to future potential crises. These can include approaches aimed at enhancing robustness of and/or recovery within the food supply system to ensure that demand can be met. Further, reorientation of expectations of what food systems can deliver can support adjustment to changes in food systems and help manage demand. These 3 ‘Rs’ (Robustness, Resilience, and Reorientation) are strategies that can be employed in isolation or combination to enhance food system resilience levels (Zurek et al., 2022). Solutions must be comprehensive and not limited to global food aid responses, which challenge budgets. A more comprehensive approach needs to be applied including catastrophic bond-type financing, for example facilities such as the Africa Risk Capacity Initiative. What is needed is engagement of all actors, government, non-government, public and private sectors, to ensure a uniform, egalitarian and urgent response. The contribution provided by Dr Avermaete is partly derived from RUSTICA, a project entitled ‘Demonstration of circular bio-based fertilisers and implementation of optimized fertilizer strategies and value chains in rural communities’ that has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No. 101000527. 

Impacts of the Ukraine–Russia Conflict on the Global Food Supply Chain and Building Future Resilience

Over the past three or four decades, we have seen substantial changes in recommendations as to how the consumption of dietary fats can be altered to promote health and prevent disease. Early on, the major culprit linking heart disease to diet was cholesterol. Later, we learned that saturated fats were far more potent at increasing blood cholesterol levels, particularly LDLcholesterol, than dietary cholesterol itself. Replacing saturated fats with high amounts of polyunsaturated fats in the diet seemed a sensible recommendation, and was adopted by many groups providing dietary guidelines. Promotion of the intake of polyunsaturated fatty acids was largely focused upon the n-6 family, with a resultant increased consumption of linoleic acid. However, more recently, there has been an increased awareness of the potential adverse effects of high intakes of n-6 polyunsaturated fatty acids, associated with their conversion to pro-inflammatory eicosanoids, and their ability to act as pro-oxidants.

Lipids: how do we convert experimental data to policy?

Dietary omega-3 fatty acids include α-linolenic acid (ALA) and the long-chain omega-3 polyunsaturated fatty acids (PUFAs) eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA). Here we review available data from rat studies on the effect of omega-3 PUFA supplementation during pregnancy and/or early life upon brain composition and functional outcomes. Brain DHA content is significantly higher, and arachidonic acid (AA) content lower, after both ALA and long-chain omega-3 PUFA supplementation in the rat. Data suggest both potential risks and benefits of omega-3 PUFA upon offspring outcome measures, with adverse effects upon fetal brain growth, rates of neonatal maturation, and auditory development, but protection against toxic brain stimulation, hypoxia, ischemia, and drug-induced mania, and improved spatial awareness, spatial memory, and recognition memory. Further studies are required to directly compare the efficacy of ALA and long-chain omega-3 PUFA during pregnancy and/or lactation in influencing brain fatty acid composition and changes to functional outcome measures.

Dietary Omega-3 Sources during Pregnancy and the Developing Brain: Lessons from Studies in Rats

Adipose tissue inflammation in human obesity and response to chronic marine omega-3 fatty acid supplementation: the BIOCLAIMS study at the University of Southampton

Complex lipids and their fatty acid components have important biological activities and are involved in the regulation of many metabolic and physiological processes. Fatty acids are important energy sources and upon complete β-oxidation yield more energy per mole and per carbon atom than glucose. Fatty acid β-oxidation occurs mainly in the mitochondria, and there are specific mechanisms for transporting fatty acids from the cytosol to the mitochondrial matrix to enable their oxidation. Ensuring fatty acid availability for oxidation reduces the need for glucose provision. Fatty acids in foods and in formulas used for nutrition support are esterified into triacylglycerols. There are specific mechanisms for releasing fatty acids from triacylglycerols provided orally and for taking these up into enterocytes. These involve coordinated physical, chemical and enzymatic activities operating from the mouth to the small intestine. In healthy people these processes are very efficient, but they can be disrupted by injury, illness or disease, including critical illness, meaning that fatty acid availability can be decreased in these situations. The products of triacylglycerol digestion and absorption ultimately appear in the bloodstream as triacylglycerols in lipoproteins called chylomicrons. Fatty acids are removed from chylomicrons by the action of lipoprotein lipase, which is promoted by insulin, and can be stored in adipose tissue following their re-esterification into triacylglycerols. In stress states or times of limited glucose availability, fatty acids are released from stored triacylglycerols and appear in the bloodstream as non-esterified fatty acids. These are the substrates for β-oxidation and energy generation. Lipid emulsions used in intravenous nutrition support are metabolised similarly to chylomicrons, but they need to acquire proteins from native lipoproteins to enable this to happen. ESPEN guidelines recommend intravenous lipid infusion in critically ill patients where enteral feeding is not possible. However, excess rates of lipid infusion can lead to hypertriacylglycerolemia and can disrupt organ function, and therefore the rate of lipid infusion needs to be controlled and limited. The critically ill patient displays alterations in lipid metabolism and lipid utilisation that result from insulin resistance, the stress response, inflammation and nutrition support. Fatty acids are the preferred fuel in critical illness, and there is an increase in whole body fat oxidation. However, fatty acid availability may be in excess of needs, and fatty acids not oxidised may be incorporated into triacylglycerols in the liver resulting in hepatic steatosis and hypertriacylglycerolemia, which may be promoted by lipid infusion and by impaired triacylglycerol clearance. Whether these events happen or not is determined by the specific state of the individual critically ill patient. Because the fatty acid components of triacylglycerols are biologically active, the precise composition of lipid used in artificial nutrition support of critically ill patients may affect metabolic, physiological and clinical outcomes.

Philip C. Calder

Papers

Impacts of the Ukraine–Russia Conflict on the Global Food Supply Chain and Building Future Resilience

Lipids: how do we convert experimental data to policy?

Dietary Omega-3 Sources during Pregnancy and the Developing Brain: Lessons from Studies in Rats

Adipose tissue inflammation in human obesity and response to chronic marine omega-3 fatty acid supplementation: the BIOCLAIMS study at the University of Southampton

Use of Lipids as Energy Substrates